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Re: Hip range of motion and low back pain
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Re: Hip range of motion and low back pain - April 19, 2005 10:35:00 AM
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coreconcepts
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From: Vancouver, BC
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Wow! It's like I opened a door to a whole new world. I had no idea physios were so divided on certain issues - namely the issues surrounding core stabilization. This is a good thing, don't get me wrong. I have theories of mine challenged daily - it forces me to do my homework and remain open-minded. There is, however a fine line between open-mindedness and gullability.
Jason - good point on the "theoretical construct" vs. "the complete story". By inner unit control, I mean the ability to fire up these muscles prior to and to conteract the effects of dynamic posture.
One more thought - I will try and dig up the study, but I read somewhere that spinal stabilization exercise is more effective than manipulation in most cases of acute LBP (I know, there are a lot of missing variables, but that's all I remeber from the study). What is your experience?
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Re: Hip range of motion and low back pain - April 19, 2005 5:30:00 PM
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eam
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From: New York, NY 10028
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Hi everybody-
With regards to the original thread concept, I don't know of any current research correlating hip rom to lbp. I speak for myself, I have about 10 degress of hip IR and 45 of ER on my left hip and my right has 40 degress of IR and 15 degrees of ER (sort of the windswept look!) Do I have LBP? Not really (knock on wood) but I do have an ache in my buttock and my lateral hip which occurs frequently, does not last long and I manage with it.
Without getting into the whole Sahrman thing ( I do use alot of her concepts-still sort of working through alot of it in my head) She talks in her low back rotation patterns the effect of limited hip ROM causing compensatory lumbo-pelvic motion thus causing the patients sx's associated with LBP.
(I guess I sort of got into the Sahrmann thing!) She is not taking a static measurement with a goniometer but rather looking at it from a movement standpoint, more dynamic. When I do this to myself I don't have low back pain but I think her premise is that over time repeated compensation like this may contribute to this pattern. Just my thoughts.
Erica
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Re: Hip range of motion and low back pain - April 20, 2005 8:44:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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I guess what I am trying to grasp an understanding on is the hip component in the Flynn, Childs CPR study. Why is hip internal rotation greater than 35 degrees one of the clinical predictors for success with manipulation?
Several months ago I started measuring various hip range of motion measurements with a bubble goniometer before and after manipulation and I have noticed anectodally that clinically significant increases in rotation occur after you manipulate the spine (lumbosacral technique). It appears that those with LBP have larger increases in ER after manipulation than normals. I am currently submitting a proposal to our IRB to perform a study on this comparing those with LBP and those without.
After performing a lit review I came up with all kinds of questions about hip range of motion and low back pain. It is interesting that we dont know how they relate.
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Alex Brenner, PT, MPT, OCS
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Re: Hip range of motion and low back pain - April 20, 2005 8:52:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Core,
The Flynn et al study (Spine 2002) and the Childs et al Validation study (Archives physical..2005)for the clinical predictors for success with manipulation in patients with acute low back pain did just what you said. They compared a lumbosacral manipulation technique against a lumbar stabilization group and found they both got better but the manipulation group did significantly better than the stab group.
Core, if you look back in previous topics in Rehabedge you will see that this has been debated alot. http://www.rehabedge.com/ubb/ultimatebb.php?/ubb/get_topic/f/1/t/000508.html
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Alex Brenner, PT, MPT, OCS
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Re: Hip range of motion and low back pain - April 21, 2005 2:15:00 AM
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SJBird55
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From: Michigan
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Alex, what if you played around with a program similar to what Christopher Powers uses? Meaning... tell the program the range of motion available in the hip joint and then see what happens with walking, sit to stand, jogging, bending... I don't know if that is possible, but whatever it is that he uses is pretty cool.
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Re: Hip range of motion and low back pain - April 21, 2005 3:07:00 AM
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JLS_PT_OCS
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Isn't Powers using a motion MRI system?
I know they have a biomechanics lab, and there might be MANY expensive gadgets in there...
I agree with Alex that I've seen anecdotally some interesting things vis a vis hip motion and back pain.
I do think that the concept of stiffness in the hip and mechanical deformation of spine vs hip during ROM/ADL is something we will see more of in research...
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: Hip range of motion and low back pain - April 21, 2005 3:27:00 AM
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Alex Brenner PT MPT OCS
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SJ,
I think there only two dynamic MRI machines in the entire world but yeah, I would love to mess around with it.
Specifically I would love to see if you can acutally move disc material in a live patient with a disc herniation using McKenizie techniques but that is another topic.
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Alex Brenner, PT, MPT, OCS
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Re: Hip range of motion and low back pain - April 21, 2005 3:30:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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[QUOTE]Alex,
What of the well documented effect of hip internal rotation on the sacral plexus?[/QUOTE]Barrett,
I am not sure, I really haven't read too much about this. Can you point me in the right direction?
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Alex Brenner, PT, MPT, OCS
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Re: Hip range of motion and low back pain - April 24, 2005 2:54:00 AM
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Lukey
Posts: 180
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From: Australia
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Hi Barrett,
Is stretching ever a component of instinctive movement?
Luke
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Re: Hip range of motion and low back pain - April 24, 2005 3:04:00 PM
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Barrett
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From: Cuyahoga Falls, Ohio
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Alex,
Sorry to take so long to get back to you.
The best study about this can be found in "Spine" Vol. 4 No. 3 1979 Pages 242-250 "Biomechanical Considerations in the Straight Leg Raising Test" by Alf Breig, a Swedish neurosurgeon who, in my mind, is the great godfather of the science behind our understanding of neural tension.
I used this as an anchor for an article I wrote for the PT Forum in '89 titled "A Simple Test of Autonomic Balance."
Luke,
Things often lengthen powerfully. Stretching is a certain phenomenon available to specific tissues and I suppose it might happen instinctively, but I think connective tissue stretching is relatively rare, and, in fact, rarely needed for pain relief. Remember that this is the purpose of instinctive movement.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Hip range of motion and low back pain - April 24, 2005 4:46:00 PM
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Lukey
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From: Australia
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Thanks Barrett.
I couldn't find "A Simple Test of Autonomic Balance." at Dorko's desk. Is it available somewhere else?
Luke
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Re: Hip range of motion and low back pain - May 8, 2005 2:22:00 AM
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anoopbal
Posts: 124
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Just curious.
What do you all think about Stuart McGill's book-Low back Disorders:Evidence-based Prevention and Rehabilitation.
From what I have read, He is supposed to be THE expert in low back care.Perhaps you guys would know better
Anoop
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Re: Hip range of motion and low back pain - May 8, 2005 9:23:00 AM
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Bournephysio
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Stu is THE or probably more correctly ONE of the experts in the biomechanics of spinal stability. He is a far cry from being THE expert in low back care. His book has great depth when it comes to the biomechanics of stability but becomes very shallow when talking about things like motor control of stability or neural tension, pain aspects, psychosocial aspects or even assessment of low back pain. To my knowledge, his ideas on low back treatment have never been tested with an rct.
Doug
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Re: Hip range of motion and low back pain - May 10, 2005 5:42:00 AM
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JLS_PT_OCS
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From: USA
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McGill has interesting ideas.
He might be AN expert in biomechanics of the spine, but not in the care of the low back.
While he promotes research in making decisions, many of his suggestions, while based on a reasonable construct, go a bit far in terms of inferring causation.
Let me give you an example.
He states we should not engage in repetitive trunk flexion activities early in the morning, as that is when the disk is most hydrated and therefore most vulnerable to pressure increases. This is a reasonable idea, but as there is not a good link between disk pressure and low back pain, we should not assume the construct holds true to fact.
His book is excellent, especially for trainers or non-medical people who want to intelligently design a core or trunk training program.
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: Hip range of motion and low back pain - May 10, 2005 6:39:00 AM
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Shill
Posts: 1097
Joined: February 13, 2003
From: Madison WI USA
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Jason,
I hear you regarding causation, BUT, there is some evidence to avoid this, regardless of whether the disc is the reason. I'll send you the article.
Journal of Occupational Rehabilitation, Vol. 12, No. 1, March 2002 ( C° 2002)
The Reduction of Chronic, Nonspecific Low Back Pain
Through the Control of Early Morning Lumbar Flexion:
3-Year Follow-Up
Stover H. Snook,1;4 Barbara S. Webster,2 and RaymondW. McGorry3
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Steve Hill PT
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Re: Hip range of motion and low back pain - May 10, 2005 8:02:00 AM
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JLS_PT_OCS
Posts: 1684
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From: USA
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Thanks for the article.
That does not speak to the disc, (as you mentioned), merely to restricting the motion of a painful part.
The results of the study are not particularly surprising to me.
Are they to anyone else?
Here's an idea: for our knee pain patients, tell them to wear an immobilizer for part of the day and see what happens. Well, if it doesn't move, it usually won't hurt, so those stairs are a lot easier to negotiate without pain now....
Is this a useful recommendation for patients?
Certainly the treatment of a painful part with avoidance hardly seems workable in the long term, as the study suggests.
Remember the old joke...
Patient: "Hey Doc, it hurts when I do this"
(patient moves body part in awkward way)
Doctor: "Well, don't do that!"
For those in whom we have reason to believe have a disc-related problem (lumbar radiculopathy, intolerance of sitting positions, etc) then certainly that seems good advice. But for everyone?
I'm not so sure.
I am wary of providing too much advice for people in the prevention of spinal pain, as we have so little knowledge about what actually causes it. I will give some lifting advice or something like that that has a good foundation in biomechanics, but I think people have a tendency to over-medicalize problems, and this sort of advice might actually encourage that.
Similarly, I would be reluctant to declare anyone with a stiff hip as a candidate for low back pain for the same reason.
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: Hip range of motion and low back pain - May 11, 2005 3:32:00 AM
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Shill
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From: Madison WI USA
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Jason,
You are right, this is kind of a "well, Duh" idea. BUT, when one considers just how much bending a typical patient does first thing in the morning, and how we can decrease their pain by showing them different ways to move so that the pain is less, or not present at all, it is a very worthwhile idea. Its not immobilization, its directional preference motion. Teach a patient to don their socks while lying in bed, rather than reproducing rip roaring pain by doing it "the old way". Not rocket science, but you better believe the patient will appreciate it. A lot of patients assume that they have to deal with this pain, each and every day, and they arent always programmed to figure out different means to get the job done with less pain.
Teach a patient to not lean over the sink to brush his or her teeth early in the AM. All that does is increase pain, and get the spit all over the face as it drools down. Teach off-loading of this weight by using an arm.
True, we may not yet know how to prevent pain recurrence, but until we do, some of the logical and plausible ideas are the best we have. It is fine to give this advice to the patient. Try it and see if it hurts less when you do it this way does not over medicalize, it simply gives them a better chance to control their pain with function.
We often dont ask with enough detail to know which tasks are most bothersome in the AM.
Everybody freaks out when decreased movement is suggested. They then jump to conclusions that we want to immobilize all parts. Not the case. Sometimes though, it does make good sense, for a time. When the pain is allowed to subside, we resume the motion.
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Steve Hill PT
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Re: Hip range of motion and low back pain - May 11, 2005 3:46:00 AM
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JLS_PT_OCS
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From: USA
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Seems to make good sense.
But "ergonomic training" or "body mechanics instruction" didn't seem to me to be the thrust of the paper.
I agree with you, those changes help patients.
I'm just not sure why the thrust is less movement per se and not instruction in painfree activity, which I am sure all of us are doing.
There seems to be a distinction here, and the study would be stronger, in my opinion, if we were studying such ergonomic training by PTs and it's effect, rather than just limiting bending.
I would bet the compliance rate might improve as well, as perhaps instruction like that might be more functional than simply limiting bending.
But I think we're on the same page here.
:)
My original point was that I believe McGill, who has done some excellent work in the area, may be taking too many research findings to their conclusion and giving advice that may not square with reality, outside the laboratory environment.
Or perhaps, those who read his work sometimes do this. I have no experience with the man, so I probably shouldn't tell you what he thinks. :)
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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