Exercise Interventions for the Lumbar Spine Flashcards
Core Stability
- core stability is instantaneous to maintain it the involved anatomy must continually adapt to changing postures & loading conditions to ensure the integrity of the vertebral column and provide a stable base for movement of the extremities
Define local stabilizers
- deep muscles, monoarticular with attachments on or near the vertebrae that primarily function to eccentrically control movement & maintain static alignment isometrically
- transverse abdominus, multifidus, pelvic floor musculature, & diaphragm
Define global mobilizers
- biarticular superficial muscles that connect the trunk to the extremities & function concentrically to produce large torques of movement & power
- rectus abdominus, internal & external obliques, quadrates lumborum, psoas major
Define transfer load group
- muscles with axial appendicular attachments
- transfer force & momentum between the extremities & core along the kinematic chain
- glute max, glute med, hip adductors, rectus femoris, iliopsoas, traps, lats, deltoid, & pectoralis major
Describe the Panjabi Stability Model
- Passive: vertebrae, discs, ligamentous support
- Active: muscles & tendons surrounding the spinal column
- Neural: CNS and PNS
Describe a dysfunctional component of any of the subsystems in the Panjabi Stability Model
- Successful compensation for any one of the subsystems: normal response
- Long term adaptation response of one or more subsystems: normal but altered spinal stabilization response
- Injury to one or more components of the subsystem: overall system dysfunction may include LBP
What interventions have strong evidence for LBP
- manual therapy
- trunk coordination, strengthening, & endurance exercises
- centralization & directional preference exercises
- progressive endurance exercise & fitness activities
- patient education & counseling: MODERATE EVIDENCE
What interventions have weak or conflicting evidence for LBP
- flexion exercises
- lower quarter nerve mobilization procedures
- traction
What are the 6 treatment based classifications for LBP
- Lower back pain with radiating pain
- Lower back pain with referred pain
- Lower back pain with mobility deficits
- Lower back pain with movement coordination impairment
- Lower back pain with cognitive & affective tendencies
- Lower back pain with generalized pain (sensitivity)
What LBP classifications are in symptom modulation
- radiating pain
- mobility deficits
- referred pain
What LBP classifications are in movement control
- movement coordination impairments
Treatment for Functional Optimization
- strength & conditioning exercises
- work/sport activities
- aerobic exercise
- general fitness
Treatment for symptom modulation
- directional preference
- manipulation/mobilization
- active rest
- traction
Treatment for movement control
- sensorimotor exercises
- stabilization exercises
- flexibility exercises
- local mobility considerations
- global mobility considerations
Primary complaint for each stage of the movement control approach
- Symptom Modulation: symptoms
- Movement Control: movement
- Functional Optimization: performance
Clinical findings & goals for symptom modulation
- Findings: volatile, avoidance of painful postures, AROM is limited & painful
- Goals: modulate symptoms, decrease pain, improve function
Direction preference/repeated movements for flexion bias and extension bias
- Flexion based: SKTC, DKTC, flexion in sitting, flexion in standing
- Extension based: lying prone, prone on elbows (POE), extension in lying (EIL) or prone press up, extension in standing (EIS)
Sets and reps for repeated motions
- completed in sets of 10 with a pre and post pain assessment
- as many set until desired symptom centralization or decrease
Static versus intermittent lumbar traction
- Static for inflamed tissue or if motion increases pain
- Intermittent with long hold times for disc protrusion
Hold relax times for lumbar traction
- Discal involvement: intermittent, 60s hold & 20s rest
- Spinal joint involvement: 15s hold & 15s rest
- Symptom severity is the guide, high severity = long hold & rest times
Force for lumbar traction
- start 30-40 lbs, use lowest force to get desired effect
- Compressed Nerve Root = 50 lbs or up to 60% body weight
- Muscle Spasm = 25% body weight
- Peripheralization = decrease force
- Centralization but still pain = increase 5-15 lbs until optimal relief
Treatment durations for lumbar traction
- 5-10 minutes initial session (severe pain = 5 min)
- 8-10 minutes for treatment of disc protrusion
Clinical signs of functional optimization
- low to absent pain (pain related to fatigue) well controlled
- low disability ratings
- mainly performance deficits (able to do ADLs without difficulty)
Coordination impairment/stabilization test item cluster
- coordination training indicated for 3/4 positive findings
- age <40
- positive prone instability test
- aberrant motion with ROM
- straight leg raise >90 degrees
Aberrant motion is present if any one of the following is identified
- instability catch
- painful arc of motion in flexion
- painful arc on return from flexion
- thigh climbing
- reversal of lumbopelvic rhythm
Difference between local mobility and global stability
- Local mobility: specific structures with specific movement (nerve, joint, or soft tissue)
- Global stability: neuromuscular performance of the body (activate, acquisition, and assimilate)
Nerve exam findings and treatment
- positive sensitized neural tension tests
- neural mobilization: if symptoms are aggravated reclassify patient into symptom modulation approach
Joint exam findings and treatment
- limitation, asymmetry or hypo mobility of joint motion in the lumbar or adjacent regions
- manual therapy for joints: manipulation and mobilization
Soft tissue exam findings and treatment
- impaired soft tissue compliance to manual pressure or passive change in joint position
- manual therapy for soft tissues: passive stretching and soft tissue mobilization
Variation of the straight leg raise
- dorsiflex w/eversion: tibial nerve
- dorsiflex w/inversion: sural nerve
- plantar flex w/inversion: common perineal tract
- hip adduction while doing SLR: nervous system/sciatic nerve
Exam findings and goals of activation stage
- motor control > endurance/strength
- Findings: observation of poor ability to activate individual muscles or isolated movement patterns (transverse abdominus, multifidus, scapular retractors, breathing pattern)
- Goals: activate hypoactive muscles (abdominal hollowing, scapular retraction, diaphragmatic breathing)
Possible interventions for activation stage
- focus on spinal awareness & neutral spine positions
- recruitment of deep stabilizers via abdominal hollowing
- diaphragmatic breathing
- relearning how to move without pain
- relearning how to reduce muscle guarding & activate deeper muscles
Describe deep stabilizer focus: transverse abdominus
- deepest of the abdominal muscles, internal to the internal oblique
- runs horizontally attached to the lumbar vertebrae via the thoraco-dorsal fascia
- innervated by the lower 6 thoracic nerves, iliohypogastric, & ilioinguinal nerves
- corset like effect to stabilize the lumbar spine & pelvis before movement of the lower and/or upper limbs occur
Describe abdominal hollowing intervention
palpate the transverse abdominus just distal to the ASIS & lateral to the rectus abdominus
- if TA contracts flat tension is felt but if internal oblique contracts a bulge is felt
- instruct patient to breathe in, breathe out, then gently draw the belly button in toward the spine to hollow out the abdominal region
- have patient maintain contract and resume breathing
Describe abdominal bracing
-abdominal bracing occurs by setting the abdominals & actively flaring out laterally around the waist
- patient should be able to hold the braced position while breathing in a relaxed manner
- more focus on global stabilization
To brace or to hollow?
- bracing of the abdominal muscles provides greater lumbar spine stability than hollowing
-bracing increases spine stability with minimal increase in spine compression loads - bracing creates patterns that better enhance stability
Deep segmental activation: Multifidus
- long, multi-segmental extensors over the sacral & lower lumbar vertebrae
- control trunk against perturbations, counteract unwanted flexion
- tonic stabilizer, large capillary network, made of type I fibers
- can control spinal segments & stiffness of the spine
- encased within the thoracolumbar fascia
- atrophy, moth looking appearance on MRI, fatty infiltrate in LBP patients
How to test for multifidus activation
- patient is standing while you palpate their back along the multifidus
- have patient either raise the contralateral arm or rock back and forth on their feet pretending to take a step
- multifidus should contract with movement of the limbs
Describe the progression of lumbar stabilization exercises with flexion bias
- pump up BP cuff and place under patients lumbar spine and finish pumping up to 40 mmHg
A) lift bent leg to 90 degrees hip flexion
B) slide heel to extend knee
C) lift straight leg to 45 degrees
1) draw in & hold 10 seconds
2) opposite LE on mat; bent leg fall out
3) A, B, C opposite LE is on table
4) A, B, C hold opposite LE 90 degrees of hip flexion with UE
5) A, B, C hold opposite LE 90 degrees of hip flexion (no UE assistance)
6) A, B, C bilateral LE movement
Describe the progression of lumbar stabilization exercises with extension bias
- patient is either in quadruped on in prone
1) flex one UE
2) extend one LE by sliding it along the exercise mat
3) extend one LE & lift 6-8 inches off exercise mat
4) flex one UE & extend contralateral LE
5) extend one LE
6) extend both LE
7) lift head, arms, and LE
Exercises for core stability
- abdominal based crunches
- plank
- bridging
- bird dogs
- beginner pilates
Exercises that activate the transverses abs and multifidus
- quadruped or prone bird dogs
- supine dying bug
- trunk extensions from prone with pelvis & LE on mat table
- leg extensions in prone with torso on mat table
- trunk and lower leg raises in prone
Exam findings and goals of the acquisition stage
- Findings: observation of impaired ability to dissociate or coordinate thoracolumbar & lumbopelvic/hip movements; impaired ability to perform active SLR, active hip extension, active hip abd
- Goals: dissociation and coordination of movements of the lumbar spine & adjacent areas, progression from single plane to multiple plane, less concern with recruitment of transverses abdominus & lumbar multifidus
Exam findings and goals of the assimilation stage
- more endurance/strength then motor control
- Findings: observation of impaired control of multiplayer movements under dynamic loading conditions; poor squat, poor lunge performance, poor rotation movement
- Goals: loaded multiplaner movements under dynamic loading conditions, return to work or sport specific training; step up/down progression, sit<>stand progression, multiplanar movement progression, rotation & anti-rotation exercises
Describe the assimilation stage
- newly acquired skills are integrated into ADLs utilizing multiplane movements in dynamic loading environments
- typically involve activities that aggravate patient’s symptoms
- push/pull, lift/lower, reaching/handling, twisting, reciprocating
- simulate these functions in the clinic
- transfer principle of motor control
Describe the different stages and how they work together
- Symptom Modulation: pain control
- Movement Control: activation, acquisition, & assimilation
- Functional Optimization: strength and conditioning
Guidelines for spinal stabilization training: principles and progression
1) begin training with awareness of safe spinal motions & the neutral spine: Activation
2) have the patient learn to activate the deep stabilizing musculature while in the neutral position: Activation
3) add extremity motions to load: Acquisition
4) increase reps to improve holding capacity (endurance and increase load to improve strength: Acquisition
5) use alternating isometric contractions & rhythmic stabilization techniques to enhance stability: Acquisition
6) progress to movement from one position to another in conjunction with extremity motions: Assimilation
7) use unstable surfaces to improve the stabilizing response & improve balance: Assimilation
Prescription of painful exercise
- prescribed with instructions for patients to experience pain that is acceptable & safe
- painful exercise reshapes the traditional belief that exercise improves biomechanics & changes at the tissue level
- promotes relearning
- reconceptualization the relationship between pain & tissue damage
Describe graded exercise
- graded exercise = increase exercise & activity tolerance using a quota system
- pain intensity is monitored but not used to make decisions regarding exercise progression
Describe graded exposure
- graded exposure = exposing patients to specific situations which they are fearful during rehab
- Example: use the FABQ to find activities fearful to patient, select the top 2-3, introduce those fearful activities, provide positive reenforcement if making progress, continue the same exposure at the same intensity if not making progression
Exercise parameters for back pain
- avoid bed rest: no benefit for healthy adults & detrimental to older adults
- aerobic training (appears to have ‘best’ evidence): moderate to vigorous if able to tolerate (50-80% HRR) and 20-40 minutes (less not beneficial)
- resistance training: dynamic resistance training - exercise large muscle groups of the upper & lower extremity & moderate intensity (strengthening parameters); isometric resistance training
Describe nociceptive mechanisms
- exercise decreases nociceptor excitability
- increases peripheral inhibition
- promotes healing of injured tissues
Describe central mechanisms
- exercise activates descending inhibitory systems with increases in endogenous opioids & altered serotonin function
- regular exercise reduces central excitability & expression of excitatory neurotransmitters in the spinal cord, brain stem, & cortical nociceptive sites
- regular exercise can modulate pain by altering central nociceptive processing & increasing central inhibition
Describe neuropathic mechanisms
- regular aerobic exercise increases anti-inflammatory cytokines at the site of injury & promotes nerve healing & analgesia (animal studies)
- in people with diabetic neuropathy, decreased pain is attributed to an increase growth of epidermal nerve fibers after regular exercise
Describe psychosocial mechanisms
- greatly influences the 3 biological pain process
- exercise improves catastrophizing, depression, cognitive dysfunction, learning, memory, & neurogenesis
- exercise reduces negative psychological factors associated with pain, improves cognitive & social factors
