Archive for the ‘lumbar spine’ Category

I read an article in the local paper today that was entitled “A Pain in the Budget: More back surgeries, not improvements.” The essential point of the article was that back surgery is not necessarily the answer to back problems. In a past blog post, I have discussed how diagnostic tests don’t always tell the whole story. And yet a patient presents with a positive MRI result or a patient’s complaint of pain that goes unresolved, surgery is quite often the next option.

I found this quote by Dr. Richard Deyo from the article quite profound.

“Intense pain is not necessarily an indication for surgery.”

If you have heard Mike Boyle speak or read his recent book, Advances in Functional Training, you have probably heard him talk about the 3 I’s. When a patient goes to see a surgeon – there are three options.

  • Ingestion – take anti-inflammatories; if that doesn’t work
  • Injection – if that doesn’t work;
  • Incision or surgery

Those are really the three choices when a patient goes to see a surgeon. Injury rehabilitation may be part of that picture but is not always a given. Essentially, there are three options for a patient with pain that doesn’t subside.

And so that is where the rubber meets the road: a patient presents with pain and the conundrum is what is the best way to rid that patient of the pain. When it comes to back pain, 80 percent of the population will suffer from back pain at some point in their life.  And yet the article alludes to several studies that indicate that 90% of low back pain will heal (or let’s just say the pain will dissipate) on their own.

So what is the best choice? – that is the question.

Deyo went on to offer another great quote:

“Many people have a very mechanical view of how the body works and imagine it is like a car. So if a tire wears out, you’ll just put in a new one. It just doesn’t work that way.”

And yet I think he is correct. Many of us look at our bodies like that. And yet we all know that the replacement parts are not as good as the originals.

So what does this mean for us – I think it means what it always has. We owe it to those in our care to continue to improve our skills and make sure we are providing the best service possible. Some surgery can’t be avoided – we know that. But let’s keep improving – expanding our knowledge and examining all that we can to do best by those in our care.

I’ve always maintained that just because everyone is doing something or just because that is how we have always done things, it doesn’t mean it is right. Just because surgeries, such as spine fusion operations, are on the rise doesn’t mean this is the best option. Let’s keep searching…

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Transverse abdominus has been associated with low back pain and exercises to activate TrA are commonly given to those with back pain. In this particular study in the Supplement of the Journal of Athletic Training, the researchers wanted to see if there was any difference in TrA activation using two selected exercises between healthy and low back pain patients.

There were 30 healthy subjects and 30 subjects with low back pain. It should be noted that the 30 low back pain patients were not currently experiencing symptoms.

The two exercises chosen to target TrA was the abdominal draw-in maneuver (ADIM) and the bird dog exercise. Each subject was familiarized with each exercise and then asked to perform each exercise. An ultrasound transducer was used to measure activation. Three images were taken at rest and during contraction for each of the subjects.

The findings of this study was that both healthy and low back pain patients were able to activate TrA after brief instruction from clinicians. Results also showed no difference of how activated TrA was during the exercises between the two groups.

Is there anything we can get from this study? Here are some things we know and some other “thinking out loud” moments if you will:

  • The abdominal draw-in maneuver and the bird dog exercise each activate tranverse abdominus – this was clearly demonstrated in the research
  • The sample size is a decent size and helps to lend additional credence to the results
  • Since both healthy and LBP subjects were able to activate TrA to the same level, can we still conclude that TrA is implicated in low back pain?
  • In that same vain, are the results as valid since the LBP individuals were not currently experiencing symptoms? Would the presence of low back pain have attributed to the inability to activate TrA? It is certainly interesting and worth noting that there were no differences between the two groups in this particular study. In an perfect world, I think it would have been more compelling if the low back patients were currently experiencing LBP but I still think the research is worth noting.
  • Does TrA play as big of a role in low back pain as we have been led to believe?

I don’t know the answers to these questions but I think that this study does yield some interesting results. Is it a slam dunk that the inability to activate TrA is or is not involved in low back pain – no, but it definitely helps us to take a step back, evaluate our exercise selection, and our rationale for exerise selection.

Instead of blindly following treatment trends, we can look at the research ourselves, evaluate the results, make informed decisions, and continue to seek new research.

Thank you to the authors for pursuing this research.

What are your thoughts? What has been your experience?

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Stuart McGill is one of the foremost experts of the spine in the world. He is an advocate of training the spine while neutral and continually explains to all who will listen about the ineffectiveness and dangers of exercises such as the crunch or sit-up. I have read his material and listened to him speak in the past – he is passionate about proper training of the spine and is truly an expert in the field.

The New York Times has an excellent video of Dr. McGill explaining and demonstrating his four recommended low back exercises:

  • the modified curl-up
  • side plank
  • stir-the-pot
  • bird dog

You may be familiar with all of these exercises but the reason for this post is to encourage you to watch the video and catch all of the “little” tips that he explains.

Many times we have a tendency to hear about or see an exercise and then try to reproduce it with our patients or athletes. This is all well and good but we have to make sure we understand all the little nuances and the tips that really elevate an exercise to be the effective exercise it was meant to be.

So make sure you take a moment to watch in on Dr. McGill’s expertise as he walks through each of the four exercises and shares the proper execution and variations of them.

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Are you looking for a way to change up a pretty standard exercise?

Well, today’s post is another video post demonstrating a single leg exercise that can be done to enhance any lower extremity injury rehabilitation program. By simply adding some ABC’s to this exercise, we utilize some arm drivers to help make this activity more challenging. This particular exercise along with a host of other functional exercises was presented at the Michigan Athletic Trainers Society Annual Meeting last year.

So check out the video post today and determine how you can add this to your repertoire.

Any other alterations that you use for a similar exercise? Share your thoughts?

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