Posture & Pain

[Mike Terrell]

Many times Barrett has stated that there is no link between posture and pain, or at least no scientific evidence. This has always been a difficult concept for me, so I went to PubMed. Below you will find several links to research studies which directly or indirectly point to "abnormal posture" as contributing factor to pain, usually spinal pain. I'm looking for comment and discussion. I'm still on the fence, not quite sure which way to jump.



http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15996890&query_hl=15&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15953751&query_hl=15&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12045525&query_hl=15&itool=pubmed_docsum


mike t

[Mike Terrell]

I intended the addresses to be hyperlinks. Not quite sure how that happened.

Call me Goofy

[Diane]

Can these studies really say, or do they really say, that abnormal posture contributes to pain, or is it merely associated with pain?

An awful lot of suppositions are made in this work about cause and effect, or what contributes to what, when in fact associations are more common.

Example: someone with lots of x-ray changes, and pain. Someone else with lots of x-ray changes, but no pain. Someone with lots of pain, no x-ray changes. No cause/effect relationship, just associations.

[nari]

Mike

The posture-thing is deeply entrenched in us.

Have you ever met someone with flexed thoracic, slack abs, protracted head, etc etc and no pain for miles?
Also someone who is model-straight and continues to have pain?
Someone with CP whose 'posture' is far from the "normal" and has no pain?

Definitely there is an association..just as someone could have a bulgy disc on CT and be symptom-free.

Somewhere along the line we have been kidded, as Diane might agree, by the military founders of the profession.

Nari

[Barrett Dorko]

Mike,

I read all three abstracts and remain unimpressed. In fact, a actual relationship between posture and pain seems to be almost entirely absent in all three. Am I misreading them?

There is also some mention of muscular activity present in one possibly painful head and neck posture. Is there an assumption made that this is the painful process? Is the brain doing the opposite of what we know it will instinctively do in response to painful signals? Why would it do that?

I respected Florence Kendall's passion, of course, but her theory was horribly flawed.

[Barrett Dorko]

Two essays related to this issue:

A Big Mistake (http://www.barrettdorko.com/a_big_mistake.htm)

The Fatal Heuristic (http://www.barrettdorko.com/articles/heurwref.htm)

[Luke Rickards]

Barrett,

I agree. The first two point toward a need for more regular movement than a need for a particular static posture. The third makes a number of suppositions - as well as proving that in so-called 'bad postures' people are more relaxed.

Luke

[stregapez]

I don't see that in the first two abstracts..

In the first one, the only statement made about a difference in pain bewteen the two groups is "The increased neck flexion angles were associated with significantly higher activity in the upper trapezius muscle and with neck and shoulder discomfort"
So, if we are to believe this implies a direct cause and effect relationship (which as Diane points out might be called into question) then there's a relationship between "bad" (ie flexed) neck posture and neck and shoulder "discomfort"

The second abstract implies a correlation between "bad" (flexed) posture and pain also. Quote : "LBP subjects sat with less hip flexion, (P=0.05), suggesting increased posterior pelvic tilt in sitting. LBP subjects postured their spines significantly closer to their end of range lumbar flexion in 'usual' sitting than the healthy controls" (again, though, it doesn't prove which came first, chicken or egg)

This one does imply that static postures *correlate* with pain "Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified."

I read the essays Barrett linked which discuss the studies sighted by the editor of the APTA journal. These studies indicate that there is no relationship between posture and pain (or posture and muscle strength), and that seems pretty impressive. The second abstract above also says that prior to that study "to date there is little empirical evidence to support that patients with back pain, posture their spines differently than pain-free subjects."

My own exeperience, which I have verified over the last few weeks, is that, for me, when sitting in a static posture at the computer, slumping results in significant low to mid back pain, whereas sitting up straight using back suport doesn't (i suppose that's not very scientific since there's only one of me)

For me, it's hard to know what to believe. Like Goofy I am stuck to the fence (and I have splinters in my butt).

Dopey

[Diane]

Again, "correlations" mean, occurring together, and "associated with" means, occurring together. Not cause and effect. That takes a lot more work/investigation to assert. Especially when there are studies that suggest otherwise. (Tweezers always worked for me.. :))

[stregapez]

I agree about the meaning of correlations

Tweezers ~ too invasive ;)

Dana

[stregapez]

Actually the study Barrett cited only addresses muscle strength and posture, not pain and posture (my bad)

Dana

[stregapez]

What might we speculate could possibly cause correlations between pain/discomfort and flexed static postures (in the two studies cited) supposing there isn't a cause and effect relationship?

Dana

[stregapez]

Mike,

There is also some mention of muscular activity present in one possibly painful head and neck posture. Is there an assumption made that this is the painful process? Is the brain doing the opposite of what we know it will instinctively do in response to painful signals? Why would it do that?


Barrett,

Forgive my ignorance here, but what will the brain instinctively do in response to painful signals?

Dana

[Luke Rickards]

Dana,

In relation to the study cited, you will notice that one group was already symptomatic.

If nerves are irritated already any prolonged static position will likely result in discomfort more quickly than in asymptomatic people. Taking the possiblities in entirely the opposite direction, we could even suppose that because a slumped seated position naturally brings extension into the upper cervical region and thus puts slack in the upper cervical nerve plexus, this position actually helps to facilitate blood flow through the plexus. Barrett's question, "Is the brain doing the opposite of what we know it will instinctively do in response to painful signals?", I think, was alluding to the fact that increased muscular activity in the upper trapezuis (as mentioned) might actually be present to bring this upper cervical extension to its complete expression, and thus correct the neural irritation responsible for the pain.

I have seen this many times when using ideomotor movement for cervical pain and headache. Much of the time patients move in various orientations of upper cervical extension before they will take the neck into flexion. Often flexion is not expressed at all.

The same goes for a 'sway back'. Again, extension might be present to increase slack in the system. I have treated many severely acute LBP patients, who can't even think about the idea of lumbar flexion, using ideomotor movement and watched a continued desire to sway the back or arch the entire spine in extension. After only 20 minutes (or so) of this full lumbar flexion is restored. (Just so the McKenzie's don't get too excited, I have also seen patients with the same presentation move straight into flexion, even thought the process is uncomforatbly painful, with the same end results.)

Luke

[stregapez]

Luke,

Now I am REALLY confused :) Maybe we're using the words extension differently or something (?) leaning over, "slumping," at the neck is what i normally think of as flexion ...What do you mean by extension of the cervical region? Do you mean putting the neck in a straight as opposed to lordotic position?

The upper traps don't facilitate that so i am doubly confused

Dana

[Luke Rickards]

To keep one's eyes looking at a computer screen while in a 'slumped' position the upper cervical spine moves into relative extension.

[nari]

Luke,

I'm glad you added the bit about the McKenzie aficionados. Actually, this corrective movement makes a bit of a sham out of the whole McKenzie thing.

It struck a neat chord with me - some time ago I developed a marked loss of flexion and a fair bit of pain due to some stupid, sustained leaning forward on both knees fighting cooch grass with roots that went to the mantle, I reckon.
I practised SC on myself and went straight into flexion. Ouch...but after about ten minutes, all was well. Full ROM, and just a small reminder from the brain not to get back to that grass...yet. Which I thought I would consciously respect for a while.

Dana,

If you sit very straight, with your head in line with the shoulders and chin tucked in as 'good' posture seems to demand, feel the trapezii; they stand up on guard with quite a bit of tension. Then let your head relax to wherever it wants to go. Those tight trapezii with the head shunted 'back' on the top vertebra might be called "shortened" and they might need "stretching". However one can't stretch out a defence mechanism permanently - it just does not happen, until the corrective position is achieved. Those tight traps are actually saying something, and it is not 'stretch me!'

Defence mechanisms such as spasms are useful; treating spasm might make a person feel better for a while, but it does not address the real issue. This applies by the way to PTs - it is not a critique of what you do when you come across sprongy bits around vertebrae...


Nari

[stregapez]

Yes, but in that first study listed above the people with the pain were more prone to be in neck flexion, right?

I would guess the upper traps are active from trying to help hold the neck up against the person willfully flexing it and keeping it in an eccentric contraction (ie both stretched and contracted) against the weight of the head (thus causing nerves to become irritated) , perhaps even somewhat subconsciously masochistically , actually, but I could be wrong, and/or missing something

I think i am going to have to go to bed. Its 3 am here ; my brain is fried

Be back later

Dana

[bernard]

Hi All,

Posture and pain is like speed and car crashes. Some are saying that speed is the primary cause but the reality is that speed aggravates the accident.

In the same way, posture is not the originator of pain, it may enhances it.

[Luke Rickards]

Dana,

It is very common for upper thoracic and lower cervical flexion to be described simply as 'neck flexion', without regard to the position of the upper cervical spine. Try to look at a computer screen with all three in flexion - it is only possible if the screen is on the floor, or you have super-strong superior rectus muscles.

Just so you are clear, erect posture is the opposite - lower cervical extension with upper cervical flexion.

If you have any experience with 'slump testing' in a pateint with LBP exhibiting signs of nerve root compression and/or dural irritation you will know just how effective upper cervical flexion is at tensioning the entire nervous system.

Luke

[Diane]

Think of an dog with a sore paw. It holds it up and gets through life for the next little while on three legs. Obviously it's "posture" seems "incorrect." Obviously some of its musculature will seem a bit too "tight." But the point is, it is protecting the paw, or perhaps more exactly, it is protecting itself against having to feel the pain in the paw as much. Or perhaps even more exactly, it's brain/motor output is defending the brain/nervous system against having to create then having to experience more pain.

The nervous system is expensive to run.. it is only 3% of the entire body but uses 20% of the oxygen, and it's purpose is survival.. of itself.. It doesn't want to spend any more than it has to and will cut corners however it can.. pain might be something it makes and spends, to save costs in the long run, costs of healing. But it likely won't make any more than it has to. Just the right amount to keep weight off the paw until the paw is better. If a cougar were to come along, chances are good that the dog's nervous system would shift over into sensing a greater threat to its survival.. sympathetics would kick in thanks to fear, suddenly the paw wouldn't hurt so much and the dog would run on 4 paws, away from certain death. Later the paw would start to hurt again, likely, and the dog (now safe) would lift its paw up again.

When the animal is a biped, this story "looks" a bit different, is all. The nervous system is still a nervous system of a mammal sort.. it still is trying to protect itself against a threat.. this time the threat of hypoxia. It doesn't want to spend more than necessary on the problem, so its motor output lifts the shoulders up a little to take the weight off the brachial plexus (as its nerve roots exit the cervical spine and gather into a net, which then separates into different cables flowing back into shoulder girdle muscles and forward and down the arm.) As the neck bends back into a deeper curve, as the back of the head gets closer to the "hump" on the upper back, the spinal cord slackens a little. A slacker nervous system will be able to have better blood flow through it, less hypoxia.

In this way, "bad" posture (i.e., shortened, crumpled looking posture, the opposite of "stand up straight" type posture) is a finding associated with pain, but not the direct cause of it.

Make any better sense yet Dana?

[Barrett Dorko]

Excellent Diane, as always. You could also use the athlete with a sprained ankle in an important game as another example.

I think it's also important to remember that Wall taught us the third stage of instinctive motor response to painful signals, resolution, would be necessary to complete full recovery. The tight/spamsed/guarded/shortened muscle palpated by generation after generation of manual practitioners is the isometric manifestation of this plan to correct the problem held in abeyance by fear of pain and/or disapproval, ignorance, self-mistrust and bad advice from therapists who don't actually know what's going on so they misinterpret what they find.

Resolution is the isotonic contraction of those muscles beyond the protective stage and it's active, of course. Any coercion, no matter how gentle, will get in its way. Handling with Simple Contact or the work with the skin described by you takes this into account and provides the therapist the requisite flexibility in technique necessary for profound and prolonged responses. Neuroscience has provided us with a sensible and defendable explanation for this, and it there that our true power resides.

Obviously, massaging the skin overlying these muscles isn't something any therapist truly understanding Wall's work would do. Therapeutic responses to that sort of work, if present at all, would be short-lived. I presume this isotonic contraction is designed to retore neural slackness as is possible. What the heck else would it be for?

It's ideomotion.

[stregapez]

Dana,

It is very common for upper thoracic and lower cervical flexion to be described simply as 'neck flexion', without regard to the position of the upper cervical spine. Try to look at a computer screen with all three in flexion - it is only possible if the screen is on the floor, or you have super-strong superior rectus muscles.

Luke

Luke,

I don't work in a office, but I have computer desk, purchased at an office supply store. If my monitior is sitting on the desk without anything under it, one way i sometimes sit (which ends up aggravating my neck) is with my thoracic spine unhunched ("straight") and my whole cervical spine bent towards the computer screen, because it is so far below my level of vision (and I am only 5' 3") This is why i have my computer screen now sitting on the thick copy of The Joy of Cooking, and ideally it should be raised a couple more inches. Granted, the people in the study have adjustable computer stations, but I can only assume the abstract is speaking of the same position I desribe above if they refer to "increased head-neck flexion angles," since it doesn't say anything about extension of the upper cervical spine

Dana

[stregapez]

Anywhere online i can find Wall's discussion of the stages of instinctual motor response to pain?

I don't mean to sound utterly "unscientific," but I would like to comment that I have had a number of people (all guys actually) tell me that they have pain, are very physically tense on on ongoing basis, but feel they "need" excessive tension because if they let go of it they won't be able to function in an unpleasant, confrontational, high-demand world.

And, for example I have distinctly observed myself, on many occassions, putting myself in to painful positions at the computer (or, less often, reading elsewhere) when i was tired, mentally frustrated, bored, and/or trying too hard (against my will, basically) to concentrate (because i thought it was important, consciously, and unconsciously thought the tension would keep me "awake," i think) Illustrating how some of us sometimes go against some of our own instincts to accomodate to civilized life.

Dana

[Mike Terrell]

I expected responses and I wasn't disappointed. Most of our therapists have been to Shirley Sahrmann's MSI courses in St. Louis. From reading previous posts on SS and RE, most of the folks reading this will significantly disagree with Sahrmann's methods, or at least disagree with the theories underlying her methods.

Having been to 2 of her courses, I can say this: you leave thinking to yourself "that made a lot of sense. They have really thought this out". When you get back to the clinic, you have system of evaluation and treatment which is relatively easy to incorporate into everyday clinic life. Once you start using her methods, you begin to see mixed results. Some improvement is seen in objective measurements, but pain does not always follow.

Sahrmann places a lot of emphasis on posture and postural correction. I have long been of the opinion that:

1) we never stand in a static, motionless posture
2) If someone has to mentally focus on maintaining a particular posture in the clinic, real world situations won't allow them that same amount of focus.
3) Even if you get someone to commit to really try to improve their posture, you are not likely to notice significant change.

So why to I keep on talking to pts. about posture?

mike t

[stregapez]

Just to clarify, the static positions i personally put myself in either when i'm feeling careless about myself mentally/emotionally and/or trying to concentarte at the wrong time, are the "slumped" postures (but i could be aberrant, i suppose)

Dana

[Barrett Dorko]

Mike,

Your question regarding why you keep focusing on posture is answered and discussed in depth in Altering the Ideal (http://www.somasimple.com/forums/showthread.php?t=2357), a thread I began earlier this month. Invite your friends in the clinic! Don't expect any party invitations in the near future if you do however.

Several Sahrmann followers were at the course I taught in Seattle last January and Chris from this board was with me there. They all spoke enthusiastically about how they wanted to follow up with him.

Last time I asked, he'd never heard a thing.

[christophb]

I wait every night by my phone... hoping for their call.

[nari]

Dana

You write about the slumped positions you end up with when you are not consciously trying to maintain tension (ie being 'straight' and 'proper').

I think your brain is trying to tell you something. If you remain slumped for too long, it will remind you to move; you sit up and it feels better.
After a while that 'nice' posture becomes uncomfortable. Time to move, or slump again, perhaps. Have a read, if you haven't already, of Barrett's Adaptive Potential article; thresholds can be changed and tolerances increased. I have a natural aversion to sitting still for more than 10 minutes; I have to move something, even if only for 5 seconds. That needs improving; but I have been that way forever; so far it's better than it used to be.

Nari

[Bas]

I still believe that prolonged static posture CAN create discomfort, but I think it is strictly due to the owner of the posture NOT being aware enough of the subtle signals of the body - not because of muscular disorders of any kind...

[stregapez]

Luke,

Dana,

If you sit very straight, with your head in line with the shoulders and chin tucked in as 'good' posture seems to demand, feel the trapezii; they stand up on guard with quite a bit of tension. Then let your head relax to wherever it wants to go. Those tight trapezii with the head shunted 'back' on the top vertebra might be called "shortened" and they might need "stretching". However one can't stretch out a defence mechanism permanently - it just does not happen, until the corrective position is achieved. Those tight traps are actually saying something, and it is not 'stretch me!'

Defence mechanisms such as spasms are useful; treating spasm might make a person feel better for a while, but it does not address the real issue. This applies by the way to PTs - it is not a critique of what you do when you come across sprongy bits around vertebrae...


Nari

I had missed this post yesterday, apparently we cross-posted the night before.

Further elaborating on my utter confusion and lack of convincedness one way or the other :yes, I see that tucking one's chin in seems to create tension in the traps (as Luke also seems to have been saying). So if we agree on that, are we not saying certain static postures do *tend* (though it may differ from one persaon to another) to increase static tension? more than other static postures? (though in this the stressor ~ tucked chin ~ is an element of the very static posture that traditionalists recommend?)

Is that (tucked chin/contracting traps) what Barrett was referring to above, by the way, as far as instinctive responses to pain?

(I scored well on reading comprehension for SATs- granted that was a long time ago :/ ...)

For the record, I've never counseled a massage client on posture, nor even though about in other people it 'til recently. Thanks to this board , and my orthopedic massage book, it's peaked my curiosity. Plus it does seem to effect me personally.

I agree prologned static "posture" (positioning?) is aggravating, period, at least for me

Dana

[stregapez]

peaked my curiosity.

Dana

"piqued" (Dana needs spell check; actually just needs to sleep well more often)


Dana

[bernard]

There is a spell checker for IE users in the edition window. :lightbulb
Just download it.

[nari]

Dana

Yes, the traditionalists recommend that we stand, sit and move in a military fashion; 2cm taller, abs tense, chin tuck, shoulders back - and somehow keep breathing. I'm sure some folk achieve this, but maybe at a cost.

Don't forget, too, that fashions in physiotherapy change, not as often as clothes do, but swing in and out of what's good and what's bad for you, depending on a majority vote taken on the latest research. Some countries still use infra-red lamps as a source of heat to fry tissues - and I'm sure it does benefit some. Placebo is everywhere, regardless of what we choose to do.

A comfortable, possibly slumped posture will be good for some and not for others. It is really up to us to tell people (patients) that what feels right for them is OK.

Nari

[stregapez]

There is a spell checker for IE users in the edition window. :lightbulb
Just download it.


mare cee bow coo

(merci beaucoup) :)

Dana

[Mike Terrell]

Nari,

Your last post is well stated. How the heck do we know? In the States we refer to that as "getting down to the nitty gritty", although I have no clue where the phrase came from. We cannot, and should not, tell someone what does and does not feel good.

If you think of Posture as the combination of position of every joint in the human body, there are almost limitless possibilities. If you then take into account the muscle, nerves, connective tissue, skin, extra fluff, as well as all the common and not so common anatomical variations of the above, we start to get into numbers with lots of zeros behind.

mike t

[Luke Rickards]

so its motor output lifts the shoulders up a little to take the weight off the brachial plexus

I've just come home from the first day of Shacklock's Upper Limb Neurodynamics course. He mentioned a very recent study that demonstrated increased EMG activity in the upper traps on neuaral tensioning of the upper limb......Direct evidence for Diane's statment.

Luke

[Barrett Dorko]

Luke,

Please remind Michael that he said he would join us here, and tell him I said hello.

Ultimately, we’re dealing with a combination of muscular activity that is perfectly appropriate given the nature of instinctive response to mechanically compromised nervous tissue (something therapists rarely if ever consider) and a culturally imposed positioning of the body that is described as both attractive and proper. Add to this our instinctive tendency to hold ourselves in positions that are meant to convey everything from submission to threat. In Las Vegas there are advertisements everywhere for the poker tournaments. They show a man looking at his opponent with this written in large letters beneath: The blanker the stare, the fatter the wallet. This is yet another strategy by that thing we call the culture to make us even less physically authentic.

Therapists call it “postural training” without ever considering any of this, and when it “looks right” to them they feel they’ve done their job. This is a sad state of affairs.

Then there’s this. In a brilliant essay by Pico Iyer in a recent issue of the Los Angeles Times (Are We a Nation of Asterics?) he writes of how Hank Aaron’s assault on Babe Ruth’s home run record was greeted with derision by many who hated the thought of a black man accomplishing such a thing. Today we see Barry Bonds attempting to break the same record amidst the catcalls of stadiums full of baseball fans. They hate the fact that his enormous strength is a consequence of steroid use.

He writes: "Yet look closer. Americans are complaining about foul play and Bonds' remaking of his body at a time when citizens are turning to Botox to erase facial lines or to Viagra to pump up their manhood. They're taking Prozac to stay happy, going to the pharmacy to regrow their hair and boosting the ratings of TV reality shows about glamorous makeovers. In such a context, it's easy to suspect that it's not baseball that's the national pastime but gaudy reinvention…. We've come a long way in 32 years, we may say, because in Bonds' case, race is not a major issue (except in the slugger's own mind). But then a weirdly over-muscled figure barrels up to the plate, the boos rise up across the nation from the artificially pumped-up and fresh-faced, and it becomes hard to say we've moved ahead at all. Perhaps it's not Bonds who needs an asterisk but 21st century America."

Wish I had said that.

[nari]

Luke

I would be very interested in new tidbits from Michael's course.

During neurodynamic Rx, I have often advised patients to elevate the shoulder to ease the pain during the day; and incorporated that action into the movements. I have found that shoulder elevation plus abduction, ER etc makes quite a difference to the pain experience after the movements are done. Then, completing abd/ER etc with shoulder neutral or even depressed is much smoother and comfortable.
Which is why I stopped telling patients to 'squeeze' the scapulae together and depress the shoulder which seems to be standard for shoulder pain. I don't think the plexus appreciates those tensioning actions...at all.

Nari

[emad]

Nari ,your last post attracted me ,you mentioned that shoulder elevation could be an easy motion for most upper quadrant patients/bracial plexus sensivity/tensioning ,however in most of my practice i ask patients to avoid elevation as technique of relaxation , i feel when the patient keeps elevation thus could put load or stress,however theortically your view is correct .

I take this chance to propose describing the opposite direction of the positive neurodynamic test ,for example if you find +ULNT1 ,then asking the patient to maintain /take opposite ULNT1 ( At least 2 motions ) .

Regards
Emad

[Diane]

I see there is a discussion going on about this right now on EIM, quite interesting actually:
http://blog.evidenceinmotion.com/evidence/2006/05/clinical_consul_4.html

[Barrett Dorko]

Yes, this is a very useful exchange. I was not surprised to see someone comment that they "just heard Florence Kendall roll over in her grave" in response to one of Jason's assertions.

Somewhere down the line we will become aware of the effects of her presence and passing. More than anything, this issue is a sociologic one - a careful look at neuroscience would have ended it long ago.

[Jason Silvernail]

Well, I came here to post the link to EIM, but I see Diane beat me to it.
I thought Britt Smith had a great post when he talked about ways to establish "causality".
Smart group over there. Reminds me of SomaSimple.
:)

J

[Diane]

Barrett,
I saw the same meme you saw. :)
Careful attention to the subtleties of what "associated with" means as opposed to "caused by" was what attracted me..

I think more adherence in general to this by Sahrmann and Kendle might not have reinforced the "sociologic illusion/:conceptual hallucination" so much. It is just as pervasive as any perceptual fantasy that exists. I agree.. so much catching up to be done in neuroscience.

Oops, hi Jason!

[Diane]

This just in from Ian: Spine. (javascript:AL_get(this, 'jour', 'Spine.');) 2002 Dec 1;27(23):2645-53. Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=12461390) Links (javascript:PopUpMenu2_Set(Menu12461390);) http://www.ncbi.nlm.nih.gov/entrez/query/egifs/http:--www.lwwonline.com-pt-pt-core-template-journal-lwwgateway-images-pmlogo.gif (http://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi?PrId=3159&uid=12461390&db=pubmed&url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0362-2436&volume=27&issue=23&spage=2645)
The impact of mental processing and pacing on spine loading: 2002 Volvo Award in biomechanics.

Davis KG (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Davis+KG%22%5BAuthor%5D), Marras WS (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Marras+WS%22%5BAuthor%5D), Heaney CA (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Heaney+CA%22%5BAuthor%5D), Waters TR (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Waters+TR%22%5BAuthor%5D), Gupta P (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Gupta+P%22%5BAuthor%5D).

Department of Environmental Health, University of Cincinnati, Ohio, USA.

STUDY DESIGN: The impact of various levels of mental processing and pacing (during lifting) on spine loading was monitored under laboratory conditions. OBJECTIVES: To explore how mental demands and pacing influence the biomechanical response and subsequent spine loading and, to determine whether individual characteristics have a modifying role in the responses. SUMMARY OF BACKGROUND DATA: Modern work often requires rapid physical exertions along with demands of mental processing (both psychosocial stressors). While the effect of physical workplace factors on spine loading has been widely documented, few studies have investigated the impact that interaction of psychosocial factors and individual factors has on spine loads. METHODS: For this study, 60 subjects lifted boxes while completing two types of mental processing tasks: 1) series tasks with decisions occurring before the act of lifting, and 2) simultaneous tasks with decisions occurring concurrently with the lift. For both of these mental processing conditions, two intensities of mental load were evaluated: simple and complex. Task pacing was also adjusted under slow and fast conditions. Finally, individual characteristics (personality and gender) were evaluated as potential modifiers. An electromyographically assisted model evaluated the three-dimensional spine loads under the experimental conditions. RESULTS: Simultaneous mental processing had the largest impact on the spine loads, with the complex intensity resulting in increases of 160 N with lateral shear, 80 N with anteroposterior shear, and 700 N with compression. Increased task pace produced greater lateral shear (by 20 N), anteroposterior shear (by 60 N), and compression loads (by 410 N). Gender and personality also influenced loadings by as much as 17%. CONCLUSIONS: Mental processing stress acted as a catalyst for the biomechanical responses, leading to intensified spine loading. Mental stress appeared to occur as a function of time pressures on task performance and resulted in less controlled movements and increases in trunk muscle coactivation. These adjustments significantly increased spine loading. These results suggest a potential mechanism for the increase in low back pain risk resulting from psychosocial stress caused by modern work demands.

PMID: 12461390 [PubMed - indexed for MEDLINE]

[BB]

So glad Ian sent in his article. I had not seen this thread.
I would like to hear what folks have to say about what I was taught by Sahrmann about posture before I became, although somewhat stubbornly, a neuronut.

She doesn't necessarily care if a curve is "abnormal" by 20 degrees or whatever unless she can somehow correlate it with painful positions/movements. For example, if someone has neck or shoulder pain, she will lift the scapula and ask for a difference. If this reduces the pain, the static posture will be significant in determining her "movement impairment syndrome" but if not, she moves on. She determines if this is part of a significant pattern through observing various movements and looking for other correlations.

Now, her explanation for how this has become a problem is what I think we can maybe discuss. I have never heard her make mention of motor control in its relation to lower brain centers, sympathetic/parasympathetic response, and she basically only acknowledges that the problem could be due to "nerve tension." This is obviously a big weakness in the theory of her approach. However, a strength could be in her explanations in regards to function. For example, if a person spends their whole day leaning to the right because the file drawer in the desk is on that side, tissues adapt over time, shortening, possibly resulting in a posture that leans to the right.

If this is the case, the shortening is not protective, but adaptive. Now, the right sided nerve roots are being compressed without relief, and an abnormal neurodynamic may be the result. I believe that Shacklock would classify this as an excessive closing dysfunction on the right.

So, is this abnormal neurodynamic the result of (cause and effect type) an adaptive posture instead of a correlation? Does this adaptation model, based on repetitive, compulsive function, hold up?

Cory

[BB]

There is a very interesting posture thread going on that I believe will likely approach my above question inevitably....

But, before this one gets too far down the list, I wanted to post my next point, not leaving it as it was in my previous post.

In our brains building of the contexts of pain, the various bits become associated with each other. The environmental surroundings, the chemical state of the body, emotional undertones, and the state of the motor system, etc. As pain is a sympathetic state, the fight/flight response gets our motor system ready to act. The movers are put on alert, the genitals protected, etc.

Since the threat causing a pain output is context driven, one aspect of that context can remind the body of the rest, ie. many triggers for pain. Thinking of the functional aspects of posture I stated above, our functional positions may cause stimulation of the motor system in ways that are similar to the motor effect of the sympathetic activation. If this is enough to remind us of a painful context...viola, we have pain.

Thinking this way, we don't need to have people memorize a million rules for every position they might find themselves in if they can learn to recognize their triggers.

Yes, no, maybe? If yes, thoughts on best ways to help them recognize?

Cory

[BB]

Oops!

Forgot to qualify that genitals remark! I was thinking about why sympathetic causes hip IR instead of using the big strong mover of the gluts, since those are the types of muscles that tend to get activated elsewhere in the body. Then I thought it was probably the sympathetic survival mechanism to protect the genitals. Thanks for that one unconcious brain centers!

Cory

[nari]

Seems logical, Cory.
The triggers you mention are referred to as neurotags - little pockets of nonconscious memory all around the brain. I think these produce pain nonconsciously; we are reminded quite sharply of previous trauma and events.
The way it works, I think is this: phobias, which many people have in some form - spiders, heights, snakes, etc -are something we know we have but probably are a result of an unfortunate encounter waaaay in the past which we may not remember.

But there are those responses we don't understand at all; like sudden pain in the back or knee for no obvious reason. The brain has perceived a threat which we do not know about and we search for reasons/causes, often with no success.

Recognising triggers or those neurotags is difficult without creating fear avoidance. Not for us, but for those patients who take on some of the rigid advice we hand out as a general rule. Fear of flexion, bad posture, the wrong chair, the wrong way to move full stop.... We know that sitting too far from the bench and stretching forward repetitively hour after hour will lead to pain; but other situations are much less easy to predict.

I'm not sure, then, if the abnormal neurodynamic could predictably result from the sort of posturing Sarhmann refers to. Certainly very repetitive neural movements such as described by Butler and Shacklock would.

Barrett?

[Diane]

Is this the thread you mean Cory?
Postural Restoration (http://www.somasimple.com/forums/showthread.php?t=2444)?

[Barrett Dorko]

Nari,

As far as I know, whether or not another hurts simply can't be seen - only heard. Even then, verbal deception, intentional or not, is rampant, especially when illness is present. The TV series House makes this point repeatedly.

I feel that therapists who claim they can "see" exactly what's wrong with their patients are fooling themselves. This is not to say that observation of certain things is useless, just that many are looking at the wrong things and overrating others. Even if we pick the right thing to assess visually (hip position, for instance), that doesn't tell us what the patient's tolerance for it is, so we don't know about the presence or absence of the sensation of pain and we have to ask. Gotta be careful about believing the answer though. In the end, clinical work is full of this sort of ambiguity. Many wish it wasn't.

In an effort to create others that please us and produce a false veneer of human perfection, pleasing apperance and supposedly predictable dysfunction and pain, symmetry is evoked if not actually worshiped.

The Altering the Ideal (http://www.somasimple.com/forums/showthread.php?t=2357) thread is specifically about this.

[BB]

Diane,
Yes, I was referring to the Postural Restoration thread. I think that if Oliver returns and attempts to answer the "why does asymetry cause pain" in a neural language, this will be a likely direction of discussion.

Nari,
I agree with you about teaching avoidance of trigger positions will almost certainly lead to fear avoidance. A better way to say what I meant would be to teach them to be aware of when the trigger response has been activated, become a better listener to their body responses. Holding the breath or shallow breathing, tightening of certain muscles such as hip IRors, etc. Once they can recognize this, they can learn to stop the cycle, and proceed, without necessarily having to withdraw.

Hopefully, then we are not promoting symetry, but instead responsiveness.

Also, I think the only thing that we can predict based on the repetitive positions is tissue stress, and even this would be a very complicated equation. And since tissue stress does not correspond directly to pain it would be impossible to predict the conclusion of pain. I guess that is my personal conclusion to my first question. Hopefully, Oliver will bring us his.

Barrett,
I wonder how you interpret the ambiguity and use it (as you imply that the ambiguity being present is OK).
I'm curious if you take the verbal description, deceptive or not, as an indicator of what value or explanation has been placed on the situation instead of an accurate account of the situation itself?

Cory

[nari]

Barrett,

True.
I think I too have said before that many PTs treat only what they see or think they see; which is why ideomotion is less acceptable than, say, a method which addresses a joint or a segment that looks 'wrong' according to a norm.

The problem is, the 'norm' is elusive and its values vary according to cultural factors and personal attributes. I don't think we will ever reach the point of establishing normative values for anything, let alone how a person looks or moves.

After all, a few centuries ago, a fat woman was considered to be ideal and the perfect choice for art work.....;) Now we admire only beanstalks...

Nari

[Barrett Dorko]

Cory,

OK or not, ambiguity is inevitable. My best guess is that all of this is true at one time or another, unpredictably.

I appreciate how much thought you're putting into its interpretation, but this seems beyond me. Please let me know if you ever figure this out. I'll probably still be here.

[Nick]

Good posture is a dynamic behaviour, not a static position.

[Luke Rickards]

On a current affairs program tonight they had an Aussi physio plugging his new invention -Spinalsensa.
SpinalSensa is a patented medical device developed to treat back pain by monitoring the patient’s spinal curvature and providing feedback to the wearer when curvature is at a pre-determined, inappropriate level.
You stick it onto your lower back and it beeps and vibrates when you move into a 'bad' posture.

Well, now the problem of pain has been solved I had better go back to uni and do accountancy or something.:confused:

[Jon Newman]

Luke,

The posture police have their final instrument--their "harrow". What's fascinating is that there is an appreciation for the fact that posture is a behavior. What I don't understand is why reducing the repertoire of behaviors is adaptive.

[nari]

If I had a Spinalsensa attached to me, it would squawk most of the day.
I think I would be a nervous (pun intended) wreck after a few hours.

Why do so many PTs desire to be control freaks? (rhetorical question).

Nari

PS I checked out Spinalsensa on google Oz - it's all about business and moneymaking, and it won the award in Texas.

[Randy Dixon]

I remember on a thread about a year ago in talking about posture and giving patients cuing, Barrett asked: What are we going to do next, shock them?

I think he meant it as a joke.

[bernard]

Spinalsensa? :confused:

I prefer this latino version => The SpinalSalsa (http://www.justsalsa.com/salsa/dance/steps/)

More pleasurable with this music (http://www.justsalsa.com/music/tracks/sopadepichon.mp3). :D

[Jason Silvernail]

I see now. The problem is that people just aren't getting enough instruction about how to move from the culture, that they need this Spinalsensa device to give them additional feedback. I'm sure that will be very helpful for pain...
:sad:

J