So far, experts, non-experts, and wanna-be-experts have all shared their opinions on what should and could be done to curtail the incidence of head injuries and concussions in the NHL. From eliminating fighting to modifying equipment to tactical rule changes, there have been countless ideas rendered of what the league can do differently to protect their players as well as the game itself.

Unfortunately, making changes isn’t easy. We all know that. Even the NHL’s arm-chair executives (the fans) know that. But collectively, I believe most if not all of us can agree that something must be done. Or else…

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While our knowledge base is still relatively limited with respect to the ramifications of sustained concussions, let alone early return to play from head injuries, we do know, as Mr Dryden stated, that:

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“Better helmets, more muscular necks and shoulders, MRIs and Rule 48 haven’t offered the answer to 220-plus-pound players moving 30 miles an hour.”

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220-plus pound players moving 30 miles an hour? Really?

The game of ice hockey has changed dramatically over the last 30 years, but what hasn’t changed, and perhaps what has been staring at us in the face the entire time, is the size of the rink. Simple physics will tell you that an ice rink measuring 200 feet by 85 feet containing the same amount of players (let alone one extra referee) that now weigh an approximate average of 20 pounds heavier and travelling approximately 15 more miles per hour may no longer be the appropriate size.

So maybe…just maybe…we need a larger fish tank.

When our pet koi outgrow their tank, we get a larger tank. And when our children outgrow their skuuts, we get them a bike.

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Now I’ll admit that I do not have the epidemiological data on concussions over in Europe where they play on larger ice surfaces, but only because of the simple reason that there hasn’t really been any significant studies published in recent times. Remember, studies take several years before the collected data turns into published research. And the only studies currently available are ones published the 90s. A lot has changed since then.

Surely, some will argue that the European game is completely different than the North American game. And I would agree. But I would also counter that there are many North Americans playing over in Europe, with my brother-in-law as an example. But I would also state that perhaps the difference in style of play across the ocean may actually be secondary to rink size more than any other significant reason. Perhaps?

Now others would argue that it would cost millions and millions of dollars to alter the ice rinks in each of the 30 North American cities where teams are located. Again I would agree. But I would also counter that millions and millions of dollars are equally spent on player salaries as well. And what good is the NHL when its highest paid players are sitting on the sidelines suffering from concussions?

So Gary Bettman states,

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“I will go where science takes me”

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As a health care practitioner, that exact statement is what I am trained to follow. But in the case of the NHL, what if the scientists are asking the wrong question? Or, maybe they are asking the right questions, but what if other specific questions aren’t being asked?

Perhaps science can take us down the path that soccer (football) in Europe and other countries around the world have taken for several years and study the area covered by players during 60 minutes of regulation play. Total distance as well as peak and average speeds can be determined via global positioning systems relative to the area of play to determine whether a need for a larger ice surface is actually necessary. And sound science must utilize comparative data so perhaps the exact same study (or studies) can be performed in the KHL, DEL, Swedish Elite leagues to name a few. Simply put, I would hypothesize that players would a) cover the same total amount of ice, travelling at the same current speed, but in a less confined area or b) cover less amount of ice in total, travelling at the same current speed, AND in a less confined area. Further, I would also hypothesize that the puck would change directions with less frequency on the larger ice surface leading to more predictable play.

And should these types of studies conversely reveal that a larger ice sheet results in a greater total amount of ice covered, then perhaps this may equate to less frequency of collisions.

I know this may seem far fetched but it is an idea. One that, in my humble opinion, may have at least an ounce of sound merit to it.

*UPDATE*

A colleague directed me to this research study. Seems as though my thoughts are not too far off!

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Biased but Brilliant - “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”

6 Lies About the Human Body You Learned in Kindergarten – “Everything you ever learned about metabolism is secretly confusing you into being fatter, making nutrition and obesity seem much more complicated than they actually are.”

Contemporary Cardio – “Regardless of the angle you look, all measures of training and recovery, inputs and outputs, track back to the autonomic nervous system.”

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Authors: R. Chou, A. Qaseem, DK Owens et al.

Journal: Annals of Internal Medicine

Date: 2011

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Summary:

• My full review of this paper was recently posted on Research Review Service but since I feel strongly about its message, I thought it would be a good idea to provide you with a brief introduction. In concert with the high incidence of low back pain in today’s society lies a relatively high rate of requisitions for diagnostic imaging of neuromusculoskeletal conditions pertaining to the lumbar spine. Unfortunately, the appropriateness of such imaging studies may be questionable at best for many of these conditions owing to the fact that the outcome of care often leads to similar results in those patients who have undergone “routine” imaging and those who have not regardless of whether such tests were performed. Certainly, such imaging may be required for those patients suffering from severe and /  or progressive neurological deficits as well as for those presenting with serious underlying conditions however, more often than not, those patients presenting in general family, chiropractic or rehabilitation practices may do well without the unnecessary doses of radiation and costs to the health care systems. This best practice advice paper provided by the Clinical Guidelines Committee of the American College of Physicians provides the medical reader with a summary of the current literature pertaining to the utility of diagnostic imaging for low back pain and advises on the rationale behind evidence-informed decision making when a patient presents with low back pain symptoms. Utilizing results from high-quality studies, suggestions are made for cost worthy diagnostic protocols and advice is given on the potential harms and benefits of radiological procedures. Additionally, a valuable summary for patients has also been provided of which can be easily accessed here.

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R. Chou, A. Qaseem, DK. Owens et al. (2011). Diagnostic imaging for low back pain: Advice for high-value health care from the american college of physicians. Annals of Internal Medicine, 154; 181-189

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Related posts:

1. Movement Patterns of the Lumbar Spine and Sacrum During the Back Squat McKean MR et al. (2010). The lumbar and sacrum movement...

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Authors: W. Meehan

Journal: Clinics in Sports Medicine

Date: 2011

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Summary:

• Here is a little review of potential interventions in one of the most influential and highly discussed injuries in ice hockey today, concussion. While the current state of the literature may still be in its infancy, each incident of this “traumatic brain injury”, particularly in professional hockey, seems to make front page news and cast a shadow of doubt on the safety of our sport. This paper by Meehan discusses various therapeutic options that may be rendered in the presence of such injury.

• First introduced is the role of physical rest in the recovery process. The stepwise return to play protocol is discussed although it is mentioned that studies have begun investigating the role of light physical activity during recovery. Since quantitative cognitive deficits have been demonstrated in the presence of such injury, academic accommodations via cognitive rest were suggested for student athletes.

• Often considered an “invisible injury”, Meehan proposes that education regarding the typical recovery process be one of the mainstays of therapeutic intervention. Studies have demonstrated fewer symptoms at follow up in those that were informed about their symptoms, coping strategies, and the likely course of recovery.

• While most athletes achieve spontaneous recovery of symptoms within days to weeks, some experience prolonged recovery to which pharmaceutical intervention may be warranted. It should be noted that the evidence for such interventions is very minimal and the following information should be taken as a summary rather than a recommendation of care. Meehan suggests that pharmacologic treatment only be considered in the presence of the following:

1. Symptoms exceeding the typical recovery period,
2. Symptoms negatively affecting quality of life to the degree that the treatment benefits outweigh its risks, and
3. The clinician rendering treatment is both knowledgeable and experienced in the management of (sport) concussion.

• Meehan asserts that pharmacologic treatment has yet to be demonstrated to speed the recovery process and that standard approaches are lacking. Instead, he reports that medications are utilized for the treatment of its signs and symptoms. Since previous literature has grouped symptoms related to sport concussion in the categories of sleep disturbance, somatic (i.e. headache), emotional, and cognitive, chosen medications must be specific to the symptom experienced.

• In the presence of sleep disturbance, sleep hygiene that includes the elimination of constant stimuli (i.e. television, computers, caffeine, etc) is strongly considered. Medically, Meehan’s first line of defence for the presence of sleep disturbance is Melatonin. Other considerations are discussed although benzodiazepines seem to be advocated against due to their negative arousal and cognition effects.

• Somatic symptoms such as headaches are common in the presence of sport concussion. Meehan discusses the potential roles of antidepressants (i.e. amitriptyline – his preferred treatment) as well as the potential negative effects (“rebound”) of analgesics such as ibuprofen. Other medications are introduced as well as physical therapy, psychotherapy, and trigger point injections.

• For athletes suffering from emotional disturbance, for example stemming from participation restrictions, Meehan suggests tricyclic antidepressants and serotonin reuptake inhibitors as a complementary intervention to coping strategies, familial support and psychological counseling.

• Finally, since cognitive symptoms are common complaints in those suffering from sport concussion, potential pharmacologic treatment may include methylphenidate for attention and speed processing deficits as well as the domaminergic agent amantadine for executive function and prefrontal cortex glucose metabolism, in addition to cognitive rehabilitation.

• It should be noted that the majority of athletes recovery both spontaneously and quickly from sport concussions. The preceding review merely discusses potential medical interventions that may have complementary roles to physical and cognitive rest and rehabilitation. It must be reiterated that the above MUST NOT be taken as prescription but merely as a review of Meehan’s academic paper, intended for medical professionals. If you or your family member has sustained a concussion, you MUST consult a physician for care.
  

Meehan WP. (2011). Medical therapies for concussion. Clinics in Sports Medicine, 30; 115-124.

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Dr. Shawn Thistle and his team of writers provides this site full of “clinically applicable, evidence-informed information for manual medicine providers and personal training professionals”.

He recently provided us with a free document that summarized 10 important research articles published in the past year ranging from topics pertaining to headaches, chronic low back pain, femoral-acetabular impingement, glucosamine, pain science, etc. This document can be downloaded here.

If you are a clinician or fitness professional, and value research and evidence in your practice, I highly encourage you to check out his site.

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Study Title: The Lumbar and Sacrum Movement Pattern During the Back Squat Exercise

Authors: MR McKean, PK Dunn & BJ Burkett

Journal: Journal of Strength & Conditioning Research

Date: October 2010

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Summary:

• Here is a recent article that takes a deeper look at the obvious. McKean and colleagues utilized thirty upper year personal training students and personal trainers to examine 1) the timing and range of movement of the lumbar and sacral regions and 2) the influence of stance width, gender, and ascent / descent phases during the back squat exercise. Incorporating no load and 1.5 x body weight loaded trials, measurements from 3-D tracking devices placed on the above regions were evaluated for maximum lumbar and sacrum angles, the time at maximum lumbar and angles, maximum lumbar flexion angles, and the time at maximum lumbar flexion angles. Unsurprisingly, it was revealed that both men and women achieved a deeper squat position with wider stance (twice ASIS width) versus narrow stance (equal to ASIS width) positions. For those interested in the technical rationale, the reasoning behind this was lower maximum lumbar, sacrum and lumbar flexion angles leading to the ability to maintain more upright lumbar spine positions. Men and women, however, differed in movements and timing of maximums where men achieved maximum sacral angles sooner for both the ascent and descent phases of the squat in comparison with women who achieved earlier maximum lumbar angles in both phases. As a result, this modification in sacrum position and timing in men appears to allow them to accommodate for the known gender differences in pelvic girdle morphology. From a safety perspective, the above differences between the narrow and wider stance positions allow the lumbar spine to maintain a more upright position decreasing the load on the posterior structures of the spine.  That said, kyphosis of the lumbar spine does occur during the deep squat although measurements were not collected beyond ASIS width.

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McKean MR et al. (2010). The lumbar and sacrum movement pattern during the back squat exercise. Journal of Strength and Conditioning Research, 24(10); 2731-2741

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Study Title: Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study.

Authors: A. Robb & J. Pajaczkowski

Journal: Journal of Bodywork & Movement Therapies

Date: January 2011

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Summary:

• Here is a nice little pilot study by two of my colleagues from Toronto on the effect of Active Release Techniques on immediate pain thresholds in elite ice hockey players. Using 9 players from AAA to the major junior level, they studied the influence of this popular manual therapy technique on its ability to modulate reported pain pressure thresholds (PPT) in acute adductor muscle strains. Up until now, the majority of the current literature on this technique had looked at the beneficial application of ART through case studies, however, few if any have looked deeper into the therapeutic effect of such protocols. PPT, “the minimal amount of pressure applied to the tissue to change the pressure sensation to discomfort or pain”,  was assessed both pre- and post-treatment via a hand-held mechanical pressure algometer. A significant improvement in PPT was demonstrated in this study. Since the painful experience involves both a bottom-up and top-down process, this study sheds some light into the potential positive effects manual therapy may have in acute pain patients. While the authors disclose that it is still difficult to conclude with certainty the exact pathophysiological and histological mechanisms responsible for these outcomes, they do provide some potential mechanisms for such reduction of pain. Certainly this study lacked a large sample size and randomization (hence a pilot study), however, the work of Drs. Robb and Pajaczkowski do pave the way for further research to validate a therapy that carries with it an extreme wealth of anecdotal evidence.

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Robb, A. & Pajaczkowski, J. (2011). Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study. Journal of Bodywork and Movement Therapies, 15, 57-62

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Study Title:

Authors: L. Purcell & L. Micheli

Journal: Sports Health

Date: May / June 2009

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Summary:

• A simple and straightforward literature review of orthopaedic causes of low back pain in young athletes. Utilizing a search of the current evidence through Medline, the authors briefly summarized the risk factors, clinical examination process, and prevention of such conditions in youth sport. A larger section of this paper was devoted to specific orthopaedic considerations including, but not limited to; spondylolysis, spondylolysthesis, posterior element overuse syndromes, and vertebral body apophyseal avulsion fractures. Interestingly, little credit was given to functional diagnoses although it was suggested that greater risk for injury may be present during periods of rapid growth. One of the recommendations given, to which I believe may be insufficient, was that “a patient who has resumed full pain-free activities…is considered clinically healed”. Given the current lifestyle in which young athletes live, I believe more attention should be paid to the athletes’ normal activities of daily living…or lack thereof!

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Purcell, L. & Micheli, L. (2009). Low back pain in young athletes. Sports Health. Vol. 1 (3): 212-222

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Here’s a brief summary of the study:

Study Purpose:

• To determine the presence of a relationship between hamstring length and PFJ stress at 3 specific knee joint angles of flexion.

Study Population:

• 16 recreationally active males divided into two groups based on knee joint angle-measured hamstring length.

Methodology:

• A biomechanical model incorporating knee joint angle, knee extensor moment, and PFJ contact area was used to quantify PFJ stress.
• MRI and 3D motion analyses were also utilized in this study.
• A one-way ANOVA to determine the variations in PFJ stress between the 2 groups (with and without reduced hamstring length) was used.

Main Findings:

• Patellofemoral Joint stresses differed significantly between the two groups at specific angles of knee flexion.
• No significant differences in hip angles between the two groups.

Clinical Application:

• This study demonstrated that subjects with reduced hamstring lengths have increased PFJ stress during various positions of the squatting movement.  As a result, such a decrease in length MAY contribute to the pathogenesis of various conditions relating to the knee.
• These results enable us to consider another factor when managing those with knee pathology.

For a complete and “evidence-informed” understanding of the study, check out my review. I have obviously left out specifics from this study in this post as Research Review Service is a paid membership site. However, if you would like more information, please do not hesitate to ask.

Photo source

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*note: the above link for RRS is an affiliate link

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Please be aware that the following information is based on my interpretation of each lecture and therefore, may be subject to “lost in translation”.

Please click here for Part 1

Please click here for Part 2

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‘Clinical Update: Emerging trends in exercise management of spinal pain’

~ Paul Hodges & Stuart McGill

This lecture was the meat and potatoes of the symposium. Dr. Hodges was the main presenter and often asked Dr. McGill to provide some practical insight into some of his interventions for low back pain. While they both stressed that they were likely very similar in their approach to spinal care, it was evident from this talk that the divergence is still glaring. In fact, even the miracle blade could not cut the tension in the air although both were very professional in their “debate”.

Here are my notes:

Basic principles:

• Dynamic control far exceeds static control
• The system as a whole is what’s important, not a single muscle
• The biopsychosocial framework must be considered during intervention
• The assessment is highly important
• The principles are drawn from multiple approaches in training

5 basic but key components to DYNAMIC CONTROL:

• Posture
• Movement
• Underactivity (tends to involve local structures)
• Overactivity (tends to be global structures)
• Evaluation of both provocative and relieving factors

Treatment Goals:

• Postural correction
• Movement correction
• Muscle Activation Optimization

Posture:

Dr. McGill gave an example of the importance of posture and its relationship with our breathing. Feel free to perform a self-assessment in the various positions

• Regular sitting – normal breath
• Slouched – breath goes directly to mid-chest level
• Military position (shoulder retraction, thoracic extension) – breath goes down to base of lungs
• Rotate and list to one side – one lung becomes compromised and breath is taken up by contralateral lung

Movement:

Dr. McGill also provided us with a movement correction example

• Upright stance and muscle activity
• A forward posture (slouched or neck protraction) vs neutral spine
• Bottom line: change posture during movement may change activity of lumbar musculature (i.e. extensors)
• For those of you who have his newest DVD, he also demonstrates this example there.

*All three (posture, movement, muscle activation optimization) are important but we as clinicians have to figure out which of these is our priority in treatment.

“STATIC STABILITY DOES NOT EQUAL FUNCTION”

Interplay between dynamic and stiffness:

• This is a continuum
• Depends on the load (high load requires high stiffness)
• Depends on the movement (greater movement requires greater dynamic control)
• Depends on the predictability (low predictability requires high stiffness)
• We need to find the right balance!

“Change in motor control is about looking at the whole system not the parts.”

Common features of motor control strategies:

Dr. McGill on posture correction:

• First try to achieve elastic equilibrium
  • First start with a position of least load / stress concentration
• Then try to modulate that with pain
  • Can be standing
  • Can be seated
  • This seated example touched upon correct posture. Rather than actively extending the thoracic spine (which increases extensor muscle activity), tilting the pelvis anteriorly is preferred

Preservation of feedback control may be via taping:

• I found this to be quite interesting in light of the various taping techniques currently on utilized in the rehabilitation and sport medicine settings
• Taping may also be used for modifying muscle activation strategies

“NEUTRAL SPINE IS NOT STATIC!”

• It needs to be variable…and within the functional range

“The gluteus maximus is a (free) knee extensor!”

• When standing, active contraction of this muscle passively extends the knee
• “Spread the floor and use the hips”
• This is advantageous as it unloads the quadriceps muscle

Activating the HIGH glutes & glute med:

• Needs core stiffness
• Externally rotate hips
• This may be done actively and reactively (minibands around the knees and around the feet)

Activating LOW glutes:

• Only achieved in a deep squat position

Posture and Movement is about load:

• How does pain change with the addition and removal of load?
• McGill  – “tolerance is a function of posture and movement”

McGill on Bracing:

• Become a dimmer switch not a light bulb
• Its all about tuning!

Hodges: There’s a difference between just making a muscle active (Transversus Abdominis) vs an optimal way of using the muscle:

• It’s not enough just to activate the muscle…you have to learn how to use it!

Hodges:

“There is no doubt that Stu and I have differing positions on the role of the deep muscles in the clinical approach but I think it is good that we have different ideas because all individuals patients are different.”

“The Transversus Abdominis is not the most important thing in low back pain but our data show that it is the most consistent deficit in low back pain presentation. Therefore it is important to address this muscle as part of the comprehensive package of treating low back pain.”

“Improving the activation of the deep muscles may decrease the over activity of the global/superficial muscles.”

Dr. McGill on the Transversus Abdominis:

• He understands that the TrA is important. His problem is that there are so many other important aspects to low back pain patients.
• …and far too often the patients that he sees are “paralyzed” by the concept of a dysfunctional TrA. They are always asking, “is my TrA working?”, “why isn’t my TrA working?”
• This is why he subscribes to the method of external focus for motor learning by Gabrielle Wulf.

Dr. Hodges:

• Counters that there is data to show that simply an internal focus to “wake the muscle up” is ok. As long as there are subsequently more functional goals to focus on

*In my opinion, It’s an apples vs oranges debate!

“Train movement control, posture and muscle activity during rehabilitation”

• If they flex the spine while bending forward then train them not to flex the spine while bending forward.
• Its that simple!

Dr. McGill:

“Fix the biggest things first to get them out of pain…THEN fine tune!

• This was his rebuttal to the TrA and MF controversy. He states that he has never encountered a patient where the TrA deficit was the most significant dysfunction

Dr. Hodges’ strategy of multifidus activation:

• Can you turn it on?
• What else happens when you turn it on?
• Do you have control over the strategies?
• Most important and effective strategy is to use imagery.

“There’s something about attention to detail that’s driving changes in neuroplasticity”

Dr. McGill:

• States that his athletes cannot individually activate muscles medial to lateral but they can superiorly and inferiorly
• BUT THE MENTAL FOCUS WAS IDEAL!!!

Dr. Hodges:

“Delays are significant in a motor system.”

• This deficit is NOT the dysfunction but only a window of opportunity to look into the system.

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As mentioned earlier, this turned out to be an interesting and enlightening high tension academic debate but both experts argue that it would be most valuable to have a patient on hand to both assess to really truly get an idea of how each think. They agreed that this would truly provide valuable insight into the magnitude of their agreement/disagreement.  Out of all of this, they state that there is mostly convergence between the two and that it may be the last (5%)…i.e. their specific methods…that may be different.

“Divergence is healthy. Because if not, what would drive research?”

*The purpose of everything is the individualized goals of each patient. That’s it!

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Please be aware that the following information is based on my interpretation of each lecture and therefore, may be subject to “lost in translation”.

Note: Please click here for Part 1

It must be stated that each of the two esteemed researchers prefaced their talks with addressing the fact that misconceptions often occur when one is asked to speak about a specific facet of their research. Both of them stated that the oft-requested material is simply a part of the big picture and as a result, labeling and misinterpretation typically occurs.

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‘Motor control changes in spinal pain: effects, mechanisms and efficacy of interventions’ ~ Paul Hodges

Adaptation & Rehabilitation: How does motor control change in the presence of pain?

Some common myths explained (in red):

The Transversus Abdominis and Multifidus are NOT the most important muscles for spine control

• However, he states that they do make a contribution and that this is often modified in the presence of low back pain.
• His rationale for addressing the importance of specific musculature is compromised control (of the system) in the presence of weakness or inhibition.
• Note: he was adamant in stating that rehabilitation does not stop here…that training these muscles should not be the sole target of lumbar rehabilitation

With respect to the debate surrounding the delay of motor activity with arm movement:

• He states that this delay is not necessarily a dysfunction in and of itself -> but simply is a “window” to look into the system.

Motor control training is NOT just about training the Transversus Abdominis

• The aim should be placed on addressing postures, movement patterns and muscle activation patterns
• A consideration of the deep musculature is simply one aspect of motor control

People should NOT be encouraged to isolate the Transversus Abdominis and Multifidus in function

• The aim should be to change their activation patterns while introducing them into function…in addition to the correction of posture, movement, and muscle activation (if necessary).

The need to isolate deep muscle activity in rehabilitation

• Some of the reasons presented pertained to organizational changes within the brain, the relationship between motor activity improvement and clinical improvement, and the applicability for the identification of individuals who may respond to motor control rehabilitation
• This was one area where he stood his ground

Some explanations as to why motor activity decreases during pain:

• Reflex inhibition
  • Change in excitability of the motor neuron (descending motor pathway) secondary to injury
• Change in organization of the motor cortex
  • In the presence of low back pain, he reported that the cortical area of TrA representation is shifted posterolaterally
  • Interestingly, individuals with the biggest temporal delays in motor activity have the largest shift in displacement (note: this does not necessarily imply causation).

Motor control isn’t always about giving people more…it may also be about taking things away

• Some people have OVERactivity!!!!
• That often individuals with low back pain have increased muscle stiffness and subsequently, poor control.

So does an increase in muscle activity during pain allow us to adapt? Yes!

Is this adaptation about protection of the injured part? Yes – the high threshold strategy

• But is this a good thing or a bad thing? Does that alter motor control?

Hmm…

Adaptation ALSO occurs in the presence of a “threat” of pain

• The “threat” of nociception caused alterations in motor activity
• Therefore nociception is actually not necessary

Adaptation may be good in the short term…but it may be detrimental in the long term

• In the short term, adaptation facilitates alteration in stresses and loads placed on the body. i.e increased trunk stiffness for spine stability
• BUT…too much secondary stiffness may perpetuate back pain due to increased compression forces
• Thus, variability is necessary to adapt to change in conditions/environment…

We have to match the system to the demands of the task!

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"...and in this corner"

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“Opinions on the links between back pain and motor control: The disconnect between clinical practice and research” ~ Stuart McGill

A WHOLE BUNCH OF OPINIONS (in red)

As mentioned earlier, Stu prefaced his lecture by stating that clinical groups develop preconceived notions of different researchers due to the requests they receive to speak about a specific component about their research.

• He is always asked to talk about stabilization strategies and therefore never gets a chance to talk about anything more than what they ask for
• He hazards a guess that there is actually about 95% convergence between himself, Hodges, and the various researchers within the field!

Notice the space in between…its actually larger than each of these two think!

• Lately he asks questions not on what causes pain but what takes pain away

“Its at the concentrations of stress where the tissues break down.”

“It is extremely important to ask if your patients have good days and bad days.”

• If so, you know you’re going to be successful – so find out what creates the good days!

“People get painful backs because of the way they move”

• We must assess Postures, Motions, and Loads to find out (within each variable) what
  • Causes pain
  • Takes pain away
  • Prevention and treatment therefore, can be summed up as “don’t do what hurts you!”

Postural dominance:

• Flexion (cyclists), extension (gymnasts), lateral flexion/rotation (cricket bowlers), etc
• Neutral spine is imperative to minimize shear loads
  • At spine neutral, the longissimus muscle is at 45 deg and therefore,  able to buttresses this shear
  • With spinal flexion, the longissimus is at 10 deg and therefore, unable to buttress this shear

Movement screening:

“Just because they can (perform an ideal movement upon screening), it doesn’t mean they will!”

• Movement screening may show you what they can do (i.e. deep squat) but it doesn’t necessarily show you what they will do….with the various tasks they have to perform throughout the day.
• Therefore, provocative testing must also be performed!

On using the term  chronic non-specific low back pain:

“Wouldn’t it be funny if we lumped all leg pain into “leg pain” and did a research study to determine the efficacy of various treatment approaches for “leg pain” (chiropractic care vs physical therapy vs massage therapy)”

• Note: In general, I, myself think researchers may be missing the boat on this argument altogether. That is, researching the efficacy of various treatment modalities on CNSLBP…especially since more evidence is pointing toward a weaker relationship between pain and tissue disruption/dysfunction the greater the chronicity of pain

“Muscles of the torso are fundamentally different than those of the limbs”

• Limb/extremity muscles – generate motion
• Torso muscles – stop motion
  • No such thing as agonist and antagonist in the spine. They all work together.

“The rectus abdominis, with its transverse tendons, is designed to create short range stiffness – otherwise God would have given us a hamstring!”

Quadratus Lumborum vs Gluteus Medius for lumbopelvic stability in the frontal plane:

• During the unilateral suitcase carry – McGill argues that the QL eccentrically contracts to hold the pelvis up during the swing phase as opposed to the current widespread belief that the gluteus medius is the primary stabilizer of femoral adduction during the stance phase

On the problem with performing a physical exam/assessment on a patient in jeans:

• Whether you ask them to perform a quadruped rock or straight leg raise, jeans tend to lock the hips and force the spine to move in greater ranges of motion than normal

Internal vs External Focus for Skill Transfer:

• Gabrielle Wulf: suggests that external focus in motor learning more effectively facilitates performance
• E.g. Pelvic Floor control
  • Rather than asking a patient to contract and relax their pelvic floor, he suggests one should focus on farting and preventing a fart

Insert random quote here:

“Pavel will kick you in the feet randomly and put you on your back before you even know it.”

On the Transversus Abdominis:

“Most clinicians would be more successful ignoring this muscle”

• His rationale was that stiffness and stability in the spine comes from a corset action – synergistic action between all core musculature
• That the TrA can simply be “tuned” up by raising ones voice

“I would be so bold to argue that Gluteal problems are much more dominant as a whole than the TVA”

• Karel Lewitt – push navel down and out to facilitate intraabdominal pressure. Stop drawing navel in!

On creating deep oblique training:

• Lay on one’s back with hips and knees flexed
• Breath with normal tidal volume – go to full tidal expiration – then KEEP FORCING AIR OUT

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There you have it. A recap of the lectures presented by arguably the two most prominent leading researchers in the field of spine control. I apologize for withholding personal opinion from this summary, but I felt that doing so would provide everyone with an unbiased narrative of their lectures. Tune in tomorrow for Part 3 of the 2010 Spine Control Symposium Recap as Professors McGill and Hodges “join forces” to provide a clinical update on the emerging trends in exercise management of spinal pain.

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Please be aware that the following information is based on my interpretation of each lecture and therefore, may be subject to “lost in translation”.

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“Spinal Stability: The six blind men and the elephant” ~ Peter Reeves

A Reductionist vs Systems approach to management

• Interaction of the various systems is extremely important
• It is normally difficult to target the actual cause of LBP, especially in the presence of multiple findings
  • Systems approach allows you to look into the interactions between the various findings
• He uses the popular parable, “Six blind men and the elephant” to demonstrate that focusing on just one sign or symptom of low back pain is analogous to taking a reductionist approach.

• When trying to determine if something is stable, all one has to do is apply a small perturbation and observe the response
  • Systems that are in a low energy configuration are going to be stable
  • For further explanation, please see my previous post titled “Variability for Stability“
• Feedback control is probably the most important aspect of dynamic stability and this corresponds to both positive and negative feedback.
  • For stability, we always have negative feedback control
  • But there’s more than one pathway for feedback control (voluntary and reflex)
    • Note: Unfortunately, the presence of pain and dysfunction will result in delays within the reflex pathways
• Reeves demonstrated a stick balancing example to explain feedback control for stability. He introduced this concept in a recent letter to the editor in the European Spine Journal. Essentially there are two main necessities for feedback mechanisms for stability:
  • The need for tracking – we need to know the position of the mass that we are concerned with.
  • The need to know the velocity of the mass’ movement
  • Lacking this results in an impairment in feedback control, and subsequently greater effort and / or displacement.
  • Note: impairments in feedback control are generally less significant during slow movement
• The future of his research and the heart of systems science lies in the modeling and its manipulation in the search for answers. His goal is to see how the system, aka the plant and the controller (see my “Variability for Stability” post), responds to different types of perturbations (not just one type of perturbation)

• The definition of “stability” is content dependent
  • Therefore he uses the concept of “risk of injury” instead.
  • He’s less concerned with the definition of stability and more concerned with how stability is achieved

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“Motor Control Changes and Back Pain: Chicken, Egg, neither or both?” ~ Lorimer Moseley

Central themes (in red)

“pain and spinal control abnormalities result from implicitly evaluated needs of the organism.”

• His focus was not on the relationship between spine control and back pain but on why people with back pain actually have pain.
• (Stu McGill taking notes as always)
• Aside from humans, even the most basic biological organisms (i.e. unicellular organisms) will repel away from threat…its all about protection!

Pain vs Nociception

• Pain – unpleasant conscious sensory and emotional experiences
• The purpose of pain is protection

• The purpose of nociception is to facilitate those protective devices that humans possess

Quote:

It is “seductive” to conclude that recorded activity in c fibers and a-delta fibers will result in pain.

• Role of the thalamus is to relay and prioritize information – “what is important for the brain to know RIGHT NOW?”
• The brain is modulating nociception all the time (we have about 600 neurons descending from periaqueductal gray to modulate one ascending nociceptive neuron).
• The relationship between nociception and pain is a variable one.

• Vision is purely a sensory experience and the brain modifies it.

Pain and the Brain

• Pain is an output of the brain into consciousness
• “What is the most appropriate conscious output here?”

“trunk muscle activity results from the implicitly perceived demands on the trunk.”

• Inducing experimental pain changes motor imagery performance

“we really don’t know whether motor control changes BECAUSE of pain”

– it’s a chicken and egg argument.

Considerations pertaining to the concept of nociception and protective motor control changes:

• Is it NECESSARY?
• Is it SUFFICIENT?
• *his answer was it is sufficient but it may not be necessary

Considerations pertaining to the concept of pain and protective motor control changes:

• Is it NECESSARY?
• Is it SUFFICIENT?
• *he quoted a previous paper by Hodges that stated “recurrent back pain patients in whom motor control changes are observed are often pain-free at the time of testing.

Motor control as an output of the brain to the muscles:

• The brain often asks “what are the demands on my trunk?” based on the current state, position, mobility, and vulnerability of the spine.
• Therefore, the brain can impart non-volitional motor control changes!!!

Pain as an output of the brain to the muscles:

• The brain often asks “how dangerous is this (nociceptive information) really?“
• Therefore, the brain will determine the need and presence of pain

So consequently, the brain asking itself “How Dangerous is this REALLY?” is in his view, what determines back pain.

…tune in tomorrow for Part 2 of the 2010 Spine Control Symposium Recap. You won’t want to miss the great McGill and Hodges “debate”!

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