Reflexology is a popular type of exercise that aims to restore the muscles that control and support the spine in a more precise and functional manner on. The therapist instructs the patient to use the muscles normally while performing simple tasks. As control and skill improve, so does the exercise progressed to complex and functional tasks involving trunk and limb muscles.
In the 1990s and 2000s, physicians around the world began to realize that primary tissues e.g. transversus abdominis lumbar multifidus and pelvic floor need investigation and are considered for inclusion in an integrated treatment regimen for low back pain 2016 systematic review who investigated the effectiveness of motor control exercise (MCE) in patients with chronic nonspecific low back pain concluded that:
MCE may produce better improvements in pain function and global mood of recovery than minimal interventions throughout the follow-up period. MCE may provide slightly better outcomes than exercise and electrophysical medications for pain disability global perspectives of recovery and physiology thing about quality of life in the short and medium term. There may be little or no difference between MCE and manual therapy in terms of both outcomes and follow-up time. Little or no difference is found between MCE and other exercises. Given the limited evidence that MCE is higher than other exercises maybe the choice of exercise for chronic LBP should be based on patient or therapist preferences therapeutic training costs and safety.
Figure 1: Transversus abdominisFigure 2: Lumbar multifidus on the left side of the lumbar spine
Justification for Use
The use of specific motor training as part of the treatment program was based on principles formulated by Richardson and colleagues.Extensive research has been published on the importance of proper motor control in the spine if including but not limited to:• An anatomical and biomechanical suitability of the core muscles to provide stability to structures in the spinal cord • Feedforward mechanisms in humans with lumbar spine degeneration (LBD) resulting in “pre-setting” the major muscles with an expected posture violence .
• Primary muscle contraction independent of the direction of trunk force and movement • Poor differences between persons with and without LBD in terms of altered feedforward mechanisms[19 ]reduced core muscle cross the sectional sizeincreased global muscle mass activity in some subgroupsand cortical representation of altered motor systems .
This important body of literature has led to the hypothesis that correction of maladaptive motor control is central to LBD rehabilitation and prevention of relapse.
- This hypothesis is reinforced on the basis of clinical data showing that the abnormal changes seen in people with LBD evolve independent of musculoskeletal disorders. less specific exercises such as over-abdominal compressions or general exercises.
- Furthermore RCTs have shown significant improvements in pain and function in participants receiving specific motor control training compared to usual care[38 ] with significant effect sizes when homogeneous subgroups are recruited.
- Recent controversies surrounding specific motor control training  have been refuted because the entire extensive literature was not adequately considered. 
- The rationale for LBD precision motor control training is supported by clear and extensive mechanistic and randomized controlled trial data.
The clinical application of lumbar motion control training  varies widely among physiotherapists.  and is often reported as a difficult concept to teach effectively in LBD patients. 
A series of clinical decision algorithms (based on established protocols) has now been developed and validated in a major clinical trial. 
The goal of the motor control program is to retrain the core muscles of the lumbar spine, including the transverse abdominis, multifidus lumbar, and pelvic floor, to maintain rigidity and voluntary contraction , with maximal voluntary contractions less than 30% of daily activity .
Figure 4: Right and wrong tummy tucks
- In most cases, this requires initial training in a non-weight-bearing position, using motorized lower abdominal traction, which has been shown to selectively activate the transverse abdominus.  The multifidus lumbar muscles and the pelvic floor muscles including the pubococcygeus have been shown to be associated with The transverse abdominis provides a “corset” for the lumbar-pelvic region , and practitioners should aim to achieve this effect in conjunction with lower abdominal stretch during movements.
- Training should initially focus on mass of motion and precise isolation of relevant core muscles, which have been shown to be important in restoring normal motor control in patients with LBD. 
- Once adequate control of the internal muscles is achieved in non-weight-bearing positions, subsequent progression to functional activities can be achieved. Importantly, this development requires global integration of the spinal cord with the core muscles during specific task performance exercise and during strength training in the trunk.
- There is increasing evidence that functional retraining of normal lumbo-pelvic kinematics can improve motor control and clinical outcomes , and these approaches should also be considered during functional motor control exercises.
There is overlap between the assessment and treatment of lumbar motor control, and these processes are summarized in Figure 5 below for the non-weight-bearing position.
ASIS=anterior superior iliac spine^MVC=maximal voluntary contraction
Figure 5: Basic non-weight bearing motor control training techniquesThe need for adequate global muscle relaxation e.g. rectus abdominis external obliques and erector spinae before attempting to contract the core stability muscles. Patients with maladaptive motor control strategies often suggest that global neurons dominate during active tasks and at rest. In retraining an appropriate motor control program, adequate relaxation is an important first step to suppress global muscle tone thereby allowing more isolated primary muscle contraction. In once a relaxed posture is achieved, a neutral spinal position should also be encouraged as this appears to improve the function of the major muscles.
- The “lower abdominal retraction inward into the pelvis” guideline should be used in accordance with the developers of the abdominal retraction technique.
- In addition to these standard guidelines, the words “gentle” and “gentle” may be added to emphasize the minimum level of interference.
- Tactile cues of the lower abdomen should be used in combination with verbal cues to further emphasize the lower abdomen contractions rather than more general contractions. 
- The non-weight-bearing position should be chosen where optimal activation of the transverse abdominis is observed , but lying on the side is often the best position for initial retraining  because of easy access to total body muscle relaxation and improved length tension The relationship of the transverse abdominus to other positions such as supine or bent.
- showed that the main result of full and submaximal transversus abdominis contraction is an isolated inward movement of the abdomen 2-3 cm approximately 3 cm above the pubic symphysis, and a slow coordinated tone change state evident in a “soft” sensation in the relaxed state for There is a “spongy” feeling at submaximal contractions. 
- These palpation findings provide the physical therapist with additional observational information about the nature of submaximal contractions. 
- A physical therapist can simultaneously palpate near the L3-L5 spinous processes to assess co-contraction of the lumbar multifidus during this process to determine whether specific multifidus retraining is also required to achieve normal motor control. A well-documented alternative strategy  should Monitor and provide patient feedback to ensure that observed lower abdominal contractions and palpation findings are not the result of general muscular activity, particularly the internal obliques.
Patients begin motor control training in the position of highest functional demand, allowing for proper contraction of the core muscles. This allows for motor control training at a location specific to the patient’s abilities, and improvements can be made between the two Conversation practice.
- For patients with poor or inconsistent motor control, side lying is usually recommended.
- If the patient is unable to engage the transverse abdominis in any position through the process described in Figure 3, the physical therapist can try a range of additional facilitation strategies (Figure 1).
- These approaches can also be used in patients who have good transverse abdominis control but poor multifidus lumbar control and/or poor awareness of pelvic floor activation.
Figure 6: Activation and facilitation of the transversus abdominis multifidus lumbar and pelvic floor motor control
In patients with difficult transversus abdominis dissection, initial focus on the pelvic floor and/or lumbar multifidus can help with activation.  In this case, apply the strategy outlined in Figure 6 while simultaneously monitoring co-contraction of the transverse abdominis muscle. exist If a co-contraction event occurs, the patient should be encouraged to focus on simultaneous activation of the transverse abdominis and awareness of the pelvic floor and/or multifidus lumbar muscles. Pelvic Floor Instructions to illustrate the anatomy of this area and provide guidance Perform submaximal isotonic contractions. The multifidus instructions are intended to provide guidance for performing submaximal isometric contractions. If desired, multifidus formation can be facilitated by providing kinesthetic feedback to the patient, first with isotonic contraction, followed by Try to transfer this awareness to the desired isometric contraction.
During all motor control training, patients should be encouraged to develop kinesthetic awareness of correct movement patterns. This is important so that the patient gets some form of proprioceptive feedback between exercises about the correct performance of the exercise. Meeting.  Subsequently, during treatment planning, sufficient kinesthetic awareness of normal motor control is also required to move to more functional and demanding exercises/activities. Due to the influence of even low force posture perturbations when starting a maladaptive motor Patterns  should instruct patients not to use self-palpation as a means of providing motor performance feedback until more consistent motor control skills have been demonstrated. Self-palpation also allows the patient to focus on the tone rather than the primary goal of drawing attention in isolation Lower abdomen.
Once the appropriate motor control strategy exercises and starting positions have been identified, a detailed information sheet should be provided and explained to the patient. Content should include information about the anatomy and normal function of the core muscles Progress motor control training from non-weight bearing to functional activities with guided breaks. The physiotherapist should document the appropriate dosing regimen on the information sheet according to the principles outlined in Figure 6. in the next course of treatment Physical therapists working with patients should aim to achieve a tonic contraction of the core muscles during a two-minute walk before moving on to more advanced functional exercises.
Figure 7: Dosage and progression of motor control training
Once adequate motor control has been demonstrated during ambulation, the patient should begin functional motor control training. Develop a graded exercise program based on the functional requirements of the patient’s own goals, based on the principles of exercise prescription and rehabilitation should be stipulated. Each exercise should be done with tonic control of the core muscles using the correct motor control pattern. The main components of the program should include: • Supervised functional exercise and motor control training performed at least weekly in an outpatient setting for at least 3 weeks Gym • Focus on quality of functional movement, including promotion of correct posture and lumbar pelvic kinematics • Simultaneous between course functional exercises and motor control training, at least 5 times per week for 15-45 minutes each • Patient records exercise compliance sex Use an exercise diary • Patient/Physiotherapist regularly reviews activities and exercise-based goals and positively reinforces progress • Plans to achieve independence after completing approximately 10 sessions and provides exercise program.
Figures 9 and 10 : Examples of functional motor control biceps curls as a means of training motor control during low level manual handling of external resistance
Lifting light weights will strengthen your core stability in preparation for gardening and lifting heavier household chores. Hold a dumbbell in each hand with palms facing forward and elbows straight. Without dropping your upper arm, bend your left elbow and twist the dumbbell up towards the shoulder. Put it down on the ground left and tap the right hand. Perform the movement using the trunk and arm control effectively.
- ↑ Jump up to:1.0 1.1 Saragiotto BT, Maher CG, Yamato TP, Costa LO, Costa LC, Ostelo RW, Macedo LG. Motor control exercise for chronic non‐specific low‐back pain. Cochrane Database of Systematic Reviews. 2016(1). Available:https://www.cochrane.org/CD012004/BACK_motor-control-exercise-chronic-non-specific-low-back-pain (accessed 3.1.2022)
- ↑ Bystrom MG, Rasmussen-Barr E, Grooten WJ. Motor control exercises reduces pain and disability in chronic and recurrent low back pain: a meta-analysis. Spine (Phila Pa 1976). 2013; 38(6): E350-8
- ↑ Jump up to:3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Richardson C, Jull G, Hodges P. Therapeutic exercise for lumbopelvic stabilisation: a motor control approach for the treatment and prevention of low back pain. Edinburgh: Churchill Livingstone; 2004
- ↑ Barker P, Briggs, CA, Bogeski, G. Tensile transmission across the lumbar fasciae in embalmed cadavers: effects of tension to various muscular attachments. Spine. 2004; 29: 129-38
- ↑ Barker P, Guggenheimer, KT, Grkovic, I, Briggs, CA, Jones, DC, Thomas, CD, Hodges, PW. Effects of tensioning the lumbar fascia on segmental stiffness during flexion and extension. Spine. 2006; 31(4): 387-405
- ↑ Barker P, Briggs C. Attachments of the posterior layer of lumbar fascia. Spine. 1999; 24(17): 1757-64
- ↑ Panjabi M. The stabilizing system of the spine: Part I: Function, dysfucntion, adaptation and enhancement. Journal of Spinal Disorders. 1992; 5: 383-9
- ↑ Wilke H, Wolf S, Claes L, Arand M, Wiesend A. Stability increase on the lumbar spine with different muscle groups. Spine. 1995; 20(2): 192-8
- ↑ MacIntosh J, Bogduk N. The biomechanics of the lumbar multifidus. Clinical biomechanics. 1986; 1: 205-13
- ↑ Kaigle A, Holm S, Mansson T. Experimental instability in the lumbar spine. Spine. 1995; 20(4): 421-30
- ↑ Hodges P, Eriksson M, Shirley D, Gandevia S. Intra-abdominal pressure increases stiffness of the lumbar spine. Journal of Biomechanics. 2005; 38(9): 1873-80
- ↑ Hodges P, Cresswell, AG, Daggfeldt, K, Thorstensson, A. In vivo measurements of the effect of intra-abdominal pressure on the human spine. Journal of Biomechanics. 2001; 34(347-353)
- ↑ Jump up to:13.0 13.1 Hodges P, Kaigle, HA, Holm, S, Ekström, L, Cresswell, A, Hansson, T, Thorstensson, A. . Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: in vivo porcine studies. Spine. 2003; 28(23): 2594-601
- ↑ Cresswell A, Oddsson, L, Thorstensson, A. The influence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing. Exp Brain res. 1994; 98: 336-41
- ↑ Hodges P, Richardson C. Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement. Exp Brain Res. 1997; 114: 362-70
- ↑ Hodges P, Richardson C. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy. 1997; 77(2): 132-44
- ↑ Cresswell A, Grundstrom H, Thorstensson A. Observations on intra-abdominal pressure and patterns of abdominal intra-muscular activity in man. Acta Physiology Scandinavia. 1992
- ↑ Hodges P, Cresswell, A & Thorstensson, A. Preparatory trunk motion accompanies rapid upper limb movement. Exp Brain Res. 1999; 124: 69-79
- ↑ Jump up to:19.0 19.1 Hodges P, Richardson C. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine. 1996; 21: 2640-50
- ↑ Jump up to:20.0 20.1 Hodges P, Richardson, CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. Journal of Spinal Disorders. 1998; 11(1): 46-56
- ↑ Jump up to:21.0 21.1 Ferreira P, Ferreira M, Hodges P. Changes in recruitment of the abdominal muscles in people with low back pain: ultrasound measurement of muscle activity. Spine. 2004; 29(22): 2560-6
- ↑ Jump up to:22.0 22.1 MacDonald D, Moseley G, Hodges P. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. Pain. 2009; 142(3): 183-8
- ↑ Jump up to:23.0 23.1 23.2 23.3 Hides J, Lambrecht G, Richardson C, Stanton W, Armbrecht G, Pruett C, et al. The effects of rehabilitation on the muscles of the trunk following prolonged bed rest. European Spine Journal. 2010
- ↑ Dickx N, Cagnie B, Parlevliet T, Lavens A, Danneels L. The effect of unilateral muscle pain on recruitment of the lumbar multifidus during automatic contraction. An experimental pain study. Manual Therapy. 2010; 15(4): 364-9
- ↑ Dankaerts W, O’Sullivan P, Burnett A, Straker L. Altered patterns of superficial trunk muscle activation during sitting in nonspecific chronic low back pain patients: importance of subclassification. Spine. 2006; 31(17): 2017-23
- ↑ Tsao H, Galea M, Hodges P. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain. 2008; 131(8): 2161-71
- ↑ Hodges P, Moseley G. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. Journal of Electromyography and Kinesiology. 2003; 13(4): 361-70
- ↑ Richardson C, Hides J, Wilson S, Stanton W, Snijders C. Lumbo-pelvic joint protection against antigravity forces: motor control and segmental stiffness assessed with magnetic resonance imaging. J Gravit Physiol. 2004; 11(2): P119-22.
- ↑ Jump up to:29.0 29.1 29.2 Tsao H, Hodges P. Immediate changes in feedforward postural adjustments following voluntary motor training. Experimental Brain Research. 2007; 181(4): 537-46
- ↑ Tsao H, Hodges P. Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain. Journal of Electromyography and Kinesiology. 2008; 18(4): 559-67
- ↑ Jump up to:31.0 31.1 31.2 31.3 Tsao H, Druitt T, Schollum T, Hodges P. Motor training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain. The Journal of Pain. 2010; 11(11): 1120-8
- ↑ Vasseljen O, Fladmark A. Abdominal muscle contraction thickness and function after specific and general exercises: a randomized controlled trial in chronic low back pain patients. Man Ther. 2010; 15(5): 482-9
- ↑ Ferreira P, Ferreira M, Maher C, Refshauge K, Herbert R, Hodges P. Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain. British Journal of Sports Medicine. 2009; 44(16): 1166-72
- ↑ Hall L, Tsao H, MacDonald D, Coppieters M, Hodges P. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of electromyography and kinesiology: official journal of the International Society of Electrophysiological Kinesiology. 2009; 19(5): 763
- ↑ Ferreira P, Ferreira M, Maher C, Herbert R, Refshauge K. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Australian Journal of Physiotherapy. 2006; 52(2): 79-88
- ↑ Jump up to:36.0 36.1 36.2 Standaert C, Weinstein S, Rumpeltes J. Evidence-informed management of chronic low back pain with lumbar stabilization exercises. The Spine Journal. 2008; 8(1): 114-20
- ↑ Rackwitz B, de Bie R, Limm H, von Garnier K, Ewert T, Stucki G. Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials. Clin Rehabil. 2006; 20(7): 553-67
- ↑ Macedo L, Maher C, Latimer J, McAuley J. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Physical Therapy. 2009; 89(1): 9-25
- ↑ Jump up to:39.0 39.1 Hodges P. Transversus abdominis: a different view of the elephant. British Journal of Sports Medicine. 2008; 42(12): 941-4
- ↑ Allison G, Morris S. Transversus abdominis and core stability: has the pendulum swung? British Journal of Sports Medicine. 2008; 42(11): 630-1
- ↑ McGill SM. Low back disorders: Evidence-based prevention and rehabilitation 2nd ed. Illinois: Human Kinetics Publishers; 2008
- ↑ Jump up to:42.0 42.1 42.2 O’Sullivan P. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Manual Therapy. 2000; 5(1): 2-12
- ↑ Ford J, Hahne A, Chan A, Surkitt L. A classification and treatment protocol for low back disorders. Part 3: functional restoration for intervertebral disc related disorders. Physical Therapy Reviews. 2012; 17(1): 55-75
- ↑ Henry S, Westervelt K. The use of real-time ultrasound feedback in teaching abdominal hollowing exercises to healthy subjects. Journal of Orthopaedic & Sports Physical Therapy. 2005; 35(6): 338-45
- ↑ Hides J, Stanton W, Freke M, Wilson S, McMahon S, Richardson C. MRI study of the size, symmetry and function of the trunk muscles among elite cricketers with and without low back pain. Br J Sports Med. 2008; 42(10): 809-13
- ↑ Hahne AJ, Ford JJ, Surkitt LD, Richards MC, Chan AY, Thompson SL, et al. Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders. BMC Musculoskeletal Disorders. 2011; 12: 104
- ↑ Jump up to:47.0 47.1 Hides J, Belavy D, Cassar L, Williams M, Wilson S, Richardson C. Altered response of the anterolateral abdominal muscles to simulated weight-bearing in subjects with low back pain. Eur Spine J. 2009; 18(3): 410-8
- ↑ Sapsford R. Contraction of the pelvic floor muscles during abdominal maneuvers. Archives of Physical Medicine and Rehabilitation. 2001; 82(8): 1081-8
- ↑ Neumann P, Gill V. Pelvic floor and abdominal muscle interaction: EMG activity and intra- abdominal pressure. Int Urogynecol J Pelvic Floor Dysfunct. 2002; 13: 125-32
- ↑ Dankaerts W, O’Sullivan P. The validity of O’Sullivan’s classification system (CS) for a sub-group of NS-CLBP with motor control impairment (MCI): Overview of a series of studies and review of the literature. Man Ther. 2010
- ↑ Richardson C, Jull G, Hodges P. Therapeutic exercise for lumbopelvic stabilisation: a motor control approach for the treatment and prevention of low back pain. Edinburgh: Churchill Livingstone; 2004
- ↑ O’Sullivan P, Dankaerts W, Burnett A, Farrell G, Jefford E, Naylor C, et al. Effect of different upright sitting postures on spinal-pelvic curvature and trunk muscle activation in a pain-free population. Spine. 2006; 31(19): E707-12
- ↑ Jump up to:53.0 53.1 53.2 Hides J, Scott Q, Jull G, Richardson C. A clinical palpation test to check the activation of the deep stabilizing muscles of the lumbar spine. International SportMed Journal. 2000; 1(4)
- ↑ Hides J, Stanton W, Wilson S, Freke M, McMahon S, Sims K. Retraining motor control of abdominal muscles among elite cricketers with low back pain. Scandinavian Journal of Medicine & Science in Sports. 2010; 20(6): 834-42
- ↑ Hides J, Stanton W, Wilson S, Freke M, McMahon S, Sims K. Retraining motor control of abdominal muscles among elite cricketers with low back pain. Scandinavian Journal of Medicine & Science in Sports. 2010; 20(6): 834-42
- ↑ Critchley D. Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing. Physiother Res Int. 2002; 7(2): 65-75