Thanks for the Refs Frank -
You wrote ; "The relationship between aberrations of abdominal muscles and LBP has
been proven as well (on several occasions), but those studies all concerned
cross-sectional relationships",
John replies ;
Well, not so... the references I supplied in answer
to Mel looked at Transversus dysfunction in terms of TIMING (much later in LBP
patients), TYPE OF CONTRACTION(tonic in NON LBP subjects, phasic burst in LBP),
NON-DIRECTION SPECIFIC contraction in non-LBP, direction specific in LBP
pop, a LOSS OF INDEPENDENT CONTROL in LBP pop, a FAILURE TO RESPOND TO NATURAL
SPEED MOVEMENTS in LBP pop etc etc (see "Therapeutic Exercise ...." Richardson
et al quoted more fully in ref to Mel for a summary of the dysfunctional
changes)
Maybe you are thinking only about MTf dysfunction
which has been shown to be in cross-sectional changes - the proven dysfunctions
in Tr Ab are much more widespread. Certainly the changes in TrAb are not just
about 'relative inactivity' as you contest but much more widespread than this-
the whole manner of activity is changed.
You wrote: The
studies that were prospective could *not* find a relationship between weakened
abdominals and subsequent incidence of LBP.
John Replies - I am pleased to hear that
prospective studies have been done - I was unaware of this (Can you please
forward the refs?). The problem I can forsee with prospective studies is that
they would have to be done on a HUGE population over a PROLONGED period of
time to pick up enough people with no history of LBP, with TrAb dysfunction
who eventually developed LBP.
But even so, if you references do show no
relationship, this does not contradict the theory. The researchers openly admit
that they are unsure whther a 'silent' dysfunction in Tr Ab eventually results
in LBP or whether low back trauma results in dysfunction in TrAb. If the latter
is the case the prospective studies would not show any causal relationship
between TrAb dysfunction in a non-back pain population and subsequent
LBP.
The important point is that there IS a relationship
bewteen LBP and TrAb dysfunction (the prospective study only answers 'chicken or
egg?' questions)
I know it may seem like nit-picking but an
important point is that you focus on "weakness" of abdominals - the dysfunction
is not to do with weakness at all and I think it confuses the issue to use this
term when the research I am aware of never mentions 'weakness' as the
dysfunction. This just leads people to think about 'strengthening' the abs which
is possibly even counter-productive in such situations.
You wrote: Neither did training the abdominals have a curing influence on
LBP
John Replies: again, see my refs to Mel that
indicate to the contrary (again, could you forward your refs?)
You wrote: Furthermore, only of the MMs has a *structural* aberration (atrophy) been
demonstrated in LBP (to my knowledge it has never been demonstrated that
the transverse abs show atrophy in LBP. This would be in agreement with the fact
that I've seen quite a number of people with wash-board abs, including
well-defined transverse abs, that still had LBP).
John Replies: How do you see "well-defined
transverse abs" Frank? This muscle is the deepest of all the abdominals and is
simply not visible (unless you have been dissecting your patients).
The fact that you associate "wash-board abs" with
good dynamic stability is a misunderstanding. Many athletes with incredible
global muscle definition have poor dynamic stability - this is kinda the whole
point. Global muscles are often over-active. Ballet dancers, for instance, often
develop instability problems.
You are right, no one has claimed Tr Abs show
atrophy, the dysfunction is one of timing and type of contraction as explained
above (and more fully in my refs to Mel)
John Spencer
----- Original Message -----
Sent: Friday, August 16, 2002 12:52
PM
Subject: Re: A Question of Posture
G'day John (Dufton),
The relationship between the Multifidus Muscles (MMs) and LBP has clearly
been demonstrated (by more than one research team), just as the dramatic
effect of *isometrically* training the MMs on the recurrence reduction of
acute LBP. See
www.ptlitup.com | Archive
& Search | Editorial June 2001 + Editorial January 2002 (both free;
the June 2001 editorial starts with the proven relationship disc lesion -
atrophy of the MMs, but further down, you'll see the evidence on the effect of
iso-training the MMs. References are included, with direct links to the
abstracts).
G'day John (Spencer),
The relationship between aberrations of abdominal muscles and LBP has
been proven as well (on several occasions), but those studies all concerned
cross-sectional relationships, and only EMG studies, showing (only) the
*relative* inactivity of the (transverse) abs. The studies that were
prospective could *not* find a relationship between weakened abdominals and
subsequent incidence of LBP. Neither did training the abdominals have a curing
influence on LBP. See Editorial July 2001 (subscribers only). In
contrast to training the MMs, as mentioned above. Furthermore, only of the MMs
has a *structural* aberration (atrophy) been demonstrated in LBP (to my
knowledge it has never been demonstrated that the transverse abs show
atrophy in LBP. This would be in agreement with the fact that I've seen
quite a number of people with wash-board abs, including well-defined
transverse abs, that still had LBP).
G'day Emily,
I agree that Hides et al's way with the Biofeedback Unit, and trying to
have the patient contract the transverse abs and the MMs together,
is too difficult for the average patient, and quite draining for the
therapist as well. Also, I think it is not unfair to mention
that Hides et al did *not* check the contraction of the transverse abs in
their RCT study patients. They only checked the contraction of the MMs with
real-time US, so it remains unclear whether the TrAbs were indeed
recruited. I claim to have found a much easier way of treating patients with
LBP, in whom extension is limited and painful, including a very simple
exercise to retrophy the MMs: see the Editorial June 2001 as well.
G'day Barrett,
Sorry to have left you dangling out there for so long, while (and
you will undoubtedly know that) I agree with you that the
(traditional) chiropractic theory of subluxation has never been proven, while
there has been every opportunity, and plenty of means, to do so. The point was
that I didn't understand well what Sahrmann was getting at
exactly: posture in general, so also sitting posture, of which it has
been clearly proven that it effects LBP (see the editorial of the next issue
of PT-LITUP), or minute segmental misalignment (the theory of subluxation)?
And whether she embraced or denounced the theory of training the active
stabilization system wasn't clear to me either (until now).
Sorry if I sound like a school teacher (gotta get some sleep, after
having worked all night and morning, so I had to choose clarity over political
correctness).
Have a good weekend,
Frank
F.J.J. Conijn, PT
Editor, Physical Therapist's Literature
Update
The Internet Journal of Updates for Clinicians in Non-Operative
Orthopaedic Medicine
www.ptlitup.com
----- Oorspronkelijk bericht -----
Verzonden: vrijdag 16 augustus 2002 3:59
Onderwerp: Re: A Question of Posture
hello john,
sorry to trouble you, particularly because i am
entering this thread late.
But perhaps you could provide the
references to your points (paricularly
point 2)below so i could take a
look at the original works.
I have read the paper regarding spondylo
and stabilization, but i am not
aware of the other ones you refer
to. Personally i have not found these
techniques have out performed
other techniques that i have used. However i
do find them more time
consuming to teach to patients. They not yet been
endoresed by any
national guidelines quite yet either as far as i know (i.e
AHCPR, UK,
Denmark, etc). Nonetheless, if stabilization has been shown to
reduce
recurrent bouts of lbp compared to other interventions that would be
a
quite an interesting read.
Thanks,
John Dufton DC
Vancouver,
BC
>
>
>1) there is a very strong correlation
between people with a measurable
>(scientifically measurable that is)
dysfunction in TrAb timing and
>recurrent low back
pain
>
>2) that addressing this dysfunction by using techniques
available to us all
>in our clinics the researchers (physiotherapists)
have been able to show
>the largest single reduction in recurrence
rates of low back pain ever
>demonstrated in an intervention initially
over a 12 month and now a 36
>month period.
>
>3) this
research, having been repeated in various fashions by clinicians
>around the Western world, has been shown to be positive in clinical
>outcomes for a whole range of patients ith low back pain from ballet
>dancers to post-partum women with SI joint
dysfunction.
>
>Why do you feel that a clincal model that is
convincing in its ability to
>reduce recurrence rates of low back pain
irrelevant to your patients?
>
>
>
>
>John
Spencer
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