• Dr. Piotr Solowiej PT, DPT

Low Back Pain: Discussion Points from MDT Course


Mechanical Diagnosis and Therapy is often associated with treating low back pain, as that is how it started. It has since evolved to be applied in all joints of the body. I like that it's a minimalist system. Incredibly refreshing in comparison to all the interventionista courses out there.


The system is geared towards keeping the locus of control in the patient's hands for as long as possible. Stepping in briefly, if required as the clinician, and then going hands off again as soon as possible. This is huge on so many levels and significantly decreases the chance of iatrogenic effects. (See this, this, and this article for evidence on the effect of extraneous factors in experience of low back pain.)


I enjoyed the class so much I even signed up for another (Part C - Advanced Lumbar Spine and Lower Extremity) in a few months, to further my understanding of the system.


While overwhelmingly a positive experience last weekend, I did want to bring up some informal moments of discussion that had me going....


Points of Discussion

Fear of Flexion

The class discussed a particular phenomenon: nocturnal imbibement. To summarize, that term is used to describe a process in which, overnight, the intervertebral discs of the spine fill with more fluid due to decreased compression forces. The resulting change in height results in increased stiffness of the spine in the morning. During the course, this phenomenon was cited as the logic behind advising patients, and people in general, to avoid spine flexion in the mornings.


If you're experiencing acute low back pain and there is clear evidence and directional preference for [temporarily] limiting flexion, then by all means limit flexion. Sound advice. Again, temporarily. As general advice though, this whole fear about flexing in the morning just doesn't make sense. If something is stiff, move it, albeit gradually. Going for a PR deadlift the moment you get out of bed is not the smartest idea. Work your way up to it, but don't avoid it outright. Why give any special treatment to the spine versus other joint in the body? Doing so only reinforces fear based behaviors and beliefs.


If someone hurts their back by bending over to brush their teeth, or putting on their socks in the morning, to me that says a lot more about the loading capacity of that particular spine than it does about spine flexion in general. This smells a bit like a post hoc fallacy in that flexion isn't dangerous for spines, but weak spines can hurt due to increased forces experienced with flexion.

Load

Speaking of deadlifts, a few sentences back, they were proverbially s#!t on during the course. Essentially we were advised to never prescribe or perform the exercise. Never. Ever.


Really?

Obi-Wan is right. Something must be said for prophylaxis of lumbar spine pathology. Spines that hurt after seemingly innocuous bending or twisting highlight the low capacity for loading in those particular directions. It is not a call for absolute restriction of those motions, but (once irritability settles) for reinforcement.


When the problem has been reduced and recovery of function begins, what better way to build strength and loading capacity in the trunk and spine? Does it HAVE to be a deadlift? Of course not, especially if you don't have experience performing or coaching the movement. Probably not a great idea. But it's a damn good tool if used in a graded, progressive manner. Whatever is done HAS to be significant enough of a stimulus to foster strength adaptation. Pelvic tilts won't cut it.


So never use a deadlift? I don't think so.

Perfect Posture

Also discussed the importance of advocating for sitting with 'perfect posture.' Will this idea die already? Posture may be a relevant factor during acute cases due to motion sensitivities but it is a poor correlate to pain and dysfunction in the longterm. This is well documented and I already did a post on this previously.

Sustaining any posture for long enough will get uncomfortable. Your best posture is your next posture. Stay moving.

Those are my thoughts. Would love for some other PT's to jump on and share theirs. I'm totally open for a discussion.

Let me know what you think,

Piotr

Address: 1942 Raymond Dr, Northbrook, IL

Phone: 630-447-9746

Fax: 630-385-0124

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