Neuro-Muscular Control

 

Neuro-muscular control plays a big role in the management and prevention of chronic back and neck pains. It complements the rehabilitation therapy components that focus on the joints, muscles and bones. With improved neuro-muscular control, the body is able to get the whole musculoskeletal system working efficiently together.

What Is Neuro-Muscular Control?

The key moving part in the body’s muscle-skeletal system is the muscle. This in turn is controlled by the nervous system. The nervous system determines how much the muscle should contract, relax when to do so, and how quickly or slowly it should do so. Neuro-muscular control refers to the ability to do each of these things well.

Why Is Neuro-Muscular Control Important?

To help us understand this, let’s think back to the time when you first learnt to ride a bicycle. Different parts make up the bike. This is similar to the human body. Some parts like the handlebar and seat should be firmly bolted to the bicycle frame. Other parts should be moving freely. We have some joints in the body that shouldn’t be tight. Instead, it needs to move more freely and other joints that need to be tighter.

Example

The other main part of the bike frame is like your skeletal structure. It basically holds everything else up. A weakened or eaten-away bike frame might give way suddenly.

Now, when you ride the bike, you take the role of the muscle and nervous control system. Here it is too important that you are very strong in order to ride a bike. Like most people, you need some practice to learn to get your ‘balance’. You can start with some training wheels at the back.

Learning how to balance is all about learning to pedal at the right pace, doing it smoothly, and making small adjustments to your body’s centre of gravity. Slight shifts to the left and right as you pedal, and small adjustments to the handlebars help to compensate.

The key to note is that it is not about strength or endurance. If you have more strength and endurance, you will be able to ride faster and for longer periods of time. But without the proper ‘balance’ control, you won’t be able to ride at all no matter how strong you are.

Coming back to the human body, neuro-muscular control is the same; only now the bike is your body instead subtly moving your joints and supporting them. Like learning to ride a bike, it is easiest to just do it right slowly and keep practising.

Case Study And Treatment

In this case study, we looked at Madam S, a lady in her late 60s. She had poor posture when walking and standing. Walking for more than 10 minutes on the flat ground caused numbness and sensations of heat in both her legs. Over the past few years, her symptoms got progressively worse.

First Phase

Initially, treatment involved a combination of different modalities and focused on the primary area of pain. Manual therapy was performed on the overactive muscles in her lower back. This is to reduce the tension and to restore normal movement (not stiff) around her lower back. She was taught exercises such as pelvic tilts. This will allow conscious dissociation of the lower back portion of the spine from the chest portion of the spine and hips. Other stretching and flexibility exercises were also taught to maintain her mobility and achieve a neutral spine position.

Second Phase

The second phase of the management involved teaching Madam S to develop an effective pattern of muscle activating to support her trunk or abdominal area.

Trunk stabilization involves re-education of the primary stabiliser muscles that help stabilise. This involves lateral costal breathing and isolation of low effort pelvic floor, transverses abdominus and multifidus muscle contraction. This was done in the supine position and separately to start. It then progressed to co-contraction of all the stabilizing muscles in functional positions, especially in standing and walking. Posture re-education and joint awareness of her lumbar spine, pelvis, and knees were practised with biofeedback.

Third Phase

Once Mrs L was able to contract the pelvic floor, transverses abdominus and multifidus and perform lateral costal expansion, the 3rd and final phase of the management was carried out. This phase involved strengthening of the secondary stabilizers. This includes the gluteal muscles, lat dorsi, and the external and internal obliques.

Status At 3 Months

After 3 months of physiotherapy, Mrs L can now walk distances of 1km without pain. Her body awareness is now better and no longer stands in a swayed back posture.

Conclusion

This case illustrates the effectiveness of a multi-approach system in solving this client’s back pain. In this instance, the role of manual therapy was to prepare the structures to adopt a more neutral posture. This is done by increasing flexibility, and “give” in the soft tissues and facet joints.

The improvement gained from the above cannot be sustained if the poor motor control present in Mrs L was not addressed. The role of transverses abdominus and multifidus is well documented and understood. However, recent literature has shown that the pelvic floor and the pattern of breathing are as important in the stabilization system.

Analogy And Implications

A good analogy is to liken the trunk to a coke can. The top of the coke is the diaphragm, the bottom of the coke can is the pelvic floor, and the side is the transverses abdominous. The multifidus stabilizes the spine at the intervertebral level. The idea of stabilization (apart from the multifidus) is to increase the intra-abdominal pressure within the abdominal cavity. This is only possible if transverses can contract in a system where there is a good tone in the pelvic floor and normal functioning of the diaphragm.

In this case, Mrs L’s pelvic floor was weak and her breathing pattern was not conducive to transverse abdominus contraction. As her pelvic floor muscle was weak, it could not hold against the intra-abdominal pressure. Her breathing pattern caused a distention in her abdomen every time she inhaled. This counteracted and opposed the activation of the transverses.

The lack of trunk stability probably led to the over-activation of her back extensors which were recruited to compensate for the deficiency. This would have led to an increased extension in the lumbar spine and hence her resultant posture.

Reference:

Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction, adaptation, and enhancement. J Spinal Disorders 1992;5:383-389.