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PHYSIO  August 2002

PHYSIO August 2002

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Subject:

Re: A Question of Posture

From:

Sarah Fern Striffler <[log in to unmask]>

Reply-To:

- for physiotherapists in education and practice <[log in to unmask]>

Date:

Sun, 18 Aug 2002 07:28:21 -0400

Content-Type:

text/plain

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Parts/Attachments

text/plain (235 lines)

Dear John,

Thank you for keeping this thread alive for so long. Your statement
that Tr Ab & other stabilizing mm are usually tonic in non-LBP
people and phasic in LBP pts leads me to wonder: Perhaps this
fact explains the discrepancy between the long-held belief that good
posture is effortless and the common response of our LBP pts that
"it's hard work to stand up straight." My own experience back when
I gave 6-8 hour-long massages/day was that my work was easiest
with my best posture until near the end of a long day. Then, as
general fatigue set in, good posture became an effort, a force of my
will, making me susceptible to injury.

Sarah Fern Striffler, PT


----- Original Message -----
From: John Spencer <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, August 16, 2002 10:47 AM
Subject: Re: A Question of Posture


> <[log in to unmask]>
> Sent: Thursday, August 15, 2002 7:48 PM
> Subject: A Question of Posture
>
>
> > John Spencer < [log in to unmask] > writes:
> >
> > <<My overall concern is that rather than dismissing Dynamic Stability
work
> on
> > the rather vague basis that it is "flawed" or on the basis that you have
> not
> > had much success with it clinically we should look to the research that
> shows
> > that:
> >
> >
> > 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.....>>
> >
> > *** Which specific studies  providde this information and which
different
> > treatment modalities were compared?  Since various list members have
> provided
> > feedback that prone back extensions over a high bench ("prone
> > hyperextensions") can also provide a very successful form of therapy,
was
> > this exercise also examined?  I mention this because numerous
> weightlifters
> > and powerlifters over many decades have found this same exercise to be
> very
> > helpful in managing back pain and dysfunction.
> >
> > Almost paradoxically, some have even discovered that "contraindicated
> > exercises" such as controlled deadlifting or pulls from the floor with
> loaded
> > barbells can also help to resolve back pain.  Another exercise which
> > currently is popular among lifters wishing to relieve back pain is what
is
> > called  "reverse prone hyperextensions", which involves lying prone over
a
> > bench and raising and lowering the lower extremities against a load
slung
> > around the ankles (note, of course, the multifidus and other back
muscles
> > serve primarily as stabilisers in this exercise).  Have any other list
> > members come across back pain and dysfunction successfully being treated
> with
> > these exercises, which many would regard as "potentially risky."?
> >
> > Dr Mel C Siff
> > Denver, USA
> > http://groups.yahoo.com/group/Supertraining/
> >
>
> Mel
>
> I don't deny that there are many anectdotal stories of LBP responding well
> to various interventions and I don't mean to be dismissive of them just
> because they are 'anectdotal' but I do think that such evidence should not
> be considered as seriously as good quality research with a randomised
> controlled group.
>
> Especially with low back pain anectdotal stories abound because of the
> exacerbation/remission cycle that is so common. Until the late 1970s most
> medical practitioners would have SWORN that prolonged bed rest was the
> response of choice to low back pain. Lots of anectdotal stories supported
> their beliefs - but is was controlled research that proved, against all
> expectations, that early return to activity was a big factor in reducing
> long-term disability. and that long-term bed rest was counter-productive.
>
> I had a physiotherapy colleague who swore by doing straight leg
> deadlifts to help his low back pain. (But then again I have had patients
who
> associated remission of arthritis with re-painting their room red).
>
> What anectdotal stories can be is a starting point for future research (as
> was dynamic stability research, inspired, to some extent I believe by
relief
> from LBP in post-partum women who completed pelvic floor exercises and
> reported reduction in LBP recurrence).
>
> As the authors of "Therapeutic Exercise for Spinal Segmental Stabilisation
> in Low Back Pain" (C Richardson, G Jull, P Hodges and J Hides -1999) say:
> "The use of evidence-based treatments is the call of the decade and the
> practice for the 21st century" (pg 105) and their book tries to summarise
> the research that provides and effective theoretical model as to their
work,
> a practical clinical application of their methods and convincing clinical
> outcomes in relatively large, randomised control groups. If you really
want
> to learn
> about what they are saying then this book is a small investment that goes
> into questions that you are asking in more detail than I can here (365
> references cited).
>
> Though I will try...
>
> Statement 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"
>
>
> Evidence:
> Having determined that, in a group of people with NO history of LBP, TrAb
> had certain 'feed forward' characteristics in movements of either the arm
or
> leg ... (ie Tr Ab fired BEFORE activity took place in the limb to be
moved)
> (Hodges P, Richardson C 1997 "Relationship between limb movement speed and
> associated contraction of the trunk muscles - Ergonomics, 40: 1220 -1230.)
>
> ....the authors then went on to study a population with recurrent Low Back
> Pain
> and with identical testing proceedures (fine wire emg timings) were able
to
> establish a significant delay (50-45ms) in the onset of contraction of
TrAb
> (- in many trials TrAb didn't even begin to contract until the associated
> limb movement was completed (let alone initiated)).
>
> (Hodges P, RichardsoCA, 1998 "Delayed postural contraction of Transversus
> Abdominus in LBP
> associated with movement of the lower limbs. Journal of Spinal Disorders
> 11:46-56) (There is also a ref for Upper Limb movements)
>
> This delay was apparent for movements of the limbs in all directions, at
all
> speeds.
>
> The study also showed that response rate of TrAb was NOT direction
specific
> (ie was consistent despite the direction of the limb being moved) in the
NON
> LBP population but became direction-specific in the LBP group (ie TrAb
> stared to act more like a Global, non-stabilisers in individuals with
> symptoms).
>
> The study also showed  dysfunctions in the LBP group in that the muscle
acts
> in a tonic, postural manner in a normal population but acts
> in a more phasic, short-duration bursts in the LBP population (a similar
> change in function to changes in VMO function in people with
Patello-femoral
> pain) (Richardson c, 1987 "Atrophy of Vastus Medialis in patello-femoral
> pain syndrome. In: Proceedings 10th International Congress World
> Confederation for Physical Therapy, Sydney, pp400-403)
>
> The authors also note other dysfunction in terms of what they call " Loss
of
> Independent
> Control" of TrAb and a "Failure to respond to natural speed movements" in
> the LBP group. The conclude with a theory as to the mechanisms behind
> these dysfunction in TrAb in a LBP group and the consequences such changes
> in behaviour might have for creating 'instability' (pages 65 to 69 of
> previously cited book).
>
> The authors then go on to cite changes in Multifidus function and anatomy
in
> people with LBP etc etc (eg changes in cross-sectional area as referred to
> in my
> posting to John Dufton)
>
> So the objective changes in function of the TrAb and MTf in a Low Back
pain
> group do seem to be measurable and significant.
>
>
>
>
> Statement 2.  that addressing this dysfunction by using techniques
available
> to usall 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.....>>
>
> Evidence - please see references cited in posting to John Dufton for
> outcomes with MTf training over 12 months (the specific refs for TRAb
> training are recently in Spine but I
> am chasing exact refs over w/end)
>
>
> Mel asks:  *** Which specific studies  provide this information and which
> different treatment modalities were compared?
>
> In the Hides study on MTf outcomes the control exercises included (from
> memory, again I will check the article this w/end)  resistance exercises
in
> the gym (I think I may be able to be more specific that this on Monday),
> swimming and abdominal crunches.
>
> I hope this answers your question - I am more than happy to repsond again
to
> future requests for references as I am keen that this list learns about
this
> research

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