Initiating core muscles - how to put into lay terms?

[mckenzie]

I'm fairly new to the world of neuro rehab and it's been a long time since I've had to explain core stability to a patient or to get them to initiate their core muscles. I remember talking about 'activating trans abs' etc but no one seems to explain it like that these days. What I'm really looking for is some good analogies to help me put it into lay terms for my patients.

Which ones do you use?

Thanks in advance
Jen

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[gcoe]

Hi Jen

I know this isn't answering your question, and I am not having a go at you personally. However this issue seems to arise quite a bit and it concerns me:

of applying some preliminary evidence about core stability muscles from one area of physiotherapy and making some giant blindfolded leap into applying core stability training to the neurological patient.

The "core stability" literature centres around muscles such as Transverse abdominus and multifidus in low back pain and lumbar instability. There has also been some work into an analogue for neck pain and neck-related headache (deep neck flexors), and some consider the VMO a similar issue in the patello femoral joint problem. However to my knowledge there is not one study that looks at the core stability of muscles in relation to neurological disease or disability.

However I have seen this core stability approach being blindly applied to patients with balance disorders and cerebellar ataxia - without a shred of evidence that this is the underlying motor control problem these patients have or that they are helped by core stability training. This is really bad science. And it trivialises what we do understand about the balance and mobility.

If you or another reader knows of even one clinical trial that provides evidence for this approach with a neurological patient group I would love to be informed.

[mckenzie]

You're right Gcoe, it didn't answer my question. But thanks for your input.

There are a LOT of approaches used in physio that are not well evidence based but this does not mean they have no role in our treatment. For example acupuncture which is now part of the NICE guidelines for low back pain. There is far too much useless research out there. If any physio claims they only use treatment that has masses of evidence to support it they are lying, it's about using our tool box of skills and treatment techniques and applying them appropriately to each individual patient using our clinical reasoning skills and the patient's own goals.

If anyone can actually answer the question I would be grateful to hear from you. Not interested in a debate about the use of core stability.
Many thanks, J

[gcoe]

Not interested in a debate about the use of core stability

Maybe not but you still seem to enter into a debate for it in your previous para.

There are a LOT of approaches used in physio that are not well evidence based but this does not mean they have no role in our treatment.

This argument justifying the avoidance of EBP approaches has been given for a long time. Sure there are huge gaps in what we know works but that doesn't mean we don't start with working with what is there. There are now getting onto 2.000 trials in neurological physiotherapy. Do you really think it is appropriate attitude in 2010? I don't think it is.

For example acupuncture which is now part of the NICE guidelines for low back pain.

The NICE Guideline Early management of persistent non-specific low back pain includes acupuncture as part of a package. This is based on sound if not conclusive evidence that acupuncture as part of an approach is effective in persistent LBP, but not acute LBP. This is well reviewed in a Cochrane reivew: Furlan AD, van Tulder MW, CherkinD, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1.

There is far too much useless research out there.

That may be but there is also some high quality evidence out there and a much larger amount of research that is of ADEQUATE quality that can be applied to give us some certainty about what may work best. Furthermore the quality of evidence has increased considerably in the last few years. Isn't it your job to locate that which is useful rather than going for a treatment that may have no plausibility and now evidence for your patient group you are dealing with?

If any physio claims they only use treatment that has masses of evidence to support it they are lying, it's about using our tool box of skills and treatment techniques and applying them appropriately to each individual patient using our clinical reasoning skills and the patient's own goals.

This isn't an all-or-nothing thing. If there is a tool in your tool box where there is not only an absence of evidence but also evidence of absence would you still use it? I wouldn't. If there is an absence of evidence but there isn't much in the way of evidence for an alternative treatment then I would fall back on what is available. Studies of plausibility would be a good start. Evidence-based practice is not about ignoring clinical expertise or patient preferences. EBP does not preclude clinical reasoning. However it is about making the best use of what is available. And one of the unpleasantries about clinical practice is that we tend to fool ourselves into thinking we are more effective than we really are. That is one of the key reasons we are supposed to be behaving as an applied science. So we don't keep repeating the mistakes of earlier generations. And don’t start developing unfounded new treatments based on some latest fad or some unrelated area of practice.

[mckenzie]

Sorry Gcoe, but there was really no need for all that. I haven't even read your full response as it has nothing to do with my original question. At no point did I indicate a want for a debate, I just wanted some ideas from fellow physios re core stability and the best way to teach it. I gave no indication of my patients problems, goals, or treatment preference but you were too quick to get over excited about whether core stability exercise is evidence based which is irrelevant to my original question. If I was interested in people's view of the use of it that is what I would have asked. J

[roopoo82]

In reply to your original post Jen, I use the fairly crude analogy of stopping yourself peeing mid-flow (and I know its a little controversial, but in my experience guys have more success with this analogy than ladies). Can also use the stopping yourself peeing whilst holding in a fart if you're really struggling!! Everyone seems to get it!!
However, I work in outpatient setting, and you may (depending on patient, neural damage to bladder/bowel, control etc) find this an unproductive exercise. But you can judge for yourself.

Hope it helps and that you get some more ideas from somewhere if not!

R.

[Fyzzio]

I just wanted some ideas from fellow physios re core stability and the best way to teach it.

Didn't you start off with comment that you were fairly new to the world of neuro rehab???
Well then, please allow those of us who are "ancients" in that world to ask questions as to why you would even want to teach core stability - we might be too old to understand.
Only if we understand what the purpose of your exercise is, we might be able to give you some analogies for neurological patients. You might not believe it, but you won't get far using musculoskeletal approaches in neuro rehab.
Anyway - probably also a typical neuro question - why do you even try to explain with words? Why don't you go and use your hands and get the patient to feel???

@ roopoo82: don't you mix up core stability with pelvic floor contractions???? Sorry, but I was taught your 'examples' at my post-partum pelvic floor exercise class. The core stability, which I only know from Pilates is certainly very different....

Regards,
Fyzzio