Note: a reminder that these blogs are often written from perspective of those that have attended our lectures.
The reader shoulder be reminded of a simple, and key difference in Primitive and Postural Reflexes:
- Primitive reflexes: we are not meant to have
- Postural Reflexes: we are meant to have
When discussing the Disease Pathogenesis Framework, please remember that a mechanism can be considered a cause depending on the perspective and outcome of interest.
On our courses we discuss 3 main tissue loading mechanisms:
- Movement Pattern Control
- Translation Control of the joint
- Biomechanical Exposures to Loading
However, the common feature of chronic low back pain is the variability shown. Some people have too much stiffness (control) and some have too little stiffness (control). This relates to a common criticism of the movement pattern control school of thought: tissue loading can occur with too little control, but also too much control. Quite a lot of rehabilitation programs and schools of thought are based on those that have too little stiffness (e.g., the variety of ‘core stability’ programs and many strengthening methods). This is a major limitation since many people have “too much stiffness”.
To address the ‘extremes’ of these stiffness variations, it may be necessary to think neurologically about these orthopaedic conditions. This type of clinical reasoning is difficult for many since it challenges the very roots of many schools of thought they have learned their trade in. However, primitive and postural reflexes are ideally suited for these extremes.
To help appreciate this, reflect on the Disease Pathogenesis Framework. Here we discuss that although we often start to focus rehabilitation on mechanisms. This would be tissue loading if the primary pain mechanism is nociceptive. However, we can’t ignore neurological regulation as a mechanism. This can act a ’cause’ of tissue loading (e.g., changes in movement patterns and control).
It is a misconception to thin Primitive reflex inhibition techniques only inhibit muscle tone. It is best to view them as ‘normalizing’ muscle tone. This makes them ideal for the rehabilitation of these extremes of muscle stiffness.
A classic example of this is the Landau reflex. It is a wonderful exercise to start changing Motor Behavior. We have been recommending this primitive reflex for two decades for motor priming of gluteus maximus and lumbar multifidus (and the whole spine). Many of the reflexes are whole body and this address many regions concurrently.
It should be appreciated that not all of these presentations have a primary neurological mechanism. The priority may be behavioral, especially when there is kinesiophobia present. As well, in severe pathology, there could be high stiffness. So even if neurological soft signs are present, it is always important to rule out specific causes of pathology. In some cases, high stiffness may present as an instability, therefore, translation control is the mechanism and segmental stabilization exercises can be performed.
Summary points:
- Chronic low back pain has a variable presentation with “too much” and “too little stiffness”
- Most exercise interventions are based on increasing stiffness
- A possible way forward is to think neurologically about orthopaedic conditions.
- Primitive reflex inhibition and postural reflex facilitation are rehabilitation options for addressing too much and too little control
- These are especially useful for people with poor motor skill learning ability, atypical birth history, neurodevelopmental disorders / learning difficulties, concussion
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