I recently had the opportunity to interview Dr. Stuart McGill about his work with rehabilitation exercises for the lumbar spine.
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PhysicalTherapyContinuingEducation.Org: "Well, we know from your work that Transverse Abdominis (TrA) is not the whole answer to spinal stabilization, but isn't it beneficial to still prescribe Transverse Abdominis exercises to make sure that muscle is working well?"
Dr. Stuart McGill: "Well, I think I've just caught you in a nice little clinical controversy."
PhysicalTherapyContinuingEducation.Org: "Okay."
Dr. Stuart McGill: "Show me one study that says the Transverse Abdominis is not working."
PhysicalTherapyContinuingEducation.Org: "Well, Dr. Paul Hodges' work.
Plus I recall there was an article in JOSPT recently about Australian Football players."
Dr. Stuart McGill: "Okay.
Well, if you think Hodges' work, let's stay with that.
He's never shown that the Transverse Abdominis is not working."
PhysicalTherapyContinuingEducation.Org: "I stand corrected.
The TrA doesn't fire correctly."
Dr. Stuart McGill: "He's shown that in a very, very tightly controlled experiment of people standing - and they sort of have to relax in a very special way - and they jerk one arm into flexion.
That's the only time that he's found, in a few back pain patients, about a 30 millisecond delay in activation.
It'’s not that the TrA isn't working. It's slightly delayed in onset.
A lot of people have tried to replicate that experiment.
They haven't got as much press as Dr. Hodges has and they haven't found that pattern.
They've found delays in other muscles, absolutely, but when they sub-categorize the various flavors of back pain they've been able to show that certain back pain patients have no delays at all.
Some have much bigger delays in Erector Spinae.
There have been all sorts of studies that show Latissimus Dorsi has huge delays in rowers, for example, with back disorders.
Anyway, my point in this, it's only in this very contrived arm raise task.
You show me one other task where Transverse isn't working?
It's a myth."
***End of Transcript***
I thoroughly enjoyed speaking with Dr. McGill during this thought provoking 36 minute interview. I hope you enjoyed this excerpt.
I invite you to visit my site to listen to or download the entire interview.
My site is called Physical Therapy Continuing Education.Org.
Basically I found a way to combine my love of learning and being an internet geek. I hope you take advantage of the whole series of free interviews I am doing with some of the top rehab experts in our field.
Thank you,
Sasha Sibree, PT
PhysicalTherapyContinuingEducation.Org
I think this goes to the argument for Treatment Based Classification Systems. "Back Pain" is even more complex than "headache". There are many, many, root causes for "back pain" and "headache". More specificity will be required to determine the appropriate tests, measures, and evaluations than either term can deliver. Those tests, measures, and evaluations will need to be done in order to determine the appropriate treatment. Some LBP patients "DO" have some level of inhibition in the Transv Abdominus. I evaluate treatment regiments and methods, techniques by some pretty specific rules. 1. Is it harmful to my patient? 2. Is it likely to be of some help (even if not for the stated reason for the treatment in the first place)? 3. Is it as cost effective, and efficacious, as the next choice?
ReplyDeleteEvidence is great, where it can be had. Sometimes I think exercises designed specifically for say, Transv Abdomimus, have a splashover effect... you can not remove a patient's muscles and exercise them in a petri dish and then replace them. Many things can be happening with Transv Abdominus training, including an increase in circulation both within tissue with a profuse blood supply (muscle/perisoteum) and that with minimal blood supply (fascia, tendon, cartilage, ligamentous). That increase in circulation tends to improve the environment for healing, flushes away inflammatory mediators and may be singly responsible for changes in pain and function, regardless of the function of the Transv Abdominus muscle. Well... it's fun but have to get to work.
Sasha,
ReplyDeleteDo you have any references (forward or against) regarding Dr. McGill's commentary about the transversus abdominis and D. Hodges' work?
In another note, I really disliked when I heard Dr McGill saying something about physiotherapists having a tendency to take new (good or bad) ideas and run with them...
Hi Nicholas,
ReplyDeleteI think what Dr. McGill was saying is that many therapists, like physicians, have the tendency to advocate a particular treatment without considering the evidence for or against.
There are very few adverse side effects of physical therapy - other than time and money.
The problem occurs when treatments with negligible effects are promoted by therapists and then paid for largely with government money.
Tim
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ReplyDelete