When would you refer?

[Fiveoboy11]

I address strengthening when indicated, but not necessarily focused on it or biased toward it on every single patient. I'm aware of adding sport specific exercise to a POC when indicated.

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[jesspt]

JessPT,

What is your answer to my question? What do you do? What types of treatments do you perform instead of core stability? I am all ears.

I think the treatments PTs use, with the most immedite effects, and largest effect sizes, are those we can obviously have the most impact with. From what I've read, those tend to be repeated motions/McKenzie protocols, and manipulation, and to some degree pain science education. So, these are usually my first line of treatments, unless the subjective history or exam lead me in a different direction. If the patient falls outside of this group, I've seen little convincing data that suggests stabilization is any better than general ROM, strengthening and progresive cardiovascular exercise.

 

[facetguy]

I think the treatments PTs use, with the most immedite effects, and largest effect sizes, are those we can obviously have the most impact with. From what I've read, those tend to be repeated motions/McKenzie protocols, and manipulation, and to some degree pain science education. So, these are usually my first line of treatments, unless the subjective history or exam lead me in a different direction. If the patient falls outside of this group, I've seen little convincing data that suggests stabilization is any better than general ROM, strengthening and progresive cardiovascular exercise.

Lovin' this! I'm old enough to remember when manipulation was considered quackery.

There are studies that have looked at manual therapy, exercise, or manual therapy plus exercise, and these studies usually conclude that the combo is more effective than either alone. I think it was the UK BEAM trial that concluded that, pound for pound, manipulation delivered the most bang for the buck.

 

[Fiveoboy11]

Lovin' this! I'm old enough to remember when manipulation was considered quackery.

There are studies that have looked at manual therapy, exercise, or manual therapy plus exercise, and these studies usually conclude that the combo is more effective than either alone. I think it was the UK BEAM trial that concluded that, pound for pound, manipulation delivered the most bang for the buck.

It is quackery to manipulate the lumbar spine and proclaim it helps with bed wetting, or the neck for a sinus infection...

But I agree that manipulating plus specific exercise works really well for some people.

 

[dg1984]

I think the treatments PTs use, with the most immedite effects, and largest effect sizes, are those we can obviously have the most impact with. From what I've read, those tend to be repeated motions/McKenzie protocols, and manipulation, and to some degree pain science education. So, these are usually my first line of treatments, unless the subjective history or exam lead me in a different direction. If the patient falls outside of this group, I've seen little convincing data that suggests stabilization is any better than general ROM, strengthening and progresive cardiovascular exercise.

I don't think we are too far off on this. McKenzie in its true form is okay, but I have seen too many MDT therapists rely on lumbar extensions and cervical retractions and never assess translocations or flexion.

I generally agree with 99% of the things you say on this site, but I do not agree with your stance on core stability. I am a huge fan of repeated motions and manips. Dellito would suggest that you just put the junk group on traction and a small percentage may get better. I also think lumbar traction is not used nearly enough.

 

[dg1984]

I address strengthening when indicated, but not necessarily focused on it or biased toward it on every single patient. I'm aware of adding sport specific exercise to a POC when indicated.

Since you don't believe in exercise progression do you just start with the sport specific activity?

 

[Fiveoboy11]

Since you don't believe in exercise progression do you just start with the sport specific activity?

It doesn't have anything to do with beliefs. I progress certain patients more than others. Yes I alter POC's, quite a bit actually. I add things and subtract things here and there. But I would not necessarily call it "progression" because it got "too easy." And yes of course I progress into sport specific activity, but I don't think I need to do abdominal bracing with hip flexion marches in hooklying as a starting point.

 

[dg1984]

It doesn't have anything to do with beliefs. I progress certain patients more than others. Yes I alter POC's, quite a bit actually. I add things and subtract things here and there. But I would not necessarily call it "progression" because it got "too easy." And yes of course I progress into sport specific activity, but I don't think I need to do abdominal bracing with hip flexion marches in hooklying as a starting point.

Fair enough.

 

[fozzy40]

Great discussion everyone! I'm definitely learning a lot.

 

[fozzy40]

I just read a great review I wanted to share:

Karayannis, N. V, G. A Jull, P. W Hodges, G. Vargas-Alarcon, E. Alvarez-Leon, J. M. Fragoso, A. Vargas, et al. “Physiotherapy Movement Based Classification Approaches to Low Back Pain: Comparison of Subgroups Through Review and Developer/expert Survey.” BMC Musculoskeletal Disorders 13, no. 1 (2012): 24.

Through this discussion, there is obviously a variety of ways that PTs approach back pain. How is low back pain treatment traditionally taught in school? Is there a specific protocol?

 

[facetguy]

I just read a great review I wanted to share:

Karayannis, N. V, G. A Jull, P. W Hodges, G. Vargas-Alarcon, E. Alvarez-Leon, J. M. Fragoso, A. Vargas, et al. “Physiotherapy Movement Based Classification Approaches to Low Back Pain: Comparison of Subgroups Through Review and Developer/expert Survey.” BMC Musculoskeletal Disorders 13, no. 1 (2012): 24.

Through this discussion, there is obviously a variety of ways that PTs approach back pain. How is low back pain treatment traditionally taught in school? Is there a specific protocol?

Full text link for convenience:
http://www.biomedcentral.com/1471-2474/13/24

 

[fozzy40]

Full text link for convenience:
http://www.biomedcentral.com/1471-2474/13/24

Thank you!

 

[truthseeker]

I have his book too, big deal. He's not even a PT, and therefore does not even have experience treating patient's with physical thearpy for LBP. Where McGill and your reasoning falls short is the lack of outcome based train of thought. Stabilization exercises do not necessarily stabilize anything, and if they did does that even coorelate to symptomatic improvement? (You know, what the patient actually cares about?).

For me in LBP I typicall use a few approaches: 1) joint mobility/ROM exercise of lumbopelvic (biasing to a directional preference if there is one). 2) manipulation if indicated. 3) LE neurodynamics (if there is paresthesia or radiculopathy). 4) pt education.

I find a good program for each patient the best that I can, and usually stick to it. As opposed to "progressing." I don't comprehend everyone's reasoning when it comes to desire to progress everything in PT. Some patient's need a progression, some not so much. Some just need a good program to stick to. In medicine, do patient's receiving Rx for HTN get progressed if the treatment is working, i.e. nearly complete change of the POC?

I just found this thread. I haven't read past this one yet, but felt like I had to comment. The concept of core stabilization hasn't been supported as a stand alone treatment approach. It is very difficult to measure, however, the philosophy, in my view is sound. Why? the analogy of treating ankle sprains and ACL tears with proprioception has been supported. essentially, with an appropriate core stabilization program you are doing the same with a "sprained" back. training the muscles that control the joints to do it better. I am not talking about static, volitional core muscle contractions (akin to peroneal isometrics for treatment of ankle sprains bah) but dynamic trunk exercise that requires the "core" to respond to perturbations of the spine within painful limits. As the control gets better, you increase the perturbations and thus the challenges to those muscles.

 

[jesspt]

I just found this thread. I haven't read past this one yet, but felt like I had to comment. The concept of core stabilization hasn't been supported as a stand alone treatment approach. It is very difficult to measure, however, the philosophy, in my view is sound. Why? the analogy of treating ankle sprains and ACL tears with proprioception has been supported. essentially, with an appropriate core stabilization program you are doing the same with a "sprained" back. training the muscles that control the joints to do it better. I am not talking about static, volitional core muscle contractions (akin to peroneal isometrics for treatment of ankle sprains bah) but dynamic trunk exercise that requires the "core" to respond to perturbations of the spine within painful limits. As the control gets better, you increase the perturbations and thus the challenges to those muscles.

Truth,

I think that when the landmark study re: spinal stabilization was done in Australia in the mid-nineties, based on what we knew at the time, the philosophy was sound. But, we are seeing more and more evidence that shows that patietns treated with these exercises seem to do no better than those treated with a more general exercise program. I'll reference Neil O'Connell's blog post again - http://bodyinmind.org/more-fragility-in-core-stability/

Remember, it was once philosophically sound to cast ACL reconstructions in 20 degrees of flexion so as to protect the graft, and prior to that to perform whole meniscectomies, until we knew more, analyzed outcomes, and changed our practice patterns. In my opinion, we are at the start of a sea change regarding the importance of some of the interventions that PT has traditionally held dear such as spinal stabilization. As we know more, the philosophy that provides the underpinnings of some of our treatments will look less and less (or possibly more and more) sound.

Also, Lederman's article on "The Myth of Core Stability" is worth a read -

http://www.osteohealing.com.au/Lederman 2010- Myth of Core Stability.pdf

 

[jesspt]

I just read a great review I wanted to share:

Karayannis, N. V, G. A Jull, P. W Hodges, G. Vargas-Alarcon, E. Alvarez-Leon, J. M. Fragoso, A. Vargas, et al. "Physiotherapy Movement Based Classification Approaches to Low Back Pain: Comparison of Subgroups Through Review and Developer/expert Survey." BMC Musculoskeletal Disorders 13, no. 1 (2012): 24.

Through this discussion, there is obviously a variety of ways that PTs approach back pain. How is low back pain treatment traditionally taught in school? Is there a specific protocol?

Fozzy,

Much like in medicine, there is great variability regarding what is taught from school to school regarding how to best treat low back pain. This is unfortunate for our students, and more importantly our patients.

 

[fozzy40]

Fozzy,

Much like in medicine, there is great variability regarding what is taught from school to school regarding how to best treat low back pain. This is unfortunate for our students, and more importantly our patients.

There are a couple approaches to treating medical or musculoskeletal conditions but usually there is an underlying theme. So is there an underlying theme at least? The article I cited describes 5 different approaches. Are PTs exposed to this during their training? Is this stuff on your boards?

 

[jesspt]

There are a couple approaches to treating medical or musculoskeletal conditions but usually there is an underlying theme. So is there an underlying theme at least? The article I cited describes 5 different approaches. Are PTs exposed to this during their training? Is this stuff on your boards?

You'd have to ask someone who has graduated more recently than me - the O'Sullivan, Treatment Based and Sahrman classification systems weren't even described in the literature by the time I graduated, so they wer'ent on my licensing exam. However, there were some questions regarding MDT and the TBC on my orthopaedic PT specialist exam.

 

[Fiveoboy11]

There is probably a lot of variance in PT training, even now (evidenced by the variance in practice patterns). The one common theme would be impairment based rehab with strong consideration for co-morbidities/diagnosis.

What is the common theme in the medical community when it comes to training to manage MSK conditions? Especially those amenable to conservative management?

 

[fozzy40]

There is probably a lot of variance in PT training, even now (evidenced by the variance in practice patterns). The one common theme would be impairment based rehab with strong consideration for co-morbidities/diagnosis.

What is the common theme in the medical community when it comes to training to manage MSK conditions? Especially those amenable to conservative management?

1) History and Physical
2) Consider imaging if symptoms are severe, acute neurological deficit, and/or trauma
3) RICE + medications
4) Refer if no improvement

 

[fozzy40]

There are many systems/philosophies to treat back pain. McKenzie is a popular method in my area. What are some of the criticisms about using this method?

 

[jesspt]

There are many systems/philosophies to treat back pain. McKenzie is a popular method in my area. What are some of the criticisms about using this method?

Well, there is some disagreement on the reliability of the examination/classification procedure itself, where Riddle and Rothstein found poor inter rater reliability ( k=0.26) and others have found better values (k=0.84).

I believe there are also some studies that have been done with fresh cadavers that have placed some doubt on the biomechanics of the disc model. I'll look for some references and post later.

 

[jesspt]

http://www.shelbournephysio.ca/pdfs/Discreduction.pdf

An older article, but it provides a nice overview of some of the relevant research that has been done on lumbar intervertebral disc mechanics and whether or not they correlate with MDT.

 

[dg1984]

The problem with McKenzie is 2 fold.

1. Although MDT therapists are taught to assess flexion, extension, R pelvic translocations and L pelvic translocations they tend to have a bias that extension will cure everything. Most MDT therapists that I have come across think that extension will reduce the disc herniation. There is no evidence to back this claim. The Delitto classification emphasizes assessing all motion and finding a pattern of centralization without focus on what the disc may or may not be doing.

2. McKenzie only advises manipulation as an absolute last resort when all data shows that lumbopelvic manipulation has the best effects when done early in the course of rehab.

 

[fozzy40]

The problem with McKenzie is 2 fold.

1. Although MDT therapists are taught to assess flexion, extension, R pelvic translocations and L pelvic translocations they tend to have a bias that extension will cure everything. Most MDT therapists that I have come across think that extension will reduce the disc herniation. There is no evidence to back this claim. The Delitto classification emphasizes assessing all motion and finding a pattern of centralization without focus on what the disc may or may not be doing.

2. McKenzie only advises manipulation as an absolute last resort when all data shows that lumbopelvic manipulation has the best effects when done early in the course of rehab.

Thanks for the great input! I've made the same observations in my interactions with McKenzie therapists.

JessPT, thanks for the article!

 

[jesspt]

The problem with McKenzie is 2 fold.

1. Although MDT therapists are taught to assess flexion, extension, R pelvic translocations and L pelvic translocations they tend to have a bias that extension will cure everything. Most MDT therapists that I have come across think that extension will reduce the disc herniation. There is no evidence to back this claim. The Delitto classification emphasizes assessing all motion and finding a pattern of centralization without focus on what the disc may or may not be doing.

2. McKenzie only advises manipulation as an absolute last resort when all data shows that lumbopelvic manipulation has the best effects when done early in the course of rehab.

I agree with these issues regarding McKenzie, but to some degree, those MDT trained folks are using evidence to guide their practice. We know from Long and Donelson that the presence of centralization is strongly prognostic of improved outcomes, and also know that patients who have a directional preference do better when given exercises that match that preference rather than a general exercise program. And, that vast majority of folks that have directional preference and that centralize do so into extension.

 

[dg1984]

I agree with these issues regarding McKenzie, but to some degree, those MDT trained folks are using evidence to guide their practice. We know from Long and Donelson that the presence of centralization is strongly prognostic of improved outcomes, and also know that patients who have a directional preference do better when given exercises that match that preference rather than a general exercise program. And, that vast majority of folks that have directional preference and that centralize do so into extension.

That is fine, but you have to assess all directions. I am unfamiliar with any data suggesting that the majority of people centralize with extension.