Experienced clinicians who have done neurological rotations as students and during early training have observed similarities between neurological approaches and orthopaedic approaches. This is beyond improving movement and function.

Neurological dysregulation is a subgroup of chronic musculoskeletal pain. They become relevant when they:

  • Create a barrier to rehabilitation
    • e.g., influence motor skill learning ability (and thus can’t respond to specific motor control exercises);
    • influence behavioral appraisal and increase risk for psychological presentations;
    • influence neurocognitive function and influence compliance, exposure to loading factors
  • Involved in causation of tissue loading mechanisms
    • e.g., increased tone that creates a restriction to movement
    • reduced sensory motor function and increased use of end range movements

Note: there is some overlap in above (e.g., mechanisms can be barriers).

One manifestation of neurological dysregulation are neurological soft signs. One type of neurological soft sign  primitive reflexes. Primitive reflexes (PR) are brain stem-mediated, complex automatic movement patterns that commence in utero.  If PR persist beyond their average lifespan they may begin to interfere with motor control and normal rehabilitation. Another type are the lack of postural reflexes. Postural reflexes occur in the neurodevelopmental process and their purported primary purpose is  stated to maintain a constant posture in relation to a dynamic external environment. There are three types of postural reflexes: righting reactions, placing reactions, and equilibrium reactions.

Thinking neurologically about orthopaedic conditions requires blending your current knowledge about orthopaedic conditions (e.g., muscle tightness, joint stiffness, strength, weakness, movement patterns) and their causation (e.g., loading factors, tissue adaptation) with neurological clinical reasoning.

Some examples:

  • Movement pattern: why is the central nervous system making someone move like this?
  • Muscle tightness: why is the central nervous system producing increased tone in this muscle?
  • Weakness: why is the central nervous system not sending the signals needed to produce more muscle force?
  • Posture: why is the central nervous system producing this type of muscle stiffness at rest (too much or too little)?

In the image associated with this blog, the patient has depressed scapula bilaterally. He had trapezius related myofascial pain. This was bilateral with the right greater than the left.

Some orthopaedic approaches (depending on your school of thought):

  • Strength and conditioning approach e.g., He has weakness in the shoulder girdle so we should strengthen upper trapezius (e.g., monkey shrugs)
  • Tissue adaptation approach: let’s ignore all mechanisms and gradually load it and hope his tissues adapt
  • Scapular dyskinesis approach: he has poor control of his scapulae so let’s strengthen his scapular muscles
  • Motor control approach: (control would have been assessed) He has poor control of scpaular depression so let’s train upper trapezius with low load to (1) position scapula (2) control scapular position with limb movement (3) progress to functional loads and integration into function

However, neurological clinical reasoning is different:

  • Why is the central nervous system creating this type of end range posture?
    • Is there a primitive reflex present that is pulling the scapulae down (e.g., spinal galant, abdominal reflex).
    • Is there a complete loss of proprioception?
  • Why is his central nervous system not producing enough tone in upper trapezius? Are the postural reflexes that elevate the scapulae absent?

Let’s be clear: there is absolutely nothing “normal” about this type of end range scapular posture. It is almost always associated with neurological soft signs (e.g., presence of primitive reflexes and absence of postural reflexes). The inquisitive clinician would address the primary mechanisms and their causes.

Neurological clinical reasoning can be blended with many traditional orthopaedic approaches, either concurrently or as a progression. Obviously, patient beliefs, expectations and ability to comply are all factors to consider. Targeting neurological dysregulation (eg., sensory motor feedback, sensory motor processing, primitive reflex inhibition, postural reflex facilitation) is a key bridge between orthopaedic and neurological clinical reasoning.