There is no doubt that one of the greatest challenges for the clinician working in the field of musculoskeletal medicine is explaining to a patient the concept of chronic or persistent pain. I daily review investigations and findings which do not adequately explain many patients pain symptoms, only to be asked “if nothing’s broken, why do I have pain?” Even more difficult is the patient that is fixated on surgery as the answer for a painful condition where there is no evidence (beyond the presence of pain)for surgical intervention.
It is now well established that treatment approaches utilising a bio-psycho-social approach are far more successful, and do require an active education component on the nature of pain.
The Hunter Integrated Pain Service has produced a wonderful video resource explaining the nature of pain – well worth the time for the clinician and patient reviewing and planning management going forward. Equally useful is the ACI Pain Management Network education video.
For those who love written resources to assist patients and younger professionals, “Explain Pain” by NOI is in its 10th anniversary remains one of my all time favourites.
The Clem Jones Centre Physiotherapy & Rehabilitation Clinic is up and running. Click on the link to check out the staff, services and facilities.
During the last decade, training the “core” for treatment of back pain, prevention of injury and performance enhancement has been promoted endlessly within fitness and the media. However have we been sold a false promise by incorrect interpretation and application of the research?
The term “core” has many meanings depending on the literature one reads. As such there are a wide variety of “core exercises” that have been proposed for treating and preventing low back pain, and indeed improving performance. But how robust is the evidence for these approaches promoting “isolated core activation” and stability over general principles of exercise prescription. In other words- what we have seen is the emergence of a system where exercise is prescribed “for muscle, not movement”.
An excellent review/ commentary article in Arch Phys Med Rehabil Vol 88, December 2007 by C Standaert and S Herring “Expert Opinion and Controversies in Musculoskeletal and Sports Medicine: Core Stabilization as a Treatment for Low Back Pain”provides some very interesting insights into some of the many presumptions around core or segmental stabilization exercise programs. This article identifies that exercise programs , varyingly referred to as lumbar stabilization, segmental stabilization, or core stabilization, among other terms, and are aimed at improving the neuromuscular control, strength, and endurance of a number of muscles in the trunk and pelvic floor that are believed to play important roles in the dynamic stability of the spine. Despite the tremendous degree “acceptance” and universal unquestioning of theory of these treatment concepts into the therapeutic arena, the medical literature, and the lay press there are few prospective studies on patients with LBP, and there is even more limited discussion of the concepts of patient selection, dose-response, and long-term outcome associated with these approaches. There also is a significant lack of uniformity regarding the meaning of “core stabilization” and what therapeutic exercises may be most effective.
Further this commentary identifies that research with moderate evidence that stabilization exercises are effective in improving pain and function in patients with low back pain but strong evidence that stabilization exercises are no more effective than a general exercise program administered within an activating treatment approach.
Indeed, it appears from a close examination of the research that we need to step back and take a broader look at the research and use of core stabilization exercises. Perhaps more appropriate and functional is the utilization of a kinetic chain approach, with this model leading into rehabilitation and training programs involving functional, multisegmental exercises progressing through physiologic loads and joint speeds. In this way prescribers of exercise can truly “train movement- not muscle”.