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RE: Lumbar disc herniation protocol
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RE: Lumbar disc herniation protocol - April 6, 2008 10:26:07 AM
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proud
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quote:
ORIGINAL: SJBird55
Kaden, honestly. I explain the original theory and then tell them that I really don't think that the theory is correct because we, and even I, don't go walking around thinking about contracting those muscles all day long. I tell them that the biggest problem they have is that they have pain and these particular exercises are a nice first step in teaching their body that it can move and a nice little fringe benefit is that they will strengthen their muscles in the abdominal area. I honestly think that the last little part is what sells the patient - the majority of people in society today have a dream of tight abdominals. So... most patients are compliant with the stabilization exercises, at least initially, because they can see themselves with a nice, flat stomach. LOL Unless the patient has further questions or comments, I let them keep that vision in their heads because the end justifies the means. If they do ask further questions, then I am honest and tell them that for what they envision they also definitely need to incorporate aerobic activities into their lives blah, blah blah and expend more energy than they intake with eating or drinking. (I'm in MI and the majority of my patients are obese...)
Now, more than ever in the history of mankind, sedentary lifestyles has become the norm. Now I am not talking about fat, lazy people( although there's plenty of that to go around). I'm talking about what computers, televisions with remotes, longer commutes to work in a car, video games etc etc has done to people.
I remember being younger and spending ALL winter out playing road hockey. Summers was simply....just outside. It's a lifestyle.
So then, we have Physiotherapists all wraped up in tiny specific exercises and mobilizations( I think it gives them the impression that they have secret special skills...makes them feel better about themselves). We see then that we have given away what we should ideally be suited for...exercise prescription and expert guidance in that arena. Instead we see far less qualified people in terms of understanding NMSK pathology are the ones telling these people what to do.
Meanwhile...we goof around with Tra/multifidus and trying to determine if this segement moves more or less than that one, or if there is a "trigger point"( as if that actually exists), etc etc.
What we should be doing is understanding the factors that tend to predict chronicity...scoring them and then addressing them. Understanding Pain. Yes...understanding pain.
We should be THE advocates for active lifestyles. We should know the subgrouping/classification shemes that allow us to determine how best to simply overcome patient fears and bloody well get them moving. we should be the educators about what DDD means and does not mean etc etc.
We can do this....or simply be yet another group of greater fools that contribute to the increasing impairment and disability we are seeing today. Telling patients they have a joint out of place, or a muscle "not working" only adds to the patients perception that they are truly screwed and in need of ongoing specialist attention( which by the way....tends to be an indicator for progression to chronic pain....specialists attention)
Are we experts?....or just another group of non critical thinkers?
< Message edited by proud -- April 6, 2008 10:35:56 AM >
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RE: Lumbar disc herniation protocol - April 6, 2008 11:22:22 AM
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rwillcott
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Great points proud. The majority of LBP patients need an expert to educate them on how to become active. As physiotherapists we have the knowledge to know when it is appropriate for someone to start an exercise program.
When it comes to stability exercises I agree that often times it's more important to simply encourage the patient to become more active. Many people are not willing to take the time to go for a 15 minute walk. How could we expect them to lay on their back and pull their belly button in and perform a variety of leg movements and ball exercises? I would say the benefits from an aerobic exercise program far outweigh a stabilization exercise program.
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RE: Lumbar disc herniation protocol - April 6, 2008 1:20:52 PM
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Kaden
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SJ,
Thanks for the reply I am going to add that little extra to my explanation tomorrow and see how it works. Just curious, are you only teaching and assesing TrA to these patients or do you also asses and try to get them to fire multifidus?
Obviously the research states MF becomes dysfunctional with pain and does not automatically return but the question is does this need to be addressed specifically or is TrA enough.
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RE: Lumbar disc herniation protocol - April 6, 2008 1:38:42 PM
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proud
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quote:
ORIGINAL: Kaden
SJ,
Thanks for the reply I am going to add that little extra to my explanation tomorrow and see how it works. Just curious, are you only teaching and assesing TrA to these patients or do you also asses and try to get them to fire multifidus?
Obviously the research states MF becomes dysfunctional with pain and does not automatically return but the question is does this need to be addressed specifically or is TrA enough.
What do you suppose would have the largest effect on this?
Moseley GL, Nicholas MK, Hodges PW. Does anticipation of back pain predispose to back trouble? Brain. 2004 Oct;127(Pt 10):2339-47.
Suggests that simply people's perception along with fear, etc can be enough to alter neural control.
Thus our education to these patients MAY be more important than yabbering on about their dysfunctional Tra/multifdus and how if they don't come see you to fix it....they are bound to go on and have recurring back pain....get it?
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RE: Lumbar disc herniation protocol - April 6, 2008 2:05:34 PM
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jlharris
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Now, call me on it if I'm way off base, but I approach Multif/TrA just like I do with the quad and knee injury. After the initial few days, there is inhibition to muscles crossing the injured joint (and that's all the spine is, just another joint) and part of the recovery of function in neuromuscular re-ed for those inhibited muscles. We do quad sets/hamstring sets/NMES/etc for the leg and TrA drawin's/prone hip ext/etc for the spine.
I avoid the term "instability" as I don't want the pt to believe their bones are moving around. I preach relearning control of muscle we know help in the dynamic control of the spine with activity - just like the quads and hamstrings in the knee.
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Jason L. Harris, PT, DPT
My PT Blog
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RE: Lumbar disc herniation protocol - April 6, 2008 6:37:11 PM
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mwells144
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Jason-
I take the same approach as you...Never use the word "instability". Patients will freak out and we all know that there is an emotional component (in some cases) to LBP. I think there has to be a gameplan that is explained to the patient the first day. Mine is usually that we will first centralized the symptoms and expect a moderate increase in localized pain that may last for a few days. I discuss that usually we can effect the symptoms with repeated movement alone but there are modalities ie: traction that we can use in the rare case that this doesn't improve symptoms. Once centralization occurs I am prone to work more on the myofascial level for controlling localized pain ie:STM, specific stretches to decrease the spasm. Once symptoms are managable I incorporate a cluster of TrA, exteral internal oblique, glut max, erector strengthening exercises AS Well AS showing them it won't hurt the back to ride a bike, use eliptical or move in general...anything to get them to move more. I usually only see them 3 or 4 times once the exercise for strength and CV has hit but explain to them this stage is necessary to prevent chronic pain
I am specific when i tell them I am leaving it up to them....do they want a lifestyle change that will lead to less pain and increased heart health with less fatigue....or do they want to see me again in the next 2 years
The ones that do change their habits usually thank me when i see them in the mall, ballgame ect
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RE: Lumbar disc herniation protocol - April 6, 2008 7:06:59 PM
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jlharris
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Good information MWells. And welcome to the forum.
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My PT Blog
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RE: Lumbar disc herniation protocol - April 6, 2008 9:40:43 PM
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rwillcott
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Does everyone feel that TrA and MF must be retrained with all LBP patients? I would think specific exercises such as recriutment of TrA/MF may be important for the sub-group of LBP patients that meet the CPR's for stabilization. But are they necessary for all LBP patients? Are these exercises really necessary for someone who meet's the CPR for manipulation? The CPR's for manipulation include a hypomobility.
I think it's interesting the study proud made reference to. The fear of pain can alter neural control. However, are we willing to let go of our specific 'skills' of palpating someone's TrA as they draw their belly button in without 'bulging' their internal oblique?
Rob
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RE: Lumbar disc herniation protocol - April 6, 2008 10:44:28 PM
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jlharris
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There is a difference between poor joint mobility and neuromuscular instability. You can have them both occuring at the same time. That being said, I don't see why one must include TrA/Multifidus exercises with all LBP pt's. I don't. Just like I don't give every knee injured pt quad sets.
Also, don't confuse predictors for a CPR as the cause of their problems. Meaning, hypomobility found somewhere in the lumbar spine being the reason why the manipulation worked. It could just as well be the 35 degrees of IR or the fact that no pain below the knee that is truly being "fixed" with the manipulation.
With that, the same must be said with the stabilization CPR. Maybe, as others have said, it is overcoming the fear of movement in the painful area that allows them to improve and not the fact the TrA/Multifidus are stronger.
We must be fully aware of what we know and don't know with these CPR's. IMO, what we know is that a subgroup of pt's responds well to manip/stab/directional specific ex/what ever else - but we certainly haven't come far enough to say why the do. But that's ok, we must start somewhere, and research showing it works w/o fully understanding why is better than believing we know exactly the why/what/how but no research to show that it does.
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Jason L. Harris, PT, DPT
My PT Blog
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RE: Lumbar disc herniation protocol - April 6, 2008 11:18:45 PM
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TexasOrtho
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Well said Jason. I think most reasonable people see the CPR's as another potential link in the diagnostic-therapeutic chain. Those who overstate or understate their significance have an agenda IMO. My approach to LBP in it's many forms is largely dictated by the history and pain behaviors of the patient. Biomechanics play an important role of course, but the patients response to their condition is where I really want to get involved. That seems to guide many of my mechanical treatments and helps me with my education of each patient. I'd like to think of it as getting the best of both worlds: biomechanical and biopsychosocial.
As far as the "core" training goes...I've never been comfortable with this label although it really is just that: a label. We could call it anything we like really. I think, as with many modes of therex, there is a huge amount of neurophysiology guiding the patients response to the intervention. Core training likely elicits these responses in a way that benefits certain patients, but not others. There are good articles out there demonstrating specific "core" exercises are more beneficial than generalized conditioning. Further look into the literature will reveal the exact opposite. The bottom line is exactly what Jason points out: we just don't know. As far as specific "core" training...I still have a hard time giving the TrA as much credit as many would like to, but I'm still waiting to see more information. While I understand the concept, the whole "drawing in" activity seems to miss the boat in terms of some fundamental motor control and exercise science principles. I've been treating LBP for several years with comparable results to my colleagues, and have never used this exercise. There may be some benefit, but I have not witnessed it.
Although we don't know everything, we are able to make educated guesses. The CPR's and other similar studies are allowing us to make stronger educated guesses. There will still be plenty of nonresponders to a variety of treatment modes, but I still think it goes back to our diagnoses. I'm not advocating a strict biomechanical model of diagnosis mind you. I just think we will never be able to compare these specific treatments when we still can't agree how to appropriately diagnose or classify what we are treating.
By the way, I want to share with you a personal hades I'm in right now. My flight home from Lubbock got nixed tonight and I'm posting this from a Holiday Inn. I get to fly home at 5am tomorrow morning (that's a 3am wake up call). I will finish my day with a 10-6pm'er at the clinic. Not that I don't like Lubbock mind you. I'd just rather be home with my wife!! Rant over.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Lumbar disc herniation protocol - April 7, 2008 9:14:35 AM
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Shill
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I like this thread. Excellent posts made by all. I happen to be an enormous proponent of directional preference approaches, and find that most patients will centralize if given enough opportunity. For example, the algorithms (sp?) suggested by Angelo DiMaggio in his Strategic Orthopedics course are detailed enough to guide this process to the level that if one does not centralize with this many steps, its just not going to happen. Specifically, the algorithm for lumbar spine is 3 sets of 10 of the following: flexion standing, followed by extension standing (weight bearing/loaded), followed by supine flexion, followed by prone extension (unloaded) followed by lateral shift (loaded and unloaded) (R), then (L), followed by extension combined with shift (loaded and unloaded). With use of this system, and logical use of loaded versus unloaded exercise, based on symptom behavior patterns, centralization is again something that occurs with most of the folks I see, often regardless of whether the symptom behavior is "discogenic". Lets face it, determining whether it is discogenic, facetogenic, ligamentogenic, vertebralbodyogenic, musculogenic, nervogenic, is something we will probably never be very good at deciphering with any reliable accuracy. We all have our theories, and can spout off about which one we think is the best fit.
Proud. Im in the same boat you are with the stabilization idea. There are times when I think it entertains the back muscles enough to keep them busy while other things heal. There are other times when I think that because they are paying attention to doing something, it helps. Even other times, I think it is helping to condition tissues to better handle stresses. The literature shows it may be helpful, and yet I struggle with the determination of who needs to do it, based on the fact that there are few reliable ways to determine "instability". The nice thing is, it does no harm, perhaps gets those who do it to incorporate a little more activity towards body maintenance into their routines, towards promotion of a healthier lifestyle......in between cigarette breaks that is....
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RE: Lumbar disc herniation protocol - April 7, 2008 12:34:52 PM
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Kaden
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The key with stabilization training is to identify who is most likely to respond and the preliminary CPR out there is heading the right direction. It really doesn't matter what mechanism one thinks is causing the improvement. Fact is there is evidence to show that people do benefit from TrA and MF work and so we should be doing it with the patients who will most benefit regardless of beliefs of the therapists as to how or why it works.
There is a CPR for patients with neck pain who will respond well to thoracic manipulation. One could pose many different mechanisms for why manips to TS will improve CS pain. I guess my take again is it really doesn't matter. If said patient meets criteria then that patient should get thoracic spine manipulation as long as no contraindications.
I think that is the great part of the classification system and associated CPR's. We don't necessarily know the mechanism or all the factors that make them work but clinically they do work and the evidence supports their use.
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RE: Lumbar disc herniation protocol - April 7, 2008 3:05:56 PM
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buckeye
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Adding strength through stabilization is generally a good thing but the idea of encouraging movement as others here have described is perhaps the greatest early value. I think the 'stabilization' exercises are good for neuromuscular reeducation/proprioception with regards to the neutral spine concept. Do we have evidence the neutral spine is safer or stronger for the trunk? Even though we cannot have complete muscular stabilization, if the patient can learn to maximize control and stay as close to neutral as possible, perhaps they can have less pain with movement. Perhaps we should re-name the stabilization exercises so they can be thought to have value for someone who falls out of the algorhithms for a specific type of treatment.
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RE: Lumbar disc herniation protocol - April 7, 2008 8:25:42 PM
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TexasOrtho
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Good stuff buckeye. I think sometimes the words we choose to describe things can be very distracting from the most important aspects of what we are discussing. We were talking about this in a course this weekend regarding the use of the term "capsular" patterns. The uses of terms like "core" and "stabilization" often takes us down roads that often distract more than contribute to productive dialogue. The funny thing is, can you imagine the raging debates that will ensue in trying to standardize the "core" or "stabilization" lexicon? I think it can be done, but it will require give and take from lots of folks already fully vested in this language.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Lumbar disc herniation protocol - April 7, 2008 9:04:20 PM
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proud
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Funny how this thread was meant to be a query about the specifics of what we do for things. I guess it sort of has kept on track. I think it's an excellent conversation going on here though.
Here is something to add to the stew. I think most well informed PT's will agree that getting into the tiny particulars of things( PIVMS/PAIVMS along with the stangely complex Tra/Multifus training we have all taken) likely adds much less then we have been taught it does.
However, patients have become consumers of this sort of bunk. When they come to someone to "unravel" the mystery, they expect some outstanding explaination for why they have pain. It becomes a competition between providers on who can appear to know the most via elaborate patho-anatomically driven explanations.
When in all likelihood, that patient just needs to be re-assured that the "DDD" the doctor told them they have is likley irrelevent, that the leg length descrepency that the last PT told them they had is liklely irrelevent etc etc.
Unfortuntely, within the current medical model where insurance pays for seemingly almost any sort of treatment( Chiro, massage, acupuncture etc etc), we have seen PT's lower themselves in an attempt to maintain the perception that we have special magical skills( Kind of the same slippery slop chiropractors are on).
So although straight shooting, evidence based advise and guidance would result in far better overall long-term outcomes...the public would much rather hear that their spine is out of alignment or that they have a really complex muscle imbalance. The end result is poorer outcomes....AND INSURANCE PAYS FOR IT?
How are practice owners dealing with this conundrum?
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RE: Lumbar disc herniation protocol - April 7, 2008 9:08:05 PM
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SJBird55
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Biomechanically, the contraction of those muscles creates some sort of "stabilization." What I don't think is that the relevancy of the activity hinges on the aspect that has been measured and literally observed. I don't really think the language needs to change - stabilization is fine. We just need to add more detail to the theory by adding the probable peripheral and central components of the activity (that way everyone can still stay vested in the terminology with a deeper explanation). Plus, "stabilization" is probably a whole lot easier to document than whatever explanatory terminology falls out from any debate.
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RE: Lumbar disc herniation protocol - April 7, 2008 9:48:39 PM
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TexasOrtho
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SJ. My problem with "stabilization" is that it implies a lack of stability which often feeds a patients perspectives on constructs such as their back being "out" or "in". As an extreme example, chiropractors use a specific language (IMHO) to justify a dependent relationship between the patient and provider. You and others have probably had to spend considerable time with some patients undoing this misguided use of words. In this sense, the words can play an important role in the episode of care and therapists should be more aware of this phenomenon.
I feel comfortable with what I'm doing, but patients do pay attention to the words we use and sometimes I think use of the words like "stabilization" unleashes a thought process in the patients mind that their back lacks stability and needs to be held in place. I take plenty of time with them to explain there is some reason the exercises help likely related to neuromuscular control strategy as opposed to learning to "stabilize" themselves against an instability that oftentimes doesn't necessarily exist. My way of explaining this phenomenon sometimes takes time, but I'm a real stickler on language as it can and does often come back round on us...for better or worse.
I think there are times where this vernacular is appropriate as in a true instability. However, in my patient population, instability is not always (or even rarely) the rule and the language I choose to use with them is different. Does that mean we should rewrite the entire lexicon? Probably not, but the specificity of language we use goes a long way and eventually works it's way into the lexicon of other less knowledgable folks...namely our payors.
In this context, I think the more specific our language the more we benefit. In cases where we simply aren't sure, it seems appropriate to make this transparent with our patients. We know many "stabilization" activities helps. However, the more we say it's because the "core" is "stabilizing" our spine, the more this imprecise language pervades the culture and stifles growth.
< Message edited by TexasOrtho -- April 7, 2008 9:58:00 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: Lumbar disc herniation protocol - April 8, 2008 7:07:00 AM
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SJBird55
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Ahhh, Rod. LOL Just had a lightbulb moment. NOW I understand what you are saying. I'm probably a really bad therapist in the sense of appearing really, really educated with my ability to use medical words. I actually never tell patients that they are doing "stabilization" exercises. I say something like what I typed up above. I just want to get them moving. If the patient tells me that the exercises are "core" or seem to have some characteristics of pilates, I indicate that the patient is right, the exercises are somewhat similar. I think I tend to lead the impression that the goal is to have the muscles all work together as a team or something like that. I actually don't say anything is unstable either - but not for the reasons that you are mentioning but for the simple reason: How the heck do I know it's unstable? LOL 99.99% of the time, I believe I'd appear uncredible telling anyone her spine is unstable.
I haven't really seen a study, but let's say you do have someone who has a "hypermobile" spine in the lumbar region. Forgive me for my lack of remembering test names - I'm horrible with names - but you used the test where the person is prone, PA mobe and there is pain, left feet off ground, PA mobe and no pain. Also, the person is younger, has some hypermobile segments with PT mobilization and does happen to have a bit more than 90 degrees of hip flexion with the knee extended. So, the patient should have "stabilization" exercises. Has anyone seen that the spine really changes and isn't "hypermobile?" In all honesty, if a patient is responding with "stabilization" exercises, I actually have never taken the time to reassess some of those findings - in particular PA mobes to see if the spine is no longer "hypermobile." Part of it is fear - I don't lie very well. IF the spine were still "hypermobile" AND the patient was responding, what's my brain supposed to think? AND if the patient asked me if the spine was better, what am I supposed to say? I can't lie - never had that skill, something always gives me away... so, my whole career, I've avoided reassessing the "hypermobile" segments. And in all honesty, the deep down reason is that I truly don't believe that I'd palpate a real change.
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RE: Lumbar disc herniation protocol - April 8, 2008 8:12:35 AM
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TexasOrtho
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I agree SJ. In cases where hypermobility is actually causing an instability, calling it stabilization makes tons of sense. I also agree that reassessing the motion segment would be pretty futile and unremarkable as nothing is likely to change. I think it's all about motor control in a variety of contexts. For some reason (hypermobility, hypomobility, overuse, ischemia,etc..) people lose or cannot sustain the ability to maintain proper functional stability within the context of their activity. In this case, I agree with many of the previous posts that advocate directional preference movements with pain free muscle activation. Followed my neuromuscular training within the context of their daily activity or sport, I think this approach leads to decent results in many populations.
I'm with you. I just can't be that way with patients. If I "think" that's what is happening, that's what I tell the patient. It's a little humbling not to come off knowing everything, but most patients find it refreshing.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Lumbar disc herniation protocol - April 8, 2008 10:01:56 AM
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Shill
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Proud,
You really should publish your last post. Perhaps in JOSPT, as the opening editorial, although I think they save that spot for the editor in chief..... anyway, its good.
By the way, I hate the word "core". Apples have cores, the earth has a core. Its just the trendy new word for abs that people love to latch on to. I propose we return to "solar plexus". Sounds so cool......I am kidding, as usual.
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