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!

Related posts:

1. 2010 Spine Control Symposium Recap: Part 2 A recap of the presentations put forth by Paul Hodges...
2. 2010 Spine Control Symposium Recap: Part 1 A recap of the presentations put forth by Peter Reeves...
3. 2010 Spinal Control Symposium – Toronto McGill, Moseley, Hodges, Reeves...

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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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Sure surgical interventions are dependent on the goals and functional capacity of the individual but most of us generally correlate surgery with ACL injuries, no? I mean, I thought PCL and MCL injuries were the only ones that didn’t require an operation (that was sarcasm by the way).

Well Roos (a prominent knee researcher) and colleagues recently published a paper on non-elite athletes, outlining that there were relatively little differences between in functional capacity and return to physical activity between their control and experimental groups.

Here’s an excellent summary of the study’s findings.

Surgery Might Not be Needed for ACL Tears.

To read the full paper, click here

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• In a study of Div III collegiate athletes by Chichanowski et al, 13 females who were diagnosed with unilateral “patello-femoral pain” were found to have significantly weaker hip abductor and external rotator muscle groups of the injured lower extremity.

• In a study of 15 females with “patellofemoral pain” by Ireland et al, hip abduction strength and hip external rotation strength were found to be significantly less than age-matched controls.

• Robinson and Nee’s study of 10 females who sought physical therapy for unilateral knee pain demonstrated significantly less hip extension, abduction, and external rotation strength than the same number of control subjects with no known knee pathology.

• Average hip abductor (glute medius) torque in 24 distance runners with ITBS was found by Fredericson et al to be significantly weaker than that of the uninjured limb and controls.

• Hewitt et al‘s review of ACL injuries in Females reported a number of studies that demonstrated decreased gluteal muscle activity and/or ability to absorb ground reaction forces by the hip musculature during landing in females who sustained ACL injuries than in uninjured athletes.

• Hewitt et al’s prospective study on predictors of ACL injury risk in females demonstrated significant hip and knee neuromuscular control differences than their controls.

So although “the glutes may not be firing” may indeed be an incorrect way of approaching such musculature, in my opinion ignoring their importance in injury prevention, rehabilitation, and sport performance may not be entirely accurate.

…but that’s just my opinion!

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This is a fantastic issue with topics such as Thoracic Outlet Syndrome, Neurodynamic testing for Carpal Tunnel Syndrome, and Reciprocal Inhibition (stretching), among others. I highly recommend anyone and everyone in manual therapy and rehabilitation to check it out.

On another note, I just received word that my case study on “costochondritis” has been accepted for publication. That makes two papers in press…AWESOME!

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Joe Przytula recently posted some highlights from the Athletic Trainers’ Society of New Jersey’s (ATSNJ) concussion summit of which Dr. Robert Cantu was the keynote speaker. Here are his notes (as taken directly from his blog):

• VERY important the athlete is permitted appropriate time for healing to take place.
• There is no set number of concussions that is a disqualification for further participation in contact sports.
• 2 man wedge tackling, blindside hits rule changes in American football are in order.
• No way to predict CTE in a live person; lawyers should not be driving decision making.
• Concussion accounts for 6-10% of all athletic injuries. The reported ones are just the tip of the iceberg. Subconcussive blows and their effect is an unknown factor.
• Loss of consciousness is not a good indicator of degree of brain injury.
• You don’t need to grade a concussion to manage them efficiently.
• Time to recovery is a good indicator for risk in subsequent concussions.
• When a player shows any symptoms of concussion, they should discontinue participation at least for that day.
• The cornerstone of concussion management is physical and cognitive rest until symptoms resolve.
• Prolonged post concussion syndrome (1m+) is usually associated with playing with a pevious head injury prior to the concussion.
• Concussion Research- Journal of Neural Trauma: http://www.liebertonline.com/toc/neu/27/7
• Many concussions occur at lower force, 60G’s and below. The new NFL helmet recommendations are suspect because they involved testing at higher G’s. Head and spine biomechanist specialists were not used in the study.
• Since every concussion is different, is legislating concussion guidelines a good idea?

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Here is one of his texts from my Amazon store.

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Functional rehabilitation of chronic ankle instability effective by Phil Page, PhD PT ATC

Platelet-rich plasma for muscle injuries by Alex Hutchinson, PhD

Two great studies on muscle cramps by Joe Przytula, ATC

Rotator Cuff EMG During Daily Activities by Mike Reinold, DPT ATC

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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, look out for 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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The above question is just one reason why I am looking forward to the 7th Interdisciplinary World Congress on Low Back and Pelvic Pain. Among other “questions”, answers (or at least directions) to the above will be addressed throughout this congress. Here’s a look at the preliminary program.

What are your thoughts on the above question?

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• The data from this study came from two sources (firefighters and kinesiology students).

• The main objective of this study was to assess the relationship between the V-sit test and the plank test for torso flexion endurance.

• The pearson correlation was r=0.34 (low correlation) as well as the r-squared value. It almost seems obvious that these two wouldn’t correlate well as they are two totally different positions.

I think the main reason McGill did this study was because people were using the PLANK test in place of the V-SIT to test flexion endurance (which has plenty of data correlating poor endurance times with low back disorders).

• The moral of the story is to use the V-sit when doing your tests for flexion endurance.

• He also cautioned against “training the test” due to the high compressive loads.

I do not have an image of the V-Sit test but can send you a copy of the full article if you would like. Just reply below with your email and I’ll shoot it over.

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