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  • Core stability and pain: Is it time to stop using the word stability to explain pain?

Core stability and pain: Is it time to stop using the word stability to explain pain?

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Published on: December 26, 2012

Purpose: To cherry pick a few research articles to suggest that even though our knowledge of core stability is very impressive its link to pain is poor.

Nutshell summary: People in pain have spines that function differently than those not in pain.  Many treatments can influence pain.  The spine stability model of low back pain does not explain how people have pain and takes an overly mechanical view of the pain experience.  No test has ever shown that a spine is unstable or how “increasing stability” would lead to a decrease in pain.  Thinking that our spines need more stability or control may be the completely wrong path in explaining how people have pain or how our exercises help them.   Our treatment “corrections” occur not via one specific “corrective” mechanism (e.g. improving stability) but rather through global non-specific mechanisms that our better explained by our understanding of pain neuroscience.  Making the shift from believing that “stability” is the issue with pain can thus free up to choose completely different exercise programs.  Exercise and treatment prescription thus become simpler.  We have preliminary evidence to support this view with the clinical studies that show benefits with the various exercise conditioning programs that train different schools of thought on stability or the just as effective programs that completely ignore any concepts of stability.

Caveat of Ignorance

The purpose of this post is to question things that we say about exercise, low back pain and of course “spine stability”.  This is an informed opinion piece and everything I say can be challenged strongly…that’s why I write it.  I am also going to put out some “notions” on how I think exercises can help with pain and function.  These are certainly subject to debate and will probably change with time.  I have also ended the piece with a general overview of what I do in Part Two.

A BRIEF and not complete background on spine stability across two hemispheres

Two schools of thought regarding spine stability and low back pain emerged in the 1990s.

The Australians and their inner muscles – Train the local muscles first

The first was based on Bergmark’s classification of muscles into “segmental” stabilizers and others into “global” movers.  Segmental stabilizer muscles were often considered to be tonic (constantly on) while the others were phasic (on intermittently to create movement).  This idea of muscles having different roles was suggested decades earlier by Janda.

Low back pain was assumed to occur when the segmental stabilizer muscles were inhibited and the global muscles took over.  The research supporting this idea came from the great work of Paul Hodges (A nice review of Paul Hodges and Motor control can be seen a Todd Hargroves site bettermovement.org).  In early studies, Paul showed that in healthy subjects the transverse abdominis and the multifidus muscle (two local muscles) should fire in a feedforward manner when someone is asked to lift their arm.  Lifting the arm is a perturbation to the body and muscles in the trunk and legs must turn on for us to keep our balance (some call this “stability’).  Dr. Hodges showed that the “Tranny” and MFD turn on before or within 50 milliseconds of the deltoid muscle.  Since the muscles become active  before the deltoid we can assume that the brain did some motor planning to prepare the body for the arm raising – muscle activation was NOT a reactive response to the movement of the arm.

With low back pain Dr. Hodges showed that this feedforward (or motor control planning) was delayed in the Tranny and the MFD.  And BINGO a whole  industry was born and the misapplication of science ran hogwild over common sense.  So that’s it.  All Paul showed was that in those with pain you got a DELAY in firing.  No one showed that the tranny was weak, no one showed that the muscle was turned off and no one involved in the research said that the Tranny was the most important muscle on the planet.

But somehow physiotherapists, chiros and personal trainers started telling everyone to suck in their stomach when they did squats because the muscle was erroneously deemed to be super important for spine stability.  This was never what the research suggested and caused fits in the North American Spine researchers who really railed against this simple idea.

The other school of thought – Train general core stability (a brief simple version)

Fortunately, I was innoculated against this because of my MSc with Dr Stu McGill in the late 1990s.  Dr. McGill and Dr. Sylvain Grenier were excellent in challenging the supremacy of the Tranny.  I view their research as less a repudiation of Paul Hodges’ ideas and more of an attack of the misuse of Paul Hodges’ research.  What McGill and his colleagues had always advocated and also modeled with their biological fidelitous spine model was that spine stability (aka the ability of a system to return to its normal position after a perturbation) was most robust when all of the muscles worked together in the trunk - all muscles were important for stability.  This was again nothing new and we knew this from other joints.  Muscles co-activate, create joint compression and the cost of compression is assumed to be offset by the benefit of stability.   This North American model of stability assumes that all muscles of the trunk work together to balance the stability demands of the spine.  Hence rehabilitation from low back pain should train all the muscles of the trunk in a manner that creates stability but does not do so at a huge compressive cost or adverse tissue loading cost.

Dr. McGill was a leader and pioneer in this.  He was the only one actually evaluating exercises and measuring stability and measuring the compressive/shear loading on the spine to determine which exercises might be “safe”.   Dr. McGill was able to classify exercises in to ones which were “safeish” (lower compressive or shear loading on the spine) and others which might have a high compressive penalty but an individual got a good workout (i.e. lots of muscle activity).

The clinical relevance of both the North American and the Australian views are founded on a number of assumptions and unknowns.

What both views assume is that exercise training will make the spine more robust in terms of stability (not more stable, as we know a system is either stable or unstable – you don’t make it more stable) and this will lead to less pain and perhaps decrease your injury risk.

Faulty research extrapolations to people in pain and other random stability issues

Below are a number of points regarding the limitations of the relationship between spine stabiliy and pain

1. We do not know why people have low back pain. We do not know what tissue is actually cranky/irritated, fires off a volley of nociception that may ultimately result in the production of pain in the brain (if it even is coming from some cranky/irritated nerve embedded in tissue and is not wholly a production of pain from the brain in response to some perceived threat).  We can not say that a disc is pissed off, a muscle is cranky, a facet joint is upset or if some ligament wants a vacation.  Damage in the spine has a poor correlation to pain. So if you can’t identify what tissue is the source of nociception (and we can’t) what is the mechanical basis for the prescription of any stability exercise?  How would changing the stability of the spine decrease nociception? If you think spine stability exercises actually change stability parameters by what mechanical means does this change nociception? If you think spine stability exercises help your patients and clients but you can’t explain it via a mechanical explanation (but you know it works) do you think there might be  something else going on besides stability issues that you are affecting to influence the perception of pain?

2. Who cares if a muscle is delayed 50 milliseconds?  Really, what relevance does this have.  The muscle turns on eventually and does its job during a task.  Why is a delay of 50 ms relevant in terms of biomechanics.  Is this delay a defense or a defect?  Is the problem in the spine (unlikely) or more a symptom of “something is up” with the brain (more likely, and this is where Dr. Hodges is doing most of his work now yet in popular clinical culture we are stuck at the level of spine). I will go into Hodges work later in another post because I think his work on motor control and the brain may be extremely relevant.  Big point here, Hodges never measured stability.  Just muscle activation in all the muscles that make up the trunk cylinder (side note: he did a wonderful job here, I think his research is excellent, he is an excellent researcher and his contributions to our understanding in the area of motor control are without par.  I would also prognosticate that his future research might bridge the gap from mechanical views of spine and pain neuroscience).  Everyone just jumped on the stability wagon and assumed that it was compromised.  Maybe there is something else going on here besides stability.

3. The argument for the motor control camp against bracing and planking – “Don’t brace or do planks because your spine becomes rigid” is a wee bit weak.  This is the argument against the North American model of spine stability and is used to justify”motor control” or low level exercise. It suggests that if you do a bunch of planks you will become rigid and activate your muscles too much. I disagree with this puppetry view of the body. Doing planks will not somehow carry over to rigidity in our activities of daily living.  We aren’t puppets where we can tighten and loosen the strings of our spine. This is catastrophizing against a therapy rather by the patient.  These exercises aren’t that powerful both in a negative or a positive way.  However, if you actively brace and assume a rigid posture as a choice during all of your normal activities then you can make this argument.  Don’t blame the exercise blame the conscious choice of movement.

4. Do you think your patients are really “unstable”? Patients are in pain.  They move differently, you might perceive them to have “tight” muscles.  But is their spine really unstable? Is there a vertebrae in there sloshing around, sliding this way and that, pinching on stuff.  Is the spine really buckling?  We can have patients with high levels of spondylolithesis and their spines are not unstable.  I think we might want to reconsider telling our patients that their backs are unstable and they need stability exercises.  How much fear do you think this creates?  No one has ever shown that a patient with persistent low back pain has funny uncontrolled movements at a segmental level in the spine.

5. But my SI joint needs force closure, I need to train my Tranny or MFD or some bloody fascial sling.

How  is your SI joint unstable?  What wonky movement do you really think is happening in there?   I believe that there is less than 2 degrees of movement and a few millimetres of slide in that SI joint but how is having a delay of 60 milliseconds in one muscle changing this movement?  If it does change that movement why does this cause pain? And so what if the joint slides too much.  Other joints slide around and they don’t create nociception.  And if you have a delay in the tranny won’t the big, bad global muscles be on at the same time and thus increase force closure and shut down the movement.

These global muscles certainly have the architectural requirements to create force closure.  None of this makes sense. Oh wait, those global muscles are on too much and that causes too much compression in the joint and that causes pain.  Oh, gotcha that makes perfect sense.  But guess what, no consistent research actually suggesting that this happens.   The studies showing increases show increases that are extremely subtle and again how this would cause pain is never laid out in any logical or supported manner.   Well what if that joint is fused?  That seems like a lot of compression.  Should that not be painful yet its not? And why would compression from muscles be painful? Would someone not be better lying down and not lifting weight, walking, running if compression was so nasty for the SI.  More compression on a joint is not necessarily bad and does not lead to pain.  There is something else going on here.

5. Is it really that bad to get away from the neutral spine? I agree that a neutral spine is generally stronger when the spine is undergoing maximal compressive and shear loading.  Maintaining a neutral spine when deadlifting, doing kettlebell swings, squats and picking up your sofa makes some sense to me.  But do I really need to never bend or twist my spine.  It has a certain amount of movement built into it.  Why would I not use it?  Motion is lotion.  We would never tell another body part to not move.  Taking away movement is how we torture in Guantanomo.  The majority of spine pain does not occur because of we have overloaded it to an extent where it reaches the limits of tissue injury capacity.  This may be one of those issues where we can confuse injury with pain.  Neutral spine bracing can probably help with injury and performance when under high loads but is it necessary to decrease pain in someone getting up from a chair with low back pain?  I will grant that sometimes when you brace and move with a neutral spine and get out of a chair you have less pain.  In other people it gets worse.  Maybe there is something else that explains this besides stability.

6. Patients get better with all types of spine exercise programs.

We have clinical efficacy trials showing that a motor control program (e.g sucking in your belly and then progressing with more global exercises) and a global exercise program helps for low back pain.  So do general exercise programs.   We know that exercise for the spine can help but perhaps it does not matter which exercises we do.  When we get similar results from two different theoretically supported exercise regimes perhaps there is something about the two different programs that is similar.  Perhaps it is that similarity that leads to improvements in pain.  A recent paper by Mannion et al (2012) championed a similar idea.  In other words, we get results but not for the reasons that we think we get results.

7. I think we scare the shit out of people when you tell their spine needs stability

This the default word that many of us tell our clients.  ”You’re unstable, you can’t “control” your movement and that is why you are in pain”.  Its so defeatist and catastrophizing and really has little support.  I say we stay away from these words…See my previous post here on this same topic (The words we use can harm)

Recap

You can rehab a patient using the two different schools of thought on spine stability.  You will probably have similar results.  Conversely you could just have patients exercise their entire body and they will also show improvements. You will also have good results if you just teach people about pain and give them the confidence to keep moving and not get worried about their “bloody lack of stability” that some therapist told them they once had.

Stability is probably the most inappropriate word we can use to describe our patient’s spines that are in pain.  No one has documented that patients in pain have unstable spines nor is there any reliable clinical test for it…yet we have been using this word for twenty years.  That is crazy yet so many of us think that we have to “increase the stability of the spine” in those with low back pain.  No one has shown how any dysfunctions related to “stability” actually cause pain. Again, crazy.  Yet we tell patients they need stability exercises to correct some mysterious bogeyman.   When we get results with completely different movements or exercises that totally conflict in terms of spine stability theory this tells me that the reason our treatment is effective probably has nothing to do with stability.

In part two, I will layout how the spine function is different in people in pain and also give some theories on what treatment does to help our patients.

 

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  1. Love it Greg! I’ve had many of these same thoughts in the past year or two.

  2. Great post Greg. And thanks for the link! I have a lot of the same questions and concerns as you that I have been trying to answer in advance of my part two on the Hodges conference. I am also thinking about McGill’s approach and how it compares. I asked Hodges at the conference – if the pain is causing the problem with the motor control and not the other way around, then why bother to correct it? Part of his answer and I think he has stated this in papers as well, is that the altered motor control caused by pain actually does impair function and increase wear and tear. So correcting poor motor control improved functions and avoids long term damage, even if it isn’t a magic bullet for pain. I think he has some evidence in favor of these opinions. I need to check.

    As far as McGill goes, it seems his strategy is to pick exercises that will improve core endurance at the lowest “price”, meaning exercises with the highest EMGF activation levels compared to compression levels. My question is this – if Hodges is correct that poor motor control is about bad timing, and proper division of labor, as opposed to endurance, then why would McGill
    ‘s big three be expected to alter these variables? Any thoughts?

    • Greg Lehman says:

      Thanks Todd,

      Always happy to hear your input. I will be sure to link to your new post as soon as it is done. I asked Paul the same questions (I took his two day course a few years ago) and he said something similar. The whole “wear and tear” thing is where things break down for me. How can you have wear and tear with very low load and not even highly repetitive movements. If it was wear and tear then why we would we not adapt? The “long term damage” is what I don’t get. I don’t see how any damage can even occur.

      I think Gary Alison answers your last question best. To greatly simply Gary might argue that the delay in timing is actually normal variability. Stu might say the same thing. I remember a paper I published years ago where I could not find feedforward activation (measured superficially in at the IO/tranny overlap zone) in painfree subjects. I spoke with Stu and Gary and if memory serves me correct they both suggested this was normal. I don’t know if Stu would expect the tranny timing to change with his big three. I would guess that he might think that it is not important. Paul (with Tsao or Tsai?) has published a study showing no change in timing with Stu’s exercises so there is some data there. Last, I think Hodges was involved with some research showing that spine manipulation may alter muscle timing in Tranny. If manipulation can do this than it suggests that motor control training is not the only means of changing this variable, thus how important is motor control training? Is there some other mechanism to change feedforward and is changing feedforward even that important? Related, there is a researcher named Jansen who did his thesis on adductor strains and showed alterations in Tranny feedforward with the presence of groin pain but then of course when the pain resolved with good training this was not correlated with changes in tranny onset. What does this tell us?

      Way to go Todd, you just got me asking more questions.

      Greg

  3. Bela Borfoei says:

    The lightness of being.

    The person in pain doesn’t need a more stable spine. What she needs is more awareness of the spine in her nervous system. This awareness is predominately unconscious. It is also more a movie than a static picture. This motion picture can be enhanced through the Feldenkrais Method.
    The solution is at hand, just try it!

    • Claudio says:

      And so do the exercises Bela, no matter which aproach, as we can read in the article. Whenever we contract or activate a muscle, we are actually making it more aware to the CNS, so it can have a better control over the body.

      Great article Greg!

      Cheers,

      Claudio

      • Bela Borfoei says:

        Thank you Claudio,

        Yes, you’re right. Everything gets results, but we all looking for the most efficient way to get durable results. Giving the NS the right conditions to learn it will not forget.

        Bela

        • Yael says:

          Hi,
          Just wanted to support Bela’s comment about Feldenkrais and add my thoughts. The knowledge of Feldenkrais goes beyond his method. He enabled through his research a fundamental understanding of how to approach the body in any and every condition. It’s a shame that to many he is restricted to the limited method carrying his own name. Through his understandings new methods have risen, such as “bones for life” and the “Ilan Lev method”, bringing different approaches, not necessarily new ones to the field. I strongly recommend reading his books.

  4. Drew says:

    Hey,
    Great article, but you forgot a third model for spine ‘stability’ (motor control is a better term), Pavel Kolar and the Prague school of rehab. Ontogenesis is paramount in understanding spinal motor control.

    • Greg Lehman says:

      Thanks Drew. I would throw them under the same bus too :)

      Greg

      • Drew says:

        haha, and why would you throw them under a ‘bus’?
        Pain really is an after thought to function. I agree clinicians often ‘scare’ clients into treatment plans using the ’cause and effect’ of there pain source. I’m curious to know why you feel ‘joint centration (DNS)’ or ‘joint by joint’ approach is invalid considering we all develop similarly as infants.

        • Greg Lehman says:

          Hi Drew,

          I think joint centration sounds interesting. It may or may not be related to pain. I think the joint by joint concept is too simplistic. There is not an alternating pattern of mobility to stability needs at each joint. Every joint needs both and I think that these trends are found because people look for them rather than they being obvious. While we all certainly develop from infancy I would not base ideal function on this development. We have different anthropometrics as infants/toddlers, a developing nervous system, different connective tissue properties and a huge range of variability in what is normal. My 2 1/2 year old has trouble rolling over to the right yet she can run and jump. The DNS group have ideas but I don’t think that they have data yet. They assume that they know what ideal human function is. I don’t know anything with such certainty.

          Last, they might get results with their treatment and this might lead them to conclude that it supports their previous ideas of how the body should function. However, their results could be explained via other mechanisms and they just perceive a confirmation of their ideas that may not be warranted.

          These are my observations from discussing DNS with people. I would be interested in learning more about it and perhaps my views might change.

  5. Tony Ingram says:

    Excellent stuff. This: “Making the shift from believing that “stability” is the issue with pain can thus free up to choose completely different exercise programs. Exercise and treatment prescription thus become simpler.” – that’s the whole point that people are missing. So many more options to help people with pain, such greater flexibility in our exercise prescriptions so that we can truly individualize a treatment plan.

    • Greg Lehman says:

      I’m withya. I think part of it is that we want to look like we are doing something special that differentiates us from other practitioners. Its the overcoaching of simple exercise syndrome. If you train a client you have to always touch and correct their movement as if any deviation from some assumed ideal is faulty.

  6. Thesocialphysio says:

    I appreciate the effort that has gone into the article. I may be living under a rock, but I don’t come across many physios encouraging core fitness on the grounds of “improving poor stability”. Keeping it very simple… If I have a patient who experiences pain on trunk flexion, then I encourage them to see if there are any improvements in that movement pattern with recruitment of TA and internal obliques. If it is, then I pursue the concept of improving general functional strength. I am not sure if it is urban myth …. But I read somewhere once that 80% of back pain improves by simply getting someone fitter ( easier said than done ). Exercise selection then becomes the key ; there are no recipes. We are all individuals with grossly different bio mechanical, psychological and height/weight profiles. I love the ” motion is lotion ” catch phrase. Can I use that? Often the trunk hip dis-association is crucial to encouraging more efficient movement patterns which have ‘shut down’ in response to the pain. Final point, I thankfully have never experienced back pain, however when I did some real time ultrasound experiments on my own TA, I was horrified to find that it was highly delayed in activation and completely contingent on my breathing….took me a long time and a lot of attention to separate the breath from the core.
    Too few acknowledge the importance of breath in low back pain. Thanks again for generating some discussion.

    • Greg Lehman says:

      Thanks. Why were you horrified? It sounds like you had a delay in the tranny (not sure RUSI can measure timing though) and yet you had no pain. That kind of proves my whole point. As of your treatment it all sounds reasonable to me I am just not sure that the pain improvement is because they got fitter or because you just slowly increased their exposure to increasing load over time. The fitness improvement could just be a byproduct and had nothing to do with the pain resolution.

      Greg

  7. Ronald Kan says:

    Hi Greg,
    I fully agree on all the points you made. After the ‘dynasty of the disc’ in the 30s we now entered the era of ‘the tyranny of the trannie’.
    Looking forward to your next post.
    Ronald.

  8. [...] low back pain Comments: No Comments Published on: January 1, 2013 In part one of this post I very simple reviewed some of the ideas behind core stability and how I questioned their relevance [...]

  9. Jesse Awenus says:

    Greg,
    Thanks for taking the time to write this article. No one I’ve read on the net writes as much detail, but also as interestingly as you.
    At IFOMPT in Quebec I had a chance to speak with Peter O’Sullivan. He basically told me (and a lot of other people) that is old theories regarding instability and motor control issues are junk. He went as far as to say he was dead wrong in his approach to treating specific muscle activation and he only made people worse, not better. Now he treats using a biopsychosocial model of care were pain education is his number one tool. Very little manual therapy and lots of movement based therapy. We must keep in mind that he treats primarily a chronic back pain caseload where the patients have already have extensive therapy with poor results.
    Theoretically this model makes sense, but honestly I find it’s practical application a little more tricky. Patients want the massage, they LOVE the diagnosis so they can run home to tell their family a justification for why they have back pain, and they don’t like ANY implication that their pain is in the brain…to them this means they are “faking it”. If you have any tips or resources you give patients to educate them on pain please do share!
    Thanks for writing this

    • Greg Lehman says:

      Hi Jesse,

      I think Peter’s stuff is great. I even thought of including one of his videos at the bottom of the post.

      You don’t need to come out and tell someone the pain is in their brain. You can work into this explanation slowly. You can ease this “faking” concern be saying that the brain controls everything and that the brain is part of physiology as is pain. Notice I stress physiology not psychology. You can illustrate to your patients how important the brain and nervous system are by explaining how people get stronger with strength training. We can double our strength in six weeks of training and there is probably only minor hypertrophy going on here (for some people none at all). How did the person get stronger? They got stronger because of how are nervous system recruits those muscles. The brain has the same power with pain. The brain controls how we move, this is why you can feel tight and stiff and you might think that you have shitty posture and that is the cause of everything. Rather it is the other way around, you have altered posture because the brain is producing pain and then you have changes in motor recruitment. We don’t discount that there is something going on in the body…it is the nervous system controlling this.

      Fear is also important. Ask your patient what they do when they are afraid or think they are going to get hit. They tense up protectively and without thinking about it. The low back and brain can do the same thing. Low back pain is like an overly sensitive car alarm. It goes off with just being brushed. There does not have to be an injury or damage but boy is that alarm screaming. The low back does this. Why? Because it is freaked out and afraid. Not always consciously afraid but afraid at a subconscious level. This is why it is not purely psychological but physiological. We can use manual therapy and movement/exercise to calm down the brain’s response. Our job is to teach why the nervous system is paramount – try to the strength training analogy it often helps. You can also explain about phantom limb pain or how the pain with a paper cut is massive or how you can have bruises and not know how you got them. And you can also say that they might have an injury in their back and they very well might. This is solid nociception but if they have it for 6 months its pretty unlikely that some injury is still sticking around. This is a now a problem related to pain and the movement sequelae that follows.

      I think we also create the need in patients to have simple explanations. Telling them that L3 is not gliding on L4 is bullshit or that some posterior oblique sling is not functioning makes us sound like we have some fantastic insight into function. Patients might want this but we have created the environment for them to want it.

      But, I’m with you. You can’t just say its all in the brain. First, because this is not true (there are physical and functional changes occurring) and because you can piss some patients off. You have to ease into pain education. Find stories that work for or anecdotes to explain pain are important.

      Its our job to tell the truth about back pain.

      I read your shoulder article. Well written but we should talk shop.

      Greg

      • Jesse Awenus says:

        I like your analogies…telling a client that the pain they have in their back is akin to a sensitive car alarm going off is a great one. However, how does our treatment change? Is this really of semantics? Is the entire neuro vs structural argument basically talking about how we explain their pain to our patients? Because the exercise and manual therapy are not really changing from what I’m seeing on the net from clinicians such as yourself…or am I just missing something? Do you still do acupuncture and ART or spinal manipulation? If so, how do you explain when you are doing with those interventions?

        Always up for talking shop Greg!

        • Jesse Awenus says:

          One more thing: how we then explain to a client who had no pain, them slept in a weird position and now has back pain? Is there no structural component to that? What about an athlete who develops back pain after playing their sport for an hour or 2..is that still a matter of the brain sensing a threat and relying that threat to the lower back? or can the actual muscles, joints, disc, capsule be a source of pain in and of itself? I’m under the impression that it can be since injection block studies have proved this…

          • Greg Lehman says:

            Nociception still exists. I’m not discounting this. Nociception occurs from mechanical, chemical or heat “pressure” on some neural tissue. This can happen with prolonged awkward postures but eventually that mechanical deformation subsides. When the pain sticks around I would argue that it is more than just mechanical deformation…this is where the nervous system comes into play.

            What I also think is that we develop habits of motion. We move the same way in pain and we might also keep contributing some nociception to an already sensitized nervous system.

            This is what i think “corrective exercises” might do. I don’t think they actually correct any “abnormal” posture or kinematics but rather they promote different movements. New movements, that are novel and that might desensitize the nervous system while perhaps changing up some mechanical irritiation on sensitize tissue. However, I know many would argue to ignore nociception altogether in more persistent cases. I’m not sure I can go this far.

            This is a very tough area Jesse. We are dealing with a lot of unknowns. Hence, you’ll see a lot of different opinions and evening changing opinions. I know I have certainly changed over the years.

            Greg

        • Greg Lehman says:

          Hi Jesse,

          Its not just semantics. It is about understanding what our treatments are doing. Yes,I still do lots of manual therapy, I manipulate, I prescribe exercise and I do look at how someone moves. The treatments can look similar but I simplify. I don’t tell someone their joint is out of alignment, their 5th thoracic ring is unstable, their rib is “out”, their spine is unstable and that they have scar tissue or adhesions that need to be dug out with ART.

          I published a paper more than 10 years ago suggesting that manipulation is more about neurophysiology than moving some bloody bone into position. Our treatments are more about pain modulation than mechanics. I think that mechanics change but I am unsure if they need to or how that might be related to pain.

          I explain my interventions with the best available research. That research more and more seems to suggest that our treatments work via neurophysiological principles that address the sensitize nervous system. It is not just nociception.

          The exercise and manual therapy does change. I don’t complicate things. I don’t think that I need to find one aberrant dysfunction that needs to be exactly corrected with one “correct” exercise. I don’t make up rules about the order of what exercises have to occur. I don’t say mobility before stability and have a lot of rules. Those things don’t make sense to me for altering the pain state.

          I do still do ART but don’t say I am releasing adhesions. What does ART do? The patient moves while you are touching them. You are getting them moving and activating receptors of the nervous system with your touch. This can modulate pain. You then build confidence in their movements with exercise. You give appropriate education about their pain and don’t scare them.

          I realize this sounds odd. I will work on explaining more of this in future posts.

          Greg

  10. Greg,
    Great post man! Seems like you have let it all off our chest with this one! I am definitely with you about the stability bullcrap model and have been luckily since day 1 of work. I remember learning TrA activation in a clinical internship but when I told my mentor about it when I started practicing, I almost had puke in my face :)

    Maybe it’s who I practice with or communicate online with individuals who are up to date, but do therapists still do this?! I teach my interns this model is 20 yrs old…and need to get with the program, just as you mentioned the stability wagon in the 90s. I think it was just a way for us to feel superior to other professions….that we can pick up stuff deeper by palpating which way the ASIS moves with a contraction.

    I try to pass on the new research and debunk old stuff with my interns….but that is only 1 person every 8 weeks! How can we do more to get this model out of some old school therapists and academics?
    Harrison

    • Greg Lehman says:

      Thanks Harrison,

      It is an attractive model and what is happening is that it gets replaced with more of the same. We can debunk the tyranny of the tranny but then it is replaced with dogma from the diaphragm. But, you know I think it is all worth discussing. And I know therapists still do this and there are a lot of expensive continuing education courses taught be extremely bright and well read people that still do this.

      I like biomechanics I just think it is limited. I think if you want to critique the biomechanical model you need to know it very well. I think you can even use good biomechanics to minimize the importance of biomechanics in explaining the pain experience. You can take two competing biomechanical ideas that both sound plausible (e.g the debate between shoulder packing e.g. stabilty or shoulder movement) and have clinical efficacy to support them yet they actually disagree with each other on what ideal function is. But since they are both effective in a clincial population it tells us that there is something else that is important for changing pain and changing function. That is another neat blog post.

      greg

      • Harrison Vaughan says:

        Yeh you’re right, worth talking about. Everything gets results but we all trive for quickest and most efficient. We are all on same team. Sometimes I forget this. Keep up the good writing!

  11. [...] and pick through his information. He is confrontational, he does swear, and he does make sense. Part one and part two of this discussion will take some time to get through, but I do like his ideas that [...]

  12. JP says:

    Interesting post and nice points/wake up calls in general. Also good conversation about neurophysiological side of LBP and why not any musculoskeletal pain in general. I believe that the whole biopsychosocial approach and the cognitive-behavioral side of pain and the experience of it is the road we should be exploring and understanding especially when dealing with chronic and and prolonged pain. Though there is one thing I’d like to point out concerning research related to exercise;

    We’ve seen a lot of research done on exercises from individual muscles, specific exercises including local and global stabilizers and activation exercises all the way to comparison of whole other types of exercise approaches (eg. graded exposure, stabilizing exercises and motor/movement control training) just as you mentioned.
    But so far one thing that needs to be taken into account when we determine the clinical feasibility of these studies is the set up and sub-grouping of patients. It’s true that we cannot know for sure what is the relation of the specific findings or tissues to the patient’s pain experience, but what we can observe is their function. Where I’m getting with this is that with the studies done on exercises of any kind, maybe the sub-grouping of patients hasn’t been accurate? I believe that with better sub-grouping of patients we’re soon likely to see better results in regards of exercises as well. Each intervention (whether it’s training, meds, surgery or education) works the best when we have the right indication for it. What I mean is that in a heterogenous group we will have flexion control issues, timing delays, disc irritations and lords know what kinds of patients training only stability, only motor control, only graded exposure and then we compare the groups. Surely with big enough of a sample group we’ll get a nice set up of everything in each group and the results should be similar. But what if we sub-grouped the patients into more homogenous groups and then compared the results? As I already said above, I believe we’ll get better results also from exercises.

    • Greg Lehman says:

      Sounds logical and Fritz, Childs, Flynn and company have certainly started this. Debating their clinical prediction rules (which essentially categorize patients into homogenous groups) is a whole other debate. I think that we are limited by our assessments. We need some way to stratify patients and with the pain experience being so complex I think this is difficult to do.

      Thanks for your insight. Your views certainly have a lot fans. Take a look at those authors above if you haven’t seem them already.

      Greg

  13. Jeff says:

    This was a great post. I have thought about this lately with some of my chronic pain patients. I like your examples of how to bring it up because that is the hard part. You don’t want them to think you think they are faking it. What do you do with chronic tension headache patients in this regard? Great site.

    • Greg Lehman says:

      Thanks,

      Same idea with headaches. There has to be some processing and production of pain. I think that the pain can still be downregulated by the nervous system. I would assume that there is also a peripheral component when nerves get cranky and movement changes. I would work on this. I would also work on goal setting to avoid flare ups.

      Greg

  14. John Paul Guidry says:

    Great post. As a PT I find that a great number of patients with low back pain or related issues come to me with a script that says “lumbar stabilization” or having been told by the MD that they need to improve their “core strength and stability” Therefore the patient is already coming in with an idea they they need to improve these things. I find it difficult to disagree with their MD without discrediting the MD or saying he is wrong. I have attempted to send literature to these MD’s with no response. Therefore I initiate some basic not threatening “core stability” exercises while focusing on a movement based program while trying to educate them while tiptoeing around the core stability issue. I wonder if any other PT’s have this issue?

    • Greg Lehman says:

      Thanks John Paul,

      I certainly have the same issue. Even with working with other healthcare providers I think it is prudent not stamp on other people’s beliefs. I don’t creating a pissing match ever helps a patient. I doubt we can help a patient if we just tell them that all the other people they saw are wrong. It certainly is a fine line that we walk.
      Greg

  15. ben says:

    nice post Greg, and replies from others. I think in an era of evidence-based med, we should try to search for accurate explanations of why things are the way they are (actually achieving it may be difficult due to multiple variables, etc). then again, if we’re too reductionist (eg, this nerve, nuclei, etc), only accept RCT evidence, etc then clinically we would probably not even know what to do. At the same time, an overly holistic/simplistic view (eg, adjust atlas and everything will be fine) is also not the way to go.

    btw, while researching lbp I found Martin Krause’s website..this Aussie physio has provided summaries of the major schools of thought in his article ‘the development of msk stability’ (20+ pages)

    btw Greg, i think there may be value in looking at timing delay patterns. I dont have a rct, but i do have multiple ankle injuries and at most would get grade 1 contraction in a glute med muscle test. Clamshell exercise were usrless to me cos i couldnt contract/”fire” much. Then i went for 5 deep massage sessions to ankle and lower limb, and hey i can contract much better know and can feel the glute med fire. now after much exercise, i would be able to score 3 in a muscle test.

    • Greg Lehman says:

      Thanks Ben,

      I will look into Martin Krause’ website

      As for your glutmed I buy it. I don’t discount testing our patients. You found a deficit in your function (Glut Med strength) and found that manual therapy helped this deficit. Sounds good to me. The mechanism behind the weakness is where we can study more. Bullock-Saxton put out paper more than a decade ago suggesting that muscle timing was off in the Glut Med after ankle sprains. I published a prospective case report (my wife sprained her ankle and I also had pre-ankle sprain muscle activation data on her) and followed my wife’s muscle activation patterns over two weeks. I found no consistent difference pre-sprain versus post sprain. The paper is here: http://www.ncbi.nlm.nih.gov/pubmed/16504168

      Greg

  16. M.B.S says:

    Great post, loved the follow up on your clinical reasoning as well! Put your website up as recommended reading, keep up the good work!

  17. [...] emerging, most has been around since the 90s) is applied to clinic or sport in ways that the research does not actually support.  I am also a former recreational gymastics coach and regularly “threw back tucks” [...]

  18. Arthur says:

    Greg,

    I am curious what you think is the best way to get patients better? I do a lot of intrinsic core, DNS, SFMA, NKT etc. I feel like I get a lot better results then any of the PT’s or other chiropractors in my area. I feel like when I read this that if stabilization/motor control is not changing anything then what do we have left? Just adjustments? I think you make some great points but I feel like there has to be a stability/motor control aspect in the treatment of pain somewhere.

    • Greg Lehman says:

      Hi Arthur,

      I think all those approaches can get great results I just don’t think it always because of the change in motor control and because of a change in “stability”. What other things happen when you do DNS, SFMA etc? You get the patient to move differently. You pay attention to them. They pay attention to themselves. You encourage them to move in pain free and novel ways. All of these things can desensitize a scared, fearful and upregulated system. You help allay their fears and encourage them to move more confidently. All of those great results might have nothing to do with stability. Hope that makes sense. Greg

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