Frank - Calm down!
I don't see why you are being so hostile about this! My text about you summarising the article was a gentle nudge to committ yourself to what this discussion list is all about (free discussion). Any articles that are quoted by others on this list are available freely from public libraries - yours are not. By all means tell us about your online editorials but you can't expect every list member interested in the dicussion to pay out to read your references. And if every list member won't pay out then suddenly we are creating an 'exclusive' club of people who have to pay to discuss an issue.
I think suggesting I have a 'twisted mind' for asking you to summarise research is a bit much! You note I asked you to SUMMARISE the research not 'copy and paste' it onto the list as you said I did. Academia has a long history of summarising or abstracting which is what I asked you to do. What you are saying is that unless I pay you $14.95 I don't take the truth seriously and you are not willing to discuss matters with me further - well in that case you are on the wrong discussion list!
Your comments regarding PBU and EMG are contradictory. You seem to say that a measurement tool and the thing it measures have to correlate directly in terms of magnitude for them to be effective - they simply don't Frank. Your hands are a very sensitive measurement tool, you use them to palpate muscles sometimes. They give you NO objective measurement of magnitude - you couldn't say objectively what degree of torque was being produced by a patient's biceps - are they a useless measurement tool?
You admit that in terms of measuring magnitude EMG and PBU are the same- thay fail to measure magnitude of musular torque produced but you say this makes PBU useless and EMG useful - you make no sense.
You say the PBU research I quote is the "weakest of weak evidence... because the study you refer to has never been published in a journal that is peer-reviewed, according to Medline's database." Oh Please Frank! I gave you the reference!! (Richardson CA, Jull GA, Richardson BA 1995 "A dysfunction of the deep abdominal muscles exists in low back pain patients. In: Proceedings World Confederation of Physical Therapists, Washington). Are the articles from your online journal quoted in Medline? If they are does this make them valid articles and everything not on Medline invalid?
You say about the PBU : "This means that it could very well be that it is a useless tool for clinicians that did not receive a special post-academic training and do no have extensive experience with it." YES FRANK that is EXACTLY what it means. That is the point that I have been trying to make about TrAb training is that it takes a skilled, experienced, trained clinician to make it effective. If you resent having to learn skills at a post-graduate level you are in the wrong profession.
From here, to be honst Frank, your arguments become bizarre -
*********FC: I hope you're not suggesting that body contour is related to LBP (the BMI has been demonstrated on more that one occasion to be unrelated to LBP), nor that you're suggesting that we should be assessing "substitution strategies". (We might just as well be assessing the movements of the cranial bones in LBP. )
Who mentioned Body Mass Index (is that what you mean by BMI?). Contours means that shape of the human body and physical definitions of it's anatomy. If you don't look at body contours as a clinican than you really should - how else do you see these wash-board abs you talk about?
Again, I don't think you grasp what I mean by "substitution strategies" Frank. Observing substitution strategies is part of the bread and butter of being physiotherapist. Surely you have seen how somebody with an inhibited supraspinatus muscle has to substitute other muscles or whole movement strategies to initiate abduction? Well, you can see substitution strategies in people with TrAb dysfunction too - What do YOU mean by substitution strategies?
******FC: I graduated in 1983. Since then, I've hardly seen 1 patient with a well-defined VM-quadriceps with patello-femoral pain, but if seen more than plenty of patients with wash-board abs who did have LBP.
Well that kind of proves my point - doesn't it Frank? My point is that you CAN have wash-board abs and LBP (as I have explained several times.)
You: "What do you mean by "non-structural"?
********FC: No atrophy.
Frank - where have I EVER argued that TrAb show atrophy? PLEASE read my posts properly before you respond to them.
*********FC: They were lying! The 1-2 causative relationship between smoking and lung cancer has been proven on multiple occasions! Why else do you think that a multimillion-dollar fine/settlement has been ordered in court?
I think you need to brush-up on your research skills here Frank. An Associative and a Causative relationship are not the same thing. Whether a Causative relationship has been established between smoking and cancer, is open to debate. Certainly common sense would argue that there is a causative relationship but proving it (despite strong ASSOCIATIONS), is not the same thing.
The point you were making is that there is not a CAUSATIVE relationship between LBP and TRAb dysfunction. Again, read my postings carefully, I have never argued that the causative relationship has been established (nor do the authours of the studies I refer to so often) but I think, considering the very strong ASSOCIATIONS between LBP and TrAb dysfunction we should take this dysfunction very seriously.
"The final sentence about "no special training for the TrAbs is necessary, other than that one teaches the patient with LBP to stand stable and "lock" the spine" belies a misunderstanding as to how TrAb works. It doesn't "lock" the spine."
******FC: It doesn't lock the spine? In other words: it doesn't stabilise the spine? Why then would you wanna train the TrAbs?
Come on Frank - do the words 'lock' and 'stabilise' mean the same thing? - Use your anatomy. The 'locking' position for the knee (ie in extension with all the ligaments fully tightened and most congruent surface position) is not the same thing as having a stable knee (a knee can be stable throughout it's range). Where else have you read that TrAb 'locks' the spine - give me a SINGLE reference Frank - come in, if you reply to this post please include just one single reference to TrAb 'locking' the spine.
John Spencer
----- Original Message -----
From: Frank Conijn
To: [log in to unmask]
Sent: Tuesday, August 20, 2002 6:40 AM
Subject: Re: A Question of Posture (corr.)
John,
You: "How about you save us all $14.95 and summarise the article (when you get the time!) Presumably, you are the editor of this journal from what I can gather."
*********FC: If you're not willing to spend $ 14.95, you're probably not interested in what research outcomes have to say, which makes me doubt the objectivity of your mind, which in turn makes me reluctant to discuss things further with you. If you look at the hours and the money I spend on finding the truth in matters (which apart from the long hours I have to spend on it, means going through large number of full text research articles, for which in total I have to pay a multitude of 14.95 every week!), you must have a really twisted mind asking me, as an author of some kind of book, to copy and paste the (in this case relevant) chapters of my "book" on this newsgroup, for free.
You: "The fact that MAGNITUDE of changes between Pressure Biofeedback Unit (PBU) and fine wire EMG was not correlated does not make this an ineffective clinical tool."
*********FC: Yes, it does. It tells that the Biofeedback Unit seemingly is not clinically useful.
You: "Magnitude of torque produced by muscles and surface EMG signals do not correlate - this doesn't make EMG useless.".
********FC: Indeed it doesn't make EMG useless, but it does make the Biofeedback Unit useless.
You: "The most convincing research was done by assessment of a number of individuals by a single clinician, skilled in the use of PBU, who was 'blinded' as to whether the individuals she tested had a history on LBP or not (none were in back pain at the time of the testing). The results showed that only 10% of the group with a history of LBP could perform the correct action (as indicated by the PBU) whilst 82% of the Non-LBP group could perform TrAb contraction. (Richardson CA, Jull GA, Richardson BA 1995 "A dysfunction of the deep abdominal muscles exists in low back pain patients. In: Proceedings World Confederation of Physical Therapists, Washington). This would suggest that the PBU is a useful clinical tool though, as the authors of the "Therapeutic Exercise for Sinal Segmental Stabilisation...." (As quoted before) say, it is a relatively 'crude' tool. You will get false positives and false negatives.
*****FC: That's what validity is all about: a low rate of false positives and false negatives! If percentages aren't given, but it *is* said that "it is a relatively crude tool, in which one gets false positives and false negatives", I don't have any reason to assume that the validity is in order. And what's more: the *reliability* of the BFBU has never been demonstrated either: the study you describe only mentions 1 clinician, skilled in the use of the BFBU. This means that it could very well be that it is a useless tool for clinicians that did not receive a special post-academic training and do no have extensive experience with it. In short: you've delivered the weakest of weak evidence, also because the study you refer to has never been published in a journal that is peer-reviewed, according to Medline's database.
You: "However, this is only the first tier of clinical tests, the second being observation of body contour, movements, substitution strategies and surface EMG.".
*********FC: I hope you're not suggesting that body contour is related to LBP (the BMI has been demonstrated on more that one occasion to be unrelated to LBP), nor that you're suggesting that we should be assessing "substitution strategies". (We might just as well be assessing the movements of the cranial bones in LBP. )
You: "With regards to your comments: "Regarding the not being able to visually determine the condition of the TrAbs: you're right, but I'd be very surprised if in guys and girls with wash-board abs they'd be not in order.". I can't let you get away with this. There is NO correlation between wash-board abs and effective, functional TrAb. Your conclusion presumes that all the abs are kind of the same bunch and if one is good, all of them will be. Take the Vastus Medialis Obliquus and dysfunction of in patello-femoral pain. Would you assume that the VMO must be working well because the Vastus Lateralis and Intermedius seem to be well-defined? Research suggest that this is not true at all and dysfunction can exist in VMO whilst the other quads function well.
******FC: I graduated in 1983. Since then, I've hardly seen 1 patient with a well-defined VM-quadriceps with patello-femoral pain, but if seen more than plenty of patients with wash-board abs who did have LBP.
You: "What do you mean by "non-structural"?
********FC: No atrophy.
You: "You are right that no causative relationship has been established between TrAb and LBP. That is the difficulty with smoking cigarettes and lung cancer - the cigarette companies point out that no causative relationship has been proven."
*********FC: They were lying! The 1-2 causative relationship between smoking and lung cancer has been proven on multiple occasions! Why else do you think that a multimillion-dollar fine/settlement has been ordered in court?
You: "The final sentence about "no special training for the TrAbs is necessary, other than that one teaches the patient with LBP to stand stable and "lock" the spine" belies a misunderstanding as to how TrAb works. It doesn't "lock" the spine."
******FC: It doesn't lock the spine? In other words: it doesn't stabilise the spine? Why then would you wanna train the TrAbs?
R.,
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 -----
Van: John Spencer
Aan: [log in to unmask]
Verzonden: maandag 19 augustus 2002 12:30
Onderwerp: Re: A Question of Posture (corr.)
Frank
How about you save us all $14.95 and summarise the article (when you get the time!) Presumably, you are the editor of this journal from what I can gather.
The fact that MAGNITUDE of changes between Presuure Biofeedback Unit (PBU) and fine wire EMG was not correlated does not make this an ineffective clincal tool. Magnitude of torque produced by muscles and surface EMG signals do not correlate - this doesn't make EMG useless.
The most convincing research was done by assessment of a number of individuals by a single clinician, skilled in the use of PBU, who was 'blinded' as to whether the individuals she tested had a history on LBP or not (none were in back pain at the time of the testing). The results showed that only 10% of the group with a history of LBP could perform the correct action (as indicated by the PBU) whilst 82% of the Non-LBP group could perforn TrAb contraction.
(Richardson CA, Jull GA, Richardson BA 1995 "A dysfunction of the deep abdomial muscles exists in low back pain patients. In: Proceedings World Confederation of Physical Therapists, Washington)
This would suggest that the PBU is a useful clinical tool though, as the authors of the "Therapeutic Exercise for Sinal Segmental Stbilisation...." (As quoted before) say, it is a relatively 'crude' tool. You will get false positives and false negatives.
However, this is only the first tier of clinical tests, the second being observation of body contour, movements, substitution strategies and surface EMG. The skill of the clinician here is paramount. Lack of training here may be a cause of poor outcomes as results are clearly skill dependant.
Of course, if you can afford it, a third tier of more objective assessment can be purchased, a real-time Ultrsound Scanner ($30,000!)
With regards to yourr comments: "Regarding the not being able to visually determine the condition of the TrAbs: you're right, but I'd be very surprised if in guys and girls with wash-board abs they'd be not in order."
I can't let you get away with this. There is NO correlation between wash-board abs and effective, functional TrAb. Your conclusion presumes that all the abs are kind of the same bunch and if one is good, all of them will be. Take the Vastus Medialis Obliquus and dysfunction of in patello-femoral pain. Would you assume that the VMO must be working well becuse the Vastus Lateralis and Intermedius seem to be well-defined? Research suggest that this is not true at all and dysfunction can exist in VMO whilst the other quads function well.
The whole point is that the Global muscles which act to Mobilise the body (ie Rectus Abdominus) can often be very active (too active?) and predominate over the underactive Local muscles that act to Stabilise the vertebrae (eg TrAb).
Regarding your final paragraph: "I will go through the full text of the other articles you mentioned in the response to Mell next month. The abstracts, however, in no way seem to prove a 1-2 causative relationship TrAbs - LBP. The TrAbs abnormalities seem only secondary *and* non-structural, in relation to LBP. The way I see it, is that no special training for the TrAbs is necessary, other than that one teaches the patient with LBP to stand stable and "lock" the spine if they have to make odd or power movements. But that should be standard procedure, in all methods."
What do you mean by "non-structural"?
You are right that no causative relationship has been established between TrAb and LBP. That is the difficulty with smoking cigarettes and lung cancer - the cigarette companies point out that no casuative relationship has been proven. However, the fact that there is such a strong association between smoking and lung cancer means that common sense would make you not want to smoke. Similarly the strong correlation between TrAb dysfunction and LBP and TrAb rehabilitation and reduction in LBP makes me take it very seriously as a clinical tool.
The final sentence about "no special training for the TrAbs is necessary, other than that one teaches the patient with LBP to stand stable and "lock" the spine" belies a misunderstanding as to how TrAb works. It doesn't "lock" the spine. If you have any research that indicates teaching someone to "stand stable and 'lock' the spine" is able to reduce recurrence of LBP over a 12 or 36 month period to the extent that TrAb training does - let us know!
John Spencer
----- Original Message -----
From: Frank Conijn
To: [log in to unmask]
Sent: Saturday, August 17, 2002 2:13 AM
Subject: Fw: A Question of Posture (corr.)
(Sorry, the English in the other message was too bad.)
----------------------------------------------------------------------------
I'm awfully sorry, John, but for the specific references of the articles showing no curing influence of training the abs on LBP you will have to take a subscription (~ US $ 14.95 doesn't seem a too high price, considering what more you get for it), and check out the Editorial of July 2001: its all there lined out for you, including direct links to the abstracts).
I'm just too busy (with normal work and other projects).
Regarding the not being able to visually determine the condition of the TrAbs: you're right, but I'd be very surprised if in guys and girls with wash-board abs they'd be not in order.
My objection against the method by Hides and Richardson, as already mentioned, also by other people, is that it is too difficult. And what's more: the Biofeedback Unit they use seems unreliable to measure the activation of the TrAbs, as they demonstrated themselves(!): "The clinical test involved quantification of the ability of the subjects to specifically displace the anterior abdominal wall in a way consistent with the function of the muscle. This was evaluated by use of a device designed to measure pressure reduction as the abdomen lifted off a transducer in the prone position. The laboratory test involved determination of the onset of contraction of TrA associated with rapid upper limb movement, measured using fine-wire EMG electrodes. [...] The results of the study indicate that a reduction in the ability to draw in the abdominal wall is related to changes in the coordination of TrA, [but] the magnitude of the changes were not correlated." (Hodges P, Richardson C, Jull G., Evaluation of the relationship between laboratory and clinical tests of transversus abdominis function. Physiother Res Int 1996;1(1):30-40).
I will go through the full text of the other articles you mentioned in the response to Mell next month. The abstracts, however, in no way seem to prove a 1-2 causative relationship TrAbs - LBP. The TrAbs abnormalities seem only secondary *and* non-structural, in relation to LBP. The way I see it, is that no special training for the TrAbs is necessary, other than that one teaches the patient with LBP to stand stable and "lock" the spine if they have to make odd or power movements. But that should be standard procedure, in all methods.
All for now; gotta go.
R.,
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 -----
Van: John Spencer
Aan: [log in to unmask]
Verzonden: vrijdag 16 augustus 2002 19:25
Onderwerp: Re: A Question of Posture
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 -----
From: Frank Conijn
To: [log in to unmask]
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 -----
Van: John Dufton
Aan: [log in to unmask]
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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