BODY SCHEMA ACUITY TRAINING AND FELDENKRAIS® MOVEMENTS COMPARED
TO CORE STABILIZATION BIOFEEDBACK AND MOTOR CONTROL EXERCISES:
COMPARATIVE EFFECTS ON CHRONIC NON-SPECIFIC LOW BACK PAIN IN AN
OUTPATIENT CLINICAL SETTING:
A RANDOMIZED CONTROLLED COMPARATIVE EFFICACY STUDY
A dissertation presented to
the Faculty of Saybrook University
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy (Ph.D.) in Psychology
by
Timothy J. Sobie
Oakland, California
November 2016
ProQuest Number: 10251703
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Approval of the Dissertation
BODY SCHEMA ACUITY TRAINING AND FELDENKRAIS® MOVEMENTS COMPARED
TO CORE STABILIZATION BIOFEEDBACK AND MOTOR CONTROL EXERCISES:
COMPARATIVE EFFECTS ON CHRONIC NON-SPECIFIC LOW BACK PAIN IN AN
OUTPATIENT CLINICAL SETTING:
A RANDOMIZED CONTROLLED COMPARATIVE EFFICACY STUDY
This dissertation by ___Timothy J. Sobie __ has been approved by the committee members
below, who recommend it be accepted by the faculty of Saybrook University in partial
fulfillment of requirements for the degree of
Doctor of Philosophy in Psychology
Dissertation Committee:
___________________________
Richard Sherman, Ph.D., Chair
___________________
Date
___________________________
James Stephens, Ph.D., PT, GCFP
___________________
Date
___________________________
Derek S. Scott, M.D., F.A.A.P.M.R.
___________________
Date
ii
Abstract
BODY SCHEMA ACUITY TRAINING AND FELDENKRAIS® MOVEMENTS COMPARED
TO CORE STABILIZATION BIOFEEDBACK AND MOTOR CONTROL EXERCISES:
COMPARATIVE EFFECTS ON CHRONIC NON-SPECIFIC LOW BACK PAIN IN AN
OUTPATIENT CLINICAL SETTING:
A RANDOMIZED CONTROLLED COMPARATIVE EFFICACY STUDY
Timothy J. Sobie
Saybrook University
Back problems continue to be a leading cause for disability in all of medicine and are the
number one symptom disorder for consulting integrative medicine practitioners. Feldenkrais®
practitioners aim to clarify new functional interrelationships towards an improved
neuroplasticity-based change in the cognitive construct of one’s own background body schema.
These phenomena have been found to clinically correlate to chronic pain through concurrent
distortions in the reorganization of usual sensory-motor cortical representations in the brain –
being further associated with altered body perception (Wand et al., 2016). The Feldenkrais
Method® (FM) is a comprehensive approach being manifested through manual sensory contact
(FI®) techniques and movement experiences (ATM®) and has been anecdotally purported to
improve symptoms and functions in chronic non-specific low back pain (CNSLBP). However,
there is little scientific evidence to support superior treatment efficacy.
iii
A randomized controlled trial (RCT) compared a novel Virtual Reality
Bones™/Feldenkrais® Movement (VRB3/FM) intervention against more conventional protocols
for Core Stabilization Biofeedback / Motor Control Exercises (CSB/MCE). The (VRB3)™
treatment component consisted of full-scale skeletal models, kinematic avatars, skeletal density
imagery, temporal bone-vestibular system relationships, and haptic self-touch techniques being
aimed to re-conceptualize participants' prior notions and beliefs regarding body schema and low
back pain (LBP). Participating patients (N=30) with CNSLBP were assigned to either the
experimental group (VRB3/FM @ N=15) or the control group (CSB/MCE @ N=15). Known
confounding biopsychosocial variables were controlled via stratified-random assignment on the
FABQ. Treatment Outcome measures included VAS-PAIN, RMDQ, PSFS, and Timed Position
Endurances Tests, including Flexion/Extension Ratios at baseline, two weeks, four weeks, and
eight weeks. Statistical Analysis was conducted using Wilcoxon Rank Sum and paired, twotailed t-test. Results showed that the VRB3/FM group demonstrated greater improvement in all
treatment outcome measures as compared to the matched CSB/MCE control group.
This is the first RCT study to demonstrate that a Feldenkrais Method® based approach
being combined with Virtual Reality Bones™ can be more efficacious for the treatment of
CNSLBP than the current and accepted physical medicine standard of isolated Core Stabilization
Biofeedback/Training and Motor Control Exercises. Future multi-site RCT studies with larger
sample sizes are therefore recommended.
Dedication
This body of work is dedicated to all those who seek to explore and develop an
alternative set of ideas for innovative thinking and application; beyond that from which they
were originally exposed, conditioned, or schooled.
Acknowledgments
This work would not have been possible without the help and inspiration of a great many
people. From the start, I wish to commemorate the memory of my departed mother, whose
encouragement and support continues with me through this day.
Next, I send much appreciation and gratitude to the community of professional trainers,
teachers, and colleagues for their many inspired teachings of The Feldenkrais Method® in all its
bountiful applications and diverse forms, including but not limited to Ruthy Alon, Eileen Bachy-Rita, Elizabeth Beringer, Gordon and Julie Browne, Richard Corbeil, Russell Delman, Angel
Di Benedetto, Staffan Elgelid, Larry Goldfarb, Jeff Haller, Todd Hargrove, Alan Questel, Mark
Reese, Roger Russell, Annie Thoe, Donald van Howten, Edward Yu, David Zemach-Bersin, and
most notably to my own professional trainer, Frank Wildman, for his expanding Moshe
Feldenkrais’ work into the physical therapy realm, and from which otherwise, none of this life
path toward a doctoral level of study and its level of required dedication would have ever
happened.
My advisory committee knows the struggle. Chair faculty member at Saybrook
University, Dr. Richard A. Sherman, has persisted undauntingly in transitioning the degree
specialization program in clinical psychophysiology into full fruition to such extent that it has
attracted a large and diverse population of student expertise. I thank him for guiding me through
the critically demanding and consuming process of learning how to plan for more effectively
applied research designs being conducted as clinical trials, and for what he substantially shares
from his vast experience in basic science and clinical areas. Physical Therapy and Feldenkrais
Method® research advisor, Dr. Jim Stephens, has assisted and shared both the complexity - as
well as the opportunity - for outlining the many possible paths for conducting ongoing and
expansive research inquiry into the many applications of The Feldenkrais Method® through his
dual role as both researcher and practitioner, but most notably as being chair of research
committee during more than a decade of annual conferences for the Feldenkrais Guild® of North
America. Finally, I wish to offer thanks and kind regard to medical pain management specialist,
Dr. Derek S. Scott, for his interest in paying attention to alternative and multidimensional models
for the collaborative management and interventional treatment of complex problems involving
chronic pain, and for his making clinical recommendations that truly allowed for the success of
this study to be carried out.
Let it be known that none of this research could have happened without the assistance of
dedicated staff and colleagues. I wish to thank fellow physical therapy clinicians Maria Bokor,
MPT, Dayna Briggs, DPT, Celeste Mishko, DPT, for their role in confidently conducting the
control arm of the interventional study. I would like to especially thank Yi-ran (Kenny) Li for his
primary role as research coordinator for website development, patient orientation, random
assignment, physical testing, and data collection for both arms of the study; to front office
receptionist, Angelina Zacapu, for expanding her role in keeping smooth allocation and
consistency in patient scheduling; to senior statistics tutor, Samantha Coates, of the University of
Puget Sound for her role in effectively conducting the statistical analysis of the raw data, and to
University of Washington - Tacoma graduate, Aeron Lloyd, for her skillful assistance in
formatting graphics for the study flow diagram, and for her also depicting a complex level of
visual literacy being necessary for the detailed demonstration of a novel therapeutic treatment
model. Finally, much appreciation and admiration goes out to my primary practice colleague
and friend, Jennifer Yagos, PTA, GCFP, for her role in co-conducting the combined physical
therapy and The Feldenkrais Method® interventions that were the necessary components for
completing the experimental arm of the study. Overall, she is a major reason for the success of
my practice.
Last, but by no measure the least, this body of work could never have happened without
the understanding, support, and concurrent commitment and sacrifices being made on the part of
my loving family. My loving wife and life partner, Rhonda, has sacrificed more than anyone can
know in the support of her husband in challenging times. I thank her for being there in advance
of my unexpectedly long quest, for her practical and skillful help in formatting tables and
documents, and for just being there with me. I also give added extended thanks to her parents,
Lowell and Dorothy, who were also always there for us. I give thanks for my father, Eugene,
who maintains the right mix of necessary toughness and practical resolve, being responsibly
combined with honest pride and a genuine concern for truly wanting what is best for others, as an
emulative model for both living a life and a livelihood.
Finally, from both the lessons learned and for the futures that are hoped for, I dedicate
this work and continuing livelihood to the added benefit of my first-born and fraternal twin sons,
Alexander Sobie and Nathanial Sobie. Though you are both now early in your personal histories,
and of being only a few years old at the time of this writing, you are each rapidly and assuredly
becoming your own men. And both your mom and I - and the world - look forward to the unique
contributions that each of you may someday bring.
Table of Contents
List of Tables ................................................................................................................................... v
List of Figures ..............................................................................................................................viii
CHAPTER 1: INTRODUCTION ................................................................................................... 1
CNSLBP in the Context of Physical Therapy .................................................................... 3
CNSLBP in the Context of Psychologically-Informed Physical Therapy ......................... 4
CNSLBP in the Context of a New Model as Proposed through the Current Study ............ 6
Traditional Frameworks, Alternative Viewpoints, and New Research Questions ......................... 8
Synopsis of the Problem ............................................................................................................... 11
Purpose of the Study, Aims, and Objectives ................................................................................. 15
Research Design and Hypotheses .................................................................................................. 15
Hypothesis 1 ...................................................................................................................... 16
Hypothesis 2 ...................................................................................................................... 16
Rationale ........................................................................................................................................ 16
Significance of the Study............................................................................................................... 18
Organization of the Dissertation .................................................................................................... 20
CHAPTER 2: LITERATURE REVIEW....................................................................................... 21
Overview and Background of LBP in Outpatient Physical Therapy Settings............................... 21
Core Stabilization and Motor Control Exercise: Status and Purported Efficacy .......................... 23
Limitations of Core Stabilization and Motor Control Interventions ............................................. 31
Biopsychosocial, Cognitive-Behavioral, and Graded Activity Interventions ............................... 33
The Role of Fear-Avoidance Beliefs and Chronic Non-Specific Low Back Pain ............ 34
Cognitive Behavioral and Mindfulness Interventions ....................................................... 35
Graded Activity Functional Therapy and Therapeutic Pain Neuroscience Education ...... 35
Limitations of Combined Physical and Behavioral-Psychological Interventions ......................... 38
Applying the Culmination of Recent Literature and Combined Rx into the Design ..................... 40
Emergent Findings from the Neuroscience of Chronic Pain and Neuroplasticity ........................ 42
Some Specific Brain Regions Involved in Pain Processing .............................................. 46
Bottom-Up Influences: Their Relationship to Intervention & Purported Mechanisms .... 48
Sensory Information at the Crossroads: Differentiating the Thalamus & Rerouting the
Insula ................................................................................................................................. 48
Sensory-Motor Deficiency and Excess Functional Connectivity upon fMRI Motor
Imagery .............................................................................................................................. 51
The supplemental motor area ................................................................................ 54
Superior temporal gyrus/sulcus ............................................................................. 54
Event-related functional connectivity (FC) and its meaning fMRI ....................... 55
Summary of motor imagery (MI)-driven fMRI activity............................ 56
fMRI implications for clinical understanding and future treatment .......... 57
The Pre-frontal Cognitive-Attentional & Affective-Emotional Mesolimbic Domains ..... 58
Synopsis and Rx Transition: Toward a Sensory Discriminative Perceptual Model ......... 62
Distortion of Body Schema, Somatic Education Interventions, and Virtual Reality .................... 64
Distortion of Body Schema and Chronic Pain - especially Low Back Pain ..................... 68
Somatic Education Interventions and Low Back Pain ...................................................... 69
Virtual Reality, Applications to Chronic Pain, and Prospective Studies for CNSLBP ..... 71
Differences between Feldenkrais® Virtual Reality and Traditional Guided Imagery ....... 78
Gravitation as a Virtual and Invariant Constant in the Sensory-Motor World.................. 84
Hidden Senses: A Skeletal Density-Vestibular Concept for Body Schema & Pain...................... 85
Spatial Cognition as an Internal Model for Perception of Virtual Limb Segments and
Bones ................................................................................................................................. 88
Vestibular-Ocular Representation: A Mediator of Body Schema Acuity & Motor
Dexerity ............................................................................................................................. 90
Vestibular Contribution to Affective Limbic Processes, Body Schema, & Chronic Pain
Modulation ........................................................................................................................ 92
Feldenkrais’ Postulates and Vestibular Contributions to Skeletal Organization,
Movement, and Behavior .................................................................................................. 94
Current Status of the Feldenkrais Method® and the Proposed Interventions .............................. 101
Differences Exemplified through Feldenkrais Method® Features of Application .......... 104
The Feldenkrais Method® in Research ............................................................................ 109
Applying the Proposed Intervention against Core Stabilization ..................................... 111
Evolving Practice, New Visual-Haptic Techniques: The Origin of VR Bones........................... 113
Uncovering a Universal Deficiency in the Sensory-Perceptual Acuity of Background
Body Schema via a Corresponding Normative Comparison to Anatomical Reference
Models ............................................................................................................................. 116
"Virtual Reality Hip Replacements" via Routine Deployment of a Life-Sized Femur
Model ............................................................................................................................... 121
Continuing Improvements for "Anatomical and Perceptual Reframing of Background
Body Schema" through the clarification of Skeletal Support Mechanisms that occur
during daily movement interactions between "Pelvis-Hips Opposite Head" .................. 129
The Lateral Chain of Distribution through Pedicle Densities and Costal-Thoracic
Expansion ........................................................................................................................ 143
Location of Vestibular Apparatus Augments for a sense of Visual Spatial Alignment .. 146
"Pelvis and Hips" as a Tri-Plane Model for Center of Gravity and the Detection of
Change in Center of Gravity Being Represented by "Vestibular Coordinates" as a
Combined Dynamic and Unifying Movement Strategy to be used during a Simulated
Martial Arts Task for achieving a Synergistic Spiral Quality of Efficient Action being
applied to the function of Sit to Stand ............................................................................. 150
Discovery of "Virtual Avatars" for Anatomical Re-framing, Skeletal Transmission, and
Aligning Ground Reaction Force Vectors for the Enhancement of Verticality
during Gait ....................................................................................................................... 157
Epilogue: Non-Pathological Anatomical Imagery for Highlighting Areas of Highest Bone
Density as a Contribution for Cognitive Reframing and Behavioral Adjustment........... 164
Consolidation and Synthesis of Initial Treatment Approach into the Acronym: (VRB3) .......... 172
Pilot Study and Continuing Observations from Practice-based Evidence .................................. 175
Summary...................................................................................................................................... 179
CHAPTER 3: METHODOLOGY ............................................................................................... 182
Overview ..................................................................................................................................... 182
Research Design, Adherence to Current Guidelines, Consistency to Prior Precedent ................ 183
Inclusion of Latest NIH Research Guidelines and Clinical Practice Guidelines
for CNSLBP .................................................................................................................... 184
A Historical Precedent for Consistency of Research Design & Comparative Metrics ... 186
Participants, Sources of Recruitment, Treatment Setting & Orientation to the Study ................ 187
Outpatient Treatment Setting and Neutralizing the Environment
for Matched Consistency ................................................................................................. 188
Characteristics of the Clinicians providing Interventions ............................................... 189
Orientation of Participants to and during the Study ........................................................ 191
Controlling for Fear-Avoidance and Catastrophic Pain Beliefs for Both Groups........... 193
Inclusion/Exclusion Criteria and the Stated Conditions for Continued Participation ................. 195
Inclusionary Criteria ........................................................................................................ 195
Exclusionary Criteria ....................................................................................................... 196
The Stated Conditions for Continued Participation......................................................... 197
Sample Size, FABQ Sub-Grouping, and Stratified Random Assignment into Groups .............. 197
Determining Sample Size for a Small-Scale Therapy Practice Setting –
Use of Pilot Study ............................................................................................................ 198
Sub-Grouping High Fear-Avoidance Beliefs as a Known and Confounding Variable... 200
Rationale for using Fear-Avoidance Beliefs Questionnaire (FABQ) as an Assessment
Tool.................................................................................................................................. 200
Intended population of FABQ in reference to the current study ......................... 201
Reliability of FABQ ............................................................................................ 202
Validity FABQ .................................................................................................... 202
Implementation of FABQ .................................................................................... 204
Procedure for Consent, Gathering of Baseline Data and Stratified Randomized
Assignment ...................................................................................................................... 204
Tests and Repeated Measures for Clinical Outcome ................................................................... 207
The Visual Analog Scale for Pain (VAS-PAIN) ............................................................ 207
The Roland-Morris Disability Questionnaire .................................................................. 210
The Patient-Specific Functional Scale (PSFS) ............................................................... 211
McGill’s Timed Endurance Tests (Total Endurance + Flexion / Extension Ratios) ...... 213
Flexion/Extension Endurance Ratios as an added Qualifying Measure
for Trunk Control ............................................................................................................ 217
Methodological Considerations, Determining Minimally Relevant Clinical Change................. 220
Overview of Interventions and Phase Progressions during Course of Study .............................. 221
Phase Progressions for Experimental Group ................................................................... 222
Phase Progressions for Control Group ............................................................................ 222
Time Course for Progression of Interventions, Session Content, and Flow of Study ..... 223
Control Group Interventions, Sources, and Procedure ................................................................ 225
Stabilization Biofeedback Device ................................................................................... 227
Core Stabilization Biofeedback Protocols using the PBU Device .................................. 229
Phase Progression and Content Sourcing for the Control (CSB/MCE) Group ............... 231
Experimental Group Interventions, Sources, and Procedure....................................................... 237
Embodied Perceptual Assessment of Background Body Schema and its Correlation to
Action .............................................................................................................................. 238
Phase Progression and Content Sourcing for the Experimental (VRB3 / FM) Group ..... 243
Data Collection Methods and Procedures ................................................................................... 253
Data Analysis using Statistical Tools and R Software ................................................................ 255
The Use of "R" Program Statistical Software ................................................................. 256
Data Backup and Record Retention ................................................................................ 257
CHAPTER 4: RESULTS ............................................................................................................ 258
Demographic and Medical History Profiles Between Groups .................................................... 258
Participant Attrition and Final Distribution for Data Collection ................................................. 260
Central Tendency (Mean) and Distribution of Data (SD) across Phases of Treatment .............. 262
Inferential Statistics Comparing Group Differences using Non-Parametric Tests...................... 270
Inferential Statistics Comparing Group Differences using Parametric Tests .............................. 273
Parametric Testing and Data Analysis for Comparing Pre-Post Flexion/Extension
Ratios ............................................................................................................................... 275
Purported Research Questions, Summary and Outcome for Hypothesis .................................... 276
Supported Hypothesis 1 ................................................................................................... 277
Partially-Supported Hypothesis 2 .................................................................................... 277
CHAPTER 5: DISCUSSION ...................................................................................................... 279
Overview and Interpretation of Study Results ............................................................................ 279
Both Groups Demonstrating Improved Outcomes and their Shared Mechanisms
of Influence ...................................................................................................................... 279
The control group’s intervention and corresponding mechanisms...................... 280
The experimental group’s intervention and corresponding mechanisms ............ 280
Motor control as a shared mechanism to separate pain from fear
of movement? ..................................................................................................... 282
Expectation fulfillment as a confounding variable .............................................. 284
The Experimental Group Demonstrating Superior Improvement and Some Possible
Rationale for Examining the Differentiated Mechanisms of Influence........................... 285
Other Qualitative Differences and Oppositional Contrasts Between Interventions ........ 292
A Critical Review of Outcome Measures and Findings from the Current Study ........................ 293
Mean VAS Pain Scales .................................................................................................... 294
Outcomes for RMDQ Disability Questionnaires ............................................................ 295
Outcomes for PSFS Functional Scale.............................................................................. 296
Outcomes for McGill’s Timed Endurance Tests ............................................................. 297
Participant Adherence, Attrition, and Contribution During Course of Study ............................. 299
Adherence to Intervention Training Intent, Home Program, and Medication List ......... 300
Participant Attrition, Priming Effects, and the Contribution of Intent to Treat .............. 301
Comparison of Study Results to Data Attained from Previous Studies ...................................... 302
Implications of Study Findings for Treatment of CNSLBP ........................................................ 305
Physical Therapy’s Regression to the Mean ................................................................... 308
The Preferred Future of PT Practice ................................................................................ 311
A New Intervention Model for the Systemic Adjustment of Working Body Schema ................ 313
Study Limitation .......................................................................................................................... 317
Deficiencies in the Monitoring of Adherence to Home Practice and Repetition ............ 317
Limitation of only an implied CBT and Pain Neuroscience Education Component ....... 318
Complexity of Experimental Group Intervention............................................................ 319
Sample Size and Generalizability .................................................................................... 320
Recommendations for Future Research and Practice .................................................................. 321
Enlisting Help from Larger Research Universities. fMRI Anyone? ............................... 321
The Advent and Recommendation of New Testing Instruments
and Interventional Tools .................................................................................................. 323
The multidimensional assessment of interoceptive awareness (MAIA) ............ 324
The Fremantle Back Awareness Questionnaire (FreBAQ) ................................ 327
Global perceived effect (GPE) scale ................................................................... 328
Alternatives to fitness-based physical performance testing ................................ 329
Applications of Non-Muscular Paradigms in Clinical Practice ...................................... 331
Summary and Conclusions .......................................................................................................... 334
REFERENCES ............................................................................................................................ 338
APPENDICES ............................................................................................................................. 363
Appendix A: Recruitment Flyer for Pierce County Medical Society.......................................... 363
Appendix B: Pilot Study & Combined Conference Announcement Postcards ........................... 364
Appendix C: Copy of Published Pilot Study Abstract ................................................................ 365
Appendix D: Enrollment Invitation & Clinical Research Announcement Postcard ................... 366
Appendix E: Website Landing Pages for Alliant Spine Project, LTD ........................................ 368
Appendix F: Definitions of Terms and Acronyms ...................................................................... 369
Appendix G: Copy of FABQ for Stratified Randomization ........................................................ 373
Appendix H: Copy of VAS-PAIN / Numerical Rating Scale ..................................................... 375
Appendix I: Copy of RMDQ ....................................................................................................... 376
Appendix J: Copy of PSFS .......................................................................................................... 377
Appendix K: Copy of Timed Endurance Testing Assessment Form .......................................... 378
Appendix L: Photo of Stabilizer Biofeedback (PBU) Device ..................................................... 379
Appendix M: Photo of Full Scale Skeletal Models & Source References .................................. 380
Appendix N: Sources Used for Control Group Intervention (MCE) ......................................... 381
Appendix O: Sources Used for Experimental Group Intervention (FM) ................................... 382
Appendix P: Side-by-Side Listing of Treatment Interventions Between Groups ....................... 384
Appendix Q: Copies of Home Exercise Program / Graded Activity Cover Sheets .................... 391
Appendix R: Copies of Exercise / Graded Activity Adherence Diaries + Med Lists ................. 401
Appendix S: Qualitative Differences between FM & CSE / MCE ............................................. 408
Appendix T: Principles of Ideal Movement ................................................................................ 412
Appendix U: Transparent-Translucent Contrast Images for Skeletal Density ............................ 413
Appendix V: Study Flow Diagram .............................................................................................. 416
Appendix W: Sensory-Motor Learning Model for Working Body Schema ............................... 419
Appendix X: Advisory Disclaimer and Release of Responsibility ............................................. 421
v
LIST OF TABLES
Table 1: Major Brain Areas Where Pain is Processed .................................................................. 47
Table 2: Copy of Published Pilot Study Research Abstract ........................................................ 178
Table 3: Sources of Recruitment for Study Participants ............................................................. 188
Table 4: Average Years of Experience of Clinicians delivering the Specialty "Core" vs
"Feldenkrais Method" Intervention ............................................................................................. 191
Table 5: FABQ Work Subscale (w) and the Physical Activity Subscale (pa) and their Thresholds
of Criteria for designating Excessive Scores for High Fear-Avoidance Cognitions
in CNSLBP .................................................................................................................................. 201
Table 6: Random Stratification Subgrouping Distribution based on FABQ ............................... 206
Table 7: Phase I CSB/MCE Treatment Progression: Core Stabilization and Motor Control
Exercise Interventions at 2xs per Week for First Two Weeks .................................................... 233
Table 8: Phase II CSB/MCE Treatment Progression: Static and Dynamic Motor Control Exercise
administered at 2x per Week for Second Two Weeks................................................................. 234
Table 9: Phase III CSB/MCE Treatment Progression: Dynamic and Reactive Motor Control
Exercise administered at 1x per Week for Last Four Weeks ...................................................... 235
Table 10: Virtual Realty Bones (VRB3): Phase I Imagery Intervention for Body Schema Acuity
TM
and Skeletal Density Imagery Continuity Training (SDI) also using The Feldenkrais® Method
(FM) ............................................................................................................................................ 249
Table 11: Phase II Training for Experimental (VRB3/FM) Group via 2x per Week for Second
Two Weeks - Feldenkrais Method® Themes: Expanding Sense of Ground Support via
Developmental Actions ............................................................................................................... 250
vi
Table 12: Phase III Training for Experimental (VRB3/FM) Group via 1x per Week for Last Four
Weeks - Feldenkrais Method® Themes: Reciprocating Variations of Active Movement
Trajectories .................................................................................................................................. 251
Table 13: Basic Demographics of Study Participants ................................................................. 258
Table 14: Confounding Bio-Psycho-Social, Surgical, & Orthopedic Variables of Study
Participants .................................................................................................................................. 259
Table 15: Drop-out Participants and Reasons for Leaving either at Start of Study/or prior to End
of Phase I ..................................................................................................................................... 260
Table 16: Drop-out Participants and Reasons for Leaving at Conclusion of Phase 1 Data
Collection - and without Completing Phase II or Phase III Components
of Total Intervention .................................................................................................................... 261
Table 17: Calculation and Display of Mean Scores and Standard Deviations for all Primary
Outcome Measures that occurred between Experimental Group and Control Group for the
duration of the Current Study ...................................................................................................... 263
Table 18: Wilcoxon Rank Sum Test and Bonferroni Adjustment Method to assess NonParametric Statistical Significance of p < 0.05 for VAS, RMDQ, and PSFS Scores occurring
between Groups ........................................................................................................................... 273
Table 19: Paired Two-Tailed T-Test to assess Parametric Statistical Significance of p < 0.05 for
changes occurring during Timed Endurance Testing Totals over Time ..................................... 274
Table 20: Mean Average for Flexion/Extension Endurance Ratios at Pre & Post Intervention and
Relevance to Clinically Meaningful Thresholds of < 1.5 being indicative of Improved Trunk
function via reduced Agonist-Antagonist Disparity in Experimental Group as compared to
Controls ....................................................................................................................................... 276
vii
Table 21: Comparing Current Study Results with previously published 2012 Data and MICD
Scores .......................................................................................................................................... 304
viii
LIST OF FIGURES
Figure 1: Anatomical Depictions of Transverse Abdominis (TRA)
and Lumbar Mutlifidis (LM) ........................................................................................................ 25
Figure 2: A Photo Depiction of the Pressure Biofeedback Unit "PBU" Device (a.k.a. The
Stabilizer™) .................................................................................................................................. 28
Figure 3: The Six Presented Video Clips for Mental Simulation of Daily Actions during fMRI
Recordings ..................................................................................................................................... 53
Figure 4: Pooled Motor Imagery Tasks as a Composite of Six Video Simulated Actions as
exhibited on fMRI ......................................................................................................................... 57
Figure 5: Brain Pathways for Cognitive and Emotional Influence on Pain .................................. 60
Figure 6: Differences between Traditional Guided Imagery and Feldenkrais Method Contact
Imagery .......................................................................................................................................... 83
Figure 7: Anatomical Schematic and Location of Vestibular Apparatus ...................................... 86
Figure 8: Telecast Interview of Moshe Feldenkrais .................................................................... 103
Figure 9: Moshe Feldenkrais Teaching at Amherst, MA, circa 1980 ......................................... 104
Figure 10: Discovery and Implementation of Proportionate Skeletal Models ........................... 115
Figure 11: Tri-Plane Location of Hip Socket Axis ..................................................................... 116
Figure 12: Testing for Hip Socket Anatomical Axis Perceptual Acuity. ................................... 118
Figure 13: Sample Distribution of Disparities in Accurate Perceptual Localization of
"Anatomical Hip Sockets" Commonly associated for Patients Presenting with Recurrent or
Persistent Low Back Pain Problems ............................................................................................ 119
Figure 14: Clinical Distortion of Body Schema Acuity for Hip Sockets in Chronic Low Back
Pain. ............................................................................................................................................ 120
ix
Figure 15: Demonstration of Corresponding Dimensional Relationships between Width of Hip
Socket Joint Axes and Width of Temporal Bones via the Visual Aid of Head of Femur Models
and Eyeglass Frames ................................................................................................................... 122
Figure 16: Demonstrating Hip Axis Socket/VR Hip Replacement ............................................. 124
Figure 17: Generalizing the effects of VR Hip Replacement/Body Schema Acuity Training on
Qualities of Comparative Arrangement to be Experienced and Contrasted (and therefore learned)
during Daily Routine Activities................................................................................................... 125
Figure 18: Case Example: Virtual Reality Hip Replacement
in Severe Chronic Low Back Pain............................................................................................... 128
Figure 19: Perceptual Discontinuity between Hips, Pelvis, and Low Back’s Spine Column ..... 131
Figure 20: The Superficial Region of the Posterior S-I Joint (SIJ) ............................................ 132
Figure 21: Components of Highest Bone Density within Pelvis and Head ................................ 134
Figure 22: Anatomical Outlines of Areas of Highest Bone Density ........................................... 135
Figure 23: Vertical Contiguity of Pelvis-Hips Opposite Head .................................................... 136
Figure 24: Tape Measure Rendering of Densest Bone Regions leading to the Operationalizing of
"The Proportionality of Thirds Model™" in Feldenkrais Movements ........................................ 138
Figure 25: Photo Demonstration of the Proprietary Manual Therapy Approach ........................ 139
Figure 26: Photo-Captured Demonstration of "Self-Applied Visual-Haptic Self-Touch." ......... 140
Figure 27: Anatomical Re-framing of "Core Robustness": Pelvis-Hips opposite Head ............. 141
Figure 28: Anatomical and perceptual reframing of "Top of Leg"
during Standing Trunk Rotation .................................................................................................. 142
Figure 29: Anatomic Locations and Junctions for Thoracic Pedicles
and Costo-Vertebral Joints .......................................................................................................... 146
x
Figure 30: Anatomical Models depicting Vestibular Apparatus ................................................. 147
Figure 31: Visual-Haptic Projection Techniques for Cardinal Axis Coordinates
of Vestibular Apparatus and their Anatomic Location................................................................ 148
Figure 32: Locating the Coordinates and Angles of Orientation within RIGHT Inner Ear ........ 150
Figure 33: Visual and Dimensional Relationship Correspondences between Pelvis Diagonals,
Hip Complex, and Inner Ear ........................................................................................................ 152
Figure 34: Guided Self-Exploration and Treatment involving Side-Tilting of Head ................. 153
Figure 35: Demonstration of Therapist guided Functional-Cognitive Manual Therapy (CMT)
Maneuvers ................................................................................................................................... 154
Figure 36: Latearlity of Chest and Leg "Hemispheric differences" after FI® Sessions .............. 156
Figure 37: Vicon™ Kinematic Videography Image Reconstruction for
Initial Stance Phase of Gait ......................................................................................................... 159
Figure 38: Vicon™ Kinematic Videography Image Reconstruction for
Terminal Stance Phase of Gait .................................................................................................... 160
Figure 39: Hemi-pelvis Model of Inner Ilia depicting Pathways for Contra-lateral vs. Ipsi-lateral
Skeletal Transmission .................................................................................................................. 162
Figure 40: Applications of Visual-Haptic Self-Touch Hand Placements for Simulating and
Detecting the Anatomical Pathways of Skeletal Transmission during Gait................................ 163
Figure 41: Demonstration of Skeletal Transmission Contact Points for the Simulation of Gait
Function from Ground-up............................................................................................................ 164
Figure 42: Centaur-Human Avatar .............................................................................................. 166
Figure 43: Use of Deer Antler for Augmented Sensory Reality ................................................. 167
Figure 44: Use of Imagery Robustness and Comparative Scaling for Cognitive Reframing ..... 169
xi
Figure 45: Active Anatomical Skeletal Density Imagery through
the use of Radiographic Art. ....................................................................................................... 170
Figure 46: Images Depicting Self-Simiularity of Structural Features Found to Occur within
Natural Systems ........................................................................................................................... 175
Figure 47: Site Locations and Facilities used for the Current Study ........................................... 189
Figure 48: Gray-Scale Copy of VAS-PAIN / Numerical Rating Scale....................................... 210
Figure 49: Demonstration of McGill’s Timed Endurances Tests ............................................... 216
Figure 50: Demonstration of Stopwatch Instrumentation ........................................................... 217
Figure 51: Control Group Intervention Sources .......................................................................... 225
Figure 52: Trunk Range of Motion and Segmental Hypermobility Testing ............................... 226
Figure 53: The Stabilizer™ Pressure Bio-feedback Unit ............................................................. 228
Figure 54: Demonstration of PBU Biofeedback ......................................................................... 229
Figure 55: Demonstration of PBU Biofeedback Procedure in Multiple Positions ...................... 230
Figure 56: Preliminary Physical Exam for Conducting the Initial Assessment for the (VRB3/FM)
Experimental Group .................................................................................................................... 239
Figure 57: Demonstration of Sensory Acuity Impedances at Dorsal Spine ................................ 240
Figure 58: Demonstration of Foot Contact & Surface Acuity Procedures .................................. 242
Figure 59: Pre- and Post-Body Scan Techniques for Self Assessment ....................................... 244
Figure 60: Outline of Principles that contribute to an effective Feldenkrais Method® Lesson ... 246
Figure 61: Resource Materials for HEP’s derived from Professional Feldenkrais® Audio
Programs ...................................................................................................................................... 248
Figure 62: Excel Spreadsheet Layout for Data Collection for Control Group and Experimental
Group ........................................................................................................................................... 254
xii
Figure 63: Mean Pre/Post Outcome Measures for VAS PAIN Over Time ................................. 265
Figure 64: Mean Pre/Post Outcome Measures for RMDQ DISABILITY Over Time................ 266
Figure 65: Mean Pre/Post Outcome Measures for PSFS FUNCTION Over Time ..................... 267
Figure 66: Mean Pre/Post Outcome Measures for ENDURANCE SCORES Over Time .......... 268
Figure 67: Pre/Post Outcome Measures for FLEXION/EXTENSION RATIOS Over Time ..... 269
Figure 68: Bar Graph for comparing Pre- & Post-Flexion/Extension Ratios between Groups .. 275
Figure 69: Visual Schematic for Attractor States over Time ...................................................... 291
Figure 70: Conceptual Drawings: Regional Isolation vs. Regional Interdependence ................. 293
Figure 71: Expanding the Scope for a More Multi-Factorial PT Practice .................................. 311
Figure 72: Internal Model for Sensorimotor Integration and Efference Copy
for Motor Control ........................................................................................................................ 313
Figure 73: Information Processing Model for working Body Schema during VRB3 FM Rx ..... 316
1
CHAPTER 1: INTRODUCTION
Chronic non-specific low back pain (CNSLBP) continues to remain a prevalent,
multifaceted and complex problem with increasing incidence, duration, costs, and escalating
disability and co-morbidity (Hoy et al., 2014; Manchikanti & Hirsch, 2015). This despite an
extensive array of numerous medical-surgical approaches, pharmacotherapies and procedures,
physical therapy and other rehabilitative modalities and protocols, psychotherapeutic,
psychophysiological, and cognitive-behavioral approaches, and different kinds of multi-varied
complementary and alternative medicine practices ranging from acupuncture to chiropractic, to
herbal medicine, nutrition, and naturopathy, to other massage, manual and manipulative, and
movement therapies, to exercise and personal training, Pilates and yoga-based therapies. Most
physical interventions demonstrate limited effectiveness (Assendelft, Morton, Yu, Suttorp, &
Shekelle, 2004; Furlan et al., 2005; Hayden, van Tulder, Malmivaara, & Koes, 2005; Staal, de
Bie, de Vet, Hildebrandt, & Nelemans, 2008), and different behavioral and exercise therapies
appear to be equally effective (Henschke, Ostelo, & van Tulder, 2010; Ostelo et al., 2005;
Henschke et al., 2010; van Tulder, Malmivaara, Esmail, & Koes, 2000). In sum, comparative
meta-analyses and repeated systematic reviews - including those conducted through the trusted
Cochrane Collaboration - continue to indicate that each intervention has no superiority over
others, and that each category has shown limited short- and long-term effect size for impact upon
disorder improvement. Therefore, effective treatments remain particularly elusive for CNSLBP.
Musculoskeletal pain is the dominant type of chronic pain affecting the world population,
exerting an enormous impact on individuals, societies, and health care systems (Briggs et al.,
2016; World Health Organization, 2015). Among the musculoskeletal pain conditions, low back
pain is the most common and often the most costly. The incidence of low back pain has reached
2
epidemic proportions, affecting up to 84% of adults at least once in their lives (Dagenais,
Caro, & Haldeman, 2008). Most acute low back pain episodes are self-limited, with symptoms
remitting within a few weeks and calling for little or no intervention. However, it is estimated
that up to 10% of low back pain sufferers develop and transition to a chronic pain condition
characterized by long-term pain and associated disability (Pengel, Herbert, Maher, & Refshauge
as cited in Trost & Parsons, 2014).
The Institute of Medicine has estimated that chronic pain affects approximately 100
million adults in the United States, with an estimated annual cost of up to $635 billion. In the
United States, chronic low-back pain (CNSLBP) is the most common cause of job-related
disability and a leading contributor to missed work. Back pain is also the second most common
neurological ailment in the United States — only headache is more common. Each year, lowback pain is estimated to affect approximately 38% of people worldwide (Deyo et al., 2014a).
Chronic non-specific low back pain (CNSLBP) can be defined as pain in the area on the
posterior aspect of the body from the lower margin of the 12th ribs to the lower gluteal folds with
or without pain referred into one or both lower limbs and with duration that lasts for at least 12
weeks to three months or more (Hoy et al., 2014). In the general practice and primary care
setting, and for 85% of patients who present with low back pain, the cause cannot be definitively
known - hence the term, non-specific low back pain (Waddell, 2004).
Chronic non-specific low back pain (CNSLBP) also remains the number one symptom
disorder for consulting complementary and alternative medicine (CAM) practitioners (Chenot et
al., 2007; Kanodia, Legedza, Davis, Eisenberg, & Phillips, 2010). Low back pain has
subsequently attracted a considerable amount of cross-disciplinary research. Particularly since
current approaches to the management of chronic non-specific low back pain (CNSLBP) have
3
shown limited effectiveness (Wand, Parkitny, et al., 2011). Other reviews again assert the fact
that CNSLBP is a complex disorder and highly resistant to change with generic approaches to
management (van Middelkoop et al., 2010). Effect sizes from randomized controlled trials
utilizing conservative treatment for non-specific chronic low back pain are small. Thus, chronic
low back pain remains a multifaceted and complex problem with increasing prevalence and
escalating disability and co-morbidity despite extensively numerous modalities of different kinds
of treatments (Hoy et al., 2014; Manchikanti & Hirsch 2015).
CNSLBP in the Context of Physical Therapy
Physical therapy and physical medicine interventions are perhaps the most common
recommendation for chronic and recurrent conditions that compromise human functioning.
Filling the expansive void that exists between pharmacological and surgical interventions,
physical therapists are well positioned to implement a broad spectrum of modalities, methods,
and activities from which to impact the behavioral and functional aspects of chronic conditions
that typically remain outside the scope of usual care. However, within the context of usual
physical therapy practice, and among those that have been systematically studied, only brief
courses of educational interventions, short courses of manipulation/mobilization and supervised
exercise therapy are recommended as the most marginally-effective treatment approaches for
addressing the persistent and recurring problem of CNSLBP (Airaksinen et al., 2006). Other
traditional physical therapy electrotherapeutic and thermal modalities, such as the use of
heat/cold, traction, laser, ultrasound, short wave, interferential, TENS, corsets - even repeated
massage therapy - are ‘not recommended’ as has been determined through current and
comparative evidence being accrued through European Union (EU) systematic reviews.
4
Overall and across the systematic compilation of international studies, the effect sizes for
most therapeutic procedures are rather modest. The comprehensive review summary guidelines
otherwise state that most promising approaches seem to be cognitive behavioral interventions
encouraging activity and supervised exercise. However, the review panel furthermore reports
that the “active ingredient” of exercise programs is largely unknown; this requires considerably
more research, in order to allow the development and promotion of a wider variety of low cost,
but effective exercise programs. In addition, the application of cognitive behavioral principles to
the prescription of exercises also needs to be further evaluated (Airaksinen et al., 2006).
Within composite reviews and guidelines for treatment of CNSLBP, Exercise Therapy is
defined as
Any program in which the participants are required to carry out repeated voluntary
dynamic movements and /or static muscular contractions (in each case, either 'wholebody' or 'region-specific'; and either with or without external loading), and where such
exercises were intended as a treatment for low back pain.
As an important criterion for inclusion in a systematic review, exercise programs are required to
be "supervised" and "prescribed" directly by a qualified and attending clinician (van Tulder et
al., 2000).
CNSLBP in the Context of Psychologically-Informed Physical Therapy
Traditionally, “treatments for chronic musculoskeletal disorders (CMSDs) such as
chronic low back pain (CLBP) have been anchored in a biomedical model. This model is based
on a structural pathology paradigm where insult to anatomical structures is believed to be the
sole driver of the condition” (Pelletier, Higgins, & Bourbonnais, 2015a, p. 1583). It is now
known that multiple psychological factors have been implicated in the transition and persistence
of chronic low back pain. They include anxiety and depression, catastrophizing, kinesiophobia
(fear of movement) and somatization - further defined here as the expression of distress through
5
anxiety in terms of ongoing bodily attention and the corresponding persistence of physically
referenced symptoms, but for which no physical cause can be found (Manchikanti & Hirsch,
2015). The practice and profession of physical therapy is only just beginning to actively
incorporate the inclusion of adjunctive psychological-based approaches, such as cognitive
behavioral therapy and graded exposure / graded activity methods into their usual standards for
practice.
Early evidence, particularly stemming from fear-avoidance models, has thus contributed
toward recent trends toward the development of integrative physical therapy practice, where
supervised exercise therapies are being combined with biopsychosocial and psychologicallybased graded activity strategies; the latter being informed through coping, pacing, and cognitivebehavioral principles. These hybrids of interdisciplinary influence have now emerged as among
the most commonly advocated recommendations for the treatment of CNSLBP. However, as
recent as 2016, a more highly specialized systematic review and meta-analysis study found no
statistical difference between (a) physical therapy-based rehabilitation, (b)
behavioral/psychologically informed approaches, and (c) combined interventions as a hybrid of
the two (O’Keeffe et al., 2016).
Another comparative study on physical therapy interventions found no difference in
treatment outcomes between implementing a supervised core stabilization training and motor
control exercise program (the usual conventional and biomechanically specific approach - but
without necessarily invoking cognitive behavioral principles), and a matched treatment group
that underwent supervised graded activity exercises. This intervention comprised a generalized
program of daily and graded exposure toward performing a quota of previously avoidant
activities, but being largely inclusive of cognitive behavioral therapy principles as the main
6
operative feature (Macedo et al., 2012). Since each intervention demonstrated an almost equal
similarity for treatment outcomes, and by each arm of the study concurrently using the most
common, usual, and customary outcome measures, these treatments thus remain concomitantly
represented in predominance as the current and usual practice standard in most outpatient
physical therapy and pain rehabilitation specialty centers. However, these outcomes also
demonstrate only modest overall average change in reported symptom reduction and only modest
gains in functional profile improvements, as compared to outcomes for other musculoskeletal
pain conditions.
Furthermore, the larger consortiums of systematic reviews evaluating the effectiveness of
varied categories, approaches, and types of exercise therapy commonly conclude that there is
little relationship between changes in clinical symptoms and changes in any “objectively
measured” aspect of functional capacity (e.g., logical expectancies for corresponding changes in
"strength," "flexibility," "back muscle endurance," and so on). This may explain the conclusion
that “to date” there is no convincing evidence to endorse the superiority of use for one type of
exercise over another type of exercise in the treatment of chronic low back pain (Hayden, van
Tulder, Malmivaara, et al., 2005; Macedo et al., 2012).
CNSLBP in the Context of a New Model as Proposed through the Current Study
Thus, the current status of clinical evidence must reveal itself into new a whole new level
of inquiry, especially when applied to the problem of CNSLBP by asking: (a) if the modest
effects of exercise and/or cognitive behavioral interventions - as categories in and of themselves
- are just a mere consequence of any kind of structured activity being attended to by another
person, and therefore only a non-specific effect; and (b) is there a competing intervention model
that looks to consider other underlying mechanisms, but from a newer neuroplasticity-based
7
perspective that is not necessarily exercise physiology based in the traditional sense, nor directly
a cognitive-behavioral-based progam being primarily manifested through traditional prestructured protocols. This study - herein referred to as "the current study" – instead introduces an
overview of some emergent findings being derived from the neuroscience of chronic pain and
neuroplasticity. It then postulates a possibility for the training of new sensations, of forwarding a
novel basis for treatment being based upon perceptually enhancing the complex interactions
between sensory-acuity and movement-dexterity as underlying stimulus-association-response
mechanisms that are hypothesized to be potentially effective toward creating new alterations in
and throughout the somato-topic organization of the sensory-motor cortex of the human brain;
thereby being also associated and correlated with the subjective experience of ‘body schema’
phenomena as well as for remedying the persistence and perseverance of chronic pain.
The treatment method or approach herein referred to as ‘body schema acuity training’ is
to be accomplished through implementation of lesser known somatic education and movement
therapy interventions (specifically, The Feldenkrais Method®) in conjunction with additional
imagery constructs being afforded through virtual reality based sensory-motor perceptual
experiments with a corresponding aim to invoke awareness of vestibular – temporal bone
relationships and their corresponding relationship to using skeletal density contiguities
throughout the skeleton as a total perceptual framework for the re-construction of working body
schema – all together being conceptually condensed for publication into the acronym VRB3 . The
current status of the Feldenkrais Method® and its embellishment through the addition of the
proposed VRB3 visual-tactile virtual reality interactive interventions are all comprehensively
reviewed from the perspective of both historical and current published literature as well as from
data attained from my original pilot study.
8
These foundations finally culminate into the implementation and performance of an
actual RCT design. This design, as used in the current study, is implemented to test-compare the
newly devised combined sensory-motor learning intervention, Virtual Reality Bones™ and
Feldenkrais Movements (VRB3/FM) against the current standardized one, Core Stabilization
Biofeedback and Motor Control Exercises (CSB/MCE), and to furthermore assess and discuss
their comparative and respective effects on various metrics for discerning clinical improvement
in CNSLBP that are compiled and presented in greater detail in the methods section of Chapter
3.
Traditional Frameworks, Alternative Viewpoints, and New Research Questions
Historically, the physical therapy exercise and manual therapy models being most
utilized for treatment of back pain problems, including CNSLBP, have progressed through
various stages and with trend-like fashion over the past three decades. Beginning in the late
1980s, the predominant models encompassed an isolationist, regionally specific manual therapy
and specific exercise models, which were then supplemented with general exercise programs for
strength, range of motion, cardiovascular (aerobic) endurance, and flexibility. Then, in the late
1990s, came the advent of the movement system coordination models and corresponding specific
motor control exercises directly designed for controlling aberrant movement segments – namely
inter-vertebral structures including discs and facet joints at lumbar spine.
More recently, since the early-mid 2000s, there has been a growing novel consensus
geared toward investigating the regional interdependence conceptual models in which the
concept that “seemingly unrelated impairments in a remote anatomical region may contribute to,
or be associated with, the patient’s primary presenting complaint [emphasis in original]”
(Wainner, Whitman, Cleland, & Flynn, 2007, p. 658). This model is stated to become a more
9
adequate basis for the management of patients with common musculoskeletal complaints and
with added implications for future research design and clinical practice; most notably, citing hip
joint relationships to low back problems (Cibulka, Sinacore, Cromer, & Delitto, 1998; Porter &
Wilkinson, 1997). Finally, the most recent development within the past five years has been the
necessary integration of inter-disciplinary models and biopsychosocial models to which greater
inclusion of cognitive-behavioral and graded-activity approaches are becoming more and more
incorporated into the usual scope of physical therapy practice, particularly in conjunction with
supervised exercise regimens.
Prior to the emergence of traditional core stabilization and motor control exercise, usual
physical therapy modality and manual therapy techniques, and their corresponding exercise
interventions, had deemed the clinically observable findings of stiffness of vertebral segments in
response to motion testing as the underlying mechanism and rationale for instituting a variety of
manual therapy schools and certifications. These focused on spinal mobilization techniques, and
where applicable, spinal manipulations being applied to vertebral subluxations, facilitated
segments, Grade II hypo-mobility dysfunctions, and non-allopathic manual therapy lesions and
the like, to reduce symptoms of stiffness, lack of mobility, pain, and to improve mobility
function.
Later, the widespread acceptance of lumbar core stabilization and motor control
exercises as a more validated treatment approach was supported by a new and explanatory
treatment rationale; citing low back pain as a "motor control problem" resulting in/or as a
resultant of "motor control deficit," as these findings were being repeatedly demonstrated,
observed, and quantified within a controlled laboratory setting. The originators and proponents
of segmental stabilization and lumbar-pelvic motor control exercises (Richardson, Hodges, &
10
Hides, 2004; Richardson, Jull, Hodges, & Hides, 1999) discovered (through EMGelectromyography and ultrasonography) that a distinct neural inhibition was occurring only and
specifically within deeper inter-segmental (inter-vertebral) muscle groups; namely, the
Transverse Abdominus (TrA) and the Lumbar Multifidus (LM) muscles during repeated dynamic
movement and perturbation tasks and only in patients with chronic or recurrent low back pain
(LBP) in comparison with controls that did not have back pain.
The resulting over-selection and compensatory adjustment of the more superficial, multisegmental muscle groups (i.e., Lumbar Longissimus, Quadratus Lumborum; other lumbar paraspinal groups) were demonstrated to become more reflexively activated, hypertonic, which
furthermore added to aberrant motion and relative buckling at "de-stabilized" spinal segments.
This is due to a localized loss or inhibition of intersegmental motor control and subsequent overreliance on passive ligamentous elements. Thus, it has been purported that these abberations and
disparities can result in shear, repeated trauma, and continued over-activation of superficial
multi-joint muscles that are continuously and reflexively bracing in a vicious cycle of
inflammation, nociception, stiffness, and pain.
Consequently, it was acquired hypermobility occurring at select vertebral segments due to
trauma, injury, genotype-phenotype, or poor muscular habits over time, and that deficits of
recruitment (of motor control) occurring at specific intervertebral (deep stabilizer) muscles,
normally correspondent to protect them, that was implicated as an alternative cause. That is, the
antithetical to prior mechanisms of rationale that had previously cited capsular stiffness and
corresponding joint hypo-mobility as primary or presumed culprits. As a result, these motor
control containment processes and their affected areas of deficit needed to be re-trained to
11
become more stabilized (not mobilized!) in order to reduce pain, and to improve the overall
balance of control for optimal neuromuscular function at lumbar spine segments.
Becoming known as The Queensland Model, via The University of Queensland,
Brisbane, Australia, under the direction and collaboration of its founders (Richardson, Jull,
Hodges, & Hides, 1999; Richardson, Hodges, & Hides, 2004), a host of repeated studies have
supported this approach and its corresponding rationale internationally, and these are elaborated
in Chapter 2. Subsequently, within the continued status of routine and current outpatient physical
therapy practices throughout most of Europe and North America, core stability training and
motor control exercise routines remain the dominant and standard prescription for chronic nonspecific LBP. This, despite emerging contrary evidence of non-dominance, is also elaborated in
Chapter 2.
For the current study, in lieu of investigating treatment intervention designs based on
spine mobilization (with attribution to joint hypo-mobility and structural stiffness based-on
presumed tissue pathology), or spine stabilization (with attribution to inter-segmental joint
hyper-mobility and motor control focal deficits), my research inquiry has instead put forth an
objective to test-compare a multi-modal cognitive-perceptual model for ‘spine organization’ by
instituting a novel and interactive learning approach via the implementation of a body schema
acuity training model. This is more specifically detailed by the acronym (VRB3) in later
sections, and then being operationalized through selected Feldenkrais® movements (FM) that are
clinically known to have positive influences on reducing low back pain (LBP).
Synopsis of the Problem
Although researchers have extensively conducted research on the sensory-nociceptive,
psychological, and motor factors involved or associated with musculoskeletal disorders and
12
chronic pain, they have studied these factors quite separately from each other and in limited
combinations. This has resulted in mostly separate bodies of evidence (Butera, Fox, & George,
2016).
Historically, bio-medical models have had large influence over the allied-health
professions and their development in both research and practice. Musculoskeletal rehabilitative
care and research has therefore been traditionally guided by a structural pathology paradigm
with resource emphasis being allocated towards the structural, functional, and biological
abnormalities - being located locally and exclusively within the musculoskeletal system’s tissues
and structures – as the sole basis to understand, implicate, and treat the continuing problem of
musculoskeletal disorders and musculoskeletal pain.
However, the structural pathology model does not adequately explain many of the
clinical and experimental findings in subjects with chronic musculoskeletal disorders, and more
importantly, treatment guided by this paradigm fails to effectively treat many of these conditions
(Pelletier, Higgins, & Bourbonnais, 2015b). For example, the structural-pathology paradigm fails
as a working model for resolving the continuing allusive questions, such as (a) why diagnostic
findings correlate poorly with pain and dysfunction; (b) the presence of bilateral findings with
unilateral injuries; (c) why a large proportion of persons with damage to musculoskeletal
structures being revealed upon clinical history and/or diagnostic imaging are or remain
asymptomatic; (d) why some persons heal and others go on to develop chronic musculoskeletal
pain; and (e) the presence and persistence of continuing sensory-motor abnormalities that cannot
be structurally explained upon regional or isolated testing – and often occurring in areas remotely
distant from site of original injury or onset, and furthermore bearing no correlation to other
13
clinical or structural findings – be they orthopedic, degenerative, rheumatologic, ascribed
‘subluxation,’ muscle ‘length-tension’ imbalance, myofascial referred pain, or otherwise.
More recent studies suggest that chronic musculoskeletal disorders do not simply result
from ongoing structural pathology to peripheral tissues, but instead involves a complex interplay
between original onset of peripheral or structural injury (versus the perception of threat without
actual tissue damage), altered afferent information conveyed from peripheral receptors toward
the spinal cord, brain stem, and cortical areas, compensated and protective patterns of action,
emotion, and behaviors (from whatever the source) that continue long beyond the stages of tissue
healing. These pathways are perhaps better explained through recognizing the highly distributive
neurophysiological processes that are perpetually involved in widespread neuroplasticity, central
sensitization, and change.
However, in usual practice, the current conventional interventions in physical
rehabilitation do not usually address the underlying neuroplastic changes in the central nervous
system that are inherently, intricately, and necessarily associated with both the regulation and
persistence of musculoskeletal disorders - and most particularly for chronic musculoskeletal pain
(Pelletier et al., 2015a; Snodgrass et al., 2014). In an excellent Physical Therapy journal review
article on neuroplastic changes and chronic musculoskeletal disorders, Pelletier et al. (2015a)
state that:
Failure to effectively treat conditions such as chronic non-specific low back pain
(CNSLBP) may stem from the fact that the central neuroplastic changes occurring across
distributed areas (that are) associated with this condition have largely been ignored and
may explain why treatment effects are consistently small regardless of the type of
intervention. (Pelletier et al., 2015a, p. 1585)
There is additional growing evidence that pain associated with musculoskeletal disorders
such as osteoarthritis and CLBP may be, at least in part, the result of the plasticity of the sensory
14
representation of the body and perceptual disturbances (McCabe, 2011; Pelletier et al., 2015b;
Preston & Newport, 2011; Wand, Keeves, et al., 2013). Most recently, evidence has emerged
through a prominent research team from School of Physiotherapy, The University of Notre Dame
Australia, Fremantle, Western Australia, to suggest that disrupted perceptual awareness of the
back is significantly and uniquely contributory to pain intensity within a sampled population
(N=251) of patients with CNSLBP. Most interesting among their recent research findings in
current publication is their conclusion that “disturbed body perception appears to be more
strongly associated with pain intensity than psychological distress, fear avoidance beliefs, or an
objective measure of lumbar spine sensitivity” (Wand et al., 2016, p. 1009).
Recent findings thereby suggest that a change in both conceptual model and mode of
approach is required within rehabilitation interventions such that they can begin to integrate
newly emergent findings of particular neuroplastic changes that are known to occur across
central, peripheral and autonomic levels of the nervous systems. Done so that they can be
incorporated into actual innovative treatments for the continuing and recurrent problem of
CNSLBP. As consistent with earlier research from respective fields, the interventions that target
and address cortical reorganization – the sensory and motor mappings of the body within and
throughout the brain’s representative cortex that alter and accrue through experience driven
neuroplasticity – are among the approaches that have been hypothesized and discussed to show
most promise toward producing more efficacious results in terms of decreased pain and
improved function in patients with chronic low back pain (Moseley & Flor, 2012).
Thus, more novel and innovative treatment approaches must be necessarily developed in
order to incorporate the most recent evidence-based discoveries surrounding known neuroplastic
changes that have now become known to be associated with the prevalence and persistence of
15
chronic non-specific low back pain (CNSLBP). In addition, these developments will require
further controlled research investigations to determine their efficacy upon actual clinical
application in comparison to other or existing approaches currently in use.
Purpose of the Study, Aims, and Objectives
Based upon evolving and continuing practice based evidence becoming more
substantiated through more recent peer-reviewed inter-disciplinary research and the results from
my pilot study, I propose and postulate that a body schema acuity training approach and a
neuroplasticity-based sensory-motor learning intervention - like The Feldenkrais Method® - is a
more effective strategy to address the continuing epidemic of CNSLBP as compared to the usual,
repeated conventional exercise programs that are currently in use. To test this proposal, a novel
intervention was specially designed to combine Body Schema Acuity Training using a newly
devised (VRB3) ™ Protocol as a pre-requisite for practicing a progression of selected
Feldenkrais® movements (VRB3/FM), and to compare this with an established combined usual
intervention in physical therapy for using Core Stabilization Biofeedback (via a Stabilizer™
PBU protocol) as a pre-requisite for practicing a progression of known Motor Control Exercises
(CSB/MCE) for a population of patients with CNSLBP - within the same out-patient physical
therapy setting - and under randomized controlled conditions for participant selection, consent,
and allocation.
Research Design and Hypotheses
To accomplish this study's objective, a randomized controlled trial (RCT) classical
experimental design was used to test the stated hypotheses, as described and outlined below.
16
Hypothesis 1
This study proposed that a population of persons with chronic, non-specific low back
pain (CNSLBP) who participated in a newly devised Virtual Reality Bones™
(VRB3)™ protocol using skeletal density-based anatomical models combined with motion
trajectory skeletal avatars for improving body schema acuity, and undergoing further graded
activity entrainment through corresponding Feldenkrais® Movements (The VRB3/FM group)
would demonstrate greater symptom reduction and greater functional improvement when
compared with a similar population of persons who followed a Core-Stabilization Biofeedback
training protocol emphasizing specific recruitment of Transverse Abdominis (TrA) and Lumbar
Multifidus (LM) muscle groups as an isolated and specified pre-text for motor learning/motor
control during a Motor Control Exercise and graded activity progression series (the CSB/MCE
group).
Hypothesis 2
In addition, this study predicted that all comparative outcome measures being used for
demonstrating greater symptom reduction and greater functional improvement in the
experimental (VRB3/FM) group as compared to the control (CSB/MCE) group would all occur at
a level of statistical significance being reflected at the customary p-value of less than or equal to
0.05.
Rationale
The Institute of Medicine identifies chronic pain as a nervous system disease and a highpriority societal health concern. However, current management of this disease and its
complications, including lost quality of life, movement impairment, emotional distress,
disability, relationship difficulties, and subsequent reductions in function, is inadequate. In the
17
United States (U.S.) alone, chronic pain costs the nation up to $635 billion each year in medical
treatment and lost productivity (The National Academies of Science, Engineering, Medicine,
Health and Medicine Division, 2011). Pain is a major driver for visits to physicians, a major
reason for taking medications. Of these, CNSLBP easily constitutes a majority of cases.
Of most significant and recent development, The U.S. Centers for Disease Control and
Prevention (CDC) has determined that the rates of opioid use, the prevalence of use disorder and
addiction, and cases for opioid overdose have reached epidemic proportions such that opioid
prescriptions overall topped $259 million in 2012, "enough for every adult in the United States to
have a bottle of pills," according to the CDC. Upon a systematic review of the evidence, the
CDC subsequently drafted recommendations and guidelines for primary care providers around
determining when to initiate or continue opioids for chronic pain as well as guidelines for drug
selection and dosage, and risk assessment. Its first recommendation: "Non-pharmacologic (i.e.,
non-drug) therapy and non-opioid pharmacologic therapy are much preferred as first-line
interventions for chronic pain" (Centers for Disease Control, 2016).
As a foreshadowing trend, The Institute of Medicine specifically highlighted the need for
“wider use of existing knowledge” as a main objective for transforming the understanding of
pain. While there is high-quality evidence that physical therapy-based exercise interventions
have the potential to improve health outcomes, reduce costs, and decrease the risks associated
with opioid prescriptions – most notably for hip and knee conditions - the “effect sizes of
rehabilitation approaches are otherwise consistently small regardless of intervention in many
other musculoskeletal disorders, and therefore multiple and progressive interventions may be
warranted (Nijs et al., 2014). Compared to an extensive body of literature and RCTs for both
comparing and contrasting the efficacy of Lumbar Core Stabilization and Motor Control
18
Exercises for LBP, there are essentially no RCTs to date for assessing the comparative efficacy
of other multi-modal and neuroplasticity-based alternative approaches - particularly, The
Feldenkrais Method® - on determining the comparative clinical outcome effects for chronic LBP.
Within the domain of classical scientific inquiry, The RCT is recognized the gold
standard for determining any effects of a new or existing treatment by its effects being compared
with a closely matched control group receiving an alternative form of existing treatment - and
while all other corresponding variables, to the extent possible - are kept constant. As a rationale
for a study method to compare for clinical efficacy outcomes between two highly contrasted and
varied approaches, a randomized controlled trial, classical experimental design was chosen for
conducting the current study.
Significance of the Study
Low back pain remains a substantial health problem and has subsequently attracted a
considerable amount of research. Current approaches to the management of chronic non-specific
low back pain (CNSLBP) have shown limited effectiveness (Wand, Parkitny, et al., 2011). While
Core Stabilization has gained wide acceptance as a ubiquitous idea and a most frequently
prescribed solution to the rehabilitation and treatment of CLBP in outpatient settings, it has come
under recent criticism by a host of clinicians and reviewers (Lederman, 2010b; McGill 2007).
However, to date, no study has implemented a body schema/skeletal density/vestibular imagerybased/Feldenkrais Method® intervention design that clearly seeks to ignore the isolation of
specific muscle groups, thereby effectively contrasting a basic "core tenant" or baseline principle
of traditional core stabilization and other traditional therapy exercises.
The primary focus of many therapies on purely orthopedic aspects of structural or
strength –motion functional impairments in the spine may be a factor contributing to the lack of
19
success of current treatments. Several lines of evidence suggest that structural changes by
themselves (in the absence of behavioral considerations) within the back might be unimportant,
and there is growing evidence of extensive cortical reorganization as well as neurochemical and
structural alterations in the brains of people with CNSLBP. These changes could contribute to
the persistence of the problem and might represent a legitimate dimension of approach for
therapy (Flor, Braun, Elbert, & Birbaumer, 1997; Tsao, Galea, & Hodges 2008; Wand, Parkitny,
et al., 2011) as well as an alternative to physical exam-based sub-groupings remaining dependent
upon grading of spinal motion segments by the examiner –of which inter-rater reliability remains
a question of continued bias and suggestion.
The purpose of this single-blind, randomized controlled study (RCT) was to compare a
Body Schema Acuity Training protocol using newly applied, newly developed low-cost
technology (Virtual Reality Bones™/VRB3) with a respected complementary-alternative,
movement and manual therapy, neuroplasticity-based educational intervention (The Feldenkrais
Method®) against the most commonly accepted approach being utilized within current and
conventional physical therapy practice settings (Core Stabilization Training and Graded Motor
Control Exercises). This was conducted for improving the outcomes on usual clinical outcome
measures for CNSLBP, and to determine whether there is greater clinical efficacy being
demonstrated between one combined intervention or the other for treating the widespread
problem of CNSLBP as an outcome of the study itself.
This comparative design for the current study may be among one of the first of such
comparative interventions wherein the sensory acuity training aspects of each arm of the study
are able to most directly inform a consequential and qualitative platform for motor planning –
motor control – and graded activity movements that follow them – all while simultaneously
20
controlling for the modulation of important biopsychosocial factors – (and especially of fearavoidance factors for CNSLBP) - through both stratified random assignment at pre-intervention
and corresponding provisions for pain-science education and cognitive assurances being
implemented throughout the course of all treatment sessions for both groups. In this way, both
groups are better assured an inclusion of sensory, motoric, and bio-psychosocial variables
coming into play, but with emphasis placed on the discerning variables between each
intervention, and which outline the important and contrasting qualitative differences that were
induced to occur between participants being enrolled in each arm of the study.
Organization of the Dissertation
This dissertation is organized in five chapters including: Chapter 1, which contains the
expanded introduction and study context; Chapter 2, which contains a description and review of
the literature along with my supplementing an extensive record of my historically developing a
novel intervention on the basis of practice-based evidence, outlining its detail for possible
replication, and its subsequent pilot study; Chapter 3, which contains a full description of the
current study design and its method, Chapter 4, which contains a description of the study results
and statistical analysis; and Chapter 5, which contains a discussion of the meaning of the results,
their applicability, their significance, their generalizability, their limitations, and their directions
implied for future research and practice. A new treatment model diagram is thereby outlined for
comprehensive review. The references and appendices then formally follow from these five
chapters.
21
CHAPTER 2: LITERATURE REVIEW
Overview and Background of LBP in Outpatient Physical Therapy Settings
“Back Pain Eludes Perfect Solutions.” So states the headline from The New York Times
Well Guide dated May 13, 2008. While the condition is considered epidemic in social and
economic cost, the exact cause of pain is never found in 85% of the patients. Even though it is
generally accepted that the natural course of acute low back pain (LBP) is self-resolving with
symptom reduction and functional restoration to resume work capacity within a period of 2-4
weeks for a majority of cases, the recurrence rate under usual sampled conditions from
epidemiological studies are otherwise found to be staggeringly high: ranging from 60% to 86%.
This occurs particularly within the first year after the acute episode, and with a median time
frame of recurrence within only two months. Many doctors now revert to exercise and
counseling over drugs and surgery. Of these cases, 30% can transition into long-term cases of
chronic, recurrent low back pain (Hayden, van Tulder, Malmivaara, et al., 2005).
The transition to chronic non-specific low back pain (CNSLBP) remains a most persistent
and disabling health problem worldwide with increasing prevalence and costs despite numerous
forms of medical-surgical treatments, usual physical and rehabilitative therapies, cognitivebehavioral and psychological approaches, and a broad base of integrative or other
complementary-alternative kinds of intervention. Trends toward increasing prevalence are
growing. Out of all 291 conditions studied in the Global Burden of Disease 2010 Study (Vos et
al., 2012), LBP ranked highest in terms of years lost to disability, and sixth in terms of overall
burden for disability-adjusted years lost within varied epidemiological samplings of total
lifespan. The overall global point prevalence of LBP was 9.4% with a 95% confidence interval
of 9.0 to 9.8 (Hoy et al., 2014). As an ongoing problem of persistence, current approaches to the
22
management of CNSLBP have shown limited effectiveness (Wand, Parkitny, et al., 2011). Other
reviews further assert the fact that CNSLBP is a complex disorder and highly resistant to change
with generic approaches to management (van Middelkoop et al., 2010).
Despite the purported increase in the sophistication of medical interventions, the burden
of back pain continues to rise. Thus, low back pain remains a substantial health problem and has
subsequently attracted a considerable amount of research. There is an abundant literature
reporting that intensive exercises are more effective than usual care, physical modalities, hot
packs and rest, behavioral therapy, no exercise, being put on a waiting list, or placebo treatment.
But, no particular type of exercise had been shown to be superior to any other (Bogduk, 2004).
The 2006 European guidelines for the management of chronic nonspecific low back pain
(Airaksinen et al., 2006) cite evidence levels that purport recommendations for exercise therapies
at a level A in comparison to usual general practitioner (GP) care for the reduction of pain and
disability and return to work - in at least the mid-term (3-6 months); wherein interpretations of
outcome data are based on the following scale:
● Level A (Strong Evidence): Generally consistent findings* provided by a systematic
review of multiple high quality randomized controlled trials (RCTs);
● Level B (Moderate Evidence): Generally consistent findings provided by a systematic
review of multiple low quality RCTs;
● Level C (Limited or Conflicting Evidence): One RCT (either high or low quality) or
inconsistent findings from (a systematic review of) multiple RCTs;
● Level D (No Evidence): No RCTs.
*The benchmark threshold for consistent findings becomes applicable when at least greater than
or equal to 75% of the qualifying studies being reviewed were shown to have a similar result.
23
In the history of early exercise development, strategies commonly focused on range of
motion, strength, and endurance properties of spine and trunk muscles. Historical considerations
of athletic ability and other factors of personal disposition have also weighed-in as to the
measures of predictive outcome, whether stemming from nature or nurture in the objective
assessment of low back pain. However, a more recent work has shown that “three-dimensional
low back range of motion exercises (ROM) and associated Stretching activities have no
correlation to functional test scores or even the ability to perform functional work” (Parks,
Crichton, Goldford, & McGill, 2003). Muscle strength, contrary to previous assumptions, does
not play a strong role in the risk or perpetuation of low back pain (McGill, 2006), nor as an
accustomed clinical prediction expectancy as evidenced from the contrary results of a five-year
prospective study by Luoto, Heliövaara, Hurri, and Alaranta (1995). Yet, in many physical
therapy clinical practices and physician referral prescriptions, "ROM exercises, flexibility, and
strength measures" continue to remain as persistent and accustomed components for clinical
documentation and case management.
Core Stabilization and Motor Control Exercise: Status and Purported Efficacy
Historically, previous physical therapy exercise standards had emphasized strength, range
of motion, flexibility activities, and "proper" body mechanics programs with only marginal
efficacy. During the late 1990s and 2000s, a large number of papers had been published on
lumbar motor control training, led by a renowned team of researchers from the University of
Queensland, Australia. Since the publication of the clinical textbook, Therapeutic Exercise for
Spinal Segmental Stabilization in Low Back Pain: A Scientific Basis and Clinical Approach
(Richardson et al., 1999), and its successor, Therapeutic exercise for lumbopelvic stabilization: a
motor control approach for the treatment and prevention of low back pain (Richardson et al.,
24
2004), many outpatient physical therapy practices and industry suppliers have embraced the
specific concept of “core-stabilization” or spinal stabilization. The work was also substantiated
by aspects included in the segmental instability model for disrupted motor control (movements
outside the inter-segmental neutral zone) in spinal problems as was originally proposed in
biomechanics research by Panjabi in 1992. This body of work thus accrued many of its
foundations through biomechanics and laboratory science that eventually led to the consensus
and development of spine stabilization and motor control exercises and a corresponding rationale
for the preferential selections of specifically recruiting deep local vs. superficial global muscles.
The authors Richardson et al. (1999) prefaced their book stating that:
Spinal segmental stabilization is an innovative method of delivering therapeutic exercise
to the patient. In many ways, it is the antithesis of traditional exercise methods such as
strength and endurance training, which have formed the basis for the therapeutic exercise
for musculoskeletal conditions for so long. Spinal segmental stabilization is designed to
specifically improve the underlying joint stabilization (between vertebral segments)
rather than training functional movement (in a generalized fashion) and hoping joint
control improves concurrently. (p. 1)
Yet, in the conclusion of their book, the last chapter entitled “Future Directions in
Research and Clinical Practice,” they acknowledged that:
We believe that all patients who suffer low back pain require specific exercise training
and this is based on our experience of the seemingly universal reaction in the deep
muscles to back injury and pain. This does not dismiss the benefits of or the need for
other types of exercise. Notably, it does not deny the possibility that other methods and
techniques of exercise currently in use could (also) result in successful retraining of the
deep muscle supporting function. (Richardson et al., 1999, p. 170)
Coming to be known as the Australian model for spinal stabilization or The Queensland
Model, it classifies the focal attribution of two primary ‘deep core’ intrinsic muscle groups: (a)
the Transversus Abdominis (TrA), and (b) the Lumbar Multifidus (LM) as the primary,
centrally-mediated determinants for controlling spinal inter-segmental stability by exerting a
25
corset-like distributive containment around lumbar spine inter-segmental attachments.
Anatomical re-sections of these muscle groups are highlighted and depicted in Figure 1.
Figure 1. Anatomical Depictions of Transverse Abdominis (TrA) and Lumbar Mutlifidis (LM).
Each cited as dominant inter-segmental and collective stabilizers of lumbar spine vertebrae by
virute of their anatomical attachments in combination with their exerting a syergistic corseting
effect around the lumbar spine when properly co-activated.
The diaphragm and pelvis floor are also cited as co-accessory to maintaining postural
stability. Co-modulation of relative intra-abdominal pressure and tensioning of thoraco-lumbar
fascial attachments to these groups are considered to afford a corset-like dimensional mechanism
of spinal stiffness directly maintained through both tonic and phasic degrees of muscular
contraction of these specific and targeted selections between the coordination of four muscle
groups being compositional of the core. As a composite synergy, the respiratory diaphragm and
the pelvis floor, in conjunction with the TrA and LM, are co-actively conditioned to be
maintained in the performance of daily activities and during leg leverage proprioceptive exercise
progressions. Studies have confirmed that the activity of these muscles also occurs in direct
conjunction with sudden arm movements and other postural perturbations (Hodges &
Richardson, 1996).
26
Furthermore, and irrespective of specific spine pathology, Hodges and Richardson (1996)
discovered and recorded the phenomenon of delayed activity / temporal inhibition of the
transversus abdominis and the added finding of local multifidus atrophy to be a consistent
finding and common link in subjects with low back pain. In other words, in patients with low
back pain, the untimely activation of transversus abdominis (TrA) and lumbar multifidi (LM)
fails to prepare the spine for the reactive forces from unanticipated--or even anticipated--limb
movements. Through ultrasound imaging and surface EMG recordings, they discovered that
these stabilizer muscles seem to work somewhat independently of the gross motor system.
Since inter-segmental control is impaired and diminished in the presence of low back
pain, with decreased sensory acuity and impaired ability of these focal muscle groups to
accurately reposition unstable segments, there are added broader deficits in impairment of global
factors for proprioception, inter-segmental tissue irritation, and recovery of stability in posture
control; namely, observed through impairments of balance when standing on one leg, or two
legs, or even sitting in patients with histories of LBP (Taimela & Luoto, 1999). Inhibition of
deep proximal stabilizer muscle groups in association with local facet hypermobility leads to
over-recruitment compensation by more superficial larger, longer, layers of paraspinal extensors
(i.e., erector spinae group, quadratus lumborum) resulting in what is commonly known as
splinting or spasm. Lack of control of the middle or deep layers becomes a neurological / motor
control problem consistently confirmed through the clinically observed inability of patients or
subjects with low back pain to (a) effectively recruit transversus abdominis, and/or (b)
effectively recruit or select for effective use of the multifidus in everyday functional activities.
Attribution of lumbar spine segmental instability, faulty position sense, and impaired
27
proprioception is given to the relative inactivity of these two deep select inter-segmental muscle
groups.
The prime rehabilitation prerequisite is to first stabilize and correct for activation (or reactivation) of these select stabilizer groups before restoring gross motor function activities
involving the larger, more superficial muscle groups crossing multiple spine segments. These
local facilitated actions of transverse abdominis and multifidi are by necessity sub-maximal
contractions in order to be selected in isolation without peripheral contraction of abdominal
oblique’s or flexors of the trunk. They can be selectively facilitated via palpation, sEMG, visual
ultrasonography, or more affordably via pressure biofeedback device gauges under clinical
supervision and observation. Thus, the use of a pressure biofeedback unit (PBU), commercially
known as The Stabilizer™ are used both as a widely recognized tool for facilitating optimal
selection and sub-maximal contraction of TrA and LM and as the method for “Core Stabilization
Biofeedback” in the current study.
The PBU’s inclusion as a cited training component had previously proved useful for
significantly demonstrating that segmental stabilization is superior to superficial strengthening
for all measured outcome variables for pain and disability in a previous study for chronic low
back pain; and that usual superficial strengthening using a control group did not improve TrA
activation capacity (França, Burke, Caffaro, Ramos, & Marques, 2012; França, Burke, Hanada,
& Marques, 2010). A separate study referenced effective utilization of the pressure biofeedback
unit (PBU) device during biofeedback-assisted lumbar stabilization training to inhibit and control
against unwanted lateral pelvic tilt by demonstrating that gluteus medius and internal oblique
activity could be significantly activated, while simultaneously differentiating a significant
28
reduction and inhibition of quadratus lumborum activity during a repeated sidelying hip
abduction task (Cynn, Oh, Kwon, & Yi, 2006).
The PBU testing and training instrument has also been validated by imaging and
electromyography tests that are considered to be the gold-standard measurements of TrA
performance. According Richardson et al. (1999) and Richardson et al. (2004), normal PBU
responses range from -4 to -10 mmHg; and that clinical research applications data accrued by
Hodges (2003) had indicated that composite mean normal values were around 5.82 mmHg.
A photo depiction of the PBU device (The Stabilizer™) as intended for clinical and
research use; and as applied to the comparison treatment group - the control arm in the current
study - is shown in Figure 2.
Figure 2. A Photo Depiction of the Pressure Biofeedback Unit "PBU" device (a.k.a. The
Stabilizer™). This, as intended for clinical and research use; and as applied to the comparison
treatment group via the control arm in my current study for the training of (a) core stabilization
biofeedback, and (b) the development of improved ‘motor control’ during exercise and daily
activities.
Hides, Jull, and Richardson (2001) tested the Queensland Model hypothesis in clinical
low back pain populations (patients with acute, first-episode low back pain). Thirty-nine
participating volunteers with acute LBP were divided into a traditional medical treatment
approach group and a specific exercise group. The specific exercise encompassed the Australian
method of learning techniques for co-contraction of transversus abdominis and multifidus
29
muscles and challenging this learned skill with a progression of proprioceptive activities from
non-weight bearing to weight bearing to balance training on unstable surfaces (gymnastic balls,
etc.). Questionnaires were administered one year and three years post-intervention. Results
indicated that the core stabilizer specific exercise group reported 54% fewer recurrences of low
back pain than the control group (Hides et al., 2001).
Another set of studies had revealed through ultrasonography imaging that the lumbar
multifidus muscle remained atrophied after a 10-week period when patients with acute LBP did
not exercise. But this muscle was recovered to normal size in patients who received a
stabilization exercise program that stressed deep abdominal and isolated the transverse
abdominis (TrA) and lumbar multifidus (LM) muscle contractions (Hides, Richardson, & Jull,
1996). In addition, some patient groups with low back pain had demonstrated hypertrophy of the
lumbar multifidus (LM) muscles at post-intervention subsequent to another course of specifically
directed low-load stabilization exercises (Hides et al., 2001). The efficacy of specific
stabilization exercise was shown to be effective in reducing pain and disability in chronic low
back pain with further expansion to other clinical application areas by suggestion that they could
also be helpful in the treatment of cervicogenic headache and associative neck pain as well as for
pelvic and pelvic floor pain (Ferreira, Ferreira, Maher, Herbert, & Refshauge, 2006).
Thus, these evidence-based trends in rehabilitation had suggested that the problems of
dysfunction in chronic recurrent low back pain were not an issue of strength vs. weakness,
flexibility vs. stiffness, spinal alignment vs. subluxation, or general deconditioning vs. aerobic
endurance, but one of motor control. Rather than provide inadequate general education for
facilitating the control of lumbo-pelvic position to a neutral state - as with unidirectional strength
training and generalized co-contraction exercises - updated strategies were then developed to
30
retrain the specific control of different components of the muscle system; namely, restoration of
specific control of deep local middle layer muscles Transverse Abdominis (TrA) and Lumbar
Multifidus (LM) to optimize the control of intervertebral (intersegmental) shear forces between
lumbar spine segments (Richardson et al., 1999). By selecting deep muscles, the goal is to
reduce over-activity of superficial muscles and then train coordinated control of deep and
superficial muscles to work appropriately to meet the demands of spinal control. This is
commonly instituted through a progression of exercise protocols from leg loading on spinal
stability, gymnastic ball exercises, weight-bearing exercises, and with progression to dynamic
balance training on unstable platforms and surfaces (O'Sullivan, Phyty, Twomey, & Allison,
1997; Richardson et al., 1999).
Clinical applications textbooks and course work continues to stem from this evidencebased literature. One author cited that
Success rates such as these are unheard of …and that no other method of back pain
treatment has been shown to be so completely successful at correcting the persistent
problems that develop once the spine becomes injured and in preventing future episodes
of back pain. (Jemmett, 2003, p. 42)
As such, core stabilization advocates and clinical instructors claim a validated consensus
of scientific evidence in the literature from which to give acceptance to their approach (Brill &
Couzens, 2001; Hanney, 2009). Correspondingly, usual clinical consensus and usual standards
for common practice across the world now seems to almost universally advocate for local
muscles including transversus abdominis (TrA), and lumbar multifidus (LM) - commonly called
“core” muscle groups - for assessment and training in virtually any low back integrated treatment
or exercise program, and for the improvement of motor control.
Another updated systematic review and meta-analysis evaluating the effectiveness of
motor control exercises in targeting these "stabilizer" muscles had more recently concluded that:
31
The pooled results favored motor control exercise (MCE) compared with general exercise
with regard to pain in the short and intermediate term and with regard to disability during
all time periods. MCE was also superior to spinal manual therapy with regard to
disability during all time periods but not with regard to pain. Compared with minimal
intervention, MCE was superior with regard to both pain and disability during all time
periods. (Bystrom, Rasmussen-Barr, & Grooten., 2013, p. E356)
In addition, the corollary of Pilates-based therapeutic exercise in subjects with nonspecific low back pain and functional disability has also revealed studies showing marked
improvement in the commonly used VAS-Pain and Roland-Morris questionnaires as compared
to subjects undergoing usual medical consultative treatment (p-values ranging from .002 to .023
on relevant indicators for pain intensity and disability respectively). Further, the study’s authors
(Rydeard, Leger, & Smith, 2006) reported a long-term follow-up of maintaining improvements
over a 12-month period. However, this was not matched to comparing against another exercisebased physical therapy intervention as an important and contingent variable of competing
influence.
Limitations of Core Stabilization and Motor Control Interventions
Much evidence for the clinical efficacy of Core Stabilization and Motor Control
Exercises had been originally championed by the method’s primary research proponents and
developers (Richardson et al., 1999) as well as from evidence accrued among many other
independent researchers. However, other independent studies and reviewers have detracted the
efficacy of these purported claims with contrary RCT evidence (Cairns, Foster, & Wright, 2006;
Ferreira et al., 2006; Koumantakis, Watson, & Oldham, 2005). Yet, core stability exercise
routines remain the standard prescription for chronic non-specific LBP without radiculopathy.
Moreover, other studies have shown no added specific benefit to implementing localized
spinal trunk muscle stabilization exercises in populations with acute or chronic low back pain
(Cairns et al., 2006; Koumantakis et al., 2005). These studies were also randomized controlled
32
trials comparing them with standard PT or general exercises and both offered a 12–month, longterm follow-up. Other researchers in rehabilitation medicine cited significant lack of uniformity
regarding the meaning of core-stabilization and what therapeutic exercises may be most effective
toward improving neuromuscular control, endurance and strength, and so on (Standaert &
Herring, 2007). The concepts of dynamic stability, core stability, lumbar stabilization, and
segmental stabilization, among other terms, have infiltrated the therapeutic arena, the medical
literature, the lay press, and even late-night infomercials.
Dr. Stuart McGill, a respected spine researcher from the University of Waterloo in
Canada, takes issue with concepts of isolated core stability in summarizing from his textbook
chapter on low back disorders / myths and realities of lumbar spine stability as follows:
In summary, achieving stability is not just a matter of activating a few targeted muscles,
be they the multifidus, transverse abdominis, or any other. Sufficient stability is a
moving target that continually changes as a function of the three-dimensional torques
needed to support postures. It involves achieving the stiffness needed to endure
unexpected loads, preparing for moving quickly, and insuring sufficient stiffness in any
degree of freedom of the joint that may be compromised from injury. Motor control
fitness is essential for achieving the stability target under all possible conditions for
performance and injury avoidance. (McGill, 2007, p. 121)
McGill’s summation resonates well with key tenets of the Feldenkrais Method® in
purporting that in a well-organized nervous system, uniquely selected task demands will
spontaneously organize toward a quality of adaptive behavior that is most optimal and
proportionate to the demands of the task (Thelen & Smith, 1994). McGill (2007) stated,
Virtually all muscles play a role in insuring stability, but their importance at any point in
time is determined by the unique combination of the demands involved in sustaining
postures while creating movements and anticipating sudden movements or unexpected
forces and challenged breathing. (p. 120)
In a landmark critical literature review summary of motor control principles and
treatment interventions entitled The Myth of Core Stability, author Eyal Lederman (2010b)
concluded: (a) Weak trunk muscles, weak abdominals and imbalances between trunk muscles
33
groups are not a pathology just a normal variation; (b) the division of the trunk into core and
global muscle system is a reductionist fantasy, which serves only to promote CS; (c) weak or
dysfunctional abdominal muscles will not lead to back pain; (d) tensing the trunk muscles is
unlikely to provide any protection against back pain or reduce the recurrence of back pain; (e)
core stability exercises are no more effective than, and will not prevent injury more than, any
other forms of exercise or physical therapy; (f) core stability exercises are no better than other
forms of exercise in reducing chronic lower back pain. Any therapeutic influence is related to the
exercise effects rather than stability issues; (g) there may be potential danger of damaging the
spine with continuous tensing of the trunk muscles during daily and sports activities; and (h)
patients who have been trained to use complex abdominal hollowing and bracing maneuvers
should be discouraged from using them.
Biopsychosocial, Cognitive-Behavioral, and Graded Activity Interventions
The contributory interactions of physical, psychological and social influences remain
significant as interdisciplinary factors involved in both the prevalence and enduring chronicity of
low back pain disorders being classified under the vague, but inclusive rubric of chronic
nonspecific low back pain (CNSLBP). Moreover, this has led to the development of
multidisciplinary biopsychosocial rehabilitation (MBR) programs that can now be administered
by a variety of healthcare professionals from different backgrounds, including from within the
profession of physical therapy (Kamper et al., 2014).
Within a multidimensional biopsychosocial framework, it has been proposed that
CNSLBP represents a vicious cycle associated with different combinations of provocative
factors. These include cognitive factors (such as negative beliefs, fear-avoidance behaviors,
catastrophizing, hypervigilance, anxiety, depression, stress, poor pacing and maladaptive coping
34
(Linton, 2000; Vlaeyen & Crombez, 1999; Wertli, Rasmussen-Barr, et al., 2014). Other
components of contribution have been classified as somato-physical factors, including the
maintenance of pain provocative postures and movement patterns related to altered body schema,
muscle guarding, pain behaviors, and general deconditioning (O’Sullivan, Mitchell, Bulich,
Waller, & Holte, 2006).
The Role of Fear-Avoidance Beliefs and Chronic Non-Specific Low Back Pain
In addition, numerous studies have cited the role of Fear-Avoidance Beliefs as important
confounding variables in the perpetuation of chronic pain states – especially CNSLBP (Linton,
2000; Vlaeyen & Crombez, 1999; Wertli, Rasmussen-Barr, et al., 2014). It is proposed that
patients with CNSLBP may have altered cognition and increased fear, which impacts their ability
to move, perform exercise, and partake in activities of daily living (Louw, Puentedura, &
Mintken, 2012). Thus, the fear-avoidance (FA) model of low back pain represents a leading
cognitive-behavioral account for the development and maintenance of pain and disability
following acute back injury (Leeuw et al., 2007; Vlaeyen & Linton, 2000). According to the FA
model, fear that movement or physical activity will exacerbate pain or prompt (re)injury—also
known as pain-related fear or kinesiophobia—is underscored by catastrophic appraisals of pain
sensations (Grotle, Vollestad, & Brox, 2006; Sieben, Vlaeyen, Tuerlinckx, & Portegijs as cited in
Trost & Parsons, 2014).
The main assessment tool and clinical metric for measuring fear-avoidance beliefs within
the contexts of physical activity and/or work tasks due to low back pain has been the FearAvoidance Beliefs Questionnaire or "FABQ" (Waddell, Newton, Henderson, Somerville, &
Main, 1993). The reliability and validity of this measure has also been repeatedly confirmed
(Kovacs et al., 2006). Consequently, the use of the FABQ assessment tool for its documented
35
ability to discern excessive threshold scores was implemented into this clinical study as a method
for sub-stratification of random assignment into each group of participants to control for fearavoidance as a key confounding variable – especially within a study design that compared
differences between supervised physical therapy exercise and an alternative contrasting type of
movement intervention for a population of patients with CNSLBP. This procedure is detailed in
Chapter 3.
Cognitive Behavioral and Mindfulness Interventions
Cognitive Behavioral Therapy (CBT)
Consists of highly specific learning experiences designed to teach patients (a) to monitor
their negative automatic thoughts (cognitions); (b) to recognize the connections among
cognition, affect, and behavior; (c) to examine the evidence for and against distorted
automatic thoughts; (d) to substitute more reality-oriented interpretations for these biased
cognitions; and (e) to learn to identify and alter the beliefs that predispose them to distort
their experiences. (Wedding & Corsini, 2014, p. 251)
As applied to pain management, these personal reassessments and processes aim to
change pain-related thoughts and behaviors. An alternative method, Mindfulness Based Stress
Reduction (MBSR) involves training in mindfulness meditation, which aims to cultivate a state
of free-floating, non-judgmental attention. A local integrated health system delivered these two
interventions over the course of eight weekly, two-hour programs to 294 active participants
divided into two groups as compared to a control group who underwent usual care. The
percentage of participants with clinically meaningful improvement (a change of five points) on
the RMDQ was higher for those who received MBSR (60.5%) and CBT (57.7%) than for usual
care (44.1%) with p-value = .04 and a confidence interval (CI) of 95% (Cherkin et al., 2016).
Graded Activity Functional Therapy and Therapeutic Pain Neuroscience Education
As a specialized variation of CBT intervention, Classification-Based Cognitive
Functional Therapy (CB-CFT), is more amenable to physical therapy practice. It has four main
36
components: (a) A cognitive component, wherein each patient can outline their vicious cycle of
pain in a diagram based on elucidating and reflecting upon his or her own findings from the
physical examination procedures and musculoskeletal pain questionnaires; (b) specific
movement exercises designed to normalize maladaptive movement behaviors as directed by the
movement classification; (c) targeted functional integration of activities in their daily life,
reported to be avoided or provocative by the patient; and (d) a physical activity program tailored
to the particular movement classification (Vibe Fersum, O'Sullivan, Skouen, Smith, & Kvåle,
2013).
Upon development and testing, the classification-based (CB-CFT) cognitive functional
therapy was compared to a similar cohort of control group patients with CNSLBP who
underwent only traditional manual therapy and exercise (n=59). As a total outcome, the cognitive
functional therapy group (n=62) displayed significantly superior outcomes to the comparative
control group, both statistically (p is less than 0.001) and clinically (Vibe Fersum et.al., 2013).
Therapeutic Neuroscience Education (TNE) and/or Pain Neuroscience Education (PNE)
are cognitive therapy-based approaches that teach patients about pain. It essentially conveys to
the patient a more confident assurance for reducing pain amplification by explaining the
underlying physiological pain mechanisms involved in the continuation of pain signaling
occurring mysteriously and continuously in the absence of actual (or mis-construed) tissue
damage. By re-attributions toward recognizing preeminent fear-avoidance tendencies, and of
becoming aware of overly vigilant pain responses to a perceived threat, Therapeutic
Neuroscience Education aims to change a patient's cognition regarding their pain state, which
may result in decreased fear, ultimately resulting in confrontation of pain barriers and a
resumption of normal activities (Louw et al., 2012).
37
It has been further recommended that TNE/PNE techniques aimed at decreasing fear
associated with movement may be a valuable adjunct to movement-based therapy, such as
exercise, especially for patients with CNSLBP (Louw et al., 2012). More recently (in PT Journal,
May 2014), a perspective paper contained a recommendation to combine Pain Neuroscience
Education (PNE) with Cognition-Targeted Motor Control Training. The authors’ advocated for
pre-emptive exposure in therapeutic pain neuroscience education for patients presenting with
chronic spinal pain and summarized a multi-phase model for helping patients change pain
attribution beliefs:
1. To learn to re-conceptualize their pain signaling experience in a manner that does not
automatically signify tissue damage nor correspond to or immanent or dangerous threat
(i.e., “hurt does not equal harm”);
2.
Reducing their level of hyper-excitability/vigilance being implemented both before and
during each phase of rehabilitation exercise progression, beginning with coordinated
activity of spinal muscles (i.e., citing the Core Stabilization training protocol for motor
control deficits); and
3. Progressing to more complex exercises and dynamic functional tasks (i.e., citing the
traditional Motor Control exercise progression).
4. Noting that “Cognition-Targeted” exercises advocate for using a time-contingent
approach (i.e., “Perform the exercise for five minutes regardless of pain”) in lieu of a
symptom-contingent approach (i.e., “Stop the exercise once it hurts”).
In this, the authors suggest a re-appraisal of pain threshold and diminished pain
expectancy to permit increasing gradations of activity tolerance, and furthermore for altering the
patient’s beliefs about the interplay between pain and movement; together, with evidence that
38
novel motor skill training is associated with rapid changes in cortical excitability as well as for
cortical re-organization (Nijs, et al., 2014).
Limitations of Combined Physical and Behavioral-Psychological Interventions
The most recent Cochrane Group systematic review assessed the global effectiveness of
multidisciplinary biopsychosocial rehabilitation programs for chronic low back pain by selecting
a meta-analysis of 41 RCTs with a total of 6858 participants that met their stringent criteria for
inclusion. Compared to usual care, the range across all time points equated to approximately 0.5
to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland
Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on
work outcomes. Across all time points, this sub-population’s scores translated to approximately
0.6 to 1.2 units on the pain scale and 1.2 to 4.0 points on the Roland Morris scale (Kamper et al.,
2014).
A more highly specialized systematic review and meta-analysis study was just recently
published in the February 2016 Journal of Pain for comparing treatment effectiveness by
instituting a new classification schema among the many published conservative interventions for
Non-specific Chronic Spine Pain (NSCSP) - the Australian term for persistent pain involving
cervical, thoracic, and / or lumbar-pelvic regions – but in having large correlations of
contribution for shared similar variables to its research analog: Chronic Non-specific Low Back
Pain (CNSLBP).
By sub-classifying a comparison of outcomes between the varied nomenclatures for
current conservative interventions, the study broadly divided them as (a) physical, (b) behavioral
and/or psychological, and (c) interventions that combined these approaches. Physical
interventions included using exercise, manual therapy and ergonomic advice. Behavioral and/or
39
psychologically informed interventions were classified as those that aim to improve behaviors,
cognitions or mood by using methods such as relaxation and cognitive behavioral therapy (CBT).
Combined interventions being reviewed as a hybrid, were designated as approaches which aim to
improve both physical and psychological factors contributing to patients’ pain by using some
combination of both approaches, up to an including the studies which implemented
multidisciplinary pain management programs. Because it remains unclear whether any of these
approaches are superior, and unclear as to which category of intervention has had the greatest
level of supporting evidence, this review aimed to assess the comparative relative effectiveness
of different conservative interventions for reducing pain and disability in people with NSCSP:
physical, behavioral/psychological or combined?
Nine electronic databases were searched for randomized controlled trials (RCTs). Study
quality was assessed used the Cochrane Back Review Group risk of bias criteria. Criteria for
inclusion included RCTs involving participants with NSCSP (neck, thoracic, low back, or pelvic)
for greater than a 12-week duration. RCTs had to measure pain and/or disability and have a
minimum follow-up period of 12 weeks. RCTs were only included if they had an “active”
conservative treatment control group for comparison (i.e., no treatment or waiting list
comparisons, as these were excluded). RCTs were also selectively excluded if the interventions
were from the same domain (e.g., if the study compared two physical interventions like aerobic
exercise versus strength training). At the conclusion of sampling, 24 studies were included.
Eighteen RCTs investigated patients with low back pain (LBP), while only six studies
investigated participants with neck pain (NP). The sample sizes of the included studies ranged
from 30 to 393 participants. The average age of the participants in these studies ranged from 39
to 54 years.
40
The treatment effects of physical, behavioral/psychologically informed, and combined
interventions were assessed using meta-analyses. Subsequent to meta-analyses, no clear
statistically significant clinical differences were found for reducing pain and disability between
physical, behavioral/psychologically informed, and the combined intervention groups. In
addition, only small differences in pain or disability were observed between physical,
behavioral/psychologically informed, and combined interventions.
The authors concluded that current interventions for NSCSP have similarly small
effectiveness on pain and disability and that there is still a lot of work to be done to find a longterm clinically effective intervention for chronic spine pain. However, “it is possible, though far
from certain, that attempts to better combine different components of therapy for people with
NSCSP might someday show better results [emphasis added]” (O’Keeffe et al., 2016).
Applying the Culmination of Recent Literature and Combined Rx into the Design
More recent developments comparing treatment parameters for combining two research
questions to explore outcome differences between Core Stabilization/Motor Control Exercises
and a Graded Activity/Cognitive Behavioral Therapy-based physical therapy protocol are
detailed in the PT journal article entitled Effect of Motor Control Exercises Versus Graded
Activity in Patients with Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial
(Macedo et al., 2012). By their using a selection of essentially identical (a) treatment outcome
measures, and (b) the same allocation for number of treatment sessions (12), and finally (c) the
same time-frames for administering the comparative interventions (8 – weeks) and as a similar
framework of parameters and measurement tools used for all other prior core stabilization /
motor control treatment efficacy studies that were reviewed, it will serve as a model reference for
41
comparing the outcome results of this RCT study. These are summarized in Chapter 3 of this
dissertation manuscript as well as in the Results and Discussion sections.
In addition, and for the homogenization of both treatment groups within the study,
elements of assurance being borrowed from Therapeutic Neuroscience Education/Pain
Neuroscience Education (TNE/PNE) and other CBT techniques have been detailed and discussed
in advance with all of the study participants (in both arms of the study) via having a specific
entry contained within the Study’s Consent Form and Participation Agreement. More
specifically, the consent form content addressed and outlined an open discussion regarding the
issue of pain sensitization, and furthermore disclosed the possibility of latent or spontaneous
pain flares that could occurr anywhere in the body - after or even during the course of treatment.
However, the form content also assured patients that these responses are normal at the initiation
of sub-maximal but unfamiliar movements in persons presenting with chronic pain pathway
sensitization, and that ultimately, "hurt" would in no way indicate a basis for physical harm, and
perhaps could even afford a new opportunity to get better.
The next section of this chapter now moves to explore the phenomenon of experience
dependent neuroplasticity and its role in the development and maintenance of chronic pain
sensitization and the amplification of pain signaling. The postulation of training new sensation of forwarding a novel and complex sensory-acuity and movement-dexterity perspective for reentrainment, and its postulated correspondences to new alterations in "body schema" in
association with revisionist mappings known to occur within and throughout the somatotopic
cortex of the human brain – is extrapolated as a competing mechanism toward the exploration,
development, and comparison of a new kind of treatment intervention against a similar and
closely matched control group.
42
Emergent Findings from the Neuroscience of Chronic Pain and Neuroplasticity
The phenomenon of consciousness, being neither exclusively physical-structural nor
exclusively psychological-behavioral, is a composite entity occurring within and among living
things for perceiving their relationships and correspondences - both past and present – as well as
for anticipating the future. As such, it must continually encode, conserve and renew for itself
through necessary combinations of ontogenetic predisposition, psychophysiological interaction
and sensory-motor representational processes; whereby each constitutes its own contribution
toward the mutual formations of interdependent amalgams of both inner and outer worlds as well
as for comprising and developing intrinsic models for future or anticipatory interaction. Of these,
all are neurologically mediated at some level of cognitive-embodied experience. Furthermore, as
a fundamental property of the human central nervous system - and as central to all learning,
adaptation, and plasticity – embodied cognition processes must retain their ability to remodel in
accordance with changing experience and expectation in order to adequately and flexibly
function in the continuing multidimensional world.
In case situations involving chronic pain, the modeling of experience occurs and recurs
such that an unpleasant sensory and emotional experience becomes associated with actual or
potential tissue damage, or is described in terms of such damage, and such that it develops a
multifactorial self-reinforcing and self-regulatory pattern – or an anticipatory matrix of its own whether in the presence or absence of actual tissue damage. The multiple determinants and
complexities of chronic pain as a constellation of factors perpetuating throughout the central
nervous system – as well as through the periphery - were first summarized in the original abstract
from the paper "Pain and the Neuromatrix in the Brain" by Ronald Melzack (2001):
The neuromatrix theory of pain proposes that pain is a multidimensional experience
produced by characteristic "neurosignature" patterns of nerve impulses generated by a
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widely distributed neural network-the "body-self neuromatrix"-in the brain. These
neurosignature patterns may be triggered by sensory inputs, but they may also be
generated independently of them. Acute pains evoked by brief noxious inputs have been
meticulously investigated by neuroscientists, and their sensory transmission mechanisms
are generally well understood. In contrast, chronic pain syndromes, which are often
characterized by severe pain associated with little or no discernable injury or pathology,
remain a mystery.
Furthermore, chronic psychological or physical stress is often associated with chronic
pain, but the relationship is poorly understood. The neuromatrix theory of pain provides a
new conceptual framework to examine these problems. It proposes that the output
patterns of the body-self neuromatrix activate perceptual, homeostatic, and behavioral
programs after injury, pathology, or chronic stress. Pain, then, is produced by the output
of a widely distributed neural network in the brain rather than directly by sensory input
evoked by injury, inflammation, or other pathology. The neuromatrix, which is
genetically determined and modified by sensory experience, is the primary mechanism
that generates the neural pattern that produces pain. Its output pattern is determined by
multiple influences, of which the somatic sensory input is only a part, that converge on
the neuromatrix. (Abstract)
In situations involving the chronic pain experience and sensitization or hyperalgesia,
there is ample evidence from neuroimaging and correspondent clinical presentation for
demonstrating compensatory and often widespread change in the internal processing of pain
signaling. Neurophysiological changes across different areas of the peripheral and central
nervous systems, including peripheral receptors, dorsal horn of the spinal cord, brain stem,
sensorimotor cortical areas, and the mesolimbic and prefrontal areas are associated with chronic
musculoskeletal disorders, including chronic low back pain. These findings corroborate with
altered representational processes, altered cognition, altered limbic association, and even
morphologic structural changes revealed through attritions in cortical gray matter, specifically in
bilateral dorsolateral prefrontal cortex and right thalamus (Apkarian et al., 2004), when
compared to matched asymptomatic controls. Continued neuronal epi-genesis involves a
necessary response to experience dependent changes exerting inhibitory/excitatory selection
pressures upon pathways and connections distributive throughout the brain and spinal cord
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(central processing), but also behaving sometimes independent of both non-nociceptive and
nociceptive input from the periphery (tangible body parts/afferents & efferents).
Furthermore, it is now well known from evidence in neuroscience that the human brain
undergoes neuroplastic cortical reorganization –distorted representations in the mapping of body
schema and the corresponding dexterity of the body—in response to sensitizing or challenging
experiences, but especially with chronic pain (Flor, 2003a; Flor et al., 1997; Flor & Diers, 2009;
Moseley, 2005; Moseley & Flor, 2012; Wand, Keeves, et al., 2013). Furthermore and
continuously, re-constructive and de-constructive body maps/virtual homunculi are being
constantly updated and dynamically sculpted by ongoing interoceptive and exteroceptive
experiences--both habitual and non-habitual-- and existing at multiple levels throughout the
entire CNS including cerebellar, insular, thalamic, and associated limbic regions.
Aversive events and chronic pain states commonly result in and/or co-contribute to
disordered functioning of working body schema (i.e., sensory-motor deficits in the clarity,
resolution, and dexterity of everyday actions) correspondent with topographic disruption
(smudging and dissociation) of body-related cortical representations. These unpleasant event
driven, inner altercations in structure and function have been referred to in the literature as being
the dark side of neuroplasticity (Doidge, 2007, 2015); and despite intact / normal ‘standard’
neurological screening (i.e., pinwheels, reflex hammers, sharp-dull tactile thresholds and the
like), complex sensations (graphesia, tactile acuity, visual-spatial body awareness, cross-modal
representations, discriminative proportions, etc.) remain otherwise impaired, and are co-related
to deficits in motor control.
Neuroplasticity is ordinarily the adaptive strategy and the ongoing interactive mediational
process by which the brain encodes new experiences, learns, and develops new behaviors in
45
response to environmental perturbation and or to directed intrinsic attention. Neurophysiological
changes being characteristically resultant of neuroplasticity processing can refer to
Changes in structure, function, and organization within the nervous system that occur
continuously throughout our lifetimes in response to internal stressors such as cognitive
processes, internal changes in sensory afference, and external stressors such as motor
learning and peripheral sensory stimulation. (Pelletier et al., 2015a, p. 1583)
More recently, elucidating the role and processing of pre-frontal cortical and sub-cortical
associative learning, and the anticipatory conditioning of directed focal attention toward
interoceptive discriminative stimuli being additionally co-conditioned through mesolimbic
reinforcement and memory encoding – it has been further implicated that the transition,
habituation, perpetuation, and re-definition of chronic pain can now be construed in terms of
constructing behavioral models for learning and neuroplasticity. Pioneering work by Apkarian
from 2008, Mansour, Farmer, Baliki, and Apkarian (2014) summarized through an updated
applications review the descriptive - but elusive process - as follows:
Chronic pain is defined as a state of continued suffering, sustained long after the initial
inciting injury has healed. In terms of learning and memory one could recast this
definition as: Chronic pain is a persistence of the memory of pain and/or the inability to
extinguish the memory of pain evoked by an initial inciting injury.
The novel hypothesis that we advance is that chronic pain is a state of continuous
learning, in which aversive emotional associations are continuously made with incidental
events simply due to the persistent presence of pain. Simultaneously, continued presence
of pain does not provide an opportunity for extinction because whenever the subject is reexposed to the conditioned event he/she is still in pain. Failing to extinguish, therefore,
makes the event become a reinforcement of aversive association. (pp. 4-5)
It may become emergent that chronic pain syndromes in general will someday become
re-classified under a new rubric of neuro-ontogenetic-plasticity disorders. The uncanny aspect is
that plasticity’s known mechanisms involving biased synaptic efficacy, excitatory protein
synthesis, and re-routing of selected information to widespread areas of the brain-many of which
are known to be selectively co- involved in pain processing-all happens at a level of involuntary
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involvement; plastic changes co-occurring on multiple levels (firing together), and evolving into
actual morphologic changes and constructs (wiring together) at a level well below the ordinary
conscious awareness. People are all products of multi-systemic interactive conditioning, which
ordinarily allows them to process and function better. But whether implicitly learned or
inadvertently conditioned, a preferable selection toward more optimal and resilient functional
adaptation is simply not so in situations that have culminated toward the development and the
continuing phenomenon of chronic pain.
In fact, multiple and disparate implicit and explicit associations being continually
encoded and reinforced through learning, memory, and successive behavioral stimulusassociation-response chains are phenomena that are now shown to remain continually
distributive and encoded throughout the central nervous system in select brain regions becoming
physically representative as topographic maps of chronic pain, in addition to their implicating for
the role for emotional suffering in chronic pain.
Some Specific Brain Regions Involved in Pain Processing
Areas of the brain involved in pain processing of sensory-motor association vs.
nociceptive inputs can include: amygdala, hippocampus, anterior cingulate cortex, thalamic
pathways, primary and secondary somatosensory cortex, supplementary and pre-motor cortex
areas, primary motor cortex, pre-frontal cortex, posterior parietal complex, basal ganglia,
cerebellum, hypothalamus-pituitary-adrenal (neuroendocrine) influences (HPA-axis);
furthermore involving autonomic nervous system (ANS) sympathetic arousal, in addition to
spinal cord and dorsal horn gating mechanisms (Doidge, 2015; Moller, 2014). A descriptive
consolidation of major brain areas and their varied corresponding functions implicated in pain
processing is depicted in Table 1.
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Table 1
Major Brain Areas Where Pain is Processed
Note. Sourced from Table 1, The Brain’s Way of Healing: Remarkable Discoveries and
Recoveries from the Frontiers of Neuroplasticity (Doidge, 2015, pp. 13-14). Viking
Press/Penguin Random House Publishers, New York, New York. Reprinted with Permission.
48
Bottom-Up Influences: Their Relationship to Intervention & Purported Mechanisms
International colleague and fellow Feldenkrais® Practitioner, Aurovici Sercomanens,
D.O. poses that the gate control theory - the phenomenon of sensory gating as originally
proposed by Melzack and Wall in 1962 - may be one of the most primary ways as to how both
Functional Integration® (FI®), the informative conceptual teaching through hands-on contact,
and slowly, gently applied movement facilitated sequences of action delivered through
Awareness through Movement® (ATM®) conceptual scripts - both characteristic of The
Feldenkrais Method® - might work toward the modulation of pain pathways from the outset. He
described it nicely here:
Sensory gating means that the processing and perception of sense information is reduced
by the presence of other competing sense information. If your nervous system is busy
trying to process signals resulting from (constructed, synergistic) movement (sequences)
you are making, or from the sensation of (informed and communicative) touch; it will
have less ability to perceive and process pain signals, and hence, your pain will reduce.
Areas of sensory gating, attention -perception modulation, and movement response
selection can exist at many & varied levels of the nervous system, and resultant
perception is modulated by interactions between different neurons. What the brain
receives are nociception (receptor) signals and it decides how to interpret these and make
them result in pain or not. Pain is the brain’s output after interpreting the signals. So
ultimately, Pain is an output (perception) from the brain, not an input from the body.
(Sercomanens, 2012, p. 2)
Sensory Information at the Crossroads: Differentiating the Thalamus & Rerouting the
Insula
A more central neurophysiological rationale as to how a slow, discriminatory and
Feldenkrais Method®-based movement intervention might work differently for pain modulation
than other, usual physical therapy exercise interventions, involves comparing and contrasting the
competing levels of sensory-relevant thalamic processing:
A. The ‘ventral thalamus’ is wired to process sensory information with great accuracy and
refined clarity of detail and to relay extracted, continually updated information to both
49
primary sensory and associative (poly-modal) and pre-frontal (task-responsive) cortices.
These systems have been classically described as the “Slow and Accurate” systems; the
more discriminative ‘Where’ of it all as a “high route” of highly-processed sensory
appraisal in lieu of activating lower level limbic alarm signaling to the amygdala. By
mechanisms of selective signal bias and sensory clarity, this informational pathway is
conducive toward cultivating correspondent and descending inhibitory processes that are
believed to be involved in the containment and reduction of pain signaling.
In contrast:
B. The ‘dorsal--medial thalamus’ bypasses the primary cortices and instead sends axons
directly to many dispersive areas of the brain, most notably secondary association
cortices, limbic system nuclei, lateral nuclei of the amygdala, anterior cingulate,
hippocampus, as well as PAG (periaqueductal gray) and reticular formation/activation.
This part of the sensory system (non-classical or lateral, extra-lemiscal spinal-thalamic
tract) is sub-cortically diffuse, less accurate, and less detailed and has been described as
“Fast and Dirty,” thereby biasing toward The ‘What’ of it all as a “low route” of lesserprocessed, reactive alarm response amplification to the amygdala; triggering an
endocrine, autonomic, behavioral cascade that can thus be perceived as immediate danger
or threat, and co-associated with amplified pain signaling.
As an alternative to lesser discriminant physical therapy activities (i.e., going through
usual and repeated prescriptive exercise progressions, but also likely defaulting to usual
efference copy and faulty pathway biases in the process), The Feldenkrais Method® instead
approaches to construct experiences which conductively select a bias toward taking the
neurological ‘high road’ through the ventral thalamic pathways via its emphasis on slow, non-
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threatening, highly discriminative and naturalistic movement synergies that have both informed
and constituted the original sensory-motor development in gaining a clear and accurate,
functional familiarity with the immediate world. This serves as a competing stimulus in contrast
to usual experience -- as with everyday mindless repetition of working against limitation with
more effort, as is the usual mode of traditional, prescriptive or corrective, fitness-based physical
therapy – including the social-culturally mediated and iatrogenic transfer to daily activities.
C. The Insula cortex is involved in complex relationships between thalamic and
amygdaloidal nuclei, is anatomically convergent between orbital-frontal, secondary
somatosensory, temporal, and parietal lobes and mediates vast assortments of information
processing between sensory perception and cognitive function, emotions and motor
control, temperature regulation, vestibular and autonomic homeostasis, self-awareness,
and especially, interoceptive awareness, and sense of ownership; the identification of
"one’s own body," of which the phenomenology of pain experience is quite significant. It
furthermore appears that the insula functions as a crossroads between the sensory
discriminative and the affective dimensions of pain (Bushnell, Čeko, & Low, 2013;
Pelletier et al., 2015b).
Thus,
There is both anatomical and some functional evidence of involvement of the insular lobe
in the primary integration of multi-modal sensory input -- inclusive of (substrates for)
pathological (chronic) pain, but so far, no treatment methods have been developed that
target the insula. (Moller, 2014, p. 325)
Though, perhaps, some undiscovered possibilities can someday emerge to integrate some
uniquely novel and functionally relevant, sensory-motor experiences, being developed through
cross-modal and virtual representations of enhanced body perception. These perceptual
components could furthermore become integrated with empathic provisions and emotional
51
assurances for safety and security - while at the same time, introducing and experiencing
something novel, but yet refreshingly different - all in conjunction with comprehensive, but
background intent toward clarifying and developing an improved working body schema; being
characterized here as a unifying prospect for internalizing a more effective treatment. One of the
aims of the current study was to explore and devise a psychophysical intervention that can
perhaps more directly involve and evoke the diversely unique propensities and convergent
processing components inherent to the insular cortex itself, and to harness its uniquely respective
modulatory effects with regard to controlling pain phenomena - at the crossroads.
Sensory-Motor Deficiency and Excess Functional Connectivity upon fMRI Motor Imagery
In a study entitled, "Differential Neural Processing during Motor Imagery of Daily
Activities in Chronic Low Back Pain Patients," Vrana et al. (2015) cleverly implemented a
discriminative stimulus input consisting of visually-guided motor imagery (MI) tasks via videorecordings of daily action activities in order to reveal and elucidate expected differential neural
sensorimotor processing among healthy controls (HC) as compared to chronic low back pain
(LBP) patients, while being assessed under functional magnetic resonance imaging (fMRI) of
brain, and while only mentally performing a simulation or rehearsal of the task activities that
were concurrently being demonstrated upon the embedded video display.
The motor imagery (MI) network of the brain comprises the primary motor cortex, the
premotor cortex, including the supplemental motor area (SMA), the superior and inferior parietal
lobe (SPL, IPL), temporal lobe, the insula, prefrontal regions as well as subcortical structures,
such as the basal ganglia and the thalamus, the cerebellum, and has been studied extensively in
healthy subjects, especially in motor learning and performance in sports (Vrana et al., 2015).
Behavioral and neuroimaging findings have accumulated showing that imagined actions retain
52
the same spatial-temporal characteristics as the corresponding real action when it comes to
execution (Jeannerod, 2001). Therefore, motor imagery (MI) of action observation and simple
pre-planning estimates for corollary discharge to pre-motor and parietal areas just prior to motor
execution (ME) through descending corticospinal tracts, all correspond to a subliminal activation
of the sensorimotor system in such manner that it conjunctively represents a true motor format
(Jeannerod, 2001).
The advantage of their using imagined or simulated movement in lieu of actual
movement additionally served a practical application to reduce image artifact, in that fMRI data dependent on resonance quality - are strongly sensitive to aberrant subject motion, and that fMRI
scanner parameters of physical space are themselves physically constrained, and thus prohibitive
to actualizing naturalistic movement. Twenty-nine subjects (15 chronic LBP patients, 14 HC)
were included in their study. MI stimuli consisted of six randomly presented video clips showing
every-day activities involving different whole-body movements as well as walking on even
ground and walking downstairs and upstairs. Guided by the video clips, subjects had to perform
simulated and imagined MI of these activities. Interestingly, pain ratings of the chronic LBP
group indicated that patients experienced only the MI-performance of the “activities” as painful,
while the MI of the “walking” condition was not painful (Vrana et al., 2015).
The video sample clips are shown below in Figure 3. Note that they bear striking
resemblance to graded activity and work hardening programs typical of many industrial and
work injury rehabilitation programs. As fMRI results suggest, simulated or actual immersion into
these activities directly - as an initial or continuing method of approach for the treatment of
CNSLBP, and typically supported by using "exercise specificity" and "graded functional daily
activities" as an accepted rationale– is a clinical paradigm that must soon be questioned.
53
Figure 3. The Six presented Video Clips for Mental Simulation of Daily Actions during fMRI
Recordings. A. Activities of daily living (“Activities”), and B. Walking activities (“Walking”).
*Note: Image and content courtesy of Andrea Vrana et al. (2015) and PLoS One; open access
article distributed under the terms of the Creative Commons Attribution License, 2016.
These results from the fMRI study by Vrana et al. (2015) indicated first-time novel
findings for understanding the real-time neurological events and underpinnings being
developmentally constitutive for known sensorimotor reorganization processes typically found in
the brains of chronic pain patients. In this, they discovered that motor imagery (MI-driven)
activity yielded reduced brain activation within (a) the left supplemental motor area (SMA), and
(b) the right superior temporal gyrus/sulcus (STG/STS), while fMRI connectivity analysis also
indicated (c) significantly enhanced functional connectivity (FC) becoming excessively divergent
and extraneous both within and outside the MI-neural network in chronic LBP patients as
compared to the HC group. Implications of each primary fMRI finding and its application to
typically representative clinical profiles found in patients with CNSLBP are as follows.
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The supplemental motor area. The supplemental motor area (SMA) represents an
inherent part of the MI-network and is linked to adequate motor planning and voluntary motor
control. There is also considerable evidence for the involvement of SMA in postural control, and
especially in anticipatory postural adjustments (APAs). Reduced activity in the SMA suggests
dysfunctional mechanisms in these motor control areas in addition to disrupted feed-forward
monitoring of internal efference copy to pre-motor and parietal association areas; thereby,
contributory to disrupted background body balance and posture control during voluntary
foreground intent and for the corresponding control of intended movement. Subsequently, these
findings suggest a direct involvement of the SMA in trunk movement coordination. Therefore,
the demonstrated maladaptive functioning of the SMA revealed by motor imagery perturbation
in LBP might be based on progressive dysfunction of motor circuits, and thus provides a
mechanism to explain the reported impairments in postural control that are a frequent finding in
patients with chronic LBP or CNSLBP.
Superior temporal gyrus/sulcus. When contrasted against baseline, superior temporal
gyrus/sulcus (STG/STS) activity during both “activities” and “walking” was significantly
reduced in chronic LBP patients compared to HC. The STG/STS responds to images of human
bodies and their orientations and is known to play an important role in the understanding and
interpreting of human movements as well as in matching sensory inputs with internal movement
representations (Vrana et al., 2015). Correspondingly, motor imagery (MI), and motor execution
(ME) require a high amount of sensory input processing in order to provide a "real-time
representation of the body" (e.g., a working body-schema).
In order to predict and perform everyday actions appropriately, the matching of the
internal representation of a person’s body (the body schema) with an intended movement (as
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influenced by a particular environmental affordance or task demand) is realized by comparing
the predicted sensorimotor consequences of the action through existing internal action models
(e.g., virtual body/efference copy), and the actual sensorimotor "afferent" feedback from the
body-environment. In either case, the finding of reduced STG/STS activity indicates a deficiency
in the integration of sensory inputs from whatever source, central or peripheral, internal or
external, and this diminutive feature remains a developmental characteristic that is seen in many
patients with long-standing CNSLBP.
Event-related functional connectivity (FC) and its meaning in fMRI. Evidence
continues to accumulate that connectivity measures based on the hemodynamic fluctuations and
responses measured by functional magnetic resonance imaging (fMRI) reflect meaningful
aspects of cognitive processing in terms of task, load, behavior, and pathology or psychiatric
diagnosis (Rogers, Morgan, Newton, & Gore, 2007). Functional magnetic resonance imaging is
widely used to detect and delineate regions of the brain that change their level of activation in
response to specific stimuli and tasks. The interregional correlations between fluctuations of
MRI signal potentially reveal connective relationships within and between major brain areas
during task - and in real time - based on real-time rapid metabolic distributions of blood
oxygenation level through brain-blood flow.
The organization, inter-relationship and integrated performance of these different regions
is generally described by the term “functional connectivity.” Functional connectivity (FC) has
been defined as the temporal correlation of a neurophysiological index measured in different
brain areas (Nallasamy & Tsao, 2011), or more specifically, through operational interactions of
multiple spatially-distinct brain regions that are engaged simultaneously in a task (Rogers et al.,
56
2007). These findings have been used to identify coactivating brain regions. Activity and
connectivity analyses are the two main applications of fMRI (Vrana et al., 2015).
In the differential processing of motor imagery study by Vrana et al. (2015), the chronic
LBP patients exhibited significantly enhanced MI-driven FC compared to the HC group
throughout the MI network; indicating diffuse and non-specific changes in FC, as compared to
HCs. Similar findings associated with hyper-excitability in both executive attention and sensorymotor networks have also been previously demonstrated in fibromyalgia patients; a pathology
similarly characterized by the perpetuation of ongoing and diffuse chronic pain states. With
respect to chronic LBP, diffuse and enhanced non-specific functional connectivity across the MI
network might indicate a common and widespread maladaptive neuroplasticity process that
continues to occur, thereby laying the groundwork for continued morphologic distortions
occurring within sensory-motor, accessory emotional-limbic, and autonomic networks within the
pain neuro-matrix.
Summary of motor imagery (MI)-driven fMRI activity. As calibrated for event-related
activity pooled together for “activity motor imagery” and “walking motor imagery” after
baseline, fMRI findings demonstrated whole-brain activations in both groups for frontal,
temporal and parietal cortices as well as in the occipital lobe. However, in the chronic LBP
group, the left middle frontal gyrus, which correspond to the supplemental motor area (SMA),
and the right superior temporal gyrus (STG) and middle temporal gyrus (MTG) regions of
sensory integration were effectively disengaged during the observation and simulation of the
motor imagery videography tasks. Furthermore, and equally significant, psycho-physiologicalinteraction analysis yielded significantly enhanced functional connectivity (FC) between various
MI-and non-MI-associated brain regions in chronic LBP patients; this indicated diffuse, hyper-
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excitable, and non-specific changes in FC as compared to HCs. These findings are summarized
in Figure 4.
Figure 4. Pooled Motor Imagery Tasks as a Composite of Six Video Simulated Actions as
exhibited on fMRI. A) Healthy controls (HC) on left, and B) chronic Low Back Pain (LBP)
patients on right, demonstrated significant differences in fMRI on such features as efficiency of
motor control and sensory discrimination upon mental simulation of video clip movement tasks.
Compensatory and mal-adaptive selection of non-task specific neuronal circuitry is demonstrated
in the LBP group on right in terms of non-specific functional connectivity being overly enhanced
via a proliferation of superfluous activity – accounting in part to loss of sensory-motor
integration, murky body schema, hyperexcitability, and loss of refinement for movement skill.
*(Image and content courtesy of Vrana et al. (2015) and PLoS One; open access article
distributed under the terms of the Creative Commons Attribution License, 2016.
fMRI implications for clinical understanding and future treatment. The current
investigation by Vrana et al. (2015) provides first evidence for obvious differences between
chronic LBP patients and HC subjects regarding MI-driven activity and FC. While healthy
subjects efficiently accommodated to demanding tasks by enhancing FC within the necessary
MI-network, chronic LBP patients required more extraneous cortical recruitment depicted by
enhanced FC demands occurring outside of usual MI-networks in order to perform the same
task.
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The finding of non-specifically enhanced and diffuse FC within and beyond the MI
network of chronic LBP patients might indicate pain-driven maladaptive alterations in the
sensorimotor network in terms of compensatory hyperexcitability and/or an enlarged need for
neural resources (Vrana et al., 2015). These intrinsic modifications remain unseen and "extracurricular" to the demands of the actual task. Despite retaining some ability to perform such
tasks to match criteria for placating an external examiner within an industrial and/or clinical
setting, these patients do so at a level that is most likely accompanied by some degree of spatialtemporal insufficiency, fatigue, internal resistance, extraneous effort, symptom reproduction, and
a corresponding sense of wear and tear that can never be "stretched out" or "worked out" nor
sustainably "medicated out" by conventional means. Importantly and progressively, Vrana et al.
(2015) concluded that “these findings may broaden the basis for the understanding of
sensorimotor reorganization processes in chronic LBP patients and might ultimately help
developing novel approaches for therapeutic MI-guided interventions” (p. 8).
The Pre-Frontal Cognitive-Attentional & Affective-Emotional Mesolimbic Domains
Pathologic central neuropathic chronic pain becomes a different form of pain than the
case that began with acute-nociceptive, episodic, and biologically protective pain; the latter being
more directly associated with the original trauma or incident. Only a fraction of patients who
experience an acute painful injury will develop chronic pain. How brain activity reorganizes its
structure and function with the transition from acute to abnormal chronic pain continues to
remain a topic of intensive scientific exploration and clinical research. These also become the
subjects of "top-down" regulation of sensation and pain.
The three cortical regions that consistently show decreases in grey matter within the
context of neuroimaging and correspondent with the clinical presentation of chronic pain are the
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(a) anterior cingulate cortex (ACC), (b) prefrontal cortex (PFC), and the (c) insular cortex (IC).
Molecular imaging studies also show decreases in opioid receptor binding in patients with
chronic pain in all three regions. Studies have additionally identified changes in white matter
integrity in these regions (Bushnell et al., 2013). These brain derived biomarkers - correspondent
to abnormal activity in mesolimbic and prefrontal areas - correlate strongly with clinical
measures in patients with CNSLBP and correlate better with clinical findings than do structural
physical exam and psychosocial findings. Increased insular activation is correlated with pain
duration, while medial PFC activation is correlated with pain intensity in CNSLBP subjects
(Apkarian, Hashmi, & Baliki, 2011; Pelletier et al., 2015b). These areas and regions of the brain
are associated with threat, fear, aversive conditioning, attention, motivation engagement,
negativity or disengagement, and executive control (Pelletier et al., 2015a, p. 1584). Thus,
chronic pain might be maintained through hypervigilance toward noxious stimuli due to
abnormal attentional cortical-thalamic and negatively valanced mesolimbic systems.
From experimental observations and perspectives, it has been shown that attentional and
emotional factors can modulate pain perception via different descending modulatory pathways.
Activities involving the redirection of attention have been shown to reduce the perceived
intensity of pain via the activation of circuitry involving projections from the superior parietal
lobe (SPL) to the primary somatosensory cortex (S1) and the insula. The somatosensory cortices
(S1 and S2) encode information about sensory features, such as the location and duration of pain.
Alternatively, the anterior cingulate cortex (ACC) and the insula, as transitional components of
the somato-emotional limbic system, are more important for encoding the mood states and the
motivational aspects of pain. Accordingly, psychosocial support conditions involving emotions
and placebo analgesia have been shown to alter the perceived unpleasantness of pain (but
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without significantly altering perceived intensity) primarily through circuitry co-activations
transmitting and descending throughout the anterior cingulate cortex (ACC), prefrontal cortex
(PFC) and via inhibitory influences upon the periaqueductal grey areas (Bushnell et al., 2013).
The compilation of these findings citing areas of cognitive and emotional control of pain - and its
corresponding regions of disruption in chronic pain - is depicted in Figure 5.
Figure 5. Brain Pathways for Cognitive and Emotional Influence on Pain. (a) Cognitive
/Attentional and Emotional Determinants, and (b) their corresponding Regions of Disruption in
Chronic Pain. This figure demonstrates that attentional and emotional modulation of chronic pain
occurs through differentiated pathways. Of important clinical significance to the current study, it
is worth re-stating that attentional pathways involving somatosensory cortices do not appear to
be reliant upon mechanisms for placebo anesthesia – as this is a more predominant feature of
known to occur within pre-frontal and cingulate cortices in the modulation of pain. *Image and
content courtesy of Bushnell et al. (2013) and National Library of Medicine (NLM) and Pub
Med Central (PMC); National Institutes of Health; Division of Intramural Research Program at
NCCAM; HHS Public Access Author Manuscript: Nature Reviews. Neuroscience. Macmillan
Publishers Limited © 2013.
The transition from control of acute low back pain to its disruption in chronic low back
pain has been demonstrated to occur within real time (Hashmi et al., 2013). By conducting a
combined cross-sectional and longitudinal anatomical and functional brain imaging study in a
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cohort of subjects with a single first-time episode of LBP (back pain persisting for at least four
weeks, with no prior back pain experience for at least one year), they were followed over a
period of one year as they either recovered or transitioned into chronic pain. Results of those
who transitioned to CNSLBP demonstrated a spatiotemporal dynamical reorganization of brain
activity, during which the representation of back pain over time had gradually shifted away from
sensory and nociceptive cortical regions and instead manifested toward engaging larger scale,
greater morphologic localization throughout emotional and limbic structures.
What remains an inquiry from a therapeutic neuroplasticity interventionist standpoint is
to determine whether this transition can be reversed-especially toward somato-sensory and sense
of ownership aspects of neuronal information processing, and with less emotional-limbic
divestment from body-self. Indeed, it has been shown that diminished brain regions implicated in
disrupted pain modulation, including the dorsolateral pre-frontal cortex (DLPFC) and ACC, had
reduced grey matter in chronic low back pain patients, but after successful treatment for
resolving the pain, the grey matter reductions were subsequently reversed so that the affected
brain regions were again re-normalized in size (Seminowicz et al., 2011). More specifically,
DLPFC thickness correlated with the reduction of both pain and physical disability. Additionally,
increased thickness in primary motor cortex was associated specifically with reduced physical
disability, and right anterior insula was associated specifically with reduced pain. Left DLPFC
activity during an attention-demanding cognitive task was abnormal before treatment, but
normalized following treatment (Seminowicz et al., 2011).
Other therapeutic approaches that have been shown to normalize representational cortical
changes that are associated with chronic pain (i.e., mirror box therapy for phantom limb pain)
have also been demonstrated to decrease the experience of suffering and the clinical presentation
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of pain. Mindfulness and Meditation therapies involving free-floating vs. directed attention have
also been shown to modulate and decrease pain-evoked neural activation in the dorsolateral and
ventrolateral PFC. Finally, there are preliminary studies showing that people who meditate have
thicker cortices in frontal regions, including the PFC, ACC, and insula (Lazar et al., 2005).
While studies have not yet addressed the full impact of such mind–body therapies on the brains
of patients with chronic pain, “current evidence suggests that they may have a neuroprotective
effect” (Bushnell et al., 2013, p. 12).
Synopsis and Rx Transition: Toward a Sensory Discriminative Perceptual Model
Ultimately, all pain is the net output of constitutive interpretation and affective
experience being generated from multiple influences to, from, and throughout the brain - and
often in response to continued appraisal of perceived threat to life or well-being. The
phenomenon itself, though explicitly consumptive of individual attention, is also implicit, often
intangible, negatively valent, and only indirectly accessible by another through empirical inquiry.
Yet, the aim and focus of many, if not most all, current musculoskeletal interventions
remains concentrated upon the more physicalized mechanisms of the body; treatments directed
almost exclusively to only the symptomatic structural-anatomic-isolated regions of dysfunction,
and being guided by compartmentalized performance measures being isolated to often arbitrary
and sometimes quite meaningless classification criteria with regard to overall measures for
human function. Such isolationist structural determinism - quite evident in medical imaging and
compartmentalized physical tests and especially embedded in medical language - can thereby
lead to unnecessary pathology descriptors being ascribed to certain attributional aspects of the
body parts or the perceived regions involved. These are, in all actuality, a normative, anomalous,
and noncontributory natural variation, perhaps and more than likely either congenital or
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developed over time, and cannot always be directly implicated a causal tissue aberration
mechanism or otherwise as a symptom producing structural pathology in cases of chronic pain.
Thus, the primary focus of many therapies on purely orthopedic aspects of structural or
strength-motion functional impairments in the spine may be a factor contributing to the lack of
success of current treatments. Several lines of evidence suggest that structural changes by
themselves (in the absence of behavioral considerations) within the back might be unimportant,
and there is growing evidence of extensive cortical reorganization as well as neurochemical and
structural alterations in the brains of people with CNSLBP. These changes could contribute to
the persistence of the problem and might represent a legitimate dimension of developing novel
approaches for therapy (Flor et al., 1997; Wand, Parkitny, et al., 2011) as well as an alternative
to physical exam-based sub-groupings remaining dependent upon grading of spinal motion
segments by the examiner, of which inter-rater reliability remains a question of continued bias
and suggestion. As has been cited for more than a decade, most procedures commonly used by
clinicians in the physical examination of patients with back pain demonstrate low reliability
(May, Littlewood, & Bishop, 2006).
In general, all forms of pain are affected by many high central nervous system activities
(Moller, 2014). Novel approaches to modulating neurophysiological changes occurring across
distributed areas of the nervous system (including "top down" inhibitory central and
biopsychosocial influences) may help to improve outcomes in patients with chronic
musculoskeletal disorders, in addition to desensitizing peripheral nociceptive inputs (via usual
physical medicine convention "bottom up" approaches) embedded within neural, neurovascular,
and musculoskeletal tissues.
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It thus follows that due consideration is now necessary for exploring and attending to new
treatment interventions, which aim to train/entrain/re-train and to clarify complex sensations,
with the underlying assumption that “accurate body perception underpins skilled movement,
sensation, localization acuity, laterality discrimination, cohesive emotional states, selfawareness, etc.”; and that these competing sensations, their novel processes for re-routing and
neuronal selection, and their corresponding emergent perceptions are all antithetical to the
recurring and complex phenomenology of conditioned states of ongoing pain perception.
Retrospectively and in sum, the same brain areas involved in the processing of pain are
also involved in: (a) sensory discrimination; (b) the planning, execution, and control of
movement; these are subsequently (c) correlated to the development and encoding of cortical
representation and body schema; and (d) are intricately correspondent to ongoing interpretive
cognitive conceptual-mediational processes and emotional affective appraisal qualities that give
both relevance and tone to everyday functions that are ordinary and necessary to usual life,
including those activities of doing and being that do not necessarily involve pain experience or
pain processing. Perhaps these areas of co-involvement can be implicated toward the
development of a new intervention that targets and reinforces toward selecting unaffected
functional pathways as competing information to those pathways otherwise remaining affected or
being dysfunctional.
Distortion of Body Schema, Somatic Education Interventions, and Virtual Reality
Body Schema is both a phenomenological construct (experientially - implicit) and a
conceptual construct (explanatory – explicit). Definitions and descriptions encoded for body
schema have included phenomena to account for the multisensory representation(s) of
peripersonal space (Holmes & Spence, 2004) as well as accounting for "a nonconscious system
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of processes that constantly regulate posture and movement" (Gallagher & Cole, 1995).
Grasping a conceptual basis for alterations in body schema can help explain how felt changes in
the body (the experience of somatic phenomena) can seem to correlate to corresponding and
concomitant changes in cortical mapping. While, in essence, an intrinsic phenomenological
event, these emergent cognitive-perceptual relationships being ever-interactive between self and
environment – becoming perceptually representative as a confluence of senses and a coherence of
image within working body schema – are concepts that remain yet linguistically vague and often
as intangible abstractions in the use of everyday language. However, these subjective and intersubjective phenomena have been differentiated from mere artifact or normal variance through
correspondent and scientific advances in neuro-imaging when correlated and matched to clinical
presentation data. In addition, changes in body schema or body mapping can be most profound
and disproportionate in representation when developed under the response of repeat conditions of
chronic pain.
Experimental psychologists have grappled with the mind-body problem of attempting to
define body schema, and only recently has there been consideration for the inclusion of
neurophysiological and neuroplastic correlates that are brought to light through newer advances
in imaging technology, such as PET Scans and fMRI. Leading professors and founders of The
Crossmodal Research Group, Charles Spence and Nicholas Holmes of Oxford University, United
Kingdom, have put fourth some new thinking about bodily perception and awareness, as it
relates to body schema and objects or persons in the surrounding environment becoming
relational in terms of peri-personal space:
Rather than invoking the abstract concept of the "body schema," we believe the focus
should be on experimentally more tractable aspects of bodily experience, such as the
perceived location, or the ownership of individual body-parts, the attribution of
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sensations and movement to particular body-parts, or the extent to which external objects
participate in multisensory and sensorimotor interactions....
To accomplish this, we review three broad areas of experimental research, namely: 1)
The effects of the manipulation of visual information on the felt location and identity of
individual body-parts, and the extent to which visual and tactile information is integrated
under such conditions; 2) How artificial body-parts affect the integration of visual and
tactile information, and how clothes and bodily adornments may become ‘incorporated’
into bodily representations (for example, clothes may enhance the felt dimensions of the
body or body-parts); and 3) How the skilled use of a variety of tools may lead to altered
multisensory or sensorimotor interactions, and the incorporation of such tools into bodily
representations. (Holmes & Spence, 2006, pp. 2, 6)
Classic examples of exploring these psychophysical phenomena include the "Rubber
Hand Illusion" and the "Body Transfer Illusion" - both of which use vision, touch, spatial
placement and context to convey a sense of ownership being attributable to an external
believable object (such as a realistic-looking dummy hand) or to induce the illusion in the
participating subject that even the body of another person or being is the participant's own body
(as occurs with synchronized avatar movements in immersive virtual reality technologies). The
Virtual Reality Bones™ component of this comparative intervention study employed the use of
"Virtual Limb Segments" – namely, femur bones, pelvis models, and a vestibular system
apparatus/temporal bone model – to serve as a structural corollary to "sense of ownership" being
derived from the Rubber Hand Illusion.
In addition, a full-scale, life-sized, upright standing, anatomical human skeleton model
was employed to serve as a functional corollary for inducing a corresponding sense of ownership
attribution as derived from the Body Transfer Illusion. The emergent features inherent to the
model skeleton (as an avatar being of its own) were operationalized and methodically directed to
facilitate an amplified sense of stand balance and central longitudinal postural axis, and for
relating the anatomical transmission of ground reaction forces during gait. By outlining a deeper
perspective for skeletal continuity through the densest trabecular pathways (a deeper core?) of
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the model human skeleton, I aimed to generate and convey an added sensory dimension for
internalizing a new frame of skeletal reference for updating a revitalized body schema and for
experiencing enhanced proportionality in movement being both anatomically-visually reconstructed through the senses and actively operationalized through participation in specifically
selected Feldenkrais Method®-based movements. Finally, through the deployment of a virtual
skeletal avatar consisting of pelvis, lower limbs, and arrows, and as re-constituted through
generic pre-recorded/instructional kinematic data using a Vicon™ motion capture system, I can
display a transmissible three-dimensional animation using Polygon Viewer™ software to
enhance visual-conceptual augmentation for entraining the vividness of skeletal experience being
encountered during imagined gait cycle function.
In summary, body schema ultimately and necessarily involves aspects of both central
(brain processes) and peripheral (sensory, proprioceptive) neurological systems. As a collection
of largely non-conscious processes, it registers the posture (and acture) of one's body parts in
space and in tracking limb positions, thus playing an important role in the modeling and control
of everyday action. From the essential necessity of neuroplasticity and learning, the schema is
continuously updated and encoded during body movement and remains ever-active, anticipatory
and adaptive for the spatial organization of effective action. It is therefore a pragmatic
representation of the body’s spatial properties, which includes the length of limbs and limb
segments, their arrangement, the configuration of the segments in space, their spatial-temporal
sequencing and encoding, and the shape of the body surface in interactive exchange with the
anticipatory and immediate affordances encountered in the environment (Holmes & Spence,
2004; Maravita, Spence, & Driver, 2003).
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Distortion of Body Schema and Chronic Pain – especially Low Back Pain
It is now known that patients with chronic back pain have reduced proprioceptive acuity
and sensory discrimination at the back, and have a cortical representation of the back that is
markedly different to healthy controls, and anecdotally, find subtle or differentiated movements
of their pelvis and back (i.e., movement dexterity tasks) more difficult than people without back
pain do (Moseley, 2008; Wand, Catley, Luomajoki, et al., 2014; Wand, Keeves, et al., 2013).
Furthermore, body image/body schema is known to depend on somatic and proprioceptive input
as co-determinants for cortical mapping, of which associated pain states may be inhibiting.
Fundamentally, though by no means exclusively, the cerebral representation of pain can
be considered to consist of two neural networks: One representing the discriminative and
localization dimensions of pain and one representing the affective-emotional dimension of pain.
The most studied representations of the physical body are those held in the primary (S1) and
secondary (S2) somatosensory cortices and in the primary motor cortex (M1) and remains a
continuing topic of study in other body schema based therapies, such as Graded Motor Imagery
(Lotze & Mosely, 2007; Moseley, Butler, Beames, & Giles, 2012). All are thought to be
important for the consciously-felt body – with affective dimension given to neighboring anterior
cingulate cortex, insula (predominantly the anterior regions), ventral prefrontal lobe, amygdala,
and adjacent hippocampus – also corresponding to known brain regions to be involved in pain
signaling and processing of painful experience (Doidge, 2015; Louw & Puentedura, 2013). A
descriptive consolidation of major brain areas and their varied corresponding functions
implicated in pain processing is again depicted in Table 1.
S1 and M1 probably hold the most precise and competing representations of the body.
They are tightly connected and are functional entities for movement control and execution. This
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somatotopic representation is thought to be maintained by lateral cortical inhibition, whereby
input from a particular body part exerts an excitatory influence on its target S1 neurons and an
inhibitory influence on neurons in adjacent representations. In this way, neural networks of body
representation (e.g., cortical body maps) become correspondingly built into the neural
architecture of the brain (Lotze & Moseley, 2007; Moseley et al., 2012).
Could these networks afford a competing (functional) stimulus to the inhibition signaling
of (protective) chronic pain states? It is now known that tactile input can sharpen the receptive
fields of S1 neurons, especially when the individual allocates a quality of attention to the sensory
input or a behavioral - learning objective that is associated with it (Moseley & Hodges, 2006).
Treatment interventions can thus afford the opportunity of implementing spatial-tactile acuity
and body image multi-sensory references as part of treatment for chronic back pain. As with
phantom limb pain and in chronic regional pain syndrome (CRPS), graded motor imagery,
spatial-temporal encoding of movement, and training tactile acuity has been shown to reduce
pain and increase function (Flor & Diers, 2009), and thus a same or similar strategy might be
true for modulating back pain. In fact, tactile two-point discrimination training has been
compared to be more effective in decreasing movement-related pain in patients with chronic low
back pain than traditional acupuncture, and is suggested as an underlying mechanism for
explaining the commonly seen effects of sham acupuncture (Wand, Abbaszadeh, et al., 2013).
Somatic Education Interventions and Low Back Pain
More recently, "internalized" somatic education approaches which emphasize facilitation
techniques and associated attentional exercises that are designed to improve toward the
development of a more finely tuned quality of sensory discrimination, such as The Alexander
Technique, have demonstrated significant large-scale efficacy for both symptom reduction and
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cost containment within a population of LBP patients in the United Kingdom (U.K.; Little et al.,
2008). At least one citation in Medline exists to warrant some efficacy of an approach involving
the presentation of ideokinetic imagery as a movement imagery and postural awareness
technique that was found effective for both improving posture development and reducing low
back pain. Ideokinetic imagery is defined as “a postural development technique that involves
using movement images to gain subcortical control over the spinal musculature” (Fairweather &
Sidaway, 1993).
As researchers in the field of exercise and sport, Fairweather and Sidaway (1993)
examined the effectiveness of ideokinetic imagery and flexibility compared with abdominal
strength training as methods for improving the spinal angles of lordosis and kyphosis and
reducing low back pain. Findings indicated that only ideokinetic imagery - using a noninvasive
video analysis technique to record changes in spinal angles - had a positive effect on the spinal
column with improved spinal angles and cessation of low back pain, as compared to not using
recorded movement imagery. This research concluded support for the use of ideokinetic imagery
as an inexpensive and noninvasive technique to improve poor posture and reduce low back pain.
As a qualitative impression, it can perhaps be surmised that the nature of imagery must also be
kinesthetic and/or embodied or body-based - and not just visual, or otherwise distractive from
some other pictorial image that is devoid of representing a concurrent spatial-temporal encoding
context - in order to more effectively generate and modulate corticomotor excitability both
within the spatial-relational and the functional aspects of cortical body maps.
The Feldenkrais Method®, recognized as sharing some common principles with the
Alexander Technique, ideokinetic Imagery, and Ideokinesis, seeks to link discriminative
sensory–motor learning experiences (perception through action/quality of attention to novel
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spatial-temporal configurations of embodiment) with neuro-plastic changes in the brain in
conjunction with optimal use of self through sensing the core of the entire skeleton in the
performance of everyday generalizable life tasks. As a corollary to sensory awareness process
and multimodal integration, the work of Andre Bernard depicts a special kind of experiencial
relevance toward the enhancement of skeletal – anatomical imagery references becoming more
consciously internalized through his uniquely designed guided exposure processes. One
captivating and seamless feature to his approach involves his combining descriptive and visual
imagery within a simulated design for experiencing one's own skeleton - via both its constraints
and opportunities - and for enhancing the functions of posture and movement.
These inherent phenomenological features thereby become experienced through both
existent biological structure and newly perceived form, and are addtionally substantive toward
improving and maintaining overall function. These features are furthermore made useful toward
fostering a representational mental idea or tangible cognitive image for actually experiencing and
understanding the conceptual idea behind a particular functional arrangement for skeletal
movement, “hence the term ideokinesis” (Bernard, Steinmuller, & Stricker, 2006). Creating a
tangible reality for accessing such images and ideas, as a bridge between environment and
embodiment, is the subject of the next section.
Virtual Reality, Applications to Chronic Pain, and Prospective Studies for CNSLBP
According to the Virtual Reality Society, virtual reality (VR) is the creation or
replication of a virtual environment that is presented to our senses in such a way that we
experience it as if we were really there. It uses a host of multimedia and immersive computersimulated technologies to achieve this goal, and by creating a constructive, typically threedimensional, interactive environment to target upon the senses, it can have profound effects on
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human perception, action, and cognition. Real or imagined, it simulates a user's physical
presence and environment in such a way that allows the user to interact with it, ideally through
mechanisms known to be involved in multi-sensory integration.
Multisensory integration, also known as multimodal integration, is the study of how
information from the different sensory modalities, such as sight, sound, touch, smell, selfmotion, and taste, may be integrated by the nervous system (Stein, Stanford, & Rowland 2009).
A coherent representation of objects combining modalities enables us to have meaningful
perceptual experiences. Indeed, multisensory integration is central to adaptive behavior because
it allows individuals to perceive a world of coherent perceptual entities (Lewkowicz &
Ghazanfar, 2009). Multisensory integration also deals with how different sensory modalities
interact with one another and alter each other’s processing.
Most researchers distinguish three sensory systems related to sense of touch in humans:
cutaneous, kinesthetic, and haptic (Lewkowicz & Ghazanfar, 2009; Stein et al., 2009). All
perceptions mediated by cutaneous and/or kinesthetic sensibility are referred to as tactual or
haptic perception. The term "haptic" is often associated with active touch to communicate or
recognize objects (Wagemans et al., 2012). Conversely, non-contact haptic technology utilizes
the sense of touch without physical contact of a device. This type of feedback involves
interactions with a system that are in a 3D space around the user. Thus, the user is able to
perform actions on a system in the absence of holding a physical input device – a key feature to
permit freedom of movement within whole self as within the Microsoft Kinect VR interface.
In the seminal work, The Merging of the Senses (Stein & Meredith, 1993), an extensive
review of evidence regarding the investigations of neurophysiology functions involved in
transmitting sensory information through deeper brain regions - specifically, the superior
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colliculus in cats (Meredith, Nemitz, & Stein, 1987; Meredith & Stein, 1983, 1986b) - resulted in
the distillation of three general principles by which multisensory integration may best be
described:
1. The spatial rule states that multisensory integration is more likely or stronger when the
constituent unisensory stimuli arise from approximately the same location.
2. The temporal rule states that multisensory integration is more likely or stronger when the
constituent unisensory stimuli arise at approximately the same time.
3. The principle of inverse effectiveness states that multisensory integration is more likely or
stronger when the constituent unisensory stimuli evoke relatively weak responses when
presented in isolation.
Summarized another way, the more ways that the presentation of a stimulus can co-occur
and be combined through multi-modal and cross-modal representations, and the more it can
occur within the same (temporal) time frame - and occurring or localizing within the same
general embodied location (haptic space) in relationship to its corresponding environment (visual
space), be it through peri-personal (external) or interoceptive awareness (internal) domains for
sensory reference - then the better and more integrative the multi-sensory perception becomes for
the accurate discernment and cognition of difference, and even perhaps for the constructed
meaning of the experience. It is important to note that the term “virtual reality” does not limit the
practitioner or researcher to a particular configuration of computerized hardware and software.
Instead, VR may be understood as a development of simulations that make use of various
combinations of interaction devices and sensory display systems.
Typically, the designs for these systems are developed with consideration of balancing
the level of immersiveness with the level of invasiveness. While historical uses of VR have opted
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for highly immersive experiences in gaming by using the more invasive and expensive, and
clinically cumbersome head-mounted displays (HMDs), a new generation of simulation gaming
technologies are becoming available for inducing relatively lower-level immersion experiences,
including the Microsoft Kinect™ for Windows.
Whilst such non-invasive systems involve a lower level of immersion, the
phenomenological experience of the user is one that involves a high potential for
effective interaction with (the presentation of) digital (or material) content, (and by) using
naturalistic body actions. (Trost & Parsons, 2014)
Opinions differ on what exactly constitutes a true VR experience, but in general it should
include:
●
Three-dimensional images that appear to be life-sized from the perspective of the user;
●
The ability to track a user's motions, particularly head and eye movements; and
●
To correspondingly adjust the images on the user's display to reflect the change in
perspective.
Provisions for each of these features are key components built into the Virtual Reality
Bones™ protocol and its corresponding selection for Feldenkrais movement applications as
®
intended within the experimental arm of the current study. In which case, the user’s display is
actually the user’s own body, together with its kinesthetic and haptic sensory awareness being
cultivated, integrated and combined in real time, during and inclusive of the intervention. NIH
Public Access has selected the publically-funded, author manuscript, "Virtual Reality and Pain
Management: Current Trends and Future Directions," by Li, Montaño, Chen, and Gold (2011), to
inform and guide current applications for acute pain management (i.e., VR-induced anesthesia),
and also to recommend and suggest important areas for future research, namely, the more
challenging problem of chronic pain.
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In it, Li et al. (2011) cited previous investigative work, which postulates the idea that VR
can act as a nonpharmacologic form of analgesia by exerting an array of emotional-affective and
competing cognitive-attentional processes within the body’s intricate pain modulation system. In
an earlier paper by one of its co-authors, neurobiological mechanisms were hypothesized,
suggesting that VR analgesia originates from intercortical modulations among signaling
pathways of the pain matrix through attention, emotion, memory and other senses being afforded
through VR experiences (e.g., touch, auditory, and visual), thereby producing a competing
inhibitory modulation of the conditioned pathways typically involved in the processing,
production, and maintenance of chronic pain. It is further stated that an overall decrease of
activities in the pain matrix may be accompanied by increases of activity in the anterior
cingulate cortex and orbitofrontal regions of the brain (Gold, Belmont, & Thomas, 2007),
suggesting that the cognitive demands of the task, and not simply the mechanism of attention
distraction alone may be an important factor in the attenuation and modulation of pain thresholds
(Seminowicz & Davis, 2007). Functional imaging studies of the human brain’s response to
painful stimuli have shown increases of activities in the anterior cingulate gyrus, the insula, the
thalamus, and sometimes in other regions such as the primary somatosensory cortex and the
periaqueductal gray matter (Li et al., 2011) that have yet to be investigated in response to VRbased approaches.
Future studies are underway to examine the complex interplay of cortical activity
associated with immersive VR. Recently, new applications, including VR, have been developed
to augment evidenced-based interventions, such as hypnosis and biofeedback, for the treatment
of chronic pain. Interestingly, in a case study involving a 36-year-old female with a 5-year
history of unretractable chronic neuropathic pain, a pilot intervention involving virtual reality
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augmented hypnosis was found to be more effective than hypnosis alone, by reducing pain and
prolonging the treatment effects (Oneal, Patterson, Soltani, Teeley, & Jensen, 2008). It is
anticipated that lessons learned from these early VR investigations will lead to further
applications in chronic pain management and other pain rehabilitative conditions.
Other reviews of experimental evidence suggest that rapid advancement of virtual reality
(VR) technologies are also applicable to the development of novel strategies for sensorimotor
training in neurorehabilitation, as in cases of literature being reviewed for stroke recovery
(Adamovich, August, Merians, & Tunik, 2009). The reviewer discovered through his own
research that time-variant activations of the left insular cortex corresponded to a condition of
“observing with the intent to imitate” the sequences of finger movement being performed by a
virtual hand avatar seen in first-person perspective and then computer animated by pre-recorded
kinematic data. This observation of underlying neurophysiological mechanisms revealed through
real time fMRI occurred in the experimental condition of "action observation-pre-execution"
(implicative of mirror neurons) but not in other conditions (Adamovich, August, et al., 2009).
Moreover, imitation with veridical feedback from the virtual avatar (relative to the control
condition) also recruited the angular gyrus, precuneus, and extrastriate body area, regions, which
are (along with insular cortex) associated with the sense of agency.
Thus, the virtual hand avatars may be useful for sensorimotor training by serving as
disembodied tools when observing actions and as embodied “extensions” of the subject's own
body (pseudo-tools) when practicing the actions (Adamovich, Fluet, Tunik, & Merians, 2009). In
addition, the use of tangible and prehensile haptic feedback is shown to select for automatic and
implicit processes that are more readily facilitative of instantaneous motor learning, which can
serve to bypass the effects of biased, sometimes self-critical, and over-analytical effects of
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explicit cognitive "proper performance" training (Boyd & Winstein, 2006). These studies have
strong conceptual implications for articulating some background rationale in favor of purporting
the experimental design of the current study.
Again, these inferences will thus later apply to the current study wherein (a) "virtual
pelvis and hip avatars" (visually re-constructed by computerized animation from pre-recorded
kinematic data), and (b) the tangible haptic contact of virtual reality bones™ will be used to
facilitate a basis for improving spine stability (or for at least inferring only its background
involvement) in the context of gait function and generalizing the VR entrainments into repeated
practice within separate components of the gait cycle.
Clinical research applications of VR for the problem of CNSLBP are just now underway.
A team of researchers at The University of North Texas has developed a protocol for virtual
reality graded exposure therapy (VRGET) to address several central limitations of traditional
graded exposure therapy and usual VR approaches to pain/disability treatment. They applied the
use of a skeleton tracker being embedded within the Microsoft Kinect’s interactive technology
platform to more closely match and generalize patient’s movements toward a "real world"
simulation experience. An application of trials to test their therapeutic approach for a population
of patients with pain-related fear and the clinical presentation of chronic non-specific low back
pain (CNSLBP) is now currently at the pilot stage. By using the Microsoft skeleton tracker as a
simulation tool, a calibrated skeleton model is automatically generated and proportioned through
each patient’s demonstration of movement at baseline. Participants’ can use their own bodies as
controls.
The Kinect is one of the most widely used whole-body trackers and has the ability to
integrate body-state information into various simulations. The Kinect system uses image, audio,
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and depth sensors for movement detection, facial expression identification, and speech
recognition. The Kinect’s interactive technology allows users to interact with simulations using
their own bodies as controls. An important advance in the Kinect technology is that, unlike
previous attempts at gesture or movement based controls, the patient is not encumbered by the
need to wear accessories to enable the tracking of his or her movements (Trost & Parsons, 2014;
Trost et al., 2015). Other studies have already shown improvements in common measures for
LBP studies as the resultant effects of a VR-based Wii Fit exercise program involving a
population of middle-aged, female patients presenting with LBP in South Korea (Kim, Min,
Kim, & Lee, 2014).
As a summation, adaptive and engaging virtual environments being afforded through VRbased interventions provide a unique perspective and potential to benefit patients with disordered
movement. This is accomplished in ways that facilitate and promote the massive and intensive
sensorimotor stimulation needed to induce change as necessary precursors known to be inherent
to brain reorganization and neuroplasticity.
Differences between Feldenkrais® Virtual Reality and Traditional Guided Imagery
New techniques for Virtual Reality and Traditional Guided Imagery continue to be
investigated as viable psychophysiological-based therapy approaches for implementation to the
treatment of chronic pain. Yet, chronic pain remains a continued challenge to patients and
clinicians. As was previously discussed in the Emergent Findings from the Neuroscience of
Chronic Pain and Neuroplasticity section of this chapter, chronic pain seems to be maintained by
diffuse neurophysiological changes across different areas of the peripheral and central nervous
systems, including peripheral receptors, dorsal horn of the spinal cord, brain stem, sensorimotor
cortical areas, and the mesolimbic and prefrontal areas. These have been especially studied
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among populations of patients with chronic low back pain, among other chronic musculoskeletal
disorders.
Musculoskeletal rehabilitation professionals implementing psycho-physical and
psychophysiological approaches have tools at their disposal to address these neuroplastic
changes. These include "top-down" cognitive-based interventions (e.g., pain science education,
cognitive-behavioral therapy, mindfulness meditation, biofeedback/neurofeedback and motor
imagery) in addition to more traditional "bottom-up" physical interventions (e.g., peripheral
sensory stimulation, including e-stim, manual therapy, motor control exercises, kinesio-taping,
and motor learning) that induce neuroplastic changes across distributed areas of the nervous
system and that can affect outcomes in patients with chronic musculoskeletal disorders (Pelletier
et al., 2015a).
Multiple lines of research continue to suggest that more comprehensive, integrative, and
novel approaches to modulating neurophysiological changes occurring across distributed areas
of the central nervous system may help to improve outcomes involving "self-control" in patients
with chronic musculoskeletal disorders, in addition to desensitizing afferent-nociceptive
peripheral inputs embedded within the more localized aspects of neural end-plate receptors and
musculoskeletal tissues. In tallying a composite review of possible physiological mechanisms
underlying these interventional constructs, the distinctions occurring between either "top-down"
or "bottom-up" mechanisms of action can become increasingly blurred; particularly, in cases
where newer, more integrative and holistic approaches become increasingly evolved toward
unifying upon a common and multivariate continuum.
Guided imagery is a therapeutic technique that allows a person to use his or her own
imagination to connect his or her body and mind to achieve desirable outcomes, such as
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decreased pain perception and reduced anxiety (Ackerman & Turkoski, 2000). An imagined
mental image can be defined as “a thought with sensory qualities,” so as to actively conjure up or
to re-invoke a memory experience of sensations for seeing, hearing, tasting, smelling, touching,
or feeling and to apply them to a situation. More specifically, kinesthetic or motor imagery
necessarily involves the invocation of attending to proprioception or the positional sense of body
in space as well as to corresponding body regions or body parts during actual movement or in
association with an imagined or intended movement.
The learning of new sensory-motor skills often requires the mental rehearsal of
movement being efferently fed-forward through the kinesthetic sense of the body - both it's
internal/cortical representation (including sub-cerebral and cerebellar components) and through
the body itself - for both intended and actual movement. These processes are usually contingent
upon pre-conditioned and established patterns of action having been developed, acquired, and
habituated through prior models and modes of experience, thereby serving as existing perceptual
templates or internal models from which to derive, project, and direct the guided imagery
phenomena.
Imagery can have profound physiological consequences, and depending on how skilled a
person can be in creating or re-creating a believable image or experience, his or her own
physiological responses can respond to imagery as similar as they would to a genuine or actual
external experience. However, when patients with chronic pain are exposed to their most
powerful/distressing image (an index image; being directly associated with their diagnosis, their
internally felt experience, and the perceived impact on their quality of life), the data generated
through their self-report scales and structured interviews have been found to evoke significant
increases in negative emotions, negative cognitive appraisals, and escalations in pain levels in
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response to such image exposure (Phillips, 2011). Implications for image re-scripting are thus an
important part of CBT and guided imagery, or other mind-body, mindfulness-based
interventions.
Thus, well-intended guided imagery involving some part of "the back" or "back-specific
activities" are often prone to "backfire" in that they are directly reinforcing of attention to
associated index imagery; be they radiographic images, MRI reports of spinal morphologic
changes, routine pathologic or diagnostic descriptions, or other applicable images indicating or
even remotely suggesting that "something is wrong" with the back. Even more profound, by just
imagining one’s own movement through kinesthetic or motor imagery, or even the simulated
actions of others through mirrored motor imagery - of observing and mentally imitating someone
else’s actions - will reproduce and amplify existing pain sensory response networks and invoke a
cascade of neurological pathways known to be associated with the pain experience. Thus, it can
be said that even the virtual body experiences pain.
Again, the recent study by Vrana et al. (2015) confirmed demonstrable findings for
widespread and differential neural processing activity between chronic LBP patients as
compared to healthy controls upon reviewing fMRI data during motor imagery-driven activity,
wherein each group was exposed to video clips of persons performing a graded series of
potentially strenuous "back-related" activities (the details from this study and the differential
brain regions co-involved in both chronic pain and the simulated imagery of action were aptly
discussed earlier in Chapter 2, under the Neuroscience of Chronic Pain and Neuroplasticity subsection of this dissertation). Seeing that existing imagery qualities and locus of control
competencies have become disrupted within patients with chronic pain, and that internal foci
remain pain-driven with a predisposition and sensitization toward provocation and re-triggering
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of pain pathway phenomena, it seems pertinent that a discussion of difference between
traditional therapist-mediated guided imagery and Feldenkrais -inspired virtual body imagery
®
(via also a VRB3 model of approach) is in order.
While there is much shared similarity in both approaches, traditional guided imagery
exhibits a transcendent tendency to project a pre-scripted image to the patient or client, to which
the patient or client may (or may not) internally re-construct an actual or accurate image as was
intended by the therapist. That is to say that, internally, the image itself may (or may not) be
constructed through the voluntary will, effort, or intent of either party or dyad, and without actual
contact, both the therapist and the patient will thereby operate from separate inter-subjective
fields. Guided imagery, by its nature of delivery and design, therefore, has to be pre-projected
through the imagination and the cognitive constraints of each person in a direction that is "top
down" from mind to body, and is therefore, only representative of the senses and not emergent
phenomena arising or processing from direct sensation itself.
Alternatively, in the Feldenkrais/VRB3 model of approach, the image itself (tangible and
accurate skeletal segment models and 3-D visual-kinesthetic avatars) is already pre-constructed,
and the Feldenkrais practitioner® aims to project the constructed image interactively through
direct contact to afford corresponding feedback; all while operating from a shared intersubjective phenomenological field (i.e., a shared virtual environment). In all virtual reality,
therefore, the image is pre-constructed and is projected directly onto the senses, and thus
represents a competing stimulus strategy that is constitutively "bottom-up" from body to mind,
and is automatically assimilated involuntarily. By the biological necessity of all living and
conscious entities, rarely can the introduction of novel, unexpected, and direct sensations
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(sensory commands) remain ignored or unprocessed, as a more direct experience of actual (and
virtual) representations of the internal and/or external world.
Figure 6 depicts differences in intersubjective phenomenological fields between top down
guided imagery (as an un-shared; linguistic-abstractive domain of interaction) vs. bottom up
direct contact (as a more-shared and inter-projected, concretized domain of interaction).
Example of Traditional Guided Imagery ‘Top Down’ Pre-Scripted Linguistic Domain
Example of Feldenkrais® virtual body imagery ‘Bottom-Up’ Physical Construct Domain
Figure 6. Differences betweeen Traditional Guided Imagery and Feldenkrais Method® Contact
Imagery. In traditional guided imagery, the moment by moment projected images are primarily
intra-subjective, abstracted through language, and are thereby lingusitic and fleeting in nature,
and not necessarily co-constructed toward accurate representation of embodied relationship;
resulting essentially in a separate phenomenological field, with reduced intersubjectivity
between therapist and patient. In Feldenkrais®-based contact/virtual haptic imagery (Hands-on
Functional Integration®), moment in moment images are alerady pre-constructed, mutually
explored, and continuously re-projected from a variety of multisensory contact points - such that
they are simultaneuosly expereinced as embodied relationships with enhanced intersubjectivity
betweeen practitioner and client; resulting essentially in a shared phenomenological field of
interaction and with a corresponding linkage toward fostering functional adjustment to task in
real time.
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Gravitation as a Virtual and Invariant Constant in the Sensory-Motor World
While phenomenological perception can also vary between one individual and another, at
least one predictive area involving a mutually shared and invariant constant - being cocontributory toward the evolutionary development and strategic emergence of all living things involves their cohabitation within an incessant and persistent field of gravity that is both a
universal given and an influential absolute to all known existence. Through the evolution of
species – and most particularly, through evolution of uprightness and locomotion - it is only
through the function of upwardly directed and dispersive movement (in directions of antigravity) that all living things are able to overcome, differentiate, and to distinguish some sense of
separation (i.e., some sense of morphologic identity) from the ever-present and constraining
influences of gravity. Accordingly, and adding a neurological component to the gravity of the
situation, Roger Sperry, the winner of the 1981 Nobel Prize for Medicine and Physiology,
reported that “Better than 90 percent of the energy output of the brain is used in relating the
physical body in its gravitational field. The more mechanically distorted a person is, the less
energy available for thinking, metabolism and healing [emphasis added]” (Wyszynski, 2013, p.
8, emphasis added).
The development and seemingly spontaneous formations of loops, twists, and dynamic
spirals at all levels of existence (both living and non-living) appears most inherent as an optimal
organizational strategy for navigating a responsive and effective relationship to gravity. Thus,
serving as a reflective platform for assimilating against a seamless array of un-mitigating forces
while simultaneously achieving curvilinear, dynamic confluence along parallel and contiguous
lines being characteristic and predictive of gravity’s direction. By being dimensionally
responsive through more expansive and distributive confluences of interwoven shape and form,
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it seems that curvilinear and semi-circular arcs - becoming intrinsically elevated and discernable
within the vestibular sensory systems of all skeletal vertebrates - are well-positioned for
informing a more predictive and adjustable platform for sensory navigation during locomotion;
and for incremental detection of time and space variances, while occurring across changing body
positions, which especially happens during the transition to uprightness of head orientation
(cranial aspects) over and opposite that of a caudal base of support (i.e., lower quadrant ground
reaction/support surfaces under legs and feet); and finally, most ultimately and fundamentally,
while counterbalancing and rising up against gravity itself.
It so happens that sustaining these primitive functions are also the same activities that are
found to be the most challenging and difficult for patients afflicted with chronic non-specific low
back pain (CNSLBP). While the back itself and/or its immediately adjacent areas are most
commonly cited as a source of visible rationale for producing problems and symptoms in the
diagnostic foreground - there is also a hidden contribution of invisible rationale existing deeply
remote in the background of everyday movement and in direct response to the push and pull of
gravity - yet far away from any particular lumbar spine segment. An “above the lumbar spine”
versus a “below the lumbar spine” categorical or regional perspective is virtually unknown for
inclusion, and thereby remains as an undisclosed component of body schema referencing for
most persons; let alone for occurring within the functional body awareness ‘diagnostic schemata’
of most all healthcare professionals and patients alike.
Hidden Senses: A Skeletal Density-Vestibular Concept for Body Schema & Pain
The vestibular system, as "a hidden sense" being deeply encased below the temporal
lobes of the brain and within either side of the densest skull base, is very likely a key component
for body schema in motor control, and quite possibly, an overlooked factor of dysregulation in
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the maintenance of chronic pain. An anatomical schematic of a vestibular sense end organ is
exposed and depicted in Figure 7.
Figure 7. Anatomical Schematic and Location of Vestibular Apparatus. Encased within temporal
bone to either side of skull and within each inner ear.
The vestibular sensory apparatus itself, being composed of the three semicircular canals,
and the utricle-saccule otoliths within the inner ear, is a multimodal sensory system that is
involved in many functions including balance and equilibrium, righting reflexes, vision
stabilization during body movement, spatial navigation, the ongoing perception of body
configuration and proportionate length; and for maintaining the necessary consciousness
alertness that is required for keeping a skeletal-vertebrate animal upright against gravity.
Developmentally, it is among the first of the paired special senses to develop, becoming encased
within the densest of all skeletal structures (the bony labyrinth: within the temporal bones of
each side of the skull and within each inner ear), and are among the first to undergo myelination
during early stage development, while still in utero (Tecklin, 2014).
The vestibular system is phylogenetically the oldest part of the inner ear, yet it was only
recognized as an entity distinct from the cochlea (for hearing) in the middle of the 19th
century. This is because when the system is functioning normally, we are usually
unaware of a distinct sensation arising from vestibular activity; it is integrated with
visual, proprioceptive and other extra-vestibular information such that combined
experience leads to a sense of motion. (Cullen, 2012)
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Most vestibular research has focused on the encoding of gravitational and inertial signals
emanating and reciprocating throughout each vestibular end organ (namely, through the three
semicircular canals and otoliths on each contralateral side) and their dual projections to brain
stem and cerebellar areas. Laboratory findings and clinical investigations have thus been applied
toward understanding the involuntary neurological mechanisms involved in righting responses,
including vestibulo-ocular and vestibulo-spinal reflexes, and their corresponding role in
maintaining gaze stabilization during vision perturbation as well as for balance and posture
control under conditions of disequilibrium or gravitational instability, and for the treatment of
pathologic dizziness or vertigo.
However, more recently, a more complete understanding of vestibular function is being
advocated for by conducting new investigations into the role of cortical influences and the higher
processing of vestibular-generated sensory phenomena. Consequently, new areas of inquiry have
recently emerged to engage some other, often taken for granted psycho-physical aspects that are
inherently important to human perception and effective functional actions, as they routinely recur
throughout the gravitational and social world of everyday living. These include:
1. Spatial Cognition and the role of vestibular sensory impressions for spatial navigation,
spatial interpretation, and the encoding of spatial memory;
2. Body Representation – including spatial proportion and representations of body part size,
the perceived distances between body regions, changes in tactile sensitivity toward
attenuation versus amplification of sensory phenomena, and most relational to the current
investigation, having anatomical-functional correlates to sensory distortions and
kinesthetic mismatches that are correspondent to known changes in somatorepresentations in association with states of chronic pain; and finally,
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3. An associative role for disparities in vestibular signaling toward the development, high
comorbidity, and/or sustenance of affective processes and mood disorders, including
anxiety, panic, and depression.
Knowledge gained through these research areas and other studies using the manipulation
of vestibular input (e.g., body motion, imagined rotation of self and/or other objects, in vitro
laboratory inductions through inner ear caloric stimulation and /or galvanic vestibular
stimulations, and their concomitant neuroimaging correlates) have concluded that observed
behavioral responses for each of the three research clusters are indeed co-associated, at least in
part, with different neuronal core mechanisms:
1. Spatial transformations draw on parietal areas,
2. Body representation is associated with somatosensory areas, and
3. Affective processes involve insular and cingulate cortices.
While all these functions are indeed conducive toward receiving (the common
denominator of) vestibular input, the consensus of caveat in the literature concedes that “even
though a wide range of different vestibular cortical projection areas have been ascertained, their
functionality still is scarcely understood” (Mast, Preuss, Hartmann, & Grabherr, 2014, p. 1).
Perhaps more complex interventions can aid to clarify inter-relationships between necessarily
complex, inter-associative phenomena.
Spatial Cognition as an Internal Model for Perception of Virtual Limb Segments and
Bones
Interestingly, the vestibular system is not only involved in the usual processing of bodyself motion in the physical world, it also seems to play an important role in building and
maintaining a mental representation of the internal world. Even though people are bound to
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physical space, they are able to represent objects and movements mentally in order to optimally
predict actions, respond to events, and to solve new problems.
Influences of vestibular stimulation on tactile perception and body representation in
healthy subjects and patients alike indeed seem neurologically plausible given the anatomical
overlap of vestibular and somatosensory networks (Lopez & Blanke, 2011; Lopez et al. as cited
in Mast et al., 2014). A recent fMRI study that applied tactile and caloric vestibular stimulation
in the same subjects also revealed important overlapping cortical activation in the dorsal
posterior insula and the parietal areas (zu Eulenburg et al. as cited in Mast et al., 2014).
It has now become evident that vestibular information is necessary for maintaining metric
properties of representational space and for encoding, predicting, and mentally simulating
movements in situations that do not involve displacements of the body, as in motor imagery or
imagined tool use. Imaging studies involving patients with vestibular loss (as in Meniere’s
Disease) have demonstrated impaired ability to access object-based mental transformations
(OBMTs – defined here as imagined rotations or translations of objects relative to the
environment) as compared to healthy controls. These findings indicate that vestibular signals are
necessary to perform OBMTs and thereby provide a reliable demonstration of the critical role of
vestibular signals in the cognitive processing of metric properties of objects and their
corresponding mental representations. They suggest that “vestibular loss disorganizes brain
structures commonly involved in mental imagery, and more generally in mental representation”
(Péruch et al., 2011).
Furthermore, studies involving induced sensory imbalance in healthy controls (via
receptor activation of one [ipsilateral] vestibular organ subsequent to caloric vestibular
stimulation; with resultant comparative inhibition from the contralateral receptor) have been
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shown to induce specific "bottom-up" changes in spatial cognitive tasks in healthy controls.
Conversely and potentially-therapeutically, it has also been shown that "top-down" higher
cognitive processes, such as mental imagery, can be demonstrated to alter, effect, and modulate
the perception of induced vestibular stimuli. The spatial-temporal sensing of virtual and actual
limb segments; their corresponding mental representation, and their explorations in proportion
with controlled Feldenkrais® movements involving their correspondent relationships of "pelviships opposite head" are a central feature of the experimental arm of the current study.
Vestibular-Ocular Representation: A Mediator of Body Schema Acuity & Motor
Dexterity?
A second important area of psychophysical research demonstrates remarkable evidence
that vestibular activation is compositionally involved in mediating the neuroplasticity processes
that update and encode for body representation acuity in real time. Studies have now shown that
the perceived size of the hand is increased during caloric vestibular stimulation in comparison to
sham stimulation, implying an enlarged somato representation due to vestibular stimulation.
Numerous other studies have also demonstrated that vestibular stimulation changes the
representation of body parts, including altered sensitivity to tactile input - inclusive of perceived
pain intensity - in relationship to perceived size (Mast et al., 2014).
Interdependently, eye movements also assert and reflect an organizing modulatory effect
affording a sense of stability, congruity, and contiguity of direction for all body movement and
experience. There is direct neurological connection between the eye muscles, the head-neckspine, and vestibular system through the medial longitudinal fasciculus and other pathways.
Within central processing between primary nuceli, the medial vestibulospinal tract is found only
in the cervical spine and above. Its pathways projects bilaterally to infra-medullary regions of the
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spinal cord and is particularly involved in controlling the neurons associated with the spinal
accessory nerves (cranial nerve XI), which innervate the trapezius and sternocleidomastoid
muscles. These muscles are prime movers and stabilizers of the head and neck. Additional and
recursive vestibular-ocular tracts also project upward to help keep the eyes “yoked” together
during rapid head movement and to maintain gaze stabilization during usual locomotion and
transposition. Thus, the medial vestibular projections are of particular significance for linking (a)
vestibular, (b) visual, and (c) somatosensory information through corresponding head-eye-body
movements and to co-regulate whole-body orientation and posture control through the composite
outcome of multi-sensory and variable input (Fitzgerald, Gruener, & Mtui, 2012). Contradirectionally, the lateral vestibulospinal tract projects ipsilaterally down the spinal cord (e.g., the
right inner ear projects down the right side of the body), and thereby serves to maintain balance
and posture by co-regulating para-spinal flexor-extensor muscle tone (i.e., motor control of
antigravity muscles) throughout the trunk, spine and lower extremity (Fitzgerald et al., 2012).
Notable researchers in the rehabilitation of vestibular disorders have stated that the
human vestibular system can be said to “play a key role in the spinal movement symphony”
(Herdman & Clendaniel, 2014). Thus, the vestibular and ocular systems integrate to play an
important role in the multisensory coordination and detection of body representation, with
corresponding informative linkages to background body schema sensory acuity and motor
dexterity. Indeed, many Feldenkrais®-based movement self-explorations involve coordinating,
comparing, contrasting, and understanding (through direct experience) the vital relationships
between movements of the eyes (visual), movements of the head (vestibular), and the
movements of other parts of the body (somato-sensory). These have been seen to have
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observable and beneficial (yet anecdotal) effects towards the resolution of stubbornly persistent
musculoskeletal pain conditions and other mobility deficit problems (Cheikin, 1986-2011).
Vestibular Contribution to Affective Limbic Processes, Body Schema, & Chronic Pain
Modulation
Linkages between parieto-insular cortices and vestibular nuclei have been identified
using fMRI (Eickhoff, Weiss, Amunts, Fink, & Zilles, 2006). Thus, the cerebral cortex
processing of vestibular sensations is known to extend from cortical to cortical projections into
the insula, and at least one exceptional clinical correlation case study report revealed that a small
lesion in the right anterior insular cortex could be implicated as a likely cause for loss of balance
and vertigo after ruling out other peripheral and brainstem causes for the patient's symptoms
(Papathanasiou et al., 2006). In terms of affect regulation and sense of self, the insular cortex is
increasingly recognized as an important area for assigning emotional valence to subjective
feelings and a sense of self-agency and personal relevance to sensory experience. In this, it
contributes a primary basis toward the formation of interoceptive awareness, with added control
of autonomic homeostasis through the afferent-efferent connections between sympathetic and
parasympathetic systems.
Recent experiments suggest that vestibular-insular pathways may also provide a possible
interaction between vestibular and nociceptive processing (zu Eulenburg as cited in Mast et al.,
2014). Cross-modal assessment upon neuroimaging has revealed selectively distinct, shared
activation of the anterior insula by both caloric vestibular stimulation and aversive (tactile heat)
stimuli, as contrasted by more generalized activation of posterior insula by all other
multisensory/multimodal signals - including vestibular, tactile, and non-nociceptive
somatosensory – all converging together when demonstrated upon fMRI. It has also been
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hypothesized that the posterior insula plays a key role in the neural underpinnings of pain
alleviation induced via non-nociceptive vestibular stimulation, and change in orientation, which
in turn is proposed to inhibit the continued generation of pain signaling in the anterior cingulate
cortex (ACC).
Most recently, an osteopathic neuroscience clinical specialty group and research team
conducted a study to assess the incidence of vestibular dysfunction in patients receiving
medication and pharmacotherapy for chronic, noncancerous pain or other underlying neurologic
disorders. They found that vestibular deficits were detected in 66.9% of their patient sample.
Patient ages ranged from 29 through 72 years, with a mean age of 50.7 years for women and 52.5
years for men (Gilbert et al., 2014).
Upon consideration that vestibular information aids in reconstructing the global body
schema, Mast et al. (2014) hypothesized that “vestibular stimulation can alleviate pain by
contributing to ameliorate the impaired body schema and to help restore the “body matrix”
(Moseley et al. as cited by Mast et al., 2014). “Thus, conditions like complex regional pain
syndrome or chronic back pain, where disturbed body representations have been described
(Moseley, 2005; Moseley, Zalucki, & Wiech, 2008), should benefit the most” (Mast et al., 2014,
p. 13).
Vestibular contributions toward awareness of baseline body arrangement, trans-positional
body configuration and coordination within space and time, implicit/explicit attention to
gravitational relationship during novel movement explorations, sensory conflict negotiation,
proportionate action through reduced effort, felt-emotional associations, and the continuous
readjustment to move more fluidly through everyday functional tasks are all-inclusive as key
tenants of comprehensive practice applications being embodied within The Feldenkrais
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Method®. They are conducive to both "optimal use of whole self" and as an ongoing behavioral
template for the revision and enactment of continuous body schema.
Feldenkrais’ Postulates and Vestibular Contributions to Skeletal Organization, Movement,
and Behavior
In his original book, Body and Mature Behavior, Moshe Feldenkrais (1949/2005) had
accurately described much of what has only now come to be revealed through recent advances in
neuroscience and the modern neuro-imaging of vestibular relationships to action, emotion, and
neuroplasticity. First, from an evolutionary and developmental standpoint:
Animals born with a more fully grown brain come with “ready-made” (instinctual)
reactions to external stimuli, and to most stimuli they are likely to encounter in life…But
in man, whose adult brain in several times its weight at birth, has fewer ready-made
responses to external stimuli. His nervous system is growing while the external stimuli
are reaching it…In man, there is no genetic inheritance of language, gait, or any other
muscular activity (and these activities must therefore be individually learned through
extended experience and apprenticeship)… Environment therefore, has a greater
influence on his nervous system than on that of any other animal…Learning, in the most
general sense, means acquiring new responses to stimuli…The bulk of stimuli arriving at
the nervous system is from muscular activity being constantly affected by gravity.
Therefore (upright) posture (and sensory-motor-coordination development) is one of the
best clues not only to evolution, but also to the activity of the brain. (Feldenkrais,
1949/2005, pp. 36-37, 38-39)
A predominating physical feature of the human biped is that the "center of gravity"
relative to "base of support" is maintained at a higher vertical position than to that of any other
animal. As such, there is more propensity to move in any direction more equally and with
minimal expenditure of energy, particularly in rotation. However, the relative 360 degrees of
immediate freedom, much of it imparted through automated potential energy while upright, also
necessitates constraints, and these are neurologically evolved through sensory-motor processes
and the regulatory achievement of motor control.
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As a system, no segment of the body can be moved without corresponding adjustment of
all the others to a new configuration particular to actual circumstance. Rather than attempt to
reduce highly varied and complex acts into predictive-isolated mechanisms consisting of targeted
components, or specific muscle groups, as has been the traditional mode of thinking in analytical
biomechanics and for so much of conventional physical therapy, Feldenkrais instead found it
more useful to describe visible features of optimally synergistic ‘motor control’ functions that
could arise or emerge as explanatory outcomes for such inter-segmental co-operation within a
unified whole system.
First that, (a) as a matter of natural inclination, a body could be neurologically organized
and responsive to initiate for selected movement dimensions in any direction with equal ease;
that (b) it can start a movement without any hesitation, pre-preparation, preoccupation, or any
other energy-consuming preliminary adjustment; that (c) any initiated movement can be equally
and easily reversible; and that (d) all movements are performed with minimum work and
maximum efficiency. In this, “the musculature shows no useless contraction in any part of the
body. All the articulations participate in every act. None is held rigidly in any particular
configuration not dictated by the immediate task being performed” (Feldenkrais, 1949/2005, p.
77). “This means also that no movement unnecessary for the act is done. The body moves,
therefore, smoothly, and describes clear curves and lines. The aesthetic search for design and
purity in movement is thus also satisfied” (p. 72). Conversely, it can be stated that dysfunction
occurs when these qualities of movement become disrupted and mal-synergistic by intrinsically
working against oneself, as can be seen when patients with chronic pain – including LBP and
Fibromyalgia – perform usual and routine exercise movements.
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Similarly, Feldenkrais (1949/2005), as an originating sensory integrationist, knew that
multisensory influences played a key role by stating that “there is no isolated sensory impulse”
(p. 79). In further discussing antigravity mechanisms involved in posture and motor control, and
beyond mere "vestibular stimulation" in and of itself, he stated that "there is (continual)
integrative action of the nervous system, insuring that only one final algebraic sum of all the
incitations reaches the muscle at any one time” (p. 55). These sensory afferent-efferent impulses
derive from multiple sources, including: (a) vestibular labyrinths composed of otoliths (utricle
and saccule) and semicircular canals of the inner ear; (b) the proprioceptive sense organs richly
innervating muscle fibers, tendons, and ligaments between bones; (c) exteroceptive nerve
endings and receptors embedded throughout skin and connective tissue as preliminary contact
surfaces preceding bone; (d) interoceptive and enteric innervations throughout viscera, smooth
muscle, and vaso-motor responses being influential of affect and postural attitude, including their
relationships and responses to autonomic and neuroendocrine functions; and finally, (e)
teleceptors embedded within the head and directly responsive for orientation of head position,
such that paired relationships between eyes, auditory ears, and olfactory nostrils can more
precisely envelop their coordinates in order to apprehend a sense of direction and proximity for
more distant stimuli in the outside and/or virtual-imagined world.
Taken together, orientation in space and in relationship to gravity is an essential function
for any living organism for its continued survival. For the animal kingdom, all perception and
sensation takes place within a background of some form of muscular activity. And though people
are perhaps impervious, habituated, or unaware of the background influence as humans, all
muscular activity is most strictly predicated and shaped by the incessant influence of gravity.
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While the sensory systems outlined above all co-contribute as responses to the control of
movement and body orientation in space, Feldenkrais had stated that
the vestibular apparatus is ‘the co-ordinating chef d’ orchestre’…it coordinates all
sensory impulses that influence muscular tone and attitudes…(and while) we are not
necessarily aware of the special relation of the body to space and orientation, the
vestibular apparatus takes a definite part in every single perception. (Feldenkrais,
1949/2005, p. 79)
Feldenkrais knew that vestibular dysfunction was contributory to sensory distortion for
appreciating the visual size and weight of objects, including the image people make of
themselves and their own body weight. He recognized that loss of balance occurs during episodic
dizziness because one side of the body is sensed as lighter and that righting toward a false
vertical axis becomes inappropriately skewed. In vestibular-based dis-coherence and
disequilibrium, pallor, nausea and vomiting are common, and upon lesser threshold, alterations
in breathing and cardiovascular pulse are in direct relationship to modulatory influences of the
vestibular system onto autonomic and vegetative responses. Finally, he recognized that sensorymotor-vegetative perceptual sets are co-conditioned, co-associated, and inseparable as unified
sensory impressions in experience. “The whole situation may therefore be reinstated by either of
the three elements of a set, or as a total reaction” (Feldenkrais, 1949/2005, p. 82). Consequently,
Feldenkrais postulated and proposed a linkage of vestibular function to the body pattern of
anxiety.
Most generally, the body pattern of fear-avoidance and pain becomes most expressed by
some form of muscular co-contraction being typified in terms of postural defense, under-support
and withdrawal of limbs, or by some other literal or figurative behavior of "holding back."
Feldenkrais observed instinctual patterns across the animal kingdom in response to danger or
perceived threat such that flexor activation first occurs via an initial protective lowering of head
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and curling of trunk, with corresponding inhibition of spinal extensors. This action is
immediately contrasted and counter-reciprocated by strong-antagonistic activation of extensors
via the mechanism of tensile stretch reflexes, being most typically posterior to gravity, as a
precursor to fight, or upon more effectively impacting the ground during flee or flight.
Feldenkrais also recognized a remarkably similar unconditioned reaction of newborn
human infants in response to withdraw of support and falling. As an astute observer of human
behavior and development, he was able to distinguish innately instinctual aspects of universally
biological and physiological responses as contrasted from otherwise independently learned
individual life experience or early pre-conditioning. The sudden acceleration which accompanies
loss of support, disequilibrium, and falling is most likely and intrinsically first detected by the
inner ear vestibular-otolith receptors, with strong immediate activation of the vestibular branch
of the vestibulocochlear nerve (cranial nerve VIII). Co-opted and intricately interconnected with
the cochlear branch of the eighth cranial nerve and thereby diffusive of loud noises being
associated, both pathways (as transmissive of unconditioned physical threats) are conducive
toward inciting strong impulses diffusing into medullary nuclei involving excitation of the vagus
nerve (cranial nerve X); thereby affecting a sudden reflexive diaphragmatic disturbance of
halting the breath with corresponding rhythmic disturbance in the cardiac region – both
contributory toward being sensed as anxiety. Early and developmentally, Feldenkrais thereby
concluded that “the first experience of anxiety is therefore connected with a stimulation of the
vestibular branch of the VIIIth cranial nerve” (Feldenkrais, 1949/2005, p. 85). Furthermore, “the
fear of falling elicits the first inhibition of the antigravity muscles, and that anxiety is associated
with this process” (p. 89). “All other fears and sensations of anxiety syndrome are therefore
conditioned” (p. 87).
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Examined further, the acquired body pattern of anxiety could also serve as a possible
contributory co-determinant and explanatory factor involved in how the development and
maintenance of chronic nonspecific low back pain (CNSLBP) might occur and become sustained
or inadvertently learned over time:
This pattern of flexor contraction is reinstated every time the individual reverts to passive
protection of himself when lacking the means, or doubting his power, of active resistance.
The extensors or antigravity muscles are perforce partially inhibited…(Yet), the muscular
contraction being voluntarily controllable, creates a feeling of power and of control over
sensations and emotions…and (a sense of) passive safety is brought about by flexor
contraction and extensor inhibition….In the long run, this becomes habitual and remains
unnoticed. The whole character is, however, affected. The partially inhibited extensors
become (stretch) weak, the hip joint flexes and the head leans forward…The (preferred
and tonically finessed) pattern of reflective erect standing is (therefore) disrupted…The
antigravity mechanisms are at work without break. Like all fatigued nervous functions,
they are initially overactive; hence the tonic contraction and string-like texture of the
antigravity extensors. (Feldenkrais, 1949/2005, pp. 92-93)
Well before fully developing and implementing his application methods, and well ahead
of his time, Moshe Feldenkrais had hinted at harnessing the power of neuroplasticity long before
"plasticity" itself was to become an appreciative concept emerging through modern
neurosciences. Feldenkrais believed the human condition could be improved toward the
systematic unlearning of faulty behavioral and postural patterns at any age by stating that
the outstanding quality of the human conscious innervations seems to be a unique
capacity to form new nervous paths, associations, and regroupings of interconnections.
Those made while the pyramidal (motor control) tract is growing are the most stable, but
even these are more labile than in other animals. (Feldenkrais, 1949/2005, p. 149)
Flash forward to the 21st century, the very recent article by Mast et al. (2014) again
surmises a role for spatial cognition, body representation, and affective processes as
representative outcomes of vestibular information beyond that of ocular reflexes and control of
posture; these statements by Mast et al. are remarkably consistent with some of the early
functional prognostications between body movement, behavior, and affect that were originally
made and postulated by Feldenkrais as early as 1949:
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Disequilibrium is a stressor indicating an unintended mismatch between frames of
reference. This is where the interface between balance and affective processes—both
phylogenetically old mechanisms—comes into play. Disequilibrium and falls are a threat
to the organism that triggers an affective response. In real life, it is possible that the
body’s immediate and fast reflex loops precede the affective response such as when we
miss a step on the stairs without actually falling. We start to feel the increase in heart beat
just after having successfully avoided a fall. The existence of this vestibulo-affective
interaction will unfold to its maximum when immediate correction of posture is impeded.
Affect and body motion are interconnected, and future research will be needed to explore
the underlying mechanisms. (Mast et al., 2014, p. 20)
It is important to note that the experimental arm of the current intervention study (VRB3
+ FM) did not perform traditional "vestibular rehabilitation" or balancing exercises, but rather
highlighted the corresponding positon of the vestibular apparatus’ representative spatial location
within the skull through a combination of visually projected coordinates and haptic self-touch
techniques (see Figures 31 and 32). It also used a succession series of Feldenkrais®-based
movements throughout the study to differentiate head and eye movement, but only in secondary
response to more-proximal pelvis-hip initiation of movement.
As a contrasting research design-based response to the traditional core-stabilization
model of motor control (specifying mainly the TrA and LM trunk musculature), it is worth
suggesting that the semi-circular canals of each inner ear - being fixated and compartmentalized
within each temporal bone - are quite likely (and with good reason) to be the most fixated and
stable of all structures within the entire human body. That is to say that "gyrating the position of
the gyrator itself" would certainly result in less reliable and unpredictable "mixed-signals" with
regard to control of dynamic posture orientation and head in space. While it’s anatomical preposition can be considered to be a highly fixed-variable in itself, awareness of its dynamic
involvement in motor control, body schema, and personal affect is indeed quite multivariate and yet skeletally dependent.
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Current Status of the Feldenkrais Method® and the Proposed Interventions
“We act in accordance with our self-image.” So states Moshe Feldenkrais (1972/1990, p.
3) in his book: Awareness Through Movement. He furthermore stated:
The behavior of human beings is firmly based on the self-image they have made for
themselves. Accordingly, if one wishes to change one’s behavior, it will be necessary to
change this image.
What is self-image? I would argue that it is a body image; namely, it is the shape and
relationship of the bodily parts, which means the spatial and temporal relationships, as
well as the kinesthetic feelings. Included with this are feelings and emotions and one’s
thoughts. All of these form an integrated whole. (Feldenkrais as cited in Beringer, 2010,
p. 3)
A biographical account of Moshe Feldenkrais and his life can attest to his integration of
scientific disciplines, systemic inquiries, practical applications, innovations, and international
teachings that would later become disseminated and known as The Feldenkrais Method
®
worldwide.
Moshé Pinhas Feldenkrais (May 6, 1904 – July 1, 1984) was born in Slavuta, in the
present-day Ukrainian Republic. Feldenkrais received his Bar Mitzvah, completed two years of
high school, and received an education in the Hebrew language and Zionist philosophy.
Subsequent to World War I (WWI), in 1918, Feldenkrais left by himself on a six-month journey
to Palestine where he worked as a laborer doing construction until 1923 when he returned to high
school to earn a diploma. While attending school he made a living by tutoring and teaching selfdefense. After graduating in 1925, he worked for the British survey office as a cartographer. In
1930, Feldenkrais went to Paris to attend university. He graduated in 1933 with specialties in
mechanical systems and electrical engineering from the École des Travaux publics de Paris.
Thereafter, he worked as a research assistant under Frédéric Joliot-Curie at the Radium Institute,
while studying for his Ingénieur-Docteur degree at the Sorbonne. Feldenkrais later married Yona
Rubenstein, a pediatrician, in 1938 wherein he became further intrigued to observe child
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development. From 1939-1940, he worked under Paul Langevin doing research on magnetics
and ultra-sound.
At the advent of World War II (WWII), Feldenkrais escaped to England in 1940, just as
the Germans arrived in Paris. Becoming commissioned as a nuclear physicist and scientific
officer in the British Admiralty, he conducted anti-submarine sonar research in Scotland from
1940-1945, while also teaching Judo and self-defense classes to his military ranks, which led to
his 1942 publication manual of Practical Unarmed Combat, and Higher Judo in 1949.
Feldenkrais began working with himself to deal with knee troubles that had recurred during his
escape from France, and while walking on submarine decks.
Feldenkrais gave a series of lectures about his new ideas, began to teach experimental
classes, and work privately with some colleagues. In 1946 Feldenkrais left the Admiralty,
and moved to London. He published his first book on his Method, Body and Mature
Behavior in 1949. During his London period he also directly studied the work of other
somatics and consciousness pioneers including George Gurdjieff, F. M. Alexander, and
neuro-ophthalmologist, vision method trainer, William Bates... (Reese, 2015)
In 1951, Feldenkrais returned to Israel to direct the Israeli Army Department of
Electronics. This era marked his difficult transition from a securely-known, distinguished
physicist and research scientist to pioneering his own work and discoveries about the human
condition into greater practicum, and out of obscurity. “Around 1954 he moved permanently to
Tel Aviv and, for the first time, made his living solely by teaching his Method” (Reese, 2015).
In the late 1950s through the mid-1960s, awareness of his methods grew, and Feldenkrais
presented his work through lectures, presentations, and interactive workshops throughout Europe
and North America. His discoveries caught the attention of cross-cultural anthropologist,
Margaret Mead, who after observing his demonstrations being congruent with cybernetics and
systems theory, had declared at a televised news feature event that “The Feldenkrais Method is
the most sophisticated and effective method I have seen for the prevention and reversal of
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deterioration and function.” A photograph of her meeting Feldenkrais, together with
neuroscientist Karl Pribram, is captured in Figure 8.
Figure 8. Telecast Interview of Moshe Feldenkrais. (a) Karl Pribram, and (b)Margaret Mead.
Moshe Feldenkrais (seated at right), with (a) Karl Pribram (left and kneeling), and (b) Margaret
Mead (center and left). Images courtesy of International Feldenkrais Federation (IFF).
Throughout the 1960s, 1970s, and into the 1980s, Feldenkrais presented public
workshops on Awareness Through Movement® and gave public demonstrations and private
sessions of Functional Integration® throughout Europe and in North America, including a
program for human potential trainers conducted at the famed Esalen Institute in Big Sur,
California in 1972. Within this time, he also began to enroll and train teachers in the method so
they could further develop and present the work to others. He trained the first group of 13 Israeli
and European teachers in the method from 1969–1971, in Tel Aviv. Over the course of four
summers from 1975–1978, he trained 65 teachers in San Francisco Bay area at Lone Mountain
College under the auspices of the Humanistic Psychology Institute. In 1980, 235 students began
his four-year summer teacher-training course at Hampshire College in Amherst, Massachusetts.
After becoming ill from onset of stroke-related illness in the fall of 1981, and after teaching only
two of the planned four summers, he returned to his original studio at Alexander Yanai Street in
Tel Aviv, and had continued to mentor trainees to complete and carry forward his future
programs, but had otherwise stopped teaching publicly. He died on July 1, 1984. Photo-captured
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images to both demonstrate and commemorate his last formal training program are depicted in
Figure 9.
Figure 9. Moshe Feldenkrais Teaching at Amherst, MA, circa 1980. Images courtesy of
International Feldenkrais Federation (IFF).
Toward the end of his prolific life, over 1000 of his audio sessions at roughly 45 minutes
each – and each a creative and fruitful exploration on its own – had been originally recorded
during live presentations in Hebrew. Much of this most creative work has only recently been
transcribed into English, French, and German through the mutual cooperation and efforts of The
International Feldenkrais Federation (IFF), and The Feldenkrais Guild® of North America
(FGNA).
Differences Exemplified through Feldenkrais Method® Features of Application
A predominating feature about Feldenkrais Method® applications is that there is much
more happening beneath the surface of techniques for touch and movement than simply moving
stuff around. Karl Pribram, M.D., Neuroscientist, Stanford University Professor, Winner of the
2000 Havel Prize in Neuroscience, and co-developer of the Holonomic Model of Brain
processing theory is quoted to have said: “Feldenkrais is not just pushing muscles around, but
changing things in the brain itself.” The Feldenkrais Method® of somatic education seeks to link
novel and discriminative sensory–motor—informational learning experiences (perception
through action and quality of attention to novel spatial-temporal configurations of embodiment
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supplemented by imagery) with neuro-plastic changes in the brain in conjunction with optimal
use of self through sensing the core of entire skeleton in the performance of everyday
generalizable life tasks in a functionally applicable and reproducible context. In referencing "the
essential unity of mind and body," Feldenkrais believed them to be "one and the same," as two
sides of the same coin, to which as an objective reality, they are not just somehow related, but
rather, “an inseparable whole while functioning. A brain without a body could not think”
(Feldenkrais as cited in Beringer, 2010, p. 28).
In practicum, Feldenkrais never dealt with the affected part or articulation of the body
before first bringing about an improvement in the head-neck relationship, in grounding at an
expanded base of support while in supine, back-lying repose, and in service of breathing. These
in turn could not be achieved without factoring involvement for spine and thorax configurations,
and nearly pre-requisite to this, enabling a series of adjustive corresponding and differential
explorations to discover and select for improving the relationships between pelvis and abdomen.
While Feldenkrais acknowledged that “some improvement in tension can be achieved through
muscular awareness alone,” he added that “beyond that, no improvement will (likely) be carried
over into normal life unless people increase awareness of the (entire) skeleton and its
orientation.” Elaborating much more specifically, and as a central premise re-discovered
subsequent to the current study’s initial intervention design, he stated that:
Here the most difficult joints are the hip joints. Awareness of the location and function of
these joints is (virtually) non-existent in Western cultures, as compared with that of
people who sit on the ground and not on chairs. The chair sitter is almost without
exception completely out of place when locating the hip joints. Moreover, chair sitters
incorrectly use their legs as if they were articulated at imaginary points in the body image
and not where they actually are. (Feldenkrais as cited in Beringer, 2010, p. 36)
Feldenkrais Trainer, Richard Corbeil, of Seattle-Eastside Feldenkrais Teacher
®
®
Trainings, Kirkland, Washington, United States of America (USA), had stated at an in-house
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advanced training (in 2002) that the unique intent quality of a Feldenkrais® Practitioner’s touch
was “to construct and project an image.” It is this primary feature of clarity of contact and
linkage to function, and in such manner that both practitioner and client "co-construct an image"
of how they both correlate and contribute toward each other’s actions in the real time present
moment, that differentiates Feldenkrais Functional Integration from most other manual,
®
®
manipulation, and other "bodywork" therapies. Of which, isolated structural entities and
disordered biomechanical tissue categories most predominate, but not their composite functions
as linked to whole person in simultaneous skeletal arrangement to their presenting environment.
Each Feldenkrais® lesson is structured around a particular function.
Feldenkrais defined a function as movements with a definite purpose such as walking,
bending, turning and so on. He did not deal with movements around a certain area or a
certain part of the body, but rather with the function and its components...we are not
dealing with movements, but rather with improving the organization of the function.
(Shelhav & Golomb, 2003, p. I)
Feldenkrais emphasized that change in behavior, as applied to function, did not simply mean
substituting or replacing one mode of acting with another, which would amount to nothing more
than static (1st order), or non-systemic change. Instead, he suggested a mode of approach that
could develop a larger scale ‘2nd order’ systemic change; a fundamental change in the dynamic
arrangement, organization, and order of process within the function.
Since each function is made up of many components, and since any one component may
be used in various functions, improvement in the components of one function can bring
about improvement in other components that participate in other functions....
[Furthermore,] there are no Awareness Through Movement® (ATM ) lessons which do
not deal, in one way or another, with these primal elements of ‘equilibrium’...having to
do with the coordinated distribution of weight being coordinated throughout the skeleton.
(Shelhav & Golomb, 2003, p. 45)
®
Such delicacy of functional balance while moving indeed requires a listening and attentive
quality of both tactile and kinesthetic awareness.
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In this model, if a quality of touch or movement – despite its small magnitude, its
attentive slowness of pacing and listening, and its inquisitively gentle nature -- should, in whole
or in part, inadvertently trigger a pain signaling output from the client, then the quality of the
activity itself is also concurrently modulated, altered, and adapted to differentiate the activity in
some other way that re-creates a new distribution of attention and a new context for curious
open-ended exploration in facilitating an alternate possibility in sense, feeling, or action. This
can take the form of re-orienting the person into a constructive or novel rest position with respect
to reducing the influence of gravity and of enhancing internal-external support; re-directing
attentional sets by approaching and comparing the movement from a remote distal vs. local
proximal perspective, providing strategic placement of external positional supports (props,
pillows, foam rollers), or by offering internal images that could functionally contextualize the
activity toward something purposeful or personally relevant; and even through the practitioner
altering his or her own body arrangement within the subject’s peri-personal space, so as to
facilitate a social-perceptual condition for enhancing a more informed quality of support and
movement.
Through richly interactive comparisons and contrasts, new movement variations and
novel sensory explorations become much more important than the usual and customary
adherences to blind repetition. Thus, non-reproduction of symptoms and a process for learning to
move without pain can often be strategically selected for accomplishing at least an initial
approximation for the particular pain-avoidant task that yet remains necessarily desired, but from
a much more varied, newly coordinated, and internalized perspective as to how.
Feldenkrais acknowledged and considered that there are two major roads for changing a
person’s behavior – either through the psyche or the body. However, he believed that real change
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required a more integrative process, such that both the body and the psyche could be changed
simultaneously. Otherwise, the change will last only as long as a person can veritably maintain
partial awareness in not reverting or relapsing back into spontaneous habitual patterns. In noting
that thoughts and feelings are fleeting and abstractive in nature, he believed that approaching
mental and physical unity through the body was more reliable and simpler because muscular
expression is more concrete, more reproducibly tangible, and easier to locate. Again, in
recognizing mind-body unity as an indivisible gestalt (and in contrast to mind-body separateness
or dualism), Feldenkrais remarked that:
the state of the cortex is directly observable on the body’s periphery by these
configurations of posture and muscular tonus. A change in the central nervous system
always means a change in these configurations. Each, as we have pointed out, is the other
side of the same coin. (Feldenkrais as cited in Beringer, 2010, p. 24)
Thus, somatic education approaches, like The Feldenkrais Method®, incorporating visualhaptic imagery with kinesthetic feedback through movement are yet another composite inroad
toward the cultivation of aggregation of emergent therapeutic neuroplasticity models, which aim
to improve function and develop long-term potentiation through immersive sensory-motor
experience, changing dimensions and perceptions of surface contact, and a continuous platform
for body learning. Feldenkrais' theory is that cognitive thinking, emotions, and feeling, sensory
perception, and especially the qualitative organization of movement, are all closely interrelated
and influential of each other as a unified system.
In sum, “The Feldenkrais Method® aims to improve people's quality of movement, their
overall physical function, and their general wellbeing by increasing students' awareness of
themselves and by expanding their movement repertoire” (Claire, 2006, p. 76). Education about
“the reduction of pain and the elimination of biomechanically unsound movement habits is often
an important part of this process” (Knaster, 1996, p. 233). Some criticisms of Feldenkrais®
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movements from participants interviewed through qualitative research indeed has indicated that
"some ambivalence about the method was expressed, especially regarding the difficulty to
continue the exercises at home" (Ohman, Aström, & Malmgren-Olsson, 2011). By nature of its
extensive sequential diversity and variety, this is understandable.
The Feldenkrais Method® in Research
A review of case utilization and prior field studies for implementing The Feldenkrais
Method® (FM) for chronic back pain - and for pain management in general - has been
consolidated by James Stephens, PT, Ph.D., while he served as Research Chair for The
Feldenkrais Guild® of North America's 2010 Research Meeting:
Pain management: Case studies describing the resolution of chronic back pain following
the failure of other methods to ameliorate the problems had been published by Lake and
Panarello-Black. A retrospective study of 34 patients using FM as an adjunct to treatment
in a chronic pain management clinic showed that FM helped to reduce the pain and
improve function and still was used independently by patients 2 years’ post-discharge.
Dennenberg showed decreased pain and increased functional mobility using FM as a
component of treatment for 15 pain patients. The primary result of this study was to
show that there were changes in the pattern of health locus of control in patients
participating in FM. A study using a group ATM® intervention with five fibromyalgia
patients showed significant decrease in pain and improved posture, gait, sleep, and body
awareness. Lake showed changes in posture in patients with chronic back pain following
FM. Chinn et al showed improvements in functional reach in symptomatic subjects.
Ideberg showed significant change in pelvic rotation and pelvic obliquity during rapid
walking in 10 patients with back pain compared to normal controls, following a series of
Functional Integration lessons. Narula showed decreased pain and improved function,
including improved biomechanical efficiency, measured by motion analysis, in a sit-tostand transfer from a chair, in several people with rheumatoid arthritis following 6 weeks
of ATM® lessons. (Stephens, 2012)
More recently, however, in a region of the world well known for prolific contributions to
clinical research across many disciplines, a national review board did not bring good news. In
2015, the Australian Government's Department of Health published the results of a review of
alternative therapies that sought to determine if any were suitable for being covered by health
insurance. The Feldenkrais Method® (FM) was among one of 17 alternative therapies being
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evaluated. Among 10 published systematic reviews (SR) and only three randomized controlled
trials (RCT) involving only three clinical conditions (neck and shoulder pain, anxiety and low
back pain, and fall risk for older adults) and a total of 178 participants, it was determined through
systematic review panels that “The effectiveness of Feldenkrais® for the improvement of health
outcomes in people with any clinical condition is uncertain” (Baggoley, 2015). Overall, it was
concluded that available evidence remains limited by insufficient statistical power due to few
numbers of qualified RCTs, and of small sample sizes. “Future research, if conducted, should
focus on rigorous, well-designed RCTs that assess the effectiveness of the Feldenkrais Method®
in improving health outcomes in specific patient populations” (Baggoley, 2015).
A concurrent, perhaps more updated, systematic review by Hillier and Worley (2015)
conversely identified 13 single, randomized-controlled studies that were able to report
statistically significant, positive benefits compared to modest control interventions for areas
involving neck pain vs. neck comfort after single sessions: Decreased effort of upper body
torso/limb discomfort after group classes; improved balance in people with MS after eight FM
sessions; improved body image parameters in people with eating disorders after a nine-hour FM
course; had a reduction in nocturnal bruxism in young children after 10-week course of FM
lessons; and improved dexterity in healthy young adults after a single session of FM class. Seven
of the 20 studies failed to show any superior positive effects of FM compared to other
comparison modalities.
The authors advocated that clinicians and professionals may promote the use of FM in
populations interested in more efficient and comfortable physical performance, for increasing
self-efficacy, and for improving balance in older people. The study’s recommendations also
concurred for implications in future research by stating that (a) best practice designs are needed
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to further higher quality research trials, by (b) comparing FM to other modalities in the form of
well-designed RCTs, and that (c) the mechanisms of effect underlying the purported benefits of
the Feldenkrais Method® also need to be investigated (Hillier & Worley 2015).
Applying the Proposed Intervention against Core Stabilization
Feldenkrais® trainer, Frank Wildman, has been quoted from his workshop, The Brain as
Core of Strength and Stability, stating that:
The brain doesn’t think in terms of muscles or muscle groups (as if dissected out from
one end-point to another), it rather images and selects the necessary and particular fibers
from a variety of muscle groupings in relation to whole body proportion references in
order to accomplish the perceived demands of a task. (Wildman, 2009)
Feldenkrais® practitioner/physical therapist, intervention advisor, and colleague, Gordon
Browne, of Seattle-Bellevue, Washington, USA, has authored A Manual Therapist’s Guide to
Movement: Teaching Motor Skills to the Orthopedic Patient (Browne, 2006a). Although he cited
the work of Hodges (University of Queensland, Australia) as “a great start in rethinking the
whole approach to low back pain, we need to expand the concept of inter-segmental stabilization
to include the chest and thoracic spine, the feet and knees, and most especially the hip joints”
(Browne, 2006a).
He further stated:
It is my suspicion that this arthrokinematic system (the transversus abdominus and
multifidus muscle groups selected to function in isolation as primary intersegmental
spinal stabilizers) has corollaries elsewhere throughout the body. If the lumbar spine is to
be stable, then the pelvis needs to be stable on the femurs, the tibia needs to be stable on
the femur, the tibia needs to be stable on the talus, and the foot needs to be stable on the
floor. (Browne, 2006a, p. 233)
Indeed, recent trends regarding the importance of "regional interdependence" becoming
applicable to everyday physical therapy practice can finally be cited to support this view
(Reiman, Weisbach, & Glynn, 2009; Sueki, Cleland, & Wainner, 2013). As stated earlier,
"regional interdependence" can be understood in terms of new clinical reasoning models,
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indicating that “seemingly unrelated impairments in a remote anatomical region may contribute
to, or be associated with, the patient’s primary presenting complaint” (Wainner et al., 2007, p.
658), most notably citing hip joint relationships to low back problems (Cibulka, Sinacore,
Cromer, & Delitto, 1998; Porter & Wilkinson, 1997; Reiman et al., 2009).
Furthermore, exercise effects and neuroscience correlational studies are now confirming
a more systemic and dynamic view by citing some added importance for enriching the variability
and not just the routine for neuro-musculo-skeletal functions in rehabilitation – and also for
everyday fitness lifestyle habituations in stating that “it is not isolated physical activity itself that
is ‘good for the brain’…but rather physically skillful activity in the context of (variant) cognitive
challenges” that matters the most (Fabel & Kemperman, 2008; Kleim et al., 2007), and
especially as people experience sensory-motor learning situations rich in complexity and novelty
that could presumably benefit from more new neuronal and synaptic connections.
The overall hint here is that there are no key stabilizer muscles per se, nor is there strong
rationale for exacting a precisely repeated invariant routine for real world contingencies in
selecting for optimal adaptive stability. Any set of muscles can serve a stability function to some
degree of proportionate representation contingent on task. The common denominators that
remain constants are the constraints of the skeleton itself, and the coordinative structures of the
brain that organize them.
Inherent to the design of the intact skeleton are certain densities and proportions that
optimize a support into action strategy, and from which varied conditions necessary for the
transmission of biomechanical stresses can be more effectively selected, constrained, and
predictably controlled. In particular, when compared to the lesser predictive neuromuscular
contractile or "soft tissue" muscular elements (from which increased variability necessitates a
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greater synergistic requirement demand for resolution and selection of necessarily regionally
inter-dependent relationships), there is also the corresponding added demand for necessarily
invoking a much more vast array of contrasting and potentially antagonistic functions; being less
efficiently contributory to the desired or predicted function.
Indeed, of all the body tissues and/or body systems that can be purported to have built-in
constraints against excessive motor control variances and degrees of freedom (and therefore,
greater intrinsic predictability), it is perhaps the inner scaffolding and intrinsic lattice-work
within the inherent design and distribution, and relative solidity of the intact human skeleton that
most probably ranks # 1. Thus, in these models, the facilitation of an isolated muscle contraction
to a localized region or part is of minimal importance for motor control compared to developing
an optimal use for the intrinsic design of the skeleton, as guided by enhanced visual imagery,
sensory dexterity, and movement patterns guided by global synergistic intent. Therefore, there
are functional corollaries and considerations to cite variables that must necessarily exist well
beyond the concept of "core specific" muscle entrainment of Transverse Abdominis (TrA) or
Lumbar Mutifidus (LM).
Perhaps deploying the use of an entire, realistic, and life-proportioned model skeleton,
plus, a therapeutic construct for its functional representation as a whole system to thereby
facilitate and invoke a more proportionate distribution of whole person movement using The
Feldenkrais Method®, is yet another treatment and training option to consider?
Evolving Practice, New Visual-Haptic Techniques: The Origin of VR Bones™
Through over 20 years of clinical applications experience, my certification in The
Feldenkrais Method® has continually influenced and developed a large portion of my practice
approach, my personal-professional-sensory development, and a continually evolving treatment
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philosophy long since it was first awarded in 1996. It now continues to grow further to influence
my development of conducting current research in support of somatically-inferred discoveries
and to disseminate their clinical application into new areas upon validation. Even today, the
method still remains in the periphery of mainstream practice, and a unique and relatively rare
certification among a wide diversity of rehabilitation professionals, and from which, its
applications continue to differentiate.
At the start of the Millennium (2000-2002), I attempted to construct a new and novel
treatment approach known as Vestibular Ergonomics™. This was accomplished using Vestibular
Apparatus location, perceptual awareness, and interactive anatomical modeling as a 3-dimensinal
imagery concept for employing “internal ergonomics” to navigate the seated work desk
(computer-keyboard-visual display interface) environment as an intervention combined with
"whole-self" Feldenkrais movements to remedy the effects of sitting posture fatigue and for the
®
treatment of repetitive strain problems being attributable to work-related musculoskeletal
disorders involving symptomatology throughout regions of the head, neck, upper back, arms, and
hands. It was intended to be compared against a routine prescriptive approach to simple manual
stretching techniques at the computer desk, as described in a popular self-help book at the time,
all while controlling for psychological distress variables being accounted for via stratified
random assignment of participating volunteers who scored excessively high thresholds on the
Occupational Stress Inventory-Revised (OSI-R). This project was soon deemed as impractical at
the time, given the constraints of restricted access to employees, worksite office environments,
and corporations during an extended period of heightened national security after the events of
9/11/2001, and the project was subsequently abandoned.
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From 2003-2005, I considered an alternative research question and preliminary design for
re-training maladaptive and habituated skeletal-postural configurations of chest-thorax and intercostal diaphragm to purportedly enhance the effectiveness of respiratory biofeedback and
resonant frequency training using Feldenkrais directed movements; and for examining their
®
comparative effects on rapidly producing and maintaining an optimal measure of sympathetic –
parasympathetic balance as measured by increasing Heart Rate Variability (HRV) for a
population of subjects with generalized anxiety disorder and episodic panic attack. This too
proved impractical, as both the population and the technique – though interesting – did not
constitute my usual scope of everyday clinical practice.
From 2005-2006, I received a set of anatomical loose bones for product demonstration
and advocating for educational product re-sale at Feldenkrais Conferences via courtesy of their
manufacturer: Pacific Research, Inc. (also well-known within the orthopedic internship-surgical
apprenticeship trade as ‘The Sawbones Bone Factory’) of Vashon Island, WA. Nothing else was
®
known about what would come of it. See Figure 10.
(a)
(b)
Figure 10. Discovery and Implementation of Proportionate Skeletal Models. (a) Newly acquired
full-scale and proportionate skeletal models placed alongside the full scale model articulated
skeleton, circa 2005; and (b) a personal depiction of prelude and foreshadowing as to how
Feldenkrias Method® based functional applications and body schema-based multi-sensory
perceptions would later lead to the development of Virtual Reality Bones™
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Uncovering a Universal Deficiency in the Sensory-Perceptual Acuity of Background Body
Schema via a Corresponding Normative Comparison to Anatomical Reference Models
Since acquiring a set of anatomical bones in 2005-2006, the following sets of exploratory
dialog for directive attention and introspective touch have now become a routine commonplace
inquiry during the daily course of my clinic’s practice. For each new patient with LBP, I quote:
With the precision of two finger widths at your fingertips...and somewhere between your
base ribs and your knees.... can you pinpoint the exact location of where your own your
legs attach to your own body - via your torso? These would be the ‘ball and sockets’ or
‘hip joints’ that support your own weight during everyday standing balance and walking.
Within this usual course of practice, I discovered through "practice-based evidence" that
there was almost universal misrepresentation of discernment for locating, with precision and
anatomical accuracy, the exact location of an articular axis that was truly representative for
depicting "actual hip joints'" articular surface among all patients, but mostly in LBP patients
when queried. Figure 11 demonstrates a tri-plane axial proximation of location for true hipsocket axis, where head of femur meets concave cup of acetabulum.
Figure 11. Tri-Plane Location of Hip Socket Axis. Pin-pointing a Tri-plane anatomical location
of hip socket axis where femoral head meets acetabulum for the transmission of antigravity and
ground reaction forces during all biped locomotion.
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Looks of confusion and curious bewilderment would typically accompany this open
inquiry as well, as they lay on back with legs supported over foam roller cylinders in a
proportionate size arrangement – typically six-inch diameter behind knees and three-inch
diameter behind ankles to simulate a prospective natural sway dimension for upright standing –
and while relieving pressure from the all too common muscular excesses in lumbar para-spinal
extensor tone that occurs when most LBP patients lay supine and with their legs fully extended
without supports. Figures 12 and 13 depict a typical exploration of this all too common
perceptual and/or clinical phenomenon.
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(a)
(b)
(c)
(d)
Figure 12. Testing for Hip Socket Anatomical Axis Perceptual Acuity. (a) Opening inquiry in
supine supported position; then, (b) order of sequence depicting the most common perceptual
mislocalization response site (estimated to occur in at least 85% of all respondents) for the
anatomical mislocalization of hip sockets; followed by (c) the initial deployment of skeletal
model femur bones as an intervention /correction for improving the informed accuracy of visualtactile acuity; and finally, (d) a more anatomically accurate perception for re-localization of
"true" hip sockets.
An additional sample distribution of collected photos being indicative of observable
disparities for what could almost be routinely considered as a universal phenomenon in
association with the continuing prevalence and persistence of low back pain affecting greater
than 80% of the population as well as other neurological or musculoskeletal disorders which
adversely affect everyday locomotor functions. These are captured and depicted in Figure 13.
Through daily practice and observational testing of patients with a variety of conditions, but
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especially for CNSLBP, I have found that the inability to accurately discern and locate actual
hip-socket axes as "true spatial coordinates" depictive of anatomically accurate representations
for the gauging of perceptual acuity for one’s own body schema is almost always impaired.
Again, a montage sampling of these disparities being associated for recurrent low back pain
problems are depicted in Figure 13.
Figure 13. Sample Distribution of Disparities in Accurate Perceptual Localization of
"Anatomical Hip Sockets" Commonly associated for Patients Presenting with Recurrent or
Persistent Low Back Pain Problems.
Upon continuing comparative observation, I also discovered that a variant trend was
emerging through a sub-population of individuals with more longstanding and/or functionally
incapacitating levels of severity in chronic pain. Generally, I found that the more chronic the
problem, the less accurate and more distant (the more distorted? the more asymmetric?) is the
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perception of anatomically accurate localization for regional body parts, especially deep articular
joints. Known cases are depicted in Figure 14.
Figure 14. Clinical Distortion of Body Schema Acuity for Hip Sockets in Chronic Low Back
Pain. Photo-captured responses indicating "clinical distortion of body schema acuity" and
correspondent asymmetric disparity for accurately locating their "best perceptual estimate" for
visually-tactilely "pinpointing" the exact location of anatomical hip joints (ball and socket axes)
as sampled from two patients with long standing chronic nonspecific low back pain (CNSLBP)
and with duration greater than five years. *I speculate that chronicity of pain conditions over
time and their corresponding movement dysfunctions and aberrations of motor control (as maladaptive and developed over time) may be positively correlated to greater discrepancies of not
being able to discern an appropriate level of internal body reference that is comparatively
consistent with "more discernable body schema acuity" of which the latter can become more
consistently predictable through the use of high-quality anatomical skeletal models serving as
ideal frames of reference for re-discovering correspondent proportionally and more accurate
actuality of body part representation that is closer to ‘true’- and most particularly in cases for
highlighting and comparing the position(s) of lesser accessible deep articular joints.
Usual treatment interventions involving the use of thermal or electrical modalities, antiinflammatory NSAIDs and/or other pain meds, relaxation or medical massage, passive spinal
manipulation, traction or decompression therapy, range of motion exercises and back
strengthening, targeted flexibility and core stability exercises, or any other approach based on
exercise performance impairment, structural lesion or malformation, or any other ascribed
medical diagnosis or tissue-based-pathology; all seemed especially irrelevant and invalid for
approaching what could now be better classified as a perceptual misrepresentation phenomenon.
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Thus, as a necessarily valid (yet elusive) prerequisite to any future treatment plan,
something of a "perceptual clarification intervention" was needed to more accurately discern and
locate a more refined, tangible, and experiential basis for more accurately accessing internal
references for body awareness/body image/body schema, and concurrently matching each
patient’s phenomenological experience and exploration toward re-referencing and clarifying a
more predictable and accessible anatomical benchmark to be found in the external world.
Somewhere between intuitive awareness and an unintended discovery over time, the fully intact
life-sized model skeleton occupying the out of the way corner of my treatment room, together
with a scattering of life-sized anatomical skeletal and vestibular models laying around the office
space would readily lend themselves toward a new framework of perceptual intervention in
helping to bridge the gap.
“Virtual Reality Hip Replacements” via Routine Deployment of a Life-Sized Femur Model
As has been originally developed and now routinely implemented in my practice, the
treatment, which most often occurs the first day for a majority of patients, and without regard or
relevance to their particular diagnosis (unless a clear contra-indication was evident), and usually
within the latter 15 minutes of their initial intake appointment and correlative assessment, my
team now routinely administers the use of "visual-tactile applications" of anatomical skeleton
models. Their use is not to explain pathology (as is usually the case for display models), but
rather to convey a clearer depiction for sensory awareness by converging a geometric visualspatial sense for a outlining a more accurate location of femoral head-acetabular /articular joint
surfaces at the central axis point relationship for either L or R or both hips.
This is accomplished by (a) having an extra, separate, full length femur bone being
shown adjacent (as a replica or replication) to the one actually attached to a full-scaled, life sized
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neighboring skeleton propped -up on its own display stand in treatment-exam room. A sense of
regional inter-relationship for geometric proportion was conveyed in the sense of stating that
“the length of Left to Right widths between hip socket locations roughly equates with the same
width of our eyes,” by first indicating the vicinity of the pelvis hip sockets as a "local-focal
picture" and then upon stating that “this is the big picture,” I would place my eyeglasses over the
face landmarks of “an astute-looking professor skeleton” and then immediately fold the ear
pieces and transfer the width of the frame’s corners to match the width of the spaces between L
and R acetabulum, within and above the supra-pubic symphysis and anterior to the inner ring
(pectineal line) of the inner ilia of the pelvis. This process is procedurally displayed in Figure 15.
Figure 15. Demonstration of Corresponding Dimensional Relationships between Width of Hip
Socket Joint Axes and Width of Temporal Bones via the Visual Aid of Head of Femur Models
and Eyeglass Frames.
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I would then (b) ask the patient to place the width of their index and middle fingers (both
between and inclusive of each hand) to match the precise width of their own imagined eyeglasses
or sunglasses and to direct this "converged fingertips" arrangement to a space overlying the
anterior creases slightly above the groin to either side of the ilia to furthermore imagine an
overlay of where the new location for a precisely located actual hip socket might be. I would
then (c) implement use of the anatomical femur model as a "virtual limb segment" to offer the
patient a “virtual reality hip replacement” procedure, but that I would also need their help.
There would be no need for anesthesia and no loss of blood. I would ask them to
"imagine that they are a comic book super hero with laser beam finger tips that can aptly
and precisely direct a vivid and clear beam virtually anywhere to illuminate and detect a
location."
I would then proceed to place the model femur to overlay the femoral head directly over
the anterior hip crease with the distal end roughly corresponding caudally in the direction
of the knee. The patient was then asked to conform their hand around the spherical shape
of the bone model’s femoral head while I simultaneously apprehended the roundness of
the patient’s heel at the calcaneus with a similar conforming hand shape hold and stating
that “the size of your heel is likely roughly the size of your hip socket location”…to
which I would then direct them to converge all five finger-tips together to form a
convergent laser beam to direct it in an A-P (anterior-posterior/front to back) line of
direction focalized over the hip crease while I covertly slipped out the femur bone to set it
aside for the moment...I would then state that “I too am a comic book super hero with
laser beam fingertips and that I was going to assist them in solidifying their new hip
replacement."
Most patients would invariably reveal a limitation in the direction of internal rotation and
a corresponding tendency to hold both the pelvis and the trochanter muscle insertions (i.e.,
piriformis, obturator externus) in a retracted, extensor biased direction, which I would
demonstrate by holding the model femur in a similar orientation to mimic a tactilely observed
external rotation, holding pattern tonal bias. Attempts to "directly stretch" a shortened muscle
were deemed futile, whereas instead a known Feldenkrais® principle of "going with and
supporting the direction that is already happening" and connecting a vector line in the direction
of head and spine in an upwardly projected manual diagonal was performed to convey a sense of
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relationship that can be felt to informationally occur in more rapid and conducive fashion, with a
corresponding shift of head position also typically happening upon the application and
completion of this manually applied maneuver.
I would then apply a vector line of manual support from a lateral to medial direction to
proximate the joint surfaces further – while at the same time re-directing the patient to
attend to a precise vertical A-P direction of their (imagined) laser beam in a direction
perpendicular to my (imagined) laser beam and stating that...
“where our two beams meet inside you – the point of reference for coordinates crossing
over each other, as a space between four street corners, a cross-point; this is the new
location for your new hip socket!?! ......note that it is not behind you …it is not in front of
you…it is actually within you at this level”
…as I rotate the patient’s actual femur inward and outward along it’s longitudinal
axis…before moving to their foot and transmitting a vector line through the "core of their
hip socket" as informed from yet another sensory directional perspective; but this time
from a caudal, weight –bear direction -- upward.
Not to be construed with energetic mechanisms for "laying on of hands" these novel
haptic sense augmentation techniques for "laying on of bones" are roughly demonstrated in
Figure 16.
________________________________________________________________________
Figure 16. Demonstrating Hip Axis Socket/VR Hip Replacement. Note width of eyeglasses’
temple frames roughly corresponds to width between L and R hip socket axes (i.e., between L
and R acetabular cup and L and R femoral head interface).
Note also that though these newly created VR Hip Replacement techniques require some prior
element of manipulation and manual therapy skill being developed on the part of the therapist,
these novel techniques are also otherwise quite differentiated from usual high-velocity, low-
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amplitude thrust techniques being more commonly instituted through chiropractic and
osteopathy. This is due to the fact that the patient is actively involved in producing his or her own
outcome through co-opting his or her own application of haptic self-touch/self-contact. And by
his or her directing his or her own visual-tactile imagery toward manifesting a task-oriented
quality of intrinsic attention, he or she can thereby continue to participate in continued
ownership of his or her own experience. In other words, patients are not just being passively
manipulated and/or objectively corrected.
I then took the experience into sitting, standing, and walking to explore and generalize
the experience into other contexts of postural orientation. These features, and their
correspondence toward improving the quality of posture and movement during sitting and gait,
are demonstrated in Figure 17.
(a)
(b)
Figure 17. Generalizing the effects of VR Hip Replacement/Body Schema Acuity Training on
Qualities of Comparative Arrangement to be Experienced and Contrasted (and therefore learned)
during Daily Routine Activities. (a) sitting, and (b) for standing and walking. In both situations,
the first picture represents the mis-localization of proximal hip axis condition (perception of false
axis), whereas the second vs. third pictures represent the re-localization of hip socket ("trueaxis") as being correspondent to the improved sensory acuity perceptual condition that was
instituted post-treatment.
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On continued observation and implementation, I discovered that just by clarifying a
patient’s visual-tactile mental representation (body schemata) for improving accuracy for "pinpointing" the exact and central location of the articular joint surfaces representing the mislocated verbal schemata for "hip socket," that qualitative movement improvements also occurred
for:
● A-P pelvic tilts/pelvic rocks becoming more accessible and symmetrical;
● Pelvis Floor Kegel’s Exercises demonstrating more immediate and effective calibration
of control for various magnitudes of contraction gradient with greater precision,
dexterity, and reversibility;
● Markedly reduced para-spinal muscle guarding/unnecessary parasitic/dysponetic muscle
tone during rest in both supine lying and in upright sitting/standing positions;
● Spontaneously maintained improvements in frontal and sagittal plane postural
symmetries in standing alignment for head, neck, shoulders, and inferior costal margin
landmarks, as well for lower quadrant landmarks at pelvis iliac crest, trochanters of hips,
and fibular heads at both knees bilaterally;
● Improved extensibility of active/passive motions for deep lateral hip rotators (i.e.,
piriformis) to permit legs/feet to cross midline upon internal rotation as well as to reextend laterally; and
● Improvements in walking revealed through spontaneous and un-prompted demonstrations
of more harmonious, deviation-diminished qualities of gait, concurrent with more
efficient and sustained ground reaction support becoming more evenly reciprocated by a
corresponding smoothness of contralateral swing phase. This quality became more
pronounced while having patients co-conduct their own enhanced sensory referencing
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from the new perspective of their new hip socket as a new anatomical reference via their
own application of visual-haptic self-touch techniques while walking.
Furthermore, when patients were asked to revert back their attention to imagine walking
from the previous erroneous location of hip axis schemata and re-placing their hands there,
(usually at least three inches superior and lateral from actual hip axis location, thereby
proximating a vicinity just below or laterally behind the prominent ASIS bony landmark; being
the most and tangible and superficial aspect of pelvis’ usual surface anatomy), it was rediscovered that the faulty gait pattern returned, as did an almost immediate corresponding report
of return of familiar pain symptom recurrence throughout the low back and buttock regions that
were originally assessed at intake for at least one-half of the patients encountered. They were
then asked to re-reference the new location again with ever-increasing sense of acuity-accuracy,
which again corresponded with freer movement dexterity and restoration of more fluid gait
quality as well as symptom improvement with regard to decreased stiffness, improved steadiness,
or decreased pain.
These initial sessions were most commonly supplemented with both in-clinic and athome Feldenkrais®-based Awareness Through Movement® audio recorded programs being
specifically chosen and selected from my audio file CD library to best simulate and to reinforce
learning conditions for re-discovering a truer hip axis within the context of developmental
patterns and/or within functional movement sequence progressions, and as tailored for each
individual patient. As applied to the current low back pain study, Figure 18 further demonstrates
effects of interactive "virtual reality hip replacements" as a method for body schema acuity
training in a patient with long standing chronic nonspecific low back pain (CNSLBP) and with a
severity of duration at greater than five years. While she had been originally referred for
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participation in the current study, her initial appointment was not able to be scheduled until two
weeks after the IRB-approved enrollment period and subsequent study closure. She nonetheless
received the same benefits as study participants in terms of content and delivery of treatment
involvement as a regular patient.
a
(a)
(b)
(c)
Figure 18. Case Example: Virtual Reality Hip Replacement in Severe Chronic Low Back Pain.
Effects of "virtual reality hip replacements," as a method for more accurate body schema acuity
training. Beginning with the usual baseline inquiry condition (a) the patient perceives a marked
disparity for accurately localizing the anatomical location their own hip socket axes; and (b)
continuing with the patient undergoing a therapist facilitated transition for re-localization of
"more accurate" Hip Socket Acuity location as a novel treatment and training intervention using
"life-sized femur bone models," along with facilitating awareness for improving a closer
proximation of "perceived space-distance" in support of longitudinally arranged lumbar
vertebrae anatomical segment models placed above waistline - as a corresponding connection of
virtual props. At re-test, (c) the result is a more accurate anatomical hip axis location from the
patient’s newfound perspective. *Accurate representation for hip socket axes and improved body
schema acuity (upon post-treatment) most commonly results in (a) improved symptom
modulation for decreased awareness of usual pain; (b) improved dexterity for posture control and
symmetry of sitting and standing; and (c) improved quality of gait being exhibited through
harmonious, more proportionate and reciprocating qualities of support and movement occurring
between "stance" absorption and pre-propulsion "swing" phases during post-intervention
observation of their repeated gait cycle.
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Finally, it should be disclosed that the discovery of this phenomenon and the applied use
of anatomical femur models onto patients with a variety of conditions was a process that had first
occurred over many years in my clinic (since at least 2006), and within the usual context of my
daily clinical practice, and much in advance of designing conditions for any formalized type of
applied clinical research program. Like the Feldenkrais Method® itself, there was really no
accurate, peer-reviewed consensus of verbal nomenclature to accurately describe what I was
doing at the time. Only later was it discovered from the literature review in preparation for
publication of my original pilot study (2012-2013), and for the internal review approval process
in preparation for the current dissertation study (2015) that a conceptual language and verbal
construct for "mis-localization of tactile acuity for patients with chronic LBP" was to be found in
the literature via the associated and published works of Benedict Martin Wand et al. of The
School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western
Australia, Australia (Wand, Catley, Luomajoki, et al., 2014, Wand, Di Pietro, George, &
O'Connell 2010; Wand, Keeves, et al., 2013).
Continuing Improvements for "Anatomical and Perceptual Reframing of Background Body
Schema" through the clarification of Skeletal Support Mechanisms that occur during daily
movement interactions between "Pelvis-Hips Opposite Head"
While the visible results achieved through the previously described "virtual reality hip
replacements" interventions have been seen to be most often reliable, predictable, and
reproducible among nearly all cases treated, I nonetheless commonly advise patients not to
become over-invested in "hip joint localization" as an end-all or be-all panacea. There are still
hidden insights throughout the rest of the body that have yet to be uncovered. I, in fact, refer to
any new-found shift of body schema or change of body awareness become self-directed to such
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an extent that it can maintain itself "as only a loose assembly" and not as something to be rigidly
held or overly rehearsed, so as to become over-habituated as a narrowly applied prescriptive
dictate. Instead, a looser directive is facilitated toward adopting an otherwise unaccustomed
mindset for inherent flexibility. This quality is especially important to better permit the
generalization and integration of new skills into the naturalistic environment of ever-changing
systemic conditions, and to more fluidly provide a background context from which adapt to
possible unexpected perturbations or exposures that could likely require an alternative version of
the originally adopted response.
Consequently, as a second follow-up to evolving the treatment progression, and as most
commonly applied for patients with low back or knee problems, patients are next told that:
The hip replacement you received last time is not the whole story...we didn’t reveal the
whole truth last time...and perhaps the anatomical femur itself is not really the "top of
leg"... In fact, your "top of leg" may actually be somewhere else...Look here, if I placed
my model skeleton on all-fours and place a saddle on his back - like a riding horse - then
his pelvis...this area here just behind the saddle - would actually become the true "top of
his legs" and he could gallop away!
But now look, stand him up here on his vertical post and put some dress slacks and a nice
belt on him, make him feel human again...then this same area suddenly gets transformed
to becoming his waistline again...where the top of his pelvis and sacrum meet-up upon
his low back vertebrae...
That’s the area of what doctors and nearly everyone else calls out as being "the small of
the back" - but maybe that’s not altogether true...maybe...like a drumstick on a
chicken...by its original true support function and primal form...it’s really the "top of the
leg." We just don’t know it yet!
Figure 19 demonstrates the new question for phenomenological and somatic inquiry to
enable patients - and nearly everyone - to re-consider their accustomed unawareness and high
likelihood of maintaining their vaguely under-explored sense of ongoing perceptual discontinuity
occurring between hips, pelvis, and low back:
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Figure 19. Perceptual Discontinuity between Hips, Pelvis, and Low Back’s Spine Column.
Ordinarily conceptualized as separate anatomical regions is remedied to question via the aid of
using comparative developmental anatomy imagery, plus the handy prop of a horse saddle.
Common low back pain (LBP) mostly occurs in regions largely associated to the areas of
the body that are most often linguistically referred to as "the small of the back" from a common
or colloquial perspective. Physical exams will frequently elicit point tenderness throughout L5S1 paraspinal regions upon palpation/inspection, and with particular targeting of pain or
provocation becoming more directly reproduced when examiners more directly pinpoint the
posterior sacral sulcus anatomical landmark of concavity overlying the posterior S-I joint;
otherwise being characteristically referred to as "the divot portion" of the sacral-iliac joint. This
region is pictured in Figure 20.
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Figure 20. The Superficial Region of the Posterior S-I Joint (SIJ). Frequently indexed as a source
of pain emanating from what is also colloquially described as the "small of the back" in many
common outpatient clinical settings.
Many clinicians – perhaps mistakenly - will immediately equate this finding as a positive
diagnostic feature for classifying the many varieties of "sacral-iliac dysfunction" and will then
cite this region as a primary cause and progenitor of low back pain. However, such pre-directed
and overly-determinant or conclusive qualities of inspection/palpation may also inadvertently
and erroneously re-sensitize the supposed region at fault, and thereby reinforce a localized
somatic marker or body reference neurotag that furthermore implies and sensitizes a continued
fragile or dysfunctional state (e.g., think "subluxation") becoming co-conditioned, co-associated
and thereby ever-perceptually linked to the "S-I joint posterior" as a pervasive and selfreinforcing topic of conversation and self-report upon all future chronic pain treatment consults
with all future clinicians.
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As an antidote to such erroneous - but not uncommon - construct development; and as a
further application for the anatomical and perceptual reframing of background body schema as a
novel and educational treatment intervention, I was able to devise an "inner-ilia hidden bridge"
session that could convert the perceived notion of "L4, L5, S-I joint" as "small of back" into a
more robust perception of instead re-depicting it as "top of leg" by creatively using the visualtactile frameworks of anatomical models being representative of "skeletal density imagery" in
conjunction with added demonstrative implications for linking the entire region to a new and
more supportive notion for function being further re-constructed and outlined in terms of
"skeletal density proportionality." These inherent and perceptually tangible characteristics of the
human skeleton can be consolidated and described in terms of bearing a "skeletal contiguity
model."
A primary and most interesting feature of a skeletal contiguity model - being based on
antigravity support mechaisms and skeletal density trabecular pathways becoming biologically
emergent through interaction in the real physical and gravitational world - is its correspondingly
vivid capacity to translate itself into human conscious awareness; more specificially, through a
tangibley apprehensible visual-tactile, spatial-conceptual, and multi-sensory array of dimensions
for accessing an experiencial inroad into the inner representative and movement-based
perceptual worlds.
The component regions of highest bone density, considered as robust skeletal properties
within pelvis and head are vividly displayed in Figures 21 and 22. These features, in turn,
become part and parcel of every succeeding anatomical imagery interactive intervention
program having to do with the conceptual visualization and the experiential transmission of
skeletal-gravitational forces, while being concurrently guided through Feldenkrais Method ®
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based Awareness Through Movement lessons, and most particularly within the design
®
framework of the prospective and current low back pain study.
(a)
(b)
Figure 21. Components of Highest Bone Density within Pelvis and Head. Regions of highest
bone density within (a) pelvis, and (b) head as revealed by highlighted anatomical illustration
and whiteness contrast being classically indicative of greater structural density upon
radiographic viewing of x-ray films. As can be seen, femoral cortical bone leading into inner
concavity of acetabulum (ball and socket) and inner ilia pectineal line/ring to anterior ilio-sacral
(I-S) joints (as "inner bridges") and lateral pedicles of spine vertebrae (corresponding columns in
parallel) all ascend to upwardly converge through the temporal bones of the skull as the
corresponding structures of highest radiographic bone density.
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(a)
(b)
(c)
Figure 22. Anatomical Outlines of Areas of Highest Bone Density. These areas (darkened and
embellished by clay overlay being placed over them) represent the densest anatomical and
structural landmarks of the humnan skeleton. More specifically, they are visually highlighted as
areas that are known to represeent the regions of greatest concentration for skeletal vs. trabecular
"highest bone desnisity" on both sides of the body, and for the transmission vs. absorbtion of
gravitational forces between "hips-pelvis opposite head" as a partial model for skeletal
continuity: (a) Right inner-ilia/pectineal ridge line aspect of R pelvis, (b) Right temporal bone
ridge within skull (and exisitng just inferior to R temporal lobe of brain), and (c) an exposed
depiction of Right vestibular apparatus with three semicircular canals, as would otherwise be
completely encased within the boney labyrynth of the Right temporal bone.
Another discovered feature is that the temporal bone-vestibular complex and the innerilia pelvis ridge and hip axis, and even the ischial tuberosity or sit bone happen to line-up
vertically and directly over each other when the skeleton is observed in neutral upright
placement. This schematic is revealed in Figure 23.
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The Temporal Bone and the Inner-ilia Hip Axis Happen to Overlie Each Other...
(b)
(a)
(c)
Figure 23. Vertical Contiguity of Pelvis-Hips Opposite Head. The depiction outlines vertical
contiguity and proportionate lateral dimensions of (a) Pelvis-Hips opposite to (b) corresponding
Dimensions of Head, and (c) revelation of the only recently discovered ‘Proportionality of
Thirds™’ model. © 2006 by Tim Sobie.
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Furthermore, and with regard to the Feldenkrais Method® principle of emphasizing for
proportionate skeletal movement, I had discovered through laboratory measurement upon my
skeletal models that the bone density length dimensions of the inner-ilia bridge within the pelvis
are roughly 2/3 larger in size than the temporal bone’s corresponding width dimension encasing
each inner ear at 1/3 the size. By having measured these dimensions in the life-sized model
skeleton, it was found that each inner ilia ridge contour curve measured out at 9 cm as was
compared to the length of each temporal bone becoming measured out at 3 cm width.
I then proposed and postulated a new "Proportionality of Thirds Model™" to predict and
guide the outcome of contextualizing and improving upon a whole range of existing
Feldenkrais® movements, and most particularly, to permit an algorithmic basis for recall and
more tangible guidance during their actual instruction and performance. These scaled features
are seen in both Figures 23 and 24.
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(a)
(b)
(c)
Figure 24. Tape Measure Rendering of Densest Bone Regions leading to the Operationalizing of
"The Proportionality of Thirds Model™" in Feldenkrais Movements. Given that (1) proximal
iniation of movement, and (2) proportionality of action in synergisitc distribution from "larger
denser powerful areas" to "smaller effector distal zones" are cited as key features for the
efficiency of movement in usual Feldenkrais Method® Practice, I discovered anatomical
geometric corelates to action function in (a) mesureing the distance from hip-socket acetabular
central axis to inner-illiosacral joint interface to measure 9 cm, and (b) the dimensions of
termporal bone’s analogous ridge containing the vestibular apparatus sensory end-organ to
measre one-third of that at 3 cm. Therefore, all Feldenkrais sessions delivered and directed
toward the current study manifested a directive for (c) 2/3 initiation of range for movement
occuring first from pelvis-hips complex then contrasted by 1/3 counter-balancing actions and
dimensions occuring at head and neck.
A compilation of interventional steps involved in clarifying and converting a more
robust functional relationship between corresponding hip axes and ilia-sacral joints as "tops of
legs" through "skeletal density imagery" and through "skeletal density proportionality"
procedures (in lieu of emphasizing focal muscle attachments and other soft tissue or joint
compression "language reference abstractions" being erroneously allocated to "small of back") is
demonstrated in Figures 25, 26, 27, and 28; and more extensively through some other image
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compilations being routinely shown, exhibited, and demonstrated to patients in my clinic in
Appendix U.
Figure 25. Photo Demonstration of the Proprietary Manual Therapy Approach. Relectively
outlining and anatomically re-framing a constructed image for depicting the "core robustness" of
the Right anterior ilio-sacral joint via congruently leveraging hip joint up through pelvis by way
of contra-diagonal directions from right foot placement press-loading and directing a contralateal
vector line of movement being projected toward the direction of left temporal bone at skull base.
Life-sized skeletal models and shortened ski poles (e.g., children’s trek poles) are again used to
faciltate visual-haptic imagination and active intention into constructed action. The procedure is
typically initiated first to the side of diminished suppport so as to create a larger sense of
difference upon recomparison within the "legs extended" rest position, and as a manner of
constructive self-assessment for comparative body schema and body scan prior to working with
the contralateral side.
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Figure 26. Photo-Captured Demonstration of "Self-Applied Visual-Haptic Self-Touch." Indexing
"right inner-ilia-as-new top of leg" for the projection of skeletal contiguity to route itself
diagonally upward and leftward through skeletal trabecular pathways to left-side of top of head
(i.e., through direction of contralateral left temporal bone as a corresponding structure of highest
bone density). A life-sized hemi-pelvis skeletal model is also deployed for retaining and
generalizing the new-found sense of pelvis-spine continuity, but this time being applied within
the actual functional context of standing fully upright, and again re-applying hand placements for
"visual-haptic self-touch" as a continuity of treatment session to extend from clinic environment
to daily life.
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(a)
(b)
Figure 27. Anatomical Re-framing of "Core Robustness": Pelvis-Hips opposite Head. (a) Photo
profiles again demonstrating the proprietary manual therapy approach for relectively outlining
and anatomically re-framing a constructed image for depicting the "core robustness" of the Left
anterior ilio-sacral joint within the conext of leveraging hip through pelvis through contradiagonal directions from Left foot placment, and directing a contralateal vector line of movement
being re-directed this time toward the direction of Right temporal bone at skull base in
conjunction with self-rehearsal of repeated acuity actions via the instructive and concurrent
deployment of visual-haptic self-touch techniques to refine the alignment vector for greater
discernrment of path line for skeletal transmission; (b) Repeated actions are then re-explored via
the assitance of self-applied ‘haptic self touch’ along with other visual imagery (e.g., the post-it
note with letter "X" marks the spot of an imaginary laser beam being directed upward)
conducting in straight line fashion from base of Left knee - via tibial plateau at distal femur through "top of leg" at I-S joint, then onward and upward through contralateral chain of pedicles
at Right side of thoracic spine, and eventualizting through Right skull base, through temporal
bone/vestibular channels, and ultimately emitting through an imaginary cattle horn spike at Right
side of top of skull/top of head. Conversely, the imaginary laser beam can also be imagined and
directed in reverse direction – from cranial top to caudal knee base – as an alternative exploration
of novelly perceived alignment relationships through "core regions" of highest bone density
within the full continuity of the skelteal chain. * This image set additionally reverals the 2/3:1/3
spatial-temporal relationship of pelvis/hip position rotation to Right (at 2/3 of motion capacity)
being opposite to that of adding-in the auxiliary movement of counter-rotating the head position
to Left ( i.e., being counterbalanced at roughly 1/3 of motion capacity).
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(a)
(b)
Figure 28. Anatomical and perceptual reframing of "Top of Leg" during Standing Trunk
Rotation. (a) Photo capture rendering of "anatomical and perceptual reframing" for backgroundforeground body schema acuity training being applied to inner-ilia pectineal line ("inner ridge"
as "inner bridge") and linking detectable spatial-temporal relationships through self-contact to
functions of standing, standing orientation variations, standing balance, and elemental qualities
for pre-gait during movement, as corroborated via visual assistance of full-scale anatomical
skeleton; (b) demonstration of correlational proportions for top of inner ilia ridge corresponding
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to outer dimensions of right foot during initial stance phase of gait; and base of inner ilia/pelvis
floor corresponding to dimensions for instep of ball of foot (which also happens to match for
width dimensions of intracranial lateral temporal bone) during terminal stance/pre-swing phase
of gait.
Envisioning for a new top of leg thereby occurs via a similar detailed process of
anatomical sample modeling and using "visual-haptic self-touch" interchangeably between the
deployment of external anatomical models and comparing and contrasting them against inner
anatomical references within the perceptual acuity aspects of envisioned whole self. However, at
this juncture – and in anticipation of developing a contrasting and evolving treatment model
against "core muscular stabilization" – the "core of the entire skeleton" is now instead referenced
through outlining a pathway of boney trabeculae ascending to "link-up" from core of hip axes
(e.g., from the initial previous session), continuing onward through the anterior ilio-sacral "inner
ridge/inner bridge" of pelvis, and then onward and upward (both laterally and contralaterally)
through thoracic pedicles, rapidly culminating toward contra vs. ipsilateral temporal bones in
skull (e.g., vestibular component); and finally, dissipating through top of head as "a
comprehensive frame of continuing body reference" for all succeeding sessions, and as a total
model for linking a broader perspective toward the enhancement and perception of total skeletal
contiguity, while also being inclusive of all its primary related and regulatory components.
The Lateral Chain of Distribution through Pedicle Densities and Costal-Thoracic
Expansion
Bone tissue is generally laid out between two types of concentrations for the distribution
of mechanical forces vs. the fluidity of self-maintenance for retaining its regenerative properties.
The two structural-functional divisions are described as cortical vs. cancellous. Cortical bone is
the outer cortex or thick outer shell aspect of compact bone and enables the primary skeletal
functions of shielding for protection to the softer internal structures of the body, and for
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longitudinal and mechanical support throughout the entire body as well as for affording
mechanical levers for movement. At the other continuum, cancellous bone, is also referred to as
trabecular bone or spongy bone because its continuity is more variable and its structural
compactness is overall less dense. The inner distribution of "structural latticework" known as the
trabeculae within cancellous bone are arranged, aligned, and concentrated according to the
mechanical and gravitational load distribution that a boney tensegrity continually experiences.
This has been most studied within long bones, such as the human femur en route to the femoral
head, with added consideration that total hip replacement surgical arthroplasties are among the
most common types of orthopedic procedures performed. By most accounts, the femur is the
strongest bone in the body as well as being the longest bone in the body. As far as short bones
are concerned, trabecular alignment has been most studied in the vertebral pedicle.
For all spine vertebrae, the vertebral arch is formed by pedicles and laminae. The pedicles
connect and "bridge-together" the anterior vertebral bodies (predominantly cancellous or
spongey bone) to the posterior-lateral boney projection processes existing for muscle
attachments (primarily cortical or compact bone). The two pedicles firmly extend and anchor
from the sides each vertebral body.
For purposes of an anatomical-perceptual reframing/cognitive educational intervention,
they are best described as paired cylinder-like structures designed for bridging gaps and for
fostering a design for structural continuity between front and back sides of body along a
longitudinal arrangement of intrinsically robust stacked vertebrae. Most importantly, the inferior
vertebral notches are of large size, and deeper than in any other region of the vertebral column.
Finally, their medial cortical layers are thicker and denser than that of their lateral aspects;
rendering them suitable for the insertion of "pedicle screws" for repair procedures in cases of
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orthopedic spinal trauma. They can therefore be cognitively re-constructed, conceptualized, and
reconsidered as a continuity of intrinsically robust (yet again, "hidden") structures manifesting
in ascending and descending fashion. Finally, they are furthermore distinguished adjacently by
the presence of superior facets on the posterior sides of corresponding vertebral bodies for
providing a tangible landmark for adjacent articulation and foundational support for the heads of
each rib and "for distinguishing each rib as a force-dissipating yard arm" at each corresponding
thoracic vertebral level during reaching.
By harnessing thoracic rib-ring and costal-vertebral mobilizations with expansive
breathing patterns, and as an added theme for anatomical-perceptual reframing, thoracic pedicles
are then used as the next linkage for bone density pathways en-route toward bridging the
perceptual gaps between pelvis-hips opposite head. A directed implementation - again using
anatomical skeletal models and corresponding imagery - is demonstrated in Figure 29.
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(a)
(b)
(c)
Figure 29. Anatomic Locations and Junctions for Thoracic Pedicles and Costo-Vertebral Joints.
Anatomic locations and junctions for (a) imaging thoracic pedicles and costo-vertebral joints;
(b) applying triplicates of anatomical rib models, informing about changing planes of facet
motion orientaion in anatomical transition zones between L1 to T12; the corresponding chain of
pedicles at each vertebral level, and harnessing the volumetric and laterality aspects of the lungs,
and finally; (c) informing awareness from hand-placements and pnuematic costal expansion that
the densest line of internal reference to transmit skeletal stresses through core of vertebrae is not
anterior-front nor posterior-dorsal, but along the lateral-medial aspects of the spine coulumn.
Location of Vestibular Apparatus Augments for a Sense of Visual Spatial Alignment
Here, I also demonstrate and correlate anatomical imagery sensory re-referencing by
exposing the tri-plane structure of the three loops that comprise the semi-circular canals (sccs) of
the vestibular system’s apparatus by again employing the full scale skeleton model and an inner
ear anatomical model together – and dimensionalizing an exploration of head position into three
comparative directions in space – using the temporal bone’s (and the corresponding vestibular
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organ’s) exacted location as a new point of internal reference for motor control. The anatomical
model references for these explorations are depicted in Figure 30.
Figure 30. Anatomical Models depicting Vestibular Apparatus. Particularly the semi-circular
canals (sccs) within each inner ear, and as encased within each temporal bone deep in the skull.
Each vestibular end-organ apparatus comprised of the three semi-circular canals (sccs),
the utricle, and the saccule - though deeply encased within the skull - can nonetheless be
perceptually accessed by implementing particular visual-haptic spatial coordinate locator
techniques that lend themselves well to the treatment concept of anatomical and perceptual
reframing for clarifying a background body schema, and for post-session improvements in
cervical active range of motion. These techniques are profiled and described in Figure 31.
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(a)
(b)
Figure 31. Visual-Haptic Projection Techniques for Cardinal Axis Coordinates of Vestibular
Apparatus and their Anatomic Location. Visual-haptic projection is self-applied for locating both
the central convergence of cardinal axis coordinates for movement and for encapsulating the
positional-structural orientation of the vestibular apparatus end organ being deeply encased
within each temporal bone on each side of the skull. (a) Locating and pinpointing the location
position for right vestibular appratus inside skull by arranging perpendicularly placed ‘imagined
laser beam’ coordinates between 2-index pointer fingers: [(1) R hand referencing finger beam is
latearlly crossing midline from right ear-hole entrance, projecting horizontally and leftward in
mid-frontal plane, and exiting through L ear hole; (2) L hand referencing finger beam is
posteriorly projecting in anterior-posterior (A-P) direction from front of pupil at right eye and
through to exit along mid-lateral saggital plane at "back of skull," but also behind the eye (i.e.,
from front to back); (3) The cross-point inside the skull of where the two beams meet together
via their perpendicularly directed coordinates is the proximate location of the right inner ear’s
vestibular end organ.] Here within this space the patient is manually and visually guided to
imagine (1) a miniture ferris wheel, (2) a miniture merry-go-round carousel, and (3) a miniature
tilted diagonal ferris wheel – all side by side and adjacent to each other. Each of these
corresponds to one of the three semi-circular canals and all three are roughly correlated to
correspond with the three primary cardinal anatomical planes commonly used for referncing the
whole body; (b) Locating the angle of orientation in right vestibular apparatus for its facing
diagonally outward by retaining the R index finger placement in R ear and connecting a single
line of reference to match the direction of L index finger beam being placed to the inside corner
of L eye – just adjacent to nose bridge.
Co-incidentally the vestibular apparatus’ surrounding temporal bone density lies directly
and vertically above the lines of trabecular density that connect vertically between corresponding
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hip axis and inner ilia-sacral joint, as has been both previously described and pictured (see
Figures 15 and 23), and conceptually re-framed via anatomical imagery techniques as combined
with deep, para-visceral manual therapy for outlining along pectineal line/inner ring of pelvis
and through to anterior Y-ligaments overlying ilia-sacral joint line (see Figures 25 and 27) - to be
intrinsically referred to again as "new top of leg," and no longer truthfully depicted as "small of
back," as remains the common colloquialism in traditional clinical exams and every-day thought.
An added photo demonstration for locating the tri-plane positional coordinates and the
three angles of orientation for the right vestibular apparatus, as dually shown in combination
with the full-scale model skeleton and an anatomical diagram for outlining the directions of
"spatial arrangement" for each semi-circular canal’s directional reference is again depicted in
Figure 32.
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Figure 32. Locating the Coordinates and Angles of Orientation within RIGHT Inner Ear. A
demonstration of locating the coordinates and angles of orientation. Here, for right semi-circular
canals in right inner ear/vestibular apparatus via the use of visual-haptic self-touch clarification
techniques and the deployment of a full-scale anatomical skeletal model. Note again the
corresponding spatial dimensions between pelvis-hips opposite head as both an internal and
external frame of reference.
"Pelvis and Hips" as a Tri-Plane Model for Center of Gravity and the Detection of Change
in Center of Gravity Being Represented by "Vestibular Coordinates" as a Combined
Dynamic and Unifying Movement Strategy to be used during a Simulated Martial Arts
Task for achieving a Synergistic Spiral Quality of Efficient Action being applied to the
function of Sit to Stand
In general, the habituated and usual function of seated sitting exhibits a more selective
tendency toward the convergence of the senses, especially for the combined visual-spatial and
manual prehension and/or precision tasks of modern life, and in synergistic association with an
activation pattern of muscular tone to concurrently select for a global internal rotation and flexor
bias activity occurring at torso and limbs.
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In contrast, moving from seated sitting to fully erect standing exhibits a greater tendency
in selecting toward divergent expansion of the senses, and with greater concurrent rotational
affordances for the selection of both global external rotation and for global extension synergies
at body and limbs; and thereby, also opening greater opportunities in the directional schemata
for re-referencing the global senses in a greater multitude of affordances for directional acuity. In
chronic low back pain, a miscalculation of spatial-temporal relationships for the optimal
coordination of smooth and efficient motor control between these two primary synergistic global
patterns is seen to most often occur in the transition from sitting to standing, especially if either
of the two end-state posture orientations has been sustained over a prolonged period of time. For
which, the availability of synergistic control for inhibition of co-contracted side-bending
movements, as accessory dimensions for translational movements during rotation, is also
typically lacking.
Interestingly, most traditional physical therapy clinics and fitness center-based exercise
programs continue to utilize equipment designs and "core exercises," which emphasize cardinal
movements being mostly limited, isolated, and constrained to occur only within a central midline
sagittal plane of action. Yet, the curvilinear design features inherent to the densest frameworks of
the human skeleton, occurring in and around a dimensional center of gravity, are anything but
linear or singular plane. The primary components depictive of curvilinear skeletal action and for
the control of movement plus adaptive recovery in a gravitational field are revealed in Figure 33.
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Figure 33. Visual and Dimensional Relationship Correspondences between Pelvis Diagonals,
Hip Complex, and Inner Ear. The diagonal pelvis orientation and posterior-lateral hip
relationship to access anterior medial opening for full hip external rotation permits a ‘stacked
quality’ of femoral extension and concurrent pelvis counter-rotation in conjunction with
curvilinear semi-circular canals also being conducive for achieving the eventual function of
maintaining fully upright and erect standing. These systems are also imperative for the
continuous detection of change in center of gravity upon the thresholds of deviation for loss of
caudal support and to permit the rapid selection of counter-actions and righting responses to
prevent falling. Were these structures to be re-designed in linear fashion, dynamic recovery
would not be possible upon crossing the threshold of a squared-off or right-angled hard surface
boundary; being the point of no return.
As an alternative, by re-linking the head through pelvis and by magnifying the effects of
their respective curvilinear features over a correspondingly round sitting surface, the
relationships between variable support and dynamic action for balance recovery can thereby be
applied and explored into the rotation transitions of sitting into standing as is demonstrated in
Figure 34 and Figure 35.
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(a)
(b)
(c)
Figure 34. Guided Self-Exploration and Treatment involving Side-Tilting of Head. This
photocapture of guided self-exploration and treatment effectively demonstrates (a) Side-tilting of
head and torso in frontal plane from left to right to determine anterior-lateral scc vestibular
influences on counterbalancing a freedom for effective displacement of contralateral pelvis-hip;
then (b) verifying the R hip as the restricted and less yielding side; the index fingers highlight for
both the position coordinates and angle of orientation for the right ear’s scc’s and corroborte the
same dimensions for R hip’s angle of inclination; before (c) self-organizing an interplay for
pelvis-hip relationships in both preparation and simulated execution for perfrorming a "martial
arts pointy star throw" via the transition from "saddle-straddle" sitting over bolster to spiraling
up into standing.
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(a)
(b)
(c)
(d)
Figure 35. Demonstration of Therapist guided Functional-Cognitive Manual Therapy (CMT)
Maneuvers. (a) Lateral ear tilt and detecting for pelvis drop counter-response while sitting
saddle-straddled over rolled cylinder pad to discern for unyielding side of limitation; (b)
provision of tele-props visual tubes applied to corresponding side of hip limitation for R inner
ear, noting especially the posterior-lateral to anterior-medial vector line for the R vestibular
apparatus' angle of orientation also corresponds to the same angle of vector line for applying
manual direction of (1) central pelvis rotation L, against (2) distal lever of femoral head
displacing anteriorly to R; while again using (c) virtual imagery anatomical bones in conjunction
contact; for (d) performing the simulated martial arts action of throwing an imagined "5-point
Ninja Star Dagger" directly and horizontally behind oneself via the actions of torso rotation L
from the vantage point of R axis hip.
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In sum, and as a common outcome for nearly all ipsi-laterally and effectively applied
Feldenkrais sessions, there occurs a unique and observable phenomenon indicative of "a
®
hemispheric laterality bias" for improving the dimensional resting qualities of embodiment, as
being revealed through lateralized variations in the volumetric distribution of resting muscle tone
and/or corresponding length-width tension relationships. For example, most patients can
immediately detect the sensation of their attended leg feeling much longer, and/or the extensor
side of their back feeling much flatter on the corresponding, ipsilateral side of the applied
therapy session by self-observing through their own "body contact scan" while in resting repose.
As a frequent yet transient feature at post-session, these differences can also be seen by an
external observer as is captured in Figure 36.
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(a)
(b)
(c)
Figure 36. Latearlity of Chest and Leg "Hemispheric differences" after FI® Sessions. These
visual and somatically embodied phenomena (being likley representative of hemispheric
differnces in motor control being revealed through differentiated laterality in resting postural
tone states) are a common observational outcome of Feldenkrais sessions. Here demonstrated
and photocaptured subsequent to (a) left hip session, (b) left diaphragm session, and (c) right ilia
session.
®
Yet, applying these changes and generalizing them into other functional contexts was not
always easy for patients to reproduce when transitioning up from floor pad or off from treatment
table from either a supine, side-lying or prone rest position, and then to sitting up, then to
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standing upright, and finally, but most especially, for generalizing them into all of walking. In
most cases, they would always notice some form of qualitative difference, but beyond the simple
"awareness of difference," there were no real tangible tools from which to exemplify a
continuing qualitative transfer for wholly representing the complete gait cycle in its entirety.
Despite its wonderful visual affordances, it was rather challenging to get a life-sized
skeleton on a display stand to effectively demonstrate a graceful and easy pattern for walking or
sauntering across a treatment room. Something of more visual-spatial importance was still
missing for visually conveying a more lasting impression of the profound lateral and
contralateral (and supposedly hemispheric) differences that were occurring on the treatment table
and somehow transferring them - with equal perceptual vividness - into the more varied
dynamics and reciprocating complexities of human gait.
Discovery of "Virtual Avatars" for Anatomical Re-framing, Skeletal Transmission, and
Aligning Ground Reaction Force Vectors for the Enhancement of Verticality during Gait
I had the good fortune of attending a technology and clinical update presentation
conducted by Dr. Christopher M. Powers, PT, Ph.D. (USC.edu), entitled “Lower Quarter
Biomechanics: New Research,” as part of the 2009 PTWA Fall Conference in Tacoma,
Washington, in October, 2009. In it, he shared a video kinematic biomechanical analysis
sampling of gait patterns being demonstrated by a student research subject using a Vicon™
Motion Capture System - side by side with a corresponding computer-animated reconstruction of
her skeletal frame being outlined from foot to pelvis over a force plate using a Polygon Viewer™
program from which to determine and visually map-out the dimensions of her ground reaction
forces during an entire cycle of gait.
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While the emphasis of his demonstration display was to codify how the knee joint would
decelerate upon the subject’s arrival toward the mid-stance phase of gait, my attention was
otherwise immediately drawn to the dynamic summation of force vectors that were moving
upward. These were all distinctly and consistently targeting most specifically through the inner
ilia aspect of the pelvis into the "top of leg" anterior ilia-sacral robustness surface that I had been
continually attempting to convey through the previously presented deep manual therapy tissue
manipulation access points.
Now it had become more visually depicted through vertical arrows and diagonal yellow
lines that were effectively outlining a believable trajectory that could more easily "connect the
dots," but only to convey the idea of a correspondent functional relationship between hip-pelvis
opposite head (and/or vice-versa) during the human gait cycle in walking. However, also
necessarily occurring through a visually-inferred, trabecular highway by having line vectors
summate and visually depict a motion pathway occurring throughout the densest longitudinal and
surface aspects of deep articular bone structures - inclusive of inferring ipsilateral and
contralateral longitudinal pathways passing directly into the reference frames for each temporal
bone – of which each paired vestibular apparatus functioning as a "hidden sense reference" is
deeply encased and contained. He already had a few copies of a replicated compact disc (CD)
file on hand, and I procured one for only $20 to put to immediate use upon return to clinic
practice the next day. Visual depiction and description of Vicon™-inspired motion-capture
virtual avatars, anatomical re-framings of body schema, and their functional relevance toward
simulating a sense for the transmission of forces through skeletal density imagery pathways as
occurs during the gait cycle are referenced in Figure 37 and in Figure 38.
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(a)
(b)
(c)
________________________________________________________________________
Figure 37. Vicon™ Kinematic Videography Image Reconstruction for Initial Stance Phase of
Gait. Vicon™ Kinematic Videography image reconstruction of (a) Right initial contact for stance
phase during gait; (b) lateral, oblique and posterior views as "high point of the hip"; and (c) real
time anterior-frontal view depicting ground-reaction force plate summation of vectors
culminating contralaterally inward and upward to Left in the direction of Left inner ear temporal
bone. These "avatar images" are presented and explained to patients in slow motion with
instructions to ‘feel and imagine this happening within yourself’ prior to therapist-assisted
"simulation of action" maneuver via haptic self-touch and corresponding Feldenkrais®
movements.
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(a)
(b)
(c)
________________________________________________________________________
Figure 38. Vicon™ Kinematic Videography Image Reconstruction for Terminal Stance Phase of
Gait. Vicon™ Kinematic Videography image reconstruction of (a) Right instep terminal stance
phase of gait as a phase transition into medial forefoot propulsion/pre-swing; (b) lateral,
posterior, and anterior views of force plate antigravity summation vectors depicting a lesser
magnitude due to forward momentum; and (c) real time anterior-frontal plane views depicting
ground reaction vector summations culminating this time ipsilaterally and upwardly in the
corresponding direction of Right temporal bone for alignment, stability, and control of Right
mid-terminal stance as a platform from which to enable a successful contralateral Left swing
phase.
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Upon reviewing the three-dimensional Vicon™ Polygon Viewer™ assembled images on
video displays for simulating the predictive summation of ground-reaction forces emanating
upward through skeletal architecture during the transitional stance components of the human gait
subject, it was found that I could also revert back to explore the same set of conditions again
through corresponding life-sized skeletal models, thereby affording a sense of haptic touch
experience to complement the visual simulation of kinematic pathways. Most interestingly, the
vector summation magnitudes for ground reaction forces - being greater at initial contact stance
and lesser at terminal stance phase of gait - were seen to correspondingly match both the
direction of distribution and the thickness of articular surface directionality upon outlining a
structural palpation/inspection survey of the ilio-sacral joint surface becoming revealed on the
hemi-pelvis skeletal model. These anatomical skeletal framework-based visual-haptic awareness
techniques, as accessories for more tangible patient-avatar interaction, are demonstrated and
displayed here in Figure 39.
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(a)
(b)
________________________________________________________________________
Figure 39. Hemi-pelvis Model of Inner Ilia depicting Pathways for Contra-lateral vs. Ipsi-lateral
Skeletal Transmission. These images convey corresponding displays for the transmission of
ground reaction forces through skeletal density transmission pathways in reverse funnel direction
from inner ilia-sacral joint upward-this time using right hemi-pelvis skeletal model via index
finger and clay overlay to depict: (a) initial stance phase conducting contralaterally upward, and
(b) terminal stance conducting ipsilaterally.
Corresponding vertical alignment experiences for the instruction of skeletal transmission
vectors becoming targeted longitudinally through the anatomical and regional pathways of
highest bone density; for the overall enhancement of verticality and reciprocation of segmental
counterbalance during gait was further achieved by co-opting varied combinations of skeletal
simulators being applied through visual-haptic self-touch; and by imagining anticipatory
responses being predictive of proportionate, anatomical trajectories within patients and
colleagues who consented to be actual live action photography models during the coordinated
demonstration of repeated gait cycles. These demonstrations are referenced in various ways –
from both top-down and from bottom-up in Figure 40 and Figure 41.
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(a)
(b)
Figure 40. Applications of Visual-Haptic Self-Touch Hand Placements for Simulating and
Detecting the Anatomical Pathways of Skeletal Transmission during Gait. (a) Right initial stance
phase of gait corresponds to imaginary longitudinal coordinates overlying the L temporal bone;
and (b) right terminal stance corresponds to self-touch linkage from right I-S joint to R ipsilateral
temporal bone. The middle pictures depict the use of ski poles to augment and highlight motion
trajectories.
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(a)
(b)
Figure 41. Demonstration of Skeletal Transmission Contact Points for the Simulation of Gait
Function Form Ground-up. (a) The L initial stance phase transmitting toward R contralateral
temporal bone, and (b) the L terminal stance phase of gait (the pre-propulsion phase)
transmitting ipsilaterally toward the direction of L temporal bone. Again, the visual-haptic selftouch techniques as internal reference cues are self-applied to the service of anatomical
awareness and perceptual re-framing.
Epilogue: Non-Pathological Anatomical Imagery for Highlighting Areas of Highest Bone
Density as a Contribution for Cognitive Reframing and Behavioral Adjustment
As a composite development throughout, the re-depiction of inner anatomical imagery is
also aggregated and operationalized into the common Feldenkrais® movement themes that
involve or begin with supine knee bending for foot placement as a platform precursor for semibridging and leveraging of pelvis to roll diagonally opposite and superior laterally.
In situations of CNSLBP wherein the lumbar-pelvic junction was deemed too heavy or
too stiff or too painfully vulnerable to move, it was succeedingly found that the inclusion of
cognitive-perceptual reframing for "new" intra-pelvic ilia-sacral joint being depicted as "top of
leg" - in lieu of the more compartmentalized and diminishing nomenclature for "small of back"
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that more spontaneous and productive actions could emerge in concurrence with decompressive
tractioning of adjacent lumbar and thoracic spine segments – all further embellished by
counterbalancing head position to rotate 1/3 of its distance – usually in opposite direction as if to
fine-tune or reflexively mediate a more effective synergy for motor control. I have observed that
this anatomical/categorical re-framing seems efficacious to create a more robust cognition that
seems to correspond with a more confident quality of emergent sensory-motor coordination for
improving standing alignment, pre-gait, and gait for dynamic stability in the relationship of
depicting “an inner bridge in support of a more solid ‘top of leg’ connection to the spine" in lieu
of referring to the region as “a small of back” or “S-I Joint Dysfunction” context, and this again
seems to diminish the region of the sacral sulcus as a palpable sore spot, and furthermore serves
to nullify any previous cognitive-emotional pre-occupation to "L4, L5, S1 as a problem area."
In this, I found that indeed, from an anatomical cognitive reframing perspective, “there is
no ‘low back’ anymore” nor is there a "central core" to invoke or protect only a "top of leg" and
that after these maneuvers I would convey the impression that: “like the horned centaur –you are
½ human – ½ horse…with new robust top of legs.” Images used to convey and animate this
impression are seen in Figure 42, and also for use of antlers in gait, in Figure 43.
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Figure 42. Centaur-Human Avatar. This is modified to invoke greater robustness for "new" top
of leg.
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Figure 43. Use of Deer Antler for Augmented Sensory Reality. The deployment of an
authentically weighted deer antler horn is used for augmenting a sense of core skeletal
transmission throughout the body during gait - with projection emphasis of selecting contact
placement over L versus R temporal bone correspondingly during initial and terminal stance
phases of gait through right lower limb. In this, participants can likely detect the inclusion of
antlers into their avatar identity for the anatomical reframing of usual background body schema.
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These maneuvers have also been termed in my practice as “cognitive-imaginative
lumbar-bypass surgery,” a virtual reality/cognitive re-attribution technique to de-emphasize the
mistaken contribution of implicating unchangeable structural findings (i.e., naturalistic
“degenerative discs” and ruminative normal variation as “subluxations”); factors known to be
involved in maintaining and perpetuating fear-avoidance beliefs, and by maintaining an "overly
localized" quality of attention as a pain focus becoming perceptually amplified toward an
emergently constructed neurotag by continually referencing neuroplastic qualities of ruminative
attention to areas between and around lumbar spine segments L1–L5. Components of the varied
anatomical and perceptual reframing maneuvers, and how their imagery after-effects can
translate and generalize into the contexts of refining for improved standing balance and gait have
been well-demonstrated in previous figures.
Other strategies for the cognitive reattribution of imagery robustness have included the
use of comparative scaling. In this application, the distorted versus actual features for
differentiating ‘articular surfaces’ at "small of back" can also provide a basis of "contrasting
evidence." By clarifying through demonstrative and dimensional models that the ilio-sacral joint
itself is the longest and largest singular continuity for a joint surface area to be found anywhere
in the body, but that it is not ordinarily seen nor verified from an anterior or front-sided
perspective is a real eye-opener. While many patients with low back pain can typically and easily
pinpoint a "nickel or dime -sized region" at the sensitized SI joint posterior with amplified
representation, a competing situation for a higher return on accurate perceptual investment is
newly rendered to in Figure 44.
An additional visual strategy makes use of radiographic artworks by Nick Veasey,
wherein the lines and pathways of highest skeletal density are robustly depicted in skeletal
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persons engaging a host of lively and vibrant life affirming activities. These are seen in Figure
45.
Figure 44. Use of Imagery Robustness and Comparative Scaling for Cognitive Reframing.
Rather than the usual and typical clinical practice of depicting size the posterior S-I joint surface
erroneously and implicitly as the mere and fragile diameter of a dime or a quarter (i.e., small of
back); the joint surface can instead be depicted more accurately - and robustly as expanding its
landscape and contours threefold – to at least the size of well packed change purse or billfold.
From the perspective of biological reserve, this is a new cognition they can truly bank on.
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Figure 45. Active Anatomical Skeletal Density Imagery through the use of Radiographic Art.
*Note: Radiographic photo art shared via coutesey of the public domain by its creator, technical
artist Nick Veasey.
Again, these novel schematic acuity relationships are generalized into broader functional
contexts by highlighting their anatomical presence and their perceptual involvement for
referencing space and supporting equilibrium during variations and/or perturbations encountered
while sitting, standing, walking, as they apply to the general and reinforcing activities of
everyday life.
It is again important to again note that (a) the "manual therapy" manipulations using
skeletal density imagery for anatomical and perceptual reframing, and (b) the Feldenkrais-based
movement patterns that follow them are intended to facilitate and develop a concept for
possibility – and not to treat or correct (and to possibly reinforce) a pathology or problem area –
such as a "subluxation" or "unstable" segment, both of which may be nothing more than a
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pedagogically misinformed, continuing social consensus, and a profession perpetuated,
delusional iatrogenic construct that continues to reinforce notions for illness and dysfunction.
In contrast, I aim to construct and implement carefully selected Feldenkrais® Movement
experiments with particular action themes that are designed to directly target a fuller utilization
of novel skeletal density properties, pathways, and congruent trajectories via the inclusion of
interregional areas that have not yet likely been multi-modally explored and brought into novel
awareness. This, in turn, can continually modify ongoing attentional and behavioral processes,
again in a new way or new manner of being, and in ways that can also have the cognitivebehavioral effect of continuously challenging some deeply rooted and pre-existing beliefs about
the quality of possibility for embodiment and diminishing the corresponding vulnerabilities to
pain. When practiced with continued novelty and variation, these processes can likely result in
the self-reinforcement and re-conditioning of newly compatible neural pathways, and new
cognitive-perceptual dendritic assemblies that perhaps cultivate toward the physical re-allocation
of newly proportioned cortical body maps; these become less compatible with selecting for
previously conditioned central sensitization pathways that had otherwise become overly efficient
for concretizing and amplifying the transmission of pain signaling.
Thus, by re-allocating attention to and affording a continuing competing stimulus (Neural
Darwinism) through skeletal density imagery and improved visual-tactile acuity for body schema
via (a) the use of virtual reality bones™ as a perceptual concept, and (b) the use of Feldenkrais®
Movements to operationalize them, then perhaps a selection against the usual conditioned
"protective – avoidant" pain processing pathways (that seem to typically dominate the spectrum
of usual cognition and constricted action in patients with longstanding chronic pain) may occur.
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Consolidation and Synthesis of Initial Treatment Approach into The Acronym: (VRB3)™
As a compilation of broad and systemically related concepts seeking order, these
intuitive, epistemological, somatic-based-phenomenological explorations derived from
immersive inquiry and contemplative reflection throughout many years of clinical practice only
later became conceptualized, revised, and consolidated as “Virtual Reality Bones™” upon the
writing of this dissertation. Through this, they now have a more concrete context and branded
identity from which to become more reproducible and communicable.
The acronym symbol “(VRB3)™ ” further consolidates a more compact description of the
methods used and coalesces the entirety of background activities that were actually implemented
during Phase I in the experimental arm of the current study. It furthermore serves to
operationalize and concretize a more reproducible method for facilitating an approach to “Body
Schema Acuity Training” - the original, but conceptually vague and incomplete description for
Phase I - as it was previously submitted prior to and during the review process.
Prior incarnations of the Phase I component had included such broad and varied
descriptions and titles as (a) Ideokinetic imagery, (b) Skeletal Density Imagery (SDI), (c) VisualTactile Acuity of Deep Articular Joints, and (d) a Skeletal Density-Vestibular Concept for Body
Schema; then, somehow relating all these components to tie into the accomplished performance
of five. “Proportioned Feldenkrais® Movements.” Given the space constraints of future
publication, title searches, editing, and especially the word limit requirements for most abstracts,
something inspirational and creative - yet also practical - had to be done to unify toward a more
concise description.
Virtual Reality Bones™ and its corresponding acronym (VRB3)™ also afforded an
added, but unexpected visual literacy symbolic component in that "VRB" phonetically reads as
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"VERB," as an implication for action and movement; and then, culminating into the three-part
final acronym “(VRB3)” to integrate, consolidate, and summarize the systematic and broad-based
conceptual ideas inherent to Phase I of the experimental intervention, outlining them into three
basic simpler ideas.
1.
(VRB1) = Virtual Reality Bones: indicates the primary use of "true to scale" anatomical
models superimposed & immersed as both augmented sensation and sense of ownership so as to enhance visual, tactile-haptic, and proprioceptive acuity.
2. (VRB2) = Vital Relationships Between: permits the delineation of inherent "skeletal
transmission" features (of seeing and sensing for trabeculae density; occurring mostly
through longitudinal shafts of bones), and the "skeletal transition" features (structural
convergences and expansions of trabeculae occurring between deep articular joint
surfaces throughout the body - and further revealed through corresponding motion
trajectories required for proportionate dissipation and re-distribution of biomechanical
stresses during functional activities. It is again important to reiterate that the cognitiveembodied internalization of these concepts is again accomplished through modeling the
entire skeleton. Again, using the complete and articulated full-scale (5-foot tall vertical
stand) anatomical model and/or kinesthetic images from both radiology and motion
capture kinematic software to convey areas of highest bone density (areas of inner
strength, lowest structural variation, and hence, highest predictability); and by more
specifically identifying the “Proportionality of Thirds” guideline for efficient movement;
scaled as a measurable relationship between “pelvis-hips (2/3-larger - as initiator of
movement) opposite the head (1/3-smaller - as fine-motor control/modulator of
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movement)," as these features are both congruently operationalized and internally
consistent with basic Feldenkrais Method® movement principles.
3. (VRB3) = Vestibular Representation of Body in Brain: As a major regulatory system for
sensory-motor integration and control of movement, the vestibular -visual system reveals
itself - and its influences throughout the body; namely, through visual-ocular reflexes
(VOR), vestibulocollicular reflexes (VCR), asymmetrical tonic neck reflexes (ATNs) and
other developmental reflexes for posture control, and the co-regulation of spinal muscle
tone as a background pre-requisite for everyday functional movement. This concept is
again both experienced and operationalized by implementing the "proportionality of
thirds" demonstration on the skeletal model, and during actual performance of
Feldenkrais® movements throughout all phases of the entire experimental intervention.
As a corollary, an added display arrangement of images depicting fractal geometry,
inspired self-similarity features in distant anatomical structures relevant to the current study can
also be demonstrated throughout the design of the skeleton; namely, through structures of the
pelvis-hips opposite head, yet all made congruent through a three-dimensional vestibular
representation. Figure 46 depicts these images below and Table 10 demonstrates how their
conceptual implementation can be implemented into Feldenkrais® movements, as are presented
later in Chapter 3.
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Figure 46. Images Depicting Self-Simiularity of Structural Features Found to Occur within
Natural Systems. Fractal geometry and self-similarity features of repeating analogous and
homologous patterns occuring within natural systems, especially for skeletal forms in
relationship to spatial orientation and survival.
All in all, it can be stated that the skeleton itself – its cognizant image construction and its
projected possible actions - affords everything that is necessary to construct a virtual and
interactive environment, including the immersive entrainment of novel movement configurations
when modeled, revealed; and thus, ultimately experienced through a cross-modal and multisensory context of application, as is reconstituted and accomplished through the composite
application of the VRB3 ™ method as a behavioral training sequence for the enhancement of
body schema acuity and movement dexterity prior to the actual administration of traditional
Feldenkrais sessions or lessons.
®
Pilot Study and Continuing Observations from Practice-based Evidence
In my earlier retrospective pilot study (Sobie, 2013) conducted at my facility (details to
follow), using an accrued "practice-based evidence" demonstration technique to supplement a
need for understanding and explaining some ideas behind The Feldenkrais Method® to the
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regular caseload of spine patients, I inadvertently discovered practical utility in using life-scaled
skeletal models and implementing their characteristics as a basis for multimodal/anatomy/skeletal density imagery explorations for each patient. Plus, I found that
perceptual accuracy experiments could be augmented for actualizing deep articular joint surface with greater and greater acuity - as a demonstration cognition for re-conceptualizing typically
held and clinically familiar notions (muscular deficiency and disc damage) that are likely
contributory to a distorted structureal perception of ‘diagnostically-based’ body schema. These
models - particularly the femur bone - were then more routinely used as a basis for clarifying and
conducting their role in corresponding Feldenkrais® movements for patients presenting with
LBP.
In the summer of 2012, a retrospective chart review was conducted through a student
assisted data compilation of LBP patients being derived from my usual clinical caseload from the
preceding eight months, (N = 40). It was discovered that there were significant changes in
reported pain level and gait quality after only three sessions of this kind of approach. Results
indicated a marked reduction of pain intensity upon repeated before and after VAS scales after
the initial three treatment sessions that were for clarifying perceptual acuity for these actual joint
articulations - in conjunction with visual-tactile tracings of adjacent skeletal density imagery
correspondences - from an average VAS rating of 6/10 at baseline to a new and significantly
reduced average of 2/10 after session three. It should be clarified that not all of these patients
were being sub-classified as acute, sub-acute, post-surgical, or chronic at the time of this study
and data sampling.
Additionally and anecdotally, it had also been consistently observed from the outcome of
all initial sessions (for clarifying hip axes through pelvis to head), that there was almost a
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universal co-observation consensus for indicating changes of awareness in gait pattern in terms
of proportionate support distribution alignment and fluidity. These observations were
qualitatively indicative of performance magnitudes that would have been likely deemed as
significant had there been a prior administration of a Dynamic Gait Index test profile and/or
other technical-based assessment tool for changes in gait cadence and/or inequalities in force
distribution (this of course becomes a prospect for conducting yet an entirely different kind of
research project at a later date). It was thereby concluded that body schema based somatic
education interventions, including the Feldenkrais Method®, appear efficacious, and deserve
further investigation. Furthermore, the interventions do not appear to rely on treating particular
anatomical regions that are specific to a diagnostic category or perceived area of involvement
(i.e. specific lumbar spine segments) directly.
This information was shared in poster presentations and approved abstracts at various
national/international scientific meetings including The Feldenkrais® Research Symposium in
San Francisco, California, in 2012, The 44th Annual Scientific Meeting of The Association for
Applied Psychophysiology and Biofeedback (AAPB) in Portland, Oregon, during March 2013,
and finally to The International Research Congress for Clinicians in Complementary and
Alternative Medicine (ICCCIM) in Chicago, Illinois, during October 2013, from which my
poster abstract became published in the Global Advances in Health and Medicine Journal, which
can also be accessed via the National Library of Medicine Internet link
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3875009/; see Sobie, 2013). The outline and
content of the abstract is further summarized below in Table 2, and a hard copy publication
reprint is also appended in Appendix C.
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Table 2
Copy of Published Pilot Study Research Abstract
Abstract P03.03.
Title: Body Schema and Feldenkrais®: Effects Upon Subjects with Low Back Pain
Timothy Sobie (1)
Scientific abstracts presented at the International Congress for Clinicians in Complementary & Integrative Medicine
2013
Focus Areas: Integrative Approaches to Care, Alleviating Pain
Background and Purpose:
Back problems continue to be the number one symptom disorder for consulting complementary and alternative
medicine (CAM) practitioners. Neuroscience continues to indicate that the human brain undergoes a process of
somato-topic cortical reorganization in association with sustained states of chronic pain.
Feldenkrais® practitioners aim to create individualized multimodal learning experiences that are believed to clarify
an improved neuroplasticity-based change in the cognitive construct of one's own body schema. A specific protocol
is applied to observe some responses in subjects with mechanical, non-specific low back pain (LBP) in a clinical
practice setting.
Methods:
Forty subjects (30 females, 10 males) diagnosed with persistent LBP attended a Feldenkrais®-based physical therapy
intervention series of sessions while assessing usual baseline measures—including Pain Intensity on VAS and
observations of Gait Quality.
Using anatomical skeleton models and proprioceptive touch, 3 inquiries for primary learning conditions were made
for clarifying anatomical imagery including (1) The Hip Socket axis of rotation, (2) Inner ilia pelvis as an inner
bridge of leg support, and (3) correlating the vestibular apparatus in combination with global Feldenkrais®
movements. No attention was given to treating isolated lumbar segments directly.
Results:
All conditions were novel interpretations of body awareness for subject's previous notions of body schema. Pain on
VAS reduced from 6/10 average to 2/10. All subjects had a more balanced gait.
Conclusions:
Body schema–based somatic education interventions, like the Feldenkrais Method®, deserve further investigation
and do not appear to rely on treating the anatomical regions of perceived involvement directly.
Note. Reprinted from Scientific Abstracts Global Adv Health Med, 20132(Suppl), p. 3.
doi:10.7453/gahmj.2013.097CP. P03.03. Reprinted with permission via Pub Med Central.
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Summary
The accurate examination and effective treatment of CNSLBP remains a continuing and
perplexing problem for many scientific researchers and clinicians as well as for conducting
health care policy guidance and administration. While research continues to indicate that no one
type of exercise intervention or program is superior in efficacy to any other, Core Stabilization
Exercise (CSE) approaches have emerged in ubiquitous popularity, and to this day, still remain
as one of the most prominent trends for implementation and utilization in physical therapy clinics
and fitness centers throughout North America, Europe, and Australia, since original research was
published in the late 1990s.
The hallmark of CSEs is to entrain patients to perform a "draw –in" maneuver via
isolated sub-maximal recruitment of Transverse Abdominus (TrA) and Lumbar Multifidus (LM)
muscle groups, most specifically with the aid of either palpation instruction and/or a pneumatic
pressure recording biofeedback device known as The Stabilizer®. Exercise progression then
implements functional and callisthenic types of activities to challenge the patient to maintain
stability (consistent core control) across a range of static positions and dynamic perturbations –
being consolidated as a progression as motor control exercises.
Conversely, The FeldenkraisMethod® of somatic education seeks to cultivate and link
discriminative sensory–motor—informational learning experiences (i.e., perception modified
through action and intrinsic qualities of interoceptive attention toward novel spatial-temporal
configurations via a range of exploratory embodiment variations that can often be supplemented
by action-oriented imagery) in conjunction with fostering new, more efficient, soon to be
habituated, neuro-plastic changes in the brain that concur with "optimal use of self," through
sensing and leveraging the core of entire skeleton in the performance of everyday generalizable
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life tasks in a functionally applicable and reproducible context; and ideally, with a proportionate
distribution of biomechanical forces such that there is no additional requirement for extraneous
or unnecessary muscular effort. Thus, said differently, Feldenkrais® practitioners aim to create
individualized multi-modal learning experiences that are believed to clarify new functional
interrelationships in both perception and action; and to effectively make better use of an
improved neuroplasticity-based change in the cognitive construct of one’s own body schema.
Again, the purpose of this single-blind, randomized controlled study (RCT) is to compare
a Body Schema Acuity Training protocol using newly applied, newly developed low-cost
technology (Virtual Reality Bones™/VRB3) with a respected complementary-alternative,
movement and manual therapy, neuroplasticity-based educational intervention (The Feldenkrais
Method®) against the most commonly accepted approach being utilized within current and
conventional physical therapy practice settings (Core Stabilization Training and Graded Motor
Control Exercises). This was conducted for improving the outcomes on usual clinical outcome
measures for CNSLBP, and to determine whether there is greater clinical efficacy being
demonstrated between one combined intervention or the other for treating the widespread
problem of CNSLBP, as an outcome of the study itself.
Finally and furthermore, consistent with entire synopsis for literature review, and in
corroboration with my attending the proceedings from the 7th Interdisciplinary World Congress
on Low Back and Pelvic Pain in Los Angeles during November 2010, it remains conclusive that
little has changed over the past five years, and that what is known about the status of expert
recommendations for the conservative management and treatment of CNSLBP in terms of
movement re-education, cognitive exposure and graded activity and/or supervised exercise
programs under the rubric of motor control can be summed-up in the following five points:
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● Movement Variation seems more important than Movement Repetitions;
● Sensory Components (the quality of discriminative selection) seems a greater variable of
importance than traditional notions of ROM, Strength, & Flexibility;
● In all movements, stability & mobility elements interact;
● Exercise programs that include imagery seem to have better outcomes than those without
(Franklin 2010); and
● Bio-Psycho-Social Factors continue to play an important role.
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CHAPTER 3: METHODOLOGY
Overview
In this chapter, the research design and its support through current NIH and APTA
guidelines and from previous empirical studies, along with its format and historical timeline, are
stated, outlined, and described. Details regarding the recruitment of patients to qualify as
volunteer human participants, assuring their inclusion and exclusion criteria, providing for their
written informed consent for voluntary participation in the study, controlling for fear-avoidance
catastrophic pain beliefs in both groups and implementing sequential procedures used for
stratified random assignment into two single-blinded treatment groups are also all described. In
conjunction with study orientation and consent, I furthermore describe how all study participants
were blinded during the course of the study while also being controlled to allow for their
individualized treatment progression and to permit their self-application toward resuming graded
activity.
Provisions for reliable data gathering methods at baseline and for repeated outcome
measures throughout the course of the study are described, and the respective tools and test
instruments, as metric indicators suitable for assessing clinical difference of change in CNSLBP,
are validated. The opposing strategic foundations and qualitative differences occurring between
control group and the experimental group’s methodological interventions are identified and
described. Finally, the determinants for sample size and the statistical analysis methods selected
for procedural comparison of different data sets are introduced and described for purposes of
discerning and quantifiably demonstrating the scale and degree of measured differences
occurring between two groups over time, and in comparative response to the two interventions.
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The entire study design was approved to meet IRB guidelines for the protection of human
subjects by Saybrook University’s IRB in April 2015. The study began on November 23, 2015,
and concluded on April 24, 2016.
Again, the purpose of this single-blind, randomized controlled study (RCT) was to
compare a Body Schema Acuity Training protocol using newly applied, newly developed lowcost technology (Virtual Reality Bones™/VRB3) with a respected complementary-alternative,
movement and manual therapy, neuroplasticity-based educational intervention (The Feldenkrais®
Method); and against the most commonly accepted approach being utilized within current and
conventional physical therapy practice settings (Core Stabilization Training and Graded Motor
Control Exercises). This was conducted for improving the outcomes on usual clinical outcome
measures for CNSLBP, and to determine whether there is greater clinical efficacy being
demonstrated between one combined intervention or the other for treating the widespread
problem of CNSLBP, as an outcome of the study itself.
Research Design, Adherence to Current Guidelines, Consistency to Prior Precedent
A randomized controlled trial (RCT) using matched control conditions to the closest
extent possible was deemed the best design method for outlining and answering the essential
research question of evaluating and comparing the respective outcome measures between two
interventions, and for the determination of superior treatment efficacy between one intervention
versus the other. While the current study makes fastidious attempt to control all variables with
exception of the outcome measures as the dependent ones, elements of a pragmatic RCT were
also included in the research design. This was to permit some flexibility of delivery within each
treatment intervention as they are rendered within the context of actual day-to-day practice, and
as adjusted to meet the individual qualities of each participant in each group. For example, if a
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participant was unable to tolerate a particular position involved in the delivery of a treatment,
then modifications were made to assure that that patient could receive the same content of the
session’s intended benefit, but from an alternative or imagined position. These adjustments were
in part co-determined by the scope, experience, and professional judgement of the treating
therapist and these situations were known to likely occur within both arms of the study.
Inclusion of Latest NIH Research Guidelines and Clinical Practice Guidelines for CNSLBP
Citing a lack of investigator consensus and inconsistency in investigations into the growing
worldwide problem of CLBP or CNSLBP, The National Institutes of Health (NIH) released a
task force report establishing new standards for research in June 2014. These new standards are
additionally and uniformly recommended to be included as necessary requirements for all future
NIH grant proposals. The recommendations happen to include:
● Definition of CLBP as "a back pain problem that has persisted at least 3 months and has
resulted in pain on at least half the days in the past 6 months."
● Stratification of CLBP impact by "personal impact" considerations including pain
intensity, pain interference with normal activities, and functional status.
● Establishment of a minimum data set for describing individuals participating in all
research studies on CLBP that captures demographics, medical history, and self-report of
symptoms and function including pain intensity, physical interference, depression, and
sleep disturbance.
● Affirmation of earlier consensus documents on outcome measures for chronic pain. (The
RMDQ and the VAS – PAIN scales qualify for this domain). (De Litto et al., 2012)
In addition, the Clinical Practice Guidelines linked to the International Classification of
Functioning, Disability, and Health from the Orthopedic Section of the American Physical
Therapy Association outline the following clinical practice guidelines concurrent with the
current research design:
● Place patients with LBP in subgroups based on items from the examination, and provide
subgroup-specific treatment [moderate evidence];
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● Consider cognitive affective factors when placing patients in subgroups [moderate
evidence];
● The Oswestry Disability Index and the Roland-Morris Disability Questionnaire should be
used as outcome measures for patients with LBP [strong evidence];
● Thrust manipulative procedures can be used as a component of a comprehensive
treatment plan to reduce pain and disability in patients with patients with mobility
deficits, acute LBP, and/or back-related buttock or thigh pain [strong evidence];
● Progressive endurance exercise and fitness activities should be encouraged for patients
with chronic LBP [strong evidence];
●
Patient education and counseling should focus on the inherent strength of the spine, how
pain is processed by the nervous system, the importance of returning to activities,
positive coping strategies for pain, and the overall favorable prognosis for LBP. In-depth
discussion on pathoanatomical sources of LBP should be avoided, as this strategy may
increase a perceived threat or fear associated with LBP [moderate evidence]. (De Litto et
al., 2012)
The design for the current research study/RCT reflects consistent adherence to both the
current NIH research guideline recommendations and the most current APTA clinical practice
guidelines being applied to both treatment groups as cited above. Beginning November 2015, I
thereby conducted the current randomized controlled trial. Patients received either an original
application of a novel intervention program (Body Schema Acuity Training) using the VRB3
approach, plus Feldenkrais® Movements (VRB3/FM; herein specified as an experimental
group), or a standard and customary intervention program (Core Stabilization Biofeedback), plus
Motor Control Exercises (CSB/MCE; herein specified as a control group). This was conducted
over the course of two months, with repeated measures after baseline data gathering occurring at
two weeks (Phase I), and again at four weeks (the end of Phase II), and at the end of eight weeks
(the conclusion of Phase III) being depicted here in this study as post-intervention.
A projected long-term follow-up is intended at six months (post-date of last day for
formal intervention at conclusion of Phase III) to assess the effects of long-term potentiation and
learning. This detail was fully disclosed in each participant’s consent agreement at start of study
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to be revisited again between September and October 2016. This trial was prospectively designed
with pre-IRB approvals of the signing dissertation committee members as of April 2015, and infollow-up to the results of a previous pilot study published in November 2013 before being
finally conducted as a full-scaled RCT from November 2015 – April 2016.
A Historical Precedent for Consistency of Research Design & Comparative Metrics
A previous comparable study conducted by a respectable team of internationally cited
investigators (Macedo et al., 2012), though not previously known during the implementation
phase of this study, and was newly referenced in the more recently updated Literature Review
section of this document being published as: “Effect of Motor Control Exercises Versus Graded
Activity in Patients with Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial.”
Again, it is important to disclose that my review for this study was actually discovered after the
original formulation of my design parameters for the current study, and within only two weeks of
finalizing the data collection and just prior to conducting the statistical analysis.
Yet, by having a comparable study design as a similar kind of benchmark or yardstick for
exploring the outcomes of treatments for CNSLBP in a comparative study, especially one that
also applied the same Core Stabilization/Motor Control Exercise model as a corresponding
control group to an alternate treatment intervention (to Graded Activity), I can perhaps at least
compare some of their outcome results with my own in terms of:
1. Their using essentially identical outcome measurement tools:
● Visual Analog Scale for Pain (VAS vis a vis NRS),
●
Roland Morris Disability Questionnaire (RMDQ), and
● Patient Specific Functional Scale (PSFS);
2. By their using a same number of intended treatment visits (12 sessions), and
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3. By their using the same distribution schedule for administering the interventions:
● 2 xs per week for first four weeks,
● 1 x per week for the following four weeks.
Otherwise, the major difference in this study is that they had a much larger and experienced
research team, more multi-site locations for the treatment setting, more significant and varied
funding resources, and hence a much larger sample size (N=172).
Participants, Sources of Recruitment, Treatment Setting & Orientation to the Study
Patients as "Participants" presenting with clinical diagnosis of Chronic, Non-Specific
Low Back Pain (CNSLBP), and without significant medical complications that would prevent
their attendance in an outpatient setting, were recruited to the clinical intervention study. This
was provided through area physicians via special referral to "Alliant Physical Therapy/Alliant
Spine Project, LTD," specifying "Chronic Pain Research & Neuroplasticity for Low Back Pain"
check box under "Tim Sobie, PT, Ph.D. Candidate." Generation of study referrals via primary
care (family practice and internal medicine) physicians occurred mostly through prior
professional networking, and less through research announcement flyers and mass mailings of
direct mail, as co-facilitated through Pierce County Medical Society. A significant source came
through direct networking with Dr. Derek S. Scott, as medical director of CHI/Franciscan Pain
Management Center, Tacoma, Washington, who also served on the dissertation committee as the
medical advisor for the current study. Other referrals came in support from University of
Washington (UW) Pain Center, Veterans Administration/Veteran’s Choice Community Access
programs, suitable referrals from other allied health professionals, and by public newspaper
announcement. All participants, whether initially referred by physician or self-referred,
underwent physical therapy screening and corroboration with their primary care physician via
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documentation of evaluation and plan of care being inclusive of "participation in low back pain
clinical study involving the use of manual therapy, graded exposure, exercise, and movement."
Table 3 summarizes sources of recruitment for study participants.
Table 3
Sources of Recruitment for Study Participants
Control Group
Primary Care
Experimental
Group
3
Pain Specialist (CHI /Franciscan)
3
4
Other Pain Specialist (UW)
1
0
Veterans Administration
2
1
Licensed Mental Health Counselor
2
0
Occupational Therapist
1
0
Self-Referred
3
6
4
Outpatient Treatment Setting and Neutralizing the Environment for Matched Consistency
All participants underwent orientation and consent, initial data collection, stratified
random assignment into groups, therapist screening assessment, continued intervention
procedures, and continued data collection within the same facility at Alliant Physical Therapy
and Integral Medicine, PLLC, care of The Alliant Building, 201 N. I Street, Tacoma, WA,
98403. Three experimental group participants opted a request to have at least ½ of their visits
allocated to the Gig Harbor satellite branch location of Alliant Physical Therapy and Integral
Medicine, PLLC, 7195 Wagner Way, Suite 105, Gig Harbor, WA, 98335, to reduce their cost of
highway 16 bridge tolls. These sessions took place on Thursdays only. Reassessment and data
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collection, however, could only take place with designated research coordinator Kenny Li and
reception staff at the Alliant Building main practice location in Tacoma.
Both facilities share common color themes and interiors, depict a warm and holistic
atmosphere, and are devoid of usual sports medicine or gymnasium fitness equipment products
that are typical of most outpatient physical therapy facilities. Figure 47 displays the session
areas for each location with the former being shared by the majority of participants between each
group.
(a)
(b)
Figure 47. Site Locations and Facilities used for the Current Study. (a) Tacoma, WA, USA; (b)
Gig Harbor, WA, USA.
Characteristics of the Clinicians providing the Interventions
The legislative scope of practice for licensed physical therapists in many areas –
including in Washington State, USA, the jurisdiction from which this study was conducted,
specifically includes “direct access to the evaluation and treatment of persons afflicted with any
mental or physical impairment that impairs function [emphasis added]" (Washington
Administrative Code, RCW 18.74.010). All physical therapists (PTs) and one physical therapy
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assistant (PTA) maintained qualified Washington licensure before, during, and months after the
study.
The control group PTs (N= 3) were contracted to be available for treating patients with
CNSLBP from November 23, 2015 – April 22, 2016. One control group PT had specific
dedicated experience as the lead PT for a comprehensive multi-disciplinary, CARF certified pain
rehabilitation center for approximately 11 years. Another was currently working for an injured
worker’s specialty facility full time, but with prior certifications in holistic-oriented CAM
therapies, including Qi Gong and Biodynamic Cranial Sacral Therapy. Both of these therapists
had accrued 25 and 17.5 years of total physical therapy experience respectively, with 20 and 15
years being respectively familiar and experienced for the delivery and training of core
stabilization and motor control exercises. The third therapist had three years of licensed
experience, but is also a daughter of physical therapy clinician and practice-owner from another
mid-western state for over 25 years. Alliant Physical Therapy’s office and support staff deemed
all to be personable and professional.
The experimental group PTs included the principal investigator having 30 years’
experience in licensed physical therapy practice, and with 20 years’ experience as a Guild
Certified Feldenkrais Method® Practitioner. The added clinician for the experimental group
intervention had 2 years’ experience as a licensed physical therapy assistant, but she has
maintained active separate certification as a Guild Certified Feldenkrais Method® Practitioner for
almost 16 years. The average years of licensed physical therapy experience compared to
specialty experience of clinicians delivering the specialty “Core Stabilization/Motor Control” vs.
the “Feldenkrais Method®-based” intervention approaches are depicted in Table 4.
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Table 4
Average Years of Experience of Clinicians delivering the Specialty “Core” vs. “Feldenkrais
Method®” Intervention
Physical Therapy (Years)
Specialty Area (Years)
Control Group
15.1
12.3
16.0
18.0
Core Ex. &
Motor
Control
Experimental Group
Feldenkrais Method®
Note. The first column quantifies average years of ‘standard PT clinical practice’ overall inclusive of specialty area for specified training.
Orientation of Participants Prior to and during the Study
Prospective participants for each group were uniformly blinded, both prior to study entry
and throughout the course of the study, by depicting a consistent language within the informed
consent form. The form adequately communicated an overall impression for study intent, but
without specifically disclosing the particular characteristics of difference distinctly inherent as
important and independent distinguishing variables uniquely attributable to either the control
group or the experimental group’s style of difference for actually depicting them as a competing
intervention. Thus, the language of the consent form was designed with mutual intent to both
inform and to necessarily blind the participating subjects between each arm of the RCT study. At
no time were study participants in either group ever referred to as being in an experimental group
or a comparison or control group.
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Vital points of consideration upon patient consent included titling the clinical research
and study description in adequate and believable terms. The consent form title read:
A Comparison of Two Body Awareness Training Methods for Maintaining Precisely
Coordinated Movements and Optimal Control of Spinal Stability for the Improvement of
both Symptoms and Activity Capacities in Daily Life: Comparative Effects on Subjects
with Chronic Non-Specific Low Back Pain in an Out-patient Clinical Setting.
Furthermore, the purpose of the study was stated in descriptive terms “to find out whether
there are significant differences between two existing types of body awareness training methods
for improved stability and control of the spine column and surrounding relationships through
precisely coordinated muscle and movement activity.” It was also clarified that “...both treatment
interventions are specifically designed for persons who commonly relapse into episodes of
chronic recurrent low back pain, have persistent pain; also known and diagnosed as Chronic,
Non-Specific Low Back Pain (CNSLBP).”
The consent from additionally depicted the background nature of the current clinical
study by stating to participants that:
You are being asked to participate in a clinical investigation trying to find out about
comparative relationships between two types of patient education and training methods
involving the awareness and experience of muscle control activities and coordinative
movements designed to improve back and spine function and to decrease the debilitating
effects of CNSLBP, including the attenuation (or reduction) of pain intensity itself.
We have discovered that for some people who have Chronic (CNSLBP) Low Back Pain,
that there is a corresponding disruption of clarity for both the sensation of where your
body is in space and how it moves, and in how muscles can both under-contract and
over-contract as if they sometimes have a mind of their own. Also, there is a
corresponding disparity of how to coordinate daily or novel movement (motor) activities
with clear dexterity-- especially for larger movements involving a balance throughout the
whole body. We believe that these ordinary activates have become hampered or blocked
over time by the predominance of pain pathways. Yet, we also believe that by training
precisely coordinated movements with these newer methods, you can invoke ‘competing
pathways’ in your brain and nervous system that are not compatible with usual, often
misunderstood, pain-invoking pathways.
....after your consent and the initial intakes, you will be informed about your status as a
continued participant in the study and be assigned to one of two groups wherein a
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licensed physical therapist - specifically trained in one of the two methods - will assess
and carry-out the respective treatment progression.
Another, most important feature embedded within the consent form was the assurance of
participant safety. Here, it seemed fitting to introduce elements and advance directives and
principles being derived through Therapeutic and Pain Neuroscience Education. This was to
control for fear-avoidance, to describe symptom relapse (of usual symptoms) as a normative
initial phenomenon in chronic pain, and to challenge the common cognitive-behavioral distortion
of "hurt equating to harm or actual tissue damage occurring under otherwise innocuous
conditions," as being an unsubstantiated automatic thought capable of reinforcing and amplifying
the pain experience.
Controlling for Fear-Avoidance and Catastrophic Pain Beliefs for Both Groups
As further referenced from the literature review, and by inferring the status of current
treatment recommendations derived through practice and research, there was added
consideration for controlling confounding bio-psychosocial variables; namely, fear-avoidance
factors. In consequence, the practice literature over past five years has documented the
emergence of newer therapy approaches that aim to combine (a) cognitive-behavioral and
exposure therapy approaches with (b) supervised exercise programs in order to entrain improved
motor control, while simultaneously seeking to alter the patient’s beliefs about the interplay
between pain and movement, in other words, that “hurt does not equal harm” (Nijs et al., 2014).
As these have become the new basis of standard for the therapeutic treatment of chronic pain –
particularly, low back pain, and in consultation with other colleagues, I have sought to include
them in the study design.
To control for this important variable, this study highlighted a brief mention of attribution
of expectancy for the possible emergence of pain output phenomena (unexpected spontaneous
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and/or latent flare-ups of escalated pain intensity being experienced) that could occur at any time
during the course of the study for either group. This offered a corresponding, but contrasting reattribution using basic principles of therapeutic neuroscience education (i.e., by stating that
"imagined movements and gentle sub-maximal forces to be employed within both groups are in
no way causal of producing actual tissue damage,"; e.g., hurt does not equal harm) by way of:
A. Embedding a description of such within the subject’s consent form/agreement to
participate in the study as a category of pre-informed risks for participation in the study;
B. Of orienting each subject about the nature and essential themes to be encountered during
each treatment session, exercise program and/or movement progression, and reminding
them that such activities will be mildly challenging to attend to (in order to progress
forward), but are not likely to be physically harmful in any direct or indirect way such
that they would cause tissue damage or injury; and
C. Of reviewing for non-correspondences in subject’s adherence/activity/home exercise log,
and/or continuously monitoring their subjective reporting during the course of the study.
The occasional phenomenon of latent or spontaneous pain flares occurring anywhere in
the body after or during the course of treatment, or at any time was explained to each subject as a
normative and common finding in activity situations involving sensitization to chronic pain.
These phenomena were re-framed as constituting “an output from the hyper-sensitized brain in
guarded response to essentially innocuous, but albeit unfamiliar events,”; and not as a
consequence of new injury/traumatic strain or tissue damage, nor likely due to any serious
“medical condition,” as was further evidenced by complete medical work-up and/or physical
therapy screening exam prior to entering the study. These pre-treatment and during-treatment
elements are essentially borrowed from Therapeutic Neuroscience Education/Pain Neuroscience
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Education and Cognitive Behavioral Therapy re-attribution principles, and were again explained,
detailed, and discussed in advance via a specific entry within the Consent Form and Participation
Agreement for the prospective volunteer participants, and for enrolled participants for both arms
of the study.
Inclusion/Exclusion Criteria and the Stated Conditions for Continued Participation
The primary criteria for participation in my current study included any patient presenting
with clinical presentation, diagnosis, and/or history of chronic, non-specific low back pain
(CNSLBP), being recurrent and/or persistent between posterior costal margins and base of
buttocks / gluteal folds, and lasting greater than three months without significant change. Age
Range 18-80, and open to all genders, classes, ethnicities, orientations, and race.
Inclusionary Criteria
More specifically, patients were eligible for inclusion if they met all of the following
inclusion criteria:
●
Chronic nonspecific low back pain (greater than three month's duration) with or without
leg pain, but not distal to knees;
●
Currently seeking care for low back pain;
●
Between 18 and 80 years of age;
●
English speaker (to allow response to the questionnaires, being amenable to therapy
instruction, and for communication with the physical therapist);
●
Clinical assessment indicated that the patient was suitable for active exercises.
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Exclusionary Criteria
Patients were excluded from the comparative clinical research study for chronic nonspecific low back pain if they presented with:
●
Peripheral radicular symptoms distal to knee;
●
Previous spinal surgery within past year or scheduled for surgery during study period;
●
History of multiple surgical lumbar spine fusions and/or resultant "failed spine
syndrome";
●
Known or suspected serious lumbar pathology including changes in bowel or bladder
function, severe weakness, other neurovascular changes, or complete loss of sensation;
●
Comorbid health conditions (cardiac, respiratory, malignant or neurological) that would
contraindicate participation in moderate to potentially strenuous exercise activity;
●
Confirmed or expectant pregnancy, or less than six months, post-partum status for LBP;
●
Recent history of epidural procedure and /or pain device implants within prior three
months;
●
Current documented risk and/or clinical presentation of severe opioid addiction or abuse;
●
Pending litigation/attorney representation for injury claim having to do with LBP;
The co-presentation of significant orthopedic hip, knee, or podiatric foot problems,
fibromyalgia syndrome as well as rheumatoid arthritis or other autoimmune conditions, was to be
considered on a case-to-case basis prior to entry into study in discussion collaboration with the
attending or primary care physician. Fortunately, there were no severe co-morbidities in
participating volunteers that precluded their participation in the current study.
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The Stated Conditions for Continued Participation
Consenting participants were permitted to maintain their current medication regimen
throughout the course of the study, but were not permitted to abruptly increase or abruptly
discontinue their dosage. Instead, they could opt to gradually titrate down their average dosing
amounts gradually over time, week by week, during the eight-week course of the study. Where
applicable, they were asked to limit their alcohol intake to two drinks per day. Addendum entry
fields were added to home program adherence diaries to permit, track, and attain records of
difference for medication intake during the course of treatment, after the eight weeks, and before
the six-month follow-up.
As an added consideration for the control of potentially confounding variables, patients
were asked not to seek any other form of physical, behavioral, and/or medical/surgical, over-thecounter interventions during the eight-week course of the study in order to remain enrolled as a
continued participant in the study. These competing intervention restrictions would have
included other physical therapy or physical or occupational therapists for back or spine, massage
and bodywork, chiropractic, osteopathy, acupuncture, interventional pain medical specialists,
naturopathic interventions, counselors, biofeedback practitioners, yoga, pilates, personal trainers,
energy healers, medical cannabis (unless already in use as a medical regimen), and so on. Other
onset of any severe medical or psychological conditions that would impair a participant’s ability
to attend or actively respond to any usual rehabilitative form of care, or that would have
endangered their safety, would also exclude them form continued participation in the study.
Sample Size, FABQ Sub-Grouping, and Stratified Random Assignment into Groups
Determining how to achieve an adequate sample size for statistical power, how to arrange
for an independent coordinator for assessment and sub-grouping, random assignment and data
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collection, and for managing the projection of added cost expenditures being anticipated to fulfill
the necessary human resource requirements, but without significant funding and stringent budget
constraints in the era of continuing managed care, began as a daunting and worrisome task.
Outside resources and other self-education venues were a necessary component toward resolving
an unrelenting and uncertain dilemma.
Determining Sample Size for a Small-Scale Therapy Practice Setting – Use of Pilot Study
One method of projecting an estimated sample size during clinical research, particularly
in new intervention situations without a prior precedent for assessing the comparative effects of a
novel approach against a standardized or current one can be achieved by conducting an ongoing
comparative statistical analysis in real time, while continuously randomizing participants into
two groups, and continuously tracking for trends of change in their data. For economy of scale,
this study could have begun with ten per group (N=20) and then followed by power analysis to
determine how many more subjects were needed for comparative statistical significance via
verification through t-test distribution. However, it was well beyond my scope to hire on an onstaff statistician at start of study.
Having the good fortune to attend the 2012 International Research Congress for
Integrative Medicine and Health (IRCIMH), being co-sponsored by Consortium of Academic
Health Centers for Integrative Medicine in Portland, Oregon, I enrolled myself in the
NIH/NCCAM-sponsored pre-conference workshop “Advancing Research Literacy,” as taught by
Claudia Witt, MD, MBA on May 15, 2012. While larger sample size numbers of 100 or more are
most desired for larger statistical power in clinical studies, she quoted the following support
guideline in her slide presentation by stating that “...however, given stability of estimates in the
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literature, an N=15 per arm of study is considered a good rule of thumb for early studies, along
with consideration of 10 participants per measured variable” (Witt, 2012).
Another more specific method for determining sample size - and in more direct
relationship to the clinical research question and current study design - is to garner data sampling
and statistical relevance of expected change as derived from prior pilot studies involving the
same or similar patient populations and the same or similar attribution characteristics as the
intervention to be prospectively studied. As was described in Chapter 2 of this dissertation
manuscript, at the conclusion of the literature review section, an in-house clinical pilot study and
retrospective review of LBP patients receiving SDI/Feldenkrais interventions (during the usual
course of treatment – no matched controls) was conducted from 2011-2012 and published in
2013. In this study, N=40 had rendered an average change in reported pain levels on VAS from
6/10 to 2/10; an interval difference of four points. Applying a formula for sample size estimate
(16 s²/d² + 1) using the pilot data of mean difference (d) between average change (4 points) and
the average standard deviation (s) from total average of the individual measurements of
variability for all individuals within the group (given +/- 2 points; an approximate per group
sample size is calculated as: 16 s²/d² + 1 > > 16 2X2 / 4X4 +1 > > 64/16 +1 >> 4+ 1 = 5/group
[N=10])
However, given the potentially equalizing factor of diminished difference using a control
group, the requirement for screening eligibility for appropriate inclusion, and for and the
likelihood of attrition and drop-out rate, I could anticipate recruiting at least 40 subjects to attain
the recommended guideline for N=30. The formula for sample size estimate was sourced
through accessing a public domain statistician’s website link:
http://www.jerrydallal.com/LHSP/SIZE.HTM
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Sub-Grouping High Fear-Avoidance Beliefs as a Known and Confounding Variable
Historically, the physical therapy profession has attempted to sub-group patients with
CNSLBP into diagnostic sub-groups based on "objective" classification physical exam findings,
but with little success. Cross-sectional data has revealed significant contribution from
biopsychosocial influences; namely, fear-avoidance and catastrophic beliefs upon the
exacerbation and magnification of chronic pain states. As a further control of potentially
confounding psychosocial variables, qualified and consenting participants (i.e., who presented
with scores exceeding preliminary pre-qualifying scores on the Fear Avoidance Belief
Questionnaire [FABQ] greater than 34 for work sub-scales and greater than 15 for physical
activity sub-scales) underwent random stratified assignments into each group at baseline/preintervention to better assure comparable representation of bio-psychosocial outlier tendencies
and greater homogeneity in each group.
Rationale for using Fear-Avoidance Beliefs Questionnaire (FABQ) as an Assessment Tool
The Fear-Avoidance Beliefs Questionnaire (FABQ) is a questionnaire based on the FearAvoidance Model of Exaggerated Pain Perception, a model created in attempts to explain why
some patients with acute painful conditions can recover while other patients develop chronic
pain from such conditions. The FABQ measures patients’ fear of pain and consequent avoidance
of physical activity because of their fear. This questionnaire consists of 16 items, with each item
scored from 0-6. Higher scores on the FABQ are indicative of greater fear and avoidance beliefs
(Waddell, Newton, et al., 1993).
Within the FABQ, two subscales exist, the, which facilitate the identification of the
patient’s beliefs about how work and physical activity affect their current low back pain (LBP).
The numbers in parentheses below designate which items from the FABQ are included in each
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subscale, along with total possible points for each subscale (Fritz & George, 2002). These are
summarized in Table 5:
Table 5
FABQ Work Subscale (w) and the Physical Activity Subscale (pa) and their Thresholds of
Criteria for designating Excessive Scores for High Fear-Avoidance Cognitions in CNSLBP
Subscale
Questions Included
Total Possible Points
High Score
FABQ w
(items 6,7,9-12, 15)
42
>34
24
>15
FABQ pa
Items 2-5
A strong relationship exists between elevated fear avoidance beliefs and chronic
disability secondary to LBP. “Avoidance may lead to reduced activity levels, an exacerbation of
the fear and avoidance behaviors, prolonged disability, and adverse physical and psychological
effects” (Vlaeyen, Kole-Snijders, Boeren, & van Eck, 1995). Thus, the FABQ is an outcome
measure that serves as a clinically useful screening tool in identifying patients with high fear
avoidance beliefs who are at risk for prolonged disability. Management of patients with elevated
FABQ scores thus requires clinicians to tailor interventions to meet those needs. Research
reviews again suggest multi-disciplinary approaches, including cognitive behavioral therapy and
graded exposure to physical activity.
Intended population of FABQ in reference to the current study. The FABQ has been
proven to be a reliable and valid assessment tool based on patients with chronic low back pain. In
recent research, the FABQ is also being used preventatively in populations with acute low back
pain to identify the risk of long-term disability (Fritz & George, 2002).
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Reliability of FABQ. Test-retest reliability of the FABQ has been classified and rated as
good to excellent through an in-depth clinical review of statistical research to rate the agreement
between repeated measures:
● Total FABQ test-retest reliability (ICC=0.97);
● FABQ Physical Activity subscale test-retest reliability (ICC=0.72-0.90); and
● FABQ Work subscale test-retest reliability (ICC=0.80-0.91). (Williamson, 2006)
Cicchetti (1994) published guidelines for interpretation for kappa inter-rater or ICC inter-class
agreement measures:
● Less than 0.40—Poor.
● Between 0.40 and 0.59—Fair.
● Between 0.60 and 0.74—Good.
● Between 0.75 and 1.00—Excellent.
Intraclass Correlation Coefficient (ICC) is an inferential statistical appraisal for the
assessment of consistency or reproducibility of quantitative measurements made by different
observers measuring the same given quantity of phenomena. In clinical research, it is most
typically applied to what is being referred to as inter-rater reliability (Cohen's kappa
coefficient), when conducted through inter-professional assessment by separate examiners; or in
terms of test-retest reliability, as when conducted through individual self-assessment in the
absence of therapeutic intervention and during a prospective period of repeat sampling.
Validity of FABQ. The validity of a measurement tool is considered to be the degree to
which the tool or testing instrument measures what it purports to measure, particularly in
relationship to current evidence in association with known theoretical constructs and observable
or measurable phenomena. Statistical conclusion validity is the degree to which conclusions
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about the relationship among variables accrued through the sampling of a data set are determined
as likely correct or reasonable (Cozby, 2009). As this type of validity is concerned solely with
the relationship that is found among discretely occurring variables, the relationship must be
qualifiedly expressed in terms of numerical correlation.
Correlation coefficients measure the strength of association between two variables. The
most common correlation coefficient, called the Pearson correlation coefficient, measures the
strength of the linear association between variables. The strongest linear relationship is indicated
by a correlation coefficient of -1 or 1. Most related phenomena correlate toward a modest
correlation coefficient value of 0.40 or more, with stronger correlations rating at 0.80 or more.
The weakest linear relationship is indicated by a correlation coefficient equal to 0, expressed in
terms as "no direct linear correlation," but only within the designated constraints of the current
sampling frame. A positive correlation means that if one variable gets bigger, the other variable
tends to get bigger too (toward +1). In contrast, a negative correlation means that if one variable
gets bigger, the other variable tends to get smaller (toward -1).
Evidence shows that the FABQ is well correlated with the Roland and Morris Disability
Questionnaire (RMDQ). By comparison, the correlation coefficients for the FABQ in total, the
FABQ W (work subscale) and the FABQ PA (physical activity subscale) are 0.52, 0.63, and
0.51, respectively. The FABQ was also shown to be correlated with the Tampa Scale of
Kinesiophobia, another measure of fear avoidance. Within its own internal construct validity for
like components, the correlation coefficients for the FABQw and the FABQpa subscales are 0.53
and 0.76, respectively (Williamson, 2006). The more recently developed STarT Back
Questionnaire is also undergoing concurrent review to assess reliability and validity as well as its
correlational relationships to other instruments.
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Implementation of FABQ. Accordingly, the current comparative study implemented the
FABQ based on criteria outlined above as a basis for stratified randomization of sampling
between each group to account for the confounding variables of fear of movement, fear of reinjury, and perceived work demand incapacity, as especially relevant to persons with chronic low
back pain disorders (CNSLBP), and to better assure a more equal representation in each arm of
the study. A copy of the Fear-Avoidance Beliefs Questionnaire (FABQ) and Score Sheet are
found in Appendix G.
Procedure for Consent, Gathering of Baseline Data and Stratified Randomized Assignment
Patients being referred as prospective participants underwent usual physical therapy
office admission and intake procedures, orientation to HIPPA privacy and protection policy,
study orientation, and signed consent to participate in the study, as was described earlier in this
chapter. Subsequent to administration of baseline tests and questionnaires by front desk
receptionist and physical performance measures by on-site research coordinator (details to be
described later), they underwent blinded procedures for stratified random assignment to one of
two groups. Two sets of randomization rosters were created in excel:
● One for patients (as consenting participants) to be scheduled into the control group
therapy block (up to 15 spaces); and
● One for therapists delivering the experimental group intervention (up to 15 spaces) being
alternated as a concurrent, but separate scheduling block from which to place the
qualified entry of prospective participants within the Practice Perfect EMR dedicated
appointment slots for each available clinician representing the control or experimental
group interventions.
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Allocation of initial group assignment corresponded with real world points of entry via
alternating the order sequence of referrals that arrived randomly either via fax or phone call to
the front office staff in real time. Once signing the informed consent, the patient was assigned to
participate in the intended group as determined by random but alternating-sequential order in the
scheduling.
All intake data was kept separate from view by principal investigator and treating
clinicians in an excel spreadsheet ledger being organized and stored in separate cabinet and data
file by an employed therapy intern and research coordinator working on-site at the therapy
setting’s back office. If it was found by the attending research coordinator that a patient as
participant either met or exceeded the indicated threshold scores in the FABQ (greater than 34
for FABQ W and/or greater than or equal to 15 for FABQ PA) upon scoring at intake, and there
was a pending imbalance in number for these participants being represented or allocated to one
group, then the research coordinator, in conjunction with front desk scheduling, would then
transfer the outlying participant into the opposite, alternate treatment group.
Participating subjects who presented with scores exceeding preliminary pre-qualifying
threshold scores on the Fear Avoidance Belief Questionnaire (FABQ), defined as exceeding
greater than or equal to 34 for work sub-scales (W) and/or greater than or equal to 15 for
physical activity (PA) sub-scales, thus underwent and adhered to provisional procedures for
random stratified assignment into each group. This alternating sequence of sub-strata assignment
cyclically continued until both groups were more or less equally matched for comprising a like
sample of high FABQ threshold scores, and this process continued as both groups approached
the necessary participation levels for sample size power at n=15.
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For this study, 10 of n=15 qualified in the control group and 10 of n=15 qualified in the
experimental group. Of this, 17 were identified to have high scores for Physical Activity (PA)
avoidance sub-scale, whereas only three were identified as qualifying for the Work (W) taskavoidance sub-stratum. Fortunately for control features of the research design, but unfortunate as
a population characteristic, it was found that high FABQ scores were a dominant feature in both
groups for participating patients having been diagnosed with CNSLBP.
All in all, 10 of 15 subjects in both groups (n=30) were accounted for in this sub-stratum
classification, with n=8 registering high in the PA sub-scale in the experimental group compared
to n=7 in the control group. For work task avoidance, n=3 participants scored high in the W subscale for the control group, as contrasted by n=2 included participants achieving concomitantly
high scores in both PA and W sub-scales for the experimental group. The final allocation of
distribution achieved for study participant’s high FABQ threshold values, being allocated for
random stratification assignment into each group, is depicted and summarized in Table 6:
Table 6
Random Stratification Subgrouping Distribution based on FABQ
Experiment
al Group
Control
Group
W-subscale:
Hi Work Task Avoidance Only (> 34)
0
3
PA-subscale:
Hi Physical Activity Avoidance Only (> 15)
8
7
2
0
10
10
W&PA-subscales combined:
Both Hi Work Task Avoidance (>34)
Hi Physical Activity Avoidance (>15)
Total Subjects qualifying for
Stratified Random Assignment
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From this metric, it can perhaps be inferred and confirmed that high scores on FABQ may be a
consistently high metric for populations of patients with CNSLBP; becoming co-morbid with a
presenting diagnosis of chronic low back pain lasting greater than three months or more.
Tests and Repeated Measures for Clinical Outcome
Tools, scales, questionnaires, physical performance tests, and other instruments that were
found to be amenable for sensitivity to change and for quantification of detecting clinically
relevant change over time for conditions involving chronic non-specific low back pain
(CNSLBP) were additionally selected on the basis on prior literature reviews; these also ran
comparative randomized controlled trials as well as other preliminary studies. Further selection
was based on known practice guidelines and substantiated by the concurrent research
recommendations from the 2014 NIH Guidelines Report. All in all, the tools that have been in
longest practice application were also the tools that were most abundantly cited. Thus, the
following instruments were chosen as a reliable benchmark for my research, especially in light of
my introducing an original, newly constructed and combined intervention.
The Visual Analog Scale for Pain (VAS-PAIN)
Routinely used for rating the intensity of Low Back Pain, the Visual Analog Scale (VAS)
also combined with implementing its relationship to a numerical rating scale (NRS), asks
patients to rate their pain intensity on an 11-point, horizontal continuum scale where “0”
indicates “no pain” and “10” indicates their “worst imaginable pain.” The patient marks on the
line the point number that they feel represents their perception of their current state. At each
administration, this study sought to contextually qualify "worst imaginable pain" (Level 10) by
adding criteria to state that "Level Ten is super-severe, such that with or without a dose of
morphine anesthesia taking hold, you would likely pass-out just in order to cope."
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Studies have been conducted with intent to discern the cut-off points on the visual
analogue scale (VAS) to distinguish among mild, moderate, and severe categories of pain level.
Boonstra, Schiphorst Preuper, Balk, and Stewart (2014) sampled the VAS scores of 456 patients
with chronic musculoskeletal pain and cross-correlated them with other health assessment
functional scales, including the commonly used Short Form-36 Health Survey (SF-36). The
study results showed that VAS scores less than 3.4 corresponded to mild interference with
functioning, whereas 3.5 to 6.4 implied moderate interference, and is greater than 6.5 implied
severe interference. Correspondingly, they interpreted VAS scores for patients with chronic
musculoskeletal pain at less than 3.4 to be descriptive as a "cut-off" point for mild pain, 3.5 to
7.4 as a demarcation for moderate pain, and is greater than 7.5 as severe pain. However, they
added the caveat that
As there appear to be no universally accepted cut-off points, and in view of the low-tomoderate associations between VAS scores and functioning and between VAS and verbal
rating scale scores, the correct classification of VAS scores as mild, moderate, or severe
in clinical practice seems doubtful. (Boonsta et al., 2014)
Stated more commonly, the patient’s pain severity "is what they say it is."
In the absence of a gold standard for measures of pain, criterion validity can only be
evaluated at face value for its purported construct. For construct validity, the NRS for pain was
shown to be highly correlated with the VAS in patients with rheumatic and other chronic pain
conditions (pain is greater than six months) with correlations ranging from 0.86 to 0.95 (Ferraz et
al., 1990). High test–retest reliability has likewise been observed in both literate and illiterate
patients with rheumatoid arthritis and other chronic pain conditions (r = 0.96 and 0.95,
respectively) before and after medical consultation (Ferraz et al., 1990).
For optimal use across multiple interpretations of ratings for the quantification of pain
intensity as a cognitive-phenomenological construct that is unique to each individual, the current
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study implemented a combined visual analog – numerical rating scale. This relied on combined
"visual" use of numerical ratings being equally ascribed to equally-spaced intervals, with
corresponding verbal quantification descriptors (cut-off points) in addition to the inclusion of
emotionally valanced verbal qualifiers (e.g., moods); all correspondent with visual shading of
color intensities along a horizontal continuum inversing from cool blue to hot red. For sake of
simplicity, its documented cross-validation with the traditional NRS, and with reference to
abundance of visual information, I have adopted to retain the name of this instrument as simply
VAS-PAIN. A shaded gray scale example of the form used is shown in Figure 48. A copy of the
VAS-PAIN reference scale as viewed in "true color" during repeat administration throughout the
course of my study is found in Appendix H.
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(a)
(b)
______________________________________________________________________
Figure 48. Gray-Scale Copy of VAS-PAIN / Numerical Rating Scale. (a) VAS-PAIN numerical
rating scale being further embellished from (b) traditional uni-linear scales with added
multimodal qualifiers from which to have participants visually re-quantify their pain intensity
during repeat administration throughout the course of the study.
The Roland-Morris Disability Questionnaire (RMDQ)
The Roland-Morris Disability Questionnaire (RMDQ) is one of the most commonly used
tools for measuring self-rated disability due to low back pain (Roland & Fairbank, 2000). The
RMDQ consists of 24 questions about activity limitations due to back pain (e.g., walking, lying,
and self-care), and is relatively easy to use in a clinical setting. Participating CNSLBP patients
simply provided yes or no answers to each statement. Each affirmation answer is worth one point
with scores ranging from “0” (no disability) to “24” (severely disabled). Upon re-administration
re-test, a change in one to two points is considered a significant change if the initial score
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showed little disability, whereas a change in seven to eight points is indicative as significant if
the original RMDQ showed high levels of disability at the initial administration.
Test-retest reliability 24-item: intraclass correlation (ICC) ranges from 0.42 – 0.91.
Construct validity for the RMDQ correlates well with other tests, which purport to measure
physical disability, including the physical subscales of SF-36, physical subscales of Sickness
Impact Profile, the Quebec Low Back Scale, the Oswestry Disability Questionnaire, and usual
scales for pain ratings (Roland & Fairbank, 2000). One study (Hall, Maher, Latimer, Ferreira, &
Costa, 2011) concluded that the RMDQ and PSFS both demonstrate good responsiveness to
assess activity level changes according to chronic LBP guidelines. However, the PSFS is more
responsive than the RMDQ for patients with low levels of activity limitation, but not for patients
with high levels of activity limitation. A copy of this scale is also provided for review in
Appendix I.
The Patient-Specific Functional Scale (PSFS)
The Patient-Specific Functional Scale (PSFS) is used to tally a patient’s self-assessed
ability and/or experienced margin of difficulty to perform or participate in the daily specific
activities in life that are deemed to be most personally relevant to them. Patients rate their current
ability to complete an activity on an 11-point scale as compared to rating the level they
experienced prior to their injury or change in functional status:
● "0" represents “unable to perform”;
●
"10" represents “able to perform at prior level. (Stratford, Gill, Westaway & Binkley,
1995)
Upon administration and orientation to the instrument, patients are asked to identify up to
three or more activities that they had difficulty with or were unable to perform as a result of their
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recurring low back pain and to rate these activities on an 11-point scale from “0” as "unable to
perform activity" to “10” as being "able to fully perform the activity at same level before back
pain." Patients as research participants select a value that best describes their current level of
ability on each activity assessed. At follow-up, and as per design of the scale, patients as subjects
are allowed to access their original scores, and are invited to rescore each activity according to
their current perception of their performance.
The scale is appropriately used for populations of subjects with chronic LBP based on its
prior history, research development, and areas of application, including previous Lumbar Core
Stabilization efficacy studies providing evidence that “patient-generated measures of disability
are more responsive than condition-specific measures” (Maher et al., 2005). The scale has also
been shown to be a sensitive measure for changes encountered before and after Feldenkrais
Sessions (Connors, Pile, & Nichols, 2011).
The PSFS’s criterion validity had been originally researched by comparing concurrent
validity with the Roland-Morris scale (RMDQ); outlining predictive correlational averages
occurring across five commonly listed PSFS functional abilities and activities as compared with
that of RMDQ (disability) scores; inversely correlated as excellent at r = -0.67 (Stratford et al.,
1995). Another series of comparisons of correlation coefficients had determined good convergent
validity for the Patient Specific Functional Scale (PSFS) when compared with the self-identified
Global Rating of Change Scale (GRC) as well as for the more generic pre-design format
contained within the 36-item Short Form Health Survey (36-SF). As applied to measuring the
instrument’s reliability, when the PSFS was applied for clinical case populations involving
chronic LBP, it was found that inter-rater reliability was determined as excellent, with an
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Intraclass Correlation Coefficient (ICC) = 0.92 (Maughan & Lewis, 2010) and with excellent
test-retest reliability of ICC = 0.97 (Stratford et al., 1995).
In the comparative instrumentation study conducted by my Australian
Physiotherapist/Feldenkrais colleague, Karol Connors, a pre/post-test cohort design was used to
investigate the use of PSFS as an outcome measurement for clients experiencing problems
performing everyday functional tasks who attended Feldenkrais sessions. Eleven Feldenkrais
practitioners submitted data on 48 clients. Changes were detected in the clients' ability to
perform everyday tasks (PSFS improved 3.8 points, p is less than 0.001), and thus this tool was
designated, among others, to be suitable for detecting changes in client function before and after
a series of Feldenkrais sessions (Connors et al., 2011). Appendix J contains the format copy of
the Patient-Specific Functional Scale (PSFS), complete with self-contained guidelines for
implementation instruction and scoring.
McGill’s Timed Endurance Tests (Total Endurance + Flexion/Extension Ratios)
As cited in the literature review, strength deficits (as measured by the capacity to
generate high forces) and range of motion limitations with corresponding flexibility deficits do
not appear contributory. The frequent impairment finding of loss of spine range of motion being
commonly cited and believed as being a primary factor in continuing low back pain has been
shown to have little to do with restoring the capacity for resuming usual functions at work (Parks
et al., 2003). Furthermore, other studies have shown that static stretching of spine ligaments was
highly correlated toward causing a higher incidence of muscle spasms and diminished protective
stretch reflex responsivity (Solomonow, Zhou, Bratta, & Burger, 2003). These biological
mechanisms are known to be e physiologically protective (McGill, 2006). Now becoming
evident through broader inquiry and further epidemiological investigation, some other common
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and perhaps more likely determinants have been found by identifying some re-appearing
observational factors being recurrent in large populations (N=480) of both men and women
where increased occurrence of first-time back troubles become correlated to recurrent episodes.
They are listed as follows:
1. Larger amounts of spine mobility with aberrant motor patterns, and
2. Less lumbar extensor muscle endurance.
Controlling for other factors, these findings were cited as significant independent factors
(Biering-Sorensen, 1984; Luoto, Heliövaara, et al., 1995), particularly with regard to endurance
factors about the back. McGill (2007) therefore surmises that “muscular endurance appears to be
more protective,” but adds the caveat that “these may be only randomly associated (co-present)
in people with poor motor control systems” (p. 13).
Since trunk muscular endurance has been timed, measured, and quantified by seconds as
the primary unit of measure in original studies, it can thus be measured and assessed in repeat
studies via the use of a simple timer or stopwatch. While original work by Biering-Sorensen
(1984) showed that decreased trunk extensor endurance was most predictive of who would be at
greater risk of developing future back troubles, “more recent work has suggested that the balance
of endurance among the torso flexors, extensors, and lateral musculature better discriminates
those who have back troubles from those who do not” (McGill, 2006, p. 230). McGill (2006)
further stated that “because these three muscle groups are involved in spine stability during
virtually any task, the endurance should be measured in all three” (p. 230).
McGill et al. (2007) went on to develop a series of timed endurance tests for Flexion,
Extension, and Lateral musculature about the trunk and torso. Each component for torso
orientation was proven to have a high reliability coefficient of at least .98 or higher when
repeated over five consecutive days and across eight weeks when re-administered to same
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sample participants and between separate test operators. Examples of each test position used in
the current study are depicted in Figure 49 and the format procedure form that was used for
repeat data collection during the current study are found in Appendix K. The timing from start to
finish for holding each sustained position time during each endurance test was measured in a
00:0.00 seconds level of accuracy using a single user’s stopwatch feature on the iPhone Model
6s (Apple Corporation, USA) for each study participant and for each repeated test. This
instrumentation is shown in Figure 50.
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(a)
(b)
(c)
Figure 49. Demonstration of McGill’s Timed Endurances Tests. Examples of each test position
used in the current study for conducting McGill’s Timed Endurance Tests for quantifying spine
function muscle endurance for both groups: (a) Trunk Flexor endurance for maintaining 45° to
50 ° trunk angle to hips while starting from wedge backrest supported to backrest unsupported;
and then, (b) Lateral Trunk muscle endurance (modified planking); first in side-lying Right, then
side-lying Left with hips/ knees in 90° semi-flexed position, and raising lateral side of pelvis off
table surface by rolling hips forward onto knees, and with uninvolved contralateral hand placed
across chest to opposite shoulder; and finally to (c) Trunk Extensor endurance testing from prone
on elbows in contact with table surface as start position (over standard-sized OPTP Pro Balance
Pad™ as soft, but supportive fulcrum placed from infra-costal / abdominal margin superiorly to
anterior pelvis/supra-pubic margin inferiorly), and then to maintain sustained full extension with
elbows off table as the timed position. The firm and predictive table surface used during all
baseline measures and repeated testing (as pictured), and during the course of most treatment and
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training interventions for both groups is shown here as The Astra-Lite™ Mat Table, Watsonville,
CA, USA. The Airex®/OPTP Pro Balance Pad™ is directly sourced from
http://www.OPTP.com, Minneapolis, MN, USA.
Figure 50. Demonstration of Stopwatch Instrumentation. McGill’s Timed Endurance Tests were
conducted via stopwatch application measured in hundredth seconds’ intervals from
continuously updated iOS software via iPhone Model 6s (Apple Corporation, USA).
Flexion/Extension Endurance Ratios as an added Qualifying Measure for Trunk Control
Through laboratory implementation and further intention for the formulation of clinical
applications targets, McGill et al. (2007) derived normative data for absolute endurance times
from a collection sampling of young, healthy, college-aged individuals (mean age of 21 years
old, N=92 men, N=137 women). Subsequently, they noted that women have greater endurance
than men in sustaining extensor activation. Later, they found that men with onset and history of
back troubles had demonstrated a lingering upset in muscle imbalance wherein extensor
endurance is diminished in comparison with flexors and lateral trunk musculature of the same
cohort without back problems. Using this total sample cohort of workers from the same
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workplace (N=24 who never had back troubles compared to N=26 who had lost work due to
LBP), they differentiated flexion/extension ratios of .71 for the asymptomatic group as compared
to 1.15 for the LBP (off work) group. Through this, they concluded that “interpreting absolute
endurance is probably secondary to interpreting the balance among the three muscle groups”
(McGill et al., 2003, p. 233), and that a discrepancy of ratio between flexion and extension
endurance at greater than one (greater than 1.0) would suggest an unbalanced endurance in an
individual.
A systematic review by May et al. (2006) revealed that there is moderate evidence in
favor of high reliability of timed muscle endurance tests as compared to most other physical and
manual testing procedures being routinely used in the physical examination of non-specific low
back pain. However, considering that the "normative" sample data values attained from McGill
et al. (McGill et al., 2003; McGill & Karpowicz, 2009) were derived from "young healthy
adults" and also from "a cohort of workers with and without LBP, but from an industrial
facility," and that the population sample of study participants with CNSLBP would likely be
much more variant in usual activity levels (with predicted long histories of sedentary lifestyle
and pain activity-avoidant behavior), my research team opted accordingly to adjust the
achievable flexion/extension endurance ratio from less than 1.0 to less than 1.5 to more closely
validate and represent a clinical population of persons perhaps more chronically afflicted with
back pains; and associated longer-term declinations in both motor control and their capacity for
performing usual physical endurance functions.
Likewise, the procedures used in my current study for application of McGill’s Timed
Tests for Assessing Muscular Endurance for Low-Back Health, which outlines the parameters
used for testing unsupported, static hold time of endurance tolerance for four sustained positions
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(Flexion, Right lateral side-planking, Left lateral side-planking, and Extension), as found in
Appendix K, were also adjusted and modified in consideration to begin at "beginner’s level" as is
actually demonstrated in Figure 49 by:
1. Allowing extension to occur from a neutrally-placed (e.g., non-hyper flexed) baseline
position; and with
2.
Side-lying lateral trunk endurance testing being initiated from a modified bent knee
position of 45 to 90 degrees’ hip-knee flexion, and rolling forward into side bridging (in
lieu of exerting a direct dead lift of side torso with hips and knees being fully extended,
as in advanced side-bridging or planking).
In his reference textbook and training manual, Ultimate Back Fitness and Performance
(2nd edition), McGill (2006) demonstrates support for valid accommodation of modified testing
and training positions in reporting that “pushing hips forward, as in beginner’s side bridge
(figure 10.52) elevates all muscle activation levels (about the trunk)” (p. 299). As well, that the
same neuromuscular activity patterns demonstrated to occur under the hips extended condition
had also occurred in similar proportion of distribution under the modified hips flexed testing
conditions being co-represented synergistically for: internal/external oblique muscle groups;
ipsilateral rectus abdominis, corresponding gluteus medius; and ipsilateral (ground-sided)
latissimus dorsi when examined concurrently for quantifying the relative distribution of
comparative microvoltage intensities. This, while under the surveillance of task-specific
electromyography and via their use of multiple channel surface electromyography (S-EMG)
instrumentation sensors being standardly placed at site-specific areas being considered as "prime
movers" for the lateral trunk side-lift task, whether at beginner’s adjusted level or at advanced
traditional (cardinal frontal plane) level.
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I then, by implementing trunk position endurance test hold-times as a physical
performance objective measure, modified the parameters of both the task performance itself and
for the designation of optimal performance ratios, so as to more validly meet the projected
constraints occurring within a clinical sub-population of patients who would most likely present
with longer-term episodes of chronic low back pain (CNSLBP) and co-morbid states of
deconditioning; and by further stating that these adjusted and modified standards at baseline had
also stayed consistent throughout all levels of continued data sampling and throughout the entire
course of the study. These are discussed and displayed in the results and discussion sections of
this dissertation.
Methodological Considerations, Determining Minimally Relevant Clinical Change
Consideration was made to determine how expected improvements for both groups could
be interpreted or considered as clinically relevant from the outcome measures that have been
already outlined, validated, and selected. A collaborative study resulting from the proceedings of
The VIII International Forum on Primary Care Research on Low Back Pain (Amsterdam,
Denmark, June 2006) provided a systematic literature review and the formation of an expert
panel to put forward an international consensus for interpreting a basis for minimal important
change scores (MIC), and for demonstrating a threshold that would identify clinically
meaningful improvement on each of the most commonly cited measures for pain and functional
status in low back pain. This study covered the European version of the Visual Analogue Scale
(0-100) and the Numerical Rating Scale (0-10) for pain, and the Roland Disability Questionnaire
(0-24) for assessment of self-reported disability.
Proposed outcome results recommended MIC values as a change in 15 points for the
Visual Analogue Scale (0-100), as contrasted by two for the Numerical Rating Scale (0-10), and
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five points for the Roland Disability Questionnaire. The general consensus was that for the range
of most commonly used back pain outcome measures, a 30% change from baseline may be
considered clinically meaningful improvement when comparing before and after measures for
individual patients (Ostelo et al., 2008).
Since then, a revised construct for minimal clinically important difference (MCID) has
been defined as “the smallest difference that patients and clinicians perceive to be worthwhile”
(Maughan & Lewis, 2010). For the scales and questionnaires most commonly used for Chronic
Nonspecific Low Back Pain (CNSLBP), Maughan and Lewis (2010) had listed the relevant
criteria of change for citing the benchmarks of discerning “minimal clinically important
difference” for each of the test instruments being used in the current study as:
● A point score change of 2.4 on the VAS (NRS),
● A point score change of 5.0 on the RMDQ, and
● A point score change of 1.4 on the PSFS corresponded to the MCID.
Applications of minimal clinically important difference (MCID) are cross evaluated with the
results attained from the current study, and with that of data attained from another previously
published and preceding study, in the discussion section of this dissertation.
Overview of Interventions and Phase Progressions during Course of Study
Patients as consenting participants in clinical research for chronic nonspecific low back
pain (CNSLBP) were randomly assigned to receive either Core Stabilization Biofeedback plus
Motor Control Exercises (CSB/MCE) as the more conventionally accepted intervention, or an
original, newly devised, and decisively non-conventional intervention, Body Schema Acuity
Training (using the VRB3 method™) plus Feldenkrais® Movements (VRB3/ FM). Both the
control group and the experimental group interventions were supplemented with inclusions and
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provisions for participants to practice their newly learned skills within the cognitive-behavioral
and pain neuroscience education contexts of a graded activity paradigm as could be made
applicable within their daily and/or previously un-avowed life activities.
Phase Progressions for Experimental Group
The experimental group (VRB3/FM) participated in a newly devised Virtual Reality
Bones™ (VRB3)™ protocol using (a) skeletal density-based, full scale anatomical models,
combined with (b) visual motion trajectory skeletal avatars, and (c) haptic self-touch as methods
intended for body schema and joint acuity training for the first four preliminary sessions as
Phase I of the total intervention. They then underwent further awareness entrainment through
eight sessions of a corresponding developmental progression of Feldenkrais® Movements, with
four sessions for Phase II (emphasizing foundation of ground support) and four sessions for
Phase III (emphasizing reciprocating variations of motion trajectories) as themes being
delivered through both Functional Integration® (FI®) and Awareness Through Movement®
(ATM®) components of the Feldenkrais Method®; however, specifically emphasizing pelvis-hip
relationships opposite righting (vestibular) responses of head and purposely ignoring any
specific directed attention being isolated to the lumbar spine itself.
Phase Progressions for Control Group
The matched control comparison group (CSB/MCE) followed a core-stabilization
training protocol emphasizing biofeedback assisted specific recruitment of Transverse
Abdominis (TrA) and Lumbar Multifidus (LM) muscle groups as an isolated differentiation from
global, multi-joint movement using a Stabilizer™ Pressure Biofeedback Device (PBU)
positioned under support surfaces in (a) supine, (b) prone, (c) sitting/quadruped, and (d) sidelying/standing positons for the first four preliminary sessions as Phase I of the total intervention.
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These prerequisite skills were then carried over into maintaining a differentiated quality of core
muscular contraction becoming generalized into Static (Phase II) and Dynamic/Rhythmic (Phase
III) motor control activities for the remaining 8 sessions and were deemed as necessary pre-sets
for properly performing motor control exercises as per The Queensland Model of Therapeutic
Exercise for Lumbopelvic Stabilization in Low Back Pain. Control group participants were
explained the anatomical rationale for specific activation of TrA and LM muscles as a
mechanism of control and containment for unstable and/or hypermobile spine segments in the
lumbar-pelvic region being suspected as the underlying cause of low back pain.
Time Course for Progression of Interventions, Session Content, and Flow of Study
Interventions for both groups were delivered and progressed at two times per week for
the first month (Phase I and Phase II), and one time per week for the second month (Phase III)
for a total of 12 sessions over eight weeks. As an essential qualitative control for both
comparative conditions, each intervention’s background theme, goal, or intent remained
internally consistent and/or otherwise objectively constant throughout all phases of the study;
thereby, preserving a methodological basis for maintaining a significant theoretical and
operational (if not also a correspondingly antithetical) difference between treatment groups.
Appendix P contains a three-part "side by side" set of detailed description tables for each phase
of each intervention program for each group, in addition to detailing the content of each session
for each group. The source references for replicating the control group’s intervention progression
are cited and embedded in each table for each session.
Embedded within the very next sub-section of this methodology chapter follows an
additional set of tables with visual depictions for each phase level of progression and with
treatment intentions being outlined for each succession of training and exercise program contents
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that are being delivered to the control group. After first describing the procedure for core
stabilization biofeedback via the use of a pressure biofeedback unit (PBU), these combined
lumbar core stabilization/motor control exercise progressions are shown in Table 7, and
continuing through Tables 8 and 9. Next, follows some image references and review sources for
depicting the experimental group’s intervention progression as they appear in Table 10, Tables
11 and 12 as well as in Appendices P and Q.
It is certainly worth mentioning in this methodology chapter’s sub-section that the overall
complexity and originality of the experimental group’s intervention design remains and
necessitates a situation such that a specialized brand of skill development and demonstrated
return competence is required for this study to ever be re-implemented or re-replicated. These
have been amply described in the evolution of visual-haptic techniques sub-section of the
literature review (Chapter 2) of this dissertation. However, as Principal Investigator and
Originator, I would anticipate a four- to six-day training program for Phase I skill-set clinician
development and another two weekends of two days each for Phase II and Phase III being taught
by either myself or another qualified Guild Certified Feldenkrais® Method Practitioner (GCFP®),
in combination with being a dually credentialed Licensed Physical Therapist.
Justifications of further need and necessity for the development, inclusion, and
implementation of more complex physical therapy and rehabilitation interventions, particularly
for applications to complex multi-factorial and multi-regional conditions like chronic
musculoskeletal pain syndromes - including CNSLBP - are emphatically and adamantly put
fourth within the discussion and conclusion sections of this dissertation. A highly detailed and
comprehensive Study Flow Diagram for outlining the sequence of progression for the current
study is otherwise appended for visual reference in Appendix V.
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Control Group Intervention, Sources, and Procedure
In designing the study intervention for the control group, Phase I addressed the question
and intent for devising an intervention to correct for lumbar spine segmental instability as a
primary and suspected contributor to CNSLBP. The control group (CSB/MCE @ N=15)
underwent initial PT assessment by a qualifiedly trained team of physical therapists - not
otherwise employed nor directly affiliated with usual therapy operations - to determine active
motion and passive stability tests as delivered through a provided source manual and CD
program authored by a national instructor for CEUs/CMEs, and entitled as Facilitation and
Training Techniques for Core Stability (Hanney, 2009). These initial assessment techniques and
the entire control group’s treatment progression were largely derived from this source manual,
and were conducted in a manner congruent with The University of Queensland Australian Model
for lumbo-pelvic stabilization and motor control exercises. These source manuals plus CD are
shown in Figure 51.
Figure 51. Control Group Intervention Sources. Course Flyer, Audio Program, and CD
Instruction Course Manual by Hanney (2009) for use by all physical therapists who were
contracted to conduct and deliver the control group’s (CSB/MCE) intervention. Also used as a
supplementary resource was a popular book and exercise progression manual for Spinal
Stabilization and Back Pain by Jemmett (2003).
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However, the (CSB/MCE) group also received added instruction in specialized training
for ‘core activation’ techniques using a specific biofeedback device - in addition to implementing
the manual hands-on facilitation techniques being taught through the course manual. Initial
therapy assessment techniques included the intake of a standard medical history and a
generalized physical therapy screening. More specific to the intervention, control group physical
therapists were required to perform an AROM spine motion screen to detect for spinal motion
instabilities. This procedure – prior to implementing the added testing and training procedures
being used with the biofeedback device - is demonstrated and depicted below in Figure 52.
(a)
(c)
(b)
(d)
Figure 52. Trunk Range of Motion and Segmental Hypermobility Testing. (a) right sacral-iliac
joint, (b) spine flexion and extension, (c) side bending right and left, and (d) trunk rotation left
and right. The clinician observes for excessive mobility and/or areas of abrupt focal change in
continuity of spine angle (i.e., apex angles); being indicative in the core stabilization model as
areas of segmental hypermobility due to ligamentous instability vs. deficits in neuromuscular
motor control. These areas are demonstrated for each picture via the addition of blue arrows.
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Stabilization Biofeedback Device
The Core Stabilization Biofeedback Protocol, as it is used in this study, is consistent with
previous studies using a pressure biofeedback unit (PBU) in both device design parameters and
in its clinical application. In particular, the Stabilizer™ Pressure Bio-feedback Unit (by
Chattanooga Group, Hixon, Tennessee [TN], USA) is most commonly used in North America
and internationally for purposes of providing feedback to ensure quality and precision in exercise
performance and movement training and testing and by better assuring the proper selection of
TrA and LM "stabilizer muscles" during motor control exercises. Conceptually originating out of
Australia and further embellished by design teams through physical therapy clinical application
and research applications, it is described as a simple device, which registers changing pressure
gradients in a closed cell flexible chamber, much like an inflated sphygmomanometer or blood
pressure cuff.
Parameters can be set such that more excessive aberrations of segmental mobility
occurring across lumbar spine segments (i.e., excessive movements that de-stabilize and deviate
from the preferred actions of proximal stabilizer muscle groups around the spine column) can
become literally inflated and readily amplified across a contained surface area. As a result, they
are detected, monitored, and acquiesced from oscillatory deviations of a sensitive needle
indicator being correspondingly represented on a pressure gauge, and thus inhibited, quieted,
contained and corrected. A sample picture of the device is shown below in Figure 53 and again
in Appendix L.
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Figure 53. The Stabilizer™ Pressure Bio-feedback Unit. The Stabilizer™ Pressure Bio-feedback
Unit (by Chattanooga Group, Hixon, TN, USA) is used as a surface contact pressure transducer
that conforms between hard surfaces and adjacent body regions at mid-trunk - but especially at
lumbar spine curvature - for learning to limit and prevent excessive movement deviations
between spine segments that are produced by over-active superficial multi-joint muscles - of
which also correspondingly exert higher pressures upon the pressure biofeedback unit itself. By
maintaining a baseline pressure setting at a constant level during limb movements and activity
perturbations (typically cited at 40 mm Hg as goal), the user is receiving positive feedback on
how to invoke and select a bias for recruiting and developing activations for the deeper stabilizer
muscle groups that are deemed responsible for stabilizing (i.e., not moving) the position of
vertebral segments – namely by biasing a selective contraction of Transverse Abdominis and
Lumbar Multifidus (TrA and LM) intersegmental muscle groups.
The PBU’s inclusion as a cited training component had previously proved useful for
significantly demonstrating that segmental stabilization is superior to superficial muscle
activation and global strengthening for all measured outcome variables for pain and disability in
a previous study for chronic low back pain; and that usual superficial strengthening using a
control group did not improve their TrA activation capacity (França et al., 2010; França et al.,
2012). The PBU testing and training instrument has also been validated by ultrasonography
imaging and electromyography tests that are considered to be the gold-standard measurements of
TrA performance.
A separate study referenced effective utilization of the pressure biofeedback device
(PBU) during biofeedback-assisted lumbar stabilization training to inhibit and control against
unwanted lateral pelvic tilt by demonstrating that gluteus medius and internal oblique activity
could be significantly activated, while simultaneously differentiating a significant reduction and
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inhibition of quadratus lumborum activity for effective "motor control" during a repeated side
lying hip abduction task (Cynn et. al., 2006). A demonstration of this technique is depicted in
Figure 54.
Figure 54. Demonstration of PBU Biofeedback. The intent is to inhibit unwanted quadratus
lumborum over activity on either side during repeated side-lying leg lift activities while lying on
right side.
Thus, the use of a pressure biofeedback unit (PBU), commercially known as The Stabilizer™ are
used as a widely recognized tool for facilitating optimal selection and sub-maximal contraction
of TrA and LM and as the method for “Core Stabilization Biofeedback” in the current study.
Core Stabilization Biofeedback Protocols using the PBU Device
The PBU Stabilizer™ was instituted along with tactile palpation to train subjects to
develop proper contraction of TrA and LM beginning the first day during session one, and its
continued training and use during the control group's entire Phase I intervention is summarized
in Table 2. According to its protocol originators, Richardson et al. (1999), the normal PBU
response deviations at start of treatment range from -4 to -10 mmHg; and through later research
measures conducted by Hodges et al. (2004), the composite mean normal values at baseline were
around -5.82 mmHg. The positions of body orientation and placement for the device for each of
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the first four sessions is shown in Figure 55. These have also correlated to 30% - 40% of
perceived maximal voluntary contraction.
(a)
(b)
(c)
(d)
(e)
Figure 55. Demonstration of PBU Biofeedback Procedure in Multiple Positions. The positions
of body orientation and placement for the Stabilizer™ PBU/biofeedback device for each of the
first four treatment sessions are shown in consecutive order for sessions 1 through 4 in
conjunction with Phase I of the control group intervention: (a) placement of unit is horizontally
across lumbar vertebrae levels between T 12 and L5-S1, such that the pressure gauge settings
and changes are available for visual feedback monitoring in dominant hand; (b) supine
placement is set at baseline to 40 mm Hg prior to activating "abdominal wall draw-in maneuver"
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to co-activate pelvis floor and TrA stabilization contractions without added motion pressure
being imparted to the device. Also, adding-in leg lift loading maneuver while maintaining the 40
mmHg threshold setting – both with and without external feedback from device gage; (c). Prone
placement under abdomen is inflated to 70 mm Hg adjusted baseline, wherein appropriate
abdominal draw-in maneuver should decrease pressure reading by only 6-10 mm Hg; (d) and (e)
Sidelying and Sitting positions are again adjusted to the 40 mmHg baseline mark prior to
directing its maintenance during de-stabilizing leg-lift movement perturbations. All contractile
movements and stabilization progressions are held for 10-15 seconds each while breathing
normally. They are ordinarily performed for 10 sets of repeated activation for 10 seconds each
(Stabilizer™ Pressure Bio-Feedback Operating Instructions booklet, Chattanooga Group of
Encore Medical, 2005).
Phase Progression and Content Sourcing for the Control (CSB/MCE) Group
The remaining motor control exercise and conditioning interventions then proceeded with
each control group participant moving through the course delineated stages for achieving a phase
level of progression as cited in the manual and CD program by Hanney (2009):
● Phase I: Core Initiation
● Phase II: Static Core Stability
● Phase III: Dynamic Core Stability
● Phase IV: Reactive Core Stability
Added recommendations were made to encourage hands-on manual therapy contact and muscle
palpation skills for purposes of teaching appropriate selections of touch contact for facilitating
the TrA and LM "core muscle group activations," inclusive to training and feedback on the
Stabilizer™ PBU device as applied during Phase I.
The second Phase of the control group intervention (Phase II) involved the transferability
of core-stabilization skills into more functional and gym-based motor control activities into static
postural, then dynamic mobility tasks, before progressing toward Phase III, wherein more
dynamic activities (use of physioballs and rollers, etc.) were expanded to higher level "dynamic
reaction" and "rhythmic recovery" activities against unexpected perturbations and in response to
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greater, more diverse forms of external resistance. Individually contracted physical therapy
clinicians were advised to progress each patient- participant according to individual patient
tolerance and in accord to their own clinical and professional judgement. The next three visual
demonstration tables consolidate the contents and activity themes for Phase I, II, and III of the
treatment progressions delivered to the CSB/MCE control group.
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Table 7
Phase I CSB/MCE Treatment Progression: Core Stabilization and Motor Control Exercise
Interventions at 2xs per Week for First Two Weeks
Visit 1: TrA and Pelvis Floor Draw-in
Maneuvers
Supine Abdominal Draw-in Manuever to Activate
TrA and Pelvis Floor without de-stabilizing
spine chain through overactive superficial muscles
Heel slides and Arm Raises
Also performed in sitting and standing positions
Visit 2: Activating Lumbar Multifidus
(LM)
The therapist palpates to facilitate the
multifidus.
Intent is to teach
patients to learn to
use the multifidus
muscles at will and
separately from
other extensor
muscles.
Visit 3: Corset Action of TrA and LM
Combined
Common “Dead bug” and “Bridging” Exercises
Visit 4: Lateral Trunk Stabilization
Goal or intent is to control the quadratus
lumborum and lateral fibers of the oblique
abdominals.
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Table 8
Phase II CSB/MCE Treatment Progression: Static and Dynamic Motor Control Exercise
administered at 2x per Week for Second Two Weeks
Visit 5: Prone over physioball and ground
Arm Bridge static holding over physioball
.
...and hip extension holding over platform
Visit 6: Supine Static Challenge Single Leg Lift
Visit 7: Seated and Standing Static Challenge
Visit 8: Quadruped Static Challenges
Supine Static Challenge Double Leg Lift
Side-lying Static-Dynamic Position
Challenges
Quadruped to Kneeling Dynamic Challenges
(Classic “Bird Dog” Position)
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Table 9
Phase III CSB/MCE Treatment Progression: Dynamic and Reactive Motor Control Exercise
administered at 1x per Week for Last Four Weeks
Visit 9: Supine Reactive Challenges on
Physioball
Visit 10: Kneel and Quadruped Resistance Drills
Visit 11: Sitting and Side-Bridging
Resistance
Visit 12: Squatting and Deep Sitting Drills
Dynamic Bridging in Extended Leg Lift
Prone and TrA / LM Extension Drills
Side-planking over Physioball
Extended Flexor Extensor Bridge Stability
+ Review of Home Exercise and Principles
+ Review of Home Exercise and
Principles
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At the conclusion of each treatment visit, each participant from the CSB/MCE group
received printed copies of home exercises selected by their individual therapist. In addition, each
participant received a "Home Exercise Program/Graded Activity Cover Sheet" to delineate
specific adherence requests and to convey some imagery specific "core principles" for both
attitudinal mindset and physical practice during each corresponding phase of the treatment
progression. Accordingly, and by verbatim, patients as participants were asked to adhere to the
following behavioral orientations on the home exercise program (HEP) cover sheets:
1. “At least once daily, practice those exercises that you feel gave you the best sense that
you were strengthening your core- and for which you were able to maintain stability and
control of your mid-section at all times.”
2. “Hold for 10 Repetitions at 10 seconds each- without losing proper form - at least once
daily.”
3. “Throughout the day, practice your draw-in maneuver the same way you felt it happen
when using the biofeedback device.”
4. “Maintain your draw-in maneuver before each progressive fitness exercise and whenever
you think something might be strenuous –so as to maintain stability and control.”
5. “As much as possible, get up and go somewhere, and try to spend a little bit more time
enduring the activities of daily life.”
Copies of each "Home Exercise Program/Graded Activity Cover Sheet" being allocated
for each primary phase of treatment progression for each group can be found in Appendix R.
Furthermore, at each return visit for each phase of treatment, patients as participants were again
asked to track their adherences to home exercise and graded activity progressions as well as for
charting any significant changes in reducing the dosage and/or frequency of their current pain
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medication regimen. Taking the format of a "Graded Activity Diary," and being specifically
scaled to each phase of treatment for each group, these form samples are sequentially outlined in
Appendix R.
Experimental Group Intervention, Sources, and Procedure
Again, as with the control group, the initial therapy assessment included the intake of a
standard medical history and a generalized physical therapy screening interview and cursory
exam. However, in designing the comparative study intervention for the experimental group,
Phase I addressed the question of devising a novel alternative to traditional "core stabilization
training" and "motor control exercise" programs, and to function as a viable and competing
approach in such manner that it was decisively antithetical to usual and customary "gym-based"
physical therapy exercise and standardized performance prescriptions in its overall design,
purpose, and intent.
By having no indication for pre-designating a specific pathology, nor by identifying a
focal neuromuscular deficit or muscle weakness as cause, nor by otherwise implicating some
other particular structural-functional mechanism or compartmentalized movement aberration at
fault, the newly devised VRB3 approach at Phase I instead outlined some components and
parameters for reconstituting an improved perceptual awareness for "coming to know" one’s own
existing background body schema - as a whole - and improving upon its functional expression in
terms of sensory acuity and motor dexterity.
In lieu of practicing unidimensional standards for repeated performance, and with little to
no flexibility for essential variation or constructive deviation being permitted for undoing a
singular plane-based prescriptive movement pattern (being usually isolated to cardinal sagittal
plane), the Feldenkrais®-based movement model instead seeks to involve all curvilinear
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possibilities inherent to the design of the human skeleton and their concurrent relationship
toward easily accessing multiple directions in space. All along with a proportionate quality of
skeletal continuity such that a more effective use of whole self could substitute as a primary
functional alternative to the usual guarded and antalgic compensatory movement patterns that are
typically associated with an individual’s body presentation occurring between baseline rest
postures and movement in CNSLBP.
Embodied Perceptual Assessment of Background Body Schema and its Correlation to
Action
The experimental (VRB3/FM) group (N=15) thus underwent a different kind of
preliminary "physical exam" in order to simply discern the capacity to shift weight in multiple
planes and to discover a preference bias for leg support from head to foot and vice-versa in both
standing and supine positions as well as assessing for weight bear biases in sitting. In other
words, the preliminary pre-treatment assessment was designed for involving both practitioner
and participant to collaborate upon a mutual interactive inquiry to ask as to
How do individuals [in the VRB3/FM group] habitually support themselves through their
skeleton, and how and where do they deviate or gravitate their changing center of mass in
relation to changing base of support, and how can this "dynamic stability quality" vary as
an acquired or preferred pattern within an incessant and constant gravitational field?
Upon determining a bias for accessing some areas of space in favor to avoidance to
others, the use of an imaginary "angels halo" and a series of imaginary "hula hoops" were used
as imagery constructs to enable an internal/external shared reference of three-dimensional
discernment for circumferential access to space; increasingly delineated by way of an imaginary
"clock dial" to demarcate areas of accessibility vs. areas of avoidance in weight shift. Beginning
at "top of head" and ending at "base of feet" these preliminary assessment procedures are
demonstrated in Figures 56 and 57. Though not pictured, these same "top-down/hands-on"
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facilitated explorations also occur in the functional contexts of sitting upon either a flat chair or a
Feldenkrais Method® table.
(a)
(b)
Figure 56. Preliminary Physical Exam for Conducting the Initial Assessment for the (VRB3/FM)
Experimental Group. (a) Standing Alignment from a hands-on top down direction with guided
imagery being converted from a usual spine curves and joint angles perspective to an angel’s
halo, circumferential rim of a clock dial and hula hoop perspective for assessing an individual’s
ability to access three dimensional space; (b) Comparative Rotation around three cardinal axial-
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planes in conjunction with ground reaction support - as analagous to three semi-circular canals of
inner ear.
Concurrent with assessment findings from the preliminary top-down circumferential
perspective, both a skilled practitioner and an attentive patient/client can typically co-discover a
side of avoidance as compared to a side of preference for leg support. Even more typical for
CNSLBP or any back-related condition, a corresponding dimension of reduced tactile contact
acuity can also be unveiled and co-detected by the use of a mesh screen seated back rest/support
surface device to reveal a uniquely palpable surface contact impedance vs. vagueness
phenomenon being largely correspondent to the same side of the stance avoidance leg. This
simple contact technique being vertically applied across back of the torso in a cephalic-caudal
descending direction para-spinally, and by comparing for friction-like impedances vs. foggy-like
amorphous qualities at left vs. right sides, is demonstrated in Figure 57.
Figure 57. Demonstration of Sensory Acuity Impedances at Dorsal Spine. A mesh-screen back
rest product was used as a contact surface amplifier for the detection of inter-subjective sensory
acuity differences and impedences occurring between left and right sides of para-spinal
musculature in patients with CNSLBP while standing.
241
While seemingly a subjectively implied phenomenological event, the timing and
localization features of the maneuver seem inter-subjectively reproducible between both patient
and examiner, and this tool remains the topic of reference for a future inter-rater reliability study
between varied samplings of participants and examiners as well as for testing for crosscorrelations between different kinds of modalities (e.g., S-EMG recordings and force plate data).
It may also serve as a possible marker for smudging phenomena being seen in the cortical brain
representation studies being disruptive of body representation in chronic pain during fMRI.
Next followed a "ground-up" correlative assessment maneuver via the application of a
foot board contact surface being compared to test against the plantar surface receptivity of each
foot – again comparing left and right - and within the context of a simulated standing positon
(i.e., laying supine on back in a "gravity attenuated" rest position). Commonly known in
Feldenkrais Method® -based colloquialism circles as “artificial floor” or "board on foot" lessons,
these comparative sensory-motor perceptual investigations again reveal a detectable difference in
quality of foot contact impedance vs. surface contact avoidance; most typically, with diminished
acuity and dexterity correspondingly occurring on same side of involvement as the CNSLBP’s
side of primary symptoms. This contact maneuver is visually demonstrated from various
orientations of interactive inquiry and through demonstrating a longitudinal “bottom-up” skeletal
perspective in Figure 58.
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Figure 58. Demonstration of Foot Contact & Surface Acuity Procedures. The “artificial floor” or
“board on foot” assessment platforms are used by Feldenkrais® Practitioners to reveal previously
under-appreciated qualities of over-aversive vs. under-responsive foot and leg alignment
synergies during the actual "contact simulation" of standing and pre-gait functions in a relatively
non-weight bearing longitudinal orientation with respect to gravity. Very often, a non- or lesserresponsive foot contact corresponds to the same side of involvement in cases of CNSLBP for
which the focus of symptoms remains more predominant to one side. My clinical practice has
referred to this commonly observed contact responsiveness deficiency as a “suspended leg
phenomenon” being perhaps representative of a global deficiency in body schema acuity overall.
Its correlates can often also be seen upon upright clinical gait assessment via correspondingly
observable deficiencies between timing and support of the more involved side. Specialized
Feldenkrais Functional Integration (FI ) sessions have been known to demonstrate an overall
improved response quality in both contact surface responding and in stance-propulsion during
gait.
®
®
By becoming emergently aware of corresponding impedances and vagueness being
distributed throughout the mostly inattentive regions of the body, and at multiple levels as a
continuum, the patient (as participant) develops some new appreciation for "the concept of
disrupted working body schema" to serve as a basis during all future sessions in the current
study. Finally, for the VRB3/FM group, no references are otherwise made during the initial
assessment to evaluate or further assess for inter-segmental AROM or PROM differences at the
lumbar spine level; nor for otherwise rating component motion stability vs. restriction at each
spinal level; nor of muscle weakness or other "dysfunctions" being isolated or directly attributed
to the lumbar spine or SI joint; nor were any of these anatomical “lumbar” or “SI Joint” regions
either directly referenced as a cause, nor were they directly treated at any time for the VRB3/FM
experimental group during or throughout the entire course of the current study.
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Phase Progression and Content Sourcing for the Experimental (VRB3 / FM) Group
Immediately following the preliminary physical exam and perceptual self-assessment of
background body schema from a mostly vertical top-down vs. bottom-up perspective, as was just
described, each succeeding session for the experimental group also involved participants
engaging in a Feldenkrais Method® -based body scan - being mostly conducted while in backlying - at both the beginning and at the end for each session in order to compare for differences
of session-directed thematic effects. In most situations involving chronic low back pain and other
back-spine related conditions, it is not uncommon to find that persons will remain totally
aversive to the prospect of extending hips and legs into a fully extended or elongated position
while laying supine on back, as this is most typically accompanied by an exaggerated arching of
lumbar spine away from floor and into a direction of extensor rigidity or lumbar lordosis (i.e.,
toward a direction of reverse curvature against the direction of gravity that is almost
immediately associated with provocation low back pain and the exacerbation of bow-string-like
qualities of muscle tension throughout lumbar extensors and hip flexors). This, all in a manner
not unlike the body pattern of anxiety that was outlined and described earlier through referencing
Feldenkrais’ (1949/2005) postulates within the "hidden senses-vestibular concept" sub-section of
the "literature review chapter" embedded within this dissertation. However, subsequent to an
effective Feldenkrais®-based Functional Integration® session or Awareness Through Movement®
class, it is also not uncommon for such persons to implicitly re-discover a new manner for
spontaneous extensor inhibition, and for truly "giving their weight to the ground" to thereby lie
more fully extended, and without concurrent exacerbation of pain symptoms or exaggeration of
spine curves. Figure 59 demonstrates guided arrangements for self-referencing of resting body
schema during: (a) "pre-intervention body scans" requiring added accommodation and support
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though bent knees and/or leg pillows or other external supports, vs. (b) "post-intervention body
scans" requiring no added accommodation or needs for added support – in that the tonic state of
the musculature is now more easily conforming to the continuous state of matching the support
affordances being directly derived through the horizontal predictability of the extended floor or
table firm surfaces upon which the person is resting or lying.
(a)
(b)
Figure 59. Pre- and Post-Body Scan Techniques for Self Assessment. Pre- and post-body scan
techniques for self assessment at (a) pre-intervention, and (b) post-intervention, as contrasted
body scans for comparing differences.
A common script for facilitating an individual’s participation toward taking a personal
inventory of his or her own body awareness acuity during a Feldenkrais class, or for invoking an
®
awareness dimension for locating internal references being constitutive of one’s own
background body schema within the current study would be as follows:
Please lay on your back with either your knees bent or your legs fully extended straight
down below you. Choose whichever is most comfortable for you.
Take a moment to notice where your attention automatically goes. Do you attend to areas
of discomfort or to areas of ease? What is the landscape of your body to each situation?
Notice the points and parts of yourself that make firm contact on the floor. Perhaps your
heels, your elbows, the back of your head...the boney parts of yourself. How about the
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pelvis? Is there more sense of weight or pressure contact behind your right buttock or
back-pocket compared to your left side? Do you feel lifted or rolled to one side? Do some
parts of your feel overtly held back? In ways that would seem more than necessary?
Now notice areas of space behind you where your body surface is not supported. Are
these areas more-clear of less-clear compared to areas that do make contact? What is the
elevation and length- span of curves behind your knees? Behind your ankles? The tops of
your thighs where they meet the buttocks. The curves that bridge upward and arch
backward to connect between the top of your waistline to the base of your ribs - and
perhaps even to the back of your shoulder girdle? How about the length of the spine
between your shoulders? At what point to these vertebrae make contact? And how do
these compare to the curves behind your neck? Does one side feel higher off the ground
overall as compared to your other side? Again, compare left and right.
Notice the length of each leg from hip to heel. Does one heel feel heavier than the
other...with more pressure behind it...and what part of the heel? From this, can you sense
what direction each foot points in the room? And without looking at it with your eyes!
Does one leg feel further from the center of your head? Where is the center of your head?
– the exact geographic center? Does one leg feel more continuous than the other? Again
compare left and right.
If you suddenly had to respond to get up...then from which direction would you most
likely roll toward? Where and how would you initiate the movement...imagine...which
areas have most affinity to respond first? Which other areas of yourself drag behind? And
if you were laying on a balance beam – would you automatically teeter off to one side?
Left or Right? Or would you congruently counterbalance? How do you know this? How
do you sense this? Does your breathing change to either side? Sense the difference
between the front half of your right lung to the back half of your right lung – and
compare this to your left side...Do the same thing from the center of each knee...Is one
side of your entire body beginning to reveal a consistent difference? ...Most interesting is
the fact that this may be the first time that you have ever encountered such noticing... and
to note that the things that you are currently noticing do not show up - and will not show
up - in routine X-Rays, CT-Scans, or MRI exams – but only through this kind of quality
of attention.
Within the actual intervention framework of the current study for the VRB3/FM
experimental group, phase I - session 1, then continues forward to conduct a "virtual reality hip
replacement" procedure as was aptly and most thoroughly described in the “Evolving Practice,
New Visual-Haptic Techniques: The Origin of VR Bones™” sub-section of this dissertation as is
extensively embedded within Chapter 2. The continuation of Phase I treatment interventions
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also follows the same descriptive progression form the same sub-section of the same chapter, and
its chief components are also again summarized and visually rendered below in Table 10.
The remaining interventions then proceeded with each experimental group participant
moving through Phase II and Phase III of the total intervention; this consisted mostly of
Feldenkrais Method®-based movement themes and sessions that are anecdotally known to have
positive effects on patients (as participants) or for clients (as students) who have presented with
long histories of CNSLBP. These session content themes are consolidated and outlined below in
Tables 11 and 12. Sessions were also chosen based upon their ability to adhere to some
authoritative principals and stated design criteria for carrying-out and conducting an effective
Feldenkrais® (2010) lesson as had been outlined in an advanced training workshop by Santa Febased Feldenkrais® Trainer, Alan Questel, in Figure 60.
Figure 60. Outline of Principles that contribute to an effective Feldenkrais Method® Lesson.
In addition, the Feldenkrais®-based Awareness Through Movement® and Functional
Integration® movement theme interventions being delivered during Phase II and Phase III of the
total intervention had also been informed and supplemented by direct personal and clinical
immersive experiences with broad assortments. Assortments of commercially available
247
professional and public audio programs from Feldenkrais Method® Teachers and Trainers
designed to address the problem of low back pain and its related dysfunctions.
Some specific tracks and lesson themes from each audio program are more thoroughly
referenced and enlarged for viewing in Appendix O. They were individually selected and
disseminated to experimental group participants on a case by case basis as per therapist judgment
to serve as respective "sample" components from which to further enrich their home exercise
programs (HEPs) - and as a corresponding complement to the particular session theme that was
clinically administered through the research protocol for that day. A photo-capture of program
titles and resource materials used during the course of intervention – again as a reinforcement of
their particular session theme - is otherwise pictured in Figure 61.
248
Figure 61. Resource Materials for HEP’s derived from Professional Feldenkrais® Audio
Programs.
249
Table 10
Virtual Realty Bones (VRB3): Phase I Imagery Intervention for Body Schema Acuity and
Skeletal Density Imagery Continuity Training (SDI) also using The Feldenkrais® Method (FM)
TM
Phase I
(VRB3)
Protocol
Session Number:
Visit 1
(Hip Sockets & Stilts)
Visit 2
(Inner Ilia & Centaur)
Visit 3
(Costo-vertebral
Pedicles)
Visit 4
(Temporal Bone &
Ninja)
Life-Sized
Skeletal Models
Life-sized and/or
life-scaled bones as
anatomical constructs
for Re-constructing
an alternative notion
for body schema
Avatar Identity
Action Scenarios
Feldenkrais
Method®
of Application
Visual action theme
scenarios as
Corresponding theme
functional-conceptual
for Feldenkrais®
contexts for
Hands-on Movement
performing an
cues to optimize:
imagery-inspired task 1. Haptic Self-touch
or movement
2. Directed Attention
3. Connected Action
250
Table 11
Phase II Training for Experimental (VRB3/FM) Group via 2x per Week for Second Two Weeks Feldenkrais Method® Themes: Expanding Sense of Ground Support via Developmental Actions
Visit 5: Prone Frog Leg Pre-Crawl Development
Prone Lumbar-Pelvis-Hip Integration in 3-D
Visit 6: Pelvis Wishbone Coupling and Diagonals
Diagonal Rib Flexion and External Spine
Visit 7:Side-Bending and Lengthening Movement
Visit 8: Inverted Sitting and Kneel over Table
Side-lying Leg Reaching and Wt. Shift
Sitting
Transition to ½ Kneeling and Contralateral Crawl
251
Table 12
Phase III Training for Experimental (VRB3/FM) Group via 1x per Week for Last Four Week Feldenkrais Method® Themes: Reciprocating Variations of Active Movement Trajectories
Visit 9: Balance Beam Rotation Flexors-Extensors
Prone Leg Tilt opposite Head and Eyes
Visit 10: Diagonal and Ipsilateral Trunk Flexion
Mid-Thoracic Extension & Contralateral Limbs
Visit 11: Side-lying Leg Lift & Torso Side Bend
Lateral Chair Movement & Side-Reach Synergies
Visit 12:
‘Head Through Gate’ and Proportionate Arching
Skeletal Transmission Resistance Contiguity
+ Review of Movement Strategies & Themes
252
At the conclusion of each treatment visit, each participant from the VRB3/FM group
received recorded samples of "matched theme" Feldenkrais Method Awareness through
®
Movement audio lessons on either CD or MP3 media as selected by their individual therapist. In
®
addition, each participant received a "Home Exercise Program/Graded Activity Cover Sheet" to
delineate specific adherence requests and to convey some specific "joint acuity/skeletal density
imagery" and "Feldenkrais Movement" principles for both attitudinal mindset and physical
®
practice during each corresponding phase of the treatment progression. Accordingly, and by
verbatim, patients as participants were asked to adhere to the following behavioral orientations
on the home exercise program (HEP) cover sheets:
1. From your program today, practice the movement sequence and skeletal alignment(s) that
helped you to detect or visualize the inner location of your newly discovered weight bear
joints and how they dissipated stress. Include "laser beam" soft touch.
2. Can you sense it from a variety of ways in manners that "connects the dots" from bottomup and through top down? Navigate and Sense it from both directions?
3. At least once daily, follow the movement sequence that works best for one side. Find a
connection that highlights your sense of constructing an inner line through your skeleton
from that "standpoint." Explore it again with slight variation for 5 times.
4. Rest before repeating same strategy on opposite side, but begin first with only imagined
movement. Then do.
5. Throughout each day, discover and attend to how awareness of these areas can be
included in daily activities as a background support for sitting, standing, walking, etc. Be
sure to maintain a flexibly aligned, softly assembled quality of being --and not a hard
focus.
6. As much as possible, get up and go somewhere, and try to spend a little bit more time
enduring the activities of daily life. If you feel you used less medication than usual, feel
free to medicate a bit less and meditate on life a bit more.
Copies of each "Home Exercise Program/Graded Activity Cover Sheet" being allocated
for each primary phase of treatment progression for each group can again be found in Appendix
Q. Furthermore, at each return visit and for each phase of treatment, patients as participants
253
were again asked to track their adherences to home exercise and graded activity progressions as
well as for charting any significant changes in reducing the dosage and/or frequency of their
current pain medication regimen. Taking the format of a Graded Activity Diary and being
specifically scaled to each phase of treatment for each group, these form samples are sequentially
outlined in Appendix R.
Data Collection Methods and Procedures
All self-reported repeated measures from all scales and questionnaires were collected by
an independent research coordinator and/or from front desk office reception staff. Each of these
employment positions was occurring on a temporary basis only, and as administrative personnel,
they had no particular stake or personal investment in the outcome of the research project. The
research coordinator, having a BSc. in Kinesiology and with intentions to become a physical
therapist, was also primarily responsible for properly conducting and overseeing the timed
position endurance test protocols by McGill, and was able to demonstrate competence in
providing instructions and supervision for proper performance, and for appropriately marking
"start" and "finish" times with use of the stopwatch.
Baseline measures of pain level, disability, functional ability, and timed-endurance
tolerance were collected upon the initial administration of (a) VAS/pain scale, (b) RMDQ, (c) the
PSFS, and (d) McGill’s times endurance tests, and again at intervals of two weeks, four weeks,
and at eight weeks, immediately at post-conclusion of each phase of the intervention for both
groups.
All succeeding data collection measures of "raw data" for both groups were entered into a
Microsoft® Excel spreadsheet, and these files were maintained in strict confidence to the blinded
exclusion of treating therapists and principal investigator throughout the entire course of the
254
study. Only at the conclusion of data collection and at notice of study closure were files then
released to principal investigator for their transmission - in their entirety- to a hired statistician
for purposes of data analysis. The names of all study participants remained confidentially
encrypted for each group. Photo-samples of Excel spreadsheets depicting the data collection
procedures for each group, and for each phase of the study, are shown in Figure 62.
Figure 62. Excel Spreadsheet Layout for Data Collection for Control Group and Experimental
Group.
Again, a highly detailed and comprehensive Study Flow Diagram for outlining the
sequence of progression for the current study, including the time-frame margins used for all
phases of data collection, is otherwise appended for visual reference in Appendix V.
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Data Analysis using Statistical Tools and R Software
Statistical analysis for this comparative study employed the use of inferential statistics
between and within both groups. Specifically, the use of Wilcoxon’s Rank Sum (paired sample)
test was employed to assess for statistically relevant and significant degrees of change in the
ordinal, non-parametric variables occurring between study participants for repeated measures
over time with regard to the VAS pain scale, the RMDQ, and the PSFS. The two-tailed t-test was
paired for repeated measures to assess for comparative statistical significance of representational
change over time, as reflected from the successive re-administration of the timed physical
endurance (sustained position tolerance) tests by McGill as the continuing interval-based
parametric variable.
At approximately 1-2 months prior to end of study closure date, I attended clinical
research mentorships at the 47th Annual Meeting of the Association for Applied
Psychophysiology and Biofeedback (AAPB) in March 9-12, 2016, in Seattle, Washington. Under
the discussion and corroboration of Saybrook faculty member and chair of the school’s Mind
Body Medicine Program, Donald Moss, Ph.D., it was determined a standard practice for doctoral
dissertation students at Saybrook University to conduct the statistical analysis of their research
data via the contracting of resource assistance and software programs at other local colleges or
universities’ math and social sciences departments that were most local or accessible to the
doctoral student. I was thereby able to contract the services of senior statistics tutor Samantha
Coates of The University of Puget Sound, Tacoma, Washington, USA, who in consultation with
my research design and her faculty, was able to make the appropriate corroboration in my
original selection of statistical tools upon pre-submission to the Saybrook University IRB (SIRB)
on April 22, 2015.
256
The two primary statistical analysis tools, the Wilcoxon’s Rank Sum and the two-tailed ttest, and their appropriate use for application in the current study were also approved as viable
and “robust” instruments via e-mail consultations on April 26, 2016, with Saybrook University
consulting statistics faculty member, Howard Barken Ph.D., and in concurrent collaboration with
Samantha Coates consulting her own two faculty advisors, University of Puget Sound
Mathematics Department faculty, Assistant Professor Wendy Dove, and their leading Associate
Professor, James Bernhard, Ph.D.
The Use of "R" Program Statistical Software
The program of choice for statistical computing being used by The University of Puget
Sound Mathematics Department was cited by Ms. Coates as being the open source “R” Program
for its flexibility to scale to a more diverse array of individualized and systemic applications.
While a majority of social science applications have traditionally implemented SPSS as the
program of choice, a more recent post by data science analyst, Robert A. Muenchen, titled as "R
Passes SPSS in Scholarly Use, Stata Growing Rapidly" had indicated that the open source
"R" package is destined to become more and more dominant as a tool being increasingly
referenced in scholarly publications by stating in a previous statistical trend study that
the use of R is experiencing very rapid growth and is pulling away from the pack,
solidifying its position in third place. In fact, extending the downward trend of SPSS and
the upward trend of R make it likely that sometime during the summer of 2014, R (likely)
became the most dominant package for analytics used in scholarly publications.
(Muenchen, 2014)
In an updated post, Muenchen (2015) stated that
SPSS is (still) by far the most dominant package, as it has been for over 15 years. This
may be due to its balance between power and ease-of-use. For the first time ever, R is in
second place with around half as many articles...R has not only caught up with SPSS, but
surpassed it with around 50% more job postings.
257
Seeing these trends, and verifying that R is a free, open source, software program for data
science that is similar to the “big three” commercial packages: SAS, SPSS, and Stata, I approved
my contractual arrangement to move forward on implementing this product for conducting the
statistical analysis of study results.
Data Backup and Record Retention
Consistent with informed consent and the study design, a substantial amount of important
data was gathered for this randomized controlled study. All data were stored electronically on an
external drive, plus a cloud-secured service in a secure location for a period of seven years. After
this time, the data hard drive will be destroyed and the cloud-server storage portion deleted.
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CHAPTER 4: RESULTS
Results from this RCT/comparative efficacy study demonstrated that the VRB3/FM
experimental group demonstrated greater improvement in all treatment outcome measures as
compared to the matched CSB/MCE control group. However, for all measures, only the Patient
Specific Functional Scale (PSFS) demonstrated the most definitive statistical significance for
greatest improvement at p is less than or equal to 0.05 upon more stringent non-parametric
testing between groups. A more detailed synopsis of descriptive statistics between sample groups
and the use of inferential statistics to extrapolate the results for application to the general
population thus follows for the entire remainder of presentation for this chapter.
Demographic and Medical History Profiles Between Groups
Through reviewing the demographic and medical history profiles between sampled
groups, it was determined that demographic and potentially confounding variables had an
essentially matched distribution of allocation; and was deemed to be likely representative of the
general population. Basic demographics of study participants for each group are displayed in
Table 13.
Table 13
Basic Demographics of Study Participants
Age
Gender
Marital
Status
Work Status
Bariatric Status
Experimen
tal
Group
47.2
9 Female
6 Male
10 Single
5 Married
6 Employed
6 Unemployed
3 Retired
8 Normal Range
4 Overweight
3 with Obesity
Control
Group
58.4
6 Female
9 Male
7 Single
8 Married
3 Employed
8 Unemployed
4 Retired
7 Normal Range
5 Overweight
3 with Obesity
259
As could be expected, a heterogeneous sampling of patients with CNSLBP being
randomly assigned to each group had problem severities, physical impairments, and functional
capacities ranging from significantly disabling (i.e., limping with stooped posture and requiring a
cane to stabilize gait) to frustratingly fatiguing by characterizing their symptoms as being a
continuing interference in limiting their full access to their preferred quality of life, but still able
to work. Fortunately, these kinds of non-predictable ranges for confounding variables were
reasonably homogenous upon randomization after stratified assignment and allocation of
participants into both groups. Table 14 outlines some potentially confounding variables that have
been controlled through fortuitous random assignment for particular Bio-Psycho-Social, Surgical
and Orthopedic situations that were found to occur as common comorbidities between study
participants for both groups.
Table 14
Confounding Bio-Psycho-Social, Surgical, & Orthopedic Variables of Study Participants
History of Back Surgery
Experimental Group
2 Yes
13 No
Control Group
3 Yes
12 No
Medication List for Pain
12 Yes
3 No
13 Yes
2 No
10 No
4 Actively Disabled
1 Pending
13 No
1 Actively Disabled
1 Pending
11 Yes
4 No
8 Yes
7 No
9 Yes
6 No
4 Yes
11 No
14 Yes
1 No
9 Yes
6 No
Disability Status
Anxiety/Depression
Upper Quadrant
Regional
Symptoms or Diagnoses
Lower Quadrant
Regional
Symptoms or Diagnoses
260
It is worth stating that although the mean chronological age difference between the
experimental group (47.2 years) and the control group (58.4 years) reflects a differential age gap
for the experimental group being essentially 10 years younger. The results of my literature
review nonetheless support a more valid assertion for implicating the role of fear-avoidance
beliefs as a more primary confounding and determinant variable from which to control the
distribution of participants through stratified random assignment into each arm of the study.
Participant Attrition and Final Distribution for Data Collection
During the course of this study, and for a sub-population of consenting enrolled
participants, there were various lifestyle and choice interruptions resulting in incomplete
attendance to the number of intended sessions, and dropouts from the study before phase one
data could even have had a chance to be accrued. These situations occurred for a variety of
disclosed versus undisclosed reasons. Table 15 displays the distribution of allocation for
participants who withdrew – or were withdrawn - before Phase I data collection, along with some
reported reasons for doing so.
Table 15
Drop-out Participants and Reasons for Leaving either at Start of Study/or prior to End of Phase
I
Experimental
Group
Control Group
4 Males
2 Males
1 Female
1. Opioid addiction relapse under medical supervision
2. “Felt uncomfortable”
3. Preferred traditional PT despite prior failures
4. Prior exposure to another Feldenkrais® practitioner;
(he presented with low symptoms & high
functioning)
1. No insurance
2. Boredom, treatment not helping
3. Family & work demands
261
Another minority sub-set of study participants had continued through only Phase I of the
study and adhered to its corresponding provisions for data collection, but had otherwise
confronted a similar set of lifestyle and choice vs. circumstantial issues that had caused them to
opt out of continued study participation; thus, their being voluntarily exempted from completing
Phase II and Phase III of the total intervention. Table 16 displays the distribution of allocation
for participants who withdrew after Phase I data collection, but who yet completed the first
introductory component for each intervention and data collection for each group.
Table 16
Drop-out Participants and Reasons for Leaving at Conclusion of Phase 1 Data Collection - and
without Completing Phase II or Phase III Components of Total Intervention
Experimental Group
Control Group
3 Females
1 Male
2 Females
3 Males
1. Family matters
2. Performance Anxiety to Adherence Diary
3. Dissonance and overwhelmed
4. Schedule conflict that was unexpected
1. Family matters
2. Transportation issues
3. Schedule conflict that was unexpected
4. Onset of other more urgent health problem
5. Too busy
In sum and for both groups, approximately 2/3 of participants (N=10 for the control
group and N=11 for the experimental group) completed the entire intervention (Phase I – III).
However, the remaining 1/3 of participants (N=5 for the control group and N= 4 for the
experimental group) completed only the Phase I preliminary component of the study before
dropping out. Participant attrition was thus essentially similar for both groups at a reasonable
margin of plus or minus one. Again, a highly detailed and comprehensive Study Flow Diagram
262
for outlining the sequence of progression for the current study, including an outline for
participant attrition at each phase, is appended for visual reference in Appendix V.
Central Tendency (Mean) and Distribution of Data (SD) across Phases of Treatment
The statistical software ‘R’ was used to conduct all statistical analysis and to create all
tables and graphical displays (R Core Team, 2015). These were tabulated and compiled by senior
statistics tutor, Samantha Coates, of The University of Puget Sound, Tacoma, WA, USA, and
were submitted for assessment and review for the dissertation write-up on April 30, 2016. Over
the course of eight weeks and for all phases of treatment intervention, the experimental group
showed improvements in VAS-Pain (from 6.07 plus or minus 1.58 points to 2.00 plus or minus
1.55 points), RMDQ-Disability (from 11.40 plus or minus 6.17 points to 3.91 plus or minus 4.01
points), and PSFS-Function scores (from 3.33 plus or minus 1.51 points to 7.08 plus or minus
1.56 points). With much wider variation, the Timed Endurance Test totals also improved (from
160.32 plus or minus 146.55 seconds to 198.58 plus or minus148.30 seconds).
The control group showed improvements in VAS-Pain (from 5.60 plus or minus 2.53
points to 3.00 plus or minus 2.96 points), RMDQ-Disability (from 12.40 plus or minus 5.80
points to 8.56 plus or minus 6.73 points), and PSFS-Function scores (from 3.93 plus or minus
1.73 points to 5.26 plus or minus1.77 points). With again similarly wide variation, the Timed
Endurance Test totals also improved for the control group (from 85.01 plus or minus 84.91
seconds to 106.69 plus or minus 48.03 seconds). These extrapolated findings for the tabulation
and calculation of Mean and Standard Deviation occurring between all measures as they were
conducted between the raw data sampling of responses from the both the experimental group and
the control group over time - from baseline to eight weeks - are further displayed for all phases
of treatment in Table 17.
263
Table 17
Calculation and Display of Mean Scores and Standard Deviations for all Primary Outcome
Measures that occurred between Experimental Group and Control Group for the duration of the
Current Study
Measurement Scale
Pain (VAS)
Baseline
2 weeks (Phase 1)
4 weeks (Phase 2)
8 weeks (Phase 3)
Disability (RMDQ)
Baseline
2 weeks (Phase 1)
4 weeks (Phase 2)
8 weeks (Phase 3)
Function (PSFS)
Baseline
2 weeks (Phase 1)
4 weeks (Phase 2)
8 weeks (Phase 3)
Endurance Test Total
Baseline
2 weeks (Phase 1)
4 weeks (Phase 2)
8 weeks (Phase 3)
Experiment Group
SD
Mean
Control Group
Mean
SD
6.07
3.93
3.45
2
1.58
2.25
2.02
1.55
5.60
3.93
3.80
3.00
2.53
2.66
2.86
2.96
11.40
8
6.18
3.91
6.17
5.69
4.38
4.01
12.40
11.13
10.50
8.56
5.80
6.03
6.82
6.73
3.33
5.29
5.80
7.08
1.51
1.95
1.78
1.56
3.93
4.83
4.66
5.26
1.73
1.81
2.25
1.77
160.32
184.75
190.42
198.58
146.55
174.85
156.04
148.30
85.01
91.02
100.00
106.69
84.91
78.91
72.14
48.03
Graphs of the mean scores for the Visual Analog Scale (VAS), Roland Morris Disability
Questionnaire (RMDQ), Patient-Specific Functionality Scale (PSFS), endurance test totals, and
the corresponding flexion/extension ratios (McGill) that occurred between the control group and
the experimental group over time were all created to reveal their respective and appropriate
visual scales; and especially from which to also compare and display the proportionate and
comparative changes that occurred between the two groups. All graphs were embellished and
264
created using the Lattice™ package (Sarkar, 2008). They are sequentially revealed as figure insets
below – in sequence of order from Figures 63, 64, 65, 66, and Figure 67.
265
(a)
(b)
Figure 63. Mean Pre/Post Outcome Measures for VAS PAIN Over Time. (a) Bar graph, and (b)
Line dot plot for Mean VAS Scores between groups over time.
266
(a)
(b)
Figure 64. Mean Pre/Post Outcome Measures for RMDQ DISABILITY Over Time. (a) Bar
graph, and (b) Line dot plot for Mean RMDQ Scores between groups over time.
267
(a)
(b)
Figure 65. Mean Pre/Post Outcome Measures for PSFS FUNCTION Over Time. (a) Bar graph,
and (b) Line dot plot for Mean PSFS Scores between groups over time.
268
(a)
(b)
Figure 66. Mean Pre/Post Outcome Measures for ENDURANCE SCORES Over Time. (a) Bar
graph, and (b) Line dot plot for Mean Timed Endurance Test Totals over time.
269
(a)
(b)
Figure 67. Pre/Post Outcome Measures for FLEXION/EXTENSION RATIOS Over Time. (a)
Bar graph, and (b) Line dot plot for viewing Flexion/Extension Ratios over time.
270
Inferential Statistics Comparing Group Differences using Non-Parametric Tests
The Wilcoxon Rank Sum test, also known as a Mann-Whitney test, was deemed the most
suitable test for comparing (a) Visual Analog Scale (VAS), (b) Roland and Morris Disability
Questionnaire (RMDQ), and (c) Patient-Specific Functional Scale (PSFS) as the efficacy-based
outcome scores that had been collected between the experimental group and control group. The
decision to use the Wilcoxon Rank Sum test was made because the outcome scores that were
collected in the current study were derived from ordinally scaled formats of reference for
measured improvement by each patient’s individual responses over time, which classifies it as
nonparametric. The Wilcoxon rank sum test, a classic nonparametric test, was also selected
because of the two-sample aspect of the study, ultimately seeking a valid measure for statistical
significant difference between the control group and the experimental group.
The Wilcoxon Rank Sum test, again being applied as a repeating statistical formula, was
implemented to compare the differences between baseline scores and three phase levels of scores
that had occurred between the experimental group and control group within the three different
outcome data sets as mentioned above. As the preferred benchmark stated in most clinical
research literature, testing at a significance level of .05 was the designated threshold that was set
for all applications upon merging the three outcome measure raw-mean data sets into the
Wilcoxon Rank Sum test. A Basic Statistics and Data Analysis (BSDA) software package
component embedded within the R package was used as the recommended feature to conduct the
test (Arnholt, 2012).
In accordance with comparative statistical applications and operating procedures, a
projected null hypothesis that the group labels (experimental and control) were assigned at
random, but that the two groups had the same distribution of scores for each individual test. In
addition, there were no differences to be found in the analysis of results was compared against
271
the alternative hypothesis, that group labels were also assigned at random, but with projected
differences to be found in the analysis of results, implying that the two groups did not have the
same distribution of scores for each test, and that there were compelling differences that likely
exceeded usual expectation or random chance.
After conducting the Wilcoxon Rank Sum test for comparing the difference of baseline
scores to various phase scores between the experimental group and the control group for
different measurement scales, I received only two statistically significant p-values at p < 0.05.
The two significant p-values came from the comparison of "baseline to phase 2" and "baseline to
phase 3" of the Patient-Specific Functional Scale (PSFS) between the two groups. The resulting
p-values were about 0.038 and 0087, respectively. These p-values suggest that the control and
experimental groups had significantly different distributions of the change between baseline
PSFS scores and both phase two (Phase II) and phase three (Phase III) PSFS scores.
In modern statistics, the Bonferroni correction is one of several methods that are used to
include a provision for the problem of multiple comparisons. For example, a given study may be
well powered to detect a certain effect size when only one test is to be made, but the same effect
size may have much lower power if several tests are to be performed. These are correspondingly
reflected as an adjusted p-value.
Using the Bonferroni adjustment/Bonferroni correction method as a more stringent
statistic for the prospect of multi-variate and repeating situations, I made the corresponding
adjustments for multiple comparisons and repeated measures. This adjustment made the
previously statistically significant p-values become not statistically significant. Under these test
conditions, it infers that I can neither say that there is or is not a significant difference between
272
the experimental and control group’s change in VAS, RMDQ, or PSFS scores from the baseline
to phase one (I), phase two (II), or phase three (III).
However, an important criticism regarding the Bonferroni correction is that its intent to
control against inflation of the Type I error rate (rejecting a null hypothesis by attributing an
important significant difference – when there really is not one; i.e., a false positive) comes at the
cost of increasing the probability of producing false negatives (as in Type II error: erroneously
accepting the null hypothesis premise of no significant difference, when there really is one), and
consequently reducing statistical power. A display of non-parametric statistical comparisons to
discern p-value using Wilcoxon and Bonferroni inferential statistics is itemized for each
measurement scale and across each phase of treatment as compared between both groups in
Table 18.
273
Table 18
Wilcoxon Rank Sum Test and Bonferroni Adjustment Method to assess Non-Parametric
Statistical Significance of p < 0.05 for VAS, RMDQ, and PSFS Scores occurring between
Groups
Measurement Scale
Comparison
Unadjusted
P-Value
0.4699
0.72
0.1093
Adjusted
P-Value
1
1
0.9837
Visual Analog Scale (VAS)
Baseline-Phase1
Visual Analog Scale (VAS)
Baseline-Phase2
Visual Analog Scale (VAS)
Baseline-Phase3
Roland Morris Disability Questionnaire
(RMDQ)
Baseline-Phase1
0.05859
0.52731
Roland Morris Disability Questionnaire
(RMDQ)
Baseline-Phase2
0.08025
0.72225
Roland Morris Disability Questionnaire
(RMDQ)
Baseline-Phase3
0.572
1
Patient-Specific Functionality Scale
(PSFS)
Baseline-Phase1
0.05565
0.50085
Patient-Specific Functionality Scale
(PSFS)
Baseline-Phase2
0.03777
0.33993
Patient-Specific Functionality Scale
(PSFS)
Baseline-Phase3
0.008714
0.078426
Note. Bolded p-values are indicative of meeting or exceeding the likelihood of random chance –
thus increasing the likelihood of change being directly attributable to the effects of the
experimental intervention.
Inferential Statistics Comparing Group Differences using Parametric Tests
A paired, two-tailed t-test was used to assess relative significance of changes of the
endurance test totals within the control group and the experimental group, individually. The setpoint for p-value statistical significance (depicted as alpha value: α) was once again tested at the
.05 level. The null hypothesis was again stated to assume the likelihood of no difference between
the baseline and phase three endurance test totals within each group, and the alternative
hypothesis was there is a significant difference between the baseline and phase three endurance
test totals. After conducting a matched t-test for each group, I received p-values of about 0.001
for the control group and 0.019 for the experimental group, both of which fall below .05 making
274
them both statistically significant. Therefore, I have evidence to believe that there was a
significant difference between the baseline endurance test total, and phase three endurance totals
that had occurred both within the control group and within the experimental group over time.
A two-sample t-test was then used to compare the average change between baseline and
phase three endurance test totals between groups. Again, my alpha value (α) was set at the
threshold of .05. The null hypothesis test is that there is no difference in the means between the
control and experimental group. After conducting this two-sample t-test, I found the p-value to
be 0.7323. Therefore, I did not find statistically significant evidence against the null hypothesis,
that there is no difference in the difference in baseline and phase three means between the control
and experimental group. I can neither say there is or is not a difference in average change
between baseline and phase three endurance test totals between the experimental group and
control group. Table 19 presents p-values within and between groups using t-test parametric
testing in order to discern the significance of effect change of repeated timed intervals for
endurance testing over time.
Table 19
Paired Two-Tailed T-Test to assess Parametric Statistical Significance of p < 0.05 for changes
occurring during Timed Endurance Testing Totals over Time
Measurement Scale
Endurance Test Total (Control Group)
Endurance Test Total (Experimental Group)
Endurance Test Total (Between Groups)
Comparison
Baseline - Phase 3
Baseline - Phase 3
Baseline - Phase 3
P-Value
0.0011
0.019
0.7323
Note. Bolded p-values again indicate significant changes – but due in part to the extreme
variability between participants, there was no essential difference between both groups to be
directly attributable to the effects of either intervention.
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Parametric Testing and Data Analysis for Comparing Pre-Post Flexion/Extension Ratios
Table 20 and Figure 68 demonstrate a total decrease in Flexion/Extension (F/E) ratio of
about seven proportions for the experimental group and a decrease of about 4.5 in the control
group. However, upon again implementing the parametric two-sample t-test, the mean difference
between Pre-intervention (Baseline) F/E Ratio and Post-intervention (Phase 3) F/E Ratios for the
two groups, the result was found to be a p-value of .5902. Thus, despite the apparent surface
magnitude of larger-scale change at face value, it was again found that that the statistical
comparison result of difference was nonetheless still registering an insignificant p-value (greater
than .05).
Yet, upon comparing the previously cited predictive threshold for F/E ratios themselves
being below 1.5 for being clinically indexed as a measure of more sufficiently balanced trunk
control, it was found that 11/15 experimental group participants met this threshold index of less
than 1.5 as compared to only 1/15 of control group participants, indicating greater episodic
phenomena of dysfunctional trunk imbalance in the control group at post-intervention, which is
itself significant.
Figure 68. Bar Graph for comparing Pre- & Post-Flexion/Extension Ratios between Groups.
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Table 20
Mean Average for Flexion/Extension Endurance Ratios at Pre & Post Intervention and
Relevance to Clinically Meaningful Thresholds of < 1.5 being indicative of Improved Trunk
function via reduced Agonist-Antagonist Disparity in Experimental Group as compared to
Controls
Control
Group
Experiment
al Group
Average Flexion / Extension Endurance Ratio at
Baseline for all study participants (Baseline)
21.865
8.545
Average Flexion / Extension Endurance Ratio at
Conclusion for all study participants (s/p Phase III)
17.197
1.398
Percentage of Change in Flexion / Extension Ratio
from Baseline to Conclusion of Study
21.35%
83.64%
1
11
Number of Participants Concluding
the Study with Clinically Relevant
Flexion / Extension Endurance Ratios < 1.5*
*Note. Threshold of clinical relevance for improved "trunk flexion/extension ratio" is modified
and adjusted to < 1.5 for a CNSLBP population as compared to a < 1.0 threshold for collegeaged healthy controls and a less-sedentary industrial worker population (McGill et al., 2003)
Purported Research Questions, Summary and Outcome for Hypothesis
Again, the purpose of this single-blind, randomized controlled study (RCT) was to
compare a Body Schema Acuity Training protocol using newly applied, newly developed lowcost technology (Virtual Reality Bones™/VRB3) with a respected complementary-alternative,
movement and manual therapy, neuroplasticity-based educational intervention (The Feldenkrais®
Method) against the most commonly accepted approach being utilized within current and
conventional physical therapy practice settings (Core Stabilization Training and Graded Motor
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Control Exercises). This was conducted for improving the outcomes on usual clinical outcome
measures for CNSLBP, and to determine whether there is greater clinical efficacy being
demonstrated between one combined intervention or the other for treating the widespread
problem of CNSLBP as an outcome of the study itself.
In accordance with traditional precepts of the scientific method, my RCT design was
necessarily set-up to permit the full probability and/or possibility for demonstrating and
confirming the outcome of a null hypothesis (i.e., no difference). However, the actual accrued
results of the current study have instead tended more toward supporting and at least partially
confirming my intuitive hunches via the projected scientific hypotheses as they were originally
stated within the introduction section of this dissertation.
Supported Hypothesis 1
The results support the hypothesis that a population of persons with chronic, non-specific
low back pain (CNSLBP) who participated in a combined Virtual Reality Bones™/Feldenkrais®
Movements (the VRB3/FM group) protocol for improving body schema acuity demonstrated
greater symptom reduction and greater functional improvement in all outcome measures, as
compared to a similar population of persons with CNSLBP who followed a Core-Stabilization
Biofeedback training/Motor Control Exercise protocol for improving motor control (the
CSB/MCE group).
Partially-Supported Hypothesis 2
The results did not fully support the hypothesis stating that all comparative outcome
measures being used for demonstrating greater symptom reduction and greater functional
improvement would all occur at a level of statistical significance being reflected at the customary
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p-value of less than 0.05 between the experimental VRB3/FM group and the CSB/MCE control
group.
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CHAPTER 5: DISCUSSION
Overview and Interpretation of Study Results
As just reported, the Virtual Reality Bones™/Feldenkrais® Movement (the VRB3/FM
group) protocol for improving body schema perceptual acuity and movement dexterity function
demonstrated greater symptom reduction and greater functional improvement in all outcome
measures, as compared to a similar population of persons with chronic non-specific low back
pain (CNSLBP) who followed a Core-Stabilization Biofeedback training/Motor Control Exercise
protocol. This was conducted for improving motor control (the CSB/MCE group), and with both
groups being encouraged to progress their graded activity levels while simultaneously
controlling for fear-avoidance via cognitive-behavioral therapy-informed qualities of therapistpatient interaction throughout the course of the study. However, only the final outcome measures
for the Patient Specific Functional Scale (PSFS) were able to demonstrate superior efficacy at a
p-value of 0.008714 for the VRB3/FM experimental group as compared to the CSB/MCE control
group.
Both Groups Demonstrating Improved Outcomes and their Shared Mechanisms of
Influence
Beyond the usually given explanatory rationale for positive treatment expectancy and
attributions to the Hawthorne effect or observer effect (to which individuals modify or improve
some aspect of their behavior just merely in response to their awareness of being attended to or
observed) there are added components and variables in both groups that can perhaps account for
both groups improving between their respective interventions. Both groups received preliminary
"awareness affordances" that necessarily required them to pay attention to certain regions of their
body in new and specified ways, and mostly (or at least more tangibly) during Phase I of the
intervention.
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The control group’s intervention and corresponding mechanisms. For the CSB/MCE
control group, this "awareness affordance" was informed through specific attention to precise
recruitment and activation of specific muscle groups; namely, Transverse Abdominis (TrA) and
Lumbar Multifidus (LM) made tangible through visual depictions of anatomical location, using
medical-anatomical nomenclature, and describing their rationale for “stabilizing and protecting
the spine.” These mechanisms for experiencing a modulated quality for muscle activation more
proactively, in contrast to reactive muscle spasm, guarding, or bracing, were further facilitated
through implementation and use of the Stabilizer™ Bio-Feedback (PBU) device. This was
conducted to accomplish a degree of trunk muscle activation and contractility specific to deep
muscle groups and at a sub-maximal threshold quality that was "not too much" and "not too
little," but "just right," furthermore affording an active experience through feedback that would
err toward generating a cognitive orientation deemed more conducive toward conditioning an
internal locus of control.
The experimental group’s intervention and corresponding mechanisms. Similarly,
for the VRB3/FM experimental group, relevant bodily attention to specific regional areas was
again informed (however, this time through non-muscular elements by giving specific attention
[or by more precisely via the acuity of attention]) to more accurately discover and locate the
more exacting self-referenced locations for deep articular joints; namely, (a) deep "hip joint"
femoral-acetabular axes, (b) inner ilia bridges, (c) costo-vertebral joint/thoracic pedicles, and
(d) paired temporal bone/vestibular apparatus locations.
This was made tangible through visual-tactile explorations and direct interactions with
full-scale, life-sized, anatomical skeletal models (i.e., virtual reality bones™ applications), again
using medical-anatomical nomenclature, and by furthermore describing their assembled and
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combined rationale for “containing and aligning an improved proportion for distribution of labor
throughout the entire skeleton” from a “hips-pelvis-legs/opposite head” whole body continuity of
perspective, and through
cultivating an awareness and use of more robust and supportive "pathways of highest
bone density" throughout the body as a way to distribute everyday ground forces
involved in sitting, standing, and walking, and to dissipate their tension during everyday
movement;
but without involving any particular attention to the lumbar spine itself; nor to involving any
attribution or target contact to "muscles themselves" or to "muscle recruitment issues" as the
source of the problem.
These mechanisms for experiencing a modulated quality of being for ‘internal selfreferencing of whole self through both experiencing and embodying the inherent properties of
skeletal contiguity’ had also demonstrated an inhibitory and proactive effect in contrast to
clinical presentations of reactive muscle spasm, guarding, or bracing – as well as being
antithetical to the training isolated muscle activation as the purported mechanism. Precision of
synergistic actions were otherwise facilitated through implementation and use of Vicon™
Kinematic Avatar images during standing and gait, and matched-theme Feldenkrais® Movements
(FM) to accomplish an enhanced degree of spatial-temporal dexterity during functional
movements, and at sub-maximal thresholds of motor control such that they were "not too much"
and "not too little," but "just right." Likewise, these sense and movement qualities furthermore
afforded an active experience, through combined mechanisms of feedforward being altered by
self-referenced visual-tactile-kinesthetic feedback (i.e., haptic self-touch) that would again err
toward generating a new cognitive orientation deemed more conducive toward conditioning an
internal locus of control during everyday action and living.
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Motor control as a shared mechanism to separate pain from fear of movement? As
was put fourth in the literature review earlier, chronic pain being exacerbated by movement has
been proposed be the result of associative learning resulting from the concurrent pairing between
movement and pain, thereby imprinting an implicitly and/or explicitly learned response that
forms into a maladaptive memory for sustaining the persistence of chronic pain. In particular,
during the presentation of discriminative neurotags or other aversive stimuli, fear of provocative
or awkward movements being one of them. Thus, a continuing aversive association is reflected
and maintained by plastic changes in the meso-limbic, sensory-motor, and prefrontal areas
(Pelletier et al., 2015a).
In a series of imaging experiments cross-referenced with clinical findings, Tsao et al.
investigated the organization of the representation of muscles in the lumbar spine within the
primary motor areas (M1) in subjects with chronic low back pain and demonstrated that
concurrent corticospinal recruitment deficiencies were correspondent to smudging of cortical
representations at M1 in a sample of patients with chronic or recurrent LBP (Tsao, Danneels, &
Hodges, 2011; Tsao, Druitt, Schollum, & Hodges, 2010). Motor Control Exercises involving the
learning of new coordination skills, inclusive of exercises to specifically recruit the Transverse
Abdominus (TrA) muscle, but not a generalized walking exercise, were shown to restore the
representation of lumbar cortico-spinal projections within M1 and that EMG activation patterns
in CLBP subjects were also more normalized as compared to a non-treatment group of healthy
controls. Thus, interventions targeted toward the improvement of coordination of movement and
correspondent cortical representations would seem to be equally efficacious toward improving
function and decreasing pain.
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However, seeing that previous clinical trials have found no difference in specific motor
control exercises in comparison to generalized supervised exercise and graded activity programs,
an alternative effect mechanism may not be as easily discernable nor reducible to implicating a
specific mechanism for ‘core musculature’ specifically. Other studies have shown that spine
stabilization exercises in the treatment of chronic low back pain do not require the demonstration
of improved abdominal and trunk muscle function as important factors being associated with a
good clinical outcome (Mannion, Caporaso, Pulkovski, & Sprott, 2012).
It has otherwise been suggested that simply moving differently from that which was
previously associated with the original injury state, or as has been otherwise continuously
conditioned through repeated cycles of pain and avoidance, is a simple and viable change agent
on its own for breaking the habits of protective bracing, inducing exercise analgesia, changing
fear, improving confidence, building self-efficacy, learning to move without pain, and to transfer
that confidence over to other activities (Lehman, 2013). Indeed, how people compensate their
movement is highly individualized, and it is likely true that movement changes that persist
beyond their original protective stage may lead to changes in function and further affect recovery
(Butera, Fox, & George 2016).
Therefore, the therapists who are most able to attend to the individual nuances as to how
a person can move differently, stand the best chances for successful outcomes in lieu of one-sizefits-all rigidly designed protocols, and these affordances - of being able to adjust treatment and
movement re-education parameters to meet the needs for individual patients enrolled in the study
- were a stated recommendation for treating clinicians in both arms of the study. In addition,
clinicians in each arm in the study were encouraged to use hands-on attention and manual
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contact as necessary in order to satisfy treatment and learning objectives for both VRB3/FM and
CSB/MCE arms of the study.
Expectation fulfillment as a confounding variable. The Expectation Fulfillment
Confounder (EFC), which, with close association to other confounding variables, including
placebo response, regression to the mean over time, and the subtleties implied through
confirmation bias and patient-practitioner belief all remain a challenge as to actually and
conclusively determine whether a particular therapy, and its purported biological mechanisms,
are actually effective or in some way causative. However, the role of expectation fulfillment
being more confirmatory to the perspective of the control group is a factor that cannot be
ignored. Certainly the ubiquitous nature of common and publicized vernaculars, such as "core
strengthening" and "core control" or "of having a weak core," have become somewhat of a
culturally-societally reinforced meme that is much more known and culturally substantiated on
the basis of face validity and social proof; this, in comparison with more diffuse models
emphasizing "correlative relationships between skeletal density pathways and corresponding
movement trajectories," as was the more arcane purview of the experimental group. Accordingly,
there is high likelihood that CNSLBP patients in both arms in the study were told at one or more
times by their primary care provider or specialist that they needed to "work on their core."
Subsequently, when they were given a specific form of "core-stabilization muscle recruitment"
trainings and a corresponding motor control exercise program that would "improve the stability
of their spine," it would "not be unusual that this subset would respond better because they had
been primed to respond better" (Lehman, 2016).
In the current study, the control group therapists were indeed talented, personable,
professionally believable, and confident in both their personal disposition and treatment delivery.
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One of them even received Valentine’s Day candy from one of more of the control group
participants. The experimental group therapists received no such offering or appreciative gift
during this time frame, but one did receive a handmade doily after patient decided to continue
with therapy for her shoulder diagnosis at post-study intervention.
The Experimental Group Demonstrating Superior Improvement and Some Possible
Rationale for Examining the Differentiated Mechanisms of Influence
As has been previously reported, there is growing evidence from neuro-imaging and
concurrent clinical presentation that the ongoing persistence of chronic body pain syndromes
results in mal-adaptive and reflective distortions in the sensory cortical representation (S1
mappings) of the body, and co-appearing in clinical concordance with various types of other
perceptual disturbances. These include nociceptive amplification, loss of sense of limb
proportion, changes in sensory and motor representations of head position in space, of laterality
and spatial dimension between torso and limbs, changes in the overall quality of movement and
posture control; thus, further disrupting the brain’s sense of movement, and ultimately resulting
in lasting perceptual changes in the body image or body schema. These have also become
especially evident in situations involving phantom limb pain and complex regional pain
syndrome (CRPS), and have become known as "the dark side of neuroplasticity" (Doidge, 2007,
2015).
Researchers in body schema phenomena and rehabilitation medicine have known that
planning and coordination of movement requires an intact perception of the body and its position
in space, and movement quality may be compromised if body perception is disrupted (Wand et
al., 2016). Suboptimal movement patterns might abnormally load the back and contribute to
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nociceptive input and movement-related pain in those with CNSLBP (Hodges & Smeets, 2015;
O’Sullivan, 2005).
Furthermore, studies in both animals and humans demonstrate that altered sensory
transmission may result in changes in neuronal properties and organization within different
subcortical and cortical areas including the thalamus, primary somatosensory cortex (S1) and the
primary motor cortex (M1) all being co-implicated in sensory transmission, perception, and
motor control (Kambi et al., 2014; Jones et al. as cited in Pelletier et al., 2015a).
Neurophysiological studies have also revealed that increased activation of insular cortex is
correlated with pain duration, while medial pre-frontal cortex activation is correlated with
continuing pain intensity in patients with CNSLBP (Apkarian, Hashmi, & Baliki, 2011).
Abnormal increased connectivity between the medial pre-frontal cortex and the nucleus
accumbens is also noted to be highly predictive of who will go on to develop chronic LBP
suggesting that there may be pre-disposing biomarkers for the development of chronicity (Baliki
et al., 2006; Mansour et al., 2013; Mansour et al., 2014). One result of the abnormal activity in
these areas is increased limbic, autonomic, and somatic vigilance, and a decreased ability to
cognitively over-ride or disengage from pain (Davis & Moayedi, 2013).
The experimental arm of the current study considered that these areas of co-involvement
could be all be comprehensively more addressed through the development of a new intervention
that targets and reinforces toward selecting unaffected functional pathways, as competing
information to those pathways otherwise remaining affected or being dysfunctional. That is to
say that “rather than attempting to target a presumed cause of the pain, and then treat it, an
alternative approach is to help a person to recover a sense of missing or lost perceptual parts of
themselves – including the asymptomatic ones – and to develop a more clear and effective
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working body schema overall; and one that is free of neuromuscular and perceptual-cognitive
belief habits that have otherwise become co-conditioned through chronic pain states.”
In this way, I more likely avoid manually contacting or attempting to directly change or
treat guarded and hyper-sensitized areas corresponding to both somatic and cortical mal-adaptive
representations and their direct corresponding association for inadvertently inducing a perceived
threat. In addition, by avoiding the topic of “low back pain” altogether during the course of
treatment, I also avoid reinforcing the cognitive-iatrogenic belief attribution that there is
something faulty or dangerously wrong in or with “the back.” Instead, a person has a unique
chance to explore regions of support, robustness, and adaptability that anatomically and
somatically exist adjacent to the back (i.e., above and below the back) but are not the back and
within the context of whole body/whole self being experienced through synergistic and attentive
supported action using Feldenkrais Method® -based movements.
By instituting a novel and interactive learning approach via the implementation of a body
schema acuity training model, more specifically, implemented by the acronym (VRB3) from
earlier sections, and then being operationalized through selected Feldenkrais® movements (FM)
that have been clinically known to have positive influences on reducing low back pain (LBP), the
experimental intervention went on to both include and be informed by some additional inquiries
and features not particularly found within the control group’s (CSB/MCE) intervention; nor for
most other common approaches to chronic low back pain that are currently in use:
•
Three general principles of multisensory and multimodal integration, including the
spatial rule, the temporal rule, and the principle of inverse effectiveness as put forth by
Stein and Meredith (1993).
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•
Three components conducible toward being recognized as a combined virtual realitybased kinesthetic and visual-haptic sensory experience including the use of (a) threedimensional images that appear to be life-sized (i.e., virtual reality bones™) from the
perspective of the user (b) the ability of a user to track their own motions, particularly
through variations of head and eye movements, and (c), to correspondingly adjust the
images on the user's display (i.e., their own body) to reflect the change in multi-sensory
perspective.
•
Three vestibular-based and temporal bone contributions being manifested toward multimodal awareness and combined neurophysiological utilizations of (a) spatial cognitions
drawing upon on parietal areas, (b) body representation being associated with
somatosensory areas, and (c) affective processes modulating insular and cingulate
cortices as cited by Mast et al. (2014).
Though not cited in the literature review, another key theoretical and practice perspective
becoming increasingly adopted through the Feldenkrais Method® practitioner community has
been the emergence of Dynamic Systems Theory. Since the publication of A Dynamic Systems
Approach to the Development of Cognition and Action by Thelen and Smith (1994), its key
tenants have served to help explain the phenomena of coordination, cognition, and learning, and
control of action in the human movement system; most especially, how interventions being
informed through applications of systems-based thinking, like the Feldenkrais Method®, can
seem to somehow rapidly and sustainably create an automatic quality of constitutive and lasting
change without having to be subservient or dependent upon an explicitly dictated performance
override for conducting "proper performance" objectives, nor for adhering to a rote protocol,
repeated regimen, or structured routine.
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The basic concept is that the organism, the task, and the context "self-organize" behavior
into a preferred form, or attractor. A dynamical approach states that during development, new
forms of behaviors (attractors) emerge as old forms (habits) lose their stability through wideranging phase shifts in behavioral organization.
However, the nature of all systems - including living systems - is such that they tend to
conserve for the self-maintenance of perpetuating their own existing and accustomed conditions
until effectively destabilized, re-adapted, or phase-shifted into a newly existing order through
appropriated interactions. Review sources from cognitive science and rehabilitative fields have
distilled this landscape into two contexts from which to interpret this further:
A dynamic system is created when conflicting forces of various kinds interact, then
resolve into some kind of partly stable, partly unstable, equilibrium. The relationships
between these forces and substances create a range of possible states that the system can
be in. This set of possibilities is called the state space of the system. The dimensions of
the state space are the variables of the system.
However, although these variables define the range of possibilities for the system, only a
few of these possibilities actually occur. (These become embedded as attractor states).
Port and van Gelder define "attractor" as " the regions of the state space of a dynamical
system toward which trajectories tend as time passes. As long as the parameters are
unchanged, if the system passes close enough to the attractor, then it will never leave that
region. (Rockwell, 2005, p. 573)
And from a therapeutic intervention standpoint:
If poor patterns are already in a deep attractor well, interventions are required that
disrupt this current stability, if possible. Patients who have experienced the bias of one
organization longer will have developed a deeper well of this preferred organization,
pulling further subsystems into a less flexible pattern.
Once the system has alternative patterns available, the therapist can assist the patient in
discovering, through natural movements, the range of possible new solutions.
Thus, the goal of treatment, according to a dynamical view, is to work on the system
when it is in transition. Treatment is change that involves seeking new, and more
adaptive, movement configurations. Therapeutic handling should allow as many degrees
of freedom to vary as the patient can flexibly explore. Control around these transition
points is one key to adaptive behavior. (Kamm, Thelen, & Jensen, 1990)
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When an attractor well is very deep, the behavior of the system becomes limited to this
area and is often described as hard-wired, stereotyped, or obligatory (Kamm et al., 1990). By
constituting chronic pain as a stuck place, or as an accrued culmination of habituated and
regressive states bearing much concurrent relationship to a limited or restrictive movement
repertoire, a "deep well attractor" image of the nervous system can serve a useful metaphor for
understanding both the transition to chronic pain and disability over time; and for outlining some
transition paths afforded through a Feldenkrais style of intervention that can "expand the
®
territory" in favor of more dynamic functions and restorative influences, and thereby contribute
to its resolution and reversal. An accrued attractor landscape is depicted below in Figure 69.
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(a)
(b)
(c)
(d)
________________________________________________________________________
Figure 69. Visual Schematic for Attractor States over Time. (a) Cumulative effects of deep
attractor well representing the downward spiral of developmental pain and compensated
movement over time and persisting into old age with increasingly restrictive movement
repertoire; (b) The effects of usual and repeated therapeutic exercise and most personal fitness
routines are only a mere rehearsal of preferred and habituated states and thus do not effectively
alter the topography landscape of the state space; (c) The institution of novel inroads afforded
through Feldenkrais® movements expands the behavioral repertoire into a preferred, but more
flexible configuration; permitting (d) a larger space for play. *Diagram and concept courtesy of
Feldenkrais® Trainer, Roger Russell, PT, FGNA 2004.
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Other Qualitative Differences and Oppositional Contrasts Between Interventions
In sum, the design of this study was set up to test-compare two types of treatment
interventions such that they could be comparatively scrutinized on the basis of their being
diametrically opposed and antithetical to each other in terms of their historical developments,
their purported mechanisms of effect, and their respective regional areas of application. The Core
Stabilization Biofeedback plus Motor Control Exercises (CSB/MCE) treatment control group
aimed to entrain the following foundational precept:
In how many ways can a patient best experience a progression of challenges for
maintaining their core stability for control of deep stabilizers about the lumbar spine via
selected sub-maximal activation and specific recruitment patterns for transverse
abdominis (TrA) and lumbar multifidus (LM) muscle groups via the aid of a regionally
applied pressure biofeedback unit (PBU) device and through therapist-directed
facilitation in supine, prone, side-lying, and sitting positions so as to more consistently
stabilize and control the position of lumbar spine segments T12-L1 through L5-S1 during
motor control exercise and for future conditioning progressions?
In comparative contrast, the Body Schema Acuity Training (using the VRB3 method™)
plus Feldenkrais® Movements (VRB3/FM) treatment experimental group concerned itself with a
different question for exploration:
In how many ways can a person best experience varied dimensions of pelvis-hips-legs
opposite that of head & vestibular orientation with emphasis on developing a sense for
skeletal continuity in three-dimensional space by perceiving their densest trabecular
skeletal pathways through global and proportionate movement experiments; mostly
through sensory interactions with life-scaled skeletal models and avatar animations, and
by aid of visual-haptic self-touch with the assistance of therapist...and essentially
ignoring any importance for particular attention to isolated spine segments being
regionally localized to lumbar vertebrae; or even to any specific muscular recruitment of
any particular name; nor of any particular kind?
Figure 70 depicts an outline of differentiated schematic intent between the two groups:
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(a)
(b)
Figure 70. Conceptual Drawings: Regional Isolation vs. Regional Interdependence. Early
preliminary conceptual drawings from the reference point of three cardinal anatomical planes
being contrasted against regional isolation vs. regional interdependence: (a) The CSB/MCE
group’s area of entrainment focus remains confined to TrA and LM muscle groups and gives
little affordance toward three-dimensional space. In contrast, (b) The VRB3/FM ignores any
reference to isolating abdominal (core) aspects of trunk and instead gives primary reference
emphasis toward experiencing dimensional relationships between pelvis-hips-legs opposite
thorax and head, and also particularly for vestibular end-organ relationships within multiple
planes of three-dimensional space.
In addition, Appendix S depicts an extremely extensive outline of the differentiated
schematic intent between the two groups. The epistemological differences, being compared and
contrasted side by side, should hopefully invoke some added understanding of each approach’s
foundational paradigms as well as providing for implications for real world applications in the
improvement of human function overall, and to hopefully influence practice and policy
development in all of health care practice, human development, and clinical research.
A Critical Review of Outcome Measures and Findings from the Current Study
Chapter 3 (Methodology section) again reveals and substantiates that all outcome
measures and tools being used for the current study had met baseline requirements for validity
and reliability, and that they had furthermore revealed long track records of superior selection
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precedent through extensive literature reviews of clinical research trials involving comparative
treatments and determinants of problems involving low back pain, especially CNSLBP.
However, added considerations are worthy of discussion in terms of how these various tools
were exemplified within the actual context of the current study.
Mean VAS Pain Scales
Post-study review reveals that a Visual Analogue Scale (VAS) is a measurement
instrument that tries to measure a characteristic or attitude (i.e., pain intensity) that is believed to
range across a continuum of values and cannot easily be directly measured, furthermore
displayed without actual segmented demarcation during assessment, and is only later quantified
at post assessment via the applied use of a millimeter ruler being placed as a pre-calibrated
overlay in correspondent alignment with the horizontal line in which the patient had ticked the
line. As a matter of correct nomenclature, it can be argued that the correct nomenclature should
actually have been more specifically classified as the Numerical Rating Scale (NRS); being
correctly described as a segmented numeric version of the visual analog scale (VAS) to which a
respondent selects a whole number (0–10 integers) that best reflects the intensity of his/her pain.
However, the important feature on application is that the 1-10 qualitative scaling criterion
was consistently used, in addition to its comprising a visual analog being repeatedly reflective of
pain experience, for all participants, and for in all phases, and for both groups in the entire study.
Furthermore, multi-modal versions of display, including the addition of language qualifies and
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colorized references to pain intensity being corroboratively scaled with the numerical ratings,
were an essential visual feature that was used in the current study, and these are displayed
together in Appendix H and in terms of their being described as Copy of VAS-PAIN/Numerical
Rating Scale. So, while the “VAS-PAIN” scale used for the current study is arguably "more
visual," it will be more likely better for future literature publications to have it be re-depicted as a
“1-10 Numerical Rating Scale for Pain (NRS-PAIN) being embellished by matching color scales
and language descriptors” for purposes of method and citation.
Outcomes for RMDQ Disability Questionnaires
RMDQ had scored as consistent at baseline with closely similar initial mean averages of
11.40 plus or minus 6.17 for the experimental group and 12.40 plus or minus 5.80 for the control
group. Subsequent to Phase I of the study, repeat administration of the RMDQ demonstrated a
change in mean scores to 8 plus or minus 5.69 for the experimental group as compared to 11.13
plus or minus 6.03 for the controls. When statistical comparisons were made using the Wilcoxon
rank sum test, the p-value of change distribution for the RMDQ between group means
subsequent to Phase I was calculated at p=0.058. Upon inclusive consideration for high
variability being reflected in corresponding standard deviations between both groups, I maintain
that this outcome signifies a positive congruence for actually supporting the outcome for the
secondary hypothesis being reasonably proximal to the pre-stated p-value of p less than or equal
to 0.050. While the remaining phases of concurrent treatment did not demonstrate closer
approximation toward reaching statistical significance, The VRB3/FM group’s results
nonetheless consistently demonstrated greater magnitude of improvement as compared to that of
the CSB/MCE control group.
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Outcomes for PSFS Functional Scale
Of all the methodological tools and instruments used in the current study, only the final
outcome measures for the Patient Specific Functional Scale (PSFS) were able to most
definitively demonstrate superior efficacy at a p-value of 0.008714 for the VRB3/FM
experimental group as compared to the CSB/MCE control group. An important factor to consider
for this outcome measure is that the Patient-Specific Functional Scale (PSFS) makes broader
consideration as to "what’s important to the patient?" Within the context of a profession, so
much of clinical practice can become a reflection of technical features that are aligned according
to the particular training bias, the professional jargon, and the particular competence
expectancies that arise for the individual clinician, but of which have little perspective or
relevance of value that is specific for the individual patient as they attempt to adjust to varied
compensatory challenges in their daily manner of living.
For example, many physical therapy- and personal trainer-based programs emphasize an
external referent for "proper performance." Patients and clients are "told what to do" and to "do
it correctly" in terms of imitative demonstration from someone with a completely different level
of personal fitness and/or proportion of body-build, and/or by saying “I want you to do this…”
and by further demonstrating some exemplary form of advanced fitness that is typically beyond
the current capacity and perception of the injured or recovering patient, or the deconditioned
person. In contrast, the Feldenkrais Method first creates conditions of internal reference and
®
outlines sequences for independent and varied exploration of what is possible, thereby generating
a sense of free-reign and inner attention toward improving a quality of movement such that a
response characteristic of enhanced self-efficacy can permit greater generalization into the usual
or preferred activities of daily life, as opposed to adhering to someone else’s pre-conditioned
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exercise program or exacting routine. From this perspective of explanation of difference between
usual fitness-based and core exercises as compared with a more patient-centered/person-centered
Feldenkrais orientation of perspective, it is somewhat easier to understand why the PatientSpecific Functional Scale (PSFS) had demonstrated more exceptional outcomes at a p-value of p
less than or equal to 0.05.
Outcomes for McGill’s Timed Endurance Tests
I have no explanation for how or why the aggregate of baseline and continuing total
endurance of mean scores for holding all four positions in the sustained position endurance tests
began substantially higher (at 160.32 seconds for the experimental group), as compared for
roughly half-that (at only 85.01 seconds) for controls. Likewise, how the experimental group
continued to remain substantially higher for post-intervention improvements (at 198.58 seconds)
in comparison to that of the control group (at only 106.69 seconds), other than random outlier
and clustering effects being inadvertently derived through random sampling.
Despite the large variation of magnitude between groups, the proportion of scaled
difference when compared using parametric paired t-tests revealed a similar p-value of 0.019 for
the experimental group as compared to 0.0011 for the control group - demonstrating comparable
statistical significance between groups and therefore indicating no statistically significant
difference being reflective of greater clinical efficacy between groups on the basis of changes for
total endurance times alone. Yet, upon comparing the previously cited predictive threshold for
Flexion/Extension timed-endurance ratios themselves being below 1.5 for being clinically
indexed as a measure of more sufficiently balanced trunk control, it was found that 11/15
experimental group participants met this threshold index of less than 1.5 at post-intervention as
compared to only 1/15 of control group participants; thus, indicating greater episodic phenomena
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of dysfunctional trunk imbalance in the control group at post-intervention, which is itself
clinically significant.
So, while similar outlier effects were shared between both groups at the start of the study,
with correspondingly high average flexion/extension (F/E) ratios at the start for both groups at
baselines of greater than 1.5 (via 8.45 total average for the experimental group as compared to
higher ratio of average proportion for the control group at 21.86), the results at eight weeks postintervention had indicated that only the experimental group had demonstrated more
proportionate success at attaining an average flexion/extension ratio at below the cited 1.5 level
threshold (via 1.39 for the experimental group as compared to continued higher perseveration
average ratios of 17.19 for the control group).These results reflect greater clinically meaningful
thresholds of less than 1.5 being indicative of improved overall resiliency in trunk function via
reduced agonist-antagonist disparity in the experimental group as compared to controls.
A possible explanation for disparity between groups is to suggest that core stabilization
training/motor control exercises (CSB/MBE), being abdominal-centric in their intended "coresetting" (vs. their un-intended excessive corseting) effects, may be inadvertently vs. overtly
conditioning a flexor bias at the expense of extensor recruitment. Thus, raising the risk factor
specter for imbalanced trunk control and resulting in decreased extensor endurance, a factor
being previously cited by researchers as a future predictor of recurrent LBP episodes (McGill,
2005).
Conversely, in lieu of conditioning and reinforcing a set of co-contraction inspired
muscular habits that more than likely already exist as a predominant behavioral tendency in
patients with CNSLBP, The VRB3/FM group instead became more well-rounded at postintervention to access multiple directions in space with equal distribution of effort, and improved
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endurance synergy between flexors and extensors, so as to maintain better balance of contralateral vs. A-P trunk tone, on demand. This outcome ties well with a known and frequently cited
quotation from Moshe Feldenkrais in his stating that:
The aim of the work is a body that is organized to move in any direction with equal ease,
and without hesitation or pre-preparation – not from muscular strength - but from an
increased consciousness of how it works. (Haller, 1997)
Finally, it is rather paradoxical to observe that the repeated exercises of the control group
intervention would - on the surface - appear more conducive toward adhering to "exercise
specificity principles" via the simulated conditioning of both strength and endurance factors, and
their corresponding positions for entrainment (planking and so forth) actually replicating the
same exacting conditions as were slated for repeated endurance testing in the McGill timed
endurance protocols. So, despite the theory of "exercise specificity" being predicative of
improving performance, the CSB/MCE group’s intervention perhaps inadvertently conditioned
the control group to co-contract and to work against themselves and to thereby fatigue earlier,
despite any surface appeal for their exercises being selected for purposes of coordinated
efficiency and improvements in "motor control." The VRB3/FM group, conversely, did nothing
to focus on specific skills being aimed or rehearsed to improve strength, "proper form" nor the
endurance simulation of specific postures being specifically replicated for the timed endurance
test protocols by McGill, and yet, they consistently performed better.
Participant Adherence, Attrition, and Contribution During Course of Study
In most cases, patients as participants had demonstrated and reported positive treatment
effects in response to each intervention immediately subsequent to its delivery and for both arms
of the study. However, the carry-over of treatment effects into retaining an adherence feature for
maintaining an independently and regularly performed or unsupervised home exercise program
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(HEP) remains a classic problem in rehabilitation medicine. While therapeutic exercise has been
shown to reduce pain and increase function in patients with chronic low back pain, it has also
been shown that up to 70% of patients do not engage in prescribed home exercise (Beinart,
Goodchild, Weinman, Ayis, & Godfrey, 2013). Additional barriers to adherence to home
exercise programs have included boredom, questionable effectiveness, complexity and the
overall burden of exercises in terms of time, effort and expectation (Palazzo et al., 2016).
Furthermore, physiotherapists/physical therapists need to understand more about the complex
factors influencing patients' adherence to prescribed home exercise to tailor their exercise
interventions more effectively and to support patients to better self-manage. Sub-factors cited for
improved adherence have included greater health locus of control, supervision, participation in
an exercise program, and participation in a general behavior change program incorporating
motivational strategies (Beinart et al., 2013).
Adherence to Intervention Training Intent, Home Program, and Medication List
In this study, these adherence and support factors were made aware to the patients, but
only monitored to the best of my ability in terms of time and resources. It was generally beyond
the scope of the research design and administrative resource to monitor and confirm these
variables regarding specific parameters for adherence, other than through return visit "verbal
self-reports," and through the anticipated written completion of graded activity and medication
logs, both of which were within themselves also an adherence issue, with only minimal
completion between participants and clinicians.
However, based on clinician discussions and interviews, it can be estimated that 30% of
the control group (CSB/MCE group) remained likely adherent to actual performance of core
stabilization/motor control home exercise program, and 70% likely adherent to simply
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understanding and applying the principles. For the experimental group, it can likewise be
estimated that 70% of participants were attentive to actively incorporating VRB3/Feldenkrais
Movement principles into their daily activities, and with both groups advancing the extent and
duration of their graded activity concomitantly. While some patients enrolled in the study had
reported either decreasing their pain medication or abstaining from continued medication use in
both arms of the study, the tracking of such data was unfortunately inconsistent, with more time
required and invested in actually being devoted to delivering the interventions themselves.
Participant Attrition, Priming Effects, and the Contribution of Intent to Treat
Patients in both groups were originally intended to receive a total of 12 sessions to
include (a) provisions for two highly differentiated methods for qualitative sensory-motor and
activity entrainment (CSB vs VRB3) in Phase I, and being subsequently applied in combination
with either (b) a supervised exercise intervention (MCE) or a movement therapy intervention
(FM) as components for both Phase II and Phase III, thus, all compositional as a combined
aggregate of continuity within each total intervention for each group. For both groups, roughly
2/3 of participants (N=10 for the control group and N=11 for the experimental group) completed
the entire intervention (Phase I – III). However, the remaining 1/3 of participants (N=5) for the
control group and (N=4) for the experimental group completed only the Phase I preliminary
component of the study before dropping out. Participant attrition was thus essentially similar for
both groups.
In this study, all results were included for data analysis and review based on accrued
principle and precedence in clinical research trials to accommodate the intention-to-treat effect.
“Intention to treat” is a strategy for the analysis of randomized controlled trials that compares
patients in the groups to which they were originally randomly assigned. This is generally
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interpreted as including all patients, regardless of whether they actually satisfied the treatment
goals and/or subsequent withdrawal or deviation from the protocol (Hollis & Campbell, 1999).
In other words, in an intention to treat population, none of the patient’s data are excluded,
and everyone who is randomized in the trial is part of the trial regardless of whether he or she
completes the trial. Randomized clinical trials analyzed by the intention-to-treat approach are
purported to provide for more unbiased comparisons among the treatment groups. In addition,
the inclusion of an intention to treat sampling methodology for data analysis also provides for
information about the potential effects of a treatment category as a whole, rather than on
attempting to isolate the potential effects of specific treatment. All participants (n=15) for each
group thus made proportionate contributions to the total data set (n=30) with respect to each
intervention’s qualitative type and for statistical analysis of total outcome as an aggregate of the
combined, integrative approaches for each group’s comparative outcome.
Comparison of Study Results to Data Attained from Previous Studies
A previous comparable study conducted by a respectable team of internationally cited
investigators, though not previously known during the implementation phase of this study, was
newly referenced in the more recently updated Literature Review chapter of this document being
published as: “Effect of Motor Control Exercises Versus Graded Activity in Patients with
Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial” by Macedo et al. in 2012.
Again, it is important to disclose that my review for this study was actually discovered after the
original formulation of my design parameters for the current study, and within only two weeks of
finalizing the data collection and just prior to conducting the statistical analysis. By having a
comparable study design as a similar kind of benchmark or yardstick for cross-comparing the
results of the current study, especially one that applied the same Core Stabilization/Motor
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Control Exercise model as a corresponding control group to an alternate treatment intervention
(to Graded Activity), with their latter approach comparison also being a sub-component of
mutual treatment orientation for both groups in the current study, I are thereby able to now
compare the outcomes from the current study retrospectively to the data sets and outcome results
that were attained from their previously published study.
Again, by their using a selection of essentially identical (a) treatment outcome measures,
(b) the same allocation for number of treatment sessions (12), and finally (c) the same timeframes for administering the comparative interventions (eight weeks) and as a similar framework
of parameters and measurement tools used for all other prior core stabilization/motor control
treatment efficacy studies that were reviewed, it serves as an appropriate model reference for
comparing the outcome results of this RCT study. As previously cited, the results accrued from
the larger-scale, multi-site study (N=172; Macedo et al., 2012) had demonstrated "no difference"
between Graded Activity (GA) and Motor Control Exercises (MCE) on symptoms, perceived
disability, and function outcomes for CNSLBP. The results from their study are cross-compared
with results from this study in Table 21.
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Table 21
Comparing Current Study Results with previously published 2012 Data and MICD Scores
A.
Measurement Scales
for
Comparative Efficacy in CNSLBP
Pre/Post Time Frames for Treatment
Outcomes
and the mean average difference between
groups
VAS
Baseline
(0-10)
8 weeks
(VRB3 & FM)
Mean Scores
(2016)
Control Group
(CSB/MCE)
Mean Score
(2016)
Graded Activity
+
Motor Control
5.60
6.10
2.00
3.00
4.10
4.7
2.6
2.0
Baseline
11.40
12.40
11.30
8 weeks
3.91
8.56
7.75
Maughan &
Lewis 2010
Mean Difference
7.49
3.84
3.55
Baseline
3.33
3.93
3.65
8 weeks
7.08
5.26
5.70
Mean Difference
3.75
1.33
2.05
Baseline
160.00
85.01
N/A
8 weeks
198.58
106.69
N/A
Mean Percent
Difference (%)
80%
0.79%
N/A
Baseline
8.545
21.865
N/A
Interval of
2.4
5 points
PSFS
Timed Total
for average
Absolute
Endurance
(in seconds)
B.
MCID
(GA + MCE)
Combined Mean
(2012)
6.07
Mean Difference
RMBQ
(0-24)
Experimental
Group
2.0 points
30% change
Flexion/Extension
Endurance Ratios
for Improving the
Balance of
Trunk Control
8 weeks
Magnitude
of
Difference
* 1.398
7.147
* 17.197
4.668
N/A
NA
*A ratio of <
1.5 is
indicative of
more
balanced
control
between
flexors &
extensors
(McGill,200
3)
(Sobie,
2016)
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*Note. (a) Pre-Post Mean Intervention scores and differences from experimental (VRB3 & FM)
and control (CSB/MCE) groups at eight weeks as compared to post-intervention graded activity
and motor control exercises (GA & MCE) combined average outcomes and differences from the
2012 PT Journal CNSLBP study by Macedo et al. (2012) after eight weeks; and (b) All
differences between mean scores compared to list of minimal clinically important differences
(MCID) in scores for clinical outcomes for CNSLBP as cited by Maughan and Lewis
(2010).*The ratio scores for unbalanced flexion/extension endurance from McGill (2003) are
adjusted and modified from threshold of <1.0 to < 1.5 to more closely represent a CNSLBP
population.
From this compilation of multiple data sets and minimally important clinical difference
(MICD) guideline sets, it can be seen that the experimental (VRB3 & FM) group outperformed
both the current control (CSB/MCE) group and the aggregate data from the combined Graded
Activity (GA) and Motor Control Exercise (MCE) quasi-control, historical groups by average
means of difference across all comparative measures - constituting a factor of almost two-fold.
Furthermore, all experimental (VRB3 & FM) group measures of mean difference for
improvement from baseline (start of study) to eight weeks (at post-treatment) had exceeded the
benchmarks for minimal clinically important difference (MCID); whereas all respective control
group measures of mean difference for improvement (whether current control group or historical
larger-scale group) either "just met" or "fell short" of achieving a clinically significant effect size
for response to treatment. This is again by itself, significant.
Implications of Study Findings for Treatment of CNSLBP
Perhaps the most broadly intriguing and far-reaching implication that can be stated from
the total outcome of this original and current comparative efficacy study is the fact that not only
did the experimental group demonstrate consistently superior results as compared to the control
group and its related historical comparative subset, but that it did so through the acquisition of
largely non-conventional observational considerations and through implementation and
discovery of entirely new categories for treatment intervention. These stand in stark contrast to
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the usual biomedical, bio-psychosocial, and other physical rehabilitation approaches commonly
in use as well as remaining quite variant from other usual complementary, alternative, and
integrative models of approach that are already stylistic in current everyday practice and in
common prescriptive use for applications intended to resolve the continuing, perplexing, and
troublesome problem of chronic non-specific low back pain (CNSLBP) and its associated
continued movement impairments and disabilities.
Most notably, the experimental group’s intervention is uniquely distinguished by the fact
that there was never any overt attention nor treatment modality intention being directed or
applied to:
Muscles, muscle groups, the naming of muscles, nor of treating, strengthening,
stretching, nor of training of muscles of any kind; nor for implicating any of its
associations to pathologically deficient structures including ligaments, tendons,
tendinosis, discs, cartilage, bursae, plica, nerve roots, fascial restriction, myofascial
trigger points, soft tissue inflammation, deep tissue scaring, capsular impingement,
neurovascular entrapment, arthritic degeneration, stenosis, subluxation; and
without none of these ever being characterized as being either symptomatic, nor for being
symptom causing nor symptom provoking. All of which is an ironic departure from usual culprits
in "musculoskeletal and structural medicine."
Thus, the key and important feature about the experimental group intervention was that
its superior outcome did not seem to depend upon nor rely upon the localized treatment of
particular anatomical regions that are specific to the diagnostic category of "low back pain"
itself, nor for being directly applied to perceived areas of involvement (i.e., of specific lumbar
spine segments) directly. In other words, within the experimental group, the symptomatic parts
and regions were decisively and distinctively avoided and not treated directly, and yet, this group
improved more and performed better for all outcome measures in and throughout the current
study.
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One possible rationale for this difference is to consider that “when patients and clinicians
pay attention to parts, the parts themselves get reinforced and become further and automatically
conditioned into mutually consensual and attentional dominance” (i.e., the painful parts or
regional areas persist in the attentional field). Whereas
When patients and clinicians pay attention to parts as relational components within a
functional context, then the parts self-organize into global functions to the extent that the
usual isolated attention - being usually given to symptomatic parts (i.e., to painful parts)
- will dominate less.
In my opinion, this intended design feature for the experimental group, of designing and
applying an experience-based "treatment condition" that emphasized and targeted only the
asymptomatic and normative areas of highest bone density that are involved in proportionate
action with each other, and for purposes of improving a more supportive framework and
organization for the integration of disrupted body schema acuity, and in conjunction with
developing an inter-systemic quality of movement distribution, and finally, being also
proportionate for improvement of movement dexterity in cases of CNSLBP, has strong
implications (if not also some necessarily strong provocations for producing cognitive
dissonance among clinicians). Implications for questioning the existing and dominant structural
determinism models that use structurally-specific diagnostic criteria to guide their treatment
methods, and to have them reconsider their thinking - and actions - when it comes to treating
chronic musculoskeletal conditions wherein the originating structural rationale or pathologic
validation for continuing such treatments have long since expired.
These more "tangible" structural pathology assumptions, being more known or more
favored in lieu of recognizing less tangible, but nonetheless clinically significant central
neuroplasticity changes that have transpired as implicit patterns over time, have permeated
medical, physical therapy, chiropractic, and massage therapy and bodywork practices for quite
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some time. Modern neuroscience and known changes in the cortical representation of the body
now imply that the "parts themselves may not the continuing cause," but that instead perhaps a
more valid contributor to chronic pain is the "misrepresentation of parts being in dysfunctional
inter-regional relationship - relative to their desired enlistment for movement tasks in an
incessantly persistent gravitational environment," and in relationship to "disrupted perceptual
sustenance of ‘whole self’ in everyday action" – as an inter-systemic and dynamic relationship
factor that matters so much more than the mere "strengthening, stretching, or training, or
injecting of muscle tissue."
Quite remarkably different, the VRB3/FM approach fosters a direction, which supports
and educates healthy cognitions that err more toward adopting the anatomy of possibility (i.e.,
reinforcing conditions for what’s potentially right with the person). This, in lieu of the usual
biomedical bias of diagnosing and explaining a disconcerting framework for automatically
reinforcing the anatomy of pathology (i.e., what’s wrong with the person), with resultant, but
unintended, dissociative and protective cognitions for mediating perceived threats being both
implicitly and limbic-ally associated toward perseverating the continued state of chronic, nonresolving musculoskeletal pain responses under continued conditions, wherein such structural
determinants can no longer provide a basis for reasonable or supported causation.
Physical Therapy’s Regression to the Mean
The real and observational conceptual phenomenon of "arrival and regression toward a
commonly shared central tendency" can trace its modern roots for linguistic classification to the
late 19th century since the publication of "Regression towards Mediocrity in Hereditary Stature"
(Galton, 1886). The geneticist, Sir Francis Galton, had observed that extreme characteristics
(e.g., height) in parents are not passed on completely to their offspring. Rather, the
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characteristics in the offspring regress towards a mediocre point (a point which has since been
identified as the mean). In much the same manner, the depth and breadth of intensive educational
content from physical therapy academic curricula has become subjected to similar phenomena.
Despite extensive training in applied neuroscience, the necessarily complex activities involving
recovery from musculoskeletal injury have remained almost exclusively to the domain of "tissuespecific exercise physiology principles" – with greater primacy for generalized strengthening,
range of motion, and endurance training, creating little applied practicum difference between
medically-trained physical therapists and fitness industry-trained personal trainers.
Virtually anyone in the United States could conduct an informal survey of outpatient
physical therapy practices in their local community, and limit their sample to orthopedics, and
"sports and spine" sports medicine type specialties as the most frequent and dominant type. Next
they could sample and view the offerings and equipment and exercise techniques at specialty
fitness centers emphasizing personalized attention from certified trainers, and again, find little to
no discernible difference. In many ways, the usual routines being primarily derived through the
fitness industry have stifled and corrupted the full potential for greater variation and
individuation within the most common of physical therapy outpatient practice settings. Humans
are not necessarily exercise machines, and nor should physical therapy outpatient clinics become
reduced to mostly exercise machines as a usual high volume, one-size-fits-all, customary practice
standard.
It is not that physical fitness is not important. It is just that it should not be used as a firstline defense intervention for persons debilitated with chronic pain who will likely remain fearful
and/or rightfully suspicious that callisthenic-like activities from gym class (which can be done
anywhere) and/or through their already existing associated memories from prior experiences
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with usual and ubiquitous fitness activities would cause them to arrive at some personal
conclusion to determine that "these have not really helped me in the past…I didn’t enjoy them
…so why pursue them?" Notwithstanding, more recent trends for commonly prescribed and
commonly endorsed "Rehabilitative Yoga" and "Rehabilitative Pilates" routines still also fall
under the usual fitness paradigm by virtue of their prescribing pre-conceived ideals for "proper
movement" and regimens for explicitly "moving correctly" in accordance with an externally
authoritative standard - to the extent that they negate the opportunities for more varied
developmental and organic explorations being permitted for implicitly affirming the uniquely
individualized internal variations that are more the properties and domains of body schema-based
awareness and cognitive practices – like the Feldenkrais Method®.
Historically, and for too long, outpatient orthopedic-based physical therapy has embraced
the structural biomechanical model to the exclusion of central representational processes more
akin toward hemispheric entrainment within the virtual body; essentially ignoring any specific
viable role for the brain or central nervous system in usual movement training – with exception
of cases involving a structural and pathological lesion being found within the brain itself, such as
a CVA malformation, tumor history, or an infarct, being co-morbid to a presenting orthopedic
condition.
Yet, seeing that the effectiveness of traditional physical therapy exercise programs being
combined with the recent addition/inclusion of psychological and cognitive behavioral therapies
(CBT) has been found to be superior to outcomes obtained from usual general practitioner care.
These nonetheless also occur with only marginal and modest outcomes at best. This shortfall
leads generation to consider a role and a place for the investigation of new treatment options that
permit the sensory inclusion for novel and interactive competing stimuli, a competing cognition-
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attention frame, and a further frame of reference for endorsing a competing behavioral set that
involves the concurrent entrainment of movement and enhanced perception as necessary
functions for human improvement, but not necessarily within the usual and repeated context of
exercise per se. A more ideal perception frame for usual physical therapy practice, particularly
for therapeutic reframing and having multi-modal opportunities for the brain to re-sample itself,
is depicted in Figure 71.
Figure 71. Expanding the Scope for a More Multi-Factorial PT Practice. A more ideal frame of
perceptual reference for interactive physical therapy practice as originally presented by Lois
Gifford and updated by Zachery Cupples. Public use of image and concept is courtesy of
https://zaccupples.com/tag/louis-gifford/. Used with Permission.
The Preferred Future of PT Practice
Metaphorically, it can be said that traditional outpatient physical therapy, having a
dominant orientation in catering toward orthopedics and sports medicine populations, has for too
long become a "performance-based gymnasium" being heavily influenced by the fitness industry,
body conformity, and an expectant familiarity to exercise specificity with stricter adherence
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toward pre-conceived routines. In contrast, very little exists in current practice that accounts for
multi-modal development of neuroplasticity-based, cortical representation, and body-schemabased movement models, which instead point toward creating and constructing a "processoriented sensorium" being informed through human developmental learning models and
embodied experiences, variations of sensory acuity and movement dexterity themes (as with
fugues occurring in musical compositions), and a re-conceptualization of attention toward
novelty and novel configurations for movement sequences serving as an opportunity to safely flee
from ordinary accustomed exploration and in to extraordinary insightful play. These manners of
activities, and the comparisons between them, thereby become "phenomenologically reperceived" from an internal constitutive reference being extremely unique to each individual in
lieu of being "prescriptively pre-conceived" from a universally prescribed or externalized or
authoritative paradigm; otherwise more conventionally known and more routinely experienced as
"one size fit all."
Patients could be better oriented toward greater functional improvement by having their
prescribing practitioners in fact state that
There’s a big difference in being explicitly told or shown what to do toward achieving
‘proper performance’ (i.e., from an external standard), and implicitly discovering and
experiencing an attenuation of multiple versions of yourself, in terms of who you are and
how you move, through exploration, attention, and perceptual experiments being wholly
inclusive of navigating your whole self;
versus the non-nuanced un-accommodation: “Here’s the corrective exercise sheet. Do these three
times per day, and make sure you do them properly.” As the current study has now made
significant contribution toward developing a reproducible protocol for revamping a multi-modal,
body schema-based orientation and approaching internalizing the patient’s experience, and for
demonstrating a more rapid capacity for change in working body schema becoming evident
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through concurrent improvements in both sensory acuity accuracy and corresponding motor
dexterity execution, a working model for sensory-motor learning has been developed to
speculate about some possible underlying mechanisms that likely occur during actual
implementation of the current study’s VRB3/FM treatment protocol.
A New Intervention Model for the Systemic Adjustment of Working Body Schema
Based on theoretical and computational studies, it has been suggested that the central
nervous system (CNS) internally simulates the behavior of the motor system in planning, control,
and learning. “Such an internal "forward" model is a representation of the motor system that uses
the current state of the motor system and motor command to predict the next state” (Wolpert &
Miall, 1996). The internal model for sensorimotor integration/efference copy schematic (as
originally formatted by Wolpert, Ghahramani, and Jordan (1995), as depicted in Figure 72,
describes the cognitive pretext of a "feed-forward internal model" for simultaneously conducting
and monitoring the accomplishment of a routine motor task, but only within the established feedforward context as it is already happening in real time; and being modified only by sensory
discrepancies and re-afferent feedback to in order to adjust the motor processes accordingly.
Figure 72. Internal Model for Sensorimotor Integration and Efference Copy for Motor Control.
*Though conceptually developed by Wolpert et al. (1995) and Wolpert and Miall (1996),
original work on applied schematic refers back to Michelle Costanzo, as seen in Theory of Motor
Control UMD Spring 2008. Licensed under the Creative Commons Attribution-Share Alike 3.0
Unported. Used with Permission.
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However, as a pre-habituated and pre-established forward model, it stereotypically "does
what it most predictably does" reflecting a continuous cycle of 1st order change. There is no
actual lasting change to the intrinsic or pre-programmed aspects of the forward model itself. It
just does what it does. In the larger Sensory-Motor Learning and "Working Body Schema/MultiModal Information Processing Model" (as schematically depicted in Figure 73 and again in
larger scale in Appendix W), this forward ‘intrinsic’ model becomes a contingency sub-set of a
larger dynamic process occurring both within and between an organism and its environment
(whether actual environment or an imagined/virtual one) and is herein embedded within the
schematic diagram being depicted as "an inner loop."
The inner loop, as an existing model, depicts only 1st order change as an individual’s
primary model of habitual approach to everyday action. It is largely constitutive of an
individual’s historical development, and pertains to the redundant processing within already
existing feed-forward models of working body schema. It includes familiar actions of sensory
anticipation and expectant routines, being constituted by habituated spatial-temporal pathways of
existing cortical and sensory-motor representation; being only exhibitive and/or behaviorally
demonstrative of merely "going through the motions" with ample repetition, but little in the way
of variation. Thereby, essentially reinforcing the current conditions in terms of quality and
distribution of movement, even if “performed correctly” according to the supervising therapists’
external (and therefore explicit) standard. This model, in fact, parallels the modus operandi of
many, if not most, traditional physical therapy "therapeutic exercise" prescriptions and routines
being carried-out and billed under the American Medical Association’s classified Current
Procedural Terminology (CPT) codes for Therapeutic Exercise (97110) and Kinetic Activity
(97530).
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In corollary contrast, the "outer loop" (in direct parallel for routing and representing the
VRB3/FM experimental intervention) depicts 2nd order change as a secondary competing model
toward non-habitual and implicit learning. This loop presents a divergent developmental model
by introducing and invoking parallel, but re-entrant qualities for novel processing of sensory
information; a compelling and competing stimulus that is essentially disruptive of the established
processing that is occurring within existing feed-forward models of working body schema
inductive and facilitative of exploratory actions and sensory re-adjustment. All this toward
cognitive re-appraisal becoming generative of deconstructing and reconstructing spatial-temporal
pathways that are involved in cortical and sensory-motor reorganization toward greater
efficiency through neuroplasticity-based mechanisms. The co-conditioning and invocation of
these processes are purported to result in the emergence of completely new actions (i.e., 2nd order
change) with much variation and differentiation toward newly-constructive cognitions for
working body schema and new habituations for new movement qualities that ultimately seek
toward integration into the existing "feed-forward models" of action, thereby, leading to
selection plasticity and change within the primary model; thus, altering the original movement
qualities of the pre-existing internal feed-forward model itself.
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Figure 73. Information Processing Model for working Body Schema during VRB3 FM Rx.
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Through this schematic, I can perhaps conclude that unless there is significant change
within a person’s internal model for the sensory representation of effective action becoming
expressed and confirmed through new attention to new movement, then there is really no change
at all.
Study Limitation
It was rather daunting to be a first-time principal investigator, combined with being a
clinical practice owner of one main practice location and two side-practice locations, during a
time of tumultuous change in the administration of health care services becoming rampant with
added time-consuming pre-authorization requirements and multiple additional documentation
steps becoming required for hopeful assurance of third party coverages for usual and customary
services and reimbursement. Also factored into my overwhelm was having to contract an
independent study research coordinator, numerous physical therapy interns, and additional office
staff as well as qualified physical therapists for administering the control group arm intervention.
Yet, by having a neutral staff member hired-on to collect and aggregate data, safeguards were
thereby in place to minimize the registration effect of confirmation bias by keeping data bases
separate from all clinical staff and for both arms of the study.
Deficiencies in the Monitoring of Adherence to Home Practice and Repetition
As was previously stated, it was generally beyond the scope of the research design and
administrative resources to monitor and confirm for adherences to graded activity and home
exercise programs via the ongoing verification of written completion of graded activity and
medication logs - both of which were within themselves also an adherence issue – occurring at
only very minimal completion between both participants and clinicians. This proves problematic
in making attempts toward generalizing the total effects of any behavioral intervention and
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contributes toward weakening the influences of the independent variables being cited as the
predominant causative attributions for inducing change in either or both groups.
Moreover, while mere exposure to differentiating and prominent or conspicuous
conditions can be of sufficient perturbation to elicit new selections for the stimulus-response
driven processing of neuroplasticity pathways, and to alter their corresponding qualities for
engaging and sustaining more prolonged and heightened states of attention, and also for
attentional association to memory, it also appears that adequate repetition for the internalization
of such processing is necessary for creating more lasting neuroplastic changes (i.e., sustained
learning, new habits, and long-term potentiation). Thus, this is an area where again, more careful
and intensive monitoring of participants’ abilities to integrate and generalize their new skills into
the contexts of daily life and/or to adhere to practicing the principals involved in their rehearsal
of new sensory-motor learning skills, would have been an improved contribution for solidifying
an assertion for implicating the results of the study.
Nonetheless, the study results indicate that there is attribution of difference coming from
somewhere, and I assert that mere exposure to discerning and qualitative mechanisms of
difference can be enough of an impetus to create widespread difference through systemic and
neuroplastic change, and that these appear to be of greater magnitude in the experimental group
in comparison to the control group under similarly controlled conditions. In particular, if they are
contextually meaningful and personally relevant to either the history and development of the
disorder, or to the current state of the organism.
Limitation of only an implied CBT and Pain Neuroscience Education Component
A second area of limitation in the current study concerned a lack of formal integration of
a duly and appropriately administered cognitive behavioral and pain neuroscience education
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program as a corresponding co-intervention during and throughout the course of the study.
Despite good intentions to include a psychological component through the administration of the
FABQ as a stratified random assignment strategy, and to make initial mention of safety
assurances and behavioral re-attributions being embedded within the consent form, this study
could have integrated a more formalized co-intervention beyond just outlining suggestion
expectancy references in the consent form. This, through otherwise only implementing ongoing
situational-mediational adjustments for re-directing some mistaken cognitions that occurred, but
only in real time, and during the usual course of movement re-training and for either arm of the
study.
As is a good point brought-up by O’Sullivan, Dankaerts, O’Sullivan, and O’Sullivan
(2015) in their cognitive functional therapy and chronic low back pain article published in
Physical Therapy, “simply combining conservative interventions (physical and psychosocial) in
a nonintegrated manner may be no more effective than either intervention provided in isolation”
(p. 1485). My research team is now aware of emerging "out of the box" integrative programs to
formally teach pain neuroscience education principles to physical therapy patients, and to
implement actual cognitive behavioral exercises as part of a more integrative program. These can
be considered for successive trials.
Complexity of Experimental Group Intervention
It is only fair to state that the VRB3/FM is a comparatively complex intervention, likely
requiring an advanced apprenticeship in order to effectively learn its nuances and applications
for this study to become replicated. Notwithstanding, there is likely probable and
presuppositional concern about the cognitive capacity of patients to actually learn and integrate
an understanding and application of these principles and activities into daily life. A common
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refrain or rebuttal from Feldenkrais® trainers is to state that "the design and the functional
organization of the nervous system can be quite a bit smarter than any pre-conceived ideas or
prescriptive dictates that we may have about them" as another way of saying "trust the process."
Correspondingly, within the current study and clinical experience, it has been observed and
found that these processes can automatically and implicitly work, and perhaps at a more
substantial sub-cortical level of interlinked neurological and reflexive processing; regardless of
the superficial or interpretive attempts for understanding or logically explaining them within the
constraints of conceptual, yet comparatively limited language.
As a matter of difference with many other interventions that continue to attempt "simple
solutions," it otherwise seems that systemic complexity is a realistically important feature to
include toward the development of newer treatment interventions, and especially for situations
pertaining to chronic pain, since simple solutions for complex problems rarely seem to
sustainably work over time. As Albert Einstein, had said: “Make everything as simple as
possible, but not simpler.”
Sample Size and Generalizability
Finally, a relatively small sample size for statistical power (N=30) and the confident
generalizability of results to be ascribed to larger populations of patients with CNSLBP is one
added limitation of inference from this study. It is particularly unknown to really know if a larger
sample size would result in greater effect size to better substantiate the outcomes of the
experimental group; or if it would show a regressive comparative improvement by larger
statistical comparison. Provisions for these are to be discussed in the next section.
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Recommendations for Future Research and Practice
Numerous citations and reviews within this dissertation have called for more innovative
treatment approaches based on motor imagery, neuroplasticity, sense of movement, virtual
reality applications, and even for the inclusion of vestibular sensory mechanisms (Mast et al.,
2014), in addition to the revamping of usual and current physical and psychological approaches.
Some final thoughts and recommendations in consideration for future studies and for re-thinking
usual clinical practice are discussed below.
Enlisting Help from Larger Research Universities. fMRI Anyone?
There is much to be gained from greater collaboration between literature- and
publication-based research institutions and various independent clinicians working in the
trenches of actual and daily clinical practice. Each domain has its own knowledge base, and its
ranges of unique – yet segregated - experience are such that neither can be independently nor
wholly known without real-time meetings and discussions for future collaboration. Of utmost
interest to the current study is to consider that if the changes being revealed through the
VRB3/FM intervention protocol for CNSLBP can be readily seen in the body and its response
behaviors, can they also be correspondingly verified in the mind-brain via the implementation of
fMRI. Furthermore, could pathways and mechanisms being constitutive of verifiable
neuroplasticity-based changes also be elucidated and discerned?
Indeed, single session pain neuroscience education/CBT has demonstrated decreased coactivation of pain and fear related cortical pathways encountered during the abdominal draw-in
maneuver (Moseley, 2005). In the differential processing of motor imagery fMRI study by Vrana
et al. (2015), the chronic LBP patients exhibited significantly excessive motor imagery-driven
functional connectivity indicating diffuse and non-specific changes becoming maladaptive to the
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usual processing of sensory-motor and kinesthetic information. It is therefore inferred that
excessive functional connectivity on fMRI between brain areas has strong correlation toward
revealing excesses in non-essential and parafunctional movement patterns when usual tasks are
imagined under originating pre-intervention conditions. A corollary hypothesis originating out of
the current study, thereby suggests that a mental simulation of action using a post VRB3/FM
intervention movement strategy (of hips-pelvis-legs opposite head, while negating specific
attention to lumbar areas) would demonstrate more effective and efficient use of primary S1 and
M1 areas upon their simulation of the same motor-imagery driven functional tasks that were used
in their 2015 study.
In the other fMRI study by Hashmi et al. (2013), results indicated that those who
transitioned to CNSLBP demonstrated a spatiotemporal dynamical reorganization of brain
activity, during which the representation of back pain over time had gradually shifted away from
sensory and nociceptive cortical regions and instead manifested toward engaging larger scale,
greater morphologic localization throughout emotional and limbic structures. What remains an
inquiry from a therapeutic neuroplasticity interventionist standpoint is to determine whether this
transition can be reversed-especially toward soamto-sensory and sense of ownership aspects of
neuronal information processing, and with less emotional-limbic divestment from body-self.
Again, I believe that the unique entrainment affordances being made available through a
VRB3/FM intervention and its correspondences for the perceptual enhancement of body schema
acuity (i.e., of localization dimensions) and of movement strategy (i.e., of dexterity relationships
for functional interaction between self and environment) would demonstrate a shift of activity
predominance back toward more normative levels of S1 and M1.
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Indeed, it has been shown through other fMRI studies in patients with CNSLBP that
diminished brain regions implicated in disrupted pain modulation, including the dorsolateral prefrontal cortex (DLPFC) and the anterior cingulate cortex (ACC), had reduced grey matter, but
after successful treatment for resolving the pain, the grey matter reductions were subsequently
reversed so that the affected brain regions were again re-normalized in size (Seminowicz et al.,
2011). In more specific regard to somatotopic representation in the primary somatosensory
cortex (S1), it has been found that patients with CNSLBP demonstrate a 2.5 cm shift of the grey
matter volume, and that these changes correlate with chronicity of symptoms (Apkarian et al.,
2004; Flor et al., 1997; Schmidt-Wilcke et al., 2006).
In similar fMRI study conditions where S1 somatotopic reorganization has been the
target of sensory discriminative training and visual distortion interventions (as with graded motor
imagery and mirror box therapies), there is purported evidence for the renormalization of S1
representation occurring in association with the attenuation of pain; and that some, but not all, of
the morphological changes in brain grey matter volume and changes in cortical somatotopic
distribution return to those seen in normal healthy subjects when pain is eliminated (Pelletier et
al., 2015a). These studies support the idea that a multi-modal approach that is coherent and
consistent with neuroplasticity-based learning principles, and with regard toward improving a
body-schema basis of entrainment for the enhancement of both functional sensory acuity and
proportionate motor dexterity – as are seen within the VRB3/FM protocol - are worthy of
continued and collaborative investigation.
The Advent and Recommendation of New Testing Instruments and Interventional Tools
The tools and instruments used in the current study have attained long-standing and
historical precedence for demonstrating their cross-comparative value upon successive re-
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implementation; in terms of their valid and reliable acceptance and correlations to a broad variety
of clinical research trials involving the ongoing assessment and treatment of outcomes for the
recurring problem of low back pain, especially CNSLBP. However, as new fMRI study findings
and their corresponding neuroplasticity mechanisms begin to unfold, and as new clinical
observations begin to implicate the role of disrupted sensation-perception in movement, some
new and innovative assessment scales and physical performance testing considerations are now
discussed for future or pending applications being re-applied to the design of the current study.
The multidimensional assessment of interoceptive awareness (MAIA). The
Multidimensional Assessment of Interoceptive Awareness (MAIA) is a qualitative and
quantitative scale that brings due consideration to the idea that mind-body interactions can
invariably produce signaling mechanisms that can emanate from anywhere in the body in
accordance with varied events, circumstances, constitutions, and coping styles, but are much
more varied in terms of their arising into detectable consciousness awareness for different
populations of individuals. The idea that awareness of interoceptive responses can prospectively
play a major role in the treatment and prognosis of chronic pain and other kinds of problems was
based upon purported benefits of somatic therapies such as Tai Chi, Mindfulness Meditation,
Yogic practice, and the Feldenkrais Method® being used to self-manage them. The instrument
was developed under the collaborative leadership of Dr. Wolf Mehling of The Osher Center for
Integrative Medicine, Institute for Health and Aging, University of California, San Francisco, in
conjunction with area practitioners in various relevant fields of mindfulness meditation, martial
arts, yoga, mind-body medicine, and somatic arts and movement practices.
The resulting 32-item multidimensional instrument was designed to measure key aspects
of mind-body interaction with eight key feature concepts for categorical assessment being
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comprised, developed and cross-validated with area individuals who were practicing mind-body
therapies. The key areas include:
●
Noticing – awareness of uncomfortable, comfortable, and neutral body sensations;
●
Not Distracting – tendency not to ignore or distract oneself from sensations of pain or
discomfort;
●
Not Worrying – tendency not to worry or feel emotional distress with sensations of pain
or discomfort;
●
Attention Regulation – ability to sustain and control attention to body sensation;
●
Emotional Awareness – awareness of the connection between body sensations and
emotional states;
●
Self-Regulation – ability to regulate psychological distress by attention to body
sensations;
●
Body Listening – active listening to the body for insight; and
●
Trusting – experiences of one’s body as safe and trustworthy.
The instrument was next applied and cross-validated to assess self-reported interoceptive
awareness in primary care patients with past or current low back pain. It was then concluded that
The MAIA may be useful in assessing changes in aspects of interoceptive awareness and in
exploring the mechanism of action in trials of mind-body interventions in pain patients. The
MAIA may therefore help in answering some important qualitative questions for the quantitative
assessment of dominant states and learned skills that individuals may be actually experiencing
and applying, while undergoing mind–body therapies (Mehling et al., 2013).
However, a more recent study for comparative interventions for chronic nonspecific low
back pain again found no difference between using a Feldnkrais Method trained physiotherapist
®
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supervising a Feldenkrais-based Awareness through Movement class program and a customary
®
course of treatment using an educational back school. The method also included the VAS-PAIN
scales, the McGill Pain Questionnaire (MPQ), the Waddel Disability Index, and the Short Form36 Health Survey (SF-36), but this time also using the MAIA instrument, and found no
difference between using a Feldnkrais Method trained physiotherapist supervising a
®
Feldenkrais-based Awareness through Movement class program and a customary course of
®
treatment using an educational back school. Its authors furthermore state that “the efficacy of the
two approaches are the same” and that "a physician can recommend a body-mind rehabilitation
approach, such as the Feldenkrais Method®, or an educational and rehabilitation program, such
as a Back School to the patient, based on individual needs." In addition, "the two rehabilitation
approaches are equally as effective in improving interoceptive awareness" (Paolucci et al., 2016).
The content and design of this study, and how it was performed, has yet to be reviewed.
However, it can be stated with confidence that prior trial failures arising from many of the other
studies that have been conducted and reviewed and claiming to use “The Feldenkrais Method®,”
as an intervention from the literature review section of this document, have in retrospective
review been determined to not be truly representative of delivering the full method of the work in
terms of selection, content allocation, accuracy, presence or depth. By comparative contrast, and
within the context of the current dissertation study, there is much broader and intensive
methodological detail being more accurately correspondent to actual Feldenkrais Method®
applications, including the provisions for including at least some form of hands-on Functional
Integration sessions. By these tokens, the research design is in direct contrast to much of what
®
has been historically presented by research teams who have purportedly not had adequate
apprenticeship nor full developmental exposure to the field.
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The Fremantle Back Awareness Questionnaire (FreBAQ). Seeing that several new
dimensions of evidence are now suggesting that body perception is altered in people with chronic
back pain, and that disturbed body perception appears to be more strongly associated with pain
intensity than psychological distress, fear avoidance beliefs, or pressure sensitivity-based
thresholds as objective measures for lumbar spine sensitivity, Wand et al. of the School of
Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia,
Australia, sought to develop and test new and intriguing questionnaire. In particular, a
questionnaire for assessing the implications of how maladaptive perceptual awareness,
specifically related to the back, might contribute to the pain experience as well as to serve as a
guide for the clinical targeting of treatment. Now cited as the Fremantle Back Awareness
Questionnaire (FreBAQ), it is a simple questionnaire comprising of nine items listed below:
1. My back feels as though it is not part of the rest of my body;
2. I need to focus all my attention on my back to make it move the way I want it to;
3. I feel as if my back sometimes moves involuntarily, without my control;
4. When performing everyday tasks, I don’t know how much my back is moving;
5. When performing everyday tasks, I am not sure exactly what position my back is in;
6. I can’t perceive the exact outline of my back;
7. My back feels like it is enlarged (swollen);
8. My back feels like it has shrunk; and
9. My back feels lopsided (asymmetrical).
In their pilot sample of patients with chronic low back pain, N=251 respondents
completed the questionnaire and were cross-compared with their taking a battery of clinical tests
to discover that their level of altered self-perception was positively correlated with pain intensity
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and disability as well as showing associations with psychological distress, pain catastrophizing,
fear avoidance beliefs, and lumbar pressure pain threshold (Wand et al., 2016). Knowing that
phenomenological perception is a central and appreciative feature of the Feldenkrais Method®,
and now having correlates to other more common clinical determinants that theoretically account
for the persistence and recurrence of chronic low back pain, this questionnaire needs and
deserves further collaboration and integration into a future replication of the current study.
Global perceived effect (GPE) scale. The Global Perceived Effect (GPE) scale is a
single item scale that simply reflects the patient’s global impression of change by asking them to
rate how much their overall condition has improved or deteriorated since some predefined time
point. It has been recommended for use as a simple outcome measure for chronic pain trials more
specifically asking: “How do you describe your situation today compared to when you first
entered the study?” As a numerical 11-point scale with scores ranging from –5 (“much worse”)
to +5 (“completely recovered”) through zero (“no change”), the patient simply rates where they
are now in comparison to where they were before. Higher scores indicate higher clinical
recovery. Intra-class correlation coefficient values of 0.90-0.99 indicate excellent test-retest
reliability, and construct validity of the Global Perceived Effect (GPE) scale is also an excellent
consideration for patients with musculoskeletal disorders (Kamper et al., 2010).
The systemic and global effects emerging from Feldenkrais Method® sessions, while
most often diffusely pleasurable and energetically revitalizing in terms of sensory experience, are
also quite often uniquely intangible for placing into exact words or existing language constructs.
So one benefit of administering a GPE scale is its ability to accept such generalized outcomes in
more global terms, and yet convert and quantify their composite effects into a more tangible
subset for measurable difference.
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Alternatives to fitness-based physical performance testing. While the use of the timed
endurance tests by McGill did reveal some interesting discoveries about imbalanced ratio
comparisons emerging between the control group and the experimental group at postintervention, there were also added concerns and reservations about using this set of performance
measures from a naturalistic perspective. For one, the required body planking and trunk postures
involved for sustained position holding appear contextually dependent, para-functional, and
overly rigidified to the meet the expectant biomechanical appeal of a North American fitnessstylized paradigm in lieu of achieving a more naturalistic, curvilinear, or organic one that is more
true to everyday living in an average, but not necessarily athletic population.
Another problem encountered, but equally distributed between groups, was my having to
accommodate and adjust for unexpected orthopedic co-morbidities (such as shoulder
impingement and rotator cuff problems that essentially precluded certain participants from
having easy access for attaining a propped-arm side-planking test on the involved side) causing
me to either abandon the test for that side, or to make hesitant modifications. Knowing that
patients with CNSLBP can exhibit much uniform difficulty with everyday transitional
movements, such as simply rising up from a chair in the waiting room, or in having to walk
rapidly at a moment’s notice, or in having to change directions suddenly, it is therefore
recommended that future studies begin with test comparing more functionally relevant ADL
metrics, including the "Timed Up and Go" (TUG) test.
The TUG simply involves having the patient begin in their accustomed seated positon in
a standardized sized chair. When the therapist or examiner says, “Go” they stand up, walk
exactly three meters, turn around and return to chair – to which the therapist or examiner stops
the timer. While this test was originally developed to assess senior citizens and persons with
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neurological disorders to assess dynamic balance and fall risk, it should also equally apply as a
valid measure for motor control and trunk control for populations of patients with CNSLBP.
From the perspective of the current study, it is hypothesized that a CSE/MCE group (cocontracting their core) would perform slower and more laboriously (by inadvertently working
against themselves) whereas the VRB3/FM group would more likely perform faster and better
given their corresponding awareness of body schema and movement trajectories becoming more
elaborated between "pelvis-hips-legs" (as most proximal to center of gravity) opposite that of
"head" (detection of change in center of gravity), giving primary functional emphasis for
transferring up and forward over base of support in lieu of a decontextualized agenda for
"contracting core muscles to protect the back" while getting-up.
Similarly, implementing the use of either a Dynamic Gait Index (DGI) or the Functional
Gait Assessment (FGA) would additionally provide a comparative basis for demonstrating both
qualitative and quantitative functional changes in coordination and trunk control within the
context of gait; though, originally intended for patients and populations with neurological
balance problems and/or vestibular disorders to assess for posture stability, unsteadiness, and fall
risks during dynamic and varied walking tasks. Again, it is hypothesized that a VRB3/FM group
would more likely perform better, given that it has been clinically observed that the most
stereotypically antalgic gait patterns that are commonly observed in patients with CNSLBP
(retracted holding of pelvis backward on corresponding side of symptoms, non-reciprocating
contra-lateral torso movements, top-down compressive momentum substitutive strategies,
limping and lurching, decreased caudal propulsion, etc.) have all demonstrated clinical and
transferrable improvement subsequent to Feldenkrais-based interventions. Again, the range of
variations of head positional movements (e.g., vertical nodding contrasted by horizontal
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rotation), speed, direction, level versus unlevel surfaces, pivoting and turning, stepping over an
obstacle, eyes closed versus eyes open, narrow versus broad base of support, ambulating
(walking) backwards – being cited as primary components of the DGI/FGA testing battery – are
certainly more dependent on body schema acuity and motion trajectory than on the pre-activation
of core muscles.
With the development of ADPM gait and balance tracker sensor technology being worn
on the body in conjunction with Mobility Lab software (Horak & Mancini, 2013), and then
possibly combining them with additional metrics that can be generated through the Microsoft®
Kinect skeletal avatar tracking system (as cited by Trost et al., 2015), there is no limit as to how
far the linkages between body schema acuity, movement trajectories, and changes in movement
compensation being dictated by pain-avoidance experiences can be further explored toward the
continued development of new and novel validations for treatment intervention.
Applications of Non-Muscular Paradigms in Clinical Practice
Since the original and seminal works of Sir Charles Scott Sherrington (1857-1952) and
his discovery of the synaptic reflex arc in the regulation of agonist-antagonist relationships in
muscle, he furthermore expressed his theory that the nervous system acts as the coordinator of
various parts of the body and that the reflexes are the simplest expressions of the interactive
action of the nervous system; thus, enabling the entire body to function toward one definite end
at a time, and by most typically being goal-directive and purposive via the establishment of
postural reflexes and their dependence on the anti-gravity stretch reflexes being traced the
afferent stimulus of the proprioceptive end organs (Pearce, 2004).
Seeing the broader picture, the overall function as it exists beyond its implied causative
or constitutive mechanisms, it seems that the prior emphasis of clinicians and therapists has been
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to treat the muscle whether through strengthening or stretching, massaging or injecting, or
through more discrete training via the mechanisms of SEMG and/or through multi-channel
electromyography biofeedback, or through pressure unit biofeedback (PBU). But suppose the
motor end-plate or individual constellation of motor units embedded within muscle tissue is only
a microcosm, an isolated mechanism being only a mere constituent to more global or meaningful
movement function, and therefore being the wrong effector or wrong end-organ from which to
focus clinical attention?
The perspective of Feldenkrais® practitioners is such that perception and action are cooptive and always on, and that the environmental task co-configurations are selective of
proactive internal adjustments that impart the corresponding selection of an action pattern and
movement trajectory, as a different kind of externalized reflex arc, thereby contributing to an
expansive and radical conclusion that "total skeletal organization" (being a more direct and
interactively operating interface in the immediate task environment) is more truly the correct
effector or end-organ; thus, from which to better focus clinical attention, and in correspondence
with the much important context of being more effectively and personally relevant toward better
engaging the macrocosm-specific tasks of everyday and distributive life.
So while muscles themselves must truly remain as the prime movers of individual bones,
they should not to be erroneously construed as the prime organizers for the whole body being
engaged in constructive and purposeful action, nor for the complete coordination of movement
trajectories by virtue of simple assumption or additive expansion becoming isolated to either
compartmentalized "origin -insertion" muscle labeling, nor through the focal activity of its motor
end-plates. Therefore, in the application of movement improvement for humans, it is perhaps now
time to newly emphasize more current and novel intervention approaches being geared toward
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developing a constructive coordination of bones in lieu of traditional over-focusing upon the
coordination of muscles, and perhaps most importantly, have these also become meaningful to
the person.
From his book, Neuromuscular Rehabilitation in Manual and Physical Therapies:
Principles to Practice (2010), noted instructor, author, and reviewer Dr. Eyal Lederman, himself
a practicing osteopath and research professor, brings forth a more expansive alternative to the
usual and accustomed structural or pathologic model by instead proposing a co-created process
model - an inclusive approach that encompasses the cognitive, behavioral, and
neurophysiological dimensions of the individual. These features are summarized in his book via
a compilation of five review recommendations that had corresponded well with the experimental
intervention process that was already conducted within the scope of the current study:
1. Co-create an environment in which an individual’s recovery (including underlying
biological processes of healing, neural regulation and repair) can be optimized.
2. Intervention should be all-inclusive…a combination of cognitive, psychosocial,
behavioral, organizational, and neuromuscular approaches.
3. In the neurological dimension, there is no injury specific rehabilitation. A body area is
rehabilitated according to its function rather than to the underlying pathology. Think
movement --not muscles.
4. Neuromuscular Rehabilitation is a creative process --it is not protocol based. It is more
about facilitating cognitive-sensory-motor processes by providing a stimulating and
variations-rich environment. Recovery of motor control is an intrinsic person / nervoussystem process. It is not just exercising.
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5. Specific exercises or techniques that aim to target, strengthen or "correct" a specific
region, a muscle group, or other structural deviation are unlikely to contribute to
recovery, nor serve as a means to improve daily function. This approach does not work.
Forget about it (Lederman, 2010a, p. 171).
Summary and Conclusions
This single-blind, randomized controlled efficacy trial (RCT) successfully compared a
Body Schema Acuity Training protocol using a newly applied, newly developed low-cost
technology (Virtual Reality Bones™/VRB3) with a respected complementary-alternative,
movement and manual therapy, neuroplasticity-based educational intervention (The Feldenkrais
Method® as FM) against the most commonly accepted approach being utilized within current and
conventional physical therapy practice settings (Core Stabilization Biofeedback Training and
Graded Motor Control Exercises - as CSB/MCE). This was conducted for treating the
widespread problem of chronic non-specific low back pain (CNSLBP), and determined that there
is greater clinical efficacy being demonstrated by the new and novel VRB3/FM experimental
intervention across all measures.
Both the control group and the experimental group clearly benefitted from concurrent
awareness of using non-habitual body sensations and respective movement experiences. In
particular, becoming self-perpetuated as an implicit vs. explicit strategy that permitted a change
in behavior such that they could begin to learn to "move differently" and with less pain, reduced
disability, greater function, and longer sustained endurance activity times during all phases of
treatment, as they were encountered throughout the study, but albeit much more so for the
experimental group than the control group.
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While current and existing standards in usual outpatient physical therapy and
rehabilitation practice continues to implicate the entrainment of core musculature, more
specifically the Transverse Abdominis (TrA) and the Lumbar Multifidus (LM), as a primary
method for "control of stability" and "balance of action" around the spine, other implications
inherent to low back function have also been stated. Specifically, to imply that “the back is a
major highway of function in the body,” and that “when the spine loses its intrinsic support,
problems ensue” and furthermore, that “being ‘upright’ involves a delicate balance in achieving
effective control around the ‘line’ of gravitational force, and that one of the many challenges in
the developmental progression is to strike the balance between too little and too much control”
(Key, 2010).
As a way to achieve and maintain such optimal control for dynamic balance between
spinal stability and spinal mobility, and as a stated outcome from the current study, I maintain
that a VRB3/FM-based approach emphasizing proportionate skeletal density and the awareness
of vestibular pathways for "hips-pelvis-legs" opposite "head" (as both a corresponding
experiential and cognitive framework for the enhancement and development of sensory acuity
and working body schema) is more thoroughly effective than a CSB/MCE approach emphasizing
an isolated muscle control strategy for the optimal coordination of trunk tone occurring within
the daily activities of patients presenting and recovering from CNSLBP. A total synopsis of body
schema acuity and its role for functionally referencing a continuous impression for navigating
the world of perception and action through both a combination of multi-modal and multi-sensory
awareness (i.e., sensory acuity) and its concurrent cognitive cultivation for the coordination of
effective and proportionate action (i.e., motor learning and motor dexterity) is summarized by
virtual reality applied researcher Giuseppe Riva (1998) below:
336
The physical world, including the body, is not given directly in our experience but
is inferred through observation and critical reasoning. This means that, in everyday life,
the representation of the body plays an important and often under-rated role. It is
interesting to note that this representation is not limited to visual "images", i.e. pictures in
one's head of one's body, but comprises the schema of all sensory input internally and
externally derived—lived experiences processed and represented within a maturing
psychic apparatus. In fact, this "virtual body" is not static but changes as a part of the
dynamic process by which we try to organize and understand our experiences.
The body schema is a model/representation of one's own body that constitutes a standard
against which postures and body movements are (continuously) judged. This
representation can be considered the result of comparisons and integrations at the cortical
(and sub-cortical) level of past sensory experiences (postural, tactile, visual, kinesthetic
and vestibular) with current sensations. This gives rise to an almost completely
unconscious "plastic" reference model that makes it possible to move easily in space and
to recognize the parts of one's own body in all situations. (p. 2)
In conclusion, body schema based somatic education interventions, like the
(VRB3)™/FeldenkraisMethod® protocol, appear more efficacious, and deserve further
investigation. Furthermore, I propose and postulate the ‘prospective axiom’ that the cultivation
of widespread functional improvements in mobility and function in terms of sensory acuity and
motor dexterity are the "inverse relationship" and antithesis of perceptual distortions and
dysfunctions involved in maintaining the conditions of continuation for producing widespread
and continuing perception of chronic pain.
I also propose that some form of introductory "Body Schema Acuity Training" should be
instituted as a vital pre-requisite pre-emptive to all usual care and exercise prescription in
outpatient physical therapy and rehabilitation settings, even to the extent that it deserves its own
CPT procedural code as an entirely new and separate classification for treatment. I also
commend that such skill levels have potentially high effect size and portable value and should
therefore be compensated at much higher levels of fair reimbursement. This is therefore a broadsweeping and far-reaching premise to be tested and expanded through multiple future studies and
337
designs. Future multi-site RCT studies with larger sample sizes for statistical power are therefore
both recommended and warranted.
338
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363
APPENDICES
Appendix A: Recruitment Flyer for Pierce County Medical Society
RECRUITMENT FLYER FOR PIERCE COUNTY MEDICAL SOCIETY
364
Appendix B: Pilot Study & Combined Conference Announcement Postcards
PILOT STUDY & COMBINED CONFERENCE ANNOUNCEMENT POSTCARDS
365
Appendix C: Copy of Published Pilot Study Abstract
COPY OF PUBLISED PILOT STUDY ABSTRACT
Note: Reprinted from Scientific Abstracts Global Adv Health Med. 2013;2 (Suppl): P03.03. DOI:
10.7453/gahmj.2013.097CP. P03.03. Reprinted with permission via Pub Med Central.
366
Appendix D: Enrollment Invitation & Clinical Research Announcement Postcard
ENROLLMENT INVITATION & CLINICAL RESEARCH ANNOUNCEMENT POSTCARD
367
368
Appendix E: Website Landing Pages for Alliant Spine Project, LTD
WEBSITE LANDING PAGES FOR ALLIANT SPINE PROJECT, LTD.
369
Appendix F: Definitions of Terms and Acronyms
DEFINITIONS OF TERMS AND ACRONYMS
AAPB – Association for Applied Psychophysiology and Biofeedback
ACC – Anterior Cingulate Cortex of brain
ADL – Activities of Daily Living
AROM – Active Range of Motion of limbs, torso and body segments
ASIS – Anterior Superior Iliac Spine – a bony landmark of superficial protuberance
ATM – Awareness Through Movement® – teaching through sequential movement progressions
using The Feldenkrais Method®, and usually conducted in group classes
A-P – Anterior Posterior direction, i.e. from front to back
BSDA – Basic Statistics and Data Analysis
CAM – Complementary and Alternative Medicine or Therapies
CARF – Commission on Accreditation of Rehabilitation Facilities
CBT – Cognitive Behavioral Therapy
CEUs – Continuing Education Units for Allied Health Professionals
CLBP – Chronic Low Back Pain
CNSLBP – Chronic Non-Specific Low Back Pain
CME – Continuing Medical Education
CMT – Cognitive Manual Therapy – Hands-on manipulation and manual therapy techniques
with intent to alter body perception away from ‘correction of illness pathology’ and forward
toward ‘the development of functional possibility’ with particular emphasis upon exploiting the
inherent robustness of skeletal density contiguities being distributed throughout the entire body
as a whole.
370
CSB – Core Stabilization Biofeedback to train specificity for TrA and LM muscle recruitment
CSB/MCE – Core Stabilization Biofeedback being combined with Motor Control Exercises
DGI – Dynamic Gait Index assessment procedure
DLPFC – Dorsal Lateral Pre-Frontal Cortex of brain
EMG – Electromyography
FABQ – Fear Avoidance Belief Questionnaire
FABQw – Fear Avoidance Belief Questionnaire work sub-scale
FABQpa – Fear Avoidance Belief Questionnaire physical activity sub-scale
FC – Functional Connectivity on fMRI of brain
FGA – Functional Gait Assessment
FGNA – Feldenkrais Guild of North America
FI – Functional Integration® – Hands-on individualized teaching using The Feldenkrais Method®
FM – The Feldenkrais Method® and/or Feldenkrais-based movements
F/E Ratios – Flexion/Extension Ratios of Trunk Endurance Testing (McGill, 2006)
HEP – Home Exercise Program as prescribed by Physical Therapists
HIPPA – Health Insurance Portability and Accountability Act – protection of privacy
IC – Insular Cortex of brain (Insula)
ICC – Intraclass Correlation Coefficient – statistical comparison for test-retest reliability
IFF – International Feldenkrais Federation
I-S Joint – Ilia-Sacral Joint – as referenced from anterior to posterior aspect of pelvis
LBP – Low Back Pain
LM – Lumbar Multifidus – a primary lumbar intersegmental stabilizer muscle group
M 1 – Primary Motor Cortex of brain
371
MCE – Motor Control Exercises
MI – Motor Imagery
MIC – Minimally Important Change
MCID – Minimal Clinically Important Difference (Maughan & Lewis, 2010)
NCCAM – National Centers for Complementary and Alternative Medicine
NIH – National Institutes of Health
NRS – Numerical Rating Scale
NSAID’s – Non-Steroidal Anti-Inflammatory Drugs
NSCSP – Non-specific Chronic Spine Pain; being essentially synonymous with CNSLBP
OBMT – Object Based Mental Transformations
OSI-R – Occupational Stress Inventory – Revised
PBU – Pressure Biofeedback Unit – such as The Stabilizer
TM
PNE – Pain Neuroscience Education
PSFS – Patient Specific Functional Scale
PFC – Pre-Frontal Cortex of brain
PT – Physical Therapy and/or Physical Therapist
PTA – Physical Therapy Assistant
R – R Statistical Software Package
RCT – Randomized Controlled Trial
RMDQ – Roland-Morris Disability Questionnaire
S 1 – Primary Sensory Cortex of brain
SCC’s – Semi-Circular Canals – as a major component of vestibular apparatus in inner ear
S-EMG – Surface Electromyography
372
S-I Joint – Sacral-Iliac Joint
SIJ – also referencing the Sacral-Iliac Joint
SMA – Supplemental Motor Areas of brain
STG – Superior Temporal Gyrus of brain
STS – Superior Temporal Sulcus of brain
TNSE – Therapeutic Neuroscience Education – as a cognitive behavioral approach to pain
treatment
TUG – Timed “Up and Go” Test – for sit, stand and walking balance
TrA – Transverse Abdominis – as a primary muscle for core stabilization activation in LBP
VAS – Visual Analog Scale
VAS-PAIN – Visual Analog Scale for the Measurement of Pain perception
VR – Virtual Reality
VRB1 – Virtual Reality Bones via use of life-scaled skeletal anatomical models
VRB2 – ‘Vital Relationships Between’ via the conduction of force transmissions through skeletal
density pathways and deep articular joints using the proportionality of thirds method
VRB3 – Vestibular Representation of the Body via using the three-dimensional coordinates of the
semi-circular canals/vestibular apparatus as a metaphor and physiological mechanism for the
representation of space.
(VRB3) – Virtual Reality Bones as the trademark entity compositional of VRB1, VRB2, and
TM
TM
VRB3.
VRB3/FM – Combined Virtual Reality Bones and Feldenkrais-based movements for the
entrainment of body schema acuity and effective action.
373
Appendix G: Copy of FABQ for Stratified Randomization
COPY OF FABQ FOR STRATIFIED RANDOMIZATION
374
375
Appendix H: Copy of VAS-PAIN / Numerical Rating Scale
COPY OF VAS-PAIN / NUMERICAL RATING SCALE
a).
b).
________________________________________________________________________
Appendix H: Gray-scale copy of a). VAS-PAIN numerical rating scale...being further
embellished via b). with added multimodal qualifiers from which to have participants visually requantify their pain intensity during repeat administration throughout the course of the study.
376
Appendix I: Copy of RMDQ
COPY OF RMDQ
377
Appendix J: Copy of PSFS
COPY OF PSFS
378
Appendix K: Copy of Timed Endurance Testing Assessment Form
COPY OF TIMED ENDURANCE TESTING ASSESSMENT FORM
Procedure and Assessment Form used for McGill’s Timed Endurance Tests
379
Appendix L: Photo of Stabilizer Biofeedback (PBU) Device
PHOTO OF STABILIZER BIO-FEEDBACK (PBU) DEVICE
TM
The Stabilizer™ Pressure Bio-feedback Unit (by Chattanooga Group, Hixon, TN, USA
380
Appendix M: Photo of Full Scale Skeletal Models & Source References
PHOTO OF FULL SCALE SKELETAL MODELS & SOURCE REFERENCES
Inner ear vestibular model from Anatomical Chart Company, Chicago, IL
Full-scaled life-sized intact skeleton model from Anatomical Chart Company, Chicago, IL.
Dis-articulated segmental models from Sawbones® Pacific Research Labs, Vashon Island, WA.
381
Appendix N: Sources Used for Control Group Intervention (MCE)
SOURCES USED FOR CONTROL GROUP INTERVENTION (MCE)
Hanney, W. (2009). Interactive CD-ROM. On Testing, facilitation training for core stability
[CD]. Rockledge: Theralinx.
Jemmett, R. (2003). Spinal Stabilization: The New Science of Back Pain (2nd ed.). Halifax, Nova
Scotia, Canada: Libris Hubris Publishing
382
Appendix O: Sources Used for Experimental Group Intervention (FM)
SOURCES USED FOR EXPERIMENTAL GROUP INTERVENTION (FM)
Individual selections derived from Feldenkrais ATM® movement sequences & programs:
Alon, R. (1993a). Lesson 3: Long Side, Short Side - Relief Through Enhancing Personal Tendency. On Free
Your Back, Disc Two [CD]. Portland, OR: The Feldenkrais Guild.
Alon, R. (1993b). Lesson 5: Healing a Hip Through Support Reflex. On Free Your Back, Disc Two [CD].
Portland, OR: The Feldenkrais Guild.
Beringer, Elizabeth (1999). The Back and Lungs Support Each Other 1. On Embodied Learning: Focus on the
Hips and Low Back with Elizabeth Beringer, Disc Two [CD]. Berkley, CA: Feldenkrais Resources.
383
Bowes, Deborah (2006). Lesson 5: Dynamic sitting with the right and left sides of the pelvic floor. On Pelvic
Health and Awareness with Deborah Bowes PT CFT, Disc Three. San Francisco, CA: Learning for Health.
Browne, G. (2006b). Lesson #15: Wishbone. On A Manual Therapist’s Guide to Movement CD Collection,
Disc 6 [CD]. Bellevue, WA: Movement Matters, Inc.
Reese, M. (1995, 2005). Lesson 7: Breathing Movements. On The Feldenkrais Method: Moving Out of Pain
with Mark Reese, Disc Four [CD]. Berkeley, CA: Feldenkrais Resources.
Reese, M. (1995, 2005). Lesson 8: Pelvis Clock. On The Feldenkrais Method: Moving Out of Pain with Mark
Reese, Disc Five [CD]. Berkeley, CA: Feldenkrais Resources.
VanHowten, D. (1997). Clarify Your Heart and Lungs in Your Self Image. On Seeking Our Healing
Memories, Disc 2 [CD]. Santa Fe, NM: Life Impressions Institute.
Wildman, F. (2006). Lesson 1: Folding Your Body With Ease - Activating the Abdominal Flexors. On The
Intelligent Body Feldenkrais Program, Volume I [CD]. Berkeley, CA: Feldenkrais Movement Institute.
Wildman, F. (2006). Lesson 2: Bending Backwards - Activating the Back Extensors. On The Intelligent Body
Feldenkrais Program, Volume I [CD]. Berkeley, CA: Feldenkrais Movement Institute.
Wildman, F. (2006). Lesson 2: The Magic Spinal Twist. On The Intelligent Body Feldenkrais Program,
Volume II [CD]. Berkeley, CA: Feldenkrais Movement Institute.
Wildman, F. (2006). Lesson 4: Lengthening the Sides - Experiencing Yourself in 3D. On The Intelligent Body
Feldenkrais Program, Volume II [CD]. Berkeley, CA: Feldenkrais Movement Institute.
Wildman, F. (2006). Lesson 5: Baby Alligator. On The Intelligent Body Feldenkrais Program, Volume I [CD].
Berkeley, CA: Feldenkrais Movement Institute.
Zemach-Bersin, D & Reese, M. (1999). Track 2: Lengthening the Spine. On Relaxercise, Disc Two [CD].
Berkeley, CA: Feldenkrais Resources.
384
Appendix P: Side-by-Side Listing of Treatment Interventions Between Groups
SIDE-BY-SIDE LISTING OF TREATMENT INTERVENTIONS BETWEEN GROUPS
(Appendix P is one continuum and continues the next six pages)
385
TABLE 2.1 Treatment Interventions administered 2x’s/week for 1st 2 Weeks
PHASE I: Core Initiation Stabilization Training
Visit#
1
vs.
Rx Session Theme for VRB3/FM Group
Perform Axial Loading from head to foot to
discern Stance Leg
(also include classic ‘Lay on Back’ Body Scan)
Test ‘Hip Axis’ Awareness & use Femur Model as
Visual-Tactile overlay to manually perform ‘Virtual
Hip Replacement’ Rx
Rx Session Detail for CSB/MCE Group
Perform AROM Spine Screen, Detect
Motion Instabilities
Test & Manually Instruct Pelvis Floor + TrA
isolated contraction
1st
wk
2
1st wk
3
2nd
wk
SUPINE Position – Stabilizer
Biofeedback Device to continue practicing
“Draw-In” Maneuver 10 sets x10 s. Repeat in
varied positions: Sitting Standing, Q-Ped,
Kneel. Maintain Lumbar at N with Heel Slides,
Clam Shells, Arm Raises. (Hanney, 2009, pp.
28-36; Jemmett, 2003, pp. 43-48).
Test & manually Instruct Lumbar
Multifidus (LM) activation from back
side to match anterior Draw-In Maneuver
from previous session.
PRONE POSITION – Stabilizer
Biofeedback Device for combined Pelvis
Floor, TrA, and Multifidus Activation.
Use combined ‘Draw-in Manuever’ to
decrease to 9 mmHg Hold for 10 sx10
repetitions. Repeat in varied position:
Supine, Sitting, Standing, Q-Ped.
Continue to hold with heel slides and arm
raises. (Hanney, 2009, pp. 42-44;
Jemmett, 2003, p. 49)
Joint Acuity/Skeletal Density Imagery
SUPINE POSITION – Multi-sensory integration of
Hip Axis in A-P pelvic rock (12-6) from feet, eyes,
see-saw breathing, bell hands. UE RadialStyloid/Spine of Scapulae to spiral reach across
midline to enable Lateral Pelvis Clock (9-3). Compare
Perpendicular Hip Axis Schema in Sit, Stand, & Gait.
Reframing ‘small of back’ SI Joint as new ‘top of leg’ from
a deep anterior ilia-sacral perspective via outlining the inner
ring-ridge of the pectineal line – as area of highest bone
density.
SUPINE POSITION (but also referencing from
Lumbar posterior back side) ‘connecting the dots’ via a hand
placement for leveraging ‘core density’ of deep anterior iliasacral joint as a base reference for distending pelvis and hips
in a caudal rotation extension direction (to a 2/3 range) via
semi-bridged leg and foot placement, countered by head
rotation opposite to 1/3 range. Proportioned Movement via
Head Lift (HODORF)
Early Static Core Control Stabilization
Progression with Activities involving ‘Keeping
One Foot On the Ground.’
SUPINE POSITION – Stabilizer
Biofeedback Device for Training the Corset
Action of TrA and LM with Leg
Loading/Alternating Leg Lifts(i.e. Dying Bug
Exercise) Maintain 40 mmHg. 10 Secondsx10
reps for each leg. Repeat progression in
Standing, Bridging, Sit, Q-ped, and Prone
(Hanney, 2009, pp. 45-48; Jemmett, 2003, pp.
64, 74-75, 77-78)
Anatomical Imagery for outlining the interface of a
chain of pedicles juxtaposed with costovertebral/transverse-costal joints as an interplay
between bone density stability along the thoracic
spine, and distributive selections for ribcage mobility.
SUPINE into SIDE-LYING transition via semibridge into contralateral elevation of costal arm
reaching via support prop reference under posteriorlateral ilia onto trochanter. Compare Contralateral
Weight Shift Alignments in Sit & Stand.
386
4
2nd
wk
Early Dynamic Core Stabilization Progression
for Balance & Stability on Unstable Surfaces
(Balls and Rollers)
Model emphasis of semi-circular canal orientations of
inner ear) vestibular apparatus) is demonstrated as a
reference for 3 dimensions of balance in space and is
encases within each Temporal Bone – the densest bone
in the body.
Side-Lying/Sitting Position –
Stabilizer Biofeedback Device for training
stability of position and preventing lateral
pelvic tilt (maintaining 40 mmHg.) during
side-lying Hip abduction-adduction.
Progress to repeat in Sit Balance activities on
standard-sized Gymnastic Physio Ball for Side
Shift to Side, A-P; Lateral and Supine
Bridging activities. (Hanney, 2009, pp. 49-52;
Jemmett, 2003, pp. 51-53, 65-72)
SIDE TILTS of Head position are correlated
to side-shifts in pelvis laterality and weight
distribution into sit bones while straddled over
contoured bolster roll with leg positions lateralized.
Posterior-lateral hip axis is correlated with trunk rotation
and the plane of orientation for each vestibular organ.
387
TABLE 2.2 Treatment Interventions administered 2x’s/week for 2nd 2 Weeks
Phase II:
Visit#
5
rd
3
wk
6
rd
3
wk
7
th
4
wk
Static into Dynamic Core Stability
Rx Session Detail for Lumbar MCE
Group
Integrative Training - Static Middle
Layer Exercises
Exercises with Floor and Physioball
vs.
Expanding Sense of Ground Support
Rx Session Theme for FM Group
Feldenkrais® Functional Integration®
Session:
PRONE POSITION STABILIZATION
Front bridging and planking activities on
floor over forearms & elbows and over
Physio ball and Foam Rollers. Maintain
TrA & LM Draw-in Maneuver at all
times. Hold for 10 Seconds X 10 Reps for
each exercise. (Jemmett, 2003, pp. 8083).
Pre-Crawl Multi-plane Developmental
Variations
emphasizing 3 spatial directions for Pelvis-hip
and Head: Emphasis on translational ground
support as a constant
PRONE-SEMIPRONE POSTION on Firm FI
Table or Floor:
1) Lumbar-Pelvic-Hip - Frog Leg
Integration in 3-D
2) Fixed Arm Distal selecting
Contralateral Frog Leg with MidThoracic Flexion-Rotation Synergy
Integrative Training - Static Middle
Layer Exercises
Exercises with Floor and Physio ball
Feldenkrais® Awareness Through
Movement® Session:
SUPINE POSITION STABILIZATION
Back bridging and planking activities on
floor and over Physio-ball – but this time
permitting both feet to rise up and leave
ground support ( i.e. Leg Lift). Maintain
Pre-set of TrA & LM Draw-in Maneuver
and Hold for 10 Seconds X 10 Reps for
each exercise. (Jemmett, 2003, pp. 75-76,
78, 79).
SUPINE Learning position generalized into
Standing diagonal flexion, walking, and Stepup activities:
·Emphasis on Diagonal LQ Rotation opposite
Head
< Pelvis Wishbone Coupled with Diagonal
Leg lift
< Stand-Diagonal Flexion with external
broom stick / dowel rod serving as ‘External
Spine Column’
Integrative Training - Static Middle
Layer Exercises
Exercises with Floor and Physio ball
Feldenkrais® Awareness Through
Movement® Session:
SIDE-LYING, STANDING & SITTING
POSITION STABILIZATION Sidebridging from knees and planking
activities, Single Leg Standing on Floor,
Sit and Side-lay on Physio-ball – this time
with 5 lb wt on lifted ankle.(Maintain Preset Draw-in maneuver at all times . Hold
for 10 Seconds X 10 Reps for each
exercise. (Jemmett, 2003, pp. 83, 64-69).
SIDE-LYING transitions into SIDE-SITTING
on either FI Table or Floor. LOP-SIDED
SITTING on Firm Chair.
Emphasis on Side-lengthening LQ Torso to
Head:
·Elevated Hip Hiking into Leg Reach to Stand
/ Walk
· Contralateral Weight Shift in Unbalanced Sit
Stand via varied ground support of chair, table
or floor
388
8
4th wk
Integrative Training - Static Middle Layer
Exercises
Exercises with Floor and Physio ball
QUADRUPED & KNEELING POSITION
STABILIZATION and planking stability
activities on Floor and over Physio ball.
Maintain Pre-set TrA and LM Draw-in
maneuver at all times . Hold for 10 Seconds X
10 Reps for each exercise. (Hanney, 2009, pp.
46-50; Jemmett, 2003, pp. 70, 86-87)
Feldenkrais® Functional Integration® Session:
QUADRUPED 4-POINTs POSITION: Kneeling
over FI Table (KOT) FI ® Session differentiating
into lateral weight shift & translational elevation of
leg climbing, crossing midline, and proportionate
nested contour of limb segment self-referencing.
Transition ½ Kneel horizon scouting, arm spiraling,
½ Squat, and Re-visiting Chair Sitting.
389
TABLE 2.3 Treatment Interventions administered 1x/week for Last 4 Weeks
Phase III: Dynamic into Reactive-Rhythmic Stability vs Reciprocating Variations of Movement
Trajectories
Visit#
9
5th
wk
10
6th
wk
11
7th
wk
Rx Session Detail for Lumbar MCE Group
Dynamic-Reactive Core Motor Control
Exercise
SUPINE POSITION for Integrative and
Advanced Training with diminished support of
over Physio balls and Foam Rollers for leg lifts
and back bridging while maintaining
NEUTRALCORE STABILITY. Progress to
applied manual resistance and perturbation via
Rhythmic Stabilization and Clam Shell
activities, (Hanney, 2009, pp. 49-53; Jemmett,
2003, pp. 74-79) then add 5 lb. free weight and
elastic band resistance. (p. Hanney, 2009, pp.
45-46; Jemmett, 2003, p. 109)
Rx Session Themes for FM Group
Feldenkrais® Awareness Though Movement®
Session
Counter-Reciprocation of Support and Movement
involves comparative relationships of trajectories
at L vs R , Front & Back, and Upper vs Lower
Body:
( Rotation / Counter-Rotation Motion Themes)
·Magic Spine Twist / Imagined Balance Beam
( Coordination of Flexors & Extensors in SUPINE)
AND
Carriage of Head affects state of the
Musculature
(PRONE LEG TILT swivel Side to Side mobilizes
the Torso)
Dynamic-Reactive Core Motor Control
Exercise
PRONE and QUADRUPED POSITION for
Integrative and Advanced Training with
diminished support of over Physio balls
and Foam Rollers with applied counterresistance via elastic bands and motion
perturbations and emphasizing Stability of
Flexion vs. Extension. (Hanney, 2009, pp.
46-47, 49-51; Jemmett, 2003, pp. 80-83,
86-89)
Feldenkrais® Awareness Though Movement®
Session
Distribution of Movement through active pressing and
lifting , head-eye orientation, and balancing the
selection between intention, attention & activation
( Diagonal Flexion / Extension Motion Themes )
Active Mid-Thoracic Extension into Big X Diagonals
AND
Activation of Flexors into Diagonal Rib Flexion
( First Prone, then Supine before Integration to Q-ped )
Dynamic-Reactive Core Motor Control
Exercise
SIDE BRIDGE / PLANKING and SITTING
POSITION for Integrative and Advanced
Training with diminished support of over
Physio balls and applied counterresistance via elastic bands and motion
perturbations for Lateral Trunk Stability.
(Hanney, 2009, pp. 43-44, 48, 50-53;
Jemmett, 2003, pp. 84, 87, 66-69)
Feldenkrais® Awareness Though Movement®
Session
Distribution of Movement through Spatial-Temporal
Coherence and Synergy of Proportionate Control from
Isolated Part to Integrated Pattern:
(Side-bend and Side-Lift Motion Themes)
Side-lying Leg Rolling in Leg Tilting
Side-Lying Leg Lift with Arm over Head Bracketing
390
12
8th
wk
Dynamic-Reactive Core Motor Control
Exercise
BRIDGING, SQUATTING, and STANDING
POSITIONS for Integrative and Advanced
Training with diminished support of
Physio balls Elastic bands, Foam Rollers
with emphasis on REVIEW OF HOME
PROGRAM and Primary Core Stability
Principles. (Hanney, 2009, pp. 51-55;
Jemmett, 2003, pp. 85, 13-48 + Education
Posters)
Feldenkrais® Awareness Though Movement®
Session
Distribution of Resistance through Core Skeletal Density
Pathways via Sensory - Motor Selections of Optimal
Skeletal alignments in Proportion to Tosk:
(Tri-Plane Summation of Motion Themes as HEP)
Distal Extremity Platforms for Head Through Gate
AND
Tactile Acuity Surface Play for Distributive Resistance
and Selecting Full Transmission of Skeletal Contiguity
391
Appendix Q: Copies of Home Exercise Program / Graded Activity Cover Sheets
COPIES OF HOME EXERCISE PROGRAM / GRADED ACTIVITY COVER SHEEETS
(Appendix Q is one continuum and continues for the next nine pages)
392
Home Exercise Program/Graded Activity Cover Sheet
Phase I: Joint Acuity/Skeletal Density Imagery
Visit 1
1. “From your program today, practice the movement sequence and skeletal
alignment(s) that helped you to detect or visualize the inner location of your newly
discovered weight bear joints and how they dissipated stress. Include ‘laser
beam’ soft touch”.
2. “Can you sense it from a variety of ways in manners that ‘connects the dots’ from
bottom-up and through top down? Navigate and Sense it from both directions?”
3. At least once daily, follow the movement sequence that works best for one side.
Find a connection that highlights your sense of constructing an inner line through
your skeleton from that ‘standpoint’. Explore it again with slight variation for 5
times.
4. Rest before repeating same strategy on opposite side --but begin first with only
imagined movement. Then do.
5. Throughout each day, discover and attend to how awareness of these areas can
be included in daily activities as a background support for sitting, standing,
walking, etc. Be sure to maintain a flexibly aligned, softly assembled quality of
being --and not a hard focus.
6. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
393
Home Exercise Program/Graded Activity Cover Sheet
Phase I: Joint Acuity/Skeletal Density Imagery
Visit 2
1. “From your program today, practice the movement sequence and skeletal
alignment(s) that helped you to detect or visualize the inner location of your newly
discovered weight bear joints and how they dissipated stress. Include ‘laser beam’
soft touch”.
2. “Can you sense it from a variety of ways in manners that ‘connects the dots’ from
bottom-up and through top down? Navigate and Sense it from both directions?”
3. At least once daily, follow the movement sequence that works best for one side.
Find a connection that highlights your sense of constructing an inner line through
your skeleton from that ‘standpoint’. Explore it again with slight variation for 5
times.
4. Rest before repeating same strategy on opposite side --but begin first with only
imagined movement. Then do.
5. Throughout each day, discover and attend to how awareness of these areas can be
included in daily activities as a background support for sitting, standing, walking, etc.
Be sure to maintain a flexibly aligned, softly assembled quality of being --and not a
hard focus.
6. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
394
Home Exercise Program/Graded Activity Cover Sheet
Phase I: Joint Acuity/Skeletal Density Imagery
Visit 3
1. “From your program today, practice the movement sequence and skeletal
alignment(s) that helped you to detect or visualize the inner location of your newly
discovered weight bear joints and how they dissipated stress. Include ‘laser beam’
soft touch”.
2. “Can you sense it from a variety of ways in manners that ‘connects the dots’ from
bottom-up and through top down? Navigate and Sense it from both directions?”
3. At least once daily, follow the movement sequence that works best for one side.
Find a connection that highlights your sense of constructing an inner line through
your skeleton from that ‘standpoint’. Explore it again with slight variation for 5
times.
4. Rest before repeating same strategy on opposite side --but begin first with only
imagined movement. Then do.
5. Throughout each day, discover and attend to how awareness of these areas can be
included in daily activities as a background support for sitting, standing, walking, etc.
Be sure to maintain a flexibly aligned, softly assembled quality of being --and not a
hard focus.
6. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
395
Home Exercise Program/Graded Activity Cover Sheet
Phase I: Joint Acuity/Skeletal Density Imagery
Visit 4
1. “From your program today, practice the movement sequence and skeletal
alignment(s) that helped you to detect or visualize the inner location of your newly
discovered weight bear joints and how they dissipated stress. Include ‘laser beam’
soft touch”.
2. “Can you sense it from a variety of ways in manners that ‘connects the dots’ from
bottom-up and through top down? Navigate and Sense it from both directions?”
3. At least once daily, follow the movement sequence that works best for one side.
Find a connection that highlights your sense of constructing an inner line through
your skeleton from that ‘standpoint’. Explore it again with slight variation for 5
times.
4. Rest before repeating same strategy on opposite side --but begin first with only
imagined movement. Then do.
5. Throughout each day, discover and attend to how awareness of these areas can be
included in daily activities as a background support for sitting, standing, walking, etc.
Be sure to maintain a flexibly aligned, softly assembled quality of being --and not a
hard focus.
6. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
396
Home Exercise Program/Graded Activity Cover Sheet
Phase II: Expanding Sense of Ground Support
Visits 5, 6, 7, & 8
1. “From your program today, practice the movement sequence and skeletal
alignment(s) that helped you to detect or visualize the inner location of your newly
discovered weight bear joints and how they dissipated stress. Include ‘laser beam’
soft touch.”
2. “Can you sense it from a variety of ways in manners that ‘connects the dots’ from
bottom-up and through top down? Navigate and Sense it from both directions?”
3. At least once daily, follow the movement sequence that works best for one side.
Find a connection that highlights your sense of constructing an inner line through
your skeleton from that ‘standpoint’. Explore it again with slight variation for 5
times.
4. Rest before repeating same strategy on opposite side --but begin first with only
imagined movement. Then do.
5. Throughout each day, discover and attend to how awareness of these areas can be
included in daily activities as a background support for sitting, standing, walking, etc.
Be sure to maintain a flexibly aligned, softly assembled quality of being --and not a
hard focus.
6. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
397
Home Exercise Program/Graded Activity Cover Sheet
Phase III: Reciprocating Variations of Movement Trajectories
Visits 9, 10, 11, &
12
1. “From your program today, practice the movement sequence and skeletal
alignment(s) that helped you to detect or visualize the inner location of your newly
discovered weight bear joints and how they dissipated stress. Include ‘laser
beam’ soft touch.”
2. “Can you sense it from a variety of ways in manners that ‘connects the dots’ from
bottom-up and through top down? Navigate and Sense it from both directions?”
3. At least once daily, follow the movement sequence that works best for one side.
Find a connection that highlights your sense of constructing an inner line through
your skeleton from that ‘standpoint’. Explore it again with slight variation for 5
times.
4. Rest before repeating same strategy on opposite side --but begin first with only
imagined movement. Then do.
5. Throughout each day, discover and attend to how awareness of these areas can
be included in daily activities as a background support for sitting, standing,
walking, etc. Be sure to maintain a flexibly aligned, softly assembled quality of
being --and not a hard focus.
6.
As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
398
Home Exercise Program/Graded Activity Cover Sheet
Phase I: Core Initiation Stabilization Training
Visits 1, 2, 3, & 4
1. “At least once daily, practice those exercises that you feel gave you the best sense
that you were strengthening your core - and for which you were able to maintain
stability and control of your mid-section at all times”.
2. “Hold for 10 Repetitions at 10 seconds each- without losing proper form - at least
once daily.
3. Throughout the day, practice your draw-in maneuver the same way you felt it
happen when using the biofeedback device.
4. Maintain your draw-in maneuver before each progressive fitness exercise and
whenever you think something might be strenuous –so as to maintain stability and
control.
5. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
399
Home Exercise Program/Graded Activity Cover Sheet
Phase II: Static into Dynamic Core Stability
Visits 5, 6, 7, & 8
1. “At least once daily, practice those exercises that you feel gave you the best sense
that you were strengthening your core - and for which you were able to maintain
stability and control of your mid-section at all times”.
2. “Hold for 10 Repetitions at 10 seconds each- without losing proper form - at least
once daily.
3. Throughout the day, practice your draw-in maneuver the same way you felt it
happen when using the biofeedback device.
4. Maintain your draw-in maneuver before each progressive fitness exercise and
whenever you think something might be strenuous –so as to maintain stability and
control.
5. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
400
Home Exercise Program/Graded Activity Cover Sheet
Phase III: Dynamic into Reactive-Rhythmic Stability
Visits 9, 10, 11, & 12
1. “At least once daily, practice those exercises that you feel gave you the best sense
that you were strengthening your core- and for which you were able to maintain
stability and control of your mid-section at all times”.
2. “Hold for 10 Repetitions at 10 seconds each- without losing proper form - at least
once daily.
3. Throughout the day, practice your draw-in maneuver the same way you felt it
happen when using the biofeedback device.
4. Maintain your draw-in maneuver before each progressive fitness exercise and
whenever you think something might be strenuous –so as to maintain stability and
control.
5. As much as possible, get up and go somewhere, and try to spend a little bit more
time enduring the activities of daily life. If you feel like you need less medication
than normal, feel free to medicate less and experience life a bit more.
401
Appendix R: Copies of Exercise / Graded Activity Adherence Diaries + Med Lists
COPIES OF EXERCISE / GRADED ACTIVITY ADHERENCE DIARIES + MED LISTS
(Appendix R is one continuum and continues for the next six pages)
402
Graded Activity Diary – Phase I: Joint Acuity/Skeletal Density Imagery
Answer each of the following on a six-point scale: Please circle the number that best describes
your ability
All The Time = 5
Most of the Time = 4
Some of the Time = 3
Rarely or Seldom = 2
Never or Not at All = 1
Don’t really Know = 0
1.
I was able to re-construct the basic movement sequences and matching skeletal
alignment(s) that helped me to detect or visualize the inner location(s) and successive
connections of newly discovered weight bear joints and how they could pass through or
include the entirety of my skeleton from one end to the other during movement.
≥_______________≤
0 1 2 3 4 5
2.
I found that during my daily activities, I could locate my sense of joint positions at any
moment, and could adjust my balance and alignment through them for greater comfort and
support. I could also engage a broader sense of curious attention throughout the lines of
distribution within my skeleton during unfamiliar or more demanding activities.
≥_______________≤
0 1 2 3 4 5
3.
I find I can spend a little bit more time engaging the things that I used to do without early
onset of my fatigue and / or my pain worsening and stopping me from doing so.
≥_______________≤
0 1 2 3 4 5
4.
I am noticing I can get by with less medication and am reducing my frequency of use dosage
accordingly.
Medication
Dose/ frequency of intake in a day.
1
2
3
Mo
Tu
Wed
Th
Fr
Sa
Su
Dose
Dos
e
Dos
e
Dose
Dose
Dose
Dose
403
Graded Activity Diary – Phase II: Expanding Sense of Ground
Support
Answer each of the following on a six-point scale: Please circle the number that best describes
your ability
All The Time = 5
Most of the Time = 4
Some of the Time = 3
Rarely or Seldom = 2
Never or Not at All = 1
Don’t really Know = 0
1.
I was able to re-construct the basic movement sequences and matching skeletal
alignment(s) that helped me to detect or visualize the inner location(s) and successive
connections of newly discovered weight bear joints and how they could pass through or
include the entirety of my skeleton from one end to the other during movement.
≥_______________≤
0 1 2 3 4 5
2.
I found that during my daily activities, I could locate my sense of joint positions at any
moment, and could adjust my balance and alignment through them for greater comfort and
support. I could also engage a broader sense of curious attention throughout the lines of
distribution within my skeleton during unfamiliar or more demanding activities.
≥_______________≤
0 1 2 3 4 5
3.
I find I can spend a little bit more time engaging the things that I used to do without early
onset of my fatigue and / or my pain worsening and stopping me from doing so.
≥_______________≤
0 1 2 3 4 5
4.
1
2
3
I am noticing I can get by with less medication and am reducing my frequency of use dosage
accordingly.
Medication
Mo
Tu
Wed
Th
Fr
Sa
Su
Dose/ frequency of intake in a day.
Dose
Dose
Dose
Dose
Dose
Dose
Dose
404
Graded Activity Diary – Phase III: Reciprocating Variations of Movement
Trajectories
Answer each of the following on a six-point scale: Please circle the number that best describes
your ability
All The Time = 5
Most of the Time = 4
Some of the Time = 3
Rarely or Seldom = 2
Never or Not at All = 1
Don’t really Know = 0
1.
I was able to re-construct the basic movement sequences and matching skeletal
alignment(s) that helped me to detect or visualize the inner location(s) and successive
connections of newly discovered weight bear joints and how they could pass through or
include the entirety of my skeleton from one end to the other during movement.
≥_______________≤
0 1 2 3 4 5
2.
I found that during my daily activities, I could locate my sense of joint positions at any
moment, and could adjust my balance and alignment through them for greater comfort and
support. I could also engage a broader sense of curious attention throughout the lines of
distribution within my skeleton during unfamiliar or more demanding activities.
≥_______________≤
0 1 2 3 4 5
3.
I find I can spend a little bit more time engaging the things that I used to do without early
onset of my fatigue and / or my pain worsening and stopping me from doing so.
≥_______________≤
0 1 2 3 4 5
I am noticing I can get by with less medication and am reducing my frequency of use dosage
accordingly
Medication
Mo
Tu
Wed Th
Fr
Sa
Dose/ frequency of intake in a day.
1
2
3
Dose
Dose
Dos
e
Dose
Dose
Dose
Su
Dose
405
Graded Activity Diary – Phase I: Core Initiation Stabilization
Training
Answer each of the following on a six-point scale: Please circle the number that best describes
your ability
All The Time = 5
Most of the Time = 4
Some of the Time = 3
Rarely or Seldom = 2
Never or Not at All = 1
Don’t really Know = 0
1.
I chose mostly exercise numbers ____, ____, ____, ____, and did them mostly at
Morning___, at Mid-day____, before bed____ for 10 times each. I was able to practice
refining my Abdominal Draw-in Maneuver before each and every new exercise movement,
and was able to hold for 10 seconds.
≥_______________≤
0 1 2 3 4 5
2.
I found that I was able to able to maintain stability and control of my mid-section at all
times during my daily activities - and by especially practicing my draw-in maneuver- if the
activity involved seemed more strenuous than usual.
≥_______________≤
0 1 2 3 4 5
3.
I find I can spend a little bit more time engaging the things that I used to do without early
onset of my fatigue and / or my pain worsening and stopping me from doing so.
≥_______________≤
0 1 2 3 4 5
4.
I am noticing I can get by with less medication and am reducing my frequency of use
dosage accordingly.
Medication
Dose/ frequency of intake in a day.
1
2
3
Mo
Tu
Wed
Th
Fr
Sa
Su
Dose
Dose
Dos
e
Dose
Dose
Dose
Dose
406
Graded Activity Diary – Phase II: Static into Dynamic Core
Stability
Answer each of the following on a six-point scale: Please circle the number that best describes
your ability
All The Time = 5
Most of the Time = 4
Some of the Time = 3
Rarely or Seldom = 2
Never or Not at All = 1
Don’t really Know = 0
1.
I chose mostly exercise numbers ____, ____, ____, ____, and did them mostly at
Morning___, at Mid-day____, before bed____ for 10 times each. I was able to practice
refining my Abdominal Draw-in Maneuver—before each and every new exercise movement,
and was able to hold for 10 seconds.
≥_______________≤
0 1 2 3 4 5
2.
I found that I was able to able to maintain stability and control of my mid-section at all
times during my daily activities - and by especially practicing my draw-in maneuver- if the
activity involved seemed more strenuous than usual.
≥_______________≤
0 1 2 3 4 5
3.
I find I can spend a little bit more time engaging the things that I used to do without early
onset of my fatigue and / or my pain worsening and stopping me from doing so.
≥_______________≤
0 1 2 3 4 5
4.
I am noticing I can get by with less medication and am reducing my frequency of use
dosage accordingly.
Medication
Dose/ frequency of intake in a day.
1
2
3
Mo
Tu
Wed
Th
Fr
Sa
Su
Dose
Dose
Dos
e
Dos
e
Dose
Dose
Dose
407
Graded Activity Diary – Phase III: Dynamic-Reactive Rhythmic
Stability
Answer each of the following on a six-point scale: Please circle the number that best describes
your ability
All The Time = 5
Most of the Time = 4
Some of the Time = 3
Rarely or Seldom = 2
Never or Not at All = 1
Don’t really Know = 0
1.
I chose mostly exercise numbers ____, ____, ____, ____, and did them mostly at
Morning___, at Mid-day____, before bed____ for 10 times each. I was able to practice
refining my Abdominal Draw-in Maneuver—before each and every new exercise movement,
and was able to hold for 10 seconds.
≥_______________≤
0 1 2 3 4 5
2.
I found that I was able to able to maintain stability and control of my mid-section at all
times during my daily activities - and by especially practicing my draw-in maneuver- if the
activity involved seemed more strenuous than usual.
≥_______________≤
0 1 2 3 4 5
3.
I find I can spend a little bit more time engaging the things that I used to do without early
onset of my fatigue and / or my pain worsening and stopping me from doing so.
≥_______________≤
0 1 2 3 4 5
4.
I am noticing I can get by with less medication and am reducing my frequency of use
dosage accordingly.
Medication
Mo
Tu
Wed
Th
Fr
Sa
Su
Dose/ frequency of intake in a day.
Dos
e
Dos
e
Dos
e
Dos
e
Dose
Dose
Dose
1
2
3
408
Appendix S: Qualitative Differences between FM & CSE / MCE
QUALITATIVE DIFFERENCES BETWEEN FM & CSE / MCE
(Appendix S is one continuum and continues the next three pages)
Appendix S outlines qualitative differences, principles, and philosophical foundations occurring
between traditional Core Stabilization Training and conventional Motor Control Exercise
programs...versus...Feldenkrais® Somatic Education approaches to Skeletal Density &
Vestibular Imagery (VRB3) being inclusive of other movement themes, explorations and
inquiries.
409
Core Stabilization Exercise protocol
for Facilitating TrA and Multifidus
Feldenkrais® Somatic Education
& VRB3 Skeletal Density Imagery
DERIVATIONS
DERIVATIONS
Concept applied is/was achieved by
Deductive Reasoning
Concept(s) applied are achieved by
Inductive Reasoning
Identification of specific cause (1 or 2 variables)
to account for controlled reproducible effects
Observing, invoking, and identifying many
variables in interaction and giving them equal
weight of opportunity to influence a system
Explicit demonstration for proper Rx
performance
Implicit Exploration for successive proximation
Integrating variables / Naturalistic research
Isolating a variable / Empirical research
BEHAVIORAL REFERENCE
BEHAVIORAL REFERENCE
Specificity of muscle contraction
Specificity of sensory discrimination
Muscle Selection precedes the Functional Task
Task Demands Organize the Skeletal Behavior
MECHANISMS
MECHANISMS
Hidden Muscles
●
Hidden Senses
Activated explicitly in a routine fashion
as a feature or precursor to exercise and
daily activities.
DIRECTIVES
Concentration of effort as a reference:
• “Keep constant core to stabilize your back”
• Isolated sub-maximal effort at 10% =
law of protective corset surrounding spinal
column between pelvis and ribs.
• Concept for ‘regional interdependence’
remains mostly compartmentalized to diaphragm
and pelvis floor as governed by TrA and LM
motor control training and exercise.
• Operationalized through the four-phased
progression Queensland Australia model.
●
Activated implicitly as a manner of
noticing and being in the functions of
everyday life
DIRECTIVES
Distribution of effort as a reference
• i.e. “One area lifts from gravity/another area
yields to gravity”
• Task selected allocations of action with
proportional distribution of effort throughout the
entire skeleton.
• Concept for ‘regional interdependence’ extends
throughout the entire continuity of the skeleton and
whole-self; from base of feet to top of head and
vice-versa.
• Operationalized through “The Law of
Proportionate Thirds”
410
Core Stabilization Exercise protocol
for Facilitating TrA and Multifidus
(Appendix S Continued)
Feldenkrais® Somatic Education
& VRB3 Skeletal Density Imagery
(Appendix S Continued)
PROCEDURES / EFFECTS
PROCEDURES / EFFECTS
‘Proximal fixation of movement’
‘Proximal initiation of movement’
• Corseting Strategy = stability through learning
isolated muscle contraction at Transversus
Abdominus (TrA) and Lumbar Multifidus (LM).
•
Hip-Pelvis Strategy, Skeletal Imagery and
Vestibular Strategy
• Serves as background foundation for all
progressive activities
•
Area of attention to control is directly
associated with lumbar spine segments and is
framed above the waistline… ending at
diaphragm; with some reference to pelvis floor
●
●
Use of sEMG or pressure unit
biofeedback device to inhibit selection
of superficial global trunk-flexor torque
producing muscles (rectus abdominus
and obliques) during initial training in
“The
Abdominal
Drawing-In
Maneuver” in order to more specifically
select the deep stabilizer TrA and LM
groups. This procedural efficacy has
been
confirmed
in
concurrent
administration of ultrasonic imaging to
co-observe learned motor skill in
actually isolating the Transverse
Abdominus.
A Pressure biofeedback device is also
used in training and selection and
repeated conformational testing of
patient’s ability to perform an isolated
contraction of the TrA. (See Figure X
re. “Prone Test”)
Foreground muscle contractions are causal and
overtly conditioned as underlying mechanisms to
decrease segmental instability and associated low
back pain.
• Foundation for stability begins in region of larger,
denser skeletal segments and muscle groups (i.e.
pelvis and hips)
• Also serves as a background foundation (by virtue
of anatomical location of center of gravity) for
virtually any gross motor activity.
• Area(s) of attention to control is a task-based
neural assembly of various elements of whole self:
For this study attention is given to:
1) Outlining, mobilizing and initiating
activity of pelvis and hips (the pelvis force
couple…wherein attention is framed to
areas below the waistline i.e. indirect and
adjacent to lumbar spine segments as a
systemic basis for segmental control – as
per Gordon Browne, PT, GCFP)
2) Counterbalancing of head – with specific
attention to the anatomical region of the
vestibular system encased in L vs. R
temporal bones.
3) Interactions between head and pelvis
through using “The Law of Proportionality
of Thirds” as a guideline for generalizing a
distributed quality of movement in both
ATM® lessons, FI® sessions, and daily
activities
Background muscle activation patterns are merely
incidental and a covert indirect consequence of
multisensory-mediated improvements in the
efficient organization of function to match the
demands of a task – with awareness. Improved
quality of movement function = decreased
segmental instability and decreased low back pain.
411
As
with
most
conventional
exercises,
proprioceptive challenges tend to occur in a
limited context of a pre-set position and most
actions are limited to being within controlled,
cardinal saggital plane.
Clinical Observations & Discovery
As with real life (and that of our ancestors),
proprioceptive challenges will occur in the
expanded context of multiple positions, the possible
variations within them, and gradations of action
within at least three planes of movement.
Clinical Observations & Discovery
Decreased TrA activation and LM atrophy is a
consistent finding in LBP (as documented
through laboratory assessment and literature
review).
The observation of inaccurate perceptual
knowledge of hip axes is also a consistent finding in
LBP (as accrued through practice-based evidence
via repeat clinical observation).
EVIDENCE
Purports to have the most evidence on efficacy
AND a specified functional mechanism for LBP
and instability
EVIDENCE
• Lacks conclusive hard evidence or controlled
studies.
• Does have an abundance of experiential
frameworks and anecdotal evidence.
CRITICISMS
Selected evidence to implicate an isolated
component or part is perhaps too deterministic
and out of context of everyday function to be
reliable.
• Principles are just beginning to be articulated but
no clear or proven mechanism to currently address
the problem of chronic LBP.
OPPORTUNITIES
Variable evidence existing throughout a system is
emergent, contingent on task or otherwise
incessantly present…but contextually active at
different times AND in different ways.
Learning Goal
Learning Goal
Train a Specific Skill…and have it generalize to
multiple tasks.
Train Constellations of Skills (i.e. Awareness) and
have them integrate (multi-systemically) toward
meeting specific task affordances (i.e. adaptive
function) selectively in real time.
One skill set …continually conditioned.
Primacy of precision for contraction of TrA and
LM muscle groups as both preliminary and
primary sources of stability and protection for all
of life’s challenges and daily activities (i.e.
“Core Strength”).
Primacy
of
orchestrating
alignment
and
proportionate action through the densest aspects of
the skeleton through highlighting multi-sensory
joint acuity and body schema clarity and for
learning experiences designed for enhancing the
optimal use of whole self.
Internal feed-forward model becomes continually
re-rehearsed as a pre-condition for learning a
new motor skill (i.e., the internal model
‘stabilizes’ it’s anticipatory expectation and
motor responses, but does not necessarily amend
itself to other changing background or nuanced
conditions). It thereby reinforces its own unidimensional quality.
Limited scope of adaptability
Internal feed-forward model becomes continually
updated through greater sensory acuity and greater
motor dexterity via movement variation and
attention-based challenges to both existing and
dynamically changing body schema in direct
relationship to changing environment.
Greater awareness of 3-dimensional space
Greater resilience and adaptability
412
Appendix T: Principles of Ideal Movement
PRINCIPLES OF IDEAL MOVEMENT
FYI #3 – Principles of Ideal Movement
● Economy of effort. Don’t put any more effort into a movement than you really have to.
Don’t strain to move farther, but figure out what you have to let go of to allow your
bones to move more freely.
● Even distribution of movement. Don’t continue to force movement in places that
already move too much, but figure out what else you can invite to participate in any given
movement.
● Proportional use of synergistic muscles. Use your larger muscles more intensely to
move your larger bones for larger movements. Use your small muscles less intensely to
move your smaller bones in more delicate movements.
● Use your legs to control the position and movement of your pelvis. Corollary to
proportional use of synergists. Use your much larger hip muscles to move and position
your pelvis and use your smaller torso muscles to control the relationship between your
pelvis and your chest.
● Bearing weight skeletally. Arrange your bones “vertically” over each other so your
bones support the weight of the bones above... not through muscle effort, joint
compression or by overstretching connective tissue.
From: Outsmarting Low Back Pain: “A revolutionary new approach to solving the low
back pain puzzle” - Book and DVD program by Gordon Browne, PT, GCFP and Julie
Browne, PTA, GCFP, (© 2005, Reprinted with permission).
Browne, G., & Browne, J. (2005). Outsmarting Low Back Pain. Bellevue, WA: Movement
Matters, Inc.
413
Appendix U: Transparent-Translucent Contrast Images for Skeletal Density
TRANSPARENT-TRANSLUCENT CONTRAST IMAGES FOR SKELETAL DENSITY
Appendix U. (Caption for images 1of 2). Comparison of transparence vs. translucence as an
image demonstration to highlight the lesser skeletal density of the ilia shell concavity below iliac
crest – but more especially to clinically contrast an image and outline for ‘greater skeletal
density’ at inner ilia and pectineal line as a depiction for the primary transmission of skeletal
weight bear forces through the inner skeletal architecture being largely constituted by boney
trabeculae and transmissive through anterior-medial aspects of ilio-sacral (I-S) joints in through
anterior-lateral aspects of corresponding sacro-iliac (S-I) joints.
414
(a) Posterior S-I joint usually indexed as ‘small of back’
(b) Uncovering the visual-spatial obstruction of simulated intra-pelvic viscera
(c) Anterior I-S joint becomes reframed as new ‘top of leg’
______________________________________________________________________________
Appendix U. Demonstration of “inner ilia VR” visual-tactile imagery session for the anatomical
reframing and conceptual transition of usual body schema. (a) The usual focal indexing of sacroiliac (S-I) joint’s posterior ‘sacral sulci’ region(s) being cited as a common pain associated
neurotag in LBP being outlined by only one or two finger’s width, and verbally depicted in a
vulnerable defeatist fashion as the colloquial ‘small of back’...to...; (b) uncovering and revealing
the hidden deeper and larger anterior ilio-sacral (IS) joints (ordinarily hidden from usual
perceptual awareness as it lies deeply embedded behind intra-pelvic organs - and yet it remains
as the longest single joint in the entire body); and to finally, (c) a re-conceptualization of the
uncovered region as the new ‘top of leg’ – further re-framing them as ‘horse-hips’ or
‘drumsticks’ - and thereby linking a corresponding non-fragile association toward greater
415
solidity and structural support– as an “inner bridge” for perceptual robustness (Note: The
posterior S-I ‘sulci’ aspect scarcely bears any weight!).
416
Appendix V: Study Flow Diagram
STUDY FLOW DIAGRAM
(Study Flow Diagram is first appended to next page for larger scale viewing)
417
Appendix V. Study Flow Diagram in Larger Scale
418
Appendix V. Study Flow Diagram and time line for the current RCT clinical research study
comparing control group and experimental group. The WHITE boxes depict steps and procedures
conducted by administrative research staff. The SHADED boxes depict interventions and steps conducted
through single-blinded clinical staff, but being necessarily inclusive of having a non-blinded Principal
Investigator. However, all Data Collection steps were otherwise double-blinded.
419
Appendix W: Sensory-Motor Learning Model for Working Body Schema
SENSORY-MOTOR LEARNING MODEL FOR WORKING BODY SCHEMA
(Diagram of model is appended to next page for larger scale viewing)
420
421
Appendix X: Advisory Disclaimer and Release of Responsibility
ADVISORY DISCLAIMER AND RELEASE OF RESPONSIBILITY
Advisory Disclaimer
The Author, his professional practice, his advisory committee, faculty, staff, and the educational
institution do not assume any responsibility for any loss or injury and/or damage to persons or
property arising out of or related to any use of the material contained in this dissertation. It is the
responsibility of the treating practitioner, relying on independent expertise and knowledge of the
patient, and their appropriate scope of practice to determine the best treatment and method of
application for the patient. Nor should these contents ever be misconstrued as a substitute for
individual medical consultation or treatment.