Stuart McGills latest text on Low Back pain (LBP) is an excellent text,
logical, well argued and referenced.
I do wholeheartedly agree with most of it, although LBP rehabilitation in
clinical practice seems to raise a number of questions, specificly re
patient and subsequently treatment selection.
As McGill notes, identifying aggravating activities and modifying these is
absolutely essential then there is the question of rehab.....
I think McGills ideas on rehab with an emphasis on stability and training
ALL the muscles of the trunk using progressive and scientifically determined
exercises probably covers the largest proportion of LBP patients.
But why does there appear to be so many discrepancies in clinical practice
that do not appear to be evidenced based. For example, on a regular basis I
get a small number of patients (probably my lowest percentage), especially
with chronic or reoccurring problems that do not respond to any type of
exercise or manual therapy (they do respond, but badly). This could
obviously be due to inadequacies on my part, although I would hope not, and
the fact that amazes me is what they do respond to... e.g. a combination of
interferential (that really shouldnt work) gentle massage and a lot of
encouragement of progressive movements in (generally) all directions. And
shock horror, this small group of patients respond unbelievably well.
Strangely, I really struggle with this as I have always believed that
science and solid evidence will provide the answers, and in LBP (for that
fact many areas of rehab and physiotherapy, look at the evidence base for
shoulder rehab for example, more like science and logic as opposed to
evidence based) this doesnt always seem to be the case.
Other areas I have issues with are range of motion(ROM)and back rehab. This
is something McGill definately appears to disagree with and again there
doesnt appear to be any good evidence that it works. BUT, the body loves
movement and although the spine needs stability why shouldnt controlled
movement be extremely beneficial? Many patients respond excellently to a
combination of active range of movements and passive mobilisations, in many
cases abolishing pain that has been present for an extended period of time.
Whether this is due to altered/increased neural input or a change in
represention or perception within the central nervous system or a number of
other factors is open to suggestion. It is interesting to note some of Chris
Thackers research that may have implications for movement looking at factors
such as up/down regulation
of local receptors or more central processes such as areas of representation
within the brain.
I think one of the most important roles I play in LBP is encouraging and not
discouraging movement, obviously there are a numbers of conditions attached
to this statement depending on the specific presentation.
As a side note and to a much lesser extent I do or have used many other
treatments for LBP including McKensie extensions, Mulligans mobilisations
with movements etc and for some patients they do seem to be appropriate.
Sorry to be so long winded and I do realise that in this world of evidence
based practice my opinions are of limited value. But do you feel that for an
area as complex as the spine and the combined "human condition" will we ever
have absolute evidence based practice for LBP?
What do others think about the role of movement (specificly ROM/mobilisation
exs)in LBP?
Why do we see clinically a number of patients with LBP with already
excellent trunk musculature control and endurance? And these individuals
again frequently seem respond to movement based therapy....
Another thought is why do people respond to therapy? For example, even
though people may be doing exercises to condition the neuromuscular system,
is the end output more dependent not on the changes in the muscular system
but more to do with changes caused by input and feedback from the
performance of the exercises whatever they may be. Although I dont have the
references on me, there have been studies comparing flexion and extension
exercises in LBP which had comparable results.....
If anyone has access to it, Louis Giffords editorial in the December 2002
Pain journal for chartered physios makes interesting reading.
I look forward to all your comments....
Regards
Steve Aspinall BSc (hons) GSR
CityPhysio
Manchester, UK.
_________________________________________________________________
MSN 8 helps eliminate e-mail viruses. Get 2 months FREE*
http://join.msn.com/?page=features/virus
|