Kolar/McGill

[brandonsteele]

Built upon post from Craig about "the Core"--- This is a great question for all clinicians. What is the Key Link? I have had the opportunity to attend seminars taught by Pavel Kolar and Prof McGill as well as see them together for the first time last weekend. Their approaches, KEY LINKS, are very different yet arrive at the same diagnosis most of the time. The key difference becomes treatment. Matching a treatment to a specific diagnosis I thought was the goal of any clinician, but these are not mutually exclusive in the eyes of McGill and Kolar. McGill utilizes a pure biomechanical assessment and treatment. While Pavel is strictly concerned with the neurophysiology as it relates to dysfunctional stabilization through out the body. These two are very different and I don’t believe they can be combined. They often found the same dysfunction, but would treat very different.

My interpretation--
McGill finds a functional deficit (i.e. insufficient stability in L/S spine via PA shear) and teaches the patient to compensate for that instability via changing squatting patterns, buttressing joints with conscious muscle activation, groove basic movement patterns, etc… His goal is to build capacity with in the musculoskeletal system to prevent breaking the back whether in athletic event, remedial exercise, or just getting up from a chair. These are all compensatory strategies if it was the CNS that provided the faulty movement pattern resulting in injury, and not tissue overload only (I’m not sure if that can be distinguished). However, if the patient can utilize these corrections a majority of the time, the tissue builds capacity to prevent injury. Personally, I find this is reassuring to the patient that he/she can get out of pain and train them pain free.
Based upon the work of Janda, Lewit, and Vojta; Pavel focus stems from joint centration (muscle synergy + osseous contact to promote optimal load transferrance) necessary for stabilization (most effective mechanical advantage of joint) as a function of CNS organization. The CNS can reorganize due to a change in afferentation from habitual posture, pathology, injury, etc. Proper stability of a joint is only achieved through sub conscious control. Inefficient motor programs must be retrained through reflex locomotion, and trained in whole body centration to provide proper afferentation. If the body is not centrated, as infants do subconsciously, sensory afferentaion to the brain will change. It is the sensory afferentation that “normalizes neural drive” to illicit proper muscle activation/relaxation. Once this is achieved, the patient can move to McGill’s work to train.

A great clinician in my training teaches core stability is like a choir concert. A picture of a choir showed up in all of his presentations. I now understand it’s purpose: that all people must be reading the same sheet music to have synergy in the tempo, lyrics, and rhythm. It doesn’t matter how strong, big, or the endurance of a select few. If they all don’t have the same sheet music the choir can’t function. My interpretation: The CNS provides the script for motor control of core stability.

I can find holes in both of their research and assessments. But I do think this model is the best available currently. If I can find evidence to promote otherwise I will consider it with the same rigor these methods have been evaluated. Incorporation of the work by Butler, Kibler, McKenzie, Gray, etc .. are all probably warranted for a specific patient a specific time matched with their goals of treatment.

This seminar was great with both presenters providing valuable information and insight into clinical practice. I am left with two questions. Has anyone seen documentation of producing efferent neural drive from afferent stimulation without conscious thought? (not spinal reflexes) Secondly, how do you determine centration if structure has changed (femoral neck anteversion, tibial torsion, etc)?

“Low back cases are a case study of one” --McGill

[Craig]

Nice post. It is true that Pr McGill focuses on biomechanics and Pavel Kolar on neurophysiology. However, they are both equally interested in motor patterns/programs. For example they both look at the quadruped position & want to ensure appropriate scap-thoracic stability. This reminds me of Karel Lewit speaking about the area we treat as being at the crossroads of neurophysiology & biomechanics. This is at the heart of both Karel & my books. A major difference in the 2 approaches though is that Pavel is very happy to "think" in terms of the CNS programs & place patients in developmental positions to activate involuntary motor reactions, whereas Pr McGill does more stability & functional training. In the end, I agree they both wind up improving motor patterns!

You mention starting w/ Pavel's work & progressing to Pr McGills. I agree & disagree with this. It is always wise to activate the diaphragm early in care & Vojta is ideal for this. But, I would never allow a new patient to leave my office w/out gaining some insight in how to spare their spine (e.g. hip hinging). This is McGill 101 & should always be part of our initial care. Additionally, if we can find a movement that activates stability patterns (e.g. bird dog or side bridge) & builds capacity w/out increasing symptoms (McGill's positive slope) this should be given on Day 1 too.

This post is very objective & rationale. We should all be skeptical about any all encompassing theory. If we are concerned w/ our patient's goals then we can learn to plug in all the great approaches you mention from Butler & McKenzie to Gray, etc. You ask:
how do you determine centration if structure has changed (femoral neck anteversion, tibial torsion, etc)?
Structural centration is not our goal, but functional dynamic stability is.
The wall angel is an ideal test for postural centration or vertical stability
Clearly in this test we are looking at all the postural signs which Pr Janda enumerated (head forward, rounded shoulders, sway back, etc)
The same can be said for the Quadruped position - Bird Dog where in addition we learn about frontal & transverse plane control of the pelvis
Another useful test of postural-functional centration is the squat & in particular single leg squat - where the foot & knee also are highlighted.

In the end patient- centered care is always empirical so your quote
“Low back cases are a case study of one” --McGill
is apropos. This is where the art of muscuoskeletal medicine trumps evidence-informed care which rigidly adheres to uni-modal instead of multi-modal care. The beauty of Pr McGill's model is he always follows the Clinical Audi Process - like McKenzie & Lewit - & looks for the positive slope. The patient's symptoms must RESPOND to the therapy.

Great question which I hope stimulates further dialogue.
Sincerely,
Craig

[rvanmatre]

Since this thread has gone dry, I look at this comparison from a different perspective, looking backward through both Stu's and Pavel's notes as to determine the desired goals/effects of the therapy, i.e. the outcomes. Both stand on common footing as they desire to have the pt conceptually understand the desired motor pattern that is better suited for their particular task or activity. Pt cognition is what is key.
I've always liked the quote from Bruce Lee in "Enter the Dragon,"

It is like a finger pointing towards the moon,
don't focus on the finger or you'll miss all the heavenly glory.

Ryan

[brandonsteele]

It would be very difficult to disagree with Craig's or Ryan's post as I agree with them both. As for combining the work of Kolar and McGill I did state that in the wrong context as I play with both concepts with each patient every visit. There is nothing more satisfying than using the assessment and bracing methods to individualize treatment/training for each patient using McGill protocols. This can usually take someone out of pain within the first visit.
Now this is for discussion only since I can't prove in the literature or through conversation with people much smarter than I: How in the world can we take afferent stimulation and create efferent coordinated movement without thought????? Is this a reflex, and please provide insight or a source. I personally do not think these are reflexes but are learned processes by the patient or baby.

I have spent countless hours reading journals, books, and talking with these practitioners with an open mind on the developmental process. I understand spinal and pathologic reflexes but those are at the spinal level with some cortical influence. I want to understand and make this work in my mind but it does not. I cannot tell myself that a baby has pre-programmed motor programs. Personally I think that a baby will try 1000's of ways to produce movement until they find the most efficient position or muscle/joint combination to complete a task. This is neural plasticity plus CONSCIOUS THOUGHT, and it has been proven. Once one task is mastered then the baby can move through the process of verticalization using the same principles with each new milestone building on top of each other. If there is abnormal development in the brain of the baby it can't learn to optimize movement, build motor programs, and ultimately be stuck with abnormal anatomy due to improper muscle synergy.

So with my "different" view of Kolar's paradigm I will go back to my original post. I don't think with these changes in anatomy and function we can go back to initial developmental positions. Instead using his concepts, initial positions, and McGill's nack for stabilization exercising we can create a new optimal movement patterns specific for each patient. These CNS movement engrams taught in clinic and practiced at home will create a new, more efficient, motor stereotypes and postures specific to this patient. This is the cerebral process the Ryan spoke of that I couldn't agree with more. The patient has to feel and see themselves perform these movements to learn the pattern of muscle synergy required. We just have to teach them how to think--not easy.

So is it conscious thought or reflex changes in neurophysiology that allows these people move properly? Maybe both, I don't know. I have seen Pavel perform "miracles" without ever talking to the patient so I know that I am missing something.

This is purely theoretical and please don't take offense to it. I am just trying to create my paradigm for treatment. I love the work of both McGill and Kolar along with the criticism of everyone on the site. Thanks

[rvanmatre]

Brandon, development theory is exactly that, theory. To answer your question,
How in the world can we take afferent stimulation and create efferent coordinated movement without thought?????
assumes that we fully understand human development. We don't. Several competing theories such as the neural-maturationist, cognitive/behavioral, cognitive/piagetian are all represented in the current literature. Most recently "dynamic systems theory" seems more plausible to me personally. Basically recognizing that there are various stages of human development that are relatively stable arising from the self-organizing, emergent properties of other systems each emerging and developing at potentially different rates.

Your question seems to suggest a common error when one first studies reflex stimulation. I mention to students in my courses that they seem to think it is "push-button." If I press here (X), while the pt is in this (Y) position, I can then expect (Z) movement to occur. It is not a linear system. Pavel suggests possible theory, but it too is still in its scientific infancy. Vojta first discovered reflex stimulation while giving a lecture. He was holding a CP baby and after he had made his introduction to the audience he noticed that the child's muscle tone had changed globally. Vojta therapy has always focused on the outcomes for the child, not the process or theory. I've viewed some of the most experienced Vojta practitioners worldwide and with each there is a universal sense of humility with their pts when using reflex-stimulation. They comment that we shall try it and see. When Vojta was asked if his therapy would help a particular child, Vojta replied, "Only God and the child know if it will be effective.”

Theodore Hellbruegge who was close friends with Vojta first observed this with his examination of the Lebensborn babies after the fall of Nazi Germany. In a most horrendous study, newborns were taken from their family and developed and raised under ideal environmental conditions. Hellbruegge noticed that the attention of the mother (talking, optical fixation, loving, smell, etc) was essential for normal human development (including motor development).

Your comment on witnessing Pavel performing "miracles" leads down a dangerous road. I have studied with Pavel for nearly ten years and I have yet to see a miracle. From a scientific standpoint, I am not interested in the divine. I'm interested in the reproducible.

Ryan

[brandonsteele]

Thank you for your reply and thoughts. It is a dangerous road not to have reproducible outcomes. I think using the word miracles was probably in the wrong syntax. Regardless, concerning development theory, Do you have suggested books or sources that I can read more on this. I think I have gone about this a little backwards learning about the neurology of pain, plasticity, processing, etc while skipping over the development.
Thanks

Brandon Steele
Staff Physician
Central Institute of Human Performance
1099 Milwaukee St STE 240
(314) 822-1001
www.cihp.com

[Craig]

Brandon,
Your comment is very exciting.
"The patient has to feel and see themselves perform these movements to learn the pattern of muscle synergy required. We just have to teach them how to think--not easy.

So is it conscious thought or reflex changes in neurophysiology that allows these people move properly? Maybe both, I don't know. I have seen Pavel perform "miracles" without ever talking to the patient so I know that I am missing something. "

Lewit taught that manual therapy "miracles" are really expected since they obey the rules of the road of the "Functional Approach". Namely, that functional disorders are reversible, whereas structural ones are not."

I believe your point that the patient has to develop the kinaesthetic sense of a movement is key. This is the strength of Pr McGill's paradigm. He wants to "get the tape running.". As you suggest it is via feedback & feedforward that movement patterns form as engrams. We must constantly correct until we get it right. If I read you right then using developmental positions may be a catalyst, but it can't be an end. Functional training must be the end. Is this correct? By the way this is my view.

Thanks,
Craig

[tyler]

Brandon,

In regards to the comment about a baby having pre-programmed motor programs, I have understood the process a little differently. My understanding has been that the programms are formed as the baby develops and that all afferent infomation is involved including emotional stimulation as well. For example, the baby is in the prone position bearing weight on the elbow, ASIS and contra knee. The sensory informantion from that stimulates proper muscle coordination, in addition to the emotional desire to get to his mother, for example. This makes it much more than just an afferent stimulation of certain sensory points on the body. An absence of any of these neurological stimulations leads to problems.

[cfrank]

okay - I'm going to jump into this thread...I'm new to this, so bear with me.
I am using developmental positions and reflex stimulation as a "catalyst" (as Craig describes it) and a way to access the brain's "operating system" and motor programs. The ultimate goal is to get the patient to utilize these "awakened" programs and muscle activation cortically and functionally, thus training the patient functionally is equally important.

My understanding is that we all come into this world with genetically pre-determined motor patterns (eg. operating system) and a immature CNS.... These motor program mature as the CNS matures, Muscle function is encoded in these programs. The most simplistic way of saying that is that we lift our heads, roll, creep, crawl, stand, and eventually walk in a set progression. A key point to all this is that muscle balance/co-activation occurs in a predictable manner through this as well allowing us to do these things. Those with CNS lesions, i.e. CP, are going to show abnormalities with muscle function and locomotor progressions. A study by Prectal (? - I still cannot find the reference that Kolar quoted) states that 30% of children do not develop in an ideal manner and this will show up in dysfunctions like poor scapular stability, flattened longitudinal arches in the feet, and scoliosis, etc.
The other type of motor behavior is the result of motor learning, conditioned reflexes that are formed by constantly repeated stimulus. These can be helpful or detrimental depending on the patterns that are formed by constantly repeated stimulus. The patterns that are detrimental are the ones that cause overstress at certain segments due to non-ideal centration of joints and muscle balance.

[rvanmatre]

Hi Clare, it is great to hear from you. While I'm not familiar with Prectal's publication, here are some recent findings:

Glascoe and Macias have estimated that up to 30% of children with developmental problems are not detected before they begin school with other studies suggesting failed detection rates closer to 50%.16,17 Studies show that children with delays have 1.5 times the number doctor visits, 3.5 times the number of hospital days and miss twice the number of school days as compared with children who have no delays.1 Controversy remains among providers and developmental specialists as to what constitutes a problem and necessitates intervention.18 The 2001 American Academy of pediatricians noted that only 15% of pediatricians always used a development screening tool. Seven out of ten providers relied on clinical judgment, though this method identifies less than 30% of children with mental retardation, learning disabilities, language impairments and other developmental delays.11,19 This confliction of health care opinion is passed on as frustration for the parent of determining what is normal, what is not and what should be cautiously monitored. This is especially true in milder cases of developmental delay.18 This frustration has led to recent publications of motor assessment analysis of the developing child in other areas of the world.6,20-22 These publications seem to fill a social need to educate parents who are uncertain in the development of their child and serve as a resource to open discussion avenues with their pediatrician.

I hope all is well .
Ryan

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