Thread by @GregLehman

OK. Hold on for this one. We are doing a session of "In Lehman's terms" where we dive into a research paper with a long Tweet Thread. Specifically, the Motor Control Issue from @JOSPT jospt.org/doi/abs/10.251… 1/

The basic question is whether instability is relevant to low back pain. My primary issue is that it was assumed from the start and throughout the paper that it is relevant. No counterpoint was made 2/

You can see this immediately in the first few paragraphs 3/

Its a great review of the evidence but the conclusion seems to have been arrived at before the review. 4/

The paper is an excellent summary of the mechanics of stability. Which is no surprise because these are all excellent biomechanists.

But we as clinicians have a duty to question whether this is relevant to our patients. 5/

We often see function being conflated with pain. There might be changes in function that are perhaps a component of stability but the case that its relevant to pain is never strongly made. 6/

This is an example of why stability or its lack may be completely irrelevant to low back pain. its just ridiculously easy to achieve 7/

And yes, its more complicated than just mechanical stability but so what? Is this "fine tuning" of stability ever a problem that drives pain? Can you support this idea? 8/

We now see what so happens in these papers. Here we have 3-4 pages supposed about pain but the vast majority of the content has nothing to do with pain. Its just filler about stability - almost implying that this is relevant without ever saying how 9/

More well researched talk that is just peripherally related to pain but never really connecting he dots. 10/

Conjecture on how too much muscle activity because of some assumed dysfunction that demands stability is causing pain. Makes no sense to me 11/

Going back to old trope that you are using your muscles wrong. You know, people turn on their Global muscles and not their little ones. I think this messaging has harmed thousands of low back pain patients. The idea that they can't control their spine optimally. Ugh 12/

Again, more on the unsupported notion that we must "carefully control" our spine for ideal function. In the papers defence the argument I put forth in the attached comment is addressed later in the paper 13

Solidifying the argument that people have too much muscle activity because of some dysfunction that causes instability. Which is weird since I'm sure many of you have worked on having your patients move fluidly, relaxed and without effort. They feel better and...

...you would have just addressed muscle activity without addressing the proposed underlying impairments that presumably caused the demand for that extra activity. What does that tell you about those "impairments" /15

This statement bothers me. How did it get through peer review. There isn't mixed evidence because NO papers have actually measured stability and low back pain. They go onto cite clinical trials. /16

This paper does acknowledge the lack of support for stability exercises. Yet, they never go to the obvious conclusion that exercises can help for reasons that have nothing to do with stability /17

The last ditch attempt to save a favoured treatment and research stream is to argue we need to subgroup. Perhaps, but that means this concept is in its infancy and perhaps we shouldn't be giving infants so much of our time /18

Why can't they just say STABILITY MAY NOT BE RELEVANT FOR PAIN?

More interesting filler. Its well written, highlights how great science is in understanding stability but fails to draw a link with pain /20

more filler on things not established to be related to pain and recovery.

And its here where my jadedness just thinks this something that I won't say online :) /21

A nice acknowledgement that much of the ideas around stability can potentially be harmful to some patients /22

The conclusion p1. Are we any farther ahead clinically then we were 20 years ago. How has the past 20 years of biomechanics stability research actually changed clinical practice for the better. I'd say clinicians are now more confident in saying don't worry about this /23

Here is the conclusion part 2 - Not a single acknowledgement let alone a 5 page viewpoint that can easily argue that stability is an irrelevant concept when it comes to low back pain or at least something mostly irrelevant /24

Final thoughts attached. Its a great issue for ONE side of the discussion BUT just one side. This could have been an amazing forum for multiple views here. Where we the other researchers and clinicians who have published dissenting views? end/