Evidence-Based Practice Proposal – Final Paper

Journal of Bodywork & Movement Therapies (2010) 14, 289e293

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

PREVENTION & REHABILITATION: EDITORIAL

About prevention

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Warrick McNeill, MCSP, Associate Editor *

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What is prevention?

About 4500 years ago, according to Chinese tradition, and Fletcher (1988), the Yellow Emperor, Huang-di, only paid his physician’s retainer when he was well and stopped paying when he was not. ‘The wise people (the sages) did not treat those who were already ill; they instructed those who were not yet ill.’ Preventative measures (nourishment, rest, exercise and sleep) consisted of 4 of the 5 modes of treatment espoused at that time.

Serge Gracovetsky, reports in an interview published on YouTube, that he once, while suffering back pain, went to see seven different Orthopaedic or Neuro Surgeons but received seven different diagnoses. Gracovetsky appears to have applied a similar principle and didn’t pay any of them to proceed with their suggested treatments. Four recom- mended surgery, three did not. He decided that the best course of action was to do nothing, but go to the Library to find out what he could about back pain.

Have we then come very far in the intervening four millennia?

On the safetylit.org website, an online source of injury prevention literature, they state: ‘Injuries have causes e they don’t simply befall us from fate or bad luck. To prevent injuries it is necessary to have information about the factors that contribute to their occurrence. With this information we may understand the options for prevention. Effective injury prevention requires a multifaceted, multidisciplinary approach.’ It is also a very broad remit. Too broad perhaps? Health and Safety Directives seem to be impinging on society and the workplace. Enough so as to encourage the UK’s Health and Safety Executive to produce ‘Myth of the Month’ posters debunking ‘Great health and safety myths.’ November 2009s

* Tel.: þ44 7973 122996. E-mail address: [email protected]

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved doi:10.1016/j.jbmt.2010.04.001

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poster points out that it is a myth that Health and Safety rules stop classroom experiments. The cartoon shows a rather sad teacher and pupils wearing safety goggles watching paint dry on a card propped up in a safety-glass cabinet.

As a Physiotherapist I use the UK Health and Safety Regulations on Display Screen Equipment (1992) (based on the relevant EC directives) in the part of my practice which involves ergonomically assessing staff at their computer workstation, but even then, I’m a second tier external consultant e only brought in when the staff member is already reporting pain, and has usually already been seen by the in-house assessors. Is my role ‘preventative’?

Prevention, as a concept of health management, appears to be wasted on the young. The hubris and inde- structibility of youth becomes more glaring as one ages and becomes more risk adverse. The young appear not to listen to sound advice, they do not appear to learn by others mistakes rather they seem to want to sustain the injury to discover that they need to avoid injuring themselves in the first place. Being an Injury Prevention specialist working with the young might not possibly score highly on a job satisfaction questionnaire, but how much ‘prevention’ work actually occurs prior to first episode injuries?

When my Physiotherapy colleagues discuss prevention it is usually about preventing recurrence of the injury, so it is after the fact of the original insult, and becomes part of rehabilitation.

Mark Ford, a Pilates/Gyrotonic/Franklin Method instructor in Australia says, ‘To me rehabilitation and prevention can not be separated. Rehab is not complete if the client doesn’t understand causes, actions and conse- quences.’ (Ford, 2010).

Chaitow (2010) says eloquently in a personal communi- cation, ‘I work with a model in which dysfunction emerges from a background of failed adaptation (to overuse, misuse, abuse and disuse). In such a model prevention is seen to involve modifying or eliminating those stressors that can be

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identified e so reducing adaptation demands bodywide, or locally. In addition, prevention entails enhancing func- tionality (bodywide and/or locally) so enabling the system or area to better cope with adaptation demands. Rehabil- itation of existing dysfunction involves a similar model of care e with specifically focussed interventions and strate- gies, as well as generalised ones (better posture, breathing, nutrition, habits of use etc). Prevention therefore only differs from rehabilitation by virtue of the context and the objectives’.

Soit appears, in the context of therapy and therapists, that prevention and rehabilitation treatments or strategies could possibly be the same thing, but just be a question of timing, before or after an incident (or injury provoking behaviour), that may itself be an original insult, second or third.

Chronic low back pain

Exciting advances made in motor control and pain research means that there is a diagnosis and management shift from a pathological and anatomical viewpoint to a dynamic systems approach according to Key (2010a). In the opening chapters of her recently published book, ‘Back Pain: A movement problem.’ Key neatly summarises Waddell who states that: only about 15% of patients with back pain show definite structural pathology, the relationship between imaging and symptoms is weak, and in the absence of a diagnosis Health professionals may look to psychological reasons for their pain, therefore, there is no surprise that the ‘biopsychosocial model’ has evolved.

While not discounting the biopsychosocial model readers of the Journal of Bodywork and Movement Therapies may too realise that hands-on or therapeutic exercise answers may exist for their clients neuromusculo-skeletal problems.

Key goes further and looks at classification systems for Chronic non-specific low back pain (CNLBP) or ‘ordinary’ back pain, quoting Riddle (1998) that current classification systems are confusing, looking at appropriate treatments, or prognoses, or pathology. She also quotes O’Sullivan (2005) who overviews 8 models, including the ‘Motor control model’ in which O’Sullivan bases his own work. Key suggests the ‘Functional movement model’ that combines many features of other CNLBP models including the bio- psychosocial (Key’s own bolding) and Motor control. She suggests that ‘altered function of the posturo-movement system is the primary problem largely responsible for the development and perpetuation of most pain syndromes.’

I asked Key (2010b) about how she considers prevention in the therapeutic context, she said, ‘I certainly consider that prevention is an important aspect of comprehensive therapeutic care e yet this aspect seems to have been largely usurped by the ‘fitness’ and related industries who have little ‘real rehabilitation’ training e hence who knows what they base their ‘‘prevention programs’’ on. I consider that if prevention strategies are to be meaningful and functionally useful, they need to be built upon a well informed understanding around a number of related aspects concerning movement control:

(a) What is ‘more ideal’ posturo-movement function? Appreciating this also enables better application of the

available evidence; to put research outcomes into the clinical context; and even question the clinical utility of some findings

(b) The evidence is pointing more towards deficiencies in motor control being associated with spinal pain disor- ders and so, more beneficial programs should focus upon the quality of our patterns of movement control rather than the ubiquitous ‘strengthening’ and ‘stretching’

(c) The practitioner needs to be cognisant of the fact that seemingly subtle changes in posturo-movement control are usually apparent before the onset of pain. These changes can tell us a lot about the potential or actual problems the patient may be/is experiencing and so this can also serve a certain predictive role e important for prevention programming.

(d) The practitioner needs to appreciate ‘‘what are the more likely patterns of dysfunctional response going to be’’? While evidence is giving us more answers in this area, at this point in time we need to rely more on our clinical pattern recognition and therapeutic skills to provide the substance of more meaningful prevention program.

(e) In essence, effective programs of care e therapeutic and preventative, depend upon a balance between artful clinical practice informed by the knowledge that science can offer.’

In summary Key said she ‘is trying to get the message out there that clients most probably need to work smarter not harder!’

We know that a marker for measuring the success of rehabilitation is in dropping recurrence rates, it is the underlining and exclamation point a researcher has when they publish their follow up study, see Hides et al. (2001) work on the deep multifidus.

The 3rd movement dysfunction conference 2009

During a dismally wet Edinburgh weekend Sahrmann (2009a) presented her Keynote Lecture on Low back pain: ‘Isolated or degenerative problem e what are the impli- cations?’. She stated that ‘90% of people are expected to experience low back pain during their life’ with a high recurrence rate ‘between 30 and 80%’ These high incidence and recurrence rates, she says, ‘are consistent with low back pain being associated with the degenerative process’ and this process consists of ‘temporary dysfunction and 4 stages of hyper-mobility before the final stage of hypo- mobility and spinal stenosis. If the ‘‘acute episodes’’ are part of the pattern of temporary dysfunction associated with segmental hyper-mobility then treatment should be directed toward control and prevention of the progressive hyper-mobility that at a minimum should slow the degen- erative process.’ She challenges physical therapists to ‘monitor the pattern of movement of the low back, designing and appropriately instructing the patient in corrective exercises and movement strategies rather than just providing episodic short-term treatment.’ Sahrmann reported that clinical examination is reliable, in trained

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people, in identifying movement faults and that there is validity in identifying (movement) subgroups (Sahrmann, 2009b).

Fass (1996), ‘Exercises: which ones are worth trying, for which patients, and when?’ found that more research on ‘different types of exercising’ in patients with chronic back pain was necessary. Sahrmann’s comments at the Move- ment Dysfunction conference suggests that there may eventually be a plethora of well reasoned, specific exer- cises for specific movement faults, identified by pattern recognition and clinical testing, that probably make up the 85% of CNLBP sufferers that do not have a structural pathology.

‘Movement screening’ was highlighted at the confer- ence, first by Gray Cook who introduced his Functional Movement Screen (FMS). Cook (2009) identified that the strongest predictor of future injury is previous injury. The FMS, is a reliable (Minick et al., 2010) predictive system for those who do not have a known musculo-skeletal injury. It assesses functional movement patterns looking for asym- metries and movement limitations, and therefore, he suggests, indicates what ‘to do’ with the client.

The test movements are relatively simple and include:

� a deep squat � a hurdle step � an in-line lunge � shoulder mobility � an active straight leg raise � a trunk stability push up, and � a rotation stability test.

Comerford (2009, 2004) in his presentation to confer- ence discussed that in sport (where improving performance becomes a major goal of the support staff, as opposed to, in the clinic where the major goal is reducing pain and disablement) the significant ‘Recurrence of injury and pain’ indicates that something is missing in our current screening and prevention strategies.

Comerford pointed out that assessments and screening of athletes is standard across the board. Screenings primarily look at testing joint range, muscle strength (power and endurance) and muscle extensibility. Comer- ford was clear that these are all relatively unsuccessful at predicting risk of re-injury or recurrence of pain. Like Cook, Comerford also identified that history of previous injury is the single most consistent and reliable predictor of high risk of re-injury. He identified that the isolationist testing of joint range of motion or normal muscle strength is not an adequate rehabilitation end point to prevent recurrence. Comerford suggested it is the assessment of the control of ‘real’ function that is the missing piece of the screening puzzle. He defines ‘real’ function as the influence of the multiple muscle interactions acting on multiple joints in functionally orientated tasks.

Comerford advocates the Perfomance Matrix screen, that he presented to the conference. I personally teach a version of this to the pilates community. At the centre of the screen is the assessment of the motion segment (or regional) ‘hyper-mobility’ referred to by Sahrmann earlier. This may be directional (i.e. flexion, extension, rotation etc) and, equally importantly, relates to the threshold at

which it occurs (low or high). Comerford terms this ‘uncontrolled movement.’ Sahrmann refers to the same concept as the ‘direction susceptible to movement’, and O’Sullivan as a ‘control impairment.’ Comerford suggests it is the threshold at which the failure occurs which dictates whether the specific exercises required to improve the uncontrolled movement should be slow motor unit domi- nant (low threshold) thereby showing a Central Nervous System (CNS) led ‘recruitment’ failure of the muscles that should be providing the control, or a fast motor unit dominant (high threshold) ‘weakness’ e meaning the hyper-mobile area needs muscular strength to provide the control. This is the key differentiation between the FMS and Performance Matrix approaches.

In the real world

Swart (2010), Physiotherapist for elite athletes in South Africa reports that ‘in the area of symptoms we mostly find uncontrolled movements with the low threshold tests which makes sense due to the fact that pain affects slow motor unit recruitment. With the Performance matrix or FMS we can determine risk factors for injury in other areas of the body before they occur preventing further time out due to injury. It is less time consuming to prevent injuries rather than treat the injuries, and athletes hate not being able to train. Once there is pathology it usually means the athlete has to rest for 6 weeks to allow for healing or at least I change their exercise program to allow them to perform unloaded training in water. Athletes usually start too quickly and try to progress too fast leading to recur- rences of injuries or injuries in other areas due to compensation.’

Barr (2010), an Injury Prevention Specialist for the New York Knicks Basketball Team, confirms the requirement for interdisciplinary co-operation. Barr does not regard re- active injury prevention programs as injury prevention e this, he says, ‘is just an extension of injury rehab.’ Like the Yellow Emperor before him Barr believes that, ‘optimal nutrition, hydration and sleep quality are all essential aspects of injury prevention. If these obvious basics are not taken care of fully, then any other injury prevention strategy employed will have a lesser effect.’

Barr suggests the athlete needs to:

� be specifically conditioned to perform in their specific sport,

� after previous bouts of exercise be fully recovered to perform,

� be in a ready state to perform physically (warmed up) and mentally (focused) and,

� have optimal neuromuscular control, stability, mobility and strength for the demands of their specific sport.

To ensure all these considerations are taken care of reliable screening and testing methods need to be frequently performed.

‘My area of expertise,’ says Barr, ‘and what I believe to be an essential part of the screening process, is the ‘‘analysis of the quality of movement.’’ In my experience screening for ‘‘movement control’’ and ‘‘producing injury

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prevention programs to improve the control of movement’’ have great success. Aside from traumatic injuries most other injuries can be related to ‘‘uncontrolled movement.’’ It is relating uncontrolled movement to the pathology that allows you to understand how uncontrolled movement is an injury risk and correcting uncontrolled movement is injury prevention.’

Crossover between pain and human performance

It is interesting to note that Cook and Comerford, system developers, and Swart and Barr, users of a system of assessing movement control, are physical (or physio) ther- apists who originally trained to treat pain and injury but have moved out from a narrow focus to look at human performance as well. They have the remit, via their professional training, to look at both patients (those in pain) and athletes (concentrating on those with perfor- mance deficits). Not all who read the JBMT will be able to move easily between these two camps. Some movement disciplines such as Pilates or Yoga are not widely regarded as ‘treatment’ and therefore their teachers should not work without the co-operation of a suitably qualified health professional or without clearance from a doctor who is knowledgeable (both about the patients condition and the discipline they are referring to). Yet many who present to Pilates or Yoga Teachers do so because they are in pain, perhaps they do not identify themselves as having pain for fear of being excluded from the session or perhaps they do not see that it is important for the teacher to know about their pain. It is often the wording of the practitioners insurance policy that defines who a Teacher can see, however, it is becoming very clear that movement dysfunctions are responsible for the internal environment that leads to pain. Pain is probably just a late sequelae of the same movement faults that Pilates and Yoga teachers see in every class that they teach. The Teachers have the tools to alter these movement faults by their interventions, cueing and handling, thereby ‘preventing’ the ‘pain’ that could have otherwise have been expected to follow.

It is the fact that exercise is often undertaken in group classes so that a teacher should ideally:

� keep the group size small, � know the clients extremely well, � have assistants, � play to the lowest common physical denominator, or ‘sub-group’ their classes to fit those with similar prob- lems together, to keep the individual in a group as ‘safe’ as possible.

Individual or ‘one to one’ sessions are a luxury that for many clients is imperative if they are to progress with the least risk of recurrence from being given an inappropriate exercise or trying too hard too soon or simply not working hard enough. In an individual session a teacher is able to discover the modifications that that client requires to zone a specific exercise into something that is maximally beneficial in that instance as opposed to performing

a ‘cheat’ in which the cheat becomes perpetuated. Criti- cism of the disciplines of Pilates and Yoga (Key, 2010a) to name but two disciplines is fair especially when poorly trained teachers, use exercise recipes and dogma instead of individual assessment, critical thought and exercise modification.

In my personal opinion the nascent scientific research looking at Pilates or Yoga often lets itself down by not defining within the research question what part of the discipline it is looking at. The disciplines have varied practices of the same activities yet a broad brush stroke description of what is undertaken is often deemed enough. Describing every detail, especially modifications of exercises encouraged and cueing used, may help the disciplines develop a scientific credibility that at present appears to be unfortunately lacking. Careful thought as to what exercises should be excluded from a particular study might be more beneficial than performing all the available repertoire. The history of chronic low back pain research over the last one or two decades, and recent thoughts on motor control and sub-grouping that are now developing, could be applied to help accelerate research in Pilates or Yoga.

Call to action

As this is the Prevention and Rehabilitation section of the Journal of Bodywork and Movement Therapies I would like to put a call out for papers with a focus on injury prevention or the prevention of injury recurrence. If we accept that motor control deficiencies eventually lead to pain and disability we want to know which movement strategies can be used as motor control tests, or whether those motor control tests currently in use are good predictors of injury risk.

Gracovetsky’s (2010) paper discussing ‘Range of Normality’ and injury prevention is an excellent example of the type of paper that improves our knowledge of injury prevention.

Feedback: core stability is a subset of motor control

Lederman’s (2010) Myth of core stability paper provoked a muted response in reply to my editorial (McNeill 2010), though it is currently, at the time of writing, the most downloaded article from the JBMT, via ScienceDirect. Comments made showed appreciation of a critical look at core stability, and reiterated that clinicians should be careful not to read too much into research that might not be there.

In relation to Core Strengthening, Marcus (2009) quoted ‘plus a change, plus c’est la mÁme chose’. (The more things change, the more they stay the same). He identified that in his time as a pain medicine MD that several exer- cise approaches have come and gone, ‘they become jargonized and thus useless. New is not necessarily better.’ Marcus et al. (2010) points out that he currently uses the Kraus exercise program in his chronic pain treatment protocol. This system (of what we might now regard as non-specific exercise) was developed in the

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1950s and reduced or eliminated back pain in 80% of those undertaking them.

It seems that despite science and fashion appearing perhaps to be opposite fields of endeavour they both appear influenced by seasons!

In this edition

In line with this editorials theme on prevention (and in this case ‘prevention of recurrence’), and with its prevalence in sports, Stephanie Panayi discusses the need for lumbar- pelvic assessment in chronic hamstring strain. Josephine Key, who has written before for the JBMT, elaborates further on Vladimir Janda’s ‘Pelvic crossed syndromes’ for this issue. Craig Liebenson’s popular self management: patient section wraps up this editions Prevention and Rehabilitation section.

As always, please feel free write to me in response to the Editorial, the papers, or the ongoing themes within the journal or affecting your own practice.

References

Barr, A., 2010. Personal correspondence. Chaitow, L., 2010. Personal correspondence. Comerford, M.J., 2004. Core stability: priorities in rehab of the

athlete. SportEx Medicine 22, 15e22. Comerford, M.J., 2009. Recurrence of injury and pain in sport e

what’s missing. Manual Therapy 14 (5), S1eS54. Cook, G., 2009. What is our baseline for movement? The clinical

need for movement screening and assessment. Manual Therapy 14 (5), S1eS54.

Fass, A., 1996. Exercises: which ones are worth trying, for which patients, and when? Spine 21 (24), 2874e2878.

Fletcher, G.F., 1988. Exercise in the Practice of Medicine, second revised ed. Futura Publishing, Mount Kisco, New York.

Ford, M., 2010. Personal correspondence. Gracovetsky, S., 2010. Range of normality versus range of motion:

a functional measure for the prevention and management of low back injury. Journal of Bodywork & Movement Therapies 14 (1), 40e49.

Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long term effects of specific stabilizing exercises for first episode low back pain. Spine 26 (11), 243e248.

HSE Booklet L26 Display screen equipment work: Health and Safety (Display Screen Equipment) Regulations 1992: guidance on regulations. ISBN: 0-7176-2582-6.

Key, J., 2010a. Back Pain: A Movement Problem. Churchill Living- stone Elsevier.

Key, J., 2010b. Personal correspondence. Lederman, E., 2010. The myth of core stability. Journal of Body-

work and Movement Therapies 14 (1), 84e98. Marcus, N., 2009. Personal correspondence. Marcus, N., Gracely, E., Keefe, K., 2010. A comprehensive protocol

to diagnose and treat pain of muscular origin may successfully and reliably decrease or eliminate pain in a chronic pain pop- ulation. Pain Medicine 11 (1), 25e34.

McNeill, W., 2010. Core stability is a subset of motor control. Journal of Bodywork and Movement Therapies 14 (1), 80e83.

Minick, K.I., Kiesel, K.B., Burton, L., Taylor, A., Plisky, P., Butler, R.J., 2010. Interrater reliability of the functional movement screen. Journal of Strength Conditioning Research 24 (2), 479e486.

O’Sullivan, P., 2005. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as an underlying mechanism. Manual Therapy 10, 242e255.

Riddle, D.L., 1998. Classification and low back pain: a review of the literature and critical analysis of selected systems. Physical Therapy 78 (7), 708e737.

Sahrmann, S., 2009a. Low back pain: isolated or degenerative problem e what are the implications? Manual Therapy 14 (5), S1eS54.

Swart, J., 2010. Personal correspondence.

Web sources

Science & Humour with Dr. Serge Gracovestsky e Part 1. http:// www.youtube.com/watch?vZqgh2C8M50Iw.

http://www.safetylit.org. http://www.hse.gov.uk/myth/nov09.pdf. Sahrmann, S., 2009b. http://www.webducate.net/icmd_blog/?

pZ53. www.functionalmovement.com. www.performance-stability.com.

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