Résonances
Européennes du Rachis, n° 15, septembre : 34-45, 1997
TOPICAL
INTEREST OF THE REEDUCATION POSTURALE GLOBALE IN THE TREATMENT OF LOW BACK PAIN
Ferrari
Silvano *, Vanti Carla **
* Physical
Therapist
Physical Therapy and Rehabilitation Centre
“L’Arcobaleno” - Milan, Italy
Professor
of Active Global Stretching (U.I.P.T.M. - France)
Professor
of the Italian School of Integrated Rehabilitation
** Physical Therapist
S.R.R.F. Ospedale S. Orsola
- Bologna, Italy
Credentialling Mechanical Diagnosis and Therapy (The McKenzie Institute International) Professor of the Italian School of
Integrated Rehabilitation
INTRODUCTION
The SIRER International Congress entitled “Treatment of low back pain -
state of the art” was held in October 1995 in Milan, Italy.
During the four days of the congress, world famous speakers, such as A.L.
NACHEMSON, Orthopedic Department, University of Goteborg (who wrote more than
400 papers on the subject) discussed the epidemiology, etiology, biomechanics,
neurophysiology, physiopathology and pain genesis, as well as the surgical and
conservative therapy of low back pain.
In particular, the latter session focused on the main rehabilitation
therapies employed by physical therapist, including Reeducation Posturale
Globale (RPG).
The contents of this congress can be helpful in verifying the actuality
of RPG treatment, comparing the scientific data and therapeutic aims of Ph
Souchard’s teaching with the pathophysiology and goals reported in this
Congress as well as in scientific literature. Thus, this is an occasion to give
scientificity to our work of physical therapists, and to generate a discussion
of the different therapeutical goals of the various techniques.
For this reason the subject of low back pain will not be approached using
the RPG language.
RPG premises on low back pain have already been explained by Ph. Souchard
during his specialization courses: the role of diaphragmatic pillars and
respiration, the psoas muscle, the retraction of the common muscles, the static
muscle chains, the unicity of each patient and the global research of causes
other than those attributable to the lumbar district, etc. (4, 8-12).
Aim of this study is to demonstrate the RPG actuality, using the models
employed by those physical therapists that do not utilize a global method, and
following the indications provided by international literature.
PREMISES
It must be remembered that the term “low back pain” in itself
indicates only the presence of pain in the lumbar region, without any
specification regarding the cause or the anatomic structures involved.
“Idiopathic” low back pain cannot be explained by a single
etiopathogenetic factor, and it is
normally regarded as a syndrome with multifactorial etiology (7). In fact,
mechanical-compressive and degenerative-inflammatory causes are deeply entwined
in the genesis of low back pain, even though great importance has been
attributed to the mechanical factors, generally regarded as the true responsible
of acute and chronic low back pain.
Boccardi ironically quotes more than 800 causes of pain referred to the
spine but, even without exaggerations, international literature reports more
than 30 causes of low back pain. Thus, if there are 30 different causes of low
back pain, there should be 30 different ways to treat it. However, each
treatment facing only one probable cause of pain, such as the intervertebral
disc or the articular facets, would be incomplete.
For this reason it can be understood that RPG, due to its premises of
UNICITY and GLOBALITY (8-12) can provide a CAUSAL THERAPY, independently from
the genesis of low back pain.
Nonetheless, in order to approach scientifically the problem, objective
data must be considered. Thus we will discuss the physiopathology of low back
pain, even though we are aware that the excessive personalization of physical
therapy may increase the difficulties in the interpretation of the data.
As regards the lumbar structures that may cause pain, we would like to
quote and article by DEYO, published in SPINE in 1993 (22). In this study DEYO
reviewed all the data published in the international literature regarding the
genesis of lumbar pain and concluded that, according to the different studies,
low back pain was caused by laxity or muscular tension, alteration of articular
facets, intervertebral disc damage and psychological problems in 80%, 50%, 95%
and 50-70% of the cases respectively. Moreover other studies reported that in
most patients low back pain was attributable to the sacral ligaments, while some
others considered the presence of fascial problems as the main cause. If we sum
all the causes, we obtain 300%!
This study by DEYO agrees with the data presented at the S.I.R.E.R.
Congress and with the concept expressed by Nachemson: “ We do not know with
certainty the causes of low back pain, and thus it is difficult to establish
which therapeutic approach, i.e. surgical or conservative, can provide the best
guarantee, especially in the initial phase.”
Moreover, the high frequency of spontaneous remission of low back pain
increases the difficulty in evaluating the real efficacy of the therapy proposed.
In fact, various studies reported a frequency of remission of 44% at one week,
and 86 and 92% at one and two months respectively.
However, if it is difficult to validate a therapeutical approach, it
could be easier to identify those that are lacking of a scientific base.
In 1994, the ACHPR Committe Fending Guidelines for Care of Acute Low Back
Pain Patients (24), evaluating 3900 studies and Acts of International Congresses,
confirmed the ideas already expressed by the supporters of Manual Therapy.
In particular:
·
The use of spine tractions, T.E.N.S. and lumbar
corsets is not supported by any scientific data
·
Heat, diathermy, massages, ultrasound, cutaneous
lasers and electric stimulations have not shown sufficient benefits to justify
their costs
·
Movement can be an efficacious therapy, thus bed
rest should not be longer than 3-4 days.
The
Guidelines provided by this Committe (composed of orthopedic surgeons, physical
therapists, chiropractors, psychologists, etc.) are superimposable to those
published in 1987 by the Quebec Task Force on Spinal Disorders for the Quebec
Workers Compensation Board. Nowadays this study is considered as a milestone in
the international literature by everyone involved in the treatment of low back
pain (26).
To summarize some of the basic aspects of low back pain treatment, as
reported by the most important international associations, we could say that a
shift from passive to active therapy took place in the last few years (6, 21,
22, 24, 26). Several Authors agree
on the following guidelines:
·
Bed rest should be as short as possible;
·
Mobilizations and manipulations may be helpful
in accelerating patients’ return to work, even though no data support their
long-term efficacy;
·
Great importance must be given to postural
teaching;
·
Prevention is essential (back school, ergonomy
and “static-dynamic hygiene” rules, etc.).
According to Deyo (22), rehabilitation for low back pain, in order to be
efficacious, must have the following Therapeutical Goals:
·
Act on the pathogenetic mechanisms, improving
the load distribution;
·
Restore the correct static-dynamic automatisms;
·
Eliminate risk factors;
·
Teach to the patient how to rationally cope with
his problem (back school).
REEDUCATION POSTURALE GLOBALE
IN LOW BACK PAIN
It may be easier now to recognize the importance of RPG in the treatment
of low back pain.
1) RPG acts on the
pathogenetic mechanisms, improving the load distribution.
The position of the spine and of the pelvis affects the amount of
pressure that is constantly applied on the nucleus and the edges of the disc
annulus; moreover recent studies reported the presence of innervation in the
more external part (one third) of the annulus (18).
A correct posture is also the condition that provides the best relation
among the different elements of the articular tripod. If this relation is
altered, intervetebral discs and articular facets have to bear an increased load
that, in turn, generates stress on discs and ligaments and may cause wear of the
cartilagen.
The RPG postures aim to normalize the tensions and restore the correct
biomechanical relations, and thus they are able to optimize the whole individual
disposition, acting primarily on the myofascial pathogenetic factors.
2) Restoration of
static-dynamic automatisms (saving the relation structure/function) is one of
the most important form of intrinsic prevention.
Every movement, to be ample, harmonic and energy-saving (function) need a
correct and physiological morphology (structure). Thus, only if the
biomechanical relations among the different structures are correct it will be
possible to obtain the static-dynamic integrated functions that are peculiar of
the spine. In order to achieve this goal, it is necessary to employ exercises
aiming at the recovery of normal postural reflexes through cynestesic and
proprioceptive re-education. This will provide an efficacious re-programming,
both sensitive as well as motory (4, 27).
Muscular tensions, especially if chronic, can alter the proprioceptive
capacity, since the body perception is strictly related to the movement: for
this reason, body parts immobilized because of chronic muscular tensions are
almost completely excluded from self perception. This causes a deficit that is
not only motory but also sensitive.
To favor the proprioceptive sensibility recovery of silent and rigid
areas, we must make the patient aware of the chronic tensions. Hence it is
necessary for the subject to assume some positions (postures) that allow him to
feel his tensions, and to perform adequate movements to verify the freedom and
the harmony of the movement itself. All
of this is part of the RPG aims.
In addition, as reported by Giovannini (1), the studies performed by
Monceaux and Tayon in 1980 clearly showed that all the structures depend on
function, and thus can be influenced by the therapeutic approach.
Every posture or exercise can be very important if it targets the
function of a particular structure; this is fundamental for the intentional and
experience aspects of the supporting structure, both in movement and in posture.
The exercise proposed must be specific for a particular muscle group,
require the minimal energy consumption, and be proposed for the time necessary
for its integration. Even these criteria are part of the therapeutical premises
and peculiar characteristics of RPG.
To illustrate the concepts described above, we can employ as an example
the posture in which the patient is standing and bending forward. This exercise
has a great proprioceptive value, since anterior flexion is physiologically an
eccentric contraction, characteristic that is searched with the posture
mentioned above.
Standing and sitting postures belong to different therapeutical
strategies, but they are both extremely important in proposing a correct
postural model, which is physiological and energy-saving in the different
situations of daily life (figure n.1).
3) RPG acts efficaciously on
risk factors
All the situations connected with structural anomalies or articular
limitations are regarded as risk factors and can cause, directly or indirectly,
low back pain (13).
Among these conditions we can quote spondylolystesis, non-horizontal L3
vertebra, antero- or retroversion of the pelvis, hyperlordosis, straightening or
lateral deviation of the spine, disequilibrium of the lower limbs, cervical
lesions, retraction of the
ischio-crural muscles, etc.
In RPG, acting on the risk factors is part of the binomial structure/function,
and of the gestual and postural control that allows the readaptation of the
information, and thus of the movement.
Since Reeducation Posturale Globale is a method that applies a global
prospective, risk factors are reduced or eliminated during treatment (stretching
of ischio-crural muscles, reduction of the rigidity of the spine segments that
alter curve functionality and harmony, correction on the pelvis positions
affecting the sacral angulus, etc.). Moreover, only a global approach can allow
us to identify all the effects left by the various forms of compensation, now
already established.
4) Prevention assumes a great
importance, as demonstrated by international literature
Low back pain is a syndrome with a high frequency of recurrence, as
demonstrated by several studies on its epidemiology (according to a study
published in the British Medical Journal in 1966, recurrence was observed in 90%
of the patients).
Prevention must be intrinsic and extrinsic, that is it must consider the
recovery of the physiological defense mechanisms of the patient ( correct
neuro-motory coordination, extensibility of ischio-crural and dorsal muscles,
perfect mobility of the limbs, especially of the proximal joints, etc.) and the
ergonomy (working place, chairs, clothes, spine position in the car seat, etc.)
(23).
Employing RPG, intrinsic prevention can be naturally obtained, including
the restoration of the correct binomial structure/function, sensitive and motory
reprogramming, postural correction and removal of all the risk factors that are
normally sought for during therapy sessions. Moreover, the seek for appropriate technical solutions and a
global consulting that includes all the components of the patient’s life
should become an essential part of the therapy
(25).
A separate chapter must be dedicated to the comparison of Reeducation
Posturale Globale with some of the therapeutical approaches commonly used in
Italy, and thus we would like to consider some aspects of the subject.
1)
LORDOSIS OR DE-LORDOSIS?
Lordosis has always been considered the cause of most cases of low back
pain, and often exercises and postures aiming to eliminate the physiological
lordosis have been incorrectly proposed (7, 19, 20).
Probably, excessive lordosis as well as the absence of any lordosis can
cause stress and mechanical conflicts, thus becoming risk factors for low back
pain.
Nowadays, we have observed a revaluation of the role played by lordosis;
it is widely recognized, for example, that it would not be possible to perform
ample flexions and extensions unless lordosis was present.
a) As demonstrated by Gracovetsky in his book “The Spinal Engine”
(2), after the separation of the spine flexion from the anterior rotation of the
pelvis, it can be observed that an anterior flexion performed in presence of a
good lordosis has a wider range compared to that of a model with a scarce
lordosis (figure n.2). As regards the function, this width of the articular
range and the possibility of a correct anterior rotation provided by the
extensibility of ischio-crural muscles decrease the stress applied on the
posterior structures of the spine.
b) Limitation of the movement range has always been considered a bad
prognostic sign; it should not be logical to think that, while we look for a
complete joint recovery in case of an ankle sprain, we should not be doing the
same for the lumbar segment of the spine. Hence, a wide movement range should
not be regarded as negative, because its limitation will leave the patient
without a physiological movement. (3, 16).
c) Lumbar curve has an important role even in static posture; the
presence of the physiologic curves increases the resistance of the spine to
axial compression, and thus an adequate lumbar curvature is essential to reduce
the “axial load” lying on the intervertebral discs (3) (figure n.3).
d) The “functional-dynamic” type described by Delmas and athletes
usually have a good lordosis; this finding is associated with the ability to
generate an increased strength, strength more “active” than that observed in
a spine in which de-lordosis has been induced. It must be remembered that the
gorilla, generally regarded as a strong animal, lacks the lumbar lordosis and
for this reason cannot lift weights bigger that half his weight.
In our opinion, rather than looking for an accentuated lordosis, the
therapist should work toward an equilibrium of the lordosis itself, harmonizing
it with the whole spine (for example making sure that L3 is horizontal). (17).
RPG proposes a therapeutical strategy that is in accordance with the
concepts described above. The treatment of low back pain, in fact, mainly
employs postures with a load, and the therapist can work controlling that the
lumbar region does not assume a de-lordosis position. The respect of
physiological lordosis is thus one of the qualifying factors of the RPG
evolution.
2) STRENGTHENING OF THE EXTENSORS OF THE SPINE?
Several tools have been developed to evaluate the strength of the trunk
muscles, in order to measure the back muscle strength and the resistance of the
spine extensors. According to some authors, the idea of quantifying the spine
functionality is very attractive, since it could allow to design specific
protocols for muscle strength training (7).
However, is it really true that, in low back pain, back muscles are weak
and thus must be strengthened? Several
clinical elements, as well as our professional experience, make us skeptical
about this statement.
Moreover, the detection of a poor function of extensor muscles in the
subject with low back pain does not clarify the cause of the deficit, which may
be due to decreased strength, pain or lack of efficacious therapeutical schemes.
Considering the results that should be provided by the strengthening exercises,
we cannot forget that the exercise should be peculiar to the function of every
muscle (5, 15, 17, 19).
In his analysis of spine statics, Perrin demonstrated the functional
dissociation of the paravertebral muscles: superficial spine muscles (longissimi
dorsi, sacrolumbar, interspinales) are kinetic and voluntary extensors and they
are employed to straighten or to control the flexion. Deep spine muscles (inter-trasversarii,
transversospinalis) are tonic extenstors that act autonomously, and are thus
responsible of static positions.
Different muscle groups, under a different neuromuscolar control,
obviously need a different “strengthening”, in particular a specific
strengthening of dynamic and static functions.
In RPG, the standing and bending forward position, utilized to act on the
posterior muscle chains and to evidence the possible compensations, has a double
function. Indeed it is useful in the neuromotory reprogramming of the anterior
flexion, but it also strengthens the dynamic muscle groups of the spine, since
it adopts an exercise with an eccentric contraction which is physiologic for the
spine and produces the highest increase in the maximal force (5).
Moreover, the selectivity and precision that can be obtained with this
posture allow the therapist to check that the patient does not perform the last
degrees of the anterior flexion through a ligament tension. It is known that, in
this position, it is easier for the patient to assume a lumbar cyphosis, thus
substituting the active muscular work required by this position with a ligament
tension.
The restoration of lumbar-pelvic control actually generates “active
strength” (figure n.4).
On the contrary, the “strengthening”, or better the re-equilibration
of the tonic muscle groups acquires a meaning only if it is associated with a
functional work with a load. This should include the search for the integration
through proprioceptivity, and the energy saving of the acquired equilibrium (12,
19, 27), as obtained in RPG (8-11).
2) STRENGTHENING OF THE ABDOMINAL MUSCLES?
Studies performed by Asmussen and Klausen in 1962, subsequently quoted by
Kapandji (3), showed that, in four out of five people, erect posture is
controlled solely by the unconscious postural reflexes, which need only the
tonic contraction of the posterior layer muscles
Abdominal muscles are indeed dynamic muscles that activate to straighten
lordosis, such as in the “stand at attention” position, or when we lift
weights, but do not take part in the unconscious statics of the spine.
The contraction of the abdominal muscles increases intrabdominal pressure
and creates a counter-pressure on the spine, thus decreasing the load applied on
the discs. However, this mechanism acts only on exertion and for short periods
of time, since it requires total apnea!
Boccardi, in a congress held in Parma in 1989 (19) said that “Extensors
of the spine and abdominal muscles are almost inactive in maintaining both erect
station and the principal postures”. Nachemson reaches the conclusion that
“The importance of the strength of spinal and abdominal muscles in the
prevention of low back pain is still doubtful”.
Taken into account these premises and that no international protocol
includes strengthening of abdominal muscles as a qualifying element for the
treatment of low back pain, we can question its validity, especially in patients
that show symptoms related to an increased intradiscal pressure.
Surely the approach of a work in RPG is more correct, since the
strengthening of the abdominal muscles is not isolated and antiphysiologic, but
takes place within a global re-equilibrium of the trunk and pelvis. Moreover RPG
considers the synergetic effect of the abdominal muscles and diaphragm, and
foresees their involvement in the stretching of the body axis.
As illustrated by figure n.1, the search for a correct posture causes the
natural restoration of an adequate abdominal wall.
CONCLUSIONS
In this article we tried to analyze the problem of low back pain
according to the international treatment protocols, looking at the basic
principles of Reeducation Posturale Globale under this different light.
The data reported clearly show the actuality of RPG, especially
considering the various therapeutic possibilities that can be employed, as
required by the different therapeutic goals.
Modern RPG is indeed able to intervene on the bio-mechanic pathogenetic
mechanisms, on the restoration of static-dynamic automatisms, and on the risk
factors of the single patient.
The great attention given to the preservation of physiological lordosis,
to the muscular strengthening (in its wider sense), to the restoration of an
ample and correct movement allow the therapist to perform an efficacious
treatment which satisfies the functional requests of the spine.
Obviously, it is part of the therapist’s duty to critically revise
rehabilitation techniques, even if already renown, and to compare them with the
international literature.
Curiosity, comparison, and the idea that every therapy can be improved,
constitute the premises that
maintain our profession culturally alive.
FIGURES
FIG.
N.1
fig.
1A Standing posture ; fig. 1B Sitting posture; fig. 1C Standing posture with
anterior flexion (From: Souchard Ph E - Lo Streching Globale Attivo - Ed.
Marrapese, 1995)
FIG.
N.2
In
first subjet, with good lordosis, the point of maximum flexion is the widerts
one. Consequently, at the same
lumbar ranging, the second subjet will suffer a greater stress on the posterior
structures of the spine.
(From:
Gracovetsky S. - The spinal engine - Springer-Verlag, 1988)
FIG.
3
The
spinal resistance to axial compression increases in presence of the physiologic
curves. Without lumbar lordosis (Fig 3E), the resistance turnes
half in comparison with the
normal spine (Fig. 3D).
(Modified from: Kapandji - Fisiologia Articolare -
Ed. Marrapese, 1977)
FIG
4
fig.
4A: Standing posture, with anterior flexion (From: Souchard Ph E – Lo
Streching Globale Attivo - Ed. Marrapese, 1995)
fig.
4B: Spinal erector activity during the anterior flexion (From: McConaill MA,
Basmajian J V - Muscles to movement, a basis for human kinesiology -
Williams & Wilkins, 1969)
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