balance

The OOV – Fabulous or familiar?


I love gadgets! New, innovative, groovy – I feel special when I have a new toy to play with. I justify my pleasure by saying “Oh it saves me SO much time”, or “I can do SO much more” – but really, it’s the wow factor that gets me every time. So it is with new and groovy treatments for pain. It used to be all “leg length discrepancy” and “muscle imbalance”, now it’s “neuroplasticity” and “educational neurophysiology”. So I think I’ve stumbled upon the Next New Thing. The OOV.  I attended a one day fundamentals workshop – incidentally, paid for by the University Department in which I work, so this is an unbiased review.

The OOV is a neat foam device shaped somewhat like a goose (if you use your imagination), or perhaps like an insect thorax. It’s curved side to side and from front to back on the bottom, while the top has two concave and one convex curve roughly approximating the curves of the spine.OOV1OOV2Designed by an osteopath, there are several principles the inventor and educators indicate underpin the rationale for the OOV. These are:

  • Functional movement training
  • Developing stability via the pelvis and deep “core” muscles, with joint mobility where this is needed (shoulders and hips)
  • Developing motor control
  • Establish endurance
  • Refine balance
  • Relaxed performance

The exercises performed on an OOV are therefore carried out slowly (almost meditatively), in time with breathing (deep diaphragmatic breathing), and with control.

Training also requires attending to feedback from using the device itself – use it with inefficient motor control and you fall off. Use it with fluid control and, over time, develop strength. The materials included in the training manual state that motor control learning requires a “closed loop feedback” process of attending to sensory information as new movements are learned. After the movements are mastered, then and only then is speed acquired. Exercises focuses on using eccentric contractions to keep movements slow and smooth – and “allows for kinetic chain sequencing to improve”, “increases cross bridge connection between muscle fibres thereby increasing strength, activates the deep muscles, stimulates the low threshold slow twitch fibres building stamina, lengthens the fascia due to long, slow and sustained load”.

The training manual also discusses myofascial slings and suggests that by training the deep core muscles (transverse abdominis, multifidus and the pelvic floor – and don’t forget the diaphragm), and the superficial units (posterior oblique, deep longitudinal, anterior oblique and the lateral muscular slings) coordination and recruitment patterns will allow for stability, strength and speed as forces generated by limbs are transmitted through the body.

Next, the manual describes several postural types. There is the so-called “ideal posture”, kyphotic-lordotic posture, flat back posture, and sway back posture – and of course, we must correct the variants so we can achieve the ideal. I’ll leave you to draw your conclusions as to the rationale for this.

Finally, there are the four pillars of movement:

  1. Axial elongation – for efficient spine articulation, the “safest” environment for movement, preventing compression and shearing forces, and providing the optimal position for the core muscles to work. Just by lying on the OOV, the spine is placed in this wonderful position, provided of course that you lie with your lumbar region in the right spot, which can be just an inch or so from where you may really want to lie.  Efficient breathing – Axial elongation allows for diaphragmatic breathing, with the head lower than the hips which apparently inhibits the secondary respiratory muscles.
  2. Hip mobilisations – to develop correct posture and proper alignment begins with the feet, by dissociating the lower half of the body from the upper half, the stationary half provides stability and support so that forces are directed towards the moving half.
  3. Shoulder and thoracic spine mobilisation – to enhance, strengthen and extend the fluid range of movement at the shoulder which, because of our terrible working environments, seems to produce faulty movement patterns.
  4. Core control – as the manual says “not enough can be said about the importance of a strong core. But strength means nothing if all the muscles that make up the core are not working efficiently during movement”.

OK, so far so good. Training is based on the principles above, with the addition of balance and proper alignment, interspersing new exercises with a balance position, adding new movement patterns to increase the challenge to the nervous system (yes! neuroplasticity!), practice to develop complex movement patterns, and finally repeated practice using weights, increased repetition etc. And if you perform a new set poorly, step back a bit, reduce the demands until motor control develops.

I spent a day using the OOV. With my sensitive nervous system letting me know three days later that I’ve been using muscles I don’t usually demand so much from, I think it does what it says it does – you definitely work a range of muscles more intensely than in everyday life. It’s fun, and because of the slow pace where control is the aim, it’s achievable even for people who wouldn’t ordinarily want to “do exercise”.

What do I think of it? Well, I predict there will be classes for OOV training in many gyms in New Zealand and the world. During the workshop I heard that performance athletes (yes! the Australian swim team!) are using it, that you can rehabilitate sore backs, shoulders, hips, whatever; I learned that you must be SO careful with your back because the discs can be smashed; that posture patterns are dysfunctional; that the reason we have back pain is because of poor core stability, that we can have an unstable pelvis; that this is the way of the future. Even 70 year old women with osteoarthritis can now manage things she couldn’t do before.

Warning: I am skeptical of any new thing. After seeing so many variations over the years I’ve worked in pain management, particularly within the musculoskeletal world, I guess I’m a bit wary of fads. Here’s the thing: While I think the OOV functions well as an option for exercise, and novelty can be a good thing to maintain motivation, let’s not inflate the potential. Buzz words like “motor control”, “neuroplasticity”, “core strength” are going to have grab. The exercises, many based on Pilates, will be familiar and yet challenging on the unstable platform of the OOV. BUT the basic assumptions that:

  • there is one ideal posture and lordosis is associated with back pain and disc degeneration (Been & Kalichman, 2014; Murray, Dixon, Hollingworth, Wilson & Doyle, 2003; Nourbakhsh & Arab, 2002)
  • backs are fragile and must be coddled, particularly the discs  (Bakker, Verhagen, van Trijffel, Lucas & Koes, 2009; Claus, Hides, Moseley & Hodges, 2008; O’Sullivan, O’Keefe, O’Sullivan, O’Sullivan & Dankaerts, 2012);
  • core stability and motor recruitment are at fault in back pain, therefore they need to be retrained ( Laird, Kent, & Keating, 2012)
  • that myofascia can be effectively stretched (Scleip, Dureselen, Vleeming, Naylor, Lehmann-Horn, Zorn et al, 2012; Turrina, Martinez-Gonzalez & Stecco, 2013)

are, I think, arguable. I particularly dislike the language associated with the reasons for developing core stability – that backs are easily damaged, that great care must be taken to avoid damage, and that a critical reason for back pain is either lack of core stability or pelvic instability. While these notions are logical from a biomechanical viewpoint, they don’t accommodate natural bony, ligamentous and muscular variations (how many clavicle variations have been identified?), they omit the nervous system, and they fail to include the active, dynamic and ever-changing, self-regulating, homeostatic human systems involved.

Consider the OOV as an adjunct, a toy, a nice way to introduce movement to people who are fearful of movement. Use it to vary an exercise routine. Have fun with it. But please don’t base your back pain rehabilitation on the idea that this device is the bees knees.

Quick addendum: GREAT critical questions about a ten-year follow-up of strengthening vs flexbility exercises with or without abdominal bracing – http://www.ncbi.nlm.nih.gov/pubmed/25271520; the original article is http://journals.lww.com/spinejournal/Abstract/2014/06010/Ten_Year_Follow_up_of_Strengthening_Versus.2.aspx

 

Bakker, E. W., Verhagen, A. P., van Trijffel, E., Lucas, C., & Koes, B. W. (2009). Spinal mechanical load as a risk factor for low back pain: a systematic review of prospective cohort studies. Spine, 34(8), E281-293.

Been, E., & Kalichman, L. (2014). Lumbar lordosis. Spine Journal: Official Journal of the North American Spine Society, 14(1), 87-97.

Claus, A., Hides, J., Moseley, G. L., & Hodges, P. (2008). Sitting versus standing: does the intradiscal pressure cause disc degeneration or low back pain? Journal of Electromyography & Kinesiology, 18(4), 550-558.

Kirilova, M., Stoytchev, S., Pashkouleva, D., & Kavardzhikov, V. (2011). Experimental study of the mechanical properties of human abdominal fascia. Medical Engineering & Physics, 33(1), 1-6.

Laird, R. A., Kent, P., & Keating, J. L. (2012). Modifying patterns of movement in people with low back pain -does it help? A systematic review. BMC Musculoskeletal Disorders, 13, 169.

Murrie, V. L., Dixon, A. K., Hollingworth, W., Wilson, H., & Doyle, T. A. (2003). Lumbar lordosis: study of patients with and without low back pain. Clinical Anatomy, 16(2), 144-147.

Nourbakhsh, M. R., & Arab, A. M. (2002). Relationship between mechanical factors and incidence of low back pain. Journal of Orthopaedic & Sports Physical Therapy, 32(9), 447-460.

O’Sullivan, K., O’Keeffe, M., O’Sullivan, L., O’Sullivan, P., & Dankaerts, W. (2012). The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review. Ergonomics, 55(8), 898-908.

Schleip, R., Duerselen, L., Vleeming, A., Naylor, I. L., Lehmann-Horn, F., Zorn, A., . . . Klingler, W. (2012). Strain hardening of fascia: static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. Journal of Bodywork & Movement Therapies, 16(1), 94-100.

Turrina, A., Martinez-Gonzalez, M. A., & Stecco, C. (2013). The muscular force transmission system: role of the intramuscular connective tissue. Journal of Bodywork & Movement Therapies, 17(1), 95-102.

A Prospective Analysis of Acceptance of Pain and Values-Based Action in Patients With Chronic Pain


ResearchBlogging.org
Lance M. McCracken and Kevin E. Vowles

These two researchers have been publishing more and more on acceptance and values and Acceptance and Commitment Therapy (ACT) and Contextual Cognitive Behavioural Therapy (CCBT), and this paper is another example of the type of work being undertaken.

The objective was to ‘prospectively investigate the combined processes of acceptance of pain and values-based action a in the emotional, physical, and social functioning of individuals with chronic pain.’

A concept I’m interested in is ‘psychological flexibility’ or the willingness individuals have to allow for ways of behaviour and goals to differ depending on the context or situation in which they occur – in other words, allow for the realities of life while all the while still aiming for things that are important to them to achieve. And by things, I mean activities that express the values of the person. ACT includes concepts such as acceptance, cognitive defusion, contact with the present moment, self-as-context, values,and committed action (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), which are construed as ‘psychological flexibility’.

Quoting from the article “Acceptance has been investigated in more than 15 studies (e.g., McCracken, Vowles, & Eccleston, 2004; Viane et al., 2003; Vowles,McCracken, & Eccleston, in press a; see McCracken & Vowles, 2006). A number of treatment studies of mindfulness-based methods support the role of the process of “contact with the present moment” (e.g., Kabat-Zinn, Lipworth, & Burney, 1985: Sephton et al., 2007), but just one study included direct assessment of mindfulness (McCracken, Gauntlett-Gilbert, & Vowles, 2007). There is just one study of values-related processes in relation to patient functioning with chronic pain (McCracken & Yang, 2006). In each of these studies the general result is that processes of acceptance, contact with the present moment, and values-based action are significantly associated with better emotional, physical, and social functioning.'[my emphasis]


Participants in this study seem familiar to me
– very similar to the chronic pain patients referred to the clinic in which I work, that is they have had pain for 77 months (8.0 – 516), in their 40’s, mostly married or in long-term relationships, mainly experiencing low back pain, lower limb pain, or whole body pain, and 60% or so not working.

They were recruited from the people referred to the Centre, and completed the questionnaires for this study when they first attended for assessment, and again roughly 18 weeks later at the commencement of their pain management programme. The questionnaires included measures of acceptance, importance and success at living according to their values, emotions, and disability.

Results?
Now as usual I’m not going into detail into the multiple regression analyses and other statistical methodology – that’s for you to read, when you read the article in depth. Suffice to say that ‘the present analyses demonstrate that measures of acceptance of pain and values-based action predict functioning later in time for patients seeking treatment for chronic pain.’

Unexpectedly, ‘there were only two of nine possible occasions where both the acceptance and values variables performed as significant predictors, in the equations for depression and psychosocial disability.’ It was thought that this would occur in every equation. The authors suggest that
‘Our inability to find these relations may have been due to the statistical control procedures that included pain intensity, a variable that shares variance with both acceptance and values, and the
overlapping variance between the acceptance and values variables, which, according to the correlation results, is estimated at 25.0%.’

They add that ‘the study interval was quite long, providing opportunity for a wide range of influences on the measures of functioning at Time 2 that could have reduced their relations with the acceptance and values measures from Time 1’.

I like this point made by the authors: Flexible and effective behavior will tend to have both qualities [of acceptance and values] and these qualities are expected to mutually enhance each other, with acceptance loosening up restrictive influences exerted by pain on behavior in the near term, and values giving direction and purpose to behavior over the longer term.

Now you know I’m going ask ‘What does that mean for us as clinicians?’
Well…people who report that they accept their situation and act to achieve things that they value in their life despite their pain present ‘better’ in terms of their results on measures of things like emotional, physical, and social functioning.

Not really rocket science in that anecdotally clinicians know that angry and resentful people rarely function as comfortably in their lives as people who are more accepting and ‘get on with life’. What is rocket science is that these concepts are based on a theoretical model that can be empirically tested, and used to help us develop ways to encourage people to become more accepting, and to live lives based on things that are important to them, rather than spend energy on seeking to return to ‘the way things were’ or ‘what might have been’.

It means that some of the work of occupational therapists whose primary focus is to help people identify important areas of activity and facilitate their achievement in these areas is validated. That perhaps over time, the urgency to ‘reduce pain’ (which in many ways constructs and reinforces disability because it implies that having pain and restrictions is not normal) may reduce. Perhaps by helping people with pain identify what is important to them, we as clinicians might look at what is important to us – making more space in our lives for things we value, like balance, family, creativity, and inquiry.

I can foresee some clinicians finding the concept of accepting pain particularly hard to reconcile with their own value system of relieving pain (almost at all costs). And this will conflict with the aims of patients who dearly want me to help them ‘remove their pain’. So, putting these concepts into therapy in an acceptable way for the people with whom I work continues to be my challenge. After all, these patients are seeking treatment – this shows that they are unhappy with their current situation, living the antithesis of acceptance. I can see this topic being discussed over and again in the next few years.

I hope you’ve enjoyed my stroll through mindfulness and acceptance over this week – have no fear, I can see that I’ll carry on this particular path many times as I continue learning and enquiring! As I discover things, I’ll be sure to post them. Keep in touch too – your comments mean a lot to me, and it’s always great to see what other people think, whether you agree or not! And if you want to subscribe, don’t forget the RSS feed link at the top right of this page – or bookmark – I post most days during the week.

McCracken, L.M., Vowles, K.E. (2008). A prospective analysis of acceptance of pain and values-based action in patients with chronic pain.. Health Psychology, 27(2), 215-220. DOI: 10.1037/0278-6133.27.2.215
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., Lillis, J. (2006).
Acceptance and Commitment Therapy: Model, processes and outcomes.
Behaviour Research and Therapy, 44, 1–25.

Pictures – and geocaching… (not really a painful topic!)


Read what you like into these two shots – photographs from my holiday to West Coast’s fabulous hidden corners, courtesy of geocaching. If you don’t know what geocaching is, it’s treasure hunting for grownups. Basically you log onto Geocaching.com find the GPS coordinates of a hidden cache (often creatively and incredibly well-hidden!) of small swaps and a logbook. The GPS coordinates will get you within 4 – 6 metres of the spot, whereupon you need to look – and look pretty hard too!! The cache container could be as big as a 10 gallon drum, or as tiny as a thumb-nail magnet. Some of the containers are cunningly disguised as rocks, or hidden as treestumps, or inside hollowed-out signs, while some are in plain sight – just difficult to get to without being ‘muggled’. Being ‘muggled’ means someone from the general public, who isn’t a geocacher spots you in the process of finding and wants to know what you’re up to, or it can refer to when a cache container is plundered by someone who is not part of the game. Once you’ve found the cache, you simply log your find on the book in the cache (and later brag about it on the online log!), and if you’re keen you can swap one of the bits and pieces from inside the cache. Some caches are temporary homes for ‘travel-bugs’ or ‘geocoins’ which have a unique number on them enabling them to be tracked as they move from cache to cache around the world.

speed-medium-web-view.jpg

Some of the caches are quite demanding, because to get the coordinates of the final location, you may need to complete a puzzle, or carry out certain tasks, or have some general knowledge. And the physical demands of some cache locations are quite extreme – up hill, down dale, and further away from civilization than is normal for townies!

But the real pleasure of geocaching for me is the location of so many caches – wee places that even for a true blue Cantabrian like my partner (who has lived in Christchurch all his life) are unknown. Many are truly pristine, quite a number mark historical spots or geological formations or just plain gorgeous.

What does this have to do with pain? Nothing (except the pain of being the second to find a brand-new cache!), or if you’ve been bush-bashing through 12 foot high gorse only to find the cache has just been archived the weekend before you went to look for it!
A balanced life, however, helps with all things – and with geocaching you can get out and about, see some wonderful places, be taken on some fantastic walks, solve some incredibly difficult puzzles, and if you use it for travelling, get to stop every 30 minutes or so ‘just got to get another cache’! A great way to see the country at a pace that even I can cope with!

Oh, and photographers – there are some truly awesome photographic opportunities…settlers-gravestone-gillespies-beach-medium-web-view.jpg