Visiting the North American Spine Society’s annual conference

Posted on December 16, 2015

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On October 17th I visited the North American Spine Society’s (NASS) annual conference. I attended the one day course for “State-of-the-Art in Motor Control and Low Back Pain.” It was quite the lineup of speakers:

State of the art NASS conference 1 State of the art NASS conference 2

The lineup included two people I feel are part of the upper echelon of all this, Linda van Dillen and Shirley Sahrmann, from the Washington University in St. Louis. I’ve been to WUSTL twice, and hung out with Shirley for a couple days one visit.

I went to this conference,

  1. It was in Chicago. I love that city. If you’re there and have any sense of humor at all, check out Second City. I’ve been three times. It’s one of the few times I’ve experienced, “Holy hell, these people are good at what they do.”
  2. To see a bunch of differing opinions all at once. I’m well versed in Sahrmann’s methods, and believe I am in others as well, but I haven’t seen as much from others in person, with the chance to interact.

2) was a big sell. I don’t know how common it is to get this level of breadth and depth in one course, but I don’t believe it’s common, at all. The description of the course, along with the emcee for the event, mentioned multiple times how rare this was. I got the impression it wasn’t so much a sales point -we all already paid- as it was just true.

For instance, Lorimer Moseley was at this conference as well, albeit not at the course I went to. The pain science world was well represented, along with the movement world, who sometimes clash. Paul Hodges, who was at this conference, actually had Lorimer Moseley -golden god of the pain science community- as his PhD student!

All in all, basically any credible viewpoint towards lower back pain was at this conference, in the same room, on the same day.

I’ll be posting some of my notes as separate posts, as well as all together in this post. Here are some of the headlines. You can click to be taken to that specific section.


Random notes

As the schedule alluded to, this thing was jam packed. We went from 8am to 6pm, with a 30 minute lunch and two 15 minute breaks thrown in. 8 hours of lecture; 1 hour of discussion. Think back to high school or college. How’d you do once a lecture got over 30 minutes? Never mind 8 hours worth!

This conference seems to be primarily attended by physicians, and then for our course, it seemed a decent amount of physical therapists were there. It cracked me up that, even amongst the most educated people in society, people who are used to lecture and having to sustain attention, I saw a lot of this going on:

cat falling asleep gif

And one or two of these:

dog falling asleep gif

Not during every lecture, but out of the 13 speakers, there were maybe 3 or 4 which were tough to get through. Throw a joke in there people! I got a new appreciation for when I hear academics go “we don’t always live in the real world.” Some talks were so obscure and esoteric, it was tough to find any practical benefit in them.

Furthermore, a lot of the presenters went fast. With so many speakers and only 30-45 minutes for most, many were having a hard time staying on time. It was routine to hear “Oh, I guess we’ll skip that slide!” I saw many pulling out their phones to take pictures of the slides, which is a pain in the ass. If we can’t keep up with you while taking notes, you’re going too fast. For a lot of the talks I actually thought the 30 minutes or so was enough time, it just wasn’t as well structured by the presenter as it could have been.

So, for my notes on this, keep in mind I wasn’t able to keep up with everything. Certain things may be fairly general or incomplete.

Before starting, the last random note is I walked around the conference for a little bit before the class started. I found it humorous the advertisements for the next few spine conferences I saw. One was in Miami and one was in Park City, Utah. The ad for these things was all about the beach, lots of sun, and then a ski lift with a beautiful mountain.

Without going off the reservation here, I’ll say I got a little more insight as to why healthcare costs what it does, and why some are so stubborn in wanting to maintain the status quo. These conferences aren’t all about learning. There is a huge vacation element to them. Very decadent vacations. I’m sure many in the system are afraid if things change too much, things like these conferences (their lifestyle) could change too.

I’m not going to hit every speaker, or go too in depth with everyone. I’m going to rattle off some quotes, or whatever I found noteworthy.

Paul Hodges

As I mentioned, Paul had Lorimer Moseley as his PhD student. I reiterate that because many seem to know who Lorimer is, at least online. I’m not sure Paul has (or wants) the same recognition.

“Plasticity occurs unless you’re dead.”

I got the impression right away Paul was perhaps, just maybe, looking to calm down some of the pain science rhetoric. It’s not as if we’ve learned how to turn plasticity on recently. It was always there.

“The purpose of motor control training is to change loading.”

I often describe to clients what we’re doing is trying to give some areas a break, and get some areas to do more work. I preferentially use this phrasing when dealing with lower back pain. “We’re just trying to get your back to calm down and not have to do as much work. In the meantime, we are going to get the rest of your body to pick up the slack.” There is of course more to it than this, but I find this resonates with the client.

“It’s more than one muscle. It’s a system.”

This was an interesting back and forth throughout the conference. Some talks would hammer on one or two muscles, describing multiple MRI studies on say, the multifidus, while other talks wanted very little to do with any one particular structure.

One of my favorite ways to elucidate this concept is to look at the connection between the knee and back. Have someone lean over and stand up like this:

Bend over knees bent GIF

If their back hurts, what do you think? “They probably shouldn’t be extending their back like that. That’s quite a big arch.”

Sure, but look at their knees. They aren’t straightening. You can cue or focus on the back all you want, but if you don’t change what the knee(s) are doing, you aren’t going to get anywhere. You need the knees to straighten as well:

Bend over knees straight GIF

“Clinical literature gives impression of simplification.”

This was again aiming things at the “it’s not one muscle” argument. So much physical therapy research is aimed at trying to target one muscle. “What’s that one thing we need to stretch or strengthen?” This rarely works.

“Optimal control is more than preventing spinal motion.”

This is one of the few spots I thought Paul struggled to make his point. He used the notion of how a runner does need some spinal motion to run. However, when it comes to someone currently in the midst of having some lower back problems, keeping the back still usually is part of the equation to getting the back feeling better.

I always use this example to make my point here: You throw your back out. Or your back is killing you. What’s the first thing nearly everyone does? They lay on their back and don’t move.

A common thing when pissing off the back is it spasms up. What does spasming help do? Stop movement.

If we get more nuanced, then we can say there are many scenarios where you don’t want to only stop a back from moving, but you want to get it moving more. For instance, a lower back which flexes too much needs to stop flexing so much and extend more. However, it only needs to extend in that it doesn’t flex. It only needs to extend in that it say, stays neutral. That doesn’t mean you go doing a bunch of extension mobilizations though. It means you stop flexing, which subsequently means you are, relative to what you’ve been doing, extending more.


Threshold argument

I’m glad Paul hit on this, as it’s a silly argument thrown around too often. Someone makes an argument for how or why doing X causes Y. Another person counters with “A good amount of people do X and don’t cause Y. X is invalid.”

Paul mentioned you instead view things on a threshold scale. Do X ENOUGH, and Y becomes more and more likely.

“Smoking causes issues.”

“But many people who smoke don’t have issues.”

Well of course not. But smoke enough, long enough, and the probability increases.

Lean over and stand up like this all day, and your back will probably start hurting:

Bend over knees bent GIF

“But so and so does that and doesn’t have issues.”

How much do they do it? How often do they do it? How many times per day, times per week, times per year? What loads are they doing it at? How long have they been doing it? Do they have any special anatomy that makes them more or less likely to suffer issues?

Gain 30 pounds this year and no, you might not get high blood pressure, diabetes, or a heart attack. Keep the weight on for 30 years, or gain even more weight, and you will probably have consequences at some point.


Where people are in their pain timeline

Paul threw up a graph that looked something like this:

Pain timeline atrophy hypertrophy graph

The idea being after you suffer from an injury, you often get some atrophy of the area nearby. If pain persists, the area will tend to hypertrophy and change fiber type, shifting to a stronger fiber type. (Type 1 = long and slow exercise; Type 2 = short and fast exercise.) Then, eventually a shift back to atrophy occurs.

One of the ideas of this course was, with something like that graph above, how you treat each person is not only different, but how you treat each person based on where they are in that graph can be different.

Few weeks or months after injury? Maybe more strengthening should be done? 6 months out? The area is plenty strong, maybe we need to get it to calm down, and focus on longer and slower exercise? 1 year out? Strength is going to be needed regardless.

My experience with the lower back is pretty much everyone needs to get their back to calm down first. That you don’t take a ticked off back and immediately go into strength work. That sometimes an area has atrophied because it’s been overworked, which means it does not need extra work for the time beingOnce you get a person moving in a variety of ways without issues, then you can add some strength on top of things, and that type of strengthening is always more endurance oriented. The fact the muscle(s) shift to a type two fiber profile -we don’t have as much type 1 as we used to so we should emphasize it- backs up this approach.

-> Why deadlifting and squatting are almost never a help to lower back pain. They target type 2 fibers, and work a spine which is already ticked off. Furthermore, especially with deadlifting, people usually do 5 reps or less. Even more type 2 focused.

A generally weak back is not a problem for most. A back that’s weak into / lacking endurance can be though.

I don’t remember who, but someone at the conference said “we know it only takes 2-3% of maximal voluntary contraction to maintain posture.” This number has jumped around as I’ve heard it many times, but it’s always a low number. Meaning you need little strength to hold most positions people are in throughout the day. You may be significantly lacking endurance though, when we consider how many repetitions people do certain movements.


Smudging doesn’t only manifest in the brain

I was so glad to see someone else talk about this.

“Smudging” is from the pain science world, and it references what happens to the brain in a chronic pain patient. People have every area of their body represented in the brain. Use the finger and part of the brain lights up. Use the foot and another part lights up. Etc. We call this the homunculus. It’s why one of the more noteworthy pain science sites is called Body In Mind.

The idea is in chronic pain, this representation gets messed up. The lower back for instance, isn’t where it usually is. It “smudges” into other areas. It’s one reason we believe people with lower back pain have issues knowing where their lower back is.

Paul used another example. Tell someone to extend their upper (thoracic) spine, and you may very well see someone do that, but also extend their lower (lumbar) spine. Not only are things smudged in the brain, they are smudged in the movement. The two areas are moving together and are not easily differentiated.

I’ve been surprised the movement science world, Sahrmann in particular, hasn’t embraced this finding as it meshes amazingly well with their approach. (I haven’t heard her dispute it at all, I just haven’t heard them use it in their rationale.) Ask someone to move their hip and they move their back. Ask someone to raise their arms and they move their back. Ask someone to lean over and they first move their back. How to help someone like this? Get them to stop moving their back.

Changing how someone moves IS changing the brain. You don’t need to start with the brain, you can start with the movement. Of course, you can do both. You don’t have to exclude one, which we always seem to want to do. In fact, if you start with movement, then you are addressing both. Someone can’t consciously move without using their brain.

Get that same person to stop extending their lower back every time they extend their upper back, and you’re probably changing the smudging in the brain also.


Opiates

There were a few talks that hit on prophylactic NSAID use. One talk mentioned ibuprofen, but also listed opiates.

I wanted to get Paul’s take on this as he seems to have more of the brain first background. I went up to him at the end of the conference and asked him how he, and perhaps the Body In Mind / pain science world, currently feels about opiate use. I made the point I think it’s a little crazy to give out opiates that easily. That sure, some ibuprofen to hopefully get ahead of the game could make sense, but going to opiates was another level, considering the grip they can take on someone.

-> I don’t give specific medication advice to people as that’s outside what I do, but I do give general guidelines, such as requesting people not take pain killers of any kind before seeing me, or before workouts. Other than very unusual cases, I don’t train people hopped up on stuff, primarily because it means they don’t know how they really feel doing what we’re doing, which means I don’t know either. I could be causing them issues, but neither of us knows it, and it makes it very hard for either of us to know what caused the problem should you feel some pain after the workout, and after the pain killer wears off.

Paul agreed, saying other than very specific cases, under very strict guidance and observation, should they be used. He said something to the effect of, “The fact the GPs [general practitioners] have helped cause this issue is very troubling.” I’ve seen this firsthand, many times, regarding how easily these things are handed out to people. No proper screening of addiction history, giving out way more pills than are necessary, no proper follow up.

Not only do the patients do the whole, “Oh, I’ll just take a pill and be done with it,” but the doctors have their own version. “Oh, I’ll just give them a bunch of pills and be done with it.”

Paul made another point how pain killers all have a similar aspect to them, even icing. That is, no matter what it is, you need and will use more and more of it to get the same effect. He mentioned some physiology I can’t remember, but I didn’t think of icing in that light. He’s right.

I’ve never much bought into the argument “chronic pain has no use.” Where acute pain has a use, but chronic pain is a flaw in our software. I think many times the practitioner isn’t looking closely or as well as they could, or we just don’t know.

As time marches on, I wouldn’t be surprised if we moved more and more away from pain killers. This is already happening, due to phenomenons such as opioid induced hyperalgesia. I could see it progressing more and more. The idea of manipulating ourselves hormonally to not feel pain always seems like a way to avoid what’s causing the pain.

-> By the way, using painkillers is primarily a brain based treatment…which clearly doesn’t work in the longer term.

Said another way, if ibuprofen weren’t so readily available, I wonder if people would as easily subject themselves to getting hungover. Or would they not do what causes the hangover as much?

Jaap Van Deen

“It’s not a matter of precision. You can be very precise and still cause issues.”

I’m not sure I’ve seen the precision argument too much, but I get where this quote is coming from. Some people are having problems because they are too precise with certain movements. Perhaps they always move their the same way when leaning over, and that needs to change.

During this presentation I saw some pictures of patients in a lab, with a lot of various equipment around them. It got me wondering how much of a point there is to testing / assessing people outside of their dominant environment.

During a break I started talking to a doctor about this. The way I phrased it to him was what’s nearly universally, the first thing people do when their back bothers them? They want to lay on the ground, typically on their back, with their legs elevated.

What position do we MRI people in? On their back, legs maybe elevated some. We’re testing people in a position that’s not provocative. Granted, a standing / sitting / leaning over / etc. MRI may not be feasible for most (but we are getting to where MRIs are becoming more and more functional like this).

I’ve seen many people who, after a couple week vacation, feel a lot better. I’ve even seen some who go on vacation and lose weight. They get outside of their normal habits, and things change. Of course they do.

Trying to assess someone’s eating while they are in a two week vacation is a futile endeavor. Is movement much different? Assess someone in a lab, with tons of gadgets, a few people around, are we sure they’re going to be doing things similarly? If someone has issues sitting at work, but you assess them sitting without any of their work stuff around them, does that assessment hold? Their environment has changed significantly. Their habits may too.

Andry Vleeming

I really enjoyed this talk. I wasn’t familiar with Vleeming’s name. For those who also aren’t, but perhaps know Tom Myers and Anatomy Trains, this talk was Tom esque in that it was very fascia oriented.

Andry discussed the following study:

The transverse abdominus, which is always a popular muscle when discussing lower back pain, was hit on. Andry wanted to get the importance of this following picture across:

I added the terms in parentheses. Begone acronyms!

I added the terms in parentheses. Begone acronyms!

The idea here is to show how muscles from the front of the torso connect into fascia, which connects into other muscles. The little triangle called LIFT.

lateral raphe lumbar triangle outlined

This triangle runs from the ilium (top of the hip) to the 12th rib. It’s long/ tall. It’s a fatty tissue, and the authors call it things like the “lumbar interfascial triangle.” The fact it’s tall has them call it the LIFT. And the general area they call the “lateral raphe.”

lateral raphe cadaver

This triangular area has the transverse abdominus connect into it, and then a continuous layer of fascia continues to and around the paraspinal muscles. It bifurcates, going anteriorly and posteriorly, forming what the group calls a “canister.”

trunk canister 2 with aconyms labeled

transverse abdominus paraspinals canister

Due to the connection of these areas, fascially, we know the muscles are related. Meaning if you do something like focus on the transverse abdominus, you are going to have an affect on the paraspinal muscles at the same time.

If the transverse abdominus tensions, it’s going to exert a force on the paraspinals. It’s like we have our own weight-belt already:

transverse abdominus paraspinals canister GIF 2

Think of it like the paraspinals are being choked:

transverse abdominus paraspinals canister GIF

We end up compressing the spine not in an up and down fashion, but in a side to side fashion.

Because the paraspinals end up being closer to the spine, their lever arm is decreased, so it’s easier for them to generate the work they might need to do. This can potentially fit well with some of the research out there showing differences in transverse abdominus activity correlating to lower back pain. Faulty activity can = faulty ability to control the spine.

Another area this is important is for those who get caught up in the “pull your stomach in” cue. Or those who squeeze their stomach to prevent any spinal motion. Some do this to such a degree it ticks their back off. I’ve seen people do an exercise where their form is great, yet they still have back pain while doing the exercise. This can even be during something low intensity, like a leg raise on your stomach.

Sometimes I find this person is squeezing their stomach so hard, trying to prevent any spinal motion, that it’s actually hurting their back.

One explanation for this is they are not only squeezing their stomach, but they are also squeezing their already sensitive back at the same time!

This is one reason it’s typically best to start with movement cues, not muscle cues. “Don’t let your back move” vs “Squeeze your stomach.” First, the latter cue is a hope cue. You’re hoping squeezing the stomach means not moving the back, when you could just tell someone to not move their back. (“Hope is not a strategy.”) Second, when you tell someone to squeeze a musculature, it’s common to squeeze as hard as possible, which can cause its own problems.

Jacek Cholewicki

“Placebo does not need to carry a negative connotation.”

Exercise may sometimes help with lower back issues for placebo reasons. While we always want to try and tease out the influence of our modalities as much as possible, what’s wrong with a placebo benefit, especially from exercise?

All modalities have side effects, but not all modalities have only positive side effects. The side effects of exercise for lower back pain may include lesser risk of heart disease, longer life span, less risk of diabetes, and forever and ever goes the list.

Maybe exercise is doing something besides only enhancing control of the spine. Well, we know it definitely is….and that’s a good thing!

There is no other modality which can so strongly say this when it comes to handling musculoskeletal issues. Drugs have an endless list of negative side effects. While a good massage may not have many detriments, though lack of self-efficacy is a huge one, if we are contrasting an hour long massage with an hour long bout of exercise, there is no comparison for health benefits.

A placebo, or nonspecific effects, or unplanned treatment benefits, doesn’t need to be a bad thing. We so often hear something like “the treatment was just a byproduct of the placebo effect.” While often not what we want to hear, “I spent how much money on something that’s bogus?” it’s not universally maligned.

Lieven Danneels

Lieven hit on how muscular (and other physiological) changes don’t necessarily go away after pain goes away. His talk focused heavily on the multifidus muscle. He mentioned things like the longer patients are pain free, the greater the cross sectional area of the muscle is.

With that, after a lower back injury or pain flare up, the multifidus muscle may atrophy some. Just because pain subsides doesn’t mean this atrophy has also gone away.

Part of the idea here was to identify potential reasons for pain recurrence.

Daneels described a few changes his research has identified.

  1. Muscle quality degrades in chronic lower back pain. The muscle has “fatty infiltration,” ala more fat in it than usual.
  2. At rest, the multifidus will have shifted towards a more type 2 fiber appearance.
  3. High load strategies get used when low load strategies should be used.
    1. Similar to the intense stomach contraction I referenced with the transverse abdominus.
  4. When inducing pain, the activity of deeper muscles get turned down while more superficial muscles get turned up.
  5. You can see these issues with the brain.  One example is a smudging of separate lower back muscles, indicating potential issues with using these muscles.

This makes for a nice picture that fits clinically.

  1. People with lower back issues tend to have trouble with smaller, slower movements. They’ll try to go too fast, use more muscle than needed, exert way too much force, for basic things. (Or, why slow exercise is needed.)
  2. People with lower back issues rarely have strength problems. It doesn’t take much strength to control the spine. People with lower back issues do often have endurance problems.
  3. Motor control exercises where you’re asking people to move differently, often necessitate a lot of mental concentration from the subject. While watching them, it’s clear they are working their brain as much as their body.

 Simon Brumagne

Simon mentioned something I’ve seen myself, those with a lower back history tend to stand from a chair like so:

Squat knees moving forward knee view GIF

Rather than:

Squat knees NOT moving forward knee view GIF

Simon referred to the former as an “ankle steer strategy.” I always tell people, “Don’t let your knees move forward when you get up.” Sometimes a mirror is needed, but usually a cue is enough.

This is one of those chicken and egg scenarios. Do people get up with the knees forward strategy cause their back to bother them, or do people whose backs bother them shift towards the knees forward strategy?

I’ve leaned towards the latter. That people in the midst of a lower back flare up, start doing everything they can to not lean forward. They do this long enough they ingrain a new habit.

When it comes to standing up, if the torso doesn’t lean forward, something else needs to. That something is the knees. Notice how much more vertical the back is here, when the knees are moving forward excessively:

Squat knees moving forward back more upright GIF

Compared how much more the spine leans over when the knees don’t move forward:

Squat knees not forward back view GIF

Spine lean over squat comparison

Knees moving forward on right.

While not terrible in the interim, this is a strategy that can start to beat the knees and ankles up some. While the “knees never in front of your toes” mantra isn’t as big of a deal as often made to be, getting up from a chair with a sharp knee angle isn’t friendly to the knees long term.

“What may appear as a mechanical problem may have a sensory issue as the true cause.”

This is another way of saying it’s not always that something is weak or tight. Sometimes it’s a person has lost sense of where their body is in space. A person who uses a knees forward strategy often doesn’t even realize it, but it’s not like a lot of stretching or strengthening is needed. Once the awareness has been implanted in the person’s head, they usually can avoid it. Their nervous system needed to wake up, not anything muscular.

Mary Barbe

Mary was probably the outcast of the group, as she was coming at this from a much different angle than everyone else. For instance, she referenced rat studies for nearly everything.

I’m nearly universally opposed to animal research. Beyond the ethics, it rarely matches up with human research. (Which makes the ethical concerns even greater.) According to animal studies, we would have cured cancer, written genetics, had a pill for obesity, and done everything else by last year. At the end of this year, we’ll have done it all over again.

But in this case animal research has some value. Part of the debate right now is how much emphasis to put on the psychological element in the bio-psycho-social model of pain. In rats, we can practically throw out the psycho element. Rats don’t have preexisting beliefs about damage and pain. Rats don’t read or listen to advertisements about what to do for their pain.

Mary referenced her research where she has rats learn a task, then repeat that task ad nauseam. She likened it to someone working pretty intense construction work, doing the same movement many times a day.

Eventually, you see these rats experience the effects of this work. She showed a slide with disrupted nerves. Instead of the nerves looking nice and smooth and rounded, they started to look jagged.

Note the increase in macrophages -white blood cells which eat biological shit- as well. She showed more pictures illustrating fibrosis occurring in the areas being excessively used.

For those incessantly telling everyone “damage does not equal pain!” there is a problem here. Do we ever look at things this deep? Sure, we MRI people, but that’s nowhere near what Mary was showing. She had things down to the microscopic nerve level. Maybe nothing shows up on a MRI, but do we know nothing is showing up at this level??? The idea tons of people are in chronic pain and nothing is abnormal about their tissue is not as true as it may seem. Is it true sometimes? I’m not sure we can say.

-> Is it true that some people have abnormal tissue, but not pain? Sure. But do we know how often this is happening? Do we know how many of these people don’t have pain now but will in the future? Is our definition of abnormal correct? Do we know what abnormal actually is? Are we sometimes calling something abnormal when it is actually adaptation?

Mary went further discussing how the rats experience cold temperature avoidance (ala their normal pain pathways are getting messed up), decreased grip strength, and the rats become less active socially.

This paints a very clear picture in this context: The movement is causing the problems. Not how the rats feel, not what they think about their MRI, not what some doctor told them, not where they are on the socioeconomic ladder, but the movement.

Mary expounded on some similarities between the flu and chronic pain. In chronic pain, she’s noticed elevated cytokine levels, where if this level stays up for a while, increased agitation occurs, lack of sleep, depression, and a fever.

She went on to describe how in the flu, elevated cytokines, agitation, a fever, not wanting to move much or be around people, is a positive adaptation to fighting the flu. The body is trying to help. I don’t remember if she made this connection, but it’s feasible in chronic pain, the situation may be similar.

Again, some in the pain science may have a significant flaw in their thinking here. If you’re going after the depression, lack of sleep, social avoidance, are you sure you’re not going after symptoms?

Things like prophylactic ibuprofen were discussed. Where, in the midst of doing the repetitive movement, if you give the rats some ibuprofen, a lot of the symptoms get significantly mitigated. But, Mary stressed, you can get the same effect by simply engaging in some basic exercise. The treadmill was used repeatedly as an example. That some extra walking can mitigate inflammation and more.

I want to also add Mary was by far one of the more entertaining presenters. She really livened things up not with only her content, but her personality. There were a few serious lulls during the day, and she helped break it up.

Greg Kawchuk

During this talk a lot was mentioned in regards to subgrouping people. A note I took down during this, and it was referenced some throughout the day, was subgrouping people into whether they need mobility or stability.

This isn’t specific enough.

Which direction is too mobile? A spine which extends too much, too often, needs more stability, right? It’s extending too often, so by having it not extend as much, we are stabilizing it?

But could we also say a spine which extends too much isn’t mobile enough into flexion. That its spinal erectors are too stiff, so we should work on our spinal flexors. Meaning it needs more mobility into flexion.

Let’s really throw a wrench in here: A spine which has some pain into extension may also have pain into flexion. A spine which extends too much may also have pain into rotation. A spine which has pain into extension may have a resting position of being flexed!

What do you do in these cases? Do you stabilize? Do you mobilize? Which direction? What does that even mean now?

Most joints you can get a very clear sense of what direction people are too mobile. The shoulder and anterior glide are a good example. However, what does a shoulder with humeral anterior glide syndrome need? Is it mobility, or is it stability?

Well, it’s too mobile into anterior glide, right? So the answer must be stability.

But, what if the reason it’s so mobile into anterior glide is because the posterior shoulder is stiff? The humeral head can’t glide posteriorly so the path of least resistance is anteriorly. Then this shoulder needs mobility, right?

The simple answer with a shoulder is to work on both. The plan then doesn’t become “we need to mobilize this or stabilize that,” the plan becomes “don’t let your humeral head anteriorly glide.” By doing that we stabilize and mobilize at the same time!

The hard answer with the spine, and really with any joint, is this is why we assess, and why a good assessment can take a while. It’s probably going to take 75 minutes give or take, and then you’re just getting started, as every time you interact with the client you’re assessing again.

Where during those assessments, you get a feel for “ok, this movement isn’t working when done this way, but doing it this way works.” “Ok, this movement is fine, that might not fit with the pattern of everything else, but it’s ok and maybe we can leave that alone.”

By going through a gluttony of movements, and finding which ones are painful, along with asking the person “what gives you pain?,” you acquire the knowledge of which movements should be worked on. The painful ones!

You get to a movement by movement basis. With most joints, you don’t need to take it this far. With the spine, you sometimes don’t, but you often do.

Linda van Dillen

“30-50% of patients have poor adherence. In chronic pain patients, it’s 50%.”

“Consider adherence before changing treatment.”

One understandable statistic: The more complex the treatment, the worse adherence. One disappointing, yet I suppose somewhat understandable statistic: The more the treatment is for preventative reasons, the worse adherence.

One thing I didn’t like, though I understand where Linda and their group is coming from, was the focus they had on having their patients report their adherence. They had a form their patients fill out, that was pretty involved.

Short of filming someone, self-reporting is one of the only go tos here, but self-reporting has a lot of issues.

Some other things you can do here are to use your eyes. For the most part, though definitely not in all instances, you can get a feel for what someone has been doing on their own. In the Linda and Washington University St. Louis’ model, they have people come in every week or two. So, they aren’t seeing the patients often.

If after a week or two you watch the person do their exercises, you’ll get a very good sense of if they’ve been doing things on their own.

Within this, something I do with clients I don’t see too often is have them go through one of workouts I gave them. I’ll tell them I’m not going to say anything, I just want to see how it looks first. I usually give a person two workouts, one for three days of the week and the other for the other three (one day is sort of an off day). If after a week or two, 3 or 6 times of doing that one workout, they aren’t doing it from memory, their adherence probably hasn’t been great.

“56% of information given is gone within minutes of patient leaving”

This is why all clients / patients need to be giving things in writing, unless they’re someone who is going to be like a three times a week client.

With clients who are just looking to work out, I’ll often tell them the first week, sometimes the first month, to not do anything on their own. I know as soon as they go attempt to repeat the workout we did, they’re going to forget at least half the things we went over, like their form. So I just don’t have them do it.

-> The other thing here is a new personal training client is often just getting back into the gym, or they’ve never even been in one. Asking them to only come in with you once or twice, versus asking them to go to the gym with you and on their own a couple times, is a big difference. The fact they’re even coming in once a week is new and a changed habit. You want to be careful about changing too much at once.

After a few times, where I’m noticing I don’t have to cue the person as much anymore, I’ll let them go on their own (if needed).

One thing I felt strongly about with Linda’s presentation was the fact they will have different clinicians handle their patients. Where you come in one week and it’s one person, but a couple weeks later it might be someone else.

I’ve done this with personal training, where me and another trainer share a client. Nearly universally, the clients AND the trainers, disliked it. I can only remember one client who was cool with it. (As her trainer, I still wasn’t too happy with it.)

It’s very hard to get any continuity with this. This is one reason some research has shown, and some doctors still believe, physicians should continue to be sleep deprived during residency. The more they sleep, the less hours they work, the more handoffs between doctors there are for the patients. When you handoff you inevitably lose information and care suffers.

Not to mention with personal training or physical therapy, there is a huge personality element to things. The client interaction element is a huge factor in all this, and it won’t be the same between two different practitioners.

The fact of the matter is this is never, ever, a doing what’s best for the customer move. It’s always a business model move. “Well, so and so isn’t available at that time, but we can schedule you with so and so instead.” The facility doesn’t want to lose money.

If you’re making burgers? McDonald’s model works great. If you’re handling people, it doesn’t.

Chris Maher

I wrote about Chris already in Looking at weather and back pain. 

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Shirley Sahrmann

First, Shirley is I believe 80 and still doing this stuff. Screw retirement!

Next, I’ve written a lot about Shirley already. This talk was, for her, an introduction into her approach. I had pretty much already seen the entire talk, which was ok. I was half-expecting that anyways.

The only thing noteworthy is this day had a lot of information given, but Shirley was the only one, maybe two, who stood out when it came to getting this information down into a system of watching people move, and what to do based on what you see.

While so many continue to debate the science side, the fact side, the theory side, one woman, and her program, have the practical side down very, very well. Just because the explanatory side of it isn’t perfect doesn’t mean the application side of it isn’t damn good.

“Why?” is an endless question. At some stage one needs to let go of it enough to get some results in the real world.

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Posted in: Lower Back Pain, Pain