Spinal Flexion

Bigger Stronger Leaner Injuries and Rehab
1

Just reading through the 6 coaches article and wanted to dive into Tony Gentilcore’s comment on spinal flexion and the external obliques. There are a couple of problems with this, and I would like someone to comment/disagree maybe shed some light if I am misunderstanding something here.

The spinal flexion issue to my understanding is not so much with isotonic flexion of the spine, like sit-ups etc. but rather flexed postural positions and or sustained isometric contractions. It is the long term eccentric overload of the deep spinal rotators, along with the sustained posterior mechanical force that occurs during this position that puts the intervertebral disc under tremendous load and stress. I agree the spinal flexion addicted societal demands we are currently facing especially with the advent of the computer is a an issue. However, to go as far as not allowing college aged athletes to perform this movement is a misunderstanding of the problem, and actually compounds the problem.

My second issue is with the external oblique. If the obliques are as involved in preventing excess lordosis as he stated, it would be the internal obliques. The RA is not only directly involved in the posture deviation mentioned, if weak and eccentrically contracted, could disrupt the proper biomechanical firing order and result in further issues. Following Janda’s theory of lower crossed syndrome pattern, while tight facilitators become more hypertonic, the weak inhibited muscles become more hypotonic under the same postural loads and demands. So it would be advantageous to tone the RA and restore the proper firing pattern if there is a disruption.

I’m not trying to nit-pik here, but the typical pattern on this site is coach says something, it becomes a mantra, and soon we have people who won’t even bend over to put their shoes on, because coach says spinal flexion is bad. Not only does this not help the real issue, this advice is even wrong in terms of restoring proper postural balance and function.

Thoughts?

2

try tilting forwards from your hips to tie your shoes. or perhaps you could squat. deadlift. lunge.

3

OP,

If its any consolation, Dr. McGill’s research has not provided any outcome studies to demonstrate his methods improve low back pain. One unvalidated clinical prediction rule for spinal stabilization without convincing results. Randomized control trials have supported the idea there is no ‘correct’ exercise routine/method (specific exercise, general exercise, graded exposure, motor control, etc.).

The Janda folks are synonymous with Grey Cook and Shirley Sahrmann. They continue trying to strenthen the weak and stretch the tight as if humans are a jenga set of blocks. The McGill’s will brace and never flex/rotate. The Hicks/Hides/Teyhan crowd with continue with specific transverus abdominis exercise and O’sullivan’s with promote motor control strategies.

What do they all have in common: lack of compelling evidence supporting their views over the next.

4

Yer, this is all getting very confusing.

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5

I did a little research and what I have come away with is that he is basically reinforcing what I just stated. It is the isometric loading of the flexed spines for extended periods, although he believes spinal flexion should be limited. The one disagreement I have is with his metal wire analogy to disc stress. I think this is a poor analogy since the body, unlike a metal wire, has regenerative and healing properties that metal does not.

I don’t think the people you mentioned have as much of a disagreement as it might seem, rather different approaches and solutions. The manual therapy community as a whole I think agree on some basic premises. Prolonged spinal flexion is not healthy for backs, and restoring proper posture, and spinal biomechanics is a must in any pain equation. Thanks for the replies.

6

Chris,

When we look to the research on physical performance indicators (strength, endurance, etc) and physical rehabilitation for low back pain, there is no correlation. I suggest reading:

van Middelkoop, M., Rubinstein, S. M., Kuijpers, T., Verhagen, A. P., Ostelo, R., Koes, B. W., & van Tulder, M. W. (2011). A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European spine journal, 20(1), 19?39.

doi:10.1007/s00586-010-1518-3

The research suggests a cognitive-behavioral mechanism for improved outcomes.

If posture and spinal biomechanics are important I would recommend reading

Roffey, D. M., Wai, E. K., Bishop, P., Kwon, B. K., & Dagenais, S. (2010). Causal assessment of awkward occupational postures and low back pain: results of a systematic review. The spine journal : official journal of the North American Spine Society, 10(1), 89?99. doi:10.1016/j.spinee.2009.09.003

or

Wai, E. K., Roffey, D. M., Bishop, P., Kwon, B. K., & Dagenais, S. (2010). Causal assessment of occupational bending or twisting and low back pain: results of a systematic review. The spine journal : official journal of the North American Spine Society, 10(1), 76?88. doi:10.1016/j.spinee.2009.06.005

or

Lederman, E. (2011). The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther, 15(2), 131?138. doi:10.1016/j.jbmt.2011.01.011

Then follow all that up with

http://cdns.bodyinmind.org/wp-content/uploads/Moseley-2012-PAIN-MANAGEM-editorial-beating-around-the-bush.pdf

7

Very interesting article- have you ever read quantum healing? This is very similar in tone to Deepok’s view of pain and diseases. Tanks for your reply, but I am not sure I entirely follow you. Would you mind being less implicit? If I am following you correctly here, wouldn’t it be advantageous to focus on discovering what mechanisms ( like the periaqualductal grey) modulate perception of stimuli, rather than re- defining receptors and the role they play? It would eliminate the need for appearing to grab at straws when explaining the pain mechanisms behind acute and chronic pain. Instead of having to shift theories that are not mutually exclusive. So in other words, mechanism A is Involved in your problem, however mechanism B modulates how you perceive information sent from mechanism A. So in addition to impacting M-A, M-B must also be considered and addressed. Does that make any sense? Thanks again.

8

Ok, I got you. I found and read through some of those sources you provided, and your comment on a computer and not on an i-phone : / . I am familiar and agree with these concepts to a large degree, and there is certainly more than meets the eye when it comes to pain, but I think there is one important piece missing from the equation, and that is the nueromuscular system and Trigger Points. I have worked with people who were seeing Chiropractors, PT’s for years; found a sound structure, no ROM issues, yet they were riddled with active and latent TrP’s. It is pretty common that I see people with bulging discs, in pain, yet 90% of their pain is caused by TrP’s and when treated go completely asymptomatic.

However, yes, there is a huge mental component involved. It is not uncommon to hear “I’m doing the same, no changes in pain”. Yet when I have them specifically list their complaints, and compare them to the initial subjective findings, in fact, very significant changes have occurred. I call it symptom amnesia. I remember one client who had to get off the treatment table just to turn over. After weeks of hearing “doing the same”, I brought it to their attention that the last couple treatments they just spun right over instead of having to get up. They reported remarkable progress from there on out.

I think we have to be careful with meta analysis conclusions. It’s similar to the placebo effect. Just because a person reports a 50% improvements in pain regardless of whether or not a person takes an asprin, morphin, or a sugar pill, does not mean we need to start handing out sourpatch kids instead of tylenol. In the same light, just because two people have the same postural distortions, yet only one reports pain, we should not disregard that part of the equation when treating that person in pain.

Anyway, thanks again!

9

If you are looking looking for mechanisms, here is a quick synopsis. The science has been very clear over the last decade: pain is an output from the brain. The receptors we have are simply that; receptors to stimuli. There is no pain signal, pain fiber, pain pathway or pain center, etc. This thought process is consistent with Rene Descrates theory of specificity from 1664 (I would argue the biomedical approach continues to use it).

It is important to explain the biology. This is what the research supports. Talk of disc pain, muscle pain, bone pain are not congruent with pain science and does not result in improved outcomes. It creates reliance on surgery and over reliance on other forms of intervention (chiropractic, physical therapy, etc). Pain biology refutes the ideas (false ideas) that pain comes from the tissues. Encourage nociception, not pain fibers. We don’t have pain fibers. If we did, how do we explain phantom limb pain, chronic/ widespread pain, hypoalgesia or allodynia?

We have four origins or pain: mechanical, chemical, abnormal impulses generating sites (peripheral sensitization), central sensitization. Within these categories we can break low back pain into:

nociceptive pain, somatic referred pain, radicular pain and radiculopathy.

For a better understanding of the complexity and current working theory of pain ( and supported by mounds of research)

11

BBB,

Nociceptor: high threshold sensory receptor in peripheral somatosensory nervous system. Capable of encoding and trasmitting nociception.

I see what you are suggesting. If you said “sensitization of nociceptors” then yes. Your statement doesn’t make sense because nociception is only the signal. Sensitization to a signal would suggest a central mechanism.

If there is increased responsiveness or reduced thresholds of nociceptive neurons this would be suggestive of peripheral mechanisms. Peripheral sensitization occurring after injury and reducing threshold is important in inflammatory pain. There is a stereotypical primary hyperalgesia. This still fails to explain dynamic tactile allodynia, the temporal summation of pain, or secondary hyperalgesia.

Increased responivenss of nociceptive neurons in the central nervous system would suggest central sensitization.

Does that make sense? I look forward to your reply. I’m pretty sure you mean would I’m saying but don’t want to put words in your mouth.

Woolf, C. J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. PAIN, 152(3 Suppl),15. doi:10.1016/j.pain.2010.09.030

12

[quote]bushidobadboy wrote:

[quote]olifter1 wrote:
We have four origins or pain: mechanical, chemical, abnormal impulses generating sites (peripheral sensitization), central sensitization. Within these categories we can break low back pain into:

[/quote]
So you don’t believe in peripheral sensitization to nociception?

BBB[/quote]

BBB! Was hoping to get your input here. I wanted to respond to olifters original post when I get a chance tomorrow. I have some answers and problems with the line of thinking you presented. I’ll expand a little more on this in another post. Quickly though- I think practically speaking, not identifying and differentiating structures involved in the pain process is not a move in the right direction. Thanks again.

13

chris,

If we continue to identify and differentiate structures involved in musculoskeletal pain we will continue to follow the biomedical approach. Take low back pain for example. This has resulted in an increase in epidural steroid injections by 629%, MRI overuse by 307%, opioids by 423% and spinal fusions by 229%. We spend more on fusions than cancer research in the US. With the sort of ‘medical advancements’ we now have, have the outcomes improved since 1998? No, they’ve actually gone down and expenditures continue to go up.

This is the problem trying to identify a structure in low back pain. In the world of conservative care, the reliability to identify the ‘structure’ responsible to the patient’s pain is unclear and the clinical efficacy is questionable. Even if we find the ‘source’ how does that change treatment in the conservative world? I know the answer in the biomedical field (starts with ‘S’ and ends in ‘urgery’). Tell and show the patient the ‘disc herniation’ and what else would an uneducated patient do?

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine : JABFM, 22(1), 62?68. doi:10.3122/jabfm.2009.01.080102

Hancock, M. J., Maher, C. G., Latimer, J., Spindler, M. F., McAuley, J. H., Laslett, M., & Bogduk, N. (2007). Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European spine journal, 16(10), 1539?1550. doi:10.1007/s00586-007-0391-1

16

[quote]bushidobadboy wrote:

[quote]chriscarani wrote:

[quote]bushidobadboy wrote:

[quote]olifter1 wrote:
We have four origins or pain: mechanical, chemical, abnormal impulses generating sites (peripheral sensitization), central sensitization. Within these categories we can break low back pain into:

[/quote]
So you don’t believe in peripheral sensitization to nociception?

BBB[/quote]

BBB! Was hoping to get your input here. I wanted to respond to olifters original post when I get a chance tomorrow. I have some answers and problems with the line of thinking you presented. I’ll expand a little more on this in another post. Quickly though- I think practically speaking, not identifying and differentiating structures involved in the pain process is not a move in the right direction. Thanks again. [/quote]

I didn’t respond to your original post because I didn’t see a need. I didn’t really agree with what the author you quoted wrote, but since it was just a ‘bite sized’ piece in an article, I assumed he had not sufficiently explained himself, so wasn’t about to get on my high horse :wink:

Identifying pain structures can be both a blessing and a curse… depending on your stance. If you are a surgeon, anesthatising facet joints that are generating nociceptive output, then I guess it is a good thing.

If you are a ‘worrier’ who has a twinge of LBP, then obsessing over what structure is exactly generating your pain, can be an exceptionally bad thing IMO.

As a ‘spinal specialist’ I fall somewhere in between. For diagnostic purposes, I very much want to know what structures are being irritated. However, that is only a part of the prognosis and plan of management.

Just my opinion.

BBB[/quote]

17

[quote]bushidobadboy wrote:

[quote]chriscarani wrote:

[quote]bushidobadboy wrote:

[quote]olifter1 wrote:
We have four origins or pain: mechanical, chemical, abnormal impulses generating sites (peripheral sensitization), central sensitization. Within these categories we can break low back pain into:

[/quote]
So you don’t believe in peripheral sensitization to nociception?

BBB[/quote]

BBB! Was hoping to get your input here. I wanted to respond to olifters original post when I get a chance tomorrow. I have some answers and problems with the line of thinking you presented. I’ll expand a little more on this in another post. Quickly though- I think practically speaking, not identifying and differentiating structures involved in the pain process is not a move in the right direction. Thanks again. [/quote]

I didn’t respond to your original post because I didn’t see a need. I didn’t really agree with what the author you quoted wrote, but since it was just a ‘bite sized’ piece in an article, I assumed he had not sufficiently explained himself, so wasn’t about to get on my high horse :wink:

Identifying pain structures can be both a blessing and a curse… depending on your stance. If you are a surgeon, anesthatising facet joints that are generating nociceptive output, then I guess it is a good thing.

If you are a ‘worrier’ who has a twinge of LBP, then obsessing over what structure is exactly generating your pain, can be an exceptionally bad thing IMO.

As a ‘spinal specialist’ I fall somewhere in between. For diagnostic purposes, I very much want to know what structures are being irritated. However, that is only a part of the prognosis and plan of management.

Just my opinion.

BBB[/quote]

Well, that is why I provided the qualifier in my original post if you read it. He has taken this advice, apparently mis-taken in fact, to a degree that he won’t allow his athletes to perform spinal flexion movements, and they are developing postural distortions. Then on top on that fact is applying a muscle that most likely won’t solve the issue. This is what I was trying to get to the bottom of. Was I mistaken and do I need to re-think my approach, or am i correct in assuming this is not wise advice? I am not sure how we got on this subject of pain… : ), but I am certainly dusting off some areas I haven’t used in a bit…

18

[quote]olifter1 wrote:
chris,

If we continue to identify and differentiate structures involved in musculoskeletal pain we will continue to follow the biomedical approach. Take low back pain for example. This has resulted in an increase in epidural steroid injections by 629%, MRI overuse by 307%, opioids by 423% and spinal fusions by 229%. We spend more on fusions than cancer research in the US. With the sort of ‘medical advancements’ we now have, have the outcomes improved since 1998? No, they’ve actually gone down and expenditures continue to go up.

This is the problem trying to identify a structure in low back pain. In the world of conservative care, the reliability to identify the ‘structure’ responsible to the patient’s pain is unclear and the clinical efficacy is questionable. Even if we find the ‘source’ how does that change treatment in the conservative world? I know the answer in the biomedical field (starts with ‘S’ and ends in ‘urgery’). Tell and show the patient the ‘disc herniation’ and what else would an uneducated patient do?

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine : JABFM, 22(1), 62?68. doi:10.3122/jabfm.2009.01.080102

Hancock, M. J., Maher, C. G., Latimer, J., Spindler, M. F., McAuley, J. H., Laslett, M., & Bogduk, N. (2007). Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European spine journal, 16(10), 1539?1550. doi:10.1007/s00586-007-0391-1[/quote]

I am merely looking at this from a practical approach. As someone who sees people on a daily basis who are in pain, they want to know what it is that is causing their pain, and what steps do they need to take fix the problem. Do we tell them, well, it’s really just all in your head? Solutions are an entirely different subject that I do agree with you on to an extent. I think however, just because we can identify a source that is most likely the culprit, it doesn’t mean that leads to drugs and surgery, which by the way do work in many cases. If we cannot identify what the source of the pain is, then how do we approach fixing the issue? More importantly, how do we know which methods are most likely to be effective if we don’t have a clear understanding of what we are applying that approach to?

I am one of the biggest critics of allopathic medicine, especially when dealing with chronic pain, however, I hear so many misleading statistics that I occasionally find myself jumping to their defense. The cancer debate is one of them. Natural practitioners like to talk about how the war on cancer has failed. That is just completely false. Cancer treatment has improved the chances of survival greatly over the past 40 years. Cancer use to be a definite death sentence, now if caught early enough the chances of survival for many cancers has gone up. I personally know a half dozen people who would not be walking on this earth were it not for advances in surgery and Western methods of cancer treatment. Do we need to see improvements? Absolutely. I think Germany has has an exemplary model that needs to be explored more, and it is!

This is true for pain as well. A complete knee replacement can change someone’s life. I find it incredible that modern science can completely replace a knee and the person is back to activities they haven’t enjoyed in years within the span of a few months. Do we tell the guy who cannot even stand or walk, well, we really can’t identify and isolate the source of your pain, because 20% of people who have an x-ray that looks like yours don’t have pain, the perception of pain is really in your brain? Do you see how ridiculous this sounds when applied to a practical real world case?

20

[quote]bushidobadboy wrote:

[quote]chriscarani wrote:

[quote]bushidobadboy wrote:

[quote]chriscarani wrote:

[quote]bushidobadboy wrote:

[quote]olifter1 wrote:
We have four origins or pain: mechanical, chemical, abnormal impulses generating sites (peripheral sensitization), central sensitization. Within these categories we can break low back pain into:

[/quote]
So you don’t believe in peripheral sensitization to nociception?

BBB[/quote]

BBB! Was hoping to get your input here. I wanted to respond to olifters original post when I get a chance tomorrow. I have some answers and problems with the line of thinking you presented. I’ll expand a little more on this in another post. Quickly though- I think practically speaking, not identifying and differentiating structures involved in the pain process is not a move in the right direction. Thanks again. [/quote]

I didn’t respond to your original post because I didn’t see a need. I didn’t really agree with what the author you quoted wrote, but since it was just a ‘bite sized’ piece in an article, I assumed he had not sufficiently explained himself, so wasn’t about to get on my high horse :wink:

Identifying pain structures can be both a blessing and a curse… depending on your stance. If you are a surgeon, anesthatising facet joints that are generating nociceptive output, then I guess it is a good thing.

If you are a ‘worrier’ who has a twinge of LBP, then obsessing over what structure is exactly generating your pain, can be an exceptionally bad thing IMO.

As a ‘spinal specialist’ I fall somewhere in between. For diagnostic purposes, I very much want to know what structures are being irritated. However, that is only a part of the prognosis and plan of management.

Just my opinion.

BBB[/quote]

Well, that is why I provided the qualifier in my original post if you read it. He has taken this advice, apparently mis-taken in fact, to a degree that he won’t allow his athletes to perform spinal flexion movements, and they are developing postural distortions. Then on top on that fact is applying a muscle that most likely won’t solve the issue. This is what I was trying to get to the bottom of. Was I mistaken and do I need to re-think my approach, or am i correct in assuming this is not wise advice? I am not sure how we got on this subject of pain… : ), but I am certainly dusting off some areas I haven’t used in a bit…
[/quote]

No, I think you are correct. He seems to have taken an idea and followed it blindly, to extremes and his clients have paid the price.

Mind you, at least he caught the issue.

BBB[/quote]

Well, sort of : ). Yea don’t get me wrong, I am not worthy of holding TG’s jockstrap, nor would I want to be near it for that matter. I don’t want to be the guy who sits in the pews and tries to catch Billy Graham in a theological contradiction. At the same time, I want to be clear on it myself and prevent perpetuating my own ignorance. Thanks again BBB!