Tuesday, November 9, 2010

The Back Pain Show 2010 (tales of knee side to side, abdominal hollowing, swiss balls & faith healing)

A few weeks ago I attended The Back Pain Show in London with my colleague Pablo (ok, that's not his real name, I am concealing his identity to protect the innocent). In case you haven't guessed it's an expo all about back pain and attracts physios, chiropractors, osteopaths and the now ubiquitous vibram five finger stand. As well as the stands and people trying to sell you stuff it has free seminars about back pain, exercise, how to manage it, as well as exercise demonstration sessions.

I waited a few weeks before I wrote this review to allow myself to calm down and consider whether I had harshly judged what I witnessed. Having given it some thought I can say that my views of what I saw haven't changed, and the state of back pain care in this country is saddening. Now, I'm sure people are doing things with the best of intentions, but that's no excuse when so much research and information is readily available.

I have an interest in lower back pain, me and my colleague Pablo (ok, he's actually called Nick) run classes for people with chronic lower back pain, as well as doing one to one sessions. And without blowing our own trumpet we have had a fair amount of success in helping people. We generally follow the evidence based approach outlined by Stuart McGill in his two books and his two dvds. This forms the base structure of our approach if you will, and then we will build on that using methods that we think are appropriate to that individual, always trying to use logic and evidence based exercise as our guide.

Before I start remember that I am talking about a show that is aimed at practitioners working with people who have back pain (specifically in most cases, lower back pain), not the general population. The show also attracts lay people and members of the public who have lower back pain, they are looking for answers. Also, I have left out the names of people and organisations as it is not my intentions to bash individual people or make them look bad, and also I don't want to get sued! Though, I can back up everything I'm about to say.

Swiss Balls, Spinal Mobility & Knee Side to Side

The first seminar we attended was given by a physiotherapist/osteopath who also works with Olympic athletes. A good start we thought. First piece of advice is sound, avoid forward bending. This is simple but effective, it's easy to try and complicate things and get too clinical, but people with back pain really just want to know what to do to make the pain go away. And this is supported by McGills work

"It is becoming clearer that repeated spine flexion - even in the absence of moderate load - will lead to discogenic troubles." (McGill, 2002:127)
In short stop bending over and stop crunches as well fools.

The next point our friendly physio makes is that a lot of people with back problems have poor mobility and need to increase their spinal mobility & flexibility, cue demonstration of lateral flexion and then a picture of someone on a swiss ball hitching their hips side to side. Hmmm, this is more troublesome. As McGill (2002;216) states

"...greater spine mobility has been associated with lower back trouble in some cases. Further, research has shown that spine flexibility has little predictive value for future low back trouble."
The joint by joint approach outlined by Boyle (2010) seems a more logical approach to me, and clients seem to grasp the concept when explaining it to them. I have seen more people than I care to mention who had lost mobility in their hips and thoracic spine and were using their lower back to stoop down, pick up objects and get out of chairs, and who squat using only their knees. Boyle (2010;31) outlines a series of mobile and stable joints stacked on top of each other

Ankle - mobile
Knee -stable
Hip - mobile
Lumbar spine -stable
Thoracic spine -mobile
Scapula -stable
Gleno-humeral -mobile

For most people with lower back pain I would contend we need to get them more mobile in the hips & t-spine while keeping their lower back in neutral and stable.

The next classic piece of advice from the presenter was to sit on a swiss ball to help your posture throughout the day, I've heard this regurgitated numerous times. Aside from the fact that there in no one best posture, according to McGill (2002; 260) sitting on a swiss ball

"greatly elevates spine load through increase muscle coactivation. For this reason, non patients should avoid prolonged sitting on gym balls, and patients should use them only once they have achieved spine stability and increase load bearing capacity."

We then moved onto the exercises the physio/osteo recommended. The first one is of course on a swiss ball. Essentially a seated bird dog (or chair dog as I like to call it). At this point he gets a woman from the audience to demonstrate it, which of course she can't without losing her balance. Then we get a superman over the swiss ball (see the picture below, these are not from the day, they are pictures I took afterwards purely for illustrative purposes). At this point, the physio actually loses his balance and can't demonstrate the exercise properly. So, why would you give an exercise to someone with low back pain, that you can't even do yourself?!

And why would you move someone straight onto an unstable surface when this increases spine load (McGill, 2002, 2004), and the individual could be doing the chair dog or bird dog on a stable surface, which would actually be more effective and allow them to get the technique correct; and you know, might actually help their back.

If you fall off, maybe you should try it on a chair first

Look, the chair doesn't move, good news for the 60 year old with back pain
Swiss ball supermans - if your physio falls off while demonstrating this, maybe you should get him to show you 4 point kneeling bird dog on the ground first
The next exercise is the all time classic, second only to the knee hug stretch in the list of exercises given by physios to clients with lower back pain. It's the knee side to side/ windscreen wiper mobility exercise

No instructors were harmed in the taking of this photo

At this point, me and Pablo look at each other in disbelief. We then have a question and answer session after the presentation, in between questions from the public about what size swiss ball to get I manage to ask my question. Now, I don't want to have a show down or try and call the guy out and maybe he can justify the knee side to side move, so I ask him what his thoughts are on McGills work on rotation and twisting of the spine and knee side to side, and I throw in Sahrmanns name for good measure. Now, he's only aware of  McGills work on bracing and not the work on rotation. (If want to see something cool, watch McGills latest dvd where you can see a disc bleeding when put under rotational stress). And then he gives me the all time classic line "You can get research to prove anything." Now at this point, I should say I've been in this situation before when a fit pro instructor demonstrated the exact same exercise, I asked the exact same question and got the the exact same answer. But this guy isn't a fit pro instructor he is a physiotherapist and osteopath working with back pain patients and Olympic athletes. He should be on the cutting edge of research, or at least give me some answer about spinal ligaments stabilising the spine like Gray Cook does in his primitive movement patterns dvd (though personally, I still would not give this exercise to back pain patients).

Yes, he does say the spine is designed to rotate, but this isn't the complete picture and obscures the reality from the public. I don't pursue the argument. But the anatomy should be clear to someone with that many years in formal education. The spine rotates mostly in the cervical and thoracic areas with some rotation in the L5/S1 region. But we should try to limit rotation in the lumbar spine. Sahrmann (2002;62) states

"Rotational ranges of 3 1/2 degrees have been show to tear the annulus of the disk."
 The abdominal muscles should limit rotation in the lumbar spine, they should provide anti-rotations and we should try to lock the pelvis to the ribcage

"A large percentage of low back problems occur because the abdominal muscles are not maintaining tight control over the rotation between the pelvis and the spine at the L5-S1 segment." (Sahrmann, 2002;70)
 And the final word to Sahrmann again

"Rotation of the lumbar spine is more dangerous than beneficial, and rotation of the pelvis and lower extremities to one side while the trunk remains either stable or is rotated to the opposite side is particularly dangerous." (Sahrmann, 2002;72)
 So in short, the answer given to me about you can get research to prove anything is a junk answer and a lazy answer. Notice, the texts I refer to are 8 years old. This is not recent stuff. I don't know everything and always want to learn more, and am surprised at how limited my spinal knowledge is when I read some research papers and texts. But I'm shocked that people leave physio school and never learn anything new or never questions anything they have been taught, or don't think logically or outside the bounds of clinical wisdom.

And don't get me wrong, I'm not one of those trainers who avoids lifting heavy stuff because it's dangerous. But we are talking about people with lower back pain here not 20 year old Olympic lifters.

Pilates & Physiotherapists - why are they all Australian?

This post is already longer than I wanted it to be, but I've got more ground to cover. In the exercise zone of the show I watched some Australian physio/ pilates instructors going through some exercises. They managed to combine an abdominal crunch with abdominal hollowing to give the spine extra instability while in flexion. Just in case you're wondering, see the first quote from McGill as to why you should avoid repeated flexion of the lumbar spine. Why hollowing makes it more unstable and you should probably be bracing is also pretty well documented, so I'm not going to go over that ground again. And why are they all Australian? Is it because that's where the original research was done showing transverse abdominis dysfunction with lower back pain and started everyone erroneously hollowing, because they only measured one muscle and didn't measure all the others which can also be dysfunctional. Or maybe they have too many fitness professional in the antipodes, as fitpro, bts, half these physiso and personal trainers in London seem to be Australian or Kiwis. And if I was from the land down under i'd probably live there rather than rainy old England, but maybe no ones got back pain in Oz or New Zealand because they are always out surfing or bungy jumping. But I digress.

Then I got healed

Mixed in with the chiropractors and massage therapists were a few more esoteric stands. I looked at one labelled 'healing', when asked if I had any pain I told a woman who was wearing a t-shirts that said 'healer' that I had some knee and mid back pain. Then one of her colleagues grabbed my hand and invoked the power of jesus to rid me of my pain ( I kid you not ), and then when I said it hadn't gone completely he commanded the pain to leave and for me to be 100% pain free, I then lied - said it was gone and got the hell out of there. Pablo said it was the funniest thing he had seen, the bemused look on my face said it all. Now there is a time and place for everything and people can believe whatever they want to believe and somethings are beyond the realms of science. But, faith healing seemed a tad incongruous in amongst the physios and seminars by spinal surgeons. It's a sad fact that people with back pain can be desperate, and having been let down by the standard medical profession will try anything to make the pain go away

I have to say I keep an open mind even if something hasn't been supported by research. I can see the benefits of massage, Qi Gong, meditation, relaxation, positive thinking (some of which have research behind them for certain things). But invoking faith healing is a step too far in my opinion, though probably no more bizarre than the Bowen technique.

Another Australian

Another Australian physio was there, she did an exercise class demonstration. And though I had never heard of her she had the endorsement of Prince Charles and a lot of people were watching and seemed to know who she was. She was dressed as if she was about to get on a yacht (probably paid for by her back pain clients, hey if McGill can start his dvd sitting on a boat then it's possible) and definitely knew how to market herself. Then she started to use phrases that didn't really add up, like 'increase the metabolic rate of your disks' (?what??), now you can increase disk nutrition for sure, but I was unaware that disks have their own metabolic rate?!

I watched a few exercises, including the classic knee hug and a statement that forward bending is ok (who needs research) and left.

This exercise session especially and to a lesser extent the Australian pilates one showed the power of marketing and the media. Where, people assume pilates or some other persons method is best because of the media exposure it gets and not because of research, evidence or results.  Gray Cook sums it up nicely in new book Movement, that I am currently reading

"The sad truth is that media and advertising interests have greater influence on the fitness culture than the professionals dedicated to fitness, athletic development and rehabilitation." (Cook, 2010;51)
One more physiotherapist and I finally lose respect for an entire profession

The last presentation I went to was on the ageing population and implications. Again we start with some good quotes about the benefits of strength training for the older population. Then we move onto a confusing statistic that was probably explained wrong, apparently for every additional hour of TV I watch I'm 26% more likely to get diabetes. Which begs the question, additional to what? And if I watch four hours extra I'm 104% likely to get diabetes.

Then we see if we can touch our toes and then we see how many squats we can do in a minute. Except, what the physio demonstrates aren't squats, they're more like partial knee bends with a back in forward flexion with not much hip movement combined with a toe touch. At this point we left and went to the pub (true story).

The fact someone in the business of rehabilitating people can't do a decent bodyweight squat should come as no surprise to me. I've met too many physios and medical professionals who were overweight, injured and obviously didn't exercise in any fashion. I used to think that there were some good physios out there, doing the right stuff, staying ahead of the research curve, practicing what they preached. Now... I'm not sure, it seems like an entire profession surrendered themselves to pilates because they couldn't think of anything better themselves. They then started saying any exercise was going to benefit back pain, hey you can swim or cycle, lets not bother to see if you have specific needs or issues or if you are forward flexion intolerant. But most of all, I'm shocked that they can trot out the same advice they learnt twenty years ago and which hasn't worked. Maybe, I'm being too harsh and I'm hopeful that there are still some quality professional out there.

Anyway, my back actually now hurts from sitting down so long to type this post. I will see you at the back pain show next year, where hopefully I'll have my own stand and be giving my own seminar on evidence based exercise and strategies for chronic lower back pain.


Boyle M (2010) Advances in Functional Training. On target publications. California, USA
Cook G (2010) Movement. On target publications. California, USA.
McGill S (2002) Low Back Disorders. Human Kinetics. Champagne, Illinois.
McGill S (2004) Ultimate Back Fitness & Performance. Wabuno Publishers. Ontario Canada
Sahrman S (2002) Diagnosis & Treatment of Movement Impairment Syndromes. Mosby. St Louis, Missouri.

Also see my recommended resources page for details of McGills dvds'

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