- Email: [email protected]
Spinal Stabilisation: Mr C M Norris replies
Spinal Stabilisation -
MADAM We congratulate Mr Norris on what appears to be a comprehensive review of spinal stabilisation (Physbthempy, February). However, while we acknowledge our limited expertise on the subject, we do have some concerns about the definition of lumbar instability (page 62)and the SFdiOn of the propriocepthre role of lumbar tissues (page 70). In the article. the distinction between lumbar hypermobility and instability is defined as ‘complete muscular control‘. This is somewhat confusing since later distinctions are made between passive, neural and a w e lumbar stabilisation systems. The definition of lumbar stability implies only active stabilisation. Another confusing aspect is the separation of the neural and active stabilisation systems; surely these
actasonesyaem. Regardingthe section on proprioception (specifically the third paragraph), it consists of a series of incorrect statements and assumptions for which the author cites no evidence to support his claims. Each is dealt with in turn: ‘Pmprioception provides a link between the three stability systems.’ Them is no evidence for neural control of passive StNCtures as shown in the figure on page 62. In addiin, the
‘Muscle force produced by the active system is detected by receptors within the passive tissues and this information is rerayed to the neural system. ’ This is incorrect; muscle force is the active system and it is not necessarily detected by changes in passive structures. Receptors in passive constraints (ligaments) discharge on deformation. Deformation results from the force generated within the passive structure and is usually associated with length changes (Matthews, 1988). Length changes of passive structures can occur without muscle activation (passive stretch). Conversely, should the muscle force in one muscle be counteractedby the co-contraction of an antagonistic muscle, then no change in length of the passive structure will occur. Therefore, there will be no receptor stimulation and the muscle force, although high, remains undetected. Muscle spindles are more likely to detect changes in muscle force (Johansson, 1991). ‘Having measured the muscle tension.’ There is no evidence that receptors in passive structures measure muscle tension. ‘Stability in this case is a dynamic process.’ Stability is a state and not a prOCS.9. ‘In addition there is a functional reserve which may be called on to provide enhanced Stability in cases of high demand.’ A functional reserve of what and where is the evidence for this?
Without wishing to be disrespectful to this author in particular,we feel that incorrect or strong statements, for which there is no scientific evidence, do not have a place in scientific peer only mechanism by which the active reviewed.publications, especially in muscular sub-system can interact authoritative review articles such as with passive structures is through this. Ifthere is controversy within a a neural pathway. The link shown subject then the various arguments betweenpssshre and active elements should be outlined. If the statement is is therefore confusing and probably established fact, then supporting eviincorrect. Overall. the diagram dence should be given. The content appean to be a poor oversimplif- of such papers, when presented in ication of a highly complicated a series in this manner, is often adopted as definitive and used as w-m(s).
a reference for teaching purposes. In this way inaccuracies about physiotherapy practice proliferate and we leave ourselves open for justifiable criticism from our scientific colleagues.
D J Beard MSc MCSP Director, Physiotherapy Research Nutfield Department of Orthopaedic Surgery
H S Gilt BEng Control Systems Bioengineer Depament of EngineeringScience Universily of Oxford
References Johansson. H, Sjolander, P and Sojka. P (1991). ‘A sensory role for the cruciate ligaments’, Clinical Orthopaedics, 268. 160-180. Matthews, P B C (1988). ‘Proprioceptors and their contribution to somatosensory mapping: Complex messages require complex processing’, CanadianJournal of Physiology and Pharmacology, 66. 430-437.
Mr C M Noms replies: Definitions of slability. The contrast of instability with hypermobility quoted from Maitland (1986) was used to introducethe stabilisati topic simply because many physiotherapists are familiar with Maitland concepts from their undergraduate training. This definition was then expanded using the Panjabi (1992) model which provided a more in-depth explanation. In the context of this article series, therefore, the second definition was used to expand on the first.
Proprioception linking the stability systems. Gill and Beard suggest that the stabilisation diagram used is a ‘poor oversimplification of a highly complicatedsystem(s)’, and question the interaction between the subsystems. The diagram is quoted from Panjabi (1992) who described the sub-systems as conceptually separate, but functionally interdependent. Proprioception has been said to modulate muscle function and initiate reflex stabilisation (Lephart et a/, 1992) and it is a functional link which is referred to rather than a direct structural pathway. Detection/measurement of muscle form. The use of the word ‘passive’ in the context of the stabilisation model refers to the non-contractileportion of
~
muscles as well as to inert structures such as ligaments, cartilage and joints capsules all of which possess sensory endings relaying information about joint position and movement (Lephartand Fu. 1995). It is accepted that co-contraction will create muscle force without the production of movement, this mechanism being fundamental to the active lumbar stabilisation process (p 139).
Stare vs process. The word ‘process’ was used in preference to ‘state’ to indicate the difference between clinical (functional)stability and mechanical stability. Clinical stability has been described as a continuously variable phenomenon while mechanical stability does not vary, a system being either stable or unstable (Bergmark, 1969). Clinical stability is the type addressed by the article series as it is controlled by co-ordinated muscle action. Mechanical stability would imply the type of bony change treated by an orthopaedic surgeon. Functionalreserve. At times of high loading, the active support mechanisms of the spine are able to increase. For example intra-abdominal pressure (p 73) is greater when
~
pulling, pushing, and lifting’, €!gom&, r,485-474. Hukins, D W L, Aspden, R M and Hickey, D S (1990). ‘Thoracolumbar fascia can increase the efficiency of the erector spinae muscles’, Clinical Biomechanics, 5,3044.
Lephart, S M, Kocher, M S, Fu, F H, Borsa. P A and Hamer, C D (1992). ‘Proprioception following anterior cruciate ligament reconstruction’. Journal of Sport Rehabilitation, 1, 100-1 96.
Lephart, s M and fu, F n (1995). m e role of proprioceptionin the treatment of sports injuries’, Sports Exercise and Injury, 1,2. 96-102.
Maitland. G D (1986). VertebralManipulation, Butterworth, London. 5th edn. Panjabi, M M (1992). ‘The stabilising system of the spine. Part 1. Function, dysfunction, adaptation and enhancement’, Joumalof Spinat Dismhrs, 5.4,383-369.
Back Pain in the Community MADAM - I was concerned by Ann Wooldridge’s comment (Letters, April) that early referral for domiciliary treatment for back pain was only available in the private sector until the recent emergence of GP based therapists. Domiciliary visits are of course the domain of the community physiotherapist. Most community physiotherapy services have been in existence for many years and would include early advice and treatment for acute back pain as part of their normal working practice.
Nicola Ford Long Ditton, Surrey
lifting heavy weights or when lifting rapidly (Davis and Troup, 1964). Force produced via the hydraulic amplifier mechanism (p 75) is greater during muscle contraction than at rest, and has been shown to increase the stress generated by the erector spinae by as much as 30% (Hukins et a/, 1990). It is these increases to which the term ‘functional reserve’ refers.
Refemn? Bergmark, A (1989). ‘Stability of the lumbar spine’, Acta Orthopaedica Scandinevice Supplementum.230.60,3-54. Davis, P A and Troup. J D G (1964). ‘Pressures in the trunk cavities when
~~
Minimising Lymphoedema -
with swelling such as lymphoedema requires time and skill. Although lymphoedema cannot be cured, its effects can be minimised using a combination of physical therapies. The ultimate aim of all treatment is to hand over necessary self care skills to the patient. In mild, moderate and uncomplicated cases the teaching of these methods can be done in three or four sessions. Compression hosiery is usually a necessary component of treatment. For a smaller number of patients with compliited or severe symptoms including truncal oedema a course of more intensive therapy (complex decongestive therapy COT) is indicated. It is at this stage that manual lymph drainage is combinedwith other aspects of treatment such as multi-layered bandagingand exercises. Such treatment continues on a daily basis for around three weeks. Following a course of intensive therapy the patient is ready to move on to the independent self care stage, known as maintenance therapy. Although CDT is tirne-consuming and costly, it will ultimately enable patients to become independent and in control of their chronic condition. A busy physiotherapy department is often not the most appropriate place for CDT. There are a numberof specialist lymphoedema clinics around the country which are funded to provide this care. These clinics may be run by physiotherapists or nurses who have had specific training in this treatment. Isuggest that in the treatment of chronic oedema there is a significant gap in service provision. The British Lymphology Interest Group is presently striving to increase professionalknowledge and services for patients with this debilitating condition.
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MADAM Further to the recent dis- Jacquelyne E Todd MCSP cussion on manual lymph drainage Ilkley, Yorkshire (March, pages 154-156) Ishould like to respond to Joyce Williams’ letter Refer--’.ennces (April, page 247). Gillham, L (1994). ‘Lymphoedema and As Mrs Williams suggests, this physiotherapists:Control not cure’, Physaspect of care takes time and is ioftlefapy, 80.12.835-843, therefore costly. However, the use of Mortimer, P (1993). Strategy for Lympneumatic compressionpumps in the phbedems Care, BLIG Administrative Centre. Oxford. treatment of protein-rich chronic swelling is not the answer. The prolonged use of this machine is often MADAMJoyce Williams’ letter (April, ineffective and even detrimental page 247) confirms my findings as to (Mottimer, 1994; Gillham, 1995). the rarity of solid publications on the Like all chronic disorders, the benefits of manual lymph drainage. successful rehabilitation of people I have been told. and sometimes
MADAM We congratulate Mr Norris on what appears to be a comprehensive review of spinal stabilisation (Physbthempy, February). However, while we acknowledge our limited expertise on the subject, we do have some concerns about the definition of lumbar instability (page 62)and the SFdiOn of the propriocepthre role of lumbar tissues (page 70). In the article. the distinction between lumbar hypermobility and instability is defined as ‘complete muscular control‘. This is somewhat confusing since later distinctions are made between passive, neural and a w e lumbar stabilisation systems. The definition of lumbar stability implies only active stabilisation. Another confusing aspect is the separation of the neural and active stabilisation systems; surely these
actasonesyaem. Regardingthe section on proprioception (specifically the third paragraph), it consists of a series of incorrect statements and assumptions for which the author cites no evidence to support his claims. Each is dealt with in turn: ‘Pmprioception provides a link between the three stability systems.’ Them is no evidence for neural control of passive StNCtures as shown in the figure on page 62. In addiin, the
‘Muscle force produced by the active system is detected by receptors within the passive tissues and this information is rerayed to the neural system. ’ This is incorrect; muscle force is the active system and it is not necessarily detected by changes in passive structures. Receptors in passive constraints (ligaments) discharge on deformation. Deformation results from the force generated within the passive structure and is usually associated with length changes (Matthews, 1988). Length changes of passive structures can occur without muscle activation (passive stretch). Conversely, should the muscle force in one muscle be counteractedby the co-contraction of an antagonistic muscle, then no change in length of the passive structure will occur. Therefore, there will be no receptor stimulation and the muscle force, although high, remains undetected. Muscle spindles are more likely to detect changes in muscle force (Johansson, 1991). ‘Having measured the muscle tension.’ There is no evidence that receptors in passive structures measure muscle tension. ‘Stability in this case is a dynamic process.’ Stability is a state and not a prOCS.9. ‘In addition there is a functional reserve which may be called on to provide enhanced Stability in cases of high demand.’ A functional reserve of what and where is the evidence for this?
Without wishing to be disrespectful to this author in particular,we feel that incorrect or strong statements, for which there is no scientific evidence, do not have a place in scientific peer only mechanism by which the active reviewed.publications, especially in muscular sub-system can interact authoritative review articles such as with passive structures is through this. Ifthere is controversy within a a neural pathway. The link shown subject then the various arguments betweenpssshre and active elements should be outlined. If the statement is is therefore confusing and probably established fact, then supporting eviincorrect. Overall. the diagram dence should be given. The content appean to be a poor oversimplif- of such papers, when presented in ication of a highly complicated a series in this manner, is often adopted as definitive and used as w-m(s).
a reference for teaching purposes. In this way inaccuracies about physiotherapy practice proliferate and we leave ourselves open for justifiable criticism from our scientific colleagues.
D J Beard MSc MCSP Director, Physiotherapy Research Nutfield Department of Orthopaedic Surgery
H S Gilt BEng Control Systems Bioengineer Depament of EngineeringScience Universily of Oxford
References Johansson. H, Sjolander, P and Sojka. P (1991). ‘A sensory role for the cruciate ligaments’, Clinical Orthopaedics, 268. 160-180. Matthews, P B C (1988). ‘Proprioceptors and their contribution to somatosensory mapping: Complex messages require complex processing’, CanadianJournal of Physiology and Pharmacology, 66. 430-437.
Mr C M Noms replies: Definitions of slability. The contrast of instability with hypermobility quoted from Maitland (1986) was used to introducethe stabilisati topic simply because many physiotherapists are familiar with Maitland concepts from their undergraduate training. This definition was then expanded using the Panjabi (1992) model which provided a more in-depth explanation. In the context of this article series, therefore, the second definition was used to expand on the first.
Proprioception linking the stability systems. Gill and Beard suggest that the stabilisation diagram used is a ‘poor oversimplification of a highly complicatedsystem(s)’, and question the interaction between the subsystems. The diagram is quoted from Panjabi (1992) who described the sub-systems as conceptually separate, but functionally interdependent. Proprioception has been said to modulate muscle function and initiate reflex stabilisation (Lephart et a/, 1992) and it is a functional link which is referred to rather than a direct structural pathway. Detection/measurement of muscle form. The use of the word ‘passive’ in the context of the stabilisation model refers to the non-contractileportion of
~
muscles as well as to inert structures such as ligaments, cartilage and joints capsules all of which possess sensory endings relaying information about joint position and movement (Lephartand Fu. 1995). It is accepted that co-contraction will create muscle force without the production of movement, this mechanism being fundamental to the active lumbar stabilisation process (p 139).
Stare vs process. The word ‘process’ was used in preference to ‘state’ to indicate the difference between clinical (functional)stability and mechanical stability. Clinical stability has been described as a continuously variable phenomenon while mechanical stability does not vary, a system being either stable or unstable (Bergmark, 1969). Clinical stability is the type addressed by the article series as it is controlled by co-ordinated muscle action. Mechanical stability would imply the type of bony change treated by an orthopaedic surgeon. Functionalreserve. At times of high loading, the active support mechanisms of the spine are able to increase. For example intra-abdominal pressure (p 73) is greater when
~
pulling, pushing, and lifting’, €!gom&, r,485-474. Hukins, D W L, Aspden, R M and Hickey, D S (1990). ‘Thoracolumbar fascia can increase the efficiency of the erector spinae muscles’, Clinical Biomechanics, 5,3044.
Lephart, S M, Kocher, M S, Fu, F H, Borsa. P A and Hamer, C D (1992). ‘Proprioception following anterior cruciate ligament reconstruction’. Journal of Sport Rehabilitation, 1, 100-1 96.
Lephart, s M and fu, F n (1995). m e role of proprioceptionin the treatment of sports injuries’, Sports Exercise and Injury, 1,2. 96-102.
Maitland. G D (1986). VertebralManipulation, Butterworth, London. 5th edn. Panjabi, M M (1992). ‘The stabilising system of the spine. Part 1. Function, dysfunction, adaptation and enhancement’, Joumalof Spinat Dismhrs, 5.4,383-369.
Back Pain in the Community MADAM - I was concerned by Ann Wooldridge’s comment (Letters, April) that early referral for domiciliary treatment for back pain was only available in the private sector until the recent emergence of GP based therapists. Domiciliary visits are of course the domain of the community physiotherapist. Most community physiotherapy services have been in existence for many years and would include early advice and treatment for acute back pain as part of their normal working practice.
Nicola Ford Long Ditton, Surrey
lifting heavy weights or when lifting rapidly (Davis and Troup, 1964). Force produced via the hydraulic amplifier mechanism (p 75) is greater during muscle contraction than at rest, and has been shown to increase the stress generated by the erector spinae by as much as 30% (Hukins et a/, 1990). It is these increases to which the term ‘functional reserve’ refers.
Refemn? Bergmark, A (1989). ‘Stability of the lumbar spine’, Acta Orthopaedica Scandinevice Supplementum.230.60,3-54. Davis, P A and Troup. J D G (1964). ‘Pressures in the trunk cavities when
~~
Minimising Lymphoedema -
with swelling such as lymphoedema requires time and skill. Although lymphoedema cannot be cured, its effects can be minimised using a combination of physical therapies. The ultimate aim of all treatment is to hand over necessary self care skills to the patient. In mild, moderate and uncomplicated cases the teaching of these methods can be done in three or four sessions. Compression hosiery is usually a necessary component of treatment. For a smaller number of patients with compliited or severe symptoms including truncal oedema a course of more intensive therapy (complex decongestive therapy COT) is indicated. It is at this stage that manual lymph drainage is combinedwith other aspects of treatment such as multi-layered bandagingand exercises. Such treatment continues on a daily basis for around three weeks. Following a course of intensive therapy the patient is ready to move on to the independent self care stage, known as maintenance therapy. Although CDT is tirne-consuming and costly, it will ultimately enable patients to become independent and in control of their chronic condition. A busy physiotherapy department is often not the most appropriate place for CDT. There are a numberof specialist lymphoedema clinics around the country which are funded to provide this care. These clinics may be run by physiotherapists or nurses who have had specific training in this treatment. Isuggest that in the treatment of chronic oedema there is a significant gap in service provision. The British Lymphology Interest Group is presently striving to increase professionalknowledge and services for patients with this debilitating condition.
-
-
-
MADAM Further to the recent dis- Jacquelyne E Todd MCSP cussion on manual lymph drainage Ilkley, Yorkshire (March, pages 154-156) Ishould like to respond to Joyce Williams’ letter Refer--’.ennces (April, page 247). Gillham, L (1994). ‘Lymphoedema and As Mrs Williams suggests, this physiotherapists:Control not cure’, Physaspect of care takes time and is ioftlefapy, 80.12.835-843, therefore costly. However, the use of Mortimer, P (1993). Strategy for Lympneumatic compressionpumps in the phbedems Care, BLIG Administrative Centre. Oxford. treatment of protein-rich chronic swelling is not the answer. The prolonged use of this machine is often MADAMJoyce Williams’ letter (April, ineffective and even detrimental page 247) confirms my findings as to (Mottimer, 1994; Gillham, 1995). the rarity of solid publications on the Like all chronic disorders, the benefits of manual lymph drainage. successful rehabilitation of people I have been told. and sometimes