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How do you explain TA contraction to your patients.
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How do you explain TA contraction to your patients. - July 31, 2008 9:11:32 PM
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Kaden
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I ask b/c I get tired of the amount of talking I need to do to explain the concept of TA and thought I would see if others have developed a stream lined method.
I feel it is important to at least provide some evidence as to why this works in a sub group of patients but often find myself talking until I am blue in the face.
So, I thought I would ask how others go about doing this is a more efficient manner.
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RE: How do you explain TA contraction to your patients. - July 31, 2008 9:45:30 PM
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TexasOrtho
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Sup Kaden. I used to have the same trouble. I worked as a technician for a group of PT's back in the mid-90's when TA was all the rave. I honestly never came up with a really good way of describing it adequately, BUT I think it's ok as I'm not sure emphasizing TA activity makes a huge difference. I focus on the movements more than specific muscle activity which is much easier for my mind to communicate. It doesn't seem to have detracted from the treatments and keeps me from looking like an idiot (barely).
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: How do you explain TA contraction to your patients. - August 1, 2008 3:28:35 PM
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Kaden
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I guess I have a hard time emphasizing moving away from teaching TA. I don't know how much I buy into the original stabilization theory but to me that doesn't matter much as there are plenty of good studies out there demonstrating that TA in a certain sub group does decrease pain, improve function, and decrease low back episodes more so than not teaching TA.
So, if you are focusing on the movement, how do you know TA is firning correctly. I guess I am not ready to give up on TA b/c for me it has worked and the evidence supports it use. I am just ready to give up on the long winded explanation, but then I find I get poorer follow through from patients when they don't understand the "why" of something they are doing.
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RE: How do you explain TA contraction to your patients. - August 1, 2008 4:21:03 PM
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Sebastian Asselbergs
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From: Barrie, Canada
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Kaden, I can understand that it is hard to let go of this concept, but HOW do you know your patient has deficient TrA? Conversely, HOW do you know that those who actually GET your explanation, end up using or activating it?
If you use palpation - however poor the support is for that - then you can use that technique to check after a Rod-like session: movement. If you use ultrasound for TrA insufficiency determination, you can use it again after the movement.....Then there is needle EMG...
In all three cases, you can test for Rod's (and incidentally, mine) approach to "back" patients - motion. Just pick your reassessment tool and check.
_____________________________
Mundi vult decipi
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RE: How do you explain TA contraction to your patients. - August 1, 2008 6:45:33 PM
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Kaden
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can you expand on what you mean by focusing on the movements. Are you having them do similar stabilization activities that typically follow TA work or something completely different. What cues do you give to make the movement focused.
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RE: How do you explain TA contraction to your patients. - August 1, 2008 9:04:41 PM
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TexasOrtho
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Kaden. I will first look at a movement such as a bridge, sit-stand, or other compound movement. I'll look for what I believe to be a discoordinated movement between the LE's, pelvis, and spine. I don't cue them - I just say "I want you to perform this movement" and I'll demonstrate with what I consider to be good form.
I will give them several repetitions to just understand the movement. Most of the time, in the absence of severe pain, they figure out the best way for their body to complete the movement. I allow for deviations from the 'norms' because most bodies are deviations from norms. I'll correct signifciant significant pelvic deviations if they are present, BUT I find that if pain is adequately managed, the patient is able to do this without me having to explain it to them. People who we call 'motor morons' sometimes need more cuing than in active or athletic populations, but even then I try to keep the cuing at a minimum. I think the body provides sufficient cuing to recruit the right muscles at the right time. What causes the changes we see is often pain induced. Again, when the pain is adequately managed, the solution get's simpler.
The example I'll use to explain this to students is gait training. I don't have to explain to the patient what walking is or how to walk. If I get their pain levels under control, their gait pattern often corrects itself without a ton of extra cuing from me. Now they may need some if they've had a gait disturbance for a long time. However, my approach to is to allow the patients body to select the most appropriate movement pattern. Minimal extrinsic cuing for maximum intrinsic output.
If I provide any physical cuing in the rare occaision I don't think the trunk is recruiting enough muscle, I will provide resistance to the movement. (eg pressing down on the ASIS during a bridge or pulling the knee anteriorly durng stance) The body will usually increase the force output in response and the patient develops a better intrinsic understanding of the movement.
I'm not sure if that explains it adequately, but that's how I've worked around the TrA construct that I never wholly bought into to begin with. I came from an exercise/motor learning background and the isolated TrA activity never completely fit within my understanding of motor control.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: How do you explain TA contraction to your patients. - August 2, 2008 11:14:02 AM
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torques
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From: Marion, IN
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 Hi Kaden,
My own way of instructing lumbar stabilization is based on theoretical concept of locking the lumbopelvic region. Position: Quadruped:Action: "Draw the belly button in and up. Imagine putting on and closing a tight pants" TrA contraction holds the ilium in a posterior tilt position in reference to the hip joint . I find it easy for patient to initiate TrA contraction (just palpate medial to ASIS to assess proper activation).Lumbar Multifidus (LM) activation is a little tricky but the way I instruct patients is "tilting the sacral base while holding the ilia in posterior tilt as described above" I do of course give them visual on the structure and dynamics of the screw home mechanism of the SI. I palpate just above the PSIS to assess its contraction. Finally, I have them do pelvic floor contraction: Kegel (assess contraction infero medial to the ILA). First session is just being aware of each contraction and integration of these 3 contraction at the same time. Frequency of home exercise:10 sec hold x 10 reps every 2 hours in at least 2 or 3 positions: prone, hooklying, quadruped, sitting, standing. Emphasize proper lumbopelvic neutral in different position before performing the exercise. In sitting, I instruct the patient to sit anterior on the ischial tuberosity. Assess muscle endurance (usually patient with weak core cant hold it >10 sec). If patient is able to perform cocontraction of these muscles effectively for 10 sec or more, I advance the training to phase 2 which is lumbopelvic stabilization while doing leg or arm movements. Advance as needed, I consider if the patient has any position bias. Patient with pain in flexion, I do Phase II in Quadruped. Patient with pain in extension: hooklying or sitting works well in my experience. This regimen works well with patient with clinical instability syndrome: pain with prolonged static position, relief with movement, active mobility:exhibit aberrant motion: instability jog, +Gower sign, Special test: positive in any of these test: vertical compression test, prone resisted hip flexor test, prone instability test et al. Hypermobility and provocation with PAIVM or PPIVIM (highly sensitive and specific). Neuro test sometimes shows impaired DTR. Assess hip muscle length especially hamstrings,hip flexors and gluteal muscles. Here are good reading materials:
Hicks GE, Fritz JM, Delitto A, Mischock J. Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Archive of Physical Medicine and Rehabilitation. 2003;84:1858-1864
Richardson CA and Jull GA. Muscle Control-pain control. What exercise would you prescribed? Manual Therapy. 1995; 1:2-1
Great Course: Hanney W. Testing, Facilitation, Training for Core stability. Integrated Clinical Solutions. 2005.
Hodges PW, Richardson CA. Inefficient Muscular Stabilization of the Lumbar Spine Associated with Low Back Pain: A motor Control Evaluation of Transversus Abdominis. Spine. 1996; 21(22):2640-2650.
Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994; 19:165-172.
Hides JA, Richardson CA, Julls GA. Multifudus muscle recovery is not automatic after resolution of acute, first episode low back pain. Spine. 1996; 21:2763-2769.
Hides JA, Stanton WR, McMahon S, Sims K, Richardson CA. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. JOSPT. 2008; 38(3): 101-108.
Hope this post help...
Julius Quezon PT MTC CPed
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RE: How do you explain TA contraction to your patients. - August 3, 2008 5:34:16 PM
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KAK
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Hi Kaden,
First I explain the anatomy of the transverse abdominus (the fibers run horizontally and connect to the fascia posteriorly). I also show them a picture in an anatomy book. I explain that it is the deepest abdominal muscle and acts as a natural corset, if you will. I explain that when they are isolating this muscle there should be no movement of their spine or pelvis. I also explain that if they raise their chest- they are compensating with their diaphragm. I start supine and have them palpate just inferior and inside the ASIS. I explain that they should feel a subtle movement under their fingers. If they are contracting more superficial muscles they will feel a rapid forceful movement. I put a BP cuff under their lumbar region to give them feed back so they don’t do a posterior tilt. This explanation, though it seemed long to type, doesn’t take long at all- maybe the picture saves a few words.
Basically my instructions are summarized as (this is what I give them to take home):
-draw belly button in toward spine
-do not move spine or pelvis
-do not raise chest
- do not hold your breath
Most get the concept right away…for some it takes a bit of concentration and practice to perform it correctly.
Kathy
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RE: How do you explain TA contraction to your patients. - August 3, 2008 7:11:23 PM
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Kaden
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Torques, thanks for the reply. I progress patients though phases in similar ways you do.
KaK, I would tend to explain things similar to your method, I have just grown tired of the constant amounth of blathering it takes to explain the anatomy and the research behind. Some patients seem to not care while I know others would not do it if I did not explain the why.
Rod,
I like your example with the bridge and agree that if you correct the big stuff and allow them to learn how to move pain free then ultimately they will find the most efficient method for their body.
However, with your method or Sebastians are we not ignoring some nice evidence out there that shows emphasizing TA results in decreased frequency of back pain episiodes and better outcomes overall compared to control group with stabilization exercises.
One may not by the theory put out there about what TA does but there is plenty of evidence to support that emphasizing it in a stabilization program improves outcomes. Not saying I disagree with your thoughts on this subject (as I would rather go your route and ingore TA) but what does the evidence say.
If I had a patient meet all four lumbar spinal manipulation CPR criteria and chose not to manip (b/c I didn't agree with the theory behind the rule) I am sure I would catch a lot of flack for ignoring the evidence. How is doing the same thing with TA any different.
Granted there are not CPR's specifically for when we should use TA but there are developing CPR's for stabilization training (don't think it is offically published yet) and combined with the evidence showing what is the most effective stabilization model (TA and MF) it seems to me we should not so easily discard b/c one doesn't by into the theory.
Does the theory matter or does sound reproducible research showing improved outcoms matter?
Food for thought.
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RE: How do you explain TA contraction to your patients. - August 3, 2008 7:38:04 PM
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TexasOrtho
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In this case I'd need to review the literature that an emphasis on TA contraction improves outcomes. Then I'd really need to look closely at the methodology of the study. I'm just not convinced that selective trunk activation of specific muscles leads to major changes in outcomes. There may be a population who would benefit from specifically targeting the TA. I just have a difficult time thinking there's a HUGE difference in outcomes emphasizing vs not emphasizing TA. My intuition and just basic observation has lead me in other directions.
There is some pretty good data out there suggesting that LBP can improve regardless of what exercise program is chosen. We still have some work to do before we can say one way is better than the other.
I would like to review the literature on this issue however as I may have formed my opinion on this before some better data on it came out. I certainly don't see any harm in it whatsoever, so go for what seems reasonable. I just focus on other aspects of the movements. Go for what seems to work for you. It's a good question Kaden and I don't have the answers. Looks like time for me to do a little reading!
< Message edited by TexasOrtho -- August 3, 2008 7:43:59 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: How do you explain TA contraction to your patients. - August 3, 2008 8:03:26 PM
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Kaden
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Agreed Rod. Probably needs to be some more specific research to outline criteria for those who specifically need TA (or if TA is valuable at all) versus just a focus on stabilization activities, or nothing at all.
I will have to browse the literature again, but I swear there is evidence grouping TA plus stabilization group and just stabilization alone and the group that had TA had better outcomes. Methodology may be an issue though.
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RE: How do you explain TA contraction to your patients. - August 3, 2008 9:52:09 PM
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TexasOrtho
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Kaden. I've got a few things cooking this week finishing up my summer session at TTU. Once I get all my stuff turned in, I'll go back and review some of those studies as I have gone back and forth on this very issue. Let's touch base on this later this week.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: How do you explain TA contraction to your patients. - August 4, 2008 11:18:23 AM
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Kaden
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no problem.
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