Neutral Spinal Posture

[Nick]

I just came from a lecture by a physiatrist on the myths of low back pain. Much of the talk was based on the work of Stuart McGill, a biomechanist from U. of Waterloo in Ontario, Canada. He has researched and written a lot on the compressive and shear forces on the spine in various positions and with various loads. Never a mention of the nervous system, however. Unless talking about a disc pressing on a nerve. A huge emphasis is placed on maintaining neutral spinal posture and developing endurance (rather than strength) in the spinal stabilizers in order to maintain this position at all times. Flexion is apparently most dangerous in the morning due to the extra hydration of that ever-dangerous disc. Oh - apparently MRI shows how extension resolves a herniated disc as well. Mckenzie has been right all these years after all! A little bit of extension will solve those disc problems no sweat. Then just teach them to never flex and they're all set. Pain solved!

So what are all you people so worried about the nerves and the brain for?

Nick

[nari]

Nick

First question of interest (and it is a rhetorical one, beware)

How does one maintain a neutral spine and still live an active life without thinking consistently about core stabilisers? Sounds like a recipe for neurolysis.

The one about the risk of flexion in the morning is straight out of McKenzie, as you would know anyway. Gotta give those discs time to rehydrate after all that horizontal stuff overnight....don't go out and get the paper until 1000 hrs. And do not feed the dog!

Aren't you glad you went to the talk?

Nari

[Nick]

Nope...not so glad I wasted an hour>

Check out this link:
http://www.backfitpro.com/recent%20articles/Enhancing%20back%20performance%20with%20super%20stiffness.pdf

Any thoughts on what "Super Stiffness" would do to neurodynamics?

Nick

[nari]

So now we are all super athletes..no, sailboats with rigid rigging.

Another case of forgetting the brain.

Nari

[Jason Silvernail]

Well, this is my main issue with McGill's work as well. He does great biomechanics, and I like his books because they are well-referenced.
As a model of spine biomechanics, his books are great.

I read once that a model has the option of being right, but irrelevant, and this is a perfect example.

In the US Army, we frequently do full situps, and early morning is our usual physical training time. I'm no fan of situps, but you would think after reading his books that every soldier would develop disc troubles in a few weeks while following this regime.
I do still treat many patients biomechanically (from nervous system unloading standpoint primarily), and his work has been helpful to me in that regard.

But his overall statement about uber-choreographed spinal postures is over the top, I think.
Plus there's this - what does biomechanics have to do with pain? Oh, yeah, very little...
J

[Nick]

Jason,

I figured you would have something to say on this and thank you for your response.

I agree that McGill's body math is interesting. For me it all adds up to - well, nothing. Irrelevant is a good word.

How has his work been helpful to you in biomechanically unloading the nervous system?

In the PGAP materials mentioned in another thread, in a section on fear of movement, there was a picture of someone standing against a wall with a straight line to show neutral posture while they put on their pants! An "advanced" manual therapist at the lecture this evening talked about her patients that feel great when they wake up only to feel pain when they bend over to put on their slippers. Her solution: get slip ons! Aaaaaarrrggh!

Why don't people realize that some discs that look quite horrible don't hurt at all???

And yes, I am frustrated.

Nick

[Diane]

Sounds like having mental Harrington rods installed.

[Jason Silvernail]

Well, I think that many therapists mistake his copious and impressive research in biomechanics as credentials for treating pain. It doesn't help that he states as much in his books, claiming expertise in back treatment and rehabilitation, and talking about all the rehab programs he's seen that include things that are biomechanically "bad" for the spine - like full situps. What therapist in their right mind ever prescribes those anyway??

His concepts have been helpful in unloading the nervous system through giving me a new perspective on how to design and progress spinal stabilization programs. However, I don't sell these programs to patients as a lifetime project, as he seems to do. I talk about unloading the relevant painful tissue for it to heal, and to build adaptive potential through motor control retraining and progressive stability challenges.

I think that for people who believe in their heart of hearts that lower back pain is purely biomechanical, he represents the ultimate goal for them - how "to know" biomechanics and thus provide the most appropriate care. I don't doubt that that's important - I treat many patients from a mechanical standpoint, usually those with some relevant pathology and not an essential diagnosis of abnormal neurodynamic - but again to see it as the "be-all, end-all" of care is rather silly. People here might like to know that his research has burst some sacred bubbles in manual therapy - such as specificity of Lx manipulation for example:

Spine. 2004 Jul 1;29(13):1452-7. Related Articles, Links

Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific?

Ross JK, Bereznick DE, McGill SM.

Spine Biomechanics Laboratory, Faculty of Applied Health Sciences, Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.

STUDY DESIGN: Sixty-four asymptomatic participants, ranging in age from 22 to 49 years, volunteered to act as patients for the study. Twenty-eight different clinicians performed thoracic and lumbar spinal manipulative procedures. The range of clinical experience was 1 to 43 years. OBJECTIVES: The purpose of this study is to first locate the joints that produce an audible sound in response to manipulation (cavitation) during spinal manipulative procedures so that the accuracy and specificity of manipulation can be assessed. SUMMARY OF BACKGROUND DATA: Clinicians utilizing spinal manipulative therapy (SMT) claim to be very specific and accurate with the delivery of their dynamic thrust. It has been suggested that the clinical success of SMT is dependent on the accurate delivery of that therapy to the target spinal joints. METHODS: Asymptomatic participants received SMT to either the thoracic or lumbar regions of their spine. Accelerometers were secured to the skin over the spinal column, and the relative time at which each accelerometer detected the vibration from the cavitation associated with the SMT was used to calculate the source of the vibration. The site of cavitation was then compared with the target location. RESULTS: For lumbar SMT, the average error from target of 124 cavitations in lumbar procedures was 5.29 cm (at least one vertebra away from target), with a range of 0 to 14 cm. Of these cavitations, 57 were deemed to be accurate and 67 were deemed to be inaccurate. The average error from target of 54 cavitations in the thoracic spine was 3.5 cm, with a range of 0 to 9.5 cm. Of these cavitations, 29 were deemed to be accurate and 25 were deemed to be inaccurate. In most cases, individual manipulative procedures were associated with multiple cavitations ranging from 2 to 6. CONCLUSIONS: In the lumbar spine, SMT was accurate about half the time. However, because most procedures were associated with multiple cavitations, in most cases, at least one cavitation emanated from the target joints. In the thoracic spine, SMT appears to be more accurate.

So I do think the man has some relevant information, and he makes some good logical points on biomechanics in his books - even discusses the highly variable nature of individual mechanical stress tolerance and at least pays lip service to biopsychosocial aspects. I think if a neuronut wanted to get an idea of what the best and brightest orthonut was saying about low back pain, his book is a worthwhile read. It's good to read things we don't necessarily agree with anyway, right?
J

[Diane]

Good points Jason.
I think the way the nervous system gets 'lost in translation' and eclipsed by mesodermic considerations is at the very moment biomechanics is taken on as something "real" rather than as a symbolic language describing function.

[Nick]

Diane,

That's a good point about biomechanics. Testing rarely describes real life situations. As Nari pointed out, it is difficult to be functional with your spine in neutral. IMO, biomechanical understanding of the spine has led to little more than fear of movement. How do they explain all those people who have horrible looking spines that do not hurt? Why is neural tissue ignored in terms of its biomechanics? It would seem that it can only be compressed by those nasty bulging tires called discs.

Nick

[bernard]

http://www.somasimple.com/flash_anims/abd05.swf

As "medical" observers we want to know within the above movie when pain will happen. The only available response is that we do not really know.

[Diane]

Bernard, what a nice cartoon of what happens to the skeletal parts when the antigravity muscles (not shown) are inhibited. :)

[bernard]

Diane,

I'm a bit surprized by your response! ;) A French Rheumatologist Professor said it was the innate fate of Humankind. Man is unable to stand up without being agressed by OA and gravitation. :thumbs_do

Vey, Nature failed with Man.
Hmmm, I prefer the Feldenkrais explanation. :lightbulb

[Diane]

I hear you Bernard. Shirley Sahrmann loves to talk about life being the "Long March to Stenosis"... amazing the sort of images are conjured up by biomechanics thinking. :rolleyes:

[nari]

Also the problem with that sort of mechanical thinking is the gloom and doom aspect so loved by the medical model. eg:

Joints degenerate and there is not much we can do about it except replace them or operate and send them to physio to have the iatrogenic effects sorted out....etc etc

Wouldn't it be nice if Bernard's little video was shown to every student in their final year and the question asked:

At what point does pain (and dysfunction) start?

If some know the answer, they're fibbing.

Nari

[bernard]

Nari,
It is possible to use this one too which is showing the "normal" aging of spine. It is a condensed life (70 years) of a disc and vertebras in few seconds.
http://www.somasimple.com/flash_anims/lumbardiane06.swf

[nari]

Bernard
I think it would confirm too many beliefs about collapsing spines and intractable pain....but it is cute.

Nari

[Diane]

Is it gravity? Dehydration? Or is it that the neuro-arrayed body suit starts to lose it's antigravity capacities due to some bits going off-line, possibly not irreversibly? I'm thinking, maybe disc height needn't be lost if people did their ideomotor movement regularly..

[bernard]

Diane,

It is just a "mythical" movie. It has nothing to see with real world but it is largely promoted by Healthcare. Just fate!

It is a biomechanical movie. It works only if the owner doesn't react or is convinced that it will happen. :eek:

[Bas]

Maybe it is just a fact of life - dehydration...collapsed curves....saggy skin....grey hair...has really nothing to do with pain or dysfunction, does it? Biomechanical theories and studies are to people as stats are to individuals - useless on a personal scale. Possibly interesting from an epidemiological view, but not very valuable therapeutically. I respect McGill for his research, but have a GREAT concern about his "therapeutic suggestions" - not a whisper of PNS/CNS aspects - not a peep about WHAT exercises exactly are supposed to accomplish and how that is....No, interesting, but quite unimportant as far as I am concerned. And yes: that IS blasphemy at this time in Canada.....

[nari]

It's rather like suggesting people sleep prone to prevent ageing-kyphosis. (Mind you, plenty of people sleep prone without any neck problems at all)

The funny/peculiar thing is, that without XRs, nobody would know that disc height decreases, and foramina narrow a bit...and we would go back to thinking some people, as they age, develop back pain. Or they develop back pain at 18...or 34...or 69....years of age.

A normal spine is in the eyes of the beholder who has read too many anatomy books and worries about deviations. (Diane (and some others!) is definitely excluded from that sweeping statement) :) :)

Nari

[Jon Newman]

If someone's understanding of painful conditions stops at the ideal spine or posture, it makes sense then than they view their job description similar to a border guard; turning back anyone trying to move east of Eden. It seems to me that ignoring the developments and advances in medical sciences is to miss a huge piece of the evidence.

[Jason Silvernail]

Absolutely, Jon.

But I think most practitioners really understand so little about pain and the biopsychosocial model that all they understand is biomechanics. So that's the way they treat. And I think, McGill in many ways represents the "Gold Standard" of biomechanical thinking. As I said before, his model is entirely correct, but in many ways irrelevant.

I think those doing research on education and CBT approaches have some catching up to do, so to speak, as far as getting the base of evidence in some large cohort or RCT studies, to help swing the pendulum the other way. I have to say, this sort of thing does seem to be happening.

PT students I get now seem to understand a bit more about neuroscience and the biopsychosocial paradigm - certainly an encouraging sign...

J

[Diane]

Nari,
A normal spine is in the eyes of the beholder who has read too many anatomy books and worries about deviations. Thank you for excluding me.
Really, I think the opposite. Such people are mesmerized by the spine, and if they look at an anatomy book, go to a dissection class, or venture out conceptually into the body at all it's to look at more joints.

No one pays attention to the minutiae, to all the other stuff in there, the tubing and piping and drain systems and how all this physiologically important stuff has to wend its way from top to bottom, how it takes anastomotic twists around large joints, becoming more horizontal, how it has to dive through so many contractile trampoline-like sheets, or slide around their edges, and change direction, and no one pays any attention to how embedded the nervous system is everywhere throughout it. No one cares! No one cares about skin! No one cares that the brain cares about the skin!

Thanks to Butler and Shacklock we have gotten a collective picture in our heads about at least the main neural cables coming into arms; before it was only ever the sciatic nerve that seemed to have any sway over the imagination. We haven't been feeding our brains everything there is to know about the body; forget the viscera for now, we are still woefully, collectively ignorant about the somatic nervous system's physicality; most of us still don't get that the PNS branches and bends and splits into infinitestimally tiny twigs and that the cutaneous portion, length for length, appears to be WAY bigger than the motor portion, and more acutely branched.

After our boot camp PT training in neuro rehab many of us want to forget about the brain as fast as possible in order to have a practice within manual therapy civilization, "hanging out at the spine", from the beginning of career to the end of it, never looking left or right off the freeway. No one wants to explore the jungle of the organism, for various reasons. No one cares. All that is for massage therapists or else a dumping ground for MDs to wade through in their own peculiar highly orderly and controlling way, in their special medical hip-waders; PTs seem to not care much for anything out there but the skeleton, and telling people how to use their own bungee cords to lift it around.

The osetopathic profession mapped out a lot about the periphery for manual therapy, a hundred years ago, and yes, left an awful lot of funny ideas behind. Most went on to enhance mythology. No one has ever thought it was very important for manual therapists to know much more about anything other than the spine, especially manual therapists ourselves, probably thanks to the chiro contingent; they have charismatically paved the way for a long time, set the tone for imagination, perceptual fantasy, conceptual hallucination, and probably more besides as they create a manual therapy culture that puts any fanciful idea together with any other fanciful idea and says it doesn't matter - if it works, it works. And the busiest place for that is at the spine. But how? HOW does it work? How does it all work together? Glad to hear Jason's students are keener, are they being encouraged by you Jason, to not clutter their hard drive up TOO much with what is proving to be irrelevant?

ignoring the developments and advances in medical sciences is to miss a huge piece of the evidence. YES! Jon. If practitioners went off the freeway more often, and took a look at everything that's out there, in detail, saw a deeper pattern than biomechanics operating, more fluid, less bone, there would be way less confusion, and if pain relief was seen as the main goal instead of an annoyance in the way of good biomechanics, more people would be happier with our care. The dusty old trails of the periphery marked by the osteos is a place to start. I don't mean a great place to start, or that their maps are great, I mean they are all we have at the moment, and badly need retrofitting with pain/brain science, updating, and serious conceptual pruning. We need a few dedicated types who aren't happy being clinicians only, to take notes and make some new maps.

[Nick]

Hi Diane,

I don't know about the West Coast, but completing Osteopathic training is becoming the "in" thing in the physio and massage community here in Halifax. It will no doubt improve technique, since they are learning gentle approaches and massage therapists will move more and rub less; HOWEVER, the funny ideas are being passed along BIG time as well. I'm of the mind that one should learn the science and then practice in a way that makes sense and be prepared to change in light of new information. It is really the individual's or group's philosophy of pain that determines what constitutes evidence. Yes, the osteopaths have some interesting ideas and have made some contributions, but there is too much nonsense. And it's damn hard to re-educate someone who has fallen for this meme.

I cannot imagine that osteopathic training is going to advance things much more than myofascial release courses. And all those bogus theories surrounding non-coercive care only ensure that the biomechanical joint-heads will never listen to why that might be a good way to approach treating someone in pain.

Nick

[Diane]

So much work, so little time. :rolleyes:

[nari]

Diane, I think you misunderstood me.
I was excluding you (and others) who are keen on anatomy trails but see much more than bone and muscle.
Someone I was talking to recently was stretching out a patient's psoas, showing them where it was on a muscle picture, and saying it would improve posture and back pain if it were longer. That bothers me in the sense that all she was thinking of, was muscle length...

Nari