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Re: SI instability
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Re: SI instability - February 7, 2005 5:18:00 AM
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Yogi
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From: San Antonio, Tx., USA
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Aha, see, I didn't even know there was a book. Good for you, Jason.
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Re: SI instability - February 7, 2005 6:15:00 AM
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JLS_PT_OCS
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Here is the book information:
Title: Therapeutic Exercise for Spinal Segmental Stabilization In Low Back Pain
by Richardson, Hodges, Hides
ISBN: 0443058024
Pub. Date: 01 December, 1998
Here's another title released in OCT04 from same authors, it sounds like it may be excellent as well:
Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain
Richardson, Hodges, Hides
ISBN #0443072930
These are what can be considered foundational texts (as far as direct treatment strategies go) for lumbar stabilization, and highly recommended reading for anyone who is interested in these concepts.
I think you can find at least the first title for about 30 dollars (american) online somewhere.
This site is helpful for book shopping:
[URL=http://www.anybook4less.com]www.anybook4less.com[/URL]
No pilates certifications required to read the book and apply the principles and techniques.
:)
Jason.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 7, 2005 8:13:00 AM
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Synergy
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From: Forney, TX
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Jason, thanks for posting the book information. I may have to order those ASAP! Seems to be some good reading.
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Chris Adams, PT, MPT
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Re: SI instability - February 7, 2005 5:19:00 PM
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srcase
Posts: 551
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From: Michigan
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Ok, for those skeptics out there I feel I must defend the use of Pilates for rehabilitation. I agree with Jason that you don't NEED to get certification (I am not certified myself) but what is valuable in taking courses from repuable schools which offer certification, is the depth of the material taught and the opportunity to experience the exercises first-hand and gain eperience teaching, observing, and correcting the movements. The 5 principles of Pilates are ones that physical therapists know to be important, but aren't always effective at teaching or facilitating in their patients: 1. deep diaphragmatic breathing 2. activation of the transverse abdominis to stabilize the spine and prepare for movement 3. rib cage placement (this ties into breathing and abdominal muscle activation) 4. scapular placement/stability for arm movement 5. and cervical spine alignment/stabilization using the deep cervical flexors.
I don't use "Pilates" exercises per se with every single patient, but from thinking in that way, I look for these principles as the foundation for efficient movement. Maybe it's my background in ballet, but I was naturally drawn to Pilates because it made sense to me. It may not be for everyone, but personally, I learn much more by doing and feeling and observing than by reading a book. I think the research going on by Richardson and Jull, etc. is excellent and relevant, but I also believe that Joseph Pilates instinctually and experientially figured it out almost one hundred years ago. (Don't even get me started on Yoga). Just because there is not any good research doesn't mean it's commercial, comical, or shameless. I am as scientifically minded as the next therapist, but I also think we should be willing to experience things that are unfamiliar to us before discounting them altogether.
The other component of Pilates that I enjoy is the variability and creativity allowed with the movements/exercises. Sure you can do one or two things with the pressure biofeedback cuff, but there are hundreds of exercises and variations on exercises that you can do with Pilates. Personally, I think this is valuable because each patient has unique needs and limitations.
Ok, enough of my soapbox. I will say that I came to Rehabedge hoping to engage in some healthy exchange of ideas, but so far I have been dissappointed by the elitism, rudeness and ridicule that occurs here.
By the way, I don't put my patients on "jungle gyms" (unless you count the Total Gym which is a Total Pilates knock-off) but I work out on one and it's really fun!
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Re: SI instability - February 8, 2005 12:42:00 AM
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JLS_PT_OCS
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S.Case-
Good summary of very interesting principles, thank you.
Please don't take my criticism of the way I have seen pilates marketed as personal to you. I never represented that you or any other therapist was treating their patients in any particular way. I only reported my experience of doing some pilates, talking with several instructors, and seeing the equipment. Don't be so quick to assume I am talking about or referring to you, that is not the case.
It seems from your posts that you are providing good, evidence-based care for your patients, and you are to be commended for that. It seems a relative rarity from what I can discern.
Clearly, I have a different experience of pilates than you do, and in fact yours seems much more in line with rehab and applicable to the clinic.
I am glad you shared your perspective, as this exercise program gains more momentum, it heartens me to think that there are some quality instructors out there, perhaps more than I had thought.
And, by the way, isn't this a healthy exchange of ideas?
I, on the other hand, really enjoy Rehabedge because there is the opportunity to share ideas and learn from each other. However, I do think some people (and again, this has nothing to do with you personally and is not aimed toward you) are upset when other Therapists/Scientists ask that they back up claims they make with evidence, and that they practice evidence based medicine.
And if there are some that consider that elitism or rudeness, we do indeed have a long way to go in moving our profession into the 21st century.
But, I digress.
Keep up the great work you are obviously doing for your patients.
A new question keeping in the context of the thread: could you describe what type of exercise progression you would use in the treatment of a patient with supposed SIJ instability?
Thanks.
Jason.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 8, 2005 3:41:00 AM
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Yogi
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From: San Antonio, Tx., USA
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S. Case, Nope, sorry don't see it. Of course, I have a kind of atypical sense of humor. So I love it when Greg Priest, Doc Wagner, or Barrett gets going good. The dialog, in whatever form, helps me, I learn new things, get different perspectives, and information to assist me in deciding things for myself. I've get to see any one intentionally hurt any ones feelings, and any misunderstandings have been resolved as soon as possible. I think you'll find the same thing, and I, personally, thank the adminstrator, moderators, and all participants with immense respect for the expertise, openness, and sensitivity, I see displayed here daily. We don't have to agree on anything, just like if we were working in the same facility, we do need to respect each Therapist's autonomy.
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Re: SI instability - February 8, 2005 4:44:00 AM
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Yogi
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From: San Antonio, Tx., USA
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S. Case, nip on over to the Bullypit.
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Re: SI instability - February 8, 2005 8:07:00 AM
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dosrinc
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From: Bonita Springs
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SJBird: interesting question, will the increased interest in Pilates as an exercise program eventually decrease the incidence of low back pain across the population? I have had patients who were hurt in classes that they were not ready for but not nearly as many who were hurt while performing yoga, med-ex, prone press ups, step aerobics and some of the other former "fad" exercise programs that were once popular for the masses. I do recommend a Pilates class on occasion for those that want or need the structure post discharge but in most cases, simply continuing the stabilization they have been taught will suffice.
Rick
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Re: SI instability - February 8, 2005 10:27:00 AM
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Randy Dixon
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Jason,
With regards to the efficacy of Pelvic belts you might be interested in this study:
http://www.kalindra.com/jan_mens.pdf
In short, Active straight leg raising had a clear correlation with pelvic instability with peri-partum pelvic girdle pain. The use of a pelvic belt reduced impairment for 20 of the 21 patients identified.
I also wondered if anyone else has used the Stuart McGill's books on stabilization. I haven't read them myself but I am ordering them based on reading some of his research.
S. Case,
I think this forum has room for thoughtful and friendly discussion, as well as discussion that is not so friendly, but what constitutes friendly differs among people. Some people feel comfortable in challenging others ideas with little attempt at being "friendly" while others consider it rude and confrontational. My personal feelings are that as long as the discussion revolves around what is posted or made public then it is fair. There are going to have to be some hard, uncomfortable discussions if Physical Therapy is going to advance. It should probably be mentioned that you entered at a time when there is a certain amount of divisivness over evidence based practice.
As to what Jason said about Pilates, I too have wondered why PT's should be willing to surrender their role as movement experts to others who are less qualified. It seems to me that PT's often seem simply unwilling to spend the energy or effort or maybe lack the confidence to think about and place themselves as experts about exercise and movement. It is a good thing to learn from experiences and other methods, but I feel that it is hurting the profession and your standing to let Pilates, Yoga, and other trainers stand in as the experts teaching PT's about movement science. They may be the experts in their techniques, some of which you may find useful, but I think there is a responsibility to the profession to be the expert. I'm not saying that you are neglecting this, only that I see a danger in having the public, and the physical therapy profession, perceive these alternatives as being superior. I have seen many Pilates for PT's classes, what I wonder is where is the PT for Pilates instructor classes?
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Re: SI instability - February 8, 2005 10:48:00 AM
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dosrinc
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From: Bonita Springs
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Nothing makes much less sense to me than to see PT's taking Pilates courses taught by those without the same level of education and I know several that have done so. I have actually treated several after they discovered that you simply can't have one exercise design to treat all patients. I do agree that several of the Pilates principles are sound and beneficial but aren't these the same principles that we learned in basic there ex in PT school. I actually know several PT's who refer to themselves as "Pilates PT's", makes about as much sense as calling oneself a "Myofascial PT" or a "Kineseotape PT". These techniques should only be one component of our care, not a definition of the way we practice. just my thoughts..
Rick
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Re: SI instability - February 8, 2005 3:35:00 PM
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srcase
Posts: 551
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From: Michigan
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Geesh, where to start. I guess I should apologize firstly if I jumped to conclusions. Thanks for the insight about the forums Jason, Yogi, Randy, and Rick. I put myself out there, so I should have expected some debate.
I am in agreement with everyone that people do get hurt taking Pilates classes that are poorly taught. In fact, there is so much variability in the education and skill of the instructors out there that I never recommend taking classes or doing videos without first getting one-on-one private lessons in Pilates to master the principles. The average person can't stabilize their lumbar spine well enough to attempt most of the "Beginner" exercises in a mat class. So, there is definitely a concern about the growing popularity of this exercise form.
The lack of standardization is also one of the obstacles to researching the efficacy of Pilates as a stabilization program. There are groups working on this such as the Pilates Method Alliance (PMA).
As for the principles themselves, I can draw many parallels between Pilates and the work of Richardson/Hodges, Sarhmann, and Janda among others. I tend to learn by assimilating information into cohesive and interrelated theories, so I am a very ecclectic therapist. I am certainly not a "Pilates PT" (not that anyone implied I was).
Interesting perspective on the responsibility of therapists to be the experts in movement science. I guess I just don't feel threatened by those who love to study human movement in any way, shape or form. I would rather learn from them than try to discredit or disrepute them. To me, if someone has spend years learning about human movement..be it through yoga, Pilates, martial arts, dance, or whatever...I respect that and feel a kinship with them. I think they all have something to offer us. No one will take the place of rehabilitation experts...but movement expert...I'm not so sure we should be monopolizing that title. I hadn't really thought about it that way before, so I am still pondering that idea.
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Re: SI instability - February 8, 2005 3:48:00 PM
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srcase
Posts: 551
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From: Michigan
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Now onto the actual topic of this thread: Jason asked me how I would treat and progress a patient with supposed SIJ instability. Honestly, I have never had a patient with true SIJ instability, but I suppose I would consider using an SI belt. THere are no muscles that directly cross the joint to stabilize it, but I would also address any muscle imbalances and/or deficits, specifically targeting the transverse abdominis, adductors, and gluteals.
I have seen patients with SIJ hypermobility, who respond well to muscle energy, strain-counterstrain, and massive amounts of stabilization exercise! If weight-bearing, especially unilateral, was a problem, I would start in supine, prone, and seated on a Swiss ball, and progress to standing movments (push/pull), lunges, and then single-leg balance. I have had some young ladies that gain strength and stability on the Pilates reformer (like a Total gym but easier to use). Oh, there I go again...... hope that is what you were looking for.....I could get more specific, but my posts have been too long as it is.
Sarah Case, MPT, CSCS
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Re: SI instability - February 8, 2005 7:10:00 PM
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Randy Dixon
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Sarah,
For some reason I thought your name must be Steve, is there someone famous named Steve Case? Anyway, it might help your impression of the elitism of therapists to know that I'm not a therapist. I'm just one of those "people who love to study human movement". It has been one of my wishes that there be a bridge between the current medical model and the fitness model,one that is professional and scientifically sound. I think the PT's are the ideal group to do that. That is one of the reasons I am advocating "staking out some turf" and also seeing to it that all PT's are at least minimally qualified to deal in that turf. I think their education is sufficient to that but many seem unwilling to accept that responsibility. I see this approach as a positive step to fix a medical model badly in need of some fixing.
About Pilates, there are things about it I like. I am beginning to become allergic to the whole TA strengthening approach though. That may just be a result of Fad-itis. I wrote a long post about this not long ago. There is one thing I would like for you to consider, just consider because I'm not making an argument. Pilates designed his exercises one hundred years ago. The conditions he saw were probably different than the conditions of today. 100 yrs. ago people were more active. We might say they were phasic-dominant: active musculature and lacked flexibility, extended. Todays population is tonic-dominant:inactive musculature, having instability, flexed. So given that, is Pilates exercises appropriate for most people today? It is flexion oriented and requires (and assumes)stability as well as promoting it.
Either way I prefer a more functionally oriented program. Provide the stimulus and let the TA, multifidus or whatever take care of themselves. Although I can feel fad-itis creeping up on me here also.
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Re: SI instability - February 9, 2005 1:39:00 AM
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JLS_PT_OCS
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Good discussion.
Randy, as usual, excellent insight.
In the study you cited, I couldn't find them studying pelvic belts, only correlating the ASLR (active straight leg raising) test to those with pelvic pain. Did I miss something?
They found that subjective reports of difficulty (not pain, necessarily) were significantly higher in those with pain than in those not in pain.
While I would say that my clincial experience also bears that out, I don't see how that is making an argument for the use of an SIJ belt.
I understand the underlying theory regarding a choice to use it, but not sure of the jump from "difficult ASLR" to "SI belt".
Since they didn't mention pain, perhaps the ASLR means we need to help decrease their pain and work on strengthening??
Sarah, glad to see you are de-personalizing forum comments and contributing openly. That's good to see.
Randy, you mention the fad-itis idea, and I think that is a fair comment. Being intimately familiar with the fitness/health world, I know that lately "core strengthening" is sweeping the fitness world like many fads have before it. As someone mentioned before, sometimes it is done well, and sometimes poorly. So I can see how some may be sort of tired of hearing about the TrA and Multifidus in low back rehab, as well as fitness.
However, it is worth noting the exceptional treatment outcomes that have been demonstrated with the approach in the back pain population. That alone is reason to jump in with both feet.
I have seen no evidence showing a preventive effect of this type of training on the incidence of back pain in the general population or in athletes, and yet that is what many proponents of the "core strengthening" or "functional training" approach in the fitness world claim.
Anyone aware of any evidence for use of this exercise protocol in the prevention of pain, in any population?
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 9, 2005 2:37:00 AM
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Shill
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From: Madison WI USA
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Jason,
I think the only thing that has been proven to prevent pain is death. Depressing but true.
I havent seen any study that shows anything that consistently or even inconsistently prevents pain, (which would include preventing recurrence) especially if we are talking about LBP, lumbosacral pain, whatever we want to call it. As Im sure you are well aware, the recurrence rate for LBP is disgusting, and I would like to see us devise a worthwhile study as to why this is the case.
_____________________________
Steve Hill PT
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Re: SI instability - February 9, 2005 4:46:00 AM
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JLS_PT_OCS
Posts: 1684
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From: USA
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I have seen some studies which showed a moderate effect of lumbar strengthening and/or some ergonomic training.
No longitudinal studies (a la Framingham for cardiovascular events) so it's hard be sure, but it would seem reasonable based on existing evidence to think that strength of lumbar extensors has some preventive effect.
It's hard to sell for sure based on what we currently know.
I think the recent lumbar stabilization research showing multifidus atrophy which does not improve without specific training goes a long way toward trying to unearth some of those issues...
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 9, 2005 9:04:00 AM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Randy, very interesting perspective. I do agree that things have probably changed in the last 100 years, and Pilates exercises have also evolved from Joseph's original work. The Stott Method based out of Toronto is very exercise physiology-based, and the McEntire Method was developed by a kinesiologist I believe. But I definitely see the problem with the promotion of flexion, and one must have an initial degree of stability to progress. I also like to use functional training mostly ala Gary Gray, Juan Carlos Santana, and Paul Chek. Recently, I too have been questioning the effectiveness of training the TrA and multifidus in isolation (whether this has any carry-over whatsoever). I have colleagues who have given up on it completely and just train functionally because they weren't getting quick enough results.
In terms of LBP prevention, I would suspect that muscle balance has much more to do with it than pure muscle strength of the lumbar extensors for example. Janda and others have shown that tight hip flexors lead to inhibited hip extensors (glute max) and tight hamstrings lead to weak abdominals (via the pelvis position). Shirley Sarhmann would say that you can't just stretch the tight muscles, however, you need to focus on retraining the antagonistic muscles that are long, weak, or inhibited. And the multifidus has been shown to be more of a lumbar segmental stabilizer than a lumbar extensor, which was once thought (see Bogduk, Twomey). Sorry I don't have specific references.
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Re: SI instability - February 9, 2005 9:57:00 AM
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JLS_PT_OCS
Posts: 1684
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From: USA
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If someone is training the TrA or multifidus in isolation, then that isn't lumbar stabilization.
Functional movements and positions are the key parts of the program.
That is "training functionally"....
And why it works so well.
I would second thoughts about muscle balance... interesting concepts there.
Here is some evidence showing that back muscle endurance testing can discriminate among those with and without low back pain:
Spine. 1999 Oct 15;24(20):2085-9; discussion 2090
"The reliability and validity of the Biering-Sorensen test in asymptomatic subjects and subjects reporting current or previous nonspecific low back pain."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10543003
So strength clearly is a factor as well, which is one reason I train the extensors so hard in my chronic back folks.
Food for thought...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 9, 2005 10:16:00 AM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Jason,
But my question is, which came first? Did the muscles all of a sudden become weak and then the patient experienced back pain, or did the pain inhibit the muscles? If it is the latter, then why wouldn't a neurological approach to treatment work better than pure strengthening???
Sarah
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Re: SI instability - February 9, 2005 4:33:00 PM
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Jon Newman
Posts: 1697
Joined: April 24, 2004
From: Amherst, WI
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Hi Sarah,
I think you might be on to something. Here's some resources as to why I think that.
Before I post those; I perform this Beiring manuever when I'm doing physical training for myself. Although not because I have or because I'm trying to prevent pain. It's part of my sports training.
Here's the links:
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12708102]link 1[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11317112]link 2[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1863921]link 3[/URL]
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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