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PHYSIO  August 2002

PHYSIO August 2002

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Subject:

Re: Movements not Muscles?

From:

Doug Bourne <[log in to unmask]>

Reply-To:

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

Date:

Tue, 20 Aug 2002 22:07:52 -0700

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Time to get this discussion back on track.  For those who haven't seen
the Hides et al. RCT here is the reference with abstract:

Spine 2001 Jun 1;26(11):E243-8
 Long-term effects of specific stabilizing exercises for first-episode
low back pain.

    Hides JA, Jull GA, Richardson CA.

    Department of Physiotherapy, Mater Misericordiae Public Hospitals,
South Brisbane, Queensland, Australia. [log in to unmask]

    STUDY DESIGN: A randomized clinical trial with 1-year and 3-year
telephone questionnaire follow-ups. OBJECTIVE: To report a specific
exercise intervention's long-term effects on recurrence rates in acute,
first-episode low back pain patients. SUMMARY OF BACKGROUND DATA: The
pain and disability associated with an initial episode of acute low back
pain (LBP) is known to resolve spontaneously in the short-term in the
majority of cases. However, the recurrence rate is high, and recurrent
disabling episodes remain one of the most costly problems in LBP. A
deficit in the multifidus muscle has been identified in acute LBP
patients, and does not resolve spontaneously on resolution of painful
symptoms and resumption of normal activity. Any relation between this
deficit and recurrence rate was investigated in the long-term. METHODS:
Thirty-nine patients with acute, first-episode LBP were medically
managed and randomly allocated to either a control group or specific
exercise group. Medical management included advice and use of
medications. Intervention consisted of exercises aimed at rehabilitating
the multifidus in cocontraction with the transversus abdominis muscle.
One year and three years after treatment, telephone questionnaires were
conducted with patients. RESULTS: Questionnaire results revealed that
patients from the specific exercise group experienced fewer recurrences
of LBP than patients from the control group. One year after treatment,
specific exercise group recurrence was 30%, and control group recurrence
was 84% (P < 0.001). Two to three years after treatment, specific
exercise group recurrence was 35%, and control group recurrence was 75%
(P < 0.01). CONCLUSION: Long-term results suggest that specific exercise
therapy in addition to medical management and resumption of normal
activity may be more effective in reducing low back pain recurrences
than medical management and normal activity alone.

I'm sure that many exercises have been shown to be beneficial but what
strikes me is the drastic decrease in recurrence rate.  This is pretty
amazing especially considering some of the valid comments others have
made. Mel stated he " also knew that activation in a given limited
situation does not necessarily mean integrated optimal involvement in
some complex motor activity involving multiarticular movement whose
patterns of muscular and other soft tissue involvement change from
moment to moment."  It also doesn't mean that a muscle pattern learned
in a limited situation will transfer to a more complex or different
motor activity.  This was drilled into us in Neuro at school.  This
study suggests that with this exercise program there may be transfer to
real life situations (by means of decreased recurrence).

Now to switch sides.  In an earlier post I mentioned the special session
on spinal stability at this years WCB.  I also mentioned the names of
the people who made up the panel (Hodges, McGill, Panjabi, Stokes,
Solomonow).  Although I'm sure that these people all believe that spinal
stability is important, they disagree on many points (which you would
expect in a developing field of biomechanics).  Although many physios
are familiar with Hodges work and Panjabi's neutral zone hypothesis I
doubt many have read much of McGill, Stokes or Solomonow's work.  I
didn't recognize Solomonow's name before the conference.  This work is
important (along with Cholewicki, Granata, Marras, and others) for
understanding the biomechanics behind spinal stability.

It is becoming in apparent in the research that classifying muscles as
either local stabilizers or global movers is flawed.  Stability relies
on the concerted effort of all muscles (even segmental stability).
Cholewicki J, VanVliet JJ 4th.
    Relative contribution of trunk muscles to the stability of the
lumbar spine during isometric exertions.
Clin Biomech (Bristol, Avon). 2002 Feb;17(2):99-105.

A couple of McGill's grad students presented interesting research that
transversus abdominus is only a very minor contributor to spinal
stability during a selection of spinal stability exercises.

Hodges presented research showing that the abnormalities in transversus
function could be replicated by making normal subjects afraid of moving
(by electric shocks) does this suggest that transversus fuction will be
restored when patient's are not afraid to move anymore?

Any comments?

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