Mel Siff on The Spinal Stability Paradox
For several years I used to run on many user groups a forum that I called
“Puzzles and Paradoxes” in Exercise Science, with a total of well over 100 of
these being produced and being used at many educational institutions. I
thought that some of these would be of interest to our list members, so here
is one to consider.
PUZZLE & PARADOX 119
INTRODUCTORY NOTE
For newcomers to this forum, these P&Ps are Propositions, not facts or
dogmatic proclamations. They are intended to stimulate interaction among
users working in different fields, to re-examine traditional concepts, foster
distance education, question our beliefs and suggest new lines of research or
approaches to training. We look forward to responses from anyone who has
views or relevant information on the topics.
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PUZZLE & PARADOX PP119
Understanding and management of spinal problems may be confused and impaired
by the misleading use of certain definitions and models of spinal stability.
PREAMBLE
The back has probably generated more concepts and models of postural
management and rehabilitation than any other part of the body, undoubtedly
because of the prevalence of back pain, dysfunction and disability in Western
populations. Entire courses, clinical rehabilitation regimes and treatment
‘protocols’ have been developed to manage back problems, with a myriad of
experts gaining almost demi-god status for their particular approaches. Thus,
we are confronted with methods such as the manipulative schemes of
chiropractors and physical therapists, as well as Alexander technique,
Maitland, McKenzie, Pilates, Feldenkrais and a host of other models which are
specifically or partially devoted to back care.
We learn about neutral spinal posture, abnormal curvatures, ‘correct’ pelvic
tilt, ’swayback’, hyperlordosis, kyphosis, ‘proper’ lifting techniques and
numerous other issues relating to how we think that the trunk work., yet
agreement on all issues is by no means universal. Many folk with so-called
‘abnormal’ curvatures or postures do not suffer from debilitating back pain
and disability, years of heavy weightlifting does not lead to the expected
high incidence of injury or malfunction, and some methods of spinal
management have minimal success with some subjects.
DEFINITIONS
The foundation of all schemes of back use and care begins with definitions of
neutrality, the spinal curvatures, balance, abnormality and pelvic
disposition. Definitions of neutrality are bandied about so casually that
one would think that neutrality in the standing position is the same as
neutrality in seated, lying, walking, running and other situations. Are we
really entitled to apply such universal definitions of neutrality, bearing in
mind that spinal disposition is the result of dynamic processes throughout
the body?
Why is neutrality in the standing anatomical position considered to be more
fundamental than neutrality in the relaxed supine position? Is it
appropriate to apply concepts of neutrality in the static standing posture
with neutrality in the more dynamic cases of walking or running? Or does
neutrality disappear when one deviates from this ‘neutral’ standing position?
Many folk refer to normal lordosis or kyphosis, yet there appears to be no
such thing as normal scoliosis. Why this discrepancy? They consider lordosis
to refer to the normal concave curvature of the lumbar spine and kyphosis to
mean the normal thoracic convex curvature, but the suffix “-sis” always
refers to some form of pathology. Thus, lordosis should be used only to
describe excessively concave lumbar curvature, while kyphosis should be used
solely to mean excessively convex thoracic curvature. Scoliosis needs no
such attention – nobody uses that term to describe normal lateral curvature
of any part of the spine.
There are some who take all of this one stage further by referring to
‘hyperlordosis’, when lordosis already happens to be a ‘hyper-’ condition.
At a popular level, the term ’swayback’ is used as a synonym for ‘lordosis’,
but some therapists attempt to distinguish between hyperlordosis and
swayback. This distinction is by no means universally accepted, yet it is
sometimes used to offer different types of therapy to treat what is
considered to be abnormal spinal posture.
LAY TERMINOLOGY
A major part of this confusion is that the colloquial word ’swayback’ is not
a clinical term and that it is inappropriate to base kinesiological or
therapeutic analyses on lay terms being used in a clinical setting. This is
tantamount to comparing a cartilage operation with a menisectomy, because the
layperson thinks that cartilage is necessarily the same as meniscus.
Thus, it would appear to be meaningless to even consider comparing ’swayback’
and lordosis – either that or an acceptable clinical term has to be
introduced to accurately describe so-called ’swayback’ which is not the same
as the colloquial use of the same term. If some believe that swayback is
different from lordosis because each has a different characteristic degree
of pelvic tilt, then we are going to get nowhere, since virtually all
anatomists just use them as clinical and non-clinical synonyms.
The tendency towards swaying back in the so-called swayback posture is
increased among those whose knee joint tends to ‘hyperextend’, while it is
used quite comfortably as a standing variant when one stands with the hands
on the hips or presses a load overhead.
Some well-meaning postural experts advise us that adults need to become more
childlike in standing or sitting, because children have not yet lost their
‘natural’ tendency to have the ideal posture. It needs to be pointed out
that it is entirely meaningless to compare adult and child postures, since
the typical human spinal curvatures are consolidated only in adulthood and
that the more flattened spinal posture is unsuitable for the greater stresses
of adult life.
IMBALANCE?
Then, when so-called imbalances are found between the different muscle groups
involved in stabilising the spine, a large array of static hands-on tests of
muscle strength are used to identify these imbalances (such as the impressive
inventory of tests of Kendall). Yet, we know that the ’strength’ of
muscles depends on joint angle, velocity of movement, region of action,
degree of neural activation and fatigue. Are we justified in extrapolating
these static tests to identify imbalances which may or may not appear under
more dynamic or explosive conditions?
Why is balance or homeostasis considered to be so precisely defined that any
small deviations from fairly rigid ‘norms’ may be blamed for leading to a
host of back problems? One therapist swears that postural realignment will
solve the problem, another swears by mobilisation, others by manipulation,
pelvic re-education, myofascial trigger point therapy, ‘active release’,
McKenzie, shoe inserts (orthotics), Pilates, acupuncture and even
reflexology. Is the success or failure of any such system due more to the
possibility that the spine is such an imprecise functional system that
numerous strategies can affect its operation?
SOLUTIONS?
Is it not possible that no posture which deviates moderately from the ‘norm’
really will cause any problems provided that it is not held for too long or
subjected to prolonged or excessive loading in any given direction? After
all, the body is in constant motion, even during sleep, which may well be the
body’s natural way of preventing any given structure from being excessively
or inappropriately loaded.
So, if we move around regularly from one posture to another, no matter how
poor each may appear to be, are we not then minimising the occurrence of any
dysfunction – as long as we don’t load the spine excessively or hold the same
posture for too long in any one state? Is it only when we forget to shift
around regularly in seated and other positions that problems begin to emerge?
Is the prevalence of back pain and dysfunction more a consequence of lack of
adequate postural variation than any single ‘correct’ posture?
Though our models of optimal spinal functioning may well be quite accurate,
is it that essential to implement them so precisely, when regular shifting
from one position to another may tend to offset most of the alleged risks of
imprecise spinal usage? Does this then imply that many of the popular
therapies and methods of spinal use and rehabilitation are unduly
prescriptive and in many cases, redundant?
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Mel Siff
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