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Do Biomechanics Matter?

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  • #61
    Originally posted by Johnny_Nada View Post
    I had a meeting last night where a PT tossed the Lederman paper in front of another, *more experienced*, PT who happened to be trained in Pilates and attributed all of her clinical success to focusing on the core.

    I just sat back and, as Barrett would say, was silent.

    The response was predictable.

    I think there are certain people you just can't challenge or engage with new ideas, and I've pretty much stopped trying.
    Ryan Appell DPT
    @Rappell_PT

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    • #62
      Originally posted by FrustratedNewGrad View Post
      Today in our clinic meeting we went over core stability exercises. A lot of it was focused on how to cue the patient to contract their transverse abdominis and also how to maintain that contraction with particular movements of the extremities. Progressions were talked about. A lot of it was quite hard to do. How do we get 80 year old Ethel with low back pain to contract their TA? Does it even matter?

      The transverse abdominis along with the multifidi are talked about routinely as the keys to "core stability". How much core stability do we actually need? How does it relate to pain? Why are we training these muscles in rigid positions? When we move, we don't keep our trunks rigid.

      One therapist always tell me if the pain is bilateral in the extremities you always have to look at their core strength. I watched as he and his student worked with one of my patients with bilateral knee OA. She doesn't have any pain, she's just really weak and needs to get stronger and has already responded pretty well to a general strengthening program of her LE. Meanwhile, they taught her "how to engage her core" because I guess they determined that was missing from my program. Is teaching her how to engage her TA really that important?
      I'm starting to think you are making this stuff up.

      Seriously.

      I mean this whole "core stability" garbage has been refuted ad nauseam now for over a decade. I good place to start would be:

      http://www.cpdo.net/Lederman_The_myt..._stability.pdf

      Would you simply invite your colleague to participate here? Sounds like they are unethically not keeping themselves current.

      Yes...I said unethically.

      Invite them here so we can better understand what the heck is going on at your clinic.

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      • #63
        This clinic is a common one.

        It takes decades to change a culture, if at all, and the ideas shared by this therapist have a tremendous weight behind them.
        Barrett L. Dorko

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        • #64
          Originally posted by proud View Post
          I'm starting to think you are making this stuff up.

          Seriously.

          I mean this whole "core stability" garbage has been refuted ad nauseam now for over a decade. I good place to start would be:

          http://www.cpdo.net/Lederman_The_myt..._stability.pdf

          Would you simply invite your colleague to participate here? Sounds like they are unethically not keeping themselves current.

          Yes...I said unethically.

          Invite them here so we can better understand what the heck is going on at your clinic.
          Are you actually surprised by the description of these clinicians proud? I see this stuff every single day and have for the last 5 years.
          Ryan Appell DPT
          @Rappell_PT

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          • #65
            Nothing has sold so well as the concept of "core stability" since I've been in practice. I began in 1973.

            It is still being taught and will be for a long time to come because of the money involved and the power of the culture that has embraced it. I suppose.

            Discussion seems off the table.

            As Upton Sinclair said early in the last century:

            It is difficult to get a man to understand something when his salary depends upon his not understanding it.
            Barrett L. Dorko

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            • #66
              I wish I could say I was making it up. Not a single therapist refuted anything said. I held my tongue.

              One of the therapists who gets on my nerves also attempts to correct my posture all the time. I want to tell him to F off.

              These therapists are very stuck on old school beliefs.

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              • #67
                I have questions regarding thoracic outlet syndrome.

                For some reason I've gotten 3 in the past month. The last one today had a prescription from the MD for rotator cuff tendonitis. Did he actually look at or touch the patient?

                How would you treat something like this. I mean it's definitely a biomechanical issue no? The compression of the the nervous and/or vascular tissue in the thoracic outlet is what causes the symptoms. Can we actually relieve the compression with exercises and manual therapy?

                Of course my colleagues say you can and I took their recommendations just because I wouldn't know how to treat it as a "ectodermist" (?) would.

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                • #68
                  Originally posted by Ryan A View Post
                  Are you actually surprised by the description of these clinicians proud? I see this stuff every single day and have for the last 5 years.
                  Well on reflection I guess I am not surprised. I would just like to think that in what sound like a fairly large clinic there would be at least one other clinician who is not a complete dullard.

                  Then again, I know supposed top of the pile orthopaedic manual therapists (their own crown)....called FCAMPT in Canada....who STILL blabber on about TA and multifidus and the importance of recruiting them.

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                  • #69
                    Frustrated,

                    Ask your colleagues if they've ever heard of The Enlightenment and see if they look it up or if they understand anything about its effect on Thomas Jefferson. One of the Fathers of my country.

                    Please don't get punched too hard.

                    We need you.
                    Barrett L. Dorko

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                    • #70
                      Mel would often say that these core folk were a product of what he referred to as DAFT-Dark Ages of Fitness Training.

                      "Why then continue with all of this isolationist emphasis on "core stability"? Why not simply accept that the core and periphery always operate interactively and that drills which involve the whole body in a manner which is closer to what is required in a given sport are more than adequate to improve sporting prowess? It is virtually impossible to train the core without the crucial involvement of the periphery, all under central nervous control, so why not bury the inappropriate and inaccurate term, "core stability" and simply refer to balance and agility training as one component of Motor learning? It would appear that proliferation of such terminology serves commercialized professionals far more than science and practice."

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                      • #71
                        I've often thought that the older therapists who practice this way and have success with their antiquated ways are only successful because they somehow convince their patients to stay with them long enough so that natural history takes it's course.

                        The older clinician's belief and perceived skill and wisdom will make a patient stay longer even if they are not really improving much. Someone like me who can't even grow full facial hair and questions everything they do just doesn't get the same level of adherence.

                        Comment


                        • #72
                          Frustrated,

                          This whole "core" thing started with Hodges work detailing the function of the transverse abdominals and the multifidae (sp?) while looking at cases of spinal pain. In Australia, by the way. Have I got that right Diane?

                          It was run with by the "abdominal strengthening" industry and the rest is history.

                          I know what I know about "thoracic outlet" pain, shoulder pain and complaints of this area from many places. I'd recommend that you see the video on Jason Silvernail's Facebook page recently.
                          Barrett L. Dorko

                          Comment


                          • #73
                            A relevant extract from a recent paper by Wirth et al. (2016) on core stability:

                            "No proof has been found for special training exercises for deeper core or segmented stabilizing muscles. We were unable to find any diagnosis or articles reporting selective deficits of these muscles in strength-trained athletes (this is for core muscles with similar functions as described above, not for a comparison between flexors and extensors). Therefore, we wonder which type of data led to the demand for specific exercises to strengthen, in particular, the deeper trunk muscles or improve the ability to selectively activate them. Furthermore, there is no evidence that classical strength-training exercises, for example, squat, deadlift, snatch, and clean and jerk, affect ‘global’ muscles only or lead to imbalances between the muscles of the trunk. Data proving this hypothesis do not exist for (back pain) patients, healthy controls, or athletes. Studies inspecting EMG recordings of several core muscles have shown simultaneous activity that varied in extent and on- and offset depending on the motor task. This is why stressing the importance of a few single muscles is not justified, and classification into ‘local’ and ‘global’ muscle groups is inappropriate. Therefore, we recommend the use of classical strength-training exercises as these provide the necessary stimuli to induce the desired adaptations."

                            As for your patient's outcomes, another relevant extract from an article by Hartman (2009):

                            "Occasionally, purposeful clinical treatment leads directly to symptom improvement. More often, patients and practitioners award credit to a particular therapy when healing is unrelated (or even imaginary). Independent of any specific treatment, measurable signs and symptoms often improve, due to the self-correcting course of many diseases; regression to the mean; placebo effects; and other factors coincident with (but directly unrelated to) treatment. Even more worrisome, symptom improvement may be only imagined, consequent to various forms of confirmation bias, and peripheral factors leading to psychological palliation.

                            Any one of these confounding factors, by itself, renders uncontrolled judgments of direct clinical efficacy unreliable. Taken together, their influence is hard to overstate. When you treat a patient, apparent outcomes often will be influenced by real, physiological changes directly unrelated to treatment, and various forms of wishful thinking. Not only can these factors lead to erroneous perception of efficacy, but they should be expected to."

                            I would highly recommend reading the Hartman paper at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770065/. In particular the section "Confirmation bias and self-fulfilling prophecy". I feel that this explains my experience with many clinicians (myself included!)

                            References:

                            Hartman SE. Why do ineffective treatments seem helpful? A brief review. Chiropr Osteopat. 2009;17:10. doi:10.1186/1746-1340-17-10.

                            Wirth K, Hartmann H, Mickel C, Szilvas E, Keiner M, Sander A. Core Stability in Athletes: A Critical Analysis of Current Guidelines. Sports Med. 2016. doi:10.1007/s40279-016-0597-7.

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                            • #74
                              I really appreciate the feedback I'm getting. You have no idea how much of a relief it is for me to hear these replies.

                              This website really keeps me from going off the deep end.

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                              • #75
                                These therapists are very stuck on old school beliefs.
                                and run a successful clinic(?) - where is the momentum for any change?

                                and if there was would the clinic be any more successful?


                                ANdy
                                "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

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