Download Name of presentation

Physical Therapy Approach
to Low Back Pain Lumbar Stabilization
Stacey Franz, DO, MSPT
Medical Director,
NorthEast Spine & Sports Medicine
Disclosures
• I have NO RELEVANT financial disclosures
How our core supplies stability
• Promote muscle stiffness to control segmental
translation
– segmental stability is dependent on recruitment of
the deep local stability muscles
• Anticipatory recruitment prior to functional loading
provides protective stiffness
• Proximal stability for movement of extremities
• Generates force to control, limit range of motion
– Concentric action through the range of motion
– isometric action to hold position
– Eccentrically control the return
Anatomy of the Core –
Lumbar Muscles
• Muscles
– Transversospinalis group
• Rotatores, Interspinales, Intertransversarii, Multifidi
– Erector spinae
• Iliocostalis, Longissimus, Spinalis
– Latissmus dorsi
– Quadratus lumborus
• Physiology
– Poor mechanical contribution to movement production
– Primarily Type I fibers = segmental stabilization
– Optimal for proprioceptive feedback
*Multifidi most important muscle in this group *
Anatomy of the Core –
Abdominal Muscles
• Muscles
– Transversus abdominus
– External obliques
– Internal obliques
• Physiology
– Provide sagittal, frontal & transverse plane stabilization
– Transversus abdominus
• increases intra-abdominal pressure = dynamic stab.
against rotational, translational stress
• Necessary for anticipatory control
– Activates prior to movement of the limbs or trunk to
increase stability of the spine, prevent unwanted
trunk movement (Cresswell 1994)
• Activity contributes to spinal control (Cresswell 1992,
Hodges 1999)
– Attach to thoracolumbar fascia = add tension w/
contraction
Anatomy of the Core –
Hip Muscles
• Muscles
– Psoas
– Glut medius
– Glut maximus
– Hamstrings
• Physiology
– Psoas tightness can be problematic
• can lead to reciprocal inhibition of glut maximus,
multifidus, erector spinae, internal oblique, TA
– lead to Extensor mechanism dysfunction
• increase shear and compressive forces at L4-L5
junction
Anatomy of the Core –
Hip Muscles (continued)
• Physiology
– Glut medius weakness
• increase frontal and transversus plane stress at
patella-femoral joint and tibiofemoral joint
– synergistic dominance of TFL & quadratus
lumboru
– Glut maximus
• Decreased activity can lead to pelvic instability,
decreased neuromuscular control
– Hamstrings
What happens to the core when
we have low back pain?
• Inefficient muscular stabilization
– Pain leads to inhibition of muscle control (Stokes & Young
1984, Hides et al. 1994)
– Motor control deficit associated with delayed timing or
recruitment deficiency (Hodges & Richardson 1996)
– Transversus abdominus shows decreased ability to
contract in patients with recurrent low back pain (Hodges
1997, Ferreira 2004)
• Impairs our anticipatory control
• Impairs our spinal control (Cresswell 1992, Hodges
1999)
What happens to the core when
we have low back pain? (continued)
• Weakness and muscle fatigue
– Multifidi atrophy in patients with chronic LBP
– In unilateral acute/ subacute LBP, there is 31% side to
side difference with atrophy of affected side - 3% in
controls (Richardson 1999)
– Decreased endurance of extensors (Jorgensen 1987,
Ebenbichler 2001)
– Abnormal flexor to extensor strength ratios (McGill 2002,
Siolie 2001
– Decrease in muscle integrity results in lack of control of
segmental translation
What happens to the core when
we have low back pain? (continued)
• Decreased spine proprioception
– Multifidi atrophy in those with LBP
• Proprioception partly from multifidi (Bogduk 1997,
Hides 2004)
– Difficulty repositioning into neutral spine posture
(O’Sullivan 2003)
• Loss of control of neutral joint position
– Postural control shown to be altered in patients with
chronic LBP (Ebenbichler 2001)
• Single leg stance balance
• Postural stability tests (Mok 2004)
– Unexpected balance challenges
• Trunk perturbation (Wilder 1996)
How Does Core Stabilization help
Low Back Pain
• Multifidi activation improves pain in acute and chronic
LBP (Hides 1996, O’Sullivan 1997)
– Multifidi dysfunction does not correct automatically
when pain resolves but specific training can correct
dysfunction
– Segmental stabilization training with co-contraction of
Transversus abdominus and Multifidi
• Abdominal bracing training stiffens the spine and
improves stability (Grenier 2007)
• Exercise, in general, beneficial for low back
– Slows degenerative conditions
– Enhances nutritional benefits to spine
Lumbar Stabilization Concepts
• What does it entail:
• Recruitment of proximal trunk & girdle muscles
• Ability of agonists, antagonists, synergists, to work
•
efficiently & interdependently
Facilitates balanced muscular functioning of the entire
kinetic chain
• How does it translate functionally:
• Enhances neuromuscular control/ efficiency throughout
•
•
•
the kinetic chain
Optimizes postural alignment & dynamic postural control
Affect arthrokinematics around lumbo-pelvic-hip complex
Promote dynamic strength
Lumbar Stab. Concepts (continued)
• Neutral vs. Dynamic Stabilization
• “Neutral spine stabilization” introduced in 1980s
– Position of comfort where muscular support
reduces stress on painful structures
• “Dynamic stabilization” introduced in 1990s
– more functional; multi-planar requiring
–
acceleration & stabilization
interest increased after Joe Montana returns to
football after lumbar spine surgery
Assessment of the Core
• Muscle strength
– Manual muscle testing
– Straight leg lowering test
• Muscle endurance
– Erector spinae assessment
• Functional testing
– Isokinetic testing
– Balance testing
– Power testing (i.e. medicine ball throws)
– Jump tests
– Sport specific, functional tests
Program Prescription
• Be mindful of pain generators
– Flexion vs. Extension vs. Neutral program
• Exercises that span the spectrum of muscle contraction
– Concentric (force production)
– Eccentric (force reduction)
– Isometric (dynamic stabilization)
• Exercises that span body positioning
– Supine
– Prone
– Quadruped
– Sitting
Program Prescription (continued)
• Progression should include additional reps rather than
duration of hold
• Should challenge the patient by progression through
function continuum
– Slow to fast
– Simple to complex
– Low force to high force
– Eyes open to eyes closed
– Static to dynamic
• Quality, not Quantity
– Poor technique and neuromuscular control results in
poor motor patterns & stabilization
Level 1 - Stabilization
• Supine
• Diaphragmatic breathing
• Abdominal bracing
• Pelvic tilts
• Arm lift
• Leg lifts
• Opposite arm lift/ leg lift
• Marching
• Bridging w/ arms at sides
• Bridging w/ arms at 90 degrees
• Bridging with marching
Level 1 –
Abdominal Draw In
• Mechanism:
– Activates the TA (Richardson 1999, Hodges 1996,
Urquhart 2005)
– Re-trains co-contraction of the deep transversus
abdominis with contraction of the deep fascicles of
multifidi (Jull 1999, Richardson 1999)
• Technique:
– “Breath in and out. Gently and slowly draw in your
lower abdomen below your navel without moving
your upper stomach, back or pelvis” (Urquhart
2005)
• Must be breathing properly – optimal muscule
activation cannot be achieved when holding
breath
Level 1 –
Abdominal Bracing
• Mechanism:
– Co-contraction of abdominal wall muscles for
greater stability
• greater external oblique activity than other
abdominal muscles (Urquhart 2005)
– Lateral flaring of abdominal wall (Kennedy 1980)
– Increase of intra-abdominal pressure (Kennedy
1980)
• Technique:
– Breath in and out. Gently and slowly swell out your
waist without drawing your abdomen inwards or
moving your back or pelvis (Urquhart 2005)
Level 1 –
Pelvic Tilts
• Mechanism:
– Reduces lumbar lordosis (Vezina 2000)
– Muscle activation
– Internal oblique > rectus abdominus, external
oblique (EO) (Urquhart 2005)
– Rectus abdominus> lateral abdominals
(Richardson 2005)
– External oblique> Rectus abdominus (Vezina
2000)
– Similar Internal oblique and Rectus abdominus
(Flint 1965, Carman 1972)
• Technique:
– Lie supine with knees bent and feet flat on the floor
– Gently rock the pelvis backward as if pushing your
back into the floor
Level 1 – Stabilization (continued)
• Prone
• Finding neutral
• Glut sets
• Arm lift
• Leg extension
• Opposite arm lift/ leg lift
• Quadruped
• Cat camel to find neutral
• Rocking to find neutral forward/ backward
• Single arm raise
• Single leg extension
• Opposite arm raise/ leg extension
• Kneeling
• Finding neutral
Level 1 – Stabilization (continued)
• Sitting
• Finding neutral
• Single arm lift
• Single leg extension
• Marching
• Opposite arm/ leg lift (leg extended)
• Opposite arm/ leg lift (marching)
• Standing
• finding neutral
• Wall slide
Level 1 - Stabilization
• ?
Level 2 – Stabilization
• Supine
• Partial, diagonal curls
• Single leg lowering
• Opposite arm/ leg lowering\Bridging with leg
extension
• Bridging with one leg
• Prone
• Single/ double arm lowering (w/ Roman chair)
• Single/ double leg lowering (w/ Roman chair)
• Push ups against wall
• Push ups with feet farther apart
• Push ups on chair
• Push ups on floor
Level 2 – Stabilization (continued)
• Quadruped
• Alternate arm/ leg with cuff weights
• One arm reach
• Kneeling
• Rock with arms and weights overhead
• With side kicks
• Push-pull with sticks
• Lifting up and down
• Half kneeling to standing
• Sitting
• Leg lifts
• Opposite arm/ leg lift
Level 2 – Stabilization (continued)
• Standing
• Wall slides
• Hip flexion with weight cuffs
• Double arm overhead with weight cuffs
• Lunges
• Push-pull with sick (up and down)
• Ball pass vs light medicine ball use
Level 2 - Stabilization
• ?
Level 3 – Stabilization
• Supine
• Double leg lowering withg 5 lb cuff weight
• Dead bug with arm/ leg cuff weights
• Bridging with calves on ball/ upper back
• Bridging with feet on ball
• Prone
• 2 Arms with 1 leg together
• Trunk extension (w/ Roman chair)
• Quadruped
• 2 Arms with 1 leg together
• Standing
• Push/ pull with sticks
Level 3 - Stabilization
• ?
Level 4 - Stabilization
• ?
Summary of Citations and
Levels of Evidence
•
Bogduk N: Clinical Anatomy of the Lumbar Spine and
Sacrum. Edinburgh, Churchill Livingstone, 1997
•
Carman DJ, Blanton PL, Biggs NL. Electromyographic study
of the anterolateral abdominal musculature utilising indwelling
electrodes. American Journal of Physical Medicine
1972;51(3):113–29.
•
Cresswell AG, Grundstrom H, Thorstensson A. Observations
on intraabdominal pressure and patterns ofabdominal intramuscular activity in man. Acta Physiologica Scandinavica
1992;144(4): 409–18.
•
Cresswell AG, Oddsson L, Thorstensson A: The influence of
sudden perturbations on trunk muscle activity and
intraabdominal pressure while standing. Exp Brain Res
1994;98: 336–341
Summary of Citations and
Levels of Evidence
•
Ebenbichler GR, Oddsson LI, Kollmitzer J, et al:
Sensorymotor control of the lower back: Implications for
rehabilitation. Med Sci Sports Exerc 2001;33:1889–98
•
Ferreira PH, Ferreira ML, Hodges PW: Changes in
recruitment of the abdominal muscles in people with low back
pain: Ultrasound measurement of muscle activity. Spine
2004;29:2560–6
•
Flint MM, Gudgell J. Electromyographic study ofabdominal
muscular activity during exercise. The Research Quarterly
1965;36(1): 29–37.
•
Grenier SG, McGill SM. Quantification of lumbar stability by
using 2 different abdominal activation strategies. Arch Phys
Med Rehabil. 2007 Jan; 88(1): 54-62
Summary of Citations and
Levels of Evidence
•
Hides J: Paraspinal mechanism and support of the lumbar
spine, in: Richardson C (ed): Therapeutic Exercise for
Lumbopelvic Stabilization, ed 2. Edinburgh, Churchill
Livingstone, 2004, pp 59–74
•
Hides JA, Richardson CA, Jull GA: Multifidus muscle
recovery is not automatic after resolution of acute, firstepisode low back pain. Spine 1996;21:2763–9\
•
Hodges PW, Cresswell A, Thorstensson A. Preparatory trunk
motion accompanies rapid upper limb movement.
Experimental Brain Research 1999;124(1):69–79.
•
Hodges PW, Richardson CA, Jull GA. Evaluation of the
relationship between laboratory and clinical tests of
transversus abdominis function. Physiotherapy Research
International 1996a;1(1): 30–40.
Summary of Citations and
Levels of Evidence
•
Hodges PW, Richardson CA: Contraction of the abdominal
muscles associated with movement of the lower limb. Phys
Ther 1997;77:132–42; discussion, 142–34
•
Hodges PW, Richardson CA. Inefficient muscular stabilization
ofthe lumbar spine associated with low back pain. A motor
control evaluation of transversus abdominis. Spine
1996b;21(22): 2640–50.
•
Jorgensen K, Nicolaisen T: Trunk extensor endurance:
Determination and relation to low-back trouble. Ergonomics
1987;30:259
•
Kennedy B. An Australian programme for management of
back problems. Physiotherapy 1980;66(4):108–11.
Summary of Citations and
Levels of Evidence
•
McGill S: Normal and injury mechanics of the lumbar spine,
in: Low Back Disorders: Evidence-Based Prevention and
Rehabilitation. Champaign, IL, Human Kinetics, 2002, pp 87–
136
•
Mok NW, Brauer SG, Hodges PW: Hip strategy for balance
control in quiet standing is reduced in people with low back
pain. Spine 2004;29:E107–12 ----Bilateral standing on short
base with eyes closed – LBP failed 4 times more than
controls
•
O’Sullivan PB, Burnett A, Floyd AN, et al: Lumbar
repositioning deficit in a specific low back pain population.
Spine 2003;28:1074–9
Summary of Citations and
Levels of Evidence
•
Richardson C, Jull G, Hodges P, et al: Traditional views of
the function of the muscles of the local stabilizing system of
the spine, in: Therapeutic Exercise for Spinal Segmental
Stabilization in Low Back Pain: Scientific Basis and Clinical
Approach. Edinburgh, Churchill Livingstone, 1999, pp 21–40
•
Richardson CA, Jull GA, Hodges PW, Hides JA. Therapeutic
exercise for spinal segemental stabilization in low back pain.
Scientific basis and clinical approache. Ediburgh: Churchill
Livingston 1999
•
Sjolie AN, Ljunggren AE: The significance of high lumbar
mobility and low lumbar strength for current and future low
back pain in adolescents. Spine 2001;26:2629–36
•
Urquhart DM et al. Manual Therapy 10(2005) 144-153
Summary of Citations and
Levels of Evidence
•
Vezina MJ, Hubley-Kozey CL, Egan DA. A review of the
muscle activation patterns associated with the pelvic tilt
exercise used in the treatment of low back pain. The Journal
of Manual and Manipulative Therapy 1998;6(4):191–201.
•
Vezina MJ, Hubley-Kozey CL. Muscle activation in
therapeutic exercises to improve trunk stability. Archives of
Physical Medicine and Rehabilitation 2000;81(10):1370–9.
•
Wilder DG, Aleksiev AR, Magnusson ML, et al: Muscular
response to sudden load: A tool to evaluate fatigue and
rehabilitation. Spine 1996;21:2628–39