State-of-the-Art in Postural Control: Pelvic Floor
Dr. Paul Hodges undertook the difficult task of explaining the intricate connection between the respiratory / pelvic floor / and abdominal muscles. I have the difficult task of summarizing what he presented! Dr. Hodges has a presentation style I really enjoyed – pose a question first and then proceed to address that question.
Question 1 – Do the muscles of respiration and continence contribute to postural control of the trunk?
Yes. Many of the muscles of the trunk (diaphragm, scalenes, erector spinae, intercostals, pelvic floor muscles) and pelvic floor (anal, periurethral, vaginal) are active during breathing and they are modulated in concert with breathing. Dr. Hodges provided evidence of this by presenting recordings from many systematic studies which measured the all of the above muscles in tasks such as respiration, modifying posture, and when a mass was unexpectedly dropped into a box held by the participate.
Question 2 – Can postural control, respiration, and continence be coordinated?
It seems that concurrent modulation of all these muscles is normal and that tonic and phasic activity can be modulated concurrently by the nervous system. In chronic respiratory disease, posture is compromised with greater disturbances in the ability to balance in the medial/lateral direction (trunk and hip stability). One obvious example of coordination is when someone is sprinting or lifting something heavy – you don’t breath for a short time (Dr. Hodges had us stand on our toes, reach up as high as we could, and notice how we held our breath).
In low back pain, postural function is disturbed for sure. But why? It seems that there is reduced activity of the transversus abdominis muscles, which leads to delayed activation, less tonic activity, muscle atrophy, and cortical reorganization.
Question 3. What are the conseqeunces of poor coordination of postural muscles?
The immediate implication is that breathing disorders, back pain, incontinence are linked together. Sure enough, Dr. Hodges presented results from an epidemiological study showing that those who had a breathing disorders were more likely to develop low back pain!
Question 4. What are the implications for rehabilitation?
For low back pain:
- Considerations from continence – activation of pelvic floor muscle to facililatet abdominal mucsle activity
- Considerations from breathing – ppl with back pain with breath in a more vertical manner (upper chest shallow breathing)
- access breathing patterns thru palpation, observation, US imaging – train breathing patterns
- goals – reduce activity, changin breathing apptern, train TVA, bretah mmore efficiently
For pelvic floor disorders:
- Consideration from lumbopelvic control – tva activiaiton may assist with PFM – supericial muscles maybe over active, change posture
- Considerations from breathing – overactive supericial abs incre IAP and can strain PFMs
For breathing disorders:
- Consideration from lumbopelvic – breathing pattern may be affected by lbp
- Consideration from incontinence – pelvic floor muscle function may be changed, consider PFM training
Although Dr. Hodges used the specific example of low back pain rehabilitation, the principles apply to other areas
- Training the transversus abdomonis successfully changed its recruitment by as evidenced by a shift in the timing of activation closer to normal controls with specific training
- Can these changes in timing be maintained? – yes
- What do you do? -Situps without conscience attention to TVA activation
- The brain of someone with LBP is different than normal control – brain mapping with TMS shows a shift in the locus of TVA cortical region – reorganization
- Specific training can make the brain look like a control
- Does motor training make a difference? – yes but the treatment needs to be targeted and indiviualized – the more severe the impairments in TVA activation the better the change with training
Conclusions
Patients will present with a range of issues, but it is impossible to separate the systems. You must look at your patients as a whole and develop a strategy that addresses all of their problems.
Bottom line – YOU MUST BE A MULTISYSTEM THERAPIST
Tim Flynn: Stop The Madness!
For your viewing pleasure, the honorable Dr. Timothy Flynn.
Link to video
Sickening Report from WSJ
Spine Surgery Greed
Already controversial, yet continually growing more common, instrumented spinal fusion surgery took a public relations hit in an article in today’s Wall Street Journal. “Top Spine Surgeons Reap Royalites, Medicare Bounty” is an excellent, if not disheartening piece of investigative health journalism.
This piece is a must read for anyone involved in the care of patients with back pain, anyone with back pain, and hopefully, anyone involved in health policy that can help. Senator Grassley, You read this, right?
“One surgeon at a hospital in the Midwest disclosed receiving between $400,000 and $1.3 million in royalty, consulting and other payments from three spine-device makers. Using the Medicare-claims database, the Journal found this surgeon performed 276 spinal fusions on Medicare patients in 2008, by far the most of any surgeon in the country.”
“At least my spine is aligned now…”
Comfortably Bad Medical Beliefs
These were the words of a friend who had just been to see a chiropractor for her sore back. I had treated her back the day before and had asked how it felt. The response was, “Well, I went to see a chiropractor today and it’s still really sore, but at least my spine is aligned now.”
While experiencing the obvious professional snub, the part of the statement I took exception to was the “aligned” part. I could tell she had taken comfort in the fact that no matter how her back felt, the chiropractor had “fixed” the alignment and she was on her way to better health. The only problem is, the explanation she was given as justification for the treatment doesn’t make any sense.
The theory of vertebral subluxation, first introduced as a medical theory in the 1800′s, has never been shown to be a valid theory. In fact, chiropractors themselves have issued loud warnings about threats to public health that come from relying on the concept that the spine can be misaligned and needs to be “adjusted” via spinal manipulation. Here’s a research article published by chiropractors which concludes:
“No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal, this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.”
But still, people take comfort when they hear a theory that makes sense to them. In these instances, the comfort of the explanation can be so powerful that it causes the person to disregard facts to the contrary. There is also a public education problem here in the case of back pain and spinal alignment. It’s a particularly interesting dilemma, in that spinal manipulation is very effective for low back pain, just not for the reasons most chiropractors purport. This perpetuation of back medical theory is a real problem as we work to help patients make smart, cost-effective choice in the face of limited resources.
The Irrational Mind of Public Health
In an excellent piece of science writing by Christie Aschwandan, entitled, “Convincing the Public to Accept New Medical Guidelines,” this interplay between strongly held beliefs and public health data is explored. Runners who take ibuprofen, the controversial new mammography guidelines, and invasive and expensive imaging for low back pain are all discussed as examples of where beliefs and data are in conflict.
“But when facts contradict a strongly held belief, they’re unlikely to be accepted without a fight. “If a researcher produces a finding that confirms what I already believe, then of course it’s correct,” MacCoun says. “Conversely, when we encounter a finding we don’t like, we have a need to explain it away.””
Such is the case with many things in life. It is easier for us to believe something that makes sense. It’s more comforting to take action. Thus, when the best course of action for back pain is to wait it out, stay active, and not to get an MRI, it feels like the wrong decision. This has as much to do with the way our minds process information as anything.
“There’s this common assumption that we’re just going to educate people about the facts, and then they’re going to make use of them,” says Brendan Nyhan, a health policy researcher and political scientist at the University of Michigan. “But that’s not how people process information — they process it through their existing beliefs, and it’s hard to override those beliefs.”
What this all translates to is the need for researchers, public health officials, and health providers to improve the way new information is communicated to the public. I guess we should include the media in that as well! As Aschwandan concludes, ”Explanations that offer hope and empowerment will always hold more appeal than those that offer uncertainty or bad news, and when new evidence offers messy truths, they must be framed in a positive light if they’re to gain traction. You can ask doctors to give up ineffective interventions, but you must never ask them or their patients to abandon hope.”
How true. Except often, it’s hard to know where to start.
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Physio-pedia
The online encyclopedia of Physical Therapy.
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