The Neuroscience of Chronic Pain

By: admin Published: March 10, 2013

by Jay McCallum, PT, DPT, OCS

This post has been a very long time in the incubator, partly because we’re all so busy and partly because we wanted to be able to give you both some science and some clinical reality.  It started last October when Amy and Jay went to a conference in Portland on the topic of chronic pain.  It was taught by a pair of amazing researchers, Paul Hodges and Lorimer Moseley.  Paul and Lorimer are both physical therapists – ‘physiotherapists’, actually, given that they’re Australians – but they have devoted their professional lives to the study of how pain works and between them have published nearly 300 scholarly articles on the topic.

Because they covered so much ground this is going to be the first of a three part blog.  I’ll talk about Paul’s work today, and then try to cram Lorimer’s material into a second blog, and finally talk about our experiences in the clinic working to implement their findings into actually treating patients.

How Does Chronic Pain Affect How We Move?

This is really what Paul Hodges’ work is about.  He is best known in the world of physical therapy as the researcher who told us all that the transversus abdominus is important in stabilizing the spine, but that’s really not at all fair to the body of his work.  What he has focused on is how the body solves the problem of keeping a stack of bones like the spine stiff enough that it doesn’t collapse, yet mobile enough to move.  And, what he’s found is that people do it in lots of different ways (of course).  There are, however, some patterns once you step back from the detailed specifics, and, more importantly, people who have a history of back pain tend to use a different set of strategies than people who don’t have back pain.  Most of the research here is focused on back pain, but it’s quite likely that similar patterns are at work with other locations of chronic pain, like the neck.

Generally speaking, the muscles of the trunk can be divided into muscles that are closer to the spine and those that are further away, with of course some muscles situated in a bit of a gray zone in between.  And Paul’s work suggests that the ‘normal’ way that we move is that the muscles that are closer to the spine activate to create just the right amount of stiffness to support the loads we put on our spines, while those further from the spine are primarily concerned with generating movement of the spine.

The best known of those deep, stabilizing muscles are the multifidus and the transversus abdominus, and the ones we tend to forget about are those that make up the pelvic floor.    These muscles are relatively small, located right in there close to the spine, and are designed to stay ‘on’ for long periods of time at a relatively low intensity.  They are also supposed to ‘pre-activate’, meaning that before you go to pick up that pencil on the floor the brain tightens them to stabilize the back.

View from the side of the multifidus, pelvic floor and transversus abdominus

What goes wrong?

We get stuck in a pattern.  When a person first injures his or her back, the body’s reaction is to brace it – to tighten the bigger muscles that are further out from the spine and have longer lever arms to pull on it.  Those muscles normally exist to generate movement, but get pressed into service to hold the injured spine in place.  That pattern is supposed to quiet after a while, but if it doesn’t it can become the “new normal,” the primary strategy for keeping the spine stable.  And that’s really a problem, because those muscles are NOT designed to be on for long periods of time, and so they complain about it, and get trigger points, and make the spine feel stiff all the time.  And they use too much force, so the underlying joints have too much pressure on them.  And they just aren’t very good at this new job, so people hurt their back picking up that innocent pencil because the nervous system didn’t stabilize the spine quite right (but they DON’T hurt their back lifting heavy things, because they consciously brace.  Sound familiar?).  And so, the classic pattern goes, people have further episodes of back pain and each one intensifies this pattern.

Hey!  That’s me!  What can I do??

And…there we have the problem.  Obviously, what we’d LIKE to do is turn off those overactive superficial muscles and re-activate the deep ones.  But, it isn’t quite so simple.  These changes in muscle activation are accompanied by changes in brain structure.  Put more simply, most people have had a LOT of practice at this pattern.  We’ll talk about this more in my third post, but a couple of key points is that pain of this type is not just a ‘strengthening’ issue – it’s much more about coordination.  And you have to work at it from a lot of angles, trying to both activate the deep ones (intentional exercise, practice, feedback) and quiet the overactive ones (stretching, motion, relaxation, massage and manual therapy).  Most importantly, treatment needs to be individualized and very attentive to details, which is how we do things at CoreBalance Therapy.

If you want to learn more, give us a call at 928-556-9935 or email us at [email protected].

Treating Low Back Pain Part 2 – Stabilization Exercises

By: admin Published: April 18, 2012

  By Lauren Shafer PT, DPT



Treating Low Back Pain is Not One Size Fits All

The second subgroup for treating low back pain is stabilization exercise. I find this to be an interesting category in the way it has evolved and what we are finding through research. It is commonly thought that “core training or stabilization” is the best way to treat low back pain, but this isn’t always the case. The literature over the past several years has prompted popularity in the prescription of stabilization exercise, however, results on its true effectiveness are inconclusive. While strong abdominal and back muscles definitely can help prevent and manage low back pain, it isn’t always the correct intervention for someone with low back pain.

The criteria for this subgroup include:

  • Age < 40
  • Greater general flexibility (straight leg raise >91°)
  • Positive prone instability test (locating a relatively more mobile segment of the lumbar spine that also reproduces symptoms when direct pressure is applied. The test is positive if pain is no longer reproduced while the patient performs a movement eliciting lumbar muscle contraction)
  • Aberrant movement when actively bending forwards and backwards, referred to as an “instability catch”, and the patient may perform “thigh climbing” when coming up.

 Is this the right intervention for me?

A person who meets at least three of the four criteria is 80% likely to report at least a 50% decrease in symptoms when a core stabilization program targeting both deep and superficial trunk muscles is utilized. What I find even more interesting is that when at least three of these factors are negative, the person is 86% likely to FAIL to improve with a stabilization program. If you currently have back pain and just can’t seem to get better no matter how strong you get, this may shed some light as to why! There is also an additional set of factors to identify women with pain who are postpartum and likely to benefit from a stabilization program.

For more information about classifications of low back pain, you can read the article here.

Call or e-mail CoreBalance Therapy to schedule an evaluation with a physical therapist so that we can determine the best approach for you!


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