Motor Behavior Therapy has been an evolving process since the late 1990’s. The goal was to provide a clinical reasoning framework for physiotherapists to begin to understand the complexity of musculoskeletal pain and to provide a targeted rehabilitation direction for all patients. We have now achieved this goal. Research into low grade systemic inflammation, motor skill learning problems in adults, body image & motor imagery, along with the existing body of evidence from various fields (e.g., strength and conditioning, physiology, motor control, psychology) has allowed this goal to be achieved.
The appreciation of Disease Pathogenesis highlights the gross limitations of previous sub-classification models and provides a framework to understand the complexity of musculoskeletal pain.
Motor Behavior Therapy (MBT) is a clinical reasoning framework for the multi-dimensional management for musculoskeletal pain for Physiotherapists. The key themes are “MCIB”:
- Mechanisms
- Causation
- Individualization
- Barriers
Motor Behavior Therapy allows the therapist to assess the dominant mechanisms contributing to an individuals pain presentation and use clinical reasoning to prioritize starting points and problem solving.
We have new options that will help with those that do not respond well to common therapies and also address those that do respond, but are slow to progress.
Disease Pathogenesis Framework
Viewing musculoskeletal pain as a disease along the disease spectrum (i.e., symptoms-syndrome-disorder-disease) immensely helps understand the complexity involved in musculoskeletal pain. Just for clarity, this does not mean musculoskeletal pain “is” a disease, but can be best viewed along this disease spectrum. An understanding of disease pathogenesis is helpful to understand where everything fits in and aids in how to target interventions. It also helps us understand many of the criticisms of contemporary treatments.
Virtually all diseases follow a pathway of stages in their causation (i. e., etiology), development, and presentation (i. e., pathogenesis).
The stages of pathogenesis are: Initiation (mechanisms); Progress (damage response); Clinical symptom development (at this stage a hypothesis of a clinical diagnosis is made); and Resolution. Resolution could refer to full recovery, death, or chronicity, therefore two other stages (trajectory and disability) have been added to better reflect chronic pain.
This “etio-pathogenesis framework” of disease has been criticized for emphasizing the biological aspect of diseases. Therefore, it could be considered as “biosocial pathogenesis” to highlight the integration of a person’s biology, biography, and lived experience.
A recent publication on this is below, but the paper does not at all describe the whole Motor Behavior Therapy framework.
https://www.researchgate.net/publication/372395298_Does_it_matter_if_you_make_a_diagnosis_of_SIJ_pain?_tp=eyJjb250ZXh0Ijp7ImZpcnN0UGFnZSI6Il9kaXJlY3QiLCJwYWdlIjoiX2RpcmVjdCIsInBvc2l0aW9uIjoicGFnZUNvbnRlbnQifX0
An overview of the “MCIB” is below:
Mechanism: A mechanism is simply a process. In this context, it is the processes by which the damage response framework is initiated. These include tissue loading, neurological dysregulation, immune dysregulation, and behavioral appraisal. It should be noted that there are likely other mechanisms involved in the complexity of chronic musculoskeletal pain that research has not yet uncovered. As well, pain mechanisms are well documented. It is a matter of debate as to their inclusion prior to the onset of clinical symptoms so they are best placed later in the framework where management or screening occurs. For simplicity, they will be included here.
- Tissue Loading Mechanisms: The processes by which tissues develop increased strain. They involve: biomechanical exposures to loading; movement pattern control; and joint translation control.
- Neurological Dysregulation: The processes involved in regulating neurocognitive function, and sensorimotor function, to meet the demands of the environment, adapt as necessary, plan and execute motor skills, and reach one’s goals for the task, with an appropriate behavioral response.
- Immune Dysregulation: The processes involved in producing increased inflammatory markers or a maladaptive change in molecular control of immune system processes. It should be noted that endocrine and autonomic dysregulation regulation appears to be associated with immune dysregulation.
- Behavioral Appraisal: Generally, psychological outputs require a conscious or unconscious appraisal of an event or stimulus. Numerous factors can influence the event, the appraisal and the emotional regulation of the output.
- Pain Mechanisms: The underlying neurophysiological processes responsible for the generation and / or maintenance of pain.
Etiology: The cause of a disease. Musculoskeletal pain has a multifactorial etiology that includes genetic, environmental, individual and social aspects. A causal web reflects this and highlights the fact that a concurrence of different “exposures” or conditions is required to induce disease, none of which is in itself necessary (Vineis and Kriebel 2006).
Individualization: The uniqueness of how you approach and tailor all aspects of your communication, assessment, management with a specific client. Numerous “individual factors” can influence this. They may include Social Factors (e.g., culture, religion, age, education level, employment); Behavioral Factors (e.g., anxiety, fear, beliefs); Mild Neurological Factors (e.g., Development Coordination Disorder; ADHD with poor motor skill learning, sensory motor and neurocognitive deficits); Pain Mechanisms; Lifestyle; trajectory and stage of rehab (e.g., acute, recurrent, chronic); pain status (e.g., pain, function and disability levels); physical activity levels (e.g., sedentary, recreational athlete); and many more. Individualization is much more than just which exercises are given and the dose of these.
Barriers: Reasons why the person does not respond to rehabilitation. There are numerous reasons why an individual may not respond to a given treatment. Ideally these would be identified prior to, or early in rehabilitation (and addressed), but this may not always be possible. Some types of barriers are noted below.
Participation: non compliance or poor compliance
Response to treatment: poor or non-response; incomplete recovery
Uncertainty: Broadly, uncertainty can be thought of as the conscious awareness of being unsure, of having doubt, of not fully knowing. This comes from the normal variability and errors that would occur with diagnostic accuracy (e.g., no test is 100% accurate) and unknowns. As much as is known, we still have incomplete knowledge (Simpkin and Armstrong, 2019). For example, we do not fully understand low grade systemic inflammation, the influence of the microbiome or genetics. Twenty-five years ago, we did not appreciate low grade systemic inflammation, neurodevelopmental disorders or body imagery. In reality, there are likely other subgroups, or mechanisms that we have not yet uncovered.
Simple Versus Complex Models
We have to accept that musculoskeletal pain can be complex (but is sometimes relatively simple). My opinion is that we need have a complex model to understand the whole of musculoskeletal pain, but accept that all interventions do not need to be complex.
A simplistic model of basic strengthening and or depending on tissue adaptation principles does not work for everyone. This may be sufficient for personal trainers, novice health care practitioners or low-cost population- based therapies, however more targeted rehabilitation needs to consider all aspects of the disease pathogeneisis if we are to achieve meaningful and long-lasting treatment effects and reduce disability rates. If we use our skills and training, the Physiotherapy profession is ideally suited to do this. Motor Behavior Therapy provides a framework to do this.
It is acknowledged that many great clinicians and researchers have had ideas, developed models, published research and contributed to aspects of this process. The framework will continue to evolve as more relevant research is published.