We attended the Fourth Interdisciplinary Congress on Low Back and Pelvic Pain in Montreal (Nov. 8-10, 2001). It was quite an experience. There were approximately 700 attendees at the Palais des Arts, but very few chiropractors, which was disturbing, as low back and pelvic pain are areas that chiropractors routinely treat quite successfully. Osteopaths; physical therapists; medical physicians; orthopedists; physiatrists; neurologists; and other manual therapy and movement therapy specialists from around the world were on hand. The largest contingent was the physical therapists.
It was exciting to listen to a lot of the presenters whose papers and books we have read. The audience and the presenters came with open minds, and there was minimal dogma. We will briefly review some of the highlighted speakers.
Two of the first three presenters were Drs. Carl DeRosa and James Porterfield, authors of Mechanical Neck Pain and Mechanical Low Back Pain: Perspectives in Functional Anatomy. Dr. DeRosa gave an overview of some of the anatomy and muscular attachments to the thoracolumbar fascial system. This was given from a functional perspective and somewhat set the tone for the weekend.
Dr. Porterfield discussed the asymmetrical overload syndrome and the ramifications of pelvic unleveling, both in regard to unilateral low back pain/sacroiliac pain, and pain in the hip and knee caused by this asymmetrical loading pattern. In summary, with these asymmetrical overload syndromes one can decrease the pain by centralizing the weightbearing and then doing the retraining from that centralized, weightbearing posture, with emphasis on training the transitional areas.
Canadian Diane Lee,PT, presented a lecture we particularly enjoyed. She has written several articles and books and has worked closely with Dr. Andre Vleeming over the years. She has been performing manipulation for quite some time. Ms. Lee showed a video evaluating and then treated a patient. Her manipulation skills were excellent. Chiropractors feel that we own manipulation, but the rest of the world does not see it that way. The ability to deliver manual therapy as Diane Lee did was impressive. We are not going to continue to own manipulation via political means, but rather by delivering outstanding adjustments. The other healing arts specialties are aware of the benefits of manipulation and are rapidly learning how to do it. Ms. Lee talked about an integrative model of joint function that she has worked on over the years with Dr. Vleeming, including the components of form closure; force closure; motor control; and emotional awareness as the four components of a properly functioning sacroiliac joint. The key point of her discussion included the idea that you could have joint dysfunction, joint locking, or joint fixation, while at the same time have functional instability. As chiropractors, we need to address all components so we can help a much broader range of patients.
John Triano,DC,PhD, of the Texas Back Institute, gave an articulate speech on the history of manipulation. As chiropractors, we already knew a lot of this history, so we would have liked him to speak a bit more about the specific benefits of manipulation. Dr. Triano, however, had limited time, and his speech was geared for the audience at large. There was great interest in his presentation. As a friend of mine often says about adjustments and nonchiropractors, "We got what they want."
The well known and respected Stuart McGill,PhD, spoke on blending engineering and clinical approaches to achieve spinal stability. He is a researcher and instructor at the University of Waterloo in Ontario, Canada. He explained some of the research going on in his laboratory and dispelled some of the thoughts many of us have about stabilization and stabilization exercises. He was quite an interesting speaker, and at one point made a comment in a joking manner that, "I don't have many opinions, do I?" One of his big points was that spinal stability does not occur via one muscle, the transverse abdominis, as some doctors believe. Rather, it is a combination of the transverse abdominis; internal obliques; external obliques; rectus abdominis, multifidus; and more muscles. He showed some exercises that were particularly effective to help achieve spine stability.
Shaun Lapenskie,PT,PhD, substituted for Peter O'Sullivan,PhD, and discussed the normalization of aberrant motor patterns for subjects with sacroiliac joint pain following a motor learning intervention. The patients with sacroiliac joint pain who had an abnormal active SLR test were improved after undergoing training exercises to strengthen the stabilizing muscles of the abdomen and low back (multifidus) and pelvic floor. Later, he presented another paper showing the difference in muscle activity with normal erect standing, or erect sitting, versus sway standing or slumped sitting. The internal obliques, lumbar multifidus, and thoracic erector spinae muscles showed a significant decrease in activity in sway standing and with slumped sitting compared to normal postures. The purpose of this was to show a link between the activity of the postural stabilizing muscles and the maintenance of a normal upright posture. Panjabi has discussed the stabilizing triad including the neural control, passive and active systems. This paper would suggest that the passive system (osteoligamentous structures) and the active system (muscular structures) are interrelated.
Vert Mooney was one of the organizers of this conference, and also spoke on Saturday. As the director of U.S. Spine and Sport Centers in California, he is a retired spine surgeon who starting these rehabilitation centers. Dr. Mooney is renown in the spine world. His talk asked whether measurement could guide a therapeutic exercise program. He runs approximately eight high-tech physical therapy centers in California, and uses various Cybex equipment and posture analysis systems. One of his points was that there needs to be standardization in the physical therapy treatment protocols for consistency of care and reimbursement from insurance providers.
Another highlight of the conference was Serge Gracovetsky,PhD, noted for mathematically proving the spine's ability to drive the body in gait, as expounded in The Spinal Engine. He blended some of the recent advances in the understanding of the lower extremities interrelation to pelvic function with his model, and also made several cameos at the podium to keep tabs on the presentations of the clinicians. When speaking informally with Dr. Gracovetsky, he informed us that he was at the conference as a favor to Dr. Andre Vleeming, editor of The Essential Role of the Pelvis.
Dr. Michael Adams, a clinical anatomist from the University of Bristol, gave a review of the recent advances in basic science applied to lower back pain. His well-rounded lecture focused on integrating the research into a functional understanding of what happens to tissue after an injury. He also mapped out some new advances in how diet, genetics and psychological well-being affect injury prevalence and healing time.
Australian researchers Professor Caroline Richardson and her former pupil, Paul Hodges,PhD, furthered their exceptional work on the inner unit motor recruitment and its role in low back and pelvis pain. Unfortunately, Julie Hides,PhD, was unable to make the conference, so Professor Richardson presented for her, emphasizing the importance of regaining control of transverses abdominus and multifidus recruitment early in the treatment of acute and chronic lower back pain. She maintained that one should be able to retrain the patient and see significant results in less than three weeks if approaching the dysfunction correctly. Dr. Hodges lectured predominantly on the feed-forward mechanism in the shutdown process of the transverses abdominus, multifidus and pelvic floor after an injury. He sought to disprove the original theory that pain was the reason the muscles failed to recruit properly, among other theories, and showed that there was a motor programming failure, regardless of symptoms.
Hodges further urged clinicians to understand that a motor programming failure must be addressed for the patient to fully recover. This further solidified Julie Hides' work (Hides 1996, Hides, et al., 1996), which had been instrumental in disproving the natural history theory (which basically says that you can smack the patient on the posterior with a shovel and the patient will get better in a couple of weeks, regardless of the treatment received).
From a joint perspective, Jan-Paul van Wingerden,PT, and Andre Vleeming,PhD, have developed a transducer system to measure stiffness in the sacroiliac joints. The particular study they did was to quantify the amount of compression needed to increase the stiffness and stability of the SI joint, and to discover which muscles were suited to do so. However, the implications of such a measurement are that they would also be able to determine if a joint was fixated and needed to be therapeutically manipulated or mobilized through this measurement. This may have profound implications on validating or discrediting chiropractic evaluations for accuracy. Diane Lee cautioned that this measurement should be a tool and not replace any type of manual assessment.
Conference coordinator Dr. Vleeming has taken a new direction in his work. He is most well known for his anatomical and biomechanical brilliance in mapping the foundations for SI joint stability and function. He stressed the idea of emotions and their impact on the locomotor system, especially spinal stability. This modifies the model originally developed by Bergmark (1989) and Panjabi (1992). He explained that patients may hold on to injuries, and if there is a significant enough limbic system dysfunction, a mechanical approach will not be enough.
Overall, there was an overwhelming amount of information presented. A great deal of it applies to everyday management of chiropractic patients. It was discouraging that so few of the attendees were chiropractors. (Editor's note): The proceedings of the 4th International World Congress on Low Back and Pelvic Pain are available by calling toll free at 888-229-6263. The cost is $65.
The fifth world congress will be held in Melbourne, Australia in 2004. We hope to see you there.
References
Joel Johnston,DC
Mark King,DC
Cincinnati, Ohio
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