The major task of moving to a new home in the USA has interfered with my
Puzzles & Paradoxes forum, but here is the latest one, at last.
PUZZLE & PARADOX 119
INTRODUCTORY NOTE
For newcomers to this forum, these P&Ps are Propositions, not facts or
dogmatic proclamations. They are intended to stimulate interaction among users
working in different fields, to re-examine traditional concepts, foster
distance education, question our beliefs and suggest new lines of research or
approaches to training. We look forward to responses from anyone who has
views or relevant information on the topics.
PP119
Understanding and management of spinal problems may be confused and impaired
by the misleading use of certain definitions and models of spinal stability.
PREAMBLE
The back has probably generated more concepts and models of postural
management and rehabilitation than any other part of the body, undoubtedly
because of the prevalence of back pain, dysfunction and disability in Western
populations. Entire courses, clinical rehabilitation regimes and treatment
'protocols' have been developed to manage back problems, with a myriad of
experts gaining almost demi-god status for their particular approaches. Thus,
we are confronted with methods such as the manipulative schemes of
chiropractors and physical therapists, as well as Alexander technique,
Maitland, McKenzie, Pilates, Feldenkrais and a host of other models which are
specifically or partially devoted to back care.
We learn about neutral spinal posture, abnormal curvatures, 'correct' pelvic
tilt, 'swayback', hyperlordosis, kyphosis, 'proper' lifting techniques and
numerous other issues relating to how we think that the trunk work., yet
agreement on all issues is by no means universal. Many folk with so-called
'abnormal' curvatures or postures do not suffer from debilitating back pain
and disability, years of heavy weightlifting does not lead to the expected
high incidence of injury or malfunction, and some methods of spinal management
have minimal success with some subjects.
DEFINITIONS
The foundation of all schemes of back use and care begins with definitions of
neutrality, the spinal curvatures, balance, abnormality and pelvic
disposition. Definitions of neutrality are bandied about so casually that
one would think that neutrality in the standing position is the same as
neutrality in seated, lying, walking, running and other situations. Are we
really entitled to apply such universal definitions of neutrality, bearing in
mind that spinal disposition is the result of dynamic processes throughout the
body?
Why is neutrality in the standing anatomical position considered to be more
fundamental than neutrality in the relaxed supine position? Is it appropriate
to apply concepts of neutrality in the static standing posture with neutrality
in the more dynamic cases of walking or running? Or does neutrality disappear
when one deviates from this 'neutral' standing position?
Many folk refer to normal lordosis or kyphosis, yet there appears to be no
such thing as normal scoliosis. Why this discrepancy? They consider lordosis
to refer to the normal concave curvature of the lumbar spine and kyphosis to
mean the normal thoracic convex curvature, but the suffix "-sis" always refers
to some form of pathology. Thus, lordosis should be used only to describe
excessively concave lumbar curvature, while kyphosis should be used solely to
mean excessively convex thoracic curvature. Scoliosis needs no such attention
- nobody uses that term to describe normal lateral curvature of any part of
the spine.
There are some who take all of this one stage further by referring to
'hyperlordosis', when lordosis already happens to be a 'hyper-' condition.
At a popular level, the term 'swayback' is used as a synonym for 'lordosis',
but some therapists attempt to distinguish between hyperlordosis and swayback.
This distinction is by no means universally accepted, yet it is sometimes used
to offer different types of therapy to treat what is considered to be abnormal
spinal posture.
LAY TERMINOLOGY
A major part of this confusion is that the colloquial word 'swayback' is not a
clinical term and that it is inappropriate to base kinesiological or
therapeutic analyses on lay terms being used in a clinical setting. This is
tantamount to comparing a cartilage operation with a menisectomy, because the
layperson thinks that cartilage is necessarily the same as meniscus.
Thus, it would appear to be meaningless to even consider comparing 'swayback'
and lordosis - either that or an acceptable clinical term has to be introduced
to accurately describe so-called 'swayback' which is not the same as the
colloquial use of the same term. If some believe that swayback is different
from lordosis because each has a different characteristic degree of pelvic
tilt, then we are going to get nowhere, since virtually all anatomists just
use them as clinical and non-clinical synonyms.
The tendency towards swaying back in the so-called swayback posture is
increased among those whose knee joint tends to 'hyperextend', while it is
used quite comfortably as a standing variant when one stands with the hands on
the hips or presses a load overhead.
Some well-meaning postural experts advise us that adults need to become more
childlike in standing or sitting, because children have not yet lost their
'natural' tendency to have the ideal posture. It needs to be pointed out that
it is entirely meaningless to compare adult and child postures, since the
typical human spinal curvatures are consolidated only in adulthood and that
the more flattened spinal posture is unsuitable for the greater stresses of
adult life.
IMBALANCE?
Then, when so-called imbalances are found between the different muscle groups
involved in stabilising the spine, a large array of static hands-on tests of
muscle strength are used to identify these imbalances (such as the impressive
inventory of tests of Kendall). Yet, we know that the 'strength' of muscles
depends on joint angle, velocity of movement, region of action, degree of
neural activation and fatigue. Are we justified in extrapolating these static
tests to identify imbalances which may or may not appear under more dynamic or
explosive conditions?
Why is balance or homeostasis considered to be so precisely defined that any
small deviations from fairly rigid 'norms' may be blamed for leading to a host
of back problems? One therapist swears that postural realignment will solve
the problem, another swears by mobilisation, others by manipulation, pelvic
re-education, myofascial trigger point therapy, 'active release', McKenzie,
shoe inserts (orthotics), Pilates, acupuncture and even reflexology. Is the
success or failure of any such system due more to the possibility that the
spine is such an imprecise functional system that numerous strategies can
affect its operation?
SOLUTIONS?
Is it not possible that no posture which deviates moderately from the 'norm'
really will cause any problems provided that it is not held for too long or
subjected to prolonged or excessive loading in any given direction? After
all, the body is in constant motion, even during sleep, which may well be the
body's natural way of preventing any given structure from being excessively or
inappropriately loaded.
So, if we move around regularly from one posture to another, no matter how
poor each may appear to be, are we not then minimising the occurrence of any
dysfunction - as long as we don't load the spine excessively or hold the same
posture for too long in any one state? Is it only when we forget to shift
around regularly in seated and other positions that problems begin to emerge?
Is the prevalence of back pain and dysfunction more a consequence of lack of
adequate postural variation than any single 'correct' posture?
Though our models of optimal spinal functioning may well be quite accurate,
is it that essential to implement them so precisely, when regular shifting
from one position to another may tend to offset most of the alleged risks of
imprecise spinal usage? Does this then imply that many of the popular
therapies and methods of spinal use and rehabilitation are unduly prescriptive
and in many cases, redundant?
_____________________________________________________________
Dr Mel C Siff
Littleton, Colorado, USA
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