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The Performance Lab A place to discuss the role of physical exercise on health in diseased and non-diseased states.

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Old 25-01-2007, 09:19 PM   #201
John A. Casler
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Originally Posted by Jason Silvernail View Post
Good find, Jon.
This is pointing (again) away from strength/stability models and towards a motor control model for understanding these concepts.
It's worth noting that even under load, the %MVIC was pretty low.

I would reiterate my previous point in that researchers in the area are looking at this from the motor control perspective. Here's a link that explains this better:
Motor Control and LBP

I attached the full text of the study protocol.

J
Hi Jason,

This is an excellent study.

It might also demonstrate the "faulty" direction I had mentioned earlier, that "doesn't work".

I thought you said that the Aussies had changed direction, but the protocol (that they found did not work) was more of the same focus on TvA, Multifidus, and "magic bullet" type protocol.

I do agree that "motor control" is an element, but the errant view of focus Hodges adds to most of the research studies he is involved in is questionable as far as I am concerned.

Maybe over time, I will be able to add enough of the pieces of the puzzle that I use, against what has been done by others to offer insight as to the differences.

But to be perfectly clear, I do not "focus" on magic bullets, but more a natural integration and reconditioning of the TSM.
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Old 25-01-2007, 09:22 PM   #202
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Originally Posted by Diane View Post
And the "fit" depends on the comprehensive capacity of the recipient.

At least one of these constructs is nervous system based. This may not make it more comprehensible or accessible, but such a construct fits with reality better than systems that do not consider the nervous system, that rely solely on biomechanical or structural explanations.
Hi Diane,

While I have offered significant biomechanical information, I must assure you that what I refer to as the TSM, is inclusive of a fully integrated activation of the CNS which includes both sensory and motor considerations.

Sorry if I led you to beleive otherwise.

Last edited by John A. Casler; 25-01-2007 at 09:38 PM.
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Old 26-01-2007, 01:20 AM   #203
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I must assure you that what I refer to as the TSM, is inclusive of a fully integrated activation of the CNS which includes both sensory and motor considerations.
Thank you for that explanation John.
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Old 26-01-2007, 06:19 AM   #204
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Hi John. Glad to see you back.

Re: medical claims-
Since you keep asking me to disregard the site and you haven't addressed your statements one way or another, I'll take that as your rejection of the claims. Fair enough.

Re: efficacy-
You state "I can only assume that you are well versed in this area, so how do you know that anything you do, is effective? You can't."
I find it difficult to grasp what you're getting at here. Are you saying there's no way to know if anything we ever do is effective? I use treatments that are supported by solid outcomes research and I use treatments based on a sound theoretical construct inclusive of pain science. So of course I know they work, and I can prove it. I could post studies if you're interested. We are still are left with three options for good practice - outcome studies, theoretical rationale, or both. What I do has at least one of the three. Your TSM training system seems to have none of the three.

Re: why people hurt-
You state "Your only option is to assemble an understanding of all the processes, and mechanisms and know that a large majority of problems are caused by mechanical failure, leading to damage.
While you may disagree with that..."
I have peer-reviewed evidence that indicates this mechanical failure and damage is not related to pain. So yes, I do disagree with that statement, since it is based on an old biomedical damage=pain concept that has since been proven inaccurate.

I don't mean to defend Hodges et al, but I find it interesting that you take such a dim view of their research. They had a theory (TVA and Multif not activating to provide stability) they liked and studied. They didn't get the results they wanted and incorporated other research (pain science and McGill's biomechanics work) to develop a new theory and a different approach.
You seem to have doggedly stuck with a theory of pain (mechanical failure and damage) which has been shown inaccurate. So who's changing with the evidence and who isn't?
Again, I could post the relevant studies if you're interested.

Re "magic bullet"-
What makes one training and conditioning approach a magic bullet and another not? This seems to be a fair descriptor for your system of conditioning the TSM to treat pain.

On Pain-
You state "Does that mean mechanical/chemical damage/irritation is not the cause of the "majority" of LBP?" We finally agree. Nociception is caused by mechanical and/or chemical stimulation, and I would agree that the evidence supports nociception as the primary factor in a pain experience.

We agree on concepts of strength and conditioning and on the origin of nociceptive drive. Where we part company is on the proposed solution to the problem.
Jason.
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Old 27-01-2007, 11:40 PM   #205
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Quote:
Originally Posted by Jason Silvernail

Re: efficacy-
You state "I can only assume that you are well versed in this area, so how do you know that anything you do, is effective? You can't."
I find it difficult to grasp what you're getting at here. Are you saying there's no way to know if anything we ever do is effective? I use treatments that are supported by solid outcomes research and I use treatments based on a sound theoretical construct inclusive of pain science. So of course I know they work, and I can prove it. I could post studies if you're interested. We are still are left with three options for good practice - outcome studies, theoretical rationale, or both. What I do has at least one of the three. Your TSM training system seems to have none of the three.
Sorry I didn't explain it well.

While the treatments you use may have research supported outcomes, the multi-factorial elements that contribute to the "lumped" category of LBP are not all included in that (or most research)

I was not questioning your treatments, or the faith you put in them, which could be based on many different things, including experience, education, awareness of research, sharing with colleagues, and others. (including this and other forums)

To be frank, studies are of less interest to me than reasonable discussion of method, and experience.

Now regarding the TSM, what is it that you have practical or theoretical doubts about.


Quote:
Originally Posted by Jason Silvernail


Re: why people hurt-
You state "Your only option is to assemble an understanding of all the processes, and mechanisms and know that a large majority of problems are caused by mechanical failure, leading to damage.
While you may disagree with that..."
I have peer-reviewed evidence that indicates this mechanical failure and damage is not related to pain. So yes, I do disagree with that statement, since it is based on an old biomedical damage=pain concept that has since been proven inaccurate.
Maybe we are talking about two different things here. If you pull or tear a muscle, herniate a disc, expel nuclear material into the nerve canal, you have mechanical, and chemically caused pain. Is this what you are talking about? or can you give an example of the non-physical based pains?


Quote:
Originally Posted by Jason Silvernail

I don't mean to defend Hodges et al, but I find it interesting that you take such a dim view of their research. They had a theory (TVA and Multif not activating to provide stability) they liked and studied. They didn't get the results they wanted and incorporated other research (pain science and McGill's biomechanics work) to develop a new theory and a different approach.
Maybe I read the study wrong, but it seemed to be the same old thing, and they even found themselves wrong. Did you look at the core protocol they used? It was the old TvA/Multifidus rehash from what I gathered.

Quote:
Originally Posted by Jason Silvernail

You seem to have doggedly stuck with a theory of pain (mechanical failure and damage) which has been shown inaccurate. So who's changing with the evidence and who isn't?
Again, I could post the relevant studies if you're interested.
No studies needed, but please expand on how, and how often, pain (LBP) is caused without physical damage to initiate it.

Quote:
Originally Posted by Jason Silvernail

Re "magic bullet"-
What makes one training and conditioning approach a magic bullet and another not? This seems to be a fair descriptor for your system of conditioning the TSM to treat pain.
Magic Bullet is not an original phrase of mine. As I understand it, it generally means finding a small ingredient or element, that can make all the difference in a larger system.

The TSM "is" the whole system. Treating it as a whole will generally treat the system's weaknesses and has no "magic bullet" qualities at all.


Quote:
Originally Posted by Jason Silvernail

On Pain-
You state "Does that mean mechanical/chemical damage/irritation is not the cause of the "majority" of LBP?" We finally agree. Nociception is caused by mechanical and/or chemical stimulation, and I would agree that the evidence supports nociception as the primary factor in a pain experience.
???? You have spent several paragraphs telling me that pain is not caused by the above, and then agree.

Call me confused, but I still need significant explanation to see where you said we disagree and then turn around and say we agree. I was never focusing on Neurophysiology, but the greater cause, not the perception mechanisms.

I have no interest in dealing with a "symptom". Pain is a symptom of a problem, and caused by something. I look more at dealing with the cause.


Quote:
Originally Posted by Jason Silvernail
We agree on concepts of strength and conditioning and on the origin of nociceptive drive. Where we part company is on the proposed solution to the problem.
Jason.
Well from the above, we may not be as far apart as you think.

Could you be more "specific"?

If we agree on the element of strengthening and conditioning, and the cause of pain, then I might suggest what we "disagree on" might be a "projected perception" of what the TSM is, and how it is valuable.

Please expand on where we "part company" (and I don't mean this in an antagonistic way)
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Old 27-01-2007, 11:44 PM   #206
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can you give an example of the non-physical based pains?
Phantom limb pain.
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Old 27-01-2007, 11:58 PM   #207
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Phantom limb pain.
Thanks Diane, but we were discussing LBP. Is Phantom Limb Pain that prevalent in causing LBP?
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Old 28-01-2007, 12:03 AM   #208
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Oh, pardon me. I thought we were discussing pain, period.
There will be overlaps, although to be sure, the trunk in general and the back in particular does not have a large representation in terms of a representation on the sensory cortex. Which doesn't mean to say that back pain can't be "created" by the brain and projected in the back. The brain can make pain that can be felt anywhere.
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Old 28-01-2007, 02:17 AM   #209
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Hi John,

You state

Quote:
Pain is a symptom of a problem, and caused by something. I look more at dealing with the cause.
When a person in pain comes to you, how do you determine what the problem is and what caused it? From your posts so far I get the idea that it is always due to a deconditioned "TSM".

A request: Could you define "TSM" more succinctly or point to where this term appears in scientific literature?--I've gotten lost as to what it is supposed to entail.

Thanks
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Old 28-01-2007, 02:32 AM   #210
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Here is an excerpt from a book I'm studying just now on the autonomic nervous system.
Quote:
Recruitment of normally mechanosensitive spinal visceral afferents under pathophysiological conditions (e.g., during inflammation) may apply to all visceral organs. For example, various structures in the retroperitoneal space, such as blood vessels, nerves, lymph nodes, etc., are innervated by afferents that are normally not activated, but are recruited in pathophysiological states (Bahns et al., 1986b). During angina pectoris, afferents may be sensitized and recruited, although Malliani believes that this is not the case (Lombardi et al. 1981). It is a matter of debate whether these silent and normally mechanoinsensitive visceral afferents constitute a distinct category of spinal visceral afferents that is recruited under inflamed and other pathophysiological conditions or whether these afferents are frankly extremely high-thresholds nociceptive fibres (for discussion see Cervero [1996]).
What this means (in regular English) is that if abdominal organs are inflamed one can experience back pain because of sensitization of similarly innervated structures that are not spinally structural (i.e., they are blood vessels, nerves, lymph nodes), yet happen to be situated in front of the spine, behind the peritoneum (membrane enclosing the organs).
It is an example of back pain that is not "physical-based."
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Old 28-01-2007, 04:37 AM   #211
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Quote:
Originally Posted by John Casler

Pain is a symptom of a problem, and caused by something. I look more at dealing with the cause.
Quote:
Originally Posted by Jon Newman
When a person in pain comes to you, how do you determine what the problem is and what caused it?
Hi Jon,

I thought I already answered that. I don't have a practice so people don't come to me with medical issues, and I don't practice medicine or rehabilitative therapy in a clinical setting.

My statement above relates to my seeking out answers to the majority of Torso and back problems I have encountered.

Additionally I work with various clients in overall conditioning and training programs. A quite high percentage have the same LBP prevalent in most of our society.

Quote:
Originally Posted by Jon Newman

From your posts so far I get the idea that it is always due to a deconditioned "TSM".
From the people I encounter, I haven't found a non-responder. Most everyone can benefit from conditioning or reconditioning the TSM, unless they are all ready at a sufficiently high level and only require maintenance to maintain that level. The same is true for all of the bodies systems, circulatory, respiratory, digestive, endocrine, etc.

Quote:
Originally Posted by Jon Newman
A request: Could you define "TSM" more succinctly or point to where this term appears in scientific literature?--I've gotten lost as to what it is supposed to entail.
I doubt you'll find it in any specific scientific literature since I developed the term myself.

As far as what it is:

It is the sum total of structures, muscles, and processes that activate or participate in support of the Torso as it conducts, creates, or absorbs forces.

It is extremely complex and I don't pretend to know all there is to know regarding its activation, but have explored many significant areas, and feel I have a rather good handle on much of it, to the point of sharing it.

I certainly can understand your apprehension, and am well aware of the fact than many have been bombarded with other more traditional research and educated opinion, which I may call into question. I am not totally "uneducated" having been in the PT Curriculum when in school, but not going for a degree for various reasons.

I have no problems with questions about the system or my opinions on the subject, since My purpose is not to "sell" anything, but to explore areas that might need more "light" and offer what some might see as "opposition" to some very traditional directions that I might view differently and why.

If that doesn't fly with someone, then at least they have been exposed to an alternative viewpoint that may "click" a bit later in their awareness program.

On a list like this, it is difficult to assess the collective level of understanding or awareness of all the elements. Is everyone familiar with disc anatomy/structure and dynamic capabilities, the evolution of the spine, all the pressures and processes that are created and modulated during stabilization, the kinetic chain snapshots that tell us what activations are taking place to manage loads, why and how small forces can cause damage, that large forces managed well may not, what structures will heal and how long they take in relations to each other, what does cross sectional area have to do with load support, how do the ribs function in torso stabilization, what role does the TvA play and how is the thoracolumbar fascia involved, what is a Valsalva Maneuver and what could it have to do with the TSM, function and structure of the vertebrae, why is the diaphragm important to the torso, why are most herniations and protrusions posterior lateral in lumbar discs, why do many have "morning back ache" and feel fine later in the day, what postures are best for sitting, walking, standing, lying, how to get in and out of a low sports car with typical back pain, and many many, many, other things.

So there are many elements to look at that provide discomfort to pain in many who suffer from typical, and simple LBP. (which obviously is anything but typical and simple)

If traditional therapies worked, we would see a reduction in the problem. We have not and will not. As much as it is a National and Worldwide problem, with all of you on the front lines, it has not improved at all.

So what is needed? First more exploration of the causes of the majority of cases. You can form your own opinion about what that is based on your practice and experience. Then it would seem that a rather significant amount of education to those in charge of the responsibility of rehabbing and then reconditioning those with the most serious problems might be in order.

And the on the final leg we might have the most difficult of tasks and that is "education" of those who must understand the basic concepts of maintaining a level of conditioning to the TSM that provides a higher level of resistance to the loads and forces that could cause serious medical damage, or to keep from reinjuring themselves if they are already sufferers.

Personally, I think it is worth discussion, sharing, and exploration and do so at every opportunity.

While I might not meet the criteria of what you might consider a "scientific reference", what I suggest will cause you to either accept or reject certain things, and offer you the awareness from which to filter new information.

If you reject what I suggest, it is either because you know more than I, and should share that with me, or I have elements that you might find will add to the puzzle you have been constructing on the subject.
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Old 28-01-2007, 04:47 AM   #212
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Originally Posted by Diane View Post
Here is an excerpt from a book I'm studying just now on the autonomic nervous system.


What this means (in regular English) is that if abdominal organs are inflamed one can experience back pain because of sensitization of similarly innervated structures that are not spinally structural (i.e., they are blood vessels, nerves, lymph nodes), yet happen to be situated in front of the spine, behind the peritoneum (membrane enclosing the organs).
It is an example of back pain that is not "physical-based."
Would you estimate that more than 50% of your LBP patients suffer from this? 20%? 10%? or what % have you encountered?
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Old 28-01-2007, 05:02 AM   #213
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I treat all back pain as a nervous system based ailment. Only rarely anymore do I bother with any specifically biomechanically based approach.
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Old 28-01-2007, 02:00 PM   #214
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I'm with Diane on that. All pain is neurogenic, and there are only 4 origins to such a problem. I see most of the mesodermalists over-thinking the issue.

Constantly considering the countless causes confounds every clinician.

There, a little alliteration for you guys this morning.

This is a well attended thread so I'm going to stick in a question that is actually somewhat related. Anybody heard of this new device, a ray gun in effect, that sends a microwave signal toward another and makes them feel as if their flesh is burning?

I presume that the victim recovers immediately. Isn't this a wonderful example of pain in the absence of injury?
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Old 28-01-2007, 02:19 PM   #215
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Louis Gifford writes," It is important to note that we are full of dysfunctions whether we are not in pain or not. If we are in pain it is easy to find something wrong relevant to a precise tissue model but which may not be relevant at all to the patients state’ .

Pretty much sums up the problem with out current treatment concepts.

John , this should help you understand why the mechanical based pain treatments have not been very succesful as you said.

http://www.pponline.co.uk/encyc/sports-injury-pain.htm
http://www.pponline.co.uk/encyc/biop...ocial-pain.htm

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Old 28-01-2007, 02:26 PM   #216
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Such sensible articles Anoop - thanks. I thought this statement (from your first link) was particularly relevant to this thread:
Quote:
Finally Stephen and Louis will discuss how this new, evidence-based approach is forcing us to re-evaluate some of the current treatment approaches to chronic neck, shoulder and back pain, such as core stability training, and why some of these current approaches may even be counterproductive in the longer term.
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Old 28-01-2007, 04:12 PM   #217
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John-

I think we have a few very key differences that keep us apart, theoretically.
Here is a brief rundown of the basics of why you and the other forum members have a different point of view, in my opinion"
We attribute the problem in the periphery (outside the brain) to either mechanical or chemical irritation of nervous tissue. This has nothing to do with "damage" to any structure. I know you said you're less interested in studies, but we do have several MRI studies showing asymptomatic people with herniated disks, degenerative disk disease, and stenosis. So if their TSM isn't working to stabilize and prevent damage, then why don't they hurt?
When you say you see pain as a symptom, we see it as the problem itself. When you say you try to get to the underlying cause, we reject causes (there are too many and no one has any idea which one is responsible) and focus on the tissue of interest, the origin of the pain. This is nervous tissue.

Does this help?
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Old 28-01-2007, 05:31 PM   #218
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Jason,

I concur.

I'm stuck on this microwave weaponry that's floating around in my head today and did a brief search. It doesn't appear to be new. What I found about its effect was the following quote from a web site somewhere:

Highly disciplined US military volunteers confirm after live tests that the pain inflicted by this latest wonder weapon is so intense, the instant and overwhelming reaction is panic. Rich Garcia was subjected to the microwave beam during testing in New Mexico. “It just feels like your skin is on fire,” he said. “When you get out of the path of the beam, or shut off the beam, everything goes back to normal. There’s no residual pain.” [India Telegraph Sept 19/04]

This sounds like Wall's "withdrawal" instinct, the first of his three responses to painful signals, and, in this case, all that would be needed to "escape" from pain. Of course, our patients or clients with back pain can't run from the stimulus so easily. Still, the withdrawal, protection and resolution needed are, according to Wall, impossible to impose upon another simply because thay are instinctive. I think that the thing that separates some of us from John most profoundly is our appreciation of the instinctive, especially the instinctive processes and behaviors that relieve pain in the absence of injury or clearly identified and relevant dysfunction.

This is the same thing that draws the distinction between my work and Hruska's Postural Restoration and Barnes' and Upledger's fantacies of fascial restriction and past-life karmic retribution.
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Old 29-01-2007, 08:17 AM   #219
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Quote:
Originally Posted by John A. Casler
Would you estimate that more than 50% of your LBP patients suffer from this? 20%? 10%? or what % have you encountered?
I could easily reply: more than 95%.
The fact is that we do not "treat" structural problems. We are engaged in a more "functional" way.
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Old 29-01-2007, 09:15 AM   #220
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Anoop.

Excellent references! Mandatory reading for PTs who are still locked in the concept of pain resulting only from injury.

Probably 90% or more of patients seen in clinic have LBP that is not strictly physically-based. Which tends to explain why discectomies and laminectomies have not got a reputation for lasting pain relief; but the full blown sequestered IVDP (intervertebral disc prolapse) does need mechanical rescue, and it is relatively rare.

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Old 02-02-2007, 03:56 AM   #221
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Quote:
Originally Posted by Anoop
Louis Gifford writes," It is important to note that we are full of dysfunctions whether we are not in pain or not. If we are in pain it is easy to find something wrong relevant to a precise tissue model but which may not be relevant at all to the patients state’ .
Hi Anoop,

What little I have read (and it is only from the exposure from this group -thanks) has me thinking that he is a bit like the Aussies I have a tendency to look critically at in their Core Therapy approaches.

While I don't "specifically" disagree with Gifford, I have a tendency to see that it is simply an altering of perspective and focus of awareness.

Quote:
Originally Posted by Anoop
Pretty much sums up the problem with out current treatment concepts.

John , this should help you understand why the mechanical based pain treatments have not been very successful as you said.

http://www.pponline.co.uk/encyc/sports-injury-pain.htm
http://www.pponline.co.uk/encyc/biop...ocial-pain.htm

Anoop


Thanks for the link (the second didn't work so I didn't see it)

But I don't have any major problem with what Gifford says here.

And it doesn't make any statement that could be interpreted as meaning that conditioning the body will not reduce its exposure, or increase its resitance to injury or irritation caused pain

He seems to want to find some new perspective that will somehow change the way we view things, but recognizing that injury based pain can sometimes cause additional injury to the nervous system is not something most aware not aware of.

And injury or tissue damage without pain is not either, and doesn't change that most pain is caused by mechanical or chemical damage or irritation.

This does move away slightly from my suggestion that a specific type of core conditioning would reduce the possibility of injury, and reoccurrence of injury, which is what this thread seemed to be about.
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Old 02-02-2007, 04:32 AM   #222
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Hi John.

Have a look at this one as well.

Quote:
a specific type of core conditioning would reduce the possibility of injury, and reoccurrence of injury, which is what this thread seemed to be about.
I wouldn't necessarily disagree with this, especially if you change "reduce the possiblity of injury" to "increase the tolerance of tissue to stress." But the old broken horse here is, why would an increase in tissue tolerance to strain before failure lead to a change in pain.

The essay above creates a bit of a link between tissue tolerance to strain and pain. It is but one small peice of adaptive potential.
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Old 02-02-2007, 04:32 AM   #223
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Quote:
Originally Posted by Jason

I think we have a few very key differences that keep us apart, theoretically.
Here is a brief rundown of the basics of why you and the other forum members have a different point of view, in my opinion"
We attribute the problem in the periphery (outside the brain) to either mechanical or chemical irritation of nervous tissue. This has nothing to do with "damage" to any structure. I know you said you're less interested in studies, but we do have several MRI studies showing asymptomatic people with herniated disks, degenerative disk disease, and stenosis. So if their TSM isn't working to stabilize and prevent damage, then why don't they hurt?
That is a confusing question since what you really mean is, if they have damaged tissues why don't they hurt.

They don't hurt because there is no pain receptor to send the signal or it is not functional.

That has nothing to do with the TSM protecting tissues that DO have pain receptors that function when damage, or irritation are experienced.

I wonder why and how some use that as a key issue?

Just because there is occasional tissue damage or trauma where little significant or any pain results, this has nothing to do with the fact that one of the primary functions of the CNS is to tell the brain when there is a problem. It also doesn't lessen the far more prevalent pain caused by this damage or irritation.

Pain and the degree of it, as you know, is based on many different factors.

Additionally, the examples of herniated disks, degenerative disk disease, and stenosis without pain are not relevant to those that exhibit pain, Observing that one exists in the absence of pain and the other doesn't, does not make the implementation of a system that could reduce damage to either less relevant,

Because those tissues, painful or not, are in a system that functions optimally when they are functional and conditioned. The fact that they have failed or are failing is an indication that supporting the TSM would help in carrying some of the load resulting from their failing.

Quote:
Originally Posted by Jason

When you say you see pain as a symptom, we see it as the problem itself. When you say you try to get to the underlying cause, we reject causes (there are too many and no one has any idea which one is responsible) and focus on the tissue of interest, the origin of the pain. This is nervous tissue.

Does this help?
Please know that I have not been critical of anyone for treating pain. However, depending on the cause of that pain, there may be treatments to eliminate or reduce the cause.

Nervous tissues do not respond for no reason. They are messengers. One cannot say "pain, causes pain" unless it is purely a "psychosomatic" cause. Even pain caused by chronic pain signals creating irritation is caused by an electro-chemical irritation.

So I guess some might consider "Core Strengthening and Conditioning" Useless, especially if they do not do it effectively, but there is little doubt that when done effectively in a way that promotes a well conditioned response of the TSM, it can and will save many a lot of pain.
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Old 02-02-2007, 04:34 AM   #224
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Here is a better link:
Biopsychosocial-pain.
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Old 02-02-2007, 04:42 AM   #225
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Quote:
Nervous tissues do not respond for no reason.
Yes, they can. Phantom limb pain for one. And in people who never ever had a limb, were born without one - experienced no trama.
Quote:
They are messengers.
Among other things. They also secrete, like glands. As a system, the entire nervous system is only 2% of the mass of the body (including that human brain that is 7 times larger than needed to run a mammal our size) but uses 20% of the oxygen - a high-maintenance system.
Quote:
One cannot say "pain, causes pain" unless it is purely a "psychosomatic" cause.
I get the feeling that you think any source of pain above the level of the foramen magnum is "psychosomatic." I assure you, there is a lot of non-conscious activity up there, and in the spinal cord itself, that can go quite wrong.
Quote:
Even pain caused by chronic pain signals creating irritation is caused by an electro-chemical irritation.
? How about hypoxia?
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Old 02-02-2007, 04:56 AM   #226
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Quote:
Originally Posted by Barrett
I think that the thing that separates some of us from John most profoundly is our appreciation of the instinctive, especially the instinctive processes and behaviors that relieve pain in the absence of injury or clearly identified and relevant dysfunction.
Hi Barrett,

Haven't seen you for some time. Your presence and occasional visit to SUPERTRAINING is missed.

Sorry if I have given anyone the impression that I am "anti-instinctive" for that is the last thing I am.

It was my search and study of instinctive and reflexive acts and actions that led me to this path.

I might also correct the perception that I think "injury" is the only cause of pain.

Obviously it can be caused by many elements both physical, chemical, electrical, or even from radiation. Additionally there are many significant examples of pain caused by simple pressure, but no damage to speak of. My grandfather used to grab my nose and squeeze it causing rather significant pain, but little real damage or injury.

Your military "Ray Gun" is an example of pain, but it isn't magic. It is simply radiation irritation, or manipulation of the molecules in the skin (and maybe other tissues] by radio frequencies.

I too found the report "very" interesting.
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Old 02-02-2007, 05:45 AM   #227
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Quote:
Originally Posted by John
a specific type of core conditioning would reduce the possibility of injury, and reoccurrence of injury, which is what this thread seemed to be about.
Quote:
Originally Posted by Cory

I wouldn't necessarily disagree with this, especially if you change "reduce the possiblity of injury" to "increase the tolerance of tissue to stress." But the old broken horse here is, why would an increase in tissue tolerance to strain before failure lead to a change in pain.
Squeeze your friends fingers till they hurt. Then squeeze them till they break, and ask him which hurts more.

So if placing 200# on somones shoulders causes pain from tissue damage, and you conditioned them to have the abilty to use 400# without pain from injury, then you have your answer.

Quote:
Originally Posted by Cory

The essay above creates a bit of a link between tissue tolerance to strain and pain. It is but one small peice of adaptive potential.
From what I can see Barrett and I are pretty much "in sync", according this and what I have read before of his posts.

I remember many of the great pro and con "posture" exchanges from another list.
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Old 02-02-2007, 05:59 AM   #228
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Quote:
Squeeze your friends fingers till they hurt. Then squeeze them till they break, and ask him which hurts more.

So if placing 200# on somones shoulders causes pain from tissue damage, and you conditioned them to have the abilty to use 400# without pain from injury, then you have your answer.
This doesn't answer a thing. It is an example. I asked why.

Also, this is not as clear cut as it appears. Squeeze your friends fingers till they break while he is in the middle of heavy combat or about to be run over by a car and see if he notices. Patrick Wall recounts war stories of traumatic amputations during combat in which the soldiers reported......wait for it.......no pain. How could this be possible based upon your assumptions?

What makes the disc so special that it has a linear relationship of strain to pain that is absent in every other tissue of the body, including nerves?
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Old 02-02-2007, 06:58 AM   #229
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Originally Posted by John A. Casler View Post
They don't hurt because there is no pain receptor to send the signal or it is not functional.
That has nothing to do with the TSM protecting tissues that DO have pain receptors that function when damage, or irritation are experienced.
John-
This is quite a bold statement. Why would you say that those with degenerative spinal changes (disc disease, facet arthritis, stenosis, HNP) lack nociceptors or have a dysfunctional nociceptor? Do you have a scientific reference for that statement? This would essentially mean that those with tissue damage but no pain had some sort of selective neuropathy of their peripheral nociceptors. Given the prevalence of these asymptomatic changes/damage, I think we have an epidemic of neuropathy on our hands! I think it's important to realize that there's no such thing as a pain receptor, since pain is an experience generated in the brain as a response to incoming signals, and nociceptive drive from peripheral tissue is only part of that.

Quote:
Originally Posted by John A. Casler View Post
Just because there is occasional tissue damage or trauma where little significant or any pain results, this has nothing to do with the fact that one of the primary functions of the CNS is to tell the brain when there is a problem. It also doesn't lessen the far more prevalent pain caused by this damage or irritation.
I think if we look at those MRI studies of the asymptomatic, you'll see that this isn't "occasional" at all. It's the norm, rather than the exception. I think we're also back to the part where we have to figure out whether the pain (which you stated is more prevalent) is coming from this normal degenerative damage process or not. If you could determine this, you would revolutionize the treatment of back pain in the modern world.

Quote:
Originally Posted by John A. Casler View Post
Additionally, the examples of herniated disks, degenerative disk disease, and stenosis without pain are not relevant to those that exhibit pain, Observing that one exists in the absence of pain and the other doesn't, does not make the implementation of a system that could reduce damage to either less relevant,

Because those tissues, painful or not, are in a system that functions optimally when they are functional and conditioned. The fact that they have failed or are failing is an indication that supporting the TSM would help in carrying some of the load resulting from their failing.
How are these examples not relevant? You said pain comes from the tissues being damaged from a poorly conditioned TSM. I have demonstrated damage is common in the absence of pain. How then can we determine who needs their TSM trained and who doesn't? Or more specifically, who could have less pain from a conditioned TSM?
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Old 02-02-2007, 07:23 AM   #230
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http://magma.nationalgeographic.com/...inarticle.html

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If you feel something brush up against you, get out of the water. Make sure that you have not been bitten. There have been reports that shark-bite victims often do not feel any pain.
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Old 02-02-2007, 05:07 PM   #231
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Hi John,

I think this statement captures much of what is being discussed.

Quote:
So if placing 200# on somones shoulders causes pain from tissue damage, and you conditioned them to have the abilty to use 400# without pain from injury, then you have your answer.
Are you presuming the reason for this progression is causal and specific to a specific regieme of conditioning the core?
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Old 03-02-2007, 11:34 PM   #232
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Going back into the vault of learning, I found this thread that seems to capture some of the elements being discussed here although not specific to core musculature.

Adaptive Potential, Pain, and Training

Maybe some of those posting then have some new insights. I'll ponder my own contributions at the time and consider if any are due to be updated.
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Old 04-06-2007, 04:23 PM   #233
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Pain. 2007 Jan 10;
A systematic review of the relation between physical capacity and future low back and neck/shoulder pain.

Hamberg-van Reenen HH, Ariëns GA, Blatter BM, van Mechelen W, Bongers PM.

The results of longitudinal studies reporting on the relation between physical capacity and the risk of musculoskeletal disorders have never been reviewed in a systematic way. The objective of the present systematic review is to investigate if there is evidence that low muscle strength, low muscle endurance, or reduced spinal mobility are predictors of future low back or neck/shoulder pain. Abstracts found by electronic databases were checked on several inclusion criteria. Two reviewers separately evaluated the quality of the studies. Based on the quality and the consistency of the results of the included studies, three levels of evidence were constructed. The results of 26 prospective cohort studies were summarized, of which 24 reported on the longitudinal relationship between physical capacity measures and the risk of low back pain and only three studies reported on the longitudinal relationship between physical capacity measures and the risk of neck/shoulder pain. We found strong evidence that there is no relationship between trunk muscle endurance and the risk of low back pain. Furthermore, due to inconsistent results in multiple studies, we found inconclusive evidence for a relationship between trunk muscle strength, or mobility of the lumbar spine and the risk of low back pain. Finally, due to a limited number of studies, we found inconclusive evidence for a relationship between physical capacity measures and the risk of neck/shoulder pain. Due to heterogeneity, the results of this systematic review have to be interpreted with caution.
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Old 05-06-2007, 10:09 AM   #234
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hey louke, interesting study, but you remember stuart macgills book on low back pain, in that he says their IS a relationship between muscle endurance specifically the ab group(core?)and low back pain, dont have the book off hand but remeber him stating that clearly, backed by solid evidence, im gonna get hm find the book and get back to you
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Old 05-06-2007, 11:12 AM   #235
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Luke, would you consider that, given the wording of the abstract, evaluation of core musculature function was included in the study? I find it hard to determine that without the full text.

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Old 06-06-2007, 12:37 PM   #236
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Matt,
If I remember correctly (perhaps Jason can help here) there is some evidence for decreased endurance of the Lx extensors muscles - measured via the Biering-Sorenson test - being a predictor of Chronic LBP. McGill does state, however, that the balance of endurance between the extensors, flexors and lateral mm better discrimates LBP patients from normal - there is no reference though.

Nari,
This was a SRL so they were looking at the evidence from previous studies. I don't know if specific evaluation or core mm perimeters was an inclusion criteria in the review. I'll check it out.
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Old 06-06-2007, 01:20 PM   #237
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Luke, as an aside, why would lumbar extensors lose "endurance" in the first place?
Seems to me, the nervous system would (as usual) be trying to preserve itself somehow. Maybe the muscles are just fine (i.e., not misbehaving mesoderm), but the dorsal roots innervating them are stressed, so the system is inhibiting their ability to be contract/remain contracted over long periods.
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Old 06-06-2007, 01:36 PM   #238
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As usual, Diane has gone to the root of the problem. The issue is not that there's a loss of endurance or some other easily measured mesodermal function, but why that happened.

Preservation of the nervous system is the simplest possible reason.
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Old 06-06-2007, 04:03 PM   #239
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Diane, I agree - You have to ask "Why?".
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Old 06-06-2007, 05:15 PM   #240
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The Biering-Sorenson test has a mixed record of predictive ability.
Luke is correct in that McGill has said that it's the ratio that matters, but I've not seen any research that examined that hypothesis specifically.

There has been some effort lately to look at fat infiltration of the multifidi to see if it can be used to sort symptomatic vs asymptomatic:

Lumbar Multifidus and Fat Infiltration 1
Multifidus and Fat Infiltration 2
Lumbar Multifidus and Fat Infiltration 3

No time to post further now - will weigh in a bit later.
Brief summary - difficult to determine chicken vs egg here and whether we need to specifically train these muscles or whether normal use when pain is reduced/eliminated will resolve the "fatty infiltration" issue. There may be a role for reconditioning exercise in some patients - that doesn't mean strengthening exercises for those with spinal pain make sense. My approach is usually - movement for pain relief first, reconditioning second.
More later...
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Old 07-06-2007, 03:01 AM   #241
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Agree with Dianne about the root of the problem being neural, also with Jason in his pain first, exercise later solutions. Seems that when the central irritation is removed, normalisation in terms of recruitment and thereby, fatigue resistance follows. This is regularly seen in the upper limb after CM to cervical and upper thoracic joints. As protective events drop away at and around these joints , normal behaviour returns to observed scapulohumeral rythym , for one. Strength returns to the hand and shoulder , clicking behaviour stops at the GH joint. Athletic power returns. Much the same is seen in the lower limb and trunk. Antalgic behaviour stops when the pain stops. A strategy that then provides emphasis on exercise is warranted as these changes appear. Trunk strength and fatigue resistance is important , but not , in my own experience, as a primary mechanism for an attempt at restoring normal patterns of recruitment. Rather more to be used in a global non specific sense, as encouragement towards self management.
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Old 08-06-2007, 05:56 PM   #242
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I attached a few pages from Stuart McGill's book 'Low Back Disorders' (Bernard - should this be in the SoS?) that explains his position on the lumbar endurance issue.
He quotes some studies to support his position. I pointed out in the file the ones he mentioned in the text, though others in the reference list are supportive also.

Unfortunately, there are also some studies that support the "it's not that simple" view, or that don't show the Sorenson test to be a discriminator:
Link
Link 2
Link 3

I will say that I do use isometric hold times for some of my low back pain patients - usually for those who have not improved with other methods, and with whom I am using a more general "graded activity" program. For these patients (or any others, really) I think the effect of endurance or "stability" exercise has as much or more to do with the cognitive behavioral aspects then with any effects on the spine itself.

Indeed, if we look at this preliminary prediction rule , we can see that one of the predictive variables for success is actually a "higher" fear avoidance score. Now I'm thinking about how long this thread is and how long it's been since I've read it, and I'm wondering if this has come up before - oh, well. It bears repeating.

Bottom line for me - there is a role I think for reconditioning exercise. But if we think that this exercise is all about the spine, then we're fooling ourselves - like most things in physical therapy, it's more about the brain.
Attached Files
File Type: pdf Lx Endurance McGill.pdf (182.7 KB, 58 views)
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Old 08-06-2007, 06:29 PM   #243
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Jason,

Short citations are allowed in a scientific context.
Normally you have to add the authors and editor.
Just add this information and it will be fine.
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Old 23-06-2007, 09:40 AM   #244
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Quote:
Bottom line for me - there is a role I think for reconditioning exercise.
Jason,
What sort of reconditioning exercises do you feel are useful for these patients? Are the ones you find beneficial the same used in the studies you refer to or do you use exercises from other sources?
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Old 23-06-2007, 01:43 PM   #245
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I think there is definitely a measure of de-conditioning associated with persistent pain, and I use general core strengthening exercises to build that back. I also believe there is a strong cognitive-behavioral aspect to strengthening, and I think that's a big part of it as well.

I don't teach people to use the TrABD much at all anymore, I use the "global approach" of light bracing while performing core stability exercises. These are exercises that include but are more advanced than the ones used in the studies - mostly because I think people who are really in pain need education, deep breathing and movement, and not muscle strengthening. Since I put conditioning exercises later in the progression, they are more aggressive. I don't really buy much into the "core stabilization" thing as everyone here probably knows, but these are used for conditioning.

Some of these I posted here are only for those with minimal to no pain, who are working back into full sports activities (and in the US Army, full situps are still a fact of life).
Hope this helps.
As always, feel free to use these handouts yourselves...
Attached Files
File Type: pdf Lx Stabilization.pdf (129.1 KB, 121 views)
File Type: pdf Lx Reverse Crunch.pdf (151.3 KB, 69 views)
File Type: pdf Lx Stick Crunch.pdf (102.3 KB, 67 views)
File Type: pdf Lx Side Bridge Reverse.pdf (551.5 KB, 76 views)
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Old 24-06-2007, 04:31 AM   #246
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Thank you Jason.
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Old 24-06-2007, 05:14 AM   #247
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Jason,
Did you post those to show us your exercises, or were you just showing off the goods?
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Old 24-06-2007, 10:11 AM   #248
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Cory-
What goods would those be? I better check which files I uploaded...
By the way, contact me for the enlarged, poster-sized versions.
I have a few *ahem* others I can send you privately.
(just kidding everyone)

The stick crunch and reverse crunch handouts were done shortly after my reading of Sahrmann's text. The reverse sidebridge was done out of a need to copy the sidebridge handout I got from Tim Flynn and Co's manual therapy CD, modified so people don't have to support their weight on their shoulder.
I've found the prone and quadruped stabilization positions easiest for most people - not sure if it's the novel positioning or biomechanically being out of the gravity or what...

Again, these are very general exercises - no TrA sucking in or anything.
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Old 11-07-2007, 06:55 PM   #249
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http://www.ppaonline.co.uk/download/..._stability.doc

re worked article --i like the bit about Beckham preparing to kick by tensing his ab's......
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Old 11-07-2007, 07:00 PM   #250
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Here is a pdf version for those that haven't Word.
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File Type: pdf myth_of_core_stability.pdf (237.4 KB, 46 views)
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