1. Physical Therapy Approach to Low Back Pain -
Lumbar Stabilization
Stacey Franz, DO, MSPT
Medical Director,
NorthEast Spine & Sports Medicine

2. Disclosures
I have NO RELEVANT financial disclosures

3. 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

4. Anatomy of the Core – Lumbar 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 *
Erector muscles:
Provides dynamic intersegmental stab.
eccentric deceleration of trunk flexion and rotation
quadratus:
Frontal plane stabilizer
Works in conjunction with gluteus medius & tensor fascia latae
Lats:
Bridge between upper extremity & core

5. Anatomy of the Core – Abdominal Muscles
Transversus abdominus
External obliques
Internal obliques
Physiology
Provide sagittal, frontal & transverse plane stabilization
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

6. Anatomy of the Core – Hip 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

7. 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
Hamstrings
Concentrically flex the knee, extend the hip & rotate the tibia
Eccentrically decelerate knee extension, hip flexion & tibial rotation
Work synergistically with the ACL to stabilize tibial translation

8. 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)

9. 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

10. 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)

11. 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

12. 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
Back stabilization continues to evolve
sport and work specific
Pilates, ball work

13. 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
Back stabilization continues to evolve
sport and work specific
Pilates, ball work

14. 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
Strength
straight leg lowering test
Supine w/ knees in extension
BP cuff placed under lumbar spine (L4-L5) & raised to 40 mmHg
With knees extended,  hips to 90°
Performs drawing in maneuver (belly button to spine) & then flattens back maximally into the table & BP cuff
Lower legs to table while maintaining flat back
Hip angle is measured with goniometer
Endurance
erector spinae perofrmance
Prone with hands behind head & spine extended 30º
Measure ability to sustain position with goniometer
Utilize axilla and table for frame of reference
Hold & maintain as long as they can

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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

23. Level 1 - Stabilization ?

24. 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

25. Level 2 – Stabilization (continued)
Quadruped
Alternate arm/ leg with cuff weights
One arm reach
Kneeling
Rock with arms and weights overhead
With side kicks
P ush-pull with sticks
Lifting up and down
Half kneeling to standing
Sitting
Leg lifts
Opposite arm/ leg lift

26. 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

27. Level 2 - Stabilization ?

28. 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
Standing
Push/ pull with sticks

29. Level 3 - Stabilization ?

30. Level 4 - Stabilization ?

31. 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 intra-muscular 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

32. 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 Jan; 88(1): 54-62

33. 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, first-episode 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.

34. 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.

35. 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– 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

36. 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)

37. 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