Like many aspects of patient presentations, it is best to view neurological soft signs and other neurological factors (e.g., motor imagery ability, proprioception, tactility – two point discrimination) on a ‘spectrum’.

One of my biases is that this represents an important subgroup of musculoskeletal pain. It is relevant in other fields (e.g., concussion), but for some reason it has been neglected in the musculoskeletal field. This is often modifiable with targeted treatment (e.g., primitive reflex inhibition, postural reflex facilitation, specific sensory motor rehab, specific motor imagery training), however does depend on causation (e.g., continuous stimulus versus one time incident).

Some people consider neurological soft signs as “normal”.  If this is normal, we also have to consider many other things as normal (e.g., kinesiophobia). It is common, but not normal. Approximately 40-45% of healthy subjects have at least one neurological soft sign, however greater than 90% of subjects with chronic pain have a battery of neurological soft signs.

The presence of more neurological soft signs / neurological factors starts impacting function (e.g., neurocognitive function, motor coordination). Below are some relevant implications of Adult-Minor Neurological Dysfunction (A-MND) in musculoskeletal rehab.

  • Poor Motor Skill Learning Ability
    • These people cannot learn exercises like segmental stabilization exercises (e.g., transversus abdominus biased abdominal hollowing) or specific movement pattern control exercises (e.g., waiters bow – maintaining the lumbar spine neutral and flexing from the hips).
    • Note: The research on these exercises is extremely limited since approximately 20% of people with chronic pain cannot learn the exercises.
    • Even without A-MND, the presence of milder neurological soft signs and neurological factors can make motor skill learning harder and rehab much longer. It is still worth rehabilitating the neurological side of the presentation.
    • The Motor Control Abilities Questionnaire screens motor skill learning ability
  • Increased Risk of multiple tissue loading mechanisms
    • There are multiple ways tissue can be loaded (e.g., movement pattern control, translation control, biomechanical exposures to loading). With the long standing poor coordination, sensory motor function and reduced ability to plan, many patients have multiple mechanisms of tissue loading which can complicate things for the novice (Top tip: Luckily, many of the neurological based rehab is whole body!).
  • Increased risk of co-morbid Behavioral diagnoses
    • These presentations often have co-morbid behavioral diagnosis. The traditional belief is that the reduced exposures, opportunities, and causation of the A-MND  was the causation of the behavioral factor. Although this is true, we must not discount that there is growing opinion that the neurological soft signs themselves (and related neurological dysregulation) may be a cause and can start before the other aspects of the causation are present. Of course, both can be present concurrently and often are. Do you know how to take a birth history?
  • Increased risk of co-morbid Neuro-immune-endocrine diagnosis
    • Chronic low grade systemic inflammation is not well defined (yet) and is also not well understood. It is highly likely this is involved in the causation of a subgroup of A-MND. Further, a vicious cycle can develop whereby people with A-MND make poor lifestyle choices, which are part of the causation of A-MND.
    • The NICE-Q screens for this.
  • Nociplastic pain mechanisms
    • Two of the mechanisms of of nociplastic pain are central sensitization and motor imagery pain. The presence of neurological soft signs and other neurological factors makes it more likely that nociplastic pain subgroups will be present.
    • Note: The background to this has not been published yet so will not be discussed here.

Summary: Neurological soft signs and neurological factors are on a spectrum. They represent an important subgroup of chronic musculoskeletal pain, which has largely been neglected. The more pronounced type is considered Adult-Mild Neurological Dysfunction and have important clinical implications. Understanding this subgroup can lead to more targeted therapies (e.g., primitive reflex inhibition, postural reflex facilitation, specific sensory motor rehab, specific motor imagery training).

Note: these comments are presented as opinions. They were formed from almost 30 years of observations and clinically related research. We are gradually getting some of the related publications out there.