Current Concepts in Lumbar Spinal Stabilizatio

Lumbar Spinal Stabiliza/on Therapy 4/20/2013

This informa/on is the property of Steve Schneider, PT and should not be copied or otherwise used without express wriDen permission of the author. 1

Biomechanical and Neurophysiological Theory

Enhanced by Research Evidence

�  Certified Manual Physical Therapist (CMPT) through the North American Institute of Orthopedic Manual Therapy (NAIOMT).

� Master of Science in Physical Therapy (MSPT) University of South Dakota

�  BA in Biology Augustana College

� To Define Biomechanical Types of Spinal Stability and Instability.

� To Discuss Evaluation/Assessment Findings for Stabilization Treatment.

� To Discuss The Role of the Neuromuscular System in Spinal Stabilization.

� To Review Pertinent Anatomy. � To Discuss Stabilization Therapy / Exercises.

Biomechanical Definitions of Spinal

Stability and Instability



Passive Stabilizers

Active Stabilizers

Motor Control

Bones, Joints, Ligaments, Disc. Provides stiffness, mostly at end range of motion

Muscles and Tendons. Contribute to stiffness throughout range of motion

Nervous System control of active stabilizers.

Coordinates concentric and, eccentric contractions along with isometric co-‐contractions of muscles.



“The functional integration of the passive spinal column, active spinal muscles, and the neural control unit in a manner that allows the individual to maintain the intervertebral neutral zones within physiological limits, while performing activities of daily living.” (Liemohn et al. 2005)

Ligamentous laxity, spondylolysis, spondylolisthesis, degenerative disc disease (DDD) and /or degenerative joint disease (DJD) that produces excessive (non-‐physiological) movement of the spine.

� Evidence on imaging. � MD diagnosis.

Positive Clinical Examination Signs of Instability.

History Findings: �  Episodic LBP Often progressively worsening. But may be first episode. �  Subjective Crepitus, Clunk, or “Giving Away” with Bending or

Twisting. �  Greater Pain Returning From Flexion, Than With Flexion. �  Difficulty Changing Positions (Catching, Locking, Pain): Rolling in bed, supine to sit, sit to stand, etc. �  Discomfort Or Pain With Unsupported Sitting Or Sustained Positions. �  Increase Pain With Sudden or Mild Movements. �  Prior good but short term relief with manipulation. Frequently Feeling Need to “Crack or Pop” Back. �  Relief with immobilization—bracing.



Differential Diagnosis / Scanning Examination Findings:

�  (+)Aberrant Spinal Motion with AROM Testing. Gower’s Sign: walking up thighs. �  (+) Excessive ROM and /or Pain at End Normal ROM. �  (+) H & I Tests: Combined Movement/Quadrant Tests. �  (+) Objective Crepitus or Clunk With ROM or Other Tests. �  (+) Prone PA Pressures: Provocative not Hypomobile. �  (+) Prone Instability Test (PA + PA with extensor contraction). �  (+/-‐) Primary (General) Stress Tests: Traction, Compression, Torsion. �  (+/-‐) Directional Preference or Centralization: Often instability pain with sustained positions.

(+) Biomechanical Examination Instability Findings. 1. Passive Physiological Inter-‐Vertebral Movements (PPIVM) or Passive Physiological Movements (PPM) in peripheral joints

2. Passive Accessory Inter-‐Vertebral Movements (PAIVM) or Passive Accessory Movements (PAM) in peripheral joints-‐-‐-‐GLIDES

3. Secondary Stress Test (Segmental or Joint Stability Tests).

(+) Biomechanical Examination Instability Findings. �  If PPIVM or PPM Tests are Negative (-‐) for hypomobility, then joint movement is normal OR

�  If PPIVM or PPM Tests are (-‐) but motion is felt to be excessive (which is often difficult to assess) or crepitus is present then a joint instability or hypermobility is suspected.

�  PAIVM or PAM would be also be (-‐) or excessive. �  Secondary (Segmental or Joint Stability) Stress Tests are needed.

(+) Biomechanical Examination Instability Findings. �  (+) Secondary (Segmental/Joint Stability) Stress Tests: 1)  Anterior Shear (plus Iliolumbar Ligament Stress Test). 2)  Posterior Shear 3)  Left and Right Torsion 4)  Lateral Shear �  (+) = Excessive Motion (difficult to feel).

Increased Pain and/or Muscle Guarding. Catching/Clicking/Clunking/Crepitus.*

* Often felt with PPIVM(PPM) and/or PAIVM(PAM).



�  Traction.

�  Specific Exercise: Directional Preference/Centralization.

� Manipulation (Not Manual Therapy/Mobilizations).

�  Stabilization. (original: Delitto et al 1995; Updated Fritz et al 2007)

(+) TBC for Traction (prevalence 9%). �  Should not be Widely Used (Fritz et al 2007). �  Conflicting Evidence (D Rated) Supporting Its Use

JOSPT LBP Clinical Guidelines. �  Can consider Traction if :

1) symptoms of nerve root compression and 2) no movements centralize symptoms.

(+) TBC for Specific Exercise/Directional Preference/ Centralization: (prevalence 17-‐47%; or 74-‐89%*) �  Directional Preference Extension:

1) Symptoms distal to buttock. 2) Symptoms centralize with extension. 3) Symptoms peripheralize with flexion.

�  Directional Preference Flexion: 1) Older than 50 y/o. 2) Imaging evidence of lumbar spinal stenosis. 3) Symptoms decrease/centralize with flexion.

�  Lateral Shift: 1) Visible frontal plane deviation (shoulder vs pelvis). 2) Symptoms decrease/centralize with shift correction.

(+) TBC for Manipulation (NOT other manual therapy). Manipulation CPR: (+) 4/5. (prevalence 23-‐59%) �  *No symptoms distal to knee. �  *Recent onset of symptoms (<16 days). �  Low FABQW (<19).

ALL 3 PROGNOSTIC �  Hyomobility of lumbar spine: BIOMECHANICAL. �  Hip IR >35 in at least one hip.

HIP and/or SI SCREEN? *some just using these 2 criteria-‐-‐-‐-‐REALLY?



Presences of a Fixation Hypomobilty: �  (+) History �  (+) Scanning Exam: Restricted ROM / Hypomobility:

AROM, Quadrant Tests (H & I), & PA. �  (+) Biomechanical exam: Hypomobility:

PPIVM, PAIVM, & fixation endfeel. �  AND (-‐) contra-‐indications for manipulation.

�  Lumbar, Thoracic, & Sacroiliac Joints Assessed.

Manual Therapy “CPR”: Presense of a Capsular Hypomobility: �  (+) History �  (+) Scanning Exam: AROM, quadrant tests, & PA: hypomobile. �  (+) Biomechanical exam: PPIVM, PAIVM, & capsular endfeel. �  AND (-‐) contra-‐indications for manual therapy.

OR Presence of a Myofascial Hypomobility: �  (+) History �  (+) Scanning Exam: AROM, quadrant tests, & PA: hypomobile. �  (+) Biomechanical exam: PPIVM, PAIVM, & myofascial endfeel. �  AND (-‐) contra-‐indications for manual therapy.

(+) TBC for Stabilization Therapy Stabilization CPR = (+) 3/4 (prevalence 13-‐26%) �  Younger Age (<40 years old). �  Greater General Flexibility: Average SLR ROM >91 Degrees; Postpartum. �  “Instability Catch” or Aberrant Movements During Lumbar Flexion/Extension ROM.

�  (+) Prone Instability Test. (Hicks et al 2005/Fritz et al 2007)

A Comparison of Select Trunk Muscle Thickness Change Between Subjects With Low Back Pain Classified in the Treatment Based Classification System and Asymptomatic Controls. JOSPT Oct 2007. Kiesel et al. �  All treatment based classifications have neurophysiological weakness of lumbar stabilizers:

Transverse Abdominis (TrA) and Lumbar Multifidus (LM). �  TrA and LM weakness is significant when comparing LBP patients to asymptomatic controls, but not different between subjects in different treatment based categories.

�  Motor control deficits may, in part, be caused by pain, irrespective of the source.



Evaluation of a treatment-‐based classification algorithm for low back pain: A cross-‐sectional study. Phys Ther. 2011; 91: 496-‐509. Stanton TR et al. �  Important for content validity of TBC for there to be exhaustiveness (all fit) and mutual exclusivity (into only 1).

�  25% of patients did not met TBC criteria—FAIL. �  25% of patients meet more than one TBC—FAIL. �  50% of patients met criteria for one TBC.

�  Hierarchy to assist with >1 TBC being met (or multimodal PT promotion)

�  No TBC met: Add new TBCs; refine existing TBC criteria (Manual Therapy, Elderly, Chronic)

What Characterizes People Who Have an Unclear Classification Using a Treatment-‐Based Classification Algorithm for LBP? A Cross-‐Sectional Study. Phys Ther. 2013; 93:345-‐355. Stanton TR et al. �  Unclear classification for approximately 42.7% (39% Acute/subacute and 62.7% Chronic) of people with LBP.—TBC Failure.

�  People with unclear classification appear to be less affected by LBP (less disability and fewer fear avoidance beliefs), despite typically having a longer duration of LBP (chronic / > 3 months duration).

�  Add classifications/refine existing TBC.

Reliability of a treatment-‐based classification system for subgrouping people with low back pain. JOSPT. Sept 2012; 42(9): 797-‐805. Henry SM et al. �  Interrater reliability is moderate to good. �  This does not mean that the treatment will work; just that PT’s can categorize patients fairly well.

�  Conflicts between stabilization and manipulation TBC. �  Conflicts between specific exercise and stabilization TBC.

�  Clinical Reality: Multimodal PT needed. Never is it going to be as simple a CPR.

Variables associated with level of disability in working individuals with non-‐acute LBP: A cross-‐sectional investigation. JOSPT. Feb 2013; 43(2): 97-‐104. Davis DS et al. �  Evidence does not support use of impairment based treatments for non-‐acute LBP.

(True Chronic Pain Patients) �  Evidence does not support the use of treatment based classification systems for non-‐acute LBP.

(True Chronic Pain Patients)



�  “Patients with low back pain often fit into more than 1 impairment / function-‐based category, and the most relevant impairment of body function, primary intervention strategy, and the associated impairment / function-‐based category(-‐ies) are expected to change during the patient’s episode of care” (JOSPT LBP Guidelines 2012).

�  Hierarchy Of TBC: (Traction), Specific Exercise, Manipulation, Stabilization.

�  SI joint pain is not the same thing as SI joint dysfunction: can have pain with/without dysfunction and can have dysfunction with/without pain.

�  SI Joint Scanning Exam: Primary Stress (Provocative) Tests.

�  SI Joint Biomechanical Exam: Motion/Kinetic Tests (WB & NWB), Position Tests (Standing and Supine), PAM/endfeels/glides, & Secondary Stress (Ligamentous/Joint Stability) Tests.

�  SI Joint Pain CPR: (+) 3/5 Provocative Tests.

�  Hip & Thoracic Spine Examinations are Part of The Lower Quarter Scanning Examination.

�  Hip and Thoracic Detailed Biomechanical Examinations if Warranted.

�  Regional Mechanical Influences Can Impact Injury and Recovery (Causations and Complications).

Stabilization Strength / Endurance Testing. LBP Clinical Guidelines 2012 JOSPT: Abdominal Tests: �  *Trunk Flexors: Double Straight Leg Lowering with Posterior Pelvic Tilt. Measure distance from heel to table when PPT is lost. �  Transversus Abdominis: Prone over a pressure biofeedback unit inflated to 70 mmHg. Instructions to draw in abdominal wall x 10 seconds and max decrease in pressure is recorded. �  *Lateral Abdominals: Timed trial of side plank from knees.



Stabilization Strength / Endurance Testing. Other Abdominal Tests: �  Abdominal Bracing: Time trial of hold trunk flexion at 60 degrees. �  Crunch: Reps/ 1 minute. �  *Plank Endurance: Time trial of plank position. �  *Side Plank Endurance: Time trail of side plank position (on feet not knees).

Stabilization Strength / Endurance Testing. LBP Clinical Guidelines 2012 JOSPT: Lumbar Extensors: �  Trunk Extensors: Time trial of prone chest lift (lumbar extension) to approximately 30 degrees.

Stabilization Strength / Endurance Testing. Other Lumbar Extensor Tests: �  *Roman Chair Endurance / Sorensen Test: Time trial of parallel position to floor being held. �  *Roman Chair Endurance at Variable Angles. Time trial of non-‐parallel positions being held. �  Roman Chair Repetitions / Minute. �  Prone Double Straight Leg Raise. Time trial �  *Quadruped Alternation UE/LE lifts. Observe control with UE, LE, and UE/LE lifts.

Failure of the active stabilizers and motor control system to maintain spinal movement in the “neutral zone”.

� A muscle or proprioceptive deficit is present.

� Symptoms of instability present. � Functional instability can lead to structural instability.



The stabilization system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992; 5: 390-‐96; discussion 397. Panjabi MM.

�  A loss of motor control over mid-‐ROM of the joint where inert structures play no role in movement constraints.

�  It is caused by pain or reflex inhibition and may progress to hypermobility or end-‐zone (articular or ligamentous) instability with potential pain and dysfunction resulting.

�  This occurs as mechanoreceptors become damaged by abusive movement patterns.

�  There will be a loss of segmental muscle bulk, poor segmental muscle activation, and poor global movement control.

�  Neutral Zone Instability might not be symptomatic.

� May have clinical instability without functional or structural instability.

� May have functional instability without clinical instability or structural instability findings.

�  ***May have structural instability findings on imaging with or without clinical instability findings and be functionally stable.***

The stabilization system of the spine. Part 1. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992; 5: 383-‐89; discussion 397. Panjabi MM. �  The stability of the spine is not solely dependent on the basic morphology of the spine, but also the correct functioning of the neuromuscular system.

�  If the basic morphology of the lumbar spine is compromised the neuromuscular system may be trained to compensate and to provide dynamic stability of the spine during the demands of daily living.

� Functional stability is relative. � Athlete versus construction worker versus office worker.

� 20 year old versus 40 year old versus 60 year old.



Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good. JOSPT. November 2011. Flynn, TW et al. �  Overutilization of lumbar imaging correlates with, and likely contributes to, a 2-‐ to 3-‐ fold increase in surgical rates over the last 10 years.

�  Patient’s knowledge of imaging abnormalities can actually decrease self-‐perception of health and may lead to fear-‐avoidance and catastrophic behaviors that may predispose people to chronicity.

�  Routine imaging and other tests usually cannot identify the precise cause of pain; do not improve patient outcomes; and incur additional expenses.

�  There is no compelling evidence that abnormal findings on imaging indicates a prolonged course of impairment or disability.

� Must frequently change the patient’s belief that their LBP will not improve unless the imaging improves.

� With high fear-‐avoidance beliefs, there is a need to break the cycle of inactivity, disuse, and increased disability.

(Flynn et al 2011)

Spinal Muscle Evaluation Using the Sorensen Test: A Critical Appraisal of the Literature. Joint Bone Spine. 73 (2006): 43-‐50. Demoulin, C et al

•  Can Discriminate Chronic LBP Patients From Health Individuals.

•  May Be Predictive of Occurrence of LBP Within a Years Time.

�  Sorensen Test: In Many Studies Endurance Time was Significantly Decreased in Patients with Chronic LBP.

�  Chronic LBP Patients are Associated with Decreased Isometric Endurance of Trunk Extensor Muscles.

�  Less than 58 seconds hold have 3 x increased risk of LBP versus hold time greater than 104 seconds.

�  Less than 176 seconds more likely to have LBP within a year.

�  Greater than 198 seconds less likely to have LBP. (Demoulin. 2006)

�  0-‐60 seconds poor; 1-‐2 minutes fair; 2-‐3 minutes good; greater than 3 minutes normal.



Screening the Lumbopelvic Muscles for a Relationship to Injury of the Quadriceps, Hamstrings, and Adductor Muscles Among Australian Football League Players. JOSPT. October 2011. Hides, JA et al. � Muscle asymmetry (relative to the preferred kicking leg) and abdominal function (drawing-‐in maneuver) at the start and end of preseason training were not related to injury.

� Multifidus muscle size showed a significant relationship with preseason injury.

�  Results indicate that players who sustained a severe hamstring, groin, or quadriceps injury during the preseason training had significantly smaller multifidus muscles at the start and end of the preseason compared with players with no injury.

�  Baseline cross sectional area of the multifidus muscles at the L5 level predicted hamstring, groin, or quadriceps injury in 83.3% of cases.

(Hides, JA et al 2011)

�  Example of Neutral Zone Instability.

�  Poor strength and motor control (delayed activation) of multifidus leading to extra demands (compensatory movements) of lower extremity muscles to stabilize the pelvis?

�  Central/peripheral sensitization/facilitation: Adductors (L2-‐3), Quadriceps (L3-‐4), Hamstrings (L5-‐S1) resulting in hypertonicity (“tightness” and ultimately weakness) predisposing muscles for strains?

Effects of stabilization training on multifidus muscle cross-‐sectional area among young elite cricketers with LBP. JOSPT. March 2008. 38(3); 101-‐108. Hides J et al. �  Despite rigorous training program, elite athletes with history of LBP may continued to have impairments of the multifidus muscle (decreased CSA).

�  Specific stabilization exercises increased the CSA of the multifidus muscle at L5.

� Multifidus atrophy and pain related to LBP can be reversed using specific stabilization exercises.



The Role of the Neuromuscular

System in Spinal Stabilization

�  Concentrically shorten to provide mobility

�  Eccentrically lengthen to provide control of motion through deceleration

�  Isometrically hold for stabilization

�  Provide proprioceptive input to the central nervous system for coordinated movement

1. Muscle Tone/Stiffness: Muscle spindle system control of slow twitch fiber contraction.

� Increase segmental stiffness and control excessive inter-‐segmental motion / translation with muscle tone resistance.

2. Co-‐contraction: Agonist and antagonist muscle co-‐contract on either side of spine act as “tension springs” to control motion of spine joints.

� This involves isometric contraction with small concentric/eccentric control phases for each spinal segment’s motion.



3.   Feedback response: Ligament/muscle Reflex. Neurological input from receptors in muscles/ ligaments/ discs/ joints of spine help regulate muscle activity.

� Protective response to perturbations and when approaching end range of motion.

4. Feedforward response: Anticipatory response in many directions prior to functional loading of the spine.

� Postural muscles contract prior to limb muscles, providing a stable spine/trunk during extremity movement.

A Magnetic Resonance Imaging Investigation of the Transversus Adominis Muscle During Drawing-‐in of the Adominal Wall in Elite Australian Football League Players With and Without Low Back Pain. JOSPT. Jan 2010; 40(1): 4-‐10. Hides, JA et al. �  The presence of LBP altered the ability of footballers to do the ADIM compared to those without LBP.

�  Reflexive responses (feed forward and feedback) enhance muscle stiffness without the metabolic cost of sole reliance on the intrinsic mechanisms and prolonged co-‐activation.

�  With an appropriate muscle spindle gain setting and trunk muscle co-‐activation level prior to perturbation (feed forward), only minimal reflex responses (feedback) are needed to maintain dynamic trunk stability.

�  The dynamic trunk stability level that exists prior to perturbation and the reflexive response that occurs following perturbation combine to influence composite dynamic trunk stiffness and stability.

(Smith et al 2008)



5.   Intra-‐abdominal pressure modulation. �  Increased intra-‐abdominal pressure has a diffuse effect on spinal stability.

�  Increased intra-‐abdominal pressure occurs as a feed-‐forward conscious postural strategy during lifting or other volitional high-‐loading tasks.

�  Can also occur as a reflexive feedback response to sudden high loading events.

6.  Remaining continuously active (stabilizing the spine) irrespective of the direction of motion.

� Endurance is more important than strength.

�  Large amounts of force are NOT needed for activities of daily living or even general, low level athletic activity-‐-‐walking, jogging etc. (Berglund 2010)

�  5-‐10% abdominal maximal volitional isometric contraction (MVIC) and as low as 25% spinal extensor MVIC needed to maximally stabilize the spine (Kibler WB. Sports Med 2006, Smith et al 2008).

�  Prolonged activation at higher amplitudes may adversely increase compression forces (Smith et al 2008)

� Therefore, do not need to train with maximum (heavy) resistance.

�  Biomechanical adaptations associated with neuromuscular fatigue and spinal muscle stiffness may influence back injury risk.

�  Fatigue negatively influences muscle spindle behavior associated with feedback reflexive responses.

�  Because of the physiological costs associated with an increased spinal load and the peripheral neuromuscular fatigue created by excessive or prolonged muscle co-‐activation, the non-‐impaired system relies less on pre-‐activation (feed forward) and more on reaction (feedback) mechanisms to maintain dynamic stability.

(Smith et al 2008)



�  Spinal stability decreases and trunk muscle activation amplitudes increases as task intensity increases.

�  Feedback delay is a destabilizing factor in neuromuscular control systems and greater kinematic errors frequently occur at faster movement velocities.

�  Decondition, inhibition, or dysfunction of muscles negatively influence dynamic trunk stabilization.

(Smith et al 2008) �  Passive stabilizer injury (sprain, herniation, fracture, DDD/DJD) negatively influences spinal stabilization and puts increased demand on the neuromuscular components.

Swing Kinematics in Skilled Male Golfers Following Putting Practice. JOSPT. July 2008; 38(7):425-‐433. Evans K et al. �  Golf swing kinematics changes were observed following 40 minutes of putting potentially related to spinal fatigue.

�  Sorensen test endurance scores were significantly reduced following 40 minutes of putting.

�  Golfers with higher BMI were least affected by putting practice fatigue.

�  Lumbar Spinal Stabilization (“Core” Muscles) �  Box of muscles surrounding the spine �  Transversus abdominis and internal obliques in front �  Short paraspinals (multifidus) and gluteals (gluteus maximus primarily) in back

�  Pelvic floor and hip girdle muscles (functional hip external rotators—Piriformis, Glut Max) the floor

�  Diaphragm is the roof �  Psoas: Origin on anterior surface of transverse processes, vertebral bodies, disc T12-‐L5.

�  To avoid excessive segmental articular micro-‐movement.

�  To maintain segmental neutral zones.

�  To provide proprioceptive input to neuromuscular system—tone, co-‐contractions, feedback response, feed-‐forward responses.

�  To reduce the compressive overloads.



Larger muscles that cross multiple spinal segments. •  Long paraspinals /Erector Spinae • Rectus abdominis •  External obliques

Upper/Lower Extremity Musculature.

�  Prime movers of the trunk and extremities

�  Balance external loads to minimize spinal forces: Further reduce compressive forces along with local stabilizer muscles.

�  Provide general trunk stabilization (not segmental)

�  Provide forces needed for activities of daily living (lifting, pushing, pulling etc) and athletics

�  Stabilization exercises coordinates global and local muscle recruitment and influence intrinsic and reflexive mechanisms to maintain the “neutral zone” during functional movements.

�  With proper training, spinal stability can rely less on pre-‐activation/feed forward mechanisms and more on reflexive feedback mechanism to maintain dynamic trunk stability.

�  Stabilization training is essential given the destabilizing influence and kinematic errors associated with faster athletic movement, high-‐load task.

(Smith C et al 2008) �  Stabilization exercises are also essential in the presence of passive structure destabilization (injury/degeneration).

�  People with LBP are unable to perform the abdominal drawing in maneuver effectively.

�  In the presence of LBP, there are muscle substitution patterns where large torque producing synergists like the rectus abdominis occurs prior to or without the activation of local (deep) stabilizing muscles like the transverus abdominis.

�  Different forms of exercise can preferentially activate and train different muscles within the abdominal complex.

�  Specific exercises can alter muscle activation recruitment patterns (ratios) during trunk-‐loading tasks.

(O’Sullivan et al 1998)



Passive Stabilizers

Active Stabilizers

Motor Control

LBP Guidelines 2012 JOSPT “A” Rated Treatments. �  Specific Exercises: Centralization and Directional Preference. � Manual Therapy: Manipulation and Non-‐thrust Mobilization. �  Stabilization Exercises �  Progressive Endurance Exercise and Fitness Activities: Global stabilization.

LBP Guidelines 2012 JOSPT. �  “Clinicians should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments and in patients post-‐lumbar microdiscectomy.”

Motor Control Exercise for Persistent, Nonspecific LBP: A Systemic Review. Phys Ther. 2009; 89:9-‐25. Macedo G et al. �  Motor control exercise is more effective than minimal intervention and adds benefit to other forms of interventions in reducing pain and disability for people with persistent, nonspecific LBP.

�  Motor control exercise alone or as a supplement to another therapy, is effective in reducing pain and disability in patients with persistent, nonspecific LBP.

�  They did not find convincing evidence that motor control exercise was superior to manual therapy, other forms of exercise, or surgery.



Motor Control Exercise for Chronic LBP: A Randomized Placebo-‐Controlled Trail. Phys Ther. 2009; 89: 1275-‐86. Costa L et al. �  Motor control exercise produced short-‐term improvements in global impression of recovery, functional activity levels, and reduced recurrent/episodic pain, but not pain intensity, for people with chronic LBP.

�  Most of the effects observed in the short term were maintained at the 6-‐ and 12-‐month follow-‐ups.

�  Small clinical improvement observed, but complete recovery is unlikely in the chronic, nonspecific population, who have aspects associated with poor outcomes.

Graded Exercise for Recurrent LBP: A Randomized, controlled trial with 6-‐, 12-‐, and 36-‐month follow ups. Spine. 2009: 34: 221-‐8. Rasmussen-‐Barr et al. �  Patients with recurrent LBP did a graded exercise intervention emphasizing stabilization exercises or a general walking program.

�  The stabilization exercise group out performed the walking group: 55% vs 26% met criteria for success.

�  Stabilization exercises seems to improve perceived disability and health parameters at short and long terms in patients with recurrent LBP.

Long-‐Term Effects of Specific Stabilization Exercise for First Episode of LBP. Spine. 2001; 26. Hides et al. �  Patients with first episode of LBP given 4 week exercise program emphasizing lumbar multifidus and transversus abdominis muscle groups.

�  The stabilization exercise group reported recurrence rates of 30% at 1 year and 35% at 3 years, compared to 84% at 1 year and 75% at 3 years for the advice and medication control group.

Evaluation of Specific Stabilization Exercise in the Treatment of Chronic Low Back Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis. Spine. Dec 1997. O’Sullivan, PB et al. �  Patients with chronic LBP and spondylolysis or spondylolisthesis showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at 30 month follow-‐up.

�  The control group showed no significant change in these parameters after intervention or at follow-‐up.



Efficacy of dynamic lumbar stabilization exercise in lumbar microdiscetomy. J Rehabil Med. Jul 2003; 35(4): 163-‐7. Yilmaz F et al. �  Dynamic lumbar stabilization exercises are an efficient and useful technique in the rehabilitation of patients who have undergone microdiscectomy.

�  Dynamic lumbar stabilization exercises relieve pain, improve functional parameters, and strengthen trunk, abdominal and low back muscles.

An intensive, progressive exercise program reduces disability and improves functional performance in patients after single-‐level lumbar microdiskectomy. Phys Ther. 2009; 89:1145-‐57. Kulig K et al. �  An intensive, progressive exercise program combined with education reduces disability and improves function in patients who have undergone a single-‐level lumbar microdiskectomy.

�  Education and stabilization exercise group had significantly greater reduction in disability (ODI), improved walking performance (5 minute walk, 50 foot walk), and lumbar extension strength/endurance (modified Sorensen test).

�  Intensive strengthening and endurance program of trunk and lower extremities is safe and effective.

Rehabilitation after lumbar disc surgery (Review). The Cochrane Collaboration. 2010, issue 2. �  Exercise programs starting 4-‐6 weeks post-‐surgery seem to lead to a faster decrease in pain and disability than no treatment.

�  High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs.

�  There is no significant difference between supervised and home exercises for pain relief, disability, or global perceived effect.

�  There is no evidence that active programs increase the re-‐operation rate after first-‐time lumbar surgery.

Altered Abdominal Muscle Recruitment in Patients With Chronic Back Pain Following a Specific Exercise Intervention. JOSPT. Feb 1998; 27(2); 114-‐24. O’Sullivan P et al. �  Patients with chronic LBP have a higher level of rectus abdominis activity during double leg raise in the control group and a greater level of activity of the internal oblique in the specific (stabilization) exercise group.

�  There was a relative increase in rectus abdominis activity in the control group and a relative decrease in the specific (stabilization) exercise group following intervention.



Segmental Stabilization and Muscular Strengthening in Chronic LBP: A Comparative Study. Clinics. Oct 2010; 65(10): 1013-‐17. Franca F et al. �  Patients with chronic LBP did segmental stabilization exercise (TrA, LM) vs superficial strengthening exercises (rectus, obliques, erector spinae).

�  Both treatments were effective in relieving pain and improving disability.

�  Segmental stabilization had significant gains for all variables compared to superficial strengthening.

�  Segmental stabilization improved TrA activation and superficial strengthening did not.

Efficacy of Trunk Balance Exercises for Individuals With Chronic Low Back Pain: A Randomized Clinical Trail. JOSPT. August 2011. Gatti, R et al. �  For patients with chronic LBP, trunk balance exercises combined with flexibility exercises were found to be more effective than a combination of strength and flexibility exercises in reducing disability and improving the physical component of quality of life.

Efficacy of Segmental Stabilization Exercise for Lumbar Segmental Instability in Patients with Mechanical LBP: A Randomized Placebo Controlled Crossover Study. N Am J Med Sci. October 2011. Kumar. �  For patients with mechanical LBP, segmental stabilization exercise therapy was more effective than placebo intervention in treatment of symptomatic lumbar segmental instability.

The effects of stabilizing exercises on pain and disability of patients with lumbar segmental instability. J Back Musculoskelet Rhabil. 2012; 25(3): 149-‐55. Javadian Y et al. �  Lumbar stabilization exercise resulted in reduced pain intensity, increased function, and increased muscle endurance compared to routine exercise alone for patients with segmental instability.



Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic LBP: A randomized, controlled trial. J Manipulative Physiol Ther. May 2012; 35(4): 279-‐85. Franca F et al. �  Both techniques improved pain and reduced disability, but stabilization exercises was superior to stretching for measured variables associated with chronic LBP.

� Passive Stabilizers: Bones, Ligaments, Discs � Abdominal Musculature: Superficial, Intermediate, Deep, Posterior Abdominal Wall.

� Pelvic Floor � Back Musculature: Superficial, Intermediate, Deep.

� Hip Stabilizer Musculature.

Passive Stabilizers

Active Stabilizers

Motor Control

�  (+) Biomechanical Examination Instability Findings.

�  (+) Stabilization Treatment Based Categorization / Clinical Predictor Rules.

�  (+) Lumbar Stabilization Muscle Weakness.

�  S/P Lumbar (Micro-‐) Discectomy.

�  After Manual Therapy Treatment for Hypomobility of Lumbar Spine or Sacroiliac (SI) Joint.

�  Everyone with Low Back Pain?



Everyone With Low Back Pain? A Comparison of Select Trunk Muscle Thickness Change Between Subjects With Low Back Pain Classified in the Treatment Based Classification System and Asymptomatic Controls. JOSPT Oct 2007. Kiesel et al. �  All treatment based classifications have neurophysiological weakness of lumbar stabilizers:

Transverse Abdominis (TrA) and Lumbar Multifidus (LM). �  TrA and LM weakness is significant when comparing LBP patients to asymptomatic controls, but not different between subjects in different treatment based categories.

�  Motor control deficits may, in part, be caused by pain, irrespective of the source.

�  Avoidance of excessive ROM by patient �  Posture and Body Mechanics Correction �  Reduce stress from adjacent joints : treat surrounding hypomobilities including hips, thoracic and lumbar spine, SI Joints—Biomechanical examination.

�  Anti-‐inflammatory modalities if necessary �  Bracing if necessary (Structural/Clinical Instability) �  Remove or decrease pain/reflex inhibition if necessary �  Stabilization therapy/exercises

1.  Pelvic Floor.

2.  Abdominal Muscles: Transversus Abdominis, Internal/External Obliques, Rectus Abominis.

3.  Multifidus.

4.  Hip Stabilizers if needed. 5.  Psoas if needed (Not Covered Today).

6.  Diaphragm if needed (Not Covered Today).

Pelvic Floor: if significantly weak and there is a need to go beyond Kagel exercises and basic instruction / cueing, then seek a women’s health specialist.

Can palpate just medial to ischial tuberosity (with caution) to cue.



Transversus Abdominis (TrA): •  Functions to hold in abdominal contents. •  TrA contraction contributes to a reduction of

lumbar lordosis which tightness the thoracolumbar fascia (TLF) and supraspinous ligament etc.

•  If TLF tightens effectively it can be used to help stabilize an unstable spine.

•  If TLF is unable to tighten effectively then the rehabilitation prognosis is worse. Then need to try to “bulk” the multifidus to tighten the TLF. (Cole et al, 2010)

Transversus Abdominis (TrA): �  TrA activation is delayed/inhibited with LBP and needs to be retrained.

�  Remission of LBP does not necessarily translate into restored TrA activation but it can be trained with specific exercise.

�  TrA feed forward activation can be unilateral and is directionally specific. (Allison G et al 2008)

�  TrA stabilizing function may be more sensory (proprioceptive/cognitive) and motor control based than mechanical (corset).

(Allison G et al 2008)

Rectus abdominis: •  Rectus abdominis strengthening can be help tighten the linea alba which is the insertion site of the transversus abdominis (central support structure).

Internal and External Obliques: •  Internal obliques are considered great spinal stabilizers and are part of deep abdominal musculature along with transversus abdominis.

•  External Obliques along with rectus abdominis are more global stabilizers.

Comparison of the Sonographic Features of the Abdominal Wall Muscles and Connective Tissues in Individuals With and Without Lumbopelvic Pain. JOSPT. Jan 2013. 43(1); 11-‐19. Whittaker JL, et al. �  There may be altered loading of the abdominal connective tissue and linea alba secondary to to an altered strategy involving a reduced contribution of the rectus abdominis (RA).

�  They found less total abdominal muscle thickness, thinner RA, thicker connective tissue, and a wider interrecti distance in people with LBP.

�  Insufficient contributions of the RA (thinner/atrophied) results in an increased role of connective tissue (thicker) to dissipate trunk loads.

�  They found no difference in external oblique, internal oblique, and transverus abdominis thickness between groups.



�  Thoracolumbar fascial tightening through abdominal muscle activation effectively introduces tension throughout the system, increasing activation efficiency.

�  The fascial system is closely associated with the regulation of trunk and extremity posture, muscular biomechanics, motor control and proprioception.

�  Axioappendicular muscles such as the latissimus dorsi and gluteus maximus futher contribute to the dynamic stability and movement through their thoracolumbar fascial attachments.

(Smith et al 2008).

Changes in Deep Abdominal Muscle Thickness During Common Trunk-‐Strengthening Exercises Using Ultrasound Imaging. JOSPT. Oct 2008; 38(10): 596-‐605. Teyhen, DS et al. �  Transversus Abdominis and Internal Oblique muscular thickness changes measured with US imaging from greatest to least:

�  Horizontal side support (side plank)* > Abdominal crunch* > Abdominal Drawing-‐in Maneuver* > Quadruped Opposite Upper and Lower Extremity Lift* > Supine Lower Extremity Extender (PPT Level 5 with bent knees)* > Abdominal Sit-‐back.

The use of lumbar spinal stabilization techniques during the performance of abdominal strengthening exercise variations. J Sports Med Phys Fitness. March 2005; 45 (1): 38-‐43. Barnett F et al. �  Surface EMG of TrA, internal obliques (IO), and upper rectus abdominis (RA).

�  Abdominal drawing in maneuver (ADIM)* is an effective method for preferentially selecting voluntary contraction of TrA/IO prior to upper RA during crunches*.

Electromyographic Analysis of Transversus Abdominis and Lumbar Multifidus Using Wire Electrodes During Lumbar Stabilization Exercises. JOSPT. Nov 2010; 40(11): 743-‐50. Okubo, YU et al. �  Wire electrodes in TrA and LM along with surface electrodes on rectus abdominis, external obliques, and errector spinae.

�  Plank with alternating UE/LE lifts had greatest activation of TrA.

�  Abdominal muscles generally more activated in prone position exercises.

�  Asymmetrical (left vs right) activation of TrA and other muscles was seen with the support side being more activated.



Truck muscle activity during lumbar stabilization exercises on both a stable and unstable surface. JOSPT. June 2010; 40(6): 369-‐75. Imai A et al. � Wire electrodes in TrA and LM along with surface electrodes on rectus abdominis, external obliques, and errector spinae.

�  Stabilization exercises on an unstable surface enhanced the activity of stabilization muscles except for bridges.

�  Global stabilizer muscles such as the external obliques were more active with unstable surface exercises.

Core muscle activation during Swiss ball and traditional abdominal exercises. JOSPT. May 2010; 40(5); 265-‐76. Escamilla, RF et al. �  Surface EMG of upper rectus abdominis (RA), lower RA, external oblique (EO), internal oblique (IO), latissimus dorsi (lats), rectus femoris, and lumbar paraspinals.

�  Prone Swiss ball exercises were as effective or more effective in generating core muscle activity compared to traditional crunch and bent knee sit-‐up with feet fixated.

�  IO (and likely TrA) highest activation with Swiss ball pike, roll-‐out, knee-‐up, and skier.

�  Rectus femoris (and likely psoas/iliacus) highest activation with bent knee sit-‐up with feet fixated and Swiss ball skier, pike, sitting march, hip extension.

�  No single spinal stabilization (core) muscle can be identified as the most important for lumbar spinal stability.

�  Lumbar stabilization exercises may be most effective when they involve the entire spinal musculature under various spine loading conditions.

�  It should be emphasized that exercises that demand high spinal stabilization muscle activity not only enhance spinal stability but also generate higher spinal compressive loading which may have adverse effects in individuals with lumbar spine pathology.

�  Maintaining a neutral lumbosacral spine might be more optimal for spinal conditions that should not be flexed (some disk pathologies, osteoporosis, etc) or extended (facet DJD, lateral/foraminal stenosis, central/spinal stenosis, sponylolisthesis, spondylolysis, etc).

(Escamill, RF et al)

�  Deep Abdominals: ADIM, PPT Level 1-‐5 (Level 1-‐8).

�  Deep & Superficial: Crunch, Oblique Crunch

�  Global Stabilization: Side Planks, Planks.



�  Planks may be too aggressive in the presence of clinical and / or structural instability.

� With segmental instability the facet joint may become the primary restraint against anterior translation (shear).

� May be pain provoking if facet DJD is present.

� Worse rehabilitation prognosis if unable to plank.

�  Standing progression. Dynamic Program. Balance. �  Everything becomes a “core” spinal stabilization exercise.

�  Diagonals with medicine balls, tubing, cable systems. �  Body blades, Bosu ball, Exercise (Swiss) ball, Plyoballs with rebounder, etc.

Multifidus: Functions to stabilize the lumbar spine during forward leaning before the thoracolumbar fascia tightens. It also produces extension and counters rotation produced by abdominals.

Multifidi are not the spinal stabilization system but they are the best indicator of how well the segmental stabilization system is functioning. (Cole et al 2010).

� Multifidi are dense in muscle spindles –feedback control of spine (Nitz, AJ. Am Surg. 1986).

� Multifidi are segmentally innervated and are inhibited within minutes to hours upon a discogenic lesion.

� Those with LBP have a loss of dynamic spinal stability due to multifidus inhibition -‐-‐They lose control of the “neutral zone”.

� The multifidus does not automatically return to its pre-‐inhibited state…but it can be trained.

(Cole et al 2010, Hides J et al 2008, Smith et al 2008)



The relationship of transversus abdominis and lumbar multifidus activation and prognostic factors for clinical success with a stabilization exercise program: a cross-‐sectional study. Ach Phys Med Rehabil. Jan 2010; 91(1): 78-‐85. Hebert JJ, et al. �  Examined the prognostic factors for the stabilization clinical predictor rule and the degree of TrA and LM muscle activation assessed by rehabilitative US imaging.

�  Decreased LM activation, but not TrA is associated with the stabilization CPR factors.

Surface EMG Analysis of the Low Back Muscles During Rehabilitation Exercises. JOSPT. 2008; 38(12); 736-‐745. Ekstrom R; Osborn R; Hauer P. �  Abdominal hollowing in quadruped does not produce any significant activity in multifidus muscles.

� Maximum Voluntary Isometric Contraction (MVIC) measured with surface EMG.

�  Bilateral Multifidus Contraction. 1. Bridge to neutral spine position with shoulders on

exercise ball and feet on floor: 38% MVIC. 2. Bridge to neutral spine position: 39% MVIC*. 3. Bridge to neutral spine position with knees

extended and feet on gymnastic ball: 44% MVIC*. 4. Bilateral lower extremity lifts to neutral from

prone position with trunk resting over an exercise ball; hands in push up position: 49% MVIC*.

5. Active back extension while hips over an exercise ball and feet on floor: 50% MVIC*.

�  Unilateral Multifidus Contraction. 1. Maximum resistance to unilateral hamstring with

knee flexed at 45 degrees: 25% MVIC*. 2. Active trunk sidebending with feet stabilized; lying

on contralateral side: 33% MVIC. 3. Sidebridge to neutral position when lying on

ipsilateral side (side plank): 35% MVIC*. 4. Maximum resistance to sidebending when lying on

the contralateral side and feet stabilzed: 39% MVIC. 5. Opposite arm and leg lifts in quadruped: 41% for side

of the leg lifted; 29% for the side of the arm lifted*. 6. Opposite arm and leg lifts in prone: 45% for side of

arm being lifted; 40% for leg being lifted*.



�  Bilateral Multifidus Contraction. 1. Sitting trunk extension with the pelvis

mechanically stabilized against elastic tubing and isometric hold at end range of motion: 62% MVIC.

2. Slow active sitting trunk extension against elastic tubing without pelvis stabilized: 62% MVIC.

3. Prone trunk extension to neutral spine at 10 rep max intensity with the LE’s stabilized: 67% MVIC.

4. Prone trunk extension with UE and LE extended (Superman lift): 77% MVIC.

5. Prone slow active trunk extension against elastic tubing with the pelvis stabilized: 78% MVIC.

�  Bilateral Multifidus Contraction. 1. Maximum resistance to prone trunk extension in

neutral spine position with the LE’s stabilized: 80% MVIC.

2. Prone trunk extension to end range with 10 rep max intensity weight held against the chest with the LE’s stabilized: 92% MVIC.

3. Maximum resistance to prone extension at end range of motion with LE’s stabilized: 98% MVIC.

Electromyographic Analysis of Transversus Abdominis and Lumbar Multifidus Using Wire Electrodes During Lumbar Stabilization Exercises. JOSPT. Nov 2010; 40(11): 743-‐50. Okubo, YU et al. � Wire electrodes in TrA and LM along with surface electrodes on rectus abdominis, external obliques, and errector spinae.

�  Lumbar extensor muscles generally more activated in supine position exercises.

�  Asymmetrical (left vs right) activation of LM and other muscles was seen with the support side being more activated.

�  Early Multifidus �  Bridges: Bilateral, Unilateral, Supine Ball: knees extended, knees flexed, hamstring curls.

�  Quadruped and Prone: ADIM, UE lift, LE lift, Alternating UE/LE lift.

�  Prone Ball: Bilateral LE lift, Alternating UE/LE lift, Spinal extension with row.

�  Roman Chair: hold and repetitions. �  Standing: Windmills, UE tubing, LE tubing, Alternation of UE/LE tubing.



�  Standing progression. Dynamic Program. Balance.

�  Everything becomes a “core” spinal stabilization exercise.

�  Combined movement with tubing / cable system-‐-‐-‐diagonals.

�  Body blades, Bosu ball, Exercise (Swiss) ball, Plyoballs with rebounder, etc.

Hip Stabilization Strengthening (if needed): � External Rotators: eccentric lengthening to

control internal rotation during gait. � Abductors—gluteus medius: keep pelvis

stable in the frontal plane. � Extensors—gluteus maximus: stabilize pelvis via tensioning thoracolumbar fascia; also a functional hip external rotator.

Development of Active Hip Abduction as a screening test for identifying occupational low back pain. JOSPT; Sept 2009: 39(9): 649-‐57. Nelson-‐Wong, E et al. �  The active hip abduction (AHAbd) test was the only clinical assessment tool that showed differences between pain developers and non-‐pain developers.

�  Individuals who scores 2 or greater with AHBbd test were 3.85 times more likely to develop LBP during 2 hour standing work task.

�  Decreased hip and pelvis control potentially predisposes people to lumbar injury and to develop LBP.

Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-‐Wire Electrodes. JOSPT. Feb 2013; 43(2): 54-‐65. Selkowitz DM et al. �  Gluteus Medius: Sidelying hip abduction* > Hip Hike*. �  Superior Gluteus Maximus: Clam* > Unilateral Bridge*. �  Tensor Fascia Lata (TFL): Sidelying hip abduction* > Hip Hike* (same as Gluteus medius).

�  Best Gluteal to TFL Activation Ratio: Clam* > Lateral band walking* > Unilateral bridge* > QP Hip extension with knee extended or knee flexed*.



�  Sidelying: Clam, Hip abduction.

�  Standing: Lateral band walking, Squats, Loop ER: open chain with lateral lunges, Tubing closed chain ER, Tubing closed chain hip abduction (hip hike).

�  Balance: Single leg stance, Single knee stance, Single Leg Squat.

1.  Large muscle strengthening

2.  Endurance training

3.  Functional training: ADL, work, sport specific exercise program.

Body Mechanics: Lifting, squatting, running, jumping…

� Muscle imbalances: If global stabilization muscles are overpowering or activated prior to local (core) spinal stabilization muscles then there will be an increase in translatory motion (shearing) at the spinal segment.

�  This will lead to more functional instability, more pain, more muscle inhibition/weakness etc.

�  Pain is not always the start of the problem. (Berglund, 2010)

�  Look for potential culprits for a patient’s pain by doing a thorough differential diagnosis evaluation and biomechanical examination.

�  Do not just treat painful area unless other potential culprits have been investigated.

(Erl Pettman/NAIOMT)



�  Neurologic Weakness should also be considered.

1.  True Conduction Loss / Palsy. 2.  Pain Inhibition. 3.  Hypertonicity via Central or Peripheral

Sensitization/ Facilitation. 4.  Axoplasmic Flow Disruption. 5.  Axonal Transport Disruption.

Specific Exercise Manual Therapy Progressive Fitness/Aerobics Stabilization Home Program (Gym Program)

Problem if other categories are not addressed first: �  Pain inhibited or hypertonic stabilization muscles are less effectively strengthened.

�  Segmental stabilization more effective if segmental motion is restored first.

�  Spinal stabilization exercises are not a panacea / cure all.

�  Spinal stabilization exercises are performed as part of a compressive rehabilitation program based on differential diagnosis examination (medical screening examination if warranted) and biomechanical examination.

�  PT Goals: Reduce pain/centralize symptoms, restore mobility, and then functionally stabilize.

�  Acute LBP PT Goals: Reduce frequency and intensity of exacerbations & Prevent Chronicity.



Clinical Evidence

Relevant Research Evidence

Patient Beliefs

Ideal Treatment

�  Pain can remain chronically for 1 to 1.5 years but functional improvements can be made.

�  Progress from local stability training to endurance training then strengthen to individual patient’s demands.

�  If pain levels limiting progress with rehabilitation then MD management /consultation needed. Medication, Injections, etc.

�  If structural instability too great to functionally manage with neuromuscular training, then surgical intervention maybe warranted, especially if radicular symptoms persist.

Current Concepts in Lumbar Spinal Stabilizatio

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