More core stability

[Jon Newman]

Ian asked me to post this link (http://cpdo.net/), especially for the powerpoint on core stability. Enjoy. I wonder if Dr. Lederman would be interested in putting this powerpoint up on physioshare?

[Barrett Dorko]

Wow.

I understand from Stan Paris that the only lecture he regularly gives these days is on "spinal stabilization." One of the reasons I hope that we can get him to participate here, or at least register, is to get his reaction to something like this. Assuming he doesn't have a heart attack, his response would certainly make all of us grow a little, and that's the purpose of Soma Simple, according to me.

This light-hearted "heart attack" comment isn't made all that lightly, by the way. If someone ever puts together as concise and well-supported a Power Point presentation on "The Myth of Ideomotion" that is how I plan on reacting, but that's just me. I doubt Stanley would take this challenge in such a fashion.

Then again, silence says a lot as well.

[nari]

I just wish there were more folk like Eyal Lederman around to publicly put some leaking holes in the treasured theories of physical therapy.

Though I figure that Jason could soon be another credible broacher of the EBP net?


Nari

[Carlos]

Prof. Eyal Lederman has a heap of courses being run in London. If I manage to get to any I will post any interesting points.

Do we have a space on this forum for course listings ?

Carlos

[Diane]

Carlos, if you scroll further down (the entire SomaSimple Index Page) there is a forum called Courses, Training, Conferences. You can post his workshops there. If you can't find it, here's a link (http://www.somasimple.com/forums/forumdisplay.php?f=21).

I wish Eyal Lederman lived closer to B.C.

[bernard]

Here is the file.
I enabled the ppt extension.

[Randy Dixon]

I don't know, I only saw one thing in there that disputed what I have learned about core stability training, that is the contention that because TrA isn't very active in standing posture that specific contraction can return it to typical activation patterns. I don't follow that argument, because the claim isn't that TrA is highly active in standing posture, only that it is inhibited in CLBP and that this interferes with normal activation patterns.


I suppose there are those who are following the strengthen the abdominals to prevent back pain, or either tense or suck in the stomach to protect the back but these concepts are pretty widely considered outdated. It looks to me like he is fighting yesterday's war.

[bernard]

Randy,

many cLBP have their TrA inhibited because they changed their breathing pattern.

Just ask/see around you how the fitness classes "make" their abds work. Often they hold breath and tighten their buttock. Try to walk with a flat belly and an pinched ass. A misery.

BTW, the core strengthening is yet a reference in Europe. Many PTs entertain a robotic behaviour in the LBP population.

[Diane]

Yeah.. Randy, the war might be yesterday's, but I'm still getting refugees coming in with pain, straight from their various pilates classes, etc., worried about their "core strength"... some of them are fitness instructors even. Guess they never got that message that the "war" is over. (Ever try deconstructing a fitness instructor?) About the breathing, they cannot eccentrically lengthen their abs at all. Bernard is right, they are in (physiological) misery.

[emad]

Carl:

Looking forward to seeing what you have of articles regarding stability .

Cheers
Emad

[nari]

I think the whole core stability concept has grown like Topsy and is out of control. More people go to gyms than to PT, I reckon, and the fitness instructors seem to follow the 'more is better' philosophy.
What with the anxiety fostered by not being 'good enough' with core work, and the resultant tension created by overzealousness, it may even have a longer term negative effect on the systems. That would not have been the intention of Hodges et al.

Nari

[Barrett Dorko]

I talk to all sorts of physical therapists. Believe me, there's nothing "yesterday" about the issues deconstructed here. Nothing.

[Jason Silvernail]

I think if anything helps me feel better about "core stabilization" it's that both myself and those doing the research in this area use the term "stabilization" a lot less and are using "motor control" more.

While those really thinking and reading feel that Prof Lederman is fighting yesterday's war (and they're right), the cat is out of the bag and far too many people are doing, and will continue to do "core strengthening", so Barrett is right as well. I've seen this both in the fitness world (those folks aren't educated enough to really understand most of what they're doing anyway) and sadly in the PT world as well.

There is some evidence to support generalized core strengthening exercises, but everyone really thinking about it knows it has everything to do with CBT and little to do with "strengthening".

I struggle intellectually with the concept of lumbar stabilization classes that are so prevalent in every PT clinic I've ever been to (full disclosure, I've started many of those programs), but when it's recast to motor control, the theory is a lot more tenable. I would be interested in a head to head trial of ideomotion vs motor control exercise, but that trial is many years away, I suspect. I've a few case studies and series to write first. :)

J

[nari]

I dunno....I just googled 'physiotherapy' and 'core stability'. Zillions of hits, and the first page was full of UK physio sites advocating isolated TA and M strengthening. Almost nothing about motor control. One UK physioclinic was describing slipped discs in detail as well as promoting core strengthening...

Jason, I would think that the potential study you mention would finally stop Topsy growing...but by that time maybe the TA obsession will have been replaced by something else entirely different.

Nari

[Barrett Dorko]

It's always interesting to ask a therapist who advocates isolated TA strengthening what Jull and Hodges actually said. I've yet to meet one who can say with any semblence of accuracy.

This new meme succeeded because it didn't have to battle any of the old ones in our profession - it reinforced them. Thus, the TA people faced no opposition from the PT culture. The tipping point was reached at light speed and its momentum remains undiminished, despite Jason's noticing a shift in terminology.

I was recently sent this description of a workshop to be offered at a state chapter meeting: "Utilizing Real-Time Ultrasound Imaging for Lumbo-Pelvic Stabilization."

The course will train participants to assess and retrain 'local' muscle dysfunction's of the lumbopelvic region, specifically, the transversus abdominis, lumbar multifidus, diaphragm, and pelvic floor musculature. Participants will be trained in the principles and parameters of real-time ultrasound to produce proper images for the clinical assessment and recruitment in lumbo-pelvic stabilization.



I'm certain they will pack them in. Bottom line: We're dead men.

[Jon Newman]

Here's another:

Description
Chronic low back pain is an epidemic phenomenon in our healthcare system. Join your colleagues in this hands-on course that will incorporate the latest evidence for the clinical examination and interventions for patients suspected to have lumbar instability. Spend two days advancing your examination and diagnostic skills to accurately identify patients likely to benefit from a stabilization approach. An update on the latest evidence from clinical trials involving core stabilization will be provided, with a focus on the application of spinal stabilization strategies and functional progression to optimize outcomes of care. Extensive laboratory sessions are included throughout.


And here's a video (http://www.evidenceinmotion.com/vidclips/player.html) you might see at the course

[ian s]

Just imagine rolling this out to the epidemic of lbp-- the cost would be enormous and bears no relationship to how people live there lives.......Teaching people to 'breath' makes more sense ....however the placebo factor would be enormous with this kind of intervention. I think the course will be very popular ?

[nari]

Could not view the video (as usual) but I have seen RTUS in action.

Doesn't the whole thing sound like a megamoneymaking exercise based on a somewhat shaky premise?

Nari

[Diane]

Nari, I think the whole production is more a "gee whiz look what we can see, and use as a "research tool" to wedge in under the PT profession to prop it up a bit more." In my part of the globe Diane Lee is famous for making US studies like this. For awhile she imaged bladders while having postpartum women try to contract their TrAs. Nice that someone has time and interest to do such things, definitely nothing I'm even remotely interested in or see the point of, really, for the rest of us. I'm thinking the premises are shaky and the conclusions will be moot, as is usually the case with PT research based on mesodermal thinking.

[nari]

Diane, I think you are right - it may be more of a case of thinking -wow, look what we can do with technologyrather than considering the actual value for clinical purposes.

Nari

[fapt]

Hi, Jon Newman
Thanks your link...lol
BTW I have got the book on the web site
I am so lucky...this new book is at my department libary:teeth:
Lucky!!!!!

[Bas]

Jon, thanks for that video link. It reminded me of technical instruction videos when I was in the army......seriously dull, not connected to anything human, focused on detail, and generally of no value (my opinion) - other than occasionally: " ok, that's kinda cool to see".

Like Jason, I was deep into core coordination (was core strength, then core-stability, and then: core-coordination) - from 1989 when I took a course for pediatric therapy with "swiss" balls. This started me on core work. I have learned a huge amount thanks to that interest, but I am now moving away from the "prescription" mode. Now, the patient and I "play" with the balls, and breathe on the balls; there seems to be an aspect of physical enjoyment of motion, that is much deeper than the training aspect of core exercises. I have the feeling that the effects are quite different as well.

[Randy Dixon]

US imaging of muscle of little practical value? I find that hard to believe. Imagine that coupled with fMRI of the brain.

[Diane]

OK, Randy, I'm really trying to imagine that. Can you elaborate on how you see that being of practical value?

[Mike Terrell]

I have recently finished reading Therapeutic Exercise for Lumbopelvic Stabilization, by Richardson, Hodges, and Hide, so I thought I should share some thoughts on their work.

1) Jason is correct, in that, the authors focus much more on motor control and less on core strength. They spend a decent bit of time focusing on how ineffective, inefficient and potentially dangerous global co-contractions are.

2) The evidence they present for abnormal firing patterns in persons w/ and w/o LBP is decent, but not conclusive. There are some issues with the amount of timing differences as well as the consistency of these timing differences.

3) From my POV, their treatment methods don't make logical sense. They progress pts. from supine/prone isolated lumbopelvic stabilizer contractions, to functional movements with a focus on lumbopelvic stabilization (neutral spine), to non-weightbearing exercise with a focus on maintaining a neutral spine while performing a variety of LE movements. My major issue is that I never see anyone moving in a manner that they describe, very robotic and stiff. Doesn't seem to happen in the real world.

4) The authors do describe outcome studies where subjects who received motor control training had a decreased likelihood of recurrence of LBP.

5) They do have an outwardly reasonable theory, based on good basic science as well as clinical/applied science. They are not promoting treatment on a method with no basis in current knowledge.

This is my impression, open for discussion.

mike t

[Randy Dixon]

Diane,

I see it advancing our knowledge of what happens and how it happens tremendously. In your treatment approach you try to feel muscles relaxing/moving and assume that it is the result of brain activity. With the combination of US-fMRI you would be able to know if that is actually the case, what areas of the brain are being affected and what muscles are actually doing, rather than just guessing. This holds true for almost any treatment approach, it also opens up whole new avenues in biofeedback approaches.

[Diane]

Randy, if only it were so easy. I'm looking at a book right now about movement and fMRI in a thread (http://www.somasimple.com/forums/showthread.php?p=20987#post20987) in the Moving Right Along forum. I've included notes from a book, Motor Control in Voluntary Movements (published 2005). In post #1 are notes on a long elucidation by the authors that explain the various constraints they have to make and careful interpretations of fMRI imaging.
2.1 Introduction
- VAST number of functional neuroimaging studies that have reported motor cortex activation in existence
- can't really say they advance all knowledge of the functional organization and response properties of the motor cortex; their contribution to understanding the motor cortex is small yet significant especially re: human motor cortex
- in examining these studies constraints/parameters were found necessary

- FIRST constraint: a focus on studies that used MRI as the functional imaging modality because of its noninvasiveness, and because its sensitivity is high enough to permit analyses that invert the usual direction of inference, i.e. from the neurophysioogy to behavior.
- SECOND constraint: studies with a focus on feasibility and methodological optimization were eliminated

- DOWNSIDE: fMRI not only exquisitely sensitve to the hemodynamic signals associated with the neural activity related to movements, but unfortunately also to the direct effects of motion.
1. have to eliminate studies of walking;
2. overt limb movement or even mere changes in muscle tone readily translate into shifts of the brain relative to the machine's imaging coordinates.. slight shifts result in devastating effects on image quality far more complex than merre displacement accounts for, not readily compensated for by simple realignment algorithms.
- therefore few successful studies exist on movements of facial, proximal or axial muscles
- a few exist on respiration and facial functions such as speaking/swallowing
- THIRD constraint therefore: most of the work is done on movements of the distal upper extremity

-FOURTH constraint: this overview omits many valuable studies that have integrated imaging of motor cortex activation into clinical context whether presurgical mapping or postlesional plasticity, influence of other disease conditions or pharmacological effects

- FIFTH constraint: despite multitude of "motor" areas in the brain focus is on studies dealing with or involving effects on activity in M1, although other motor areas are mentioned

"The purpose and hopefully the result of this chapter is to provide the reader with an overview of the contribution of fMRI to some of the prevailing topics in the study of motor control and of primary motor cortex function."
- when findings seem to disagree with those of other modalities it cannot always be related to insufficient sensitivity of this non-invasive modality
- these studies remain informative by virtue of the fact that usually the whole brain is covered
- this provides a plausibility control for localized effects
- the distribution of response foci and relation of effects observed at different sites can assist the guidance of detailed studies at the mesoscopic or microscopic spatio-temporal level
"Even when denying any single current neuroscience method a gold standard status, an adequately modest view should probably conclude that fMRI currently is mostly a tool of exploratory rather than explanatory value."

That's the state of the science just now.. maybe some day what you envision will be possible. Meanwhile, US imaging seems like it's being done mostly for research. Or as a v-e-r-y over-the-top form of visual feedback, clinically. Which is part of the point of this thread.. why focus so hard on trying to get the perfect isolated movement when out there in the real world movement is complex and done by the whole brain and body, to accomplish a purpose, and feedback must be kinesthetic? Why not work the kinesthetic awareness, teach people to do abdominal breathing, and maintain awareness of that (if anything) while doing functional things or nonconscious nonchoreographed movement?

[Jon Newman]

I think when someone labels something as an "optimal" contraction that they need to define that it is indeed optimal, what it is optimal for and go on to demonstrate that this contraction is responsible for subsequent changes in a sensory experience--assuming that it is being used to change a sensory experience.

It also makes me wonder if those that are particularly good at contracting specific muscles would likewise not suffer from chronic pains. I'm thinking the body building population should have a low prevalence of chronic pain. Anyone know?

[Diane]

Another thought about US and its visualization capacity, Michael Shacklock used it to show nerve movement at the wrist, and ankle. He made little movies and put them on a CD that comes inside his book. So, for educational purposes it can be useful.. depends what you are "visualizing" and what idea you are trying to support. Like Jon points out what exactly is meant by an "optimal contraction"? Why should I care? On the other hand, seeing the median nerve slide through the wrist when the head is sidebending, is cool.