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  • core stabilization

    Being a new grad, I have learned and been using the drawing-in-maneuver to activate the TA in patients who might benefit from stabilization exercises. I was interested if anybody has any clinical opinions about instructing patients in utilizing the drawing-in-Maneuver VS. abdominal bracing.
    Thanks

  • #2
    Dear NS Birak,
    Bear in mind that there is very little evidence to show that AH is stabilizing. Whereas, there is a wealth of evidence to support that abd bracing is stabilizing. Of course what you do is dependent on what you are after. You may wish to change an activation pattern & that might be a different matter.

    Thanks,
    Craig

    Comment


    • #3
      McGill has co- authored some good research on this:

      http://www.jelectromyographykinesiol...084-8/abstract

      seems that the 'drawing-in" is not as good as it was initially assumed.

      What you have to find out first is: IS there instability? (Can do you do that reliably?)
      Then: What drives the instability?
      And then: Is stabilizing the spine going to "fix" the problem that the patient has? (i.e. pain)
      We don't see things as they are, we see things as WE are - Anais Nin

      I suppose it's easier to believe something than it is to understand it.
      Cmdr. Chris Hadfield on rise of poor / pseudo science

      Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

      We don't need a body to feel a body. Ronald Melzack

      Comment


      • #4
        Welcome Neal! Thanks for stopping in. Don't hold it against him, but Neal was recently a student at our facility.
        Rod Henderson, PT, ScD, OCS
        It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift

        Comment


        • #5
          ...there is a wealth of evidence to support that abd bracing is stabilizing.
          This statement, I think, begs references, not to mention operational definitions of "wealth," "evidence," "abd bracing" and "stabilizing." I think new grads deserve some explication of terms.

          As it is, within the context of patients with low back pain (which is the one I assume this new PT is involved), this statement to me is about as meaningless as any I've heard.

          Here is a very meaningful and exhaustive review of the current literature regarding "core stabilization" by Professor Eyal Lederman.

          Once you have participated here some more, Neal, you will be able to access this article via this link. However, something tells me that your former CI may be able to dispatch a copy to you.
          John Ware, PT
          Fellow of the American Academy of Orthopedic Manual Physical Therapists
          "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
          “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
          be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

          Comment


          • #6
            Yes, Craig's was NOT a statement of fact as I understand the term - it was an unsupported, seemingly lofty, and yes, meaningless pronouncement.

            Maybe good enough for other forums, but not here.
            Barrett L. Dorko

            Comment


            • #7
              In fact, it is a statement of fact. Stability has been thoroughly investigated in particular by Pr McGill at his lab at the Univ of Waterloo. And, Abd Bracing in numerous investigations was found to stabilize the spine. This is not a conjecture but a scientific fact proven by biomechanical investigation.

              What is not mentioned by me is if that is proven to help a patient. That is a seperate issue which has been addressed by researchers from the Univ of Pittsburgh & Utah and they have concluded that their are clinical prediction rules for which patients are most likely to respond to stabilization exercise vs manipulation vs directional preference training.

              Lederman's work is neither a meta-analysis, scientific study, or RCT. It is however a very interesting, provocative read.

              Thanks,
              Craig

              Comment


              • #8
                Here are a few of the references:
                Liebenson, C., Karpowicz, A., Brown, S., Howarth, S., McGill, S.M. (2009) The active straight leg raise test and lumbar spine stability. Physical Medicine and Rehabilitation. 1 (6): 530-535.
                Grenier, S.G., and McGill, S.M. (2007) Quantification of lumbar stability using two different abdominal activation strategies. Arch. Phys. Med. & Rehab., 88(1):54-62.
                Vera-Garcia, F., Elvira, J.L.L., Brown, S.H.M., McGill, S.M. (2007) Effects of abdominal stabilization manoeuvres on the control of spine motion and stability against sudden trunk loading perturbations. J. EMG and Kines., 17:556-567.
                Brown*, S.H.M., Vera-Garcia, F.J., McGill, S.M. (2007) Effects of abdominal bracing on the externally pre-loaded trunk: Implications for spine stability. SPINE, 31:E387-398.
                Brown*, S.H.M., Vera-Garcia, F.J., McGill, S.M. (2006) Effects of abdominal muscle coactivation on the externally pre-loaded trunk: Variations in Motor Control and its effects on spine stability. SPINE, 31(13): E387-393.
                Vera-Garcia, F.J., Brown, S.H.M., Gray, J.R., and McGill, S.M. (2006) Effects of different levels of torso coactivation on trunk muscular and kinematic responses to posteriorly applied sudden loads. Clinical Biomechanics, 21(5): 443-455.
                Brown*, S.H. and McGill, S.M. (2005) Muscle force-stiffness characteristics influence joint stability. Clin. Biomech., 20(9): 917-922.
                Hicks, G.E., Fritz, J.M., Delitto, A., and McGill, S.M. (2005) Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch. Phys. Med. and Rehab., 86(9): 1753-1762.
                Howarth*, S.J., Allison, A.E., Grenier, S., Cholewicki, J., and McGill, S.M. (2004) On the implications of interpreting the stability index: A spine example. J. Biomech., 37(8):1147-1154.
                Kavcic*, N., Grenier, S.G., and McGill, S.M. (2004) Quantifying tissue loads and spine stability while performing commonly prescribed low back stabilization exercises. Spine., 29(20): 2319-2329.
                McGill, S.M. (2004) Linking latest knowledge of injury mechanisms and spine function to the prevention of low back disorders. J. Electromyography and Kines., 14(1):43-47.
                Kavcic*, N., Grenier, S., and McGill, S. (2004) Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine, 29(11):1254-1265.

                McGill, S.M., Grenier, S., Kavcic, N., Cholewicki, J. (2003) Coordination of muscle activity to assure stability of the lumbar spine. Journal of Electromyography and Kines. 13:353-359.

                Comment


                • #9
                  Craig,
                  Who do you think Neal is treating with abdominal drawing in maneuvers?

                  Your statement may be factual, but it is nonetheless meaningless to our new grad working with LBP patients. Do you disagree?
                  John Ware, PT
                  Fellow of the American Academy of Orthopedic Manual Physical Therapists
                  "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                  “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                  be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                  Comment


                  • #10
                    John,
                    The references were for Barrett since he claimed there was no evidence for my statement. I believe "lofty" does not apply to me. I believe we know very little.

                    Thanks
                    Craig

                    Comment


                    • #11
                      And, Abd Bracing in numerous investigations was found to stabilize the spine.
                      that their are clinical prediction rules for which patients are most likely to respond to stabilization exercise vs manipulation vs directional preference training.
                      I think the point John is making (not that he needs clarification but I've the same concern) is that the jump from McGill's findings of the trunk muscles contributing to active stiffness to an intervention approach aimed at creating stiffness, requires an assumption that the stabilization of spinal segments is the relevant target of intervention for pain.

                      It may be that the "stabilization" exercises are an active agent in decreasing pain despite the paradigm being incorrect and I think Lederman does a nice job of demonstrating refutation of the theories derived from that paradigm.

                      Lederman's work is neither a meta-analysis, scientific study, or RCT. It is however a very interesting, provocative read.
                      Do you find anything in his peice to refute, Craig?
                      Cory Blickenstaff, PT, OCS

                      Pain Science and Sensibility Podcast
                      Leaps and Bounds Blog
                      My youtube channel

                      Comment


                      • #12
                        Craig,
                        I know that Barrett always chooses each word carefully before he comments, and I have to agree with his use of the term "lofty."

                        You made a statement about solid evidence behind abdominal bracing for stiffening the spine closely juxtaposed to a discussion about the use of this treatment for LBP. I think anyone reading this thread would infer that you think there's evidence that having patients with LBP perform this activity is well-grounded in the research. And it simply isn't. You seem to be extrapolating from biomechanical research.

                        So, I think you're listing off research that is irrelevant to the question proposed by our new grad. Some may perceive this as a lofty attempt to appear erudite while detracting from the relevant clinical situation in which most of us practice.
                        John Ware, PT
                        Fellow of the American Academy of Orthopedic Manual Physical Therapists
                        "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                        “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                        be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                        Comment


                        • #13
                          You're holding up well Craig.
                          Thanks for your carefully worded distinction between biomechanical stability and actual clinical utility - this is an important point that not many people grasp.
                          Certainly not Pr McGill for example - his texts frequently conflate the two.

                          Neal-
                          For heavy lifts I teach bracing.
                          For recovery from low back pain I teach hollowing - though I don't see the "stability" construct as useful.
                          You might enjoy threads here called "The Useless Core Strengthening" and "Crossing the Chasm - Meso to Ecto".
                          They can be found with the search function above. And welcome by the way.
                          Jason Silvernail DPT, DSc, FAAOMPT
                          Board-Certified in Orthopedic Physical Therapy
                          Fellowship-Trained in Orthopedic Manual Therapy

                          Certified Strength and Conditioning Specialist


                          The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                          Comment


                          • #14
                            Originally posted by Jason Silvernail View Post
                            You're holding up well Craig.
                            Thanks for your carefully worded distinction between biomechanical stability and actual clinical utility - this is an important point that not many people grasp.
                            Certainly not Pr McGill for example - his texts frequently conflate the two.

                            Neal-
                            For heavy lifts I teach bracing.
                            For recovery from low back pain I teach hollowing - though I don't see the "stability" construct as useful.
                            You might enjoy threads here called "The Useless Core Strengthening" and "Crossing the Chasm - Meso to Ecto".
                            They can be found with the search function above. And welcome by the way.
                            I was about to write something similar. It seems, to me, that there's a significant difference between consciously bracing to reduce the chances of tissue damage (working out, playing a contact sport, etc.) and bracing as part of a treatment intervention plan to relieve pain.
                            ________
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                            Last edited by regnalt deux; 30-01-2011, 04:49 AM.
                            “Don’t believe everything you think.”

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                            • #15
                              Maybe this might be a better question. What have the clinicians determined to be the best method to help relieve low back PAIN when working with patients who fit into the stabilization category?

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