Today I'm heading to NYC to teach the Lumbar II module of our certification series. As always, I review content and today I was drawn to the review of the treatment based classification (TBC) system as summarized by Dr. Julie Fritz in the latest edition of Grieve’s Modern Musculoskeletal Physiotherapy. It is well established that treating patients through a classification system is superior (Riddel 1998/Cook 2006). In particular, I was drawn to the topic of clinical instability. There are many pitfalls in addressing “spinal/clinical” instability—the name itself is polarizing and draws therapists into different camps/belief systems and, at times, dogma.
There are several difficulties in mentioning spinal stability: first, the patient does not feel that they can control their stability, and second, they think that they require surgical stabilization. Spinal fusions have created a more complex and frustrating group of patients—the “failed back syndrome.” This week, we present an assessment of patients with less dramatic, yet consistent presentations.
Anatomy Doesn’t Lie
The anatomy of clinical instability has been studied extensively. A must reference in any anatomical textbook library is Clinical and Radiological Anatomy of the Lumbar Spine / Edition 5 (Bogduk), his anatomical study of the region is unparalleled. But for a look
back a little further I would like to visit a 1978 article by Heylings (Journal of Anatomy). First, in dissecting the supraspinous ligament, he noted that it is not present caudal to L4 in EVERY specimen. He states that the supraspinatus is inextensible that the mobility required for this region (the lower lumbar) would be too limited (there is more flexion available in the upper than lower lumbar spine).
He concludes that the medial fibers of the erector spinae tendons in the lower lumbar region replace the supraspinous tendon, stating “These tendon fibers arise from the tips of the lower lumbar and sacral spinous processes and travel posteriorly and cranially to cross midline...they are interwoven with fibers from the dorsal part of the interspinous ligament and deep fibers of the lumbodorsal fascial. This complex of tendon, ligament and fascial replacing the supraspinous ligament in the lower lumbar spine provides a more adjustable controlling mechanism” (emphasis added). Have I mentioned that I love anatomy?! For years we have been looking at the neuromuscular control of this area. Yet, even back in 1978 it was recognized that this region had an “adjustable controlling mechanism” to handle varied motions and stresses placed on the lumbar spine.
The Body Heals in a Predictable Manner
Returning to the work of Dr. Fritz, in her review of TBC (ibid) she briefly discusses the Manipulation category and the clinical prediction rule (CPR) in the 2004 research presented by Fritz, Childs and Flynn. The temporal component is a key factor and has stood the rigors of subsequent research. That is, the ideal window to treat patients in under two weeks! Dr. Fritz states that in patients “between the ages of 18-60 years with no contraindications and an acute onset or exacerbation” and an absence of pain below the knee, spinal manipulation “may be most specifically beneficial.” This is our window and we should be marketing that consistently. Not just for spinal manipulation, but for early PT in general.
— GetPT1st (@GetPT1st) August 23, 2017
The longer back a condition develops, the more complex it becomes. Research is demonstrating time creates complexity. Typically we see patients months or years after their first pain incident. By that time, we have to alter a patient's belief system because of the acquired fear from the multiple failed interventions. As PTs let's make sure we are not causing iatrogenic chronic low back pain, but empowering our patients.
Pain is in the Brain
Every day I instruct patients about the inherent strength of their spine. Also, I teach standard changes related to aging (disc bulges and spurring) are normal and not pathological. It's especially important for physical therapists to have an answer for patients who think that their spine is “unstable.” For some insight and a practical application, watch the prone instability test video below.
The key to addressing “spinal instability” is having a set of tests to perform and a set of reasonable answers for patients’ questions about stability. One of my favorite is explaining to a patient that the “core” does not need to be strong, but it does have to have excellent timing. I use the example of retraining blinking (if that need ever arose) and how much effort it would take to retrain this routine, unconscious function. Core training cannot exist in 3 sets of 10, but is essential to an effective and functionally based program layered onto regular habitual activity.
We are Prone to Clinical Reasoning Errors During a Busy Clinic Day
I have extended the reasoning error to an error pointed out by Dr. Stanley Paris andother anatomists in the 1970s and mentioned in Heylings’ article above. It appears that the orientation of the interspinous ligament was drawn in error multiple times, even in Gray’s Anatomy! The direction of the fibers travel in a posterior cranial direction (confirmed in the work by Heylings), and it is hypothesized that the error occurred
simply from drawing the image upside down, and future authors perpetuated the error.
This further illustrates the point that you need to be vigilant with all aspects of physical therapy, including well respected sources.
Treat the Person and You Win Every Time
I like this quote by Dr. Groopman as it illustrates well how we can alter a patients’ treatment experience.
Video of the Week
Again, take a look at Heylings' Supraspinous and Infraspionous ligaments of the human lumbar spine. Not only a good read, but to understand the history and appreciate the detail of our predecessors.
Want to discuss more manual therapy topics and take your clinical capabilities to the next level? Join us at an upcoming NAIOMT course:
- Dallas, TX - August 24-25, 2019 - Advanced Lower Quadrant Integration
- New York, NY - August 25-26, 2019 - Lumbopelvic Spine II
- Berrien Springs, MI - September 8-9, 2019 -Lumbopelvic Spine I
- San Diego, CA - September 13-14, 2019 - Lumbopelvic Spine II
- San Diego, CA - September 15-16, 2019 - Lower Extremity
- New York, NY - September 21-22, 2019 - Lumbopelvic Spine II
- Berrien Springs, MI - September 21-22, 2019 - Lumbopelvic Spine II
- Denver, CO - September 22-23, 2019 - Lumbopelvic Spine I
- Boston, MA - September 28-29, 2019 - Lumbopelvic Spine I
- New York, NY - October 5-6, 2019 - Lumbopelvic Spine I
- Portland, OR - October 12-13, 2019 - Lumbopelvic Spine I
- Kansas City, MO - October 12-13, 2019 - Lumbopelvic Spine I
- Seattle, WA - October 19-20, 2019 - Lumbopelvic Spine II
- Orlando, FL - October 20-21, 2019 - Lumbopelvic Spine I
Enjoy your week!