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Re: SI instability
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Re: SI instability - February 10, 2005 1:51:00 AM
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JLS_PT_OCS
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A fair question, the chicken and egg variety.
I'm not sure which came first, weakness or pain, but I'm pretty sure it's irrelevant to my treatment of those with pain.
The prevention piece is a different animal...it's hard to argue hard for strengthening as a preventive measure when the evidence is mixed. And it clearly is.
To what degree strength helps and why is just not well understood. Much like manipulation, there is a subgroup of people who will respond to Lumbar Stabilization (LS) training. There's a paper at CSM this year on spine kinematics of those likely to benefit from LS programs.
I don't claim to understand all that Lumbar Stabilization does, I don't think we've even scratched the surface on that one, and Jon posted some good links that demonstrate some of this uncertainty.
I do not think we can boil rehab down into the "Neurological" vs "Strengthening" approach.
I believe LS is doing both. In fact, strengthening is by definition a neurological phenomenon as much as it is anything else.
And I think strength and stabilization programs can address movement confidence/fear avoidance issues as much as provide objective improvements in "strength". And those changes are probably just as important, maybe more so.
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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 10, 2005 2:36:00 AM
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Shill
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What are we stabilizing? How do we (reliably) know when it is stabilized?
Stabilization is a catch phrase that caught on. You are still doing strengthening. Perhaps some "neuromuscular re-ed". We often assume something has stabilized when one becomes asymptomatic, but we dont know if that is why they became asymptomatic.
I agree that exercise is one of the good treatments for LBP, but we dont yet know which exercises are superior. There is some info, but not yet enough. Exploring this, with a direction of symptom preference is the direction we need to go. (Which direction increases pain as a result of the movement versus the direction that relieves pain as a result of the movement, or centralizes it).
Jason hit the (Silver) nail on the head once again. We probably wont ever know which came first, the weakness or the pain. It doesnt matter. It would be nice to be able to prevent the episode in the first place, but unfortunately nothing has yet been shown to prevent LBP. We need to study that 10% of people who have NEVER had LBP to see what we can figure out.
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Steve Hill PT
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Re: SI instability - February 10, 2005 4:51:00 AM
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JLS_PT_OCS
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Steve-
Good points, despite the overused pun. :)
I really don't know what we are stabilizing with this program. Keep in mind that when we say "stabilization" it is a theoretical construct that is one way to explain the effect of the exercise regimen. As I've said before, I am really less interested in why it works than I am in IF it works. And there are volumes of evidence, from RCTs to case studies, that show that it is effective. So I would argue that we do, in fact, know what type of exercise is superior.
And you're right, we should be longitudinally studying those 10% without back or SIJ pain.
I would bet some interesting risk factors would shake out.
_____________________________
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 10, 2005 2:44:00 PM
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Jon Newman
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Regarding weakness versus pain. Everyone accurately points out that we can't know which came first.
However, by the time we see a person they are already in pain so their strength, their posture/alignment and the way they move is already influenced by pain. Thus finding dysfunctions while someone is in pain is expected. It is a slippery slope to expect if we make someone look (at least to us) "aligned", or make them stronger, etc that we will make someone better although this does happen. Sometimes by coincidence and sometimes by causal action.
I agree with Jason regarding the strength thing.
jon
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Re: SI instability - February 10, 2005 9:39:00 PM
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Randy Dixon
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I don't have anything new to add that probably hasn't already been discussed but I would like to highlight something.
The isometric back extension has been shown in several studies to be the best negative predictor of LBP. Some of Jon's studies may contradict that but it seems to generally hold. It isn't necessarily so, but it seems reasonable then that doing the Biering maneuver will have some protective effect. (Of course the increase hold time for those not suffering LBP might just demonstrate pigheadedness, in which case pigheadedness is the desired quality to strive for.) I think a key point is that it is an ISOMETRIC ENDURANCE exercise. I believe this is much different neurologically than an isotonic exercise and probably a short duration isometric exercise. I am more certain that it would tend to utilize different muscle fibers and utilize them differently.
This thought became clear for me a long time ago when trying to understand PNF and Open chain-Closed chain exercises. I liked it because it has a yin-yang, chaos-order, metaphysicality about it. Stability-Mobility. In an OC ex. stability occurs proximally to distally. In a CC ex. it is opposite, stability occurs distally to proximally. I think this makes the CC neurologically more complex in some ways.(That is another discussion). I then noticed that much of the time people try to train stability using mobility exercises. Stability is basically by definition-not moving. Muscularly we would say that it is isometric, but I didn't see a lot of high level isometric training going on. So perfect stability allows no movement, but in order to move some mobility must be present. (This is the chaos-order deal)so we often see stability being provided by eccentric contraction. Again, I didn't often see eccentric actions being used to promote stability. I did see eccentric actions, virtually every exercise has a concentric and eccentric component, but none that specifically addressed stability. Ok, it's getting too long.
When we take the postural muscles, which we know are mostly type 1 fibers then we have to add another element, that of endurance. I seldom see people doing stability or postural training using long hold, isometric or limited ROM movements. Maybe they should.
Mobility and Stability: The yin and yang of human movement. Sounds like a good name for a course.
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Re: SI instability - February 11, 2005 5:23:00 AM
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JLS_PT_OCS
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I would agree with Randy that it is the "endurance" of the muscles that we should be targeting.
Stabilization training does just that.
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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 11, 2005 7:03:00 AM
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srcase
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I agree, we should make a distinction between muscular endurance and muscular strength when talking about lumbar stabilization programs. It is definitely training endurance, that's why we have them isometrically hold for at least 10 seconds.
What I don't understand is how someone can "not care" about why something works, but that's just me. I will still use the techniques, but I always have to have some sort of theoretical construct in my mind for what I am trying to effect.
Besides the Beiring-Sorenson test, how do you all objectively document core "weakness". I am familiar with the Shirley Sarhmann lower abdominal series of tests, the double-leg lowering of Kendall, and E/F ratio (which is isokinetic and not very practical to use in the clinic). What are the prerequisite findings that justify stabilization training??
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Re: SI instability - February 11, 2005 7:07:00 AM
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srcase
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Randy,
I understand where you are coming from with proximal stability leading to distal mobility, but I don't know that I agree with the statement about closed-chain exercise having stability start distally and go proximally. Is there any reference for this or did you come up with it yourself? I would think that the proximal stability would be even more important in closed-chain exercises and would have to be in place before the distal "stability". I have never thought in terms of distal stability...just stability from the trunk that affects the extremities. Can you explain what you meant?
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Re: SI instability - February 11, 2005 7:12:00 AM
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JLS_PT_OCS
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For core weakness-
I use shirley sahrmann's isometric stability test and some tests from the books I cited.
There are a few studies demonstrating some findings that would lead to the use of that therapy.
Chronic low back pain in general responds well.
The "not caring why something works" remark sounds like something I said.
It was tongue-in-cheek, and meant as a counterbalance to some who choose not to use a proven treatment because we don't know why it works. Of course I care, I just don't let not understanding get in the way of my use of the tool. Check out the "When Thoughtfulness Dies.." thread over in Barrett's Bullypit for more info and racy (but polite) discussion.
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 11, 2005 12:41:00 PM
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srcase
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Jason,
I have been following the thread. Intriguing discussion. I like Sahrmann's tests are the most reproducible in the clinic and reliable. They are tough too! I will pick up that Richardson book..I have been coveting it for a year now..it is at the top of my list!
Sarah
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Re: SI instability - February 14, 2005 4:09:00 AM
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JLS_PT_OCS
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Sarah-
Go get that book!! It is probably the best book I have ever read about how to treat back pain. It has some theory, some epidemiology, motor control issues, and most of all, some directly useful clinical approaches that are very specific...
Fantastic...
J
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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 14, 2005 8:59:00 PM
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Randy Dixon
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Sarah,
I'm a little busy so here is a quick answer. I came up with it myself.
If you look at stability in terms of not moving and therefore being able to support the movement of the next joint, we oftentimes "reverse" origin and insertion, (ok, not correct technically) We use this in MET. In essence reducing mobility an area that is usually expected to move and allowing movement in a area that usually provides stability.
We agree that in an OCK exercise stability occurs proximal to distal, but if we take a CCK
exer. that it differs. Take a push-up for example. The hand is immobile, the wrist then must be stable before the elbow, which stabilizes before the shoulder, and up the chain, while the "core" is mobile. It too must be stable in order to move coherently, but no matter how stiff the core is if the stabiliy isn't provided "downstream" then it's not moving.
Ok, that's the nickel version.
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Re: SI instability - February 14, 2005 9:03:00 PM
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Randy Dixon
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As for the isometric endurance, I'm not sure that 10 seconds qualifies. But then I'm not sure that cumulative fatigue doesn't have the same effect.
Also, while "core stability" is often trained isometrically do you use it primarily for other joints. Shoulder and knee for example? Just curious, not making a point.
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Re: SI instability - February 16, 2005 5:19:00 PM
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srcase
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Randy,
Makes sense when described that way..I shouldn't post so late at night (brain fatigue). How long would you hold for isometric endurance 30 to 60 seconds??
By the way, my husband's name IS Steve.
Sarah
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Re: SI instability - February 17, 2005 1:18:00 AM
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JLS_PT_OCS
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I tell patients that they need to do any stability exercise continuously for up to 2 minutes.
After reading some of Shirley Sahrmann's work, I have become convinced that chronic folks also need to learn to use their "global" muscles such as external oblique in addition to their "local" muscles such as TrAbd and Multifidus, so when they are doing very well on a stability routine, I will add those exercises as well. I think that until recently, I had been focusing too much on local stability muscles and not enough on global strength muscles...
"Stability" = no core movement, 1-3 reps of 1-3 minutes
"Strength" = movement of core, 3-5 sets of 8-12 reps
Just my approach, stolen without remorse from such people (smarter than me) as Jull/ Hodges/Hides, Gray Cook, and Shirley Sahrmann...
I really must get her "Movement Impairment" book...
Sarah, do you like it?
_____________________________
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 17, 2005 5:20:00 AM
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OaksPT
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Jason,
I'm familiar with the other 3, but what is the approach used by Gray Cook?
Thanks,
Oaks PT
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Re: SI instability - February 17, 2005 8:38:00 AM
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JLS_PT_OCS
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Just saw Gray speak at a seminar last weekend, very interesting stuff.
His book, "Athletic Body in Balance" is a great read, and really explains things well.
He talks a lot about assessing people's movement quality and not focusing so much on a particular area.
For example, if you have a knee patient, are they discharged when their ROM and strength are good?
Or is it their function such as gait, running, stepping, squatting, etc that matters?
He cited recent research about kinematics and hip stability issues with knee pain and gave practical progressions for how to assess and treat people with movement problems -- everything from lumbopelvic rhythmn to squat mechanics.
Nice guy, too. He changed the way I practice.
I have a feeling reading Shirley Sahrmann's book will do similar things for me...
_____________________________
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 17, 2005 2:04:00 PM
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srcase
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Jason,
I commented about this in another forum... I took the first Sahrmann course and it made a lot of sense at the time, then I got the book, and I feel I can only use bits and pieces of it in the clinic. Maybe it is her writing style, but I find the prose very difficult to follow at times. Good concepts, but not presented clearly in my opinion. I like the exercises at the back as they are very Pilates-ish (IMHO). I keep going back to the book hoping to digest a little more, but just come away confused as ever.
I will look into the Gray Cook course, it sounds good. I am trying to find a good course to take this spring,
Sarah
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Re: SI instability - February 18, 2005 1:57:00 PM
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Randy Dixon
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I've got Cook's book and I like the thinking he presented in it. I think it is a good book on functional testing, I am less impressed about the training section. What I do really like is his idea that we should have uniform functional tests so that doctors, trainers and therapists can communicate and work together much better.
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Re: SI instability - February 18, 2005 8:01:00 PM
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Synergy
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I just purchased these three from Barnes and Noble last night. They arrive next week sometime. Thanks again for the recommendations Jason.
Therapeutic Exercise for Spinal Segmental Stabilization In Low Back Pain
by Richardson, Hodges, Hides
Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain
Richardson, Hodges, Hides
Sahrmann's Movement Impairment book
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Chris Adams, PT, MPT
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