625 Lumbar stabilization

Movement Control

Onset of Sxs: May describe recurrence, agg- quick or sudden mvmts

Severity & Irritability: Min to Min/mod ODI usually < 20%

May present with aberrant mvmts, + Prone Instability Test

Impairments typically include impaired flexibility, motor control, & muscle activation impairments

Functional Optimization

Higher level patients with minimal sxs Performing ADLs & need to return to sport or work performance

Severity & Irritability low/non ODI usually < 10%

Impairments may be more in endurance, strength, and/or power

Interventions match sport/job demands

spinal instability

The spine compromises stability for mobility

Panjabi’s functional subsystems:

• Passive (bony structure, ligaments)

• Active (spinal muscle function)

• Neural (control system)

Instability = movement outside of “neutral zone” and subsystems fail

Radiographically Appreciable Instability (LBP w/ movement coordination impairments)

Failure of the passive subsystem, e.g. osseoligamentous structures

Can result in compression of neural or vascular structures

May have intermittent signs/ symptoms of cord compression or vertebral artery insufficiency

Surgical intervention is often indicated

Clinical Instability (LBP w/ movement coordination impairments)

Failure of the active and neural subsystems

Defined as abnormality of movement vs. hypermobility

Can occur without compromise to vascular or neural structures

Valid and effective criterion does not exist

Conservative intervention indicated when neural and vascular structure intact

Lumbar instability Subjective Report

Painful “locking” or “catching”

Feeling of back giving away or buckling

Intermittent clicking or popping

Relief with self-manipulation & external support, e.g. brace

Recurrent

Lumbar instability common aggs

Twisting

Transitional activities

Returning to neutral from a flexed position

Difficulty with unsupported sitting

Sudden unprotected movements

Lumbar instability observation

Spasm/over-activity of the lumbar paraspinals

Possible ower crossed syndrome

Lumbar AROM

Poor lumbopelvic control

• Hinging or pivoting with movement

• Presence of aberrant motion, Gower’s sign present

Lumbar instability strength/motor assessment

Local muscle weakness or endurance deficits

• Extensor endurance testing

• Assessment of abdominal drawing in maneuver

• Movement control testing in multiple planes

Lumbar instability spinal segmental mobility testing

Central PA testing- Hyper, hypo, normal

Prone Instability testing

Janda’s lower crossed syndrome

Weakened abs/glutes

tightened throraolumbar extensors/hip flexors

hyperlordosis

Ant tilt

Lumbar flexion normal movement pattern

Posterior sway of hips

Hips begin to flex

L/S begins to reverse the lordosis

Completion of hip flexion

Lumbar flexion aberrant movement pattern

Initiation with anterior pelvic tilt

Inadequate reversal of lumbar lordosis

Excessive hip flexion

Excessive lumbar flexion

Return from flexion – initiation with lumbar extension

Return from flexion – minimal lumbar curve movement into

Lumbar extension normal movement pattern

Initial movement

• Top down segmental movement (standing) – T/L junction to lumbosacral junction with posterior pelvic tilt/hip extension

End movement

• Hip extension

Lumbar extension aberrant movement pattern

Extension occurs primarily thru 1-2 of lumbar segments

Hypermobility at the primary segment

Hypomobility of segments above and below

Lumbar lateral flexion normal movement pattern

Top down initiation of movement (standing)

Observe shape of curve Should be a ‘C’ curve

Look for any hinging at any one or more than 1 segments

Lumbar lateral flexion aberrant movement pattern

Limitation in L/S lateral flexion Increased movement via C/S, T/S

Movement limited to 1 -2 lumbar segments

(+) hypertrophy of lumbar paraspinals

Prone instability test

Patient is lying prone on the edge of the table with feet on the floor.

Therapist performs a PA motion on the most comparable lumbar segment with the patients trunk and leg muscles relaxed.

Patient is asked to lift the legs off the floor.

Therapist reapplies the PA to the most comparable segment and assess symptom response.

Positive: Pain is reduced or alleviated with muscle contraction

Movement control common test positions

Sagittal Plane Test Positions:

• Supine – heel slides

• Supine – hip/knee flexion

• Prone - hip extension with knee flexed

Transverse Plane Test Positions:

• Supine – Hip Abd-ER (Bent knee fallouts)

• Sidelying - Hip Abd-ER

• Prone – Hip IR /ER

• Q-ped – unilateral UE/ LE raises

Goal: maintain neutral spine during movement

Utilize visual/tactile feedback

Can become training exercise

Clinical Instability OR Chronic LBP w/ movement coordination impairments: symptoms

Chronic, recurring low back pain and associated (referred) LE pain

Clinical Instability OR Chronic LBP w/ movement coordination impairments: impairments of body & function

Presence of 1 or more of the following:

• Low back and/or low back-related LE pain that worsens with sustained end- range movements

• Lumbar hypermobility with segmental motion assessment

• Mobility deficits of thorax and lumbopelvic/hip regions

• Diminished trunk or pelvic-region strength and endurance

• Movement coordination impairments while performing community/work- related recreational or occupational activities

Clinical Instability OR Chronic LBP w/ movement coordination impairments: primary intervention strategies

NMR to provide dynamic (muscular) stability to maintain the involved structures in less symptomatic, mid- range positions during household, occupational, and recreational activities

Manual therapy procedures and therex to address identify T/S, lumbopelvic, or hip mobility deficits

Therex (strengthening) exercise to address trunk and pelvic-region strength and endurance deficits

Community/work reintegration training in pain management strategies while returning to community/work activities

Transverse abdominus (TrA) activation

Important role in spinal stiffness and stability

• Avoid shear forces

• Protect neural structures

• Protect from excessive motion
  Enhances transfer of load

• Resistance of segments to displacement under load

Inhibited in patients with low back pain

Late activation of TrAin patients with low back pain

Hollowing

Isolated contraction of the TA & internal obliques

Described by Jull & Richardson (2000)

Inhibition of erector spinae

May be a good early motor control & pain relief strategy

Bracing

Abdominals are contracted & increase torso stiffness

Involves activation of the lumbar extensors

Greater trunk stability generated from “bracing” compared to “hollowing”

May be better strategy for advanced exercises & functional optimization

Engaging the TA: The “hollow” goal

identify and perform TA contraction with patient able to proprioceptively feel contraction

• Use tactile, verbal, and visual input/cueing to assist patient

• PT palpates just medial and slightly inferior to ASIS’s. Start with PT palpating to confirm correct activation. Also have patient feel so they can monitor independently for correct form (during HEP)

• Verbal cues:

  • “TA lies deep in abdomen under external/superficial abdominal muscles we can see and feel”

  • “You have to push your finger into space (below ASIS) to feel the contraction. When TA is activated it should feel like a strong band becoming taut under your finger”

  • Pair it with breathing if the need more help or aren’t getting it. “Take a deep breath in and during exhalation breath out slowly and make Shhhhhhhh sound out loud. When exhaling focus on pulling belly button down to your spine and you should feel tightening of TA under your finger.” This can also help encourage patient to avoid breath holding.

Engaging the TA: The “hollow” common mistakes

Sucking in the stomach

Taking breath in, holding and performing Valsalva

Bearing down/pushing down on pelvic floor muscles

Forcefully “crunching” abdominals & performing trunk flexion

Engaging the TA: The “hollow” : pair activation of pelvic floor muscles w/ TA contraction

PF muscles run from pubic bone to tailbone and fill space at bottom of pelvis therefore important in stabilization

Activation of PF muscles helps guide the rest of the “core” (TA, obliques, spinal extensors, hip/pelvic stabilizers)

Multifidi activation

Lumbar multifidus muscles (LMM) play an important role in lumbar stability and spinal stiffness

Presence of LMM atrophy and fatty infiltration in people with chronic low back pain

Late activation of LMM in patients with low back pain

Treatment strategies directed towards LMM activation can reduce LBP and improve function

Multifidi ex exercises

Clamshell

Quadruped alternating arm/leg (bird dog)

Side plank

Prone extension

Single arm dumbbell row

Anti-rotation exercises

Functional optimization characteristics/considerations

Low irritability & severity

Patient able to perform BADL’s & IADL’s

Need to meet demands of PLOF

Consider exercise physiology principles:

• Specificity

• Dosing

• Load

Lumbar extensor strengthening

Evidence of muscle degeneration in LBP → Decreased muscle performance & atrophy of muscles

Decreased cross-sectional area

Increased fatty infiltration

Muscles affected:

• Paraspinals

• Multifidi

CSA of lumbar extensors did not change with stabilization alone

Trunk balance exercises

Delayed muscle activation of TrA and LMM during predictable and unpredictable activities

Delayed activation of spinal stabilizing muscles is linked to recurrence of low back pain

Most therex and NMR emphasizes feedforward mechanisms

Consider integrating exercise that address feedback control mechanisms, e.g., balance, perturbation training

Considerations for healing disc

As DD increases, spinal stability decreases (Zhao)

Outer annulus has greatest healing potential

• Annular fibers are alternately obliquely oriented

• Rotational exercises may assist in tissue remodeling of outer disc

Considerations for healing disc: Phase 1

Non-rotational/Non-flexion phase (Acute Inflammatory Phase)

• Minimize inflammation

• Specific exercise for pain relief

• Teach new movement patterns

Considerations for healing disc: Phase 2

Counter-rotation/flexion phase (Repair Phase)

• Introduce controlled movement to facilitate healing

• Introduce isometric movement to improve stability in frontal and transverse planes

• Consider regional interdependence and mobility of contributing structures, e.g. thoracic spine, hip

Considerations for healing disc: Phase 3

Phase/Power Development (Remodeling Phase)

• Progression of movement to graduated dynamic movement will improve alignment and organization of collagen

• Introduce movement that facilitates stability with external load

Considerations for healing disc: phase 4

Full Return to Sport

• Progression towards movement in all 3 planes

• Stable controlled mobility throughout full ROM of sport activity

Phase I: Non-flexion /Nonrotation exercise

Specific exercises/directional preference

Early motor control “hollowing” & “bracing” exercises in neutral spine

Nerve glides as indicated (to be covered at later date)

Side lying hip ER/ABD, i.e. clamshell

Standing row and lat pulldown

Instruct hip hinge

Phase II: Counter-rotation & Flexion exercise

Plank in frontal and sagittal planes

Bridge → single leg bridge

Unilateral row

Palloff Press

Hip hinge (high rep, lowload)

Hip hinge squat

Farmer carry

Rotational & Power exercise

Hip hinge with increased load, e.g. RDL

Progress to single leg RDL

Lower quarter strengthening, e.g. lunges

Weighted squats

Band chops

Integrate power strengthening as able… Power = Force x Velocity