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Benjamin L. Kolly DPT, OMPT, ATC Xcel Physical Therapy, PLC

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1 Benjamin L. Kolly DPT, OMPT, ATC Xcel Physical Therapy, PLC
Nonsurgical Management of LBP: Static Stabilization or Dynamic Exercise for the Back: Which One Do I Choose? Benjamin L. Kolly DPT, OMPT, ATC Xcel Physical Therapy, PLC

2 Clinical Relevance Different approaches between clinicians?
Competence, Clinic Preference, Results Is one option better than the other, what does the evidence suggest? Should we use one or multiple stabilization models? May depend on outcomes, patient experience, exposure, severity Goal is to become more open minded to the individual results and modify as indicated Some backs require more than just stabilization Some patients bad experiences with proposed intervention Effective training of TA may work better in sitting than prone in different individuals Pain control may be better tolerated in partial loading positions than CKC

3 Outline What is Stabilization Continuum of Dynamic vs. Static
What is dynamic What is static Review of Literature Key concepts Suggested Implementation

4 Spinal Stabilization Definition:
Kinesthetic awareness of posture and the ability to modulate spinal stiffness during functional activities To transfer loads, disassociate limb movements from the spine, and make movements effortless. Barr et al 1:“Stability is a dynamic process that includes both static positions and controlled movement” Nmodulate stiffness and mvmt to match the demands of int and external forces

5 Stabilization Mechanisms
Panjabi described spinal stability as 3 interdepedent parts2 Bone and ligaments- most stability to passive restraint at end ROM Muscles- support forces encountered daily Negatively affected by disuse 3 Pain and injury can negatively affect these muscles through pain and reflex inhibition 4 Neural control- coordinates mm activity to imposed demands (anticipatory and non- anticipatory) Bony structure:L best stability at end ranges;…suggested that in a cadever without mm the bones and ligaments will buckle under approximately 20 lbs (Crisco JJaMMP: Euler stability of human ligamentous lumbar spine. Clin Biomech 1992; 7:19-32. Muscle: modest levels of mm activity can create stiff and stable joints; in usual situations approx 10% of maximal muscle coactivation is required to provide segmental stability….in a segment damaged by ligaments or disc this may be higher; endurance suggested as a greater role for day to day activity whereas in unanticipated events or higher load activities such as sports, recreational act, or work an absolute strength may be just as improtant Neural system must activate the correct mm at the correct time by the right amount of force for the desired mvmt or stability (controlled mvmt)…stiffness achieved with specific patterns of mm activity which different depending on positions of the spien or loads placed

6 Stabilization of other joints
Muscle system can minimize aberrant joint displacement and act as strain absorber 5 Muscle spindles may regulate mm stiffness by contracting the slow twitch tonic muscles 6 Low load contractions (25% MVC) can provide maximal joint stiffness 7 CKC activity may increase antagonist co- contraction & reduce shear forces. 8,9

7 Muscles Complex system responsible for 1) stability and 2) movement 10
1) Deeper muscles: thought to control stiffness and segmental stability I.e.: TA, multifidus 2) Superficial or global system: torque generators or movers of the spine and responsible for dissipating external loads to the spine. Contribute to stability in direction specific movements and carrying weights11 Comes at a price of increasing compressive load on the spine-possibly un-wanted in some conditions Limited control of shear forces (too far from axis of mvmt)

8 Dynamic Stabilization
Dynamic: a continuum of movement that replicates functional activities; varies between authors and studies. Dynamic Exercise: purposeful, more often closed kinetic chain, movement with the intent of replicating normal functional activities of daily living, recreation, and sporting. Activation of the Larger, more superficial muscles of the trunk. For the purposes of this lecture this will include non table / mat exercises

9 Static Stabilization Static: A theory of tightening the torso/trunk to minimize motions occurring through the trunk during physical activity or therapeutic training Static Exercises: commonly thought of as isometric, table or mat exercises emphasizing the deeper muscles Also known as motor control or specific stabilization exercises.

10 Stabilization Theories
Static Dynamic Lumbar spine function can improve without isolation of TA and multifidus To return to activity dynamic exercises need to be emphasized Isometric static holds increase intra-abdominal pressures and not practical Functional Aids in restoring confidence Required to restore atrophy of multifidus and TA Prevents compensation or substitution patterns in painful- weak muscles problems 12 Generates a trunk extensor moment and reduces tensile loading, compression, and shear loads of the spine Proper technique and repetition of mm activation will transition into functional use and thereby spinal stability.17

11 Efficacy Philadelphia Panel Evidence Based Clinical Practice Guidelines for Nonspecific LBP18 Clinical benefit on pain relief function and perception for sub acute and chronic LBP with Therapeutic Exercises 2005 Cochrane review by Hayden et al examined 6 RCT : spinal exercise is particularly helpful in the healthcare settings.19 Hicks et al20:when 3 following are found efficacy improves: < 40 years old SLR greater than 91 degrees Positive prone instability test Aberrant motion present during sagittal plane AROM 67% chance they would have significant improv (success) with meeting ¾ Clinical Prediction Rule (CPR on 54 subjects with LBP over 8 weeks, success measured by 50% improv ODI)

12 Transverse Abdominus Primarily slow twitch type I fibers (low load, endurance mm) Theorized to act bilaterally as a corset or tensioning of thoracolumbar fascia sometimes referred to as increasing intra-abdominal pressure 21 TA may be activated in a feed forward mechanism contributing to stability, stiffness. Some authors have been unable to validate this concept22,23 Found to contract before upper or lower extremity movements (anticipatory manner) preventing unwanted mvmt in subjects without LBP whereas in patients with LBP there was a delay in the contraction.24-29 Teyhen et al found R to L side thickness of the TA was equivalent between those with and without LBP but there was a 21% greater change in girth within the asymptomatic group side to side from rest to contraction30 TA is deep mm not effective for moving the spine Contraction felt just medial and slightly inferior to ASIS (laterally to rectus and inferiorly to oblique mm), no spinal movement Quadruped position of training limits substitution of rectus abdominus. Progress to Supine hooklying, leg movements (marching), bridging, functional lifting Biofeedback Pressure Cuff Unit Useful tool to indirectly monitor the amount of muscle activation by monitoring changes in pressure. (Cairns MC, Harrison K, Wright C. Pressure biofeedback: a useful tool in the quantification of abdominal muscular dysfunction? Physiother. 2000; 86: Useful when training ADIM concurrently with prone hip ext to get less recruitment of erector spinae and reduce ant pelvic tilt (lordosis). (Jae-Seop OH, Heon-Seock C, Jong-Hyuk W, Oh-Yun K, Chung-Hwi Y. Effects on performingan abdominal drawing-n manuever during prone hip extension exercises on hip and back extensor muscle activity and amount of anterior pelvic tilt. J of Orthop Man Phys Ther 2007; 37(6): ) Prone technique lower border placed at ASIS: Inflate to 70 mmHg, ADIM should lower6-10mmHg or stay approximately the same Inflate cuff to 40mmHg Pelvic Tilt: should rise to 60 or better EMG showed rectus abdominus recruitment and greater amounts when legs unsupported Abdominal Hollowing : should lower or stay the same Minimal recruitment of rectus abdominus Drysdale CL, Earl JE, Hertel J. Surface electromyographic activity of the abdominal muscles during pelvic-tilt and abdominal-hollowing exercises. J of Athl Train. 2004; 39(1) In supine, hook lying the biofeedback unit can be placed under the spine and contraction of the TA and/or multifidus should produce no change in pressure Can be objectively used to track progress of endurance and quality of contraction

13 Training of the TA Patients can retain TA contractions up to 1 week b/w sessions31 5 min instruction effectively maintain neutral spine and minimize segmental spinal motion during biceps curl, hip flexion, and hip extension.32 Some subjects with chronic LBP took 4-5 weeks of training to develop this co-contraction effectively33 Subjects with LBP less effective at performing TA contraction than asymptomatic individuals 34

14 Allison, Morris, Lay in examination of the TA (2008)35
TA was not found to stabilize the spine during bilateral extremity movement TA does not act as a corset nor does it reflect normal motor patterns seen in ballistic movement

15 Multifidus Primarily slow twitch type I fibers (low load, endurance mm) Likely more responsible for resisting or monitoring segmental rotation Largest contributors to intersegmental stability; found to contribute more than 2/3 of the stiffness at L4-5 segment 36 Evidence of atrophy in chronic LBP 37 Rich in mm spindles, attaches to facet joints, functions as proprioceptors or kinesthetic sensors 38,39 Repositioning accuracy reduced in subjects with LBP Safe exercises: Quadruped opp arm – leg, bridges, Posture training, kinesthic awareness of spinal positioning Progress to bridges with leg lift, prone exercises, ball exercises, Roman Chair but these add to compression loads on the spine Proprioception: and reduced in both subjects with and without LBP when tuning fork vibration applied

16 Evidence of Multifidus Atrophy
Paraspinal mm 10-30% smaller on affected side of unilateral post-operative LBP patients 42 Chronic LBP patients have weak spinal extensors and/or multifidus 40-42 Asymptomatic patients had a 3% +/- 4% side to side difference whereas unilateral pain patients demonstrated 31% +/- 8% difference. 43

17 Multifidi training44,45 RCT 39 subjects 1st occurrence of unilateral LBP Both groups near full resolution of symptoms at 4 wks Standard care Group multifidus size unchanged at 4 and 10 wk Treatment Group multifidus CSA restored 4 weeks 3yrs post study Standard Care Group had 9X greater likeliness of pain CG control group TG treatment group CG education and regular care TG multifidus strengthening and activation CSA cross sectional area

18 Multifidus Training in Elite Cricket Athletes46
13 week training camp, 26 young males (10 with hx of debilitating LBP) 6 wk stabilization lieu of lifting weights in gym Results CSA increased and asymmetry reduced in subjects with Hx LBP 50% decrease in pain scores Training: ADIM, isometrically contract the multifidus with focus on each level, and draw up the anterior aspect of the pelvic floor Try to swell or contract mm, no mvmt Tactile and biofeedback training Begin Non-WB and progress to WB with movement training

19 RCT of Static Stabilization
Hides et al 45 : 45 subjects 1st occurrence of LBP received standard medical care vs. multifidus/TA stabilization Short term (4 wks) no sig difference in rate of recovery from acute pain Long term (2 and 3 year f/u) showed reduced reoccurrence rates Standard Care 12 x more likely experience recurrent LBP in the first year and 9x more likely in years 2-3. O’Sullivan et al 33 : compared TA stabilization and general management who underwent 1x/week x 10 weeks Post treatment and 2.5 year f/u showed greater reductions in pain and disability in the stabilization approach. Hides study: unfortunately most acute first occurrence LBP resolves itself without Rx Osullivan: minute exercise daily with

20 RCT (Cont) Goldby et al 47: 213 subjects over 10 weekly sessions received spinal stabilization, minimal care, or manual therapy. All 3 groups 3hr back school which included advise on back exercise. No significant differences in pain, disability, QOL, and medication between groups at 3,6,12,24 months although there was within group changes from baseline. Ferreira et al 48 : 223 subjects, 12 treatments in 8 weeks received general exercise, stabilization, or manual therapy. Both exer groups received cognitive behavioral therapy and encouraged to do HEP. Stabilization and manual therapy had SLIGHTLY better short term pain and perceived functional outcomes but all groups had similar outcomes at 6 and 12 months and there was no statistical difference b/w groups. Cairns et al 49 : 97 patients with hx LBP received max 12 sessions in 12 weeks; randomized into conventional tailored PT or stabilization of multifidus and TA No significant differences in outcomes (pain, perceived disability, QOL, and psychological distress) were detected after 12 weeks, 6 mo and 1 year follow up Ferreira general exercise: group exercise stretching strengthen major mm groups, fitness Cairnes high quality clinically relevant Both groups received manual PT as indicated . Conventional tailored group prohibited from using exercises in the stabilization group. Golby Low quality , less relevant Ferreira high quality, clinically relevant

21 RCT (cont) Costa et al 50 : 154 patients with chronic LBP divided into stabilization or placebo underwent 12 sessions in 8 weeks. Small clinical improvements in stabilization group seen at 2 months and generally maintained at 6 and 12 months 12 months significant pain reduction in stabilization Stuge et al (2004) 51 : TA stabilization demonstrated long term (2 years) positive outcomes in decreasing pain and disability Costaone half hour treatments (2x/wk x 4 weeks then 1x/wkx4 weeks) Motor Control Group: Stage I train TA and multifidus and reduce over-activity of superficial mm; Stage II Train this contraction during static tasks and incorporate them into functional positions; Placebo Group: Detuned Ultrasound and Diathermy. Exercises similar to those chosen by O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercuise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:

22 Systematic Review of Motor Control (Static Stabilization)52
Better than minimal intervention (short term, intermediate, long term) and disability (long term) Better than manual therapy for pain, disability, QOL (intermediate) Better than other forms of exercise (5 RCT) in reducing disability short term Overall Motor Control may be effective in reducing pain and disability in nonspecific LBP but not superior to other forms of exercise 14 trials included motor control, specific spinal stabilization, core stability targeting specific muscles and neuromuscular control of spine/pelvis

23 General vs. Specific Trunk Stabilization53
Koumantakis et al: 67 subjects grouped into Stabilization of TA and multifidus vs general stabilization approach focusing on large mm groups (obliques and paraspinals) General group examples: crunches, prone trunk extension, pelvic tilting sitting/lying/standing positions, bridges, tilt with heel slides, lower abdominal crunches, 4-point kneeling, lateral planks, alt arm-leg movements, swiss ball exercises Specific trunk stabilization exercises: quadruped TA, multifidus manual palpation, co-contraction sit to stand, isolated movements of hip and thoracic spine, sitting on unstable base, aggravating postures, bridges with co-contraction, unstable base (swiss ball), functional co- contractions Results: no significant difference between the groups at 8 and 20 week examination No change in fear of mvmt/activity b/w groups as both groups got back book General exercise approach utilized several “stabilization” type exercises that are typically cited in rehabilitation approaches and thus it is difficult to expect sig changes CG used paraspinal and abdominal strengthening where study group leaned volitional activation of TA and multifidus and asked the to recruit throughout day.

24 Examples of Static Richardson & Hull Sahrmann Hodges

25 Richardson & Hull Exercise Theory55
Extremely difficult to determine if TA/Multifidus mm working when larger more active global mm are firing and as such you can’t effectively train or target the correct muscles Principles of stabilization: Isometric contraction segmentally they stabilize and don’t move Prolonged low level contractions slow twitch endurance mm and relatively low load required for stabilizing Begin 4 pt kneeling or prone where body weight supported Progressing holding time and reps before body weight loads Co contraction train in neutral with both TA and multifidus co contraction One of the earliest studies of Stabilization or core stability Global mm shorten or lengthen (eccentrically) as they move the trunk (Richardson Hull 1995 man ther)

26 Sahrmann56 Training of the deep lumbar muscles with concurrent extremity movements (beginning with mat exercises) critical to establish safe functional movements of the legs. Lumbar extension during active hip extension occurs as a result of decreased abdominal control to counteract anterior pelvic tilt during manuever.

27 Paul Hodges Palpate isometric contraction of multifidus by having patient swell multifidus into hand Essentually have to make a conscious contraction out of a subconscious muscle Extreme view of static, table exercise

28 Examples of More Dynamic
PNF Pilates Gary Gray Gambetta McKenzie BET

29 PNF 57 RCT 108 subjects with LBP >24 weeks underwent 4 weeks of intervention 5d/wk divided into 3 groups: alt trunk flexion- extension isometric contractions; alt concentric and eccentric contractions; C group normal daily living /avoid structured exercise. PNF exercises significantly increased spinal ROM and endurance but no significant difference between groups for disability ratings 3 x 15 reps with warm up and cool down Outcomes: ODI, Trunk endurance with modification of Sorenson back extension test, lumbar sagittal mobility, trunk flexion endurance Sorenson static hold horizontal position with ASIS off edge and thighs/ankle stabilized up to 240 sec Sorenson dynamic test consequitive extensions up to 25 at a rate of 25/min (controlled) Trunk flexion (sit up position) feet velcroed to ground arms flat on ground rate of 25/min up to 25 (metronome) Trunk flexion static (arms pointing twds knees curled up until iliac crests off table hold up to 240 seconds

30 Pilates Based58 RCT 55 subjects with LBP >6 weeks or reoccurrence at least twice/year grouped into Pilates based or control for 12 sessions in 4 weeks Statistically lower level of self reported disability and pain intensity over control Maintained for up to 12 months post intervention Exercise group Exercise group instructed in static postures then mvmt patterns to stress lumbopelvic region and finally to the Pilates reformer. Home program floor exercises of deep anterolateral abdominals and gluteus maximus 3 - 1hr sessions/week x 4 weeks plus HEP 6d/week x 15 minutes/day outcomes NRS and RMQ NRS numeric rating scale (perceived pain 0-100) RMQ Roland Morris Disability Questionnaire (24 items)

31 Gary Gray Functional Exercise
Early pioneer in closed chain-functional exercise Little documentation and no RCT Key Concepts: a) we never use our muscles in isolation during real world movements so we should not create exercises that tease out functional movements; b) rehabilitate the body the way it functions in the real world; c) begin with isolated integration and move towards integrated isolation Ex: #1 VMO activated during eccentric loading of the body so try anterior lunge but allow hip rotation, trunk positioning, or UE positioning to ease the VMO (take some demand off isolated integration) and move towards greater eccentric loading with hip position changes (ER) and UE overhead asking VMO to work harder (integrated isolation) #2 hypermobile LBP begin in upright standing pos if tol load bearing in the most specific task position (wether reaching, carrying, bending….); try to mimic that task and tweak the ROM limits or planes of motion so they can perform pain-free….conctract multifidus in protected reach position (hip height) to get eccentric lengthening to turn on the mm then progress to OH movements…. Potential problems: acute or low level patients may need to start on the table to fire the proper mm or facilitate some movement/activity

32 Vern Gambetta Rehabilitation and strengthening of athletes and individuals involves training: Movements not muscles Fundamental skills before whole specific task Use body weight before external loads Joint integrity before mobility Incorporate functional movements 

33 McKenzie method Petersen et al compared McKenzie to strengthening exercises in subacute –chronic LBP. McKenzie favored over strengthening but little statistical difference 59 Miller et al compared McKenzie to stabilization exercises in chronic LBP. No significant differences were seen between the groups 60 Long et al compared McKenzie to nonspecific or exercise groups in subacute – chronic LBP. McKenzie statistically better than both groups in the short term 61 McKenzie method is a treatment based on classification and treatment responses. Movements may be repeated movements at or near end range or static poses. The exercises are not necessarily functional but they have little if any focus on TA or multifidus contraction.

34 RCT of Dynamic Stabilization 54
Prospective study 42 patients post microdiscetomy; 3 groups (Williams – McKenzie exercises, dynamic stabilization, control group) Stabilization group showed significant improv in all parameters (P < ) Williams – McKenzie moderate improvement in all parameters (P ) Parameters (pain, perceived functional capacity, depression, spinal mobility, weight lifting capacity, body strength) Not pertain to our topic of nonsurgical but leads to discussion of Rx theories Control group showed some improv in 2 ROM scales and perceived functional capacity (ODI) suggesting surgery alone demonstrated improvements

35 Dynamic Stabilization Effectiveness
Gambetta, Gray, Pilates, PNF outcomes not well studied or documented Make sense functionally Follows many motor control theories Allows for dissipation of loads Possibly allows for better co-contraction

36 Importance of Static & Dynamic
Panjabi: effective control of BOTH the deeper muscles responsible for intervertebral stability AND the larger muscles responsible for movement across multiple levels are responsible for efficient stabilization and alterations in these neuromuscular control or loss of normal spinal mobility will cause pain 62 Dynamic important to effectively stabilize the spine during real life experiences Static beneficial where hx of poor mvmt patterns or fxnal deactivation

37 Combined Static and Dynamic
BET Paris

38 BET (Back Education and Training)63
Utilizes principles of good BOS, efficient alignment for mm recruitment, sequencing of weight shifting Progress volitional bracing (stable safe lumbar spine position) to automatic synergistic trunk activation. Early Rehab: Therapists assisted, therapist resisted mat, or table exercises self bracing Mid Rehab: dynamic stabilization and pertubation training, ball and rollers Late Rehab: active standing from weight shifting to squats, to reaching and functional movements Final phase of training is no longer active bracing but rather functional movements that involve kinesthetic awareness LPM: lumbar protective mechanism Assessment of abdominal strength functionally: patient in stride position, Examiner facing them diagonally and pushes posteriorly…look at initiation of lumbar protective mechanism (LPM), strength, and endurance Lumbar Protective Mechanism (LPM) automatic response of synergistic group of trunk mm that aid in maintaining neutral spine during functional activities. . Incorporate gym ball and roller to challenge BOS and tolerated by effective LPM over 2-3 minutes per activity

39 Stanley Paris64 Stabilization and integration an eclectic approach
Stabilization as 2 types: Static stiffening spine, holding in neutral, minimize stress on sensitive tissues. Also referred to as muscular fusion Bridges, bridges with leg raise, pelvic tilt with leg mvmts, TA seated, prone multifidus (opp SLR), quadruped UE /LE, Lunge with TA… Dynamic spinal movement safely and under control, avoid outer limits of range and sustained postures or overloads. Also referred to as Neuromuscular control Quadruped (with or without UE / LE) with examiner pertubation, resisted arm movements in standing, diagonal lifting

40 Motor Learning : Skill Acquisition
How individuals learn new tasks or exercises Several Theories, Basic Principles65 Feedback give early in learning, allow person to adjust self latter Whole task training might be better unless break down into naturally occurring elements (weight shift in walking not prone hip extension) Transfer (how training transfers to a new task or new environment): Depends on similarity of task/environment (ie if doing table exercises likely will not transfer to work demands unless practice in those environments) Motor Learning appears to better support the Dynamic Model of Exercise

41 Who benefits from stabilization?
Sub-acute and chronic18,19 Stabilization programs may be beneficial in reducing reoccurrence rates 44 Candidates with hypermobility tend to respond more favorably than those with hypomobility68 Patients with ¾ of the characteristics in the CPR 20 the CPR (<40, SLR > 91 degrees, (=) instability, aberrant motion)

42 What does all of this mean?
Stabilization appears effective Patients with LBP seem to have alterations in mm pattern, sequencing, activation, and tone 25,44,66,67 No scientific evidence to support any 1 concept over another Little if any evidence on dynamic stabilization (difficult to study) Success is likely dependant on multiple variables

43 How do we then implement program
Phase 1 (1-2weeks , 2 session/week) KISS Theory Educate re injury and recovery, teach and practice techniques for accuracy, implement self mgmt strategies, introduce positive outlook, allow for some natural healing, avoidance of pain maneuvers Progress from 10 sec to 3 minute intervals before phase 2 Phase 2 (2 +/- 6 weeks, 3 session/week) Progress stabilization towards functional restoration Incorporate larger movements Phase 3 (6-12 months) Continue exercises independently, f/u with clinician for goal setting, guidance, and exercise progression…

44 Phase I Teach pain free movement patterns and exercises: low compressive loads Reduce overload/over-activity of errector spinae mm; Wake up the smaller mm Emphasize conscious awareness of pelvic positioning / identify neutral position and movement with and without extremity movements Abdominal drawing in maneuver (ADIM) quadruped to prone, biofeedback (start at 70mmHg and have them lower 6-10mmHg for 10 +sec) May not be better than other forms of stabilization but may have role in motor control, safe exercise, reduced intradiscal pressures, allow patient to see changes and improvements Initiate co-contraction of multifidus with TA using palpation Devel core awareness: activating multifidus and TA during functional positions of sit, SDLY, prone, stand, supine Teach concepts in isolation then utilize and practice movements in more functional positions Chronic progress faster than acute Goals: noticeable relief, activation of approp mm, hold ADIM 30 reps x 30+ sec, understanding of self mgmt, standing/sitting tolerances, walking tolerances, fxnal tasks

45 Phase II Build on Phase I if very acute
Unloaded trunk ROM (quadruped), hip flexibility, aerobic exercise, ADIM supine with heel slides/leg lifts, bridging, 4 point, 4 point on roller/unstable surface, sitting/standing/walking, standing rows Quadruped multifidus unilateral arm lifts, leg lifts, ADIM in horizontal side support Progress stabilization to functional restoration Break down fxnal tasks into components to increase accuracy and minimize fear avoidance Ex: Bending over to p/u object first teach pain-free deep knee bends or lunges then incorporate rotation of the hips and ankles with the bend, and lastly add resistance Challenge spine in daily activities and movements (squatting, bending, lifting); incorporate basic body-mechanic applications Modify speed of movements, direction, and external loads in preparation for discharge Diagonals / PNF Goals: Restricted RTW or sport, increasing workloads, discharge to self

46 Phase III Continue exercises independently, f/u with clinician for goal setting, guidance, and exercise progression Prevention of future injuries Sports enhancement through core strengthening High level activities/recreation/sport while stabilizing the spine Distraction exercises (ball tosses, extreme reaching) while keeping co-contraction, simulated work/recreational activities, lifting OH Functional drills on unstable surfaces (rocker board/balls) Goals: address functional limitations, fears, enhancement

47 Important Considerations
Aerobics / Cardiovascular Endurance Cognitive Behavioral Strategies (Fear Avoidance) Body Mechanics Teach ADIM, Pelvic Tilt in isolation and with movement Train extensors (Sorenson Test > 100 sec) Train endurance: > 3 min per rep Improv neural processing to fire in nml efficient manner Consider activity and specificity of activity Fear avoidance habits – Graded exposure Train proprioception Train pertubation / anticipatory /functional activities

48 Take Home Combine treatment approaches
Movement may be just as important as stiffness to dissipate forces (reduce loads), reproduce practical movements, and minimize energy expenses Choose approaches based on patient tolerances and fear Modify treatment based on functional outcomes What works for the Goose may not work for the Gander

49 Questions Ben can be reached at

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52 21. Barker PJ, Guggenheimer KT, Grkovic I, et al
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