Trunk Balance Exercises for Chronic Low Back Pain

I am reading this article for a journal club this week, so I thought I would create a summary in the format that Bret Contreras and Chris Beardsley do every month for their strength and conditioning research review.  If you are interested, check it out here:  http://www.strengthandconditioningresearch.com/

Title:

Efficacy of Trunk Balance Exercises for Individuals With Chronic Low Back Pain: A Randomized Clinical Trial.  By Roberto Gatti et al. JOSPT August 2011

Background

Motor control research has determined that trunk muscles do not activate properly after an individual has had an episode of low back pain.  A result of this decreased activation are deficits in trunk balance and position sense as well as other measures of balance.  Motor control training has been proven effective for low back pain, but trunk balance exercises to train the motor control system have not been evaluated.

What Did The Researchers Do?

The researchers took 79 individuals with chronic low back pain (>=3 months duration) and randomly divided them into 1 of 2 groups.  Both groups exercised in groups of 4-6 2x/week for 5 weeks (for a total of 1o hours of exercise).  The exercise sessions would include 15 min of treadmill walking, 30 min of flexibility exercises (anterior / posterior pelvic tilt, single knee to chest, double knee to chest, lower trunk rotation, adductor stretch, hamstring stretch, sidelying quad stretch, prone press up, seated trunk flexion, seated trunk rotation), and then the last 15 min would differentiate the two groups.

The experimental group performed balance exercises (tall kneeling trunk rotation, tall kneeling UE flexion / extension, bridge, birddog, sitting on a corner of a table with unilateral support, single leg kneeling on edge of table).  The participants were instructed that exercises should be painfree and changed if they became painful.  Progression of exercise included closing eyes, head movement and the use of unstable surfaces.  The exact protocol for time performing the exercises is in the article.

The control group performed strength training exercises (abdominal curl up, shoulder extension, hamstring curl, leg extension). The resistance exercises were performed at 50% MVIC for 3 sets of 8 reps and the curl up was performed for 3 seconds for 3 sets of 6 reps.

Outcome measures included pain ratings, the Roland and Morris Questionnaire (RMQ) and the mental and physical components of the SF-12.  A secondary outcome measure of impact on painful positions and use of pain relieving mediations was also included

What Happened?

Pain intensity decreased somewhat in both groups, but the quantity was very low and not different between groups.  This was an insignificant finding.

The disability and quality of life scales also showed very small improvements.  In these measurements there were some meaningful clinically important differences (MCID).  For the RMQ, the improvement reached the MCID in 19 / 34 experimental subjects and 14/45 control group subjects.  For the SF12 physical component 16 subjects in each group reached the MCID.  For the SF12 mental component, changes were minimal.

The secondary outcome measures had interesting results in that 28/34 of the participants in the experimental group had decrease in painful positions where the improvement was only 27/45 in the control group.

What Were The Conclusions?

Trunk balance exercises were more effective than strengthening exercises in reducing disability and improving the physical component of the quality of life.

Limitations?

Lack of a follow up measure to determine if changes lasted.  Possible placebo effect as the groups knew what they were doing.  The most important one that I feel they mention is the fact that both groups participated in 45 minutes of exercise that was identical, so the similar results between groups may be due to that time exercising.

On a personal note, I feel that the selection of flexibility exercises could lead to more harm than good.  I would prefer a lower load spinal stretch like the cat and camel rather than seated flexion, rotation, and prone press up.

Practical Implications

Trunk balance exercises may be better for rehabilitating patients with chronic low back pain.  These positions (variety of kneeling, quadruped, bridging) are common in the functional movement / exercise world and I think that integrating those positions into a workout is a great idea in terms of addressing back pain.

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Awesome Kettlebell Snatch Instruction!

Neghar Fonooni posted a great article about the kettlebell snatch.  Since I discovered kettlebells, I have become fascinated by them  The force they provide is unique and feels very natural.  I am proud to say that I am a firm believer of functional fitness and exercise and I think kettlebells fall squarely in that arena.  The basic kettlebell movements (swing, clean, push press, and snatch) are all very artistic looking movements when performed correctly.  Check out Neghar’s advice for improving your kettlebell snatch.  This one is definitely going in my exercise library.

http://www.negharfonooni.com/2012/03/kettlebell-snatch.html

EDGE Review

This is a review of a soft tissue mobilization tool called the EDGE, created by Erson Religioso, PT.  You can find the tool at http://www.themanualtherapist.com/p/for-sale-is-300-grade-stainless-steel.html.

In the past few years, I have been reading several PT / Rehab blogs and I have come across the concept of instrument assisted soft tissue mobilization (IASTM) several times.  So, I finally broke down and bought the EDGE tool after coming across it on http://www.sportsrehabexpert.com/ and reading Mike Reinold’s blog that mentioned using the ideas of IASTM without necessarily buying the more expensive  Graston tools.

To understand my resistance, here is some background information on my viewpoint on soft tissue mobilization / massage in the PT / Rehab setting.  I was trained in PT school by a Maitland certified Fellow of the American Association of Orthopedic and Manual Physical Therapy (FAAOMPT) and the manual methods we learned were mobilization and manipulation with some static stretching.  We also repeatedly learned about the importance of evidence based practice and we kept hearing that massage / soft tissue techniques have very poor support in an evidence based world (as instructed by my PT School Instructors).

Eventually, I relented somewhat after seeing the role of foam rollers in improving knee pain in patients with ITB issues.  Then, I gave into working on trying some trigger point ischemic release and after being treated in this manner at a continuing education course.  Later, I started CrossFitting and was following Kelly Starett, the Physical Therapist of the CrossFit world.  If you have seen any of his work at http://www.mobilitywod.com, you’ll understand that he clearly sees a value of inflicting some pain in mobilizing (which matched my experience with trigger points).

The EDGE intrigued me for 3 reasons: 1) I could use my hands less, 2) Erson was teaching a very different method – superficial mobilization, and 3) value.  This concept of working superficially before going deep was very new to me and initially sounded like a waste of time, especially with my brief experience with trigger point and foam rollers, but I decided to give it a try.  Then I came across a lighter method of foam rolling / stick work while watching the Kalos Sthenos / Kettlebells from the Ground Up with Gray Cook and Brett Jones.  Gray referenced using the stick lightly to try to relax muscle in the traps.  I have really enjoyed learning about functional movement and exercis and I feel Gray Cook has something really good in his FMS and SFMA work, so this further supported my plan to try the EDGE.

So far, I have used the EDGE several times on patients and myself.  I am quite amazed by the results.  I feel the scar mobility from my surgery is improving from use of the EDGE (I wish I started earlier).  I had great results on alleviating some stress and pain in 2 patients with upper trap / levator scap tightness issues.  I also saw good results addressing some post operative biceps restrictions after subacromial decompressions and in assisting a patient s/p hamstring tear improve mobility.  Most recently, I was able to help a low back pain patient today improve his pain and ability to perform a forward bend (which ties nicely to the SFMA).

One thing that I really like about the EDGE is the ability to assess tissue with it.  I feel limited with my palpation skills in that there is so much to feel, but it is hard to objectively describe what you are feeling.  With the EDGE, the vibrations that you feel are very specific and easy to document and clearly identify.

As someone who was an adamant soft tissue skeptic, I have totally changed my opinion on the matter with the help of  this tool and Erson’s educational videos.  They are somewhat straightforward, but I think they give good examples of treatment and progressions for PTs new to the world of IASTM.

It is a great product and an inexpensive tool to improve soft tissue in a relatively more objective and technical manner.  I definitely recommend it to any PT or OT.

Thurs 4/19

Shar and Kate
Leg lowering progressions
-Kate barely passed her ASLR afterward for a 3 bilaterally, the left leg is borderline
TSPU progressions
-band assisted, Kate was able to do it with a green spri band – very impressive
-Shar looked solid with the med grey band
Quad / 1/2 kneeling hip flexor stretch
T spine foam rolling and extension over the foam roller
Tspine rotation for Kate, it’s beginning to look really good
Rotary stability for Shar – working on touching opposite knee and elbow in supine with RNT to pre activate the core, able to get it on both sides, but no carryover to qped yet.

Deadlift 70×10, the 7 sets of 3
Kate 95-105-115-120-120-125-125
Shar 95-105-115-120-120-120-125

Me
Squats x10-15 (feeling better thanks to Anne today)
Bike 2 min, then 9×30 sec moderately hard followed by 90 sec moderate w/ less resistance
Farmer carry – L suitcase carry – R suitcase carry 35 lbs each x5, 53lbs each x5, 35lbs each x5. 12-13 min

Treating Patients Based On Movement Patterns

Since I have been actively involved with learning as much information from Gray Cook and Shirley Sahrmann, I have been evaluating and treating my patients differently.  In the past 2 weeks, I have seen some impressive gains, just by looking at regional interdependence and movement patterns.

For example, I have 2 patients that have gotten dramatically better very quickly just by focusing their exercises on their deficient patterns rather than focusing on all the small non weightbearing exercises that I may have looked at in the past.  One woman demonstrated abnormal lumbopelvic rotation with motion and by working on walking, sit to stand, and some resisted upper body activities in closed chain stances, she has nearly eliminated this rotation and is almost painfree.  Another patient, who had been through PT for her shoulder for a long time is having a dramatic improvement in her symptoms by addressing her lack of thoracic rotation.

I feel I have uncovered a new way to treat patients and I am very happy with it.  If you are a Physical Therapist, spend a little more time looking at general patterns to see if you can improve those before focusing on the isolated deficits.

Keep moving,
Jason

Hunger Games

I just finished the 2nd Hunger Games book and I am excited to get going on the third.

I noticed a reference to Physical Therapy in the 2nd book, did you?  Katniss’ mother prescribes exercises for her to do as she is recovering from her jump from a tall tree to the ground.  That and the consistent treatment of patients with ice.  It felt very PT to me.

These books are incredibly depressing, but I like how they connect people everywhere.  Seems like everyone at work is or has read them and despite the very depressing plot lines and I feel everyone feels a little connected by this.  I think that’s a good thing.

Good night and keep moving,

Jason

Back To Work

I returned to work last Wednesday – 6 weeks after my hip surgery.  I’m doing well with the aide of a compressive wrap that has helped with swelling in the past.  I have a couple of observations related to the movement system that I treat as a physical therapist.

1) Shoewear – I have started wearing my Vibram’s again and I am once again so impressed by how many muscles in my lower leg are working.  They really seem to provide the feedback that works the muscles and gives me stability all at once.  When I’m not wearing them (for instance at work), I prefer my Altra Instinct running shoes.  The 2 most important features are the wide toe box and the zero heel to toe drop.  This makes movement much more natural.  The padding is good and bad – it helps me tolerate walking on concrete / hard floors all day, but it doesn’t provide anywhere near the proprioception that I get in the Vibram’s.

2) Fitbit – I started wearing this pedometer and sleep tracker a few weeks ago and I really like it.  I understand how people who wear pedometers walk more, you are constantly encouraged to keep moving to get those numbers up.  Amazingly, my long 10 hour work days do not improve my number of steps, I need to be out and about walking to get my steps count up.  I also really like the sleep tracker, I think it’s fairly accurate.  If I wake up less, then I can tell a distinct difference in my energy the next day.  I can better appreciate how more hours of sleep are really helpful.  The need for more sleep has been echoed in the Paleo Solution and I am actively trying to sleep more at night.

3) Sahrmann’s Movement System Syndrome Diagnoses are Tough.  I have started using the Movement System Syndrome evaluation and I like the information I am getting, but I find the diagnostic work to be harder than I imagined it would be – particularly for the lumbar spine.  I have a hypermobile patient with a chronic history of self and chiropractic manipulation that appears to be falling into both the lumbar flexion and extension category – which probably means he’s a rotation, but it is driving me nuts.  I plan to further expand the use of her tests to get a little more region specific.

4) Sugar is bad.  If you are not sure about it, check out the 60 minutes piece from this evening.

Take care and keep moving, Jason