2010 Spine Control Symposium Recap: Part 2

On Saturday, August 28, 2010, I had the privilege of attending the spine control symposium put forth by the University of Queensland's Centre of Clinical Research Excellence in Spinal Pain, Injury & Health. This was a must symposium for all professionals in the rehabilitation injury who manage low back pain and with the constant growth and debate pertaining to the research in this field, I am truly thankful for such an opportunity to expand my knowledge. As such, I also believe that it is my responsibility to relay that information onto my colleagues and will make an attempt to do so below.

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.

'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!


"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!
  

• 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 Lewit – 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

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.