Therapy Exercises for Lumbar Instability
Original Editors - Bruno Luca
Top Contributors -
Clinically Relevant Anatomy
The lumbar spine has normally 5 vertebrae (normal range 4-6) with a discus intervertebralis between 2 vertebral bodies. There is a cartilaginous endplate between the discus and the vertebral bodies. The discus itself has three components: the nucleus pulposus, annulus fibrosus and the endplates. The lumbar discs are larger than the cervical discs but the components are the same. The nucleus (in the middle) of the disc and has a larger water component but does not have much collagen fibers. The endplate is a thin layer of cartilage tissue between the vertebral body and the disc. The annulus fibrosus consists of concentric rings of collagen fiber layers that surround the nucleus. The sacrum is a triangular bone with a concave and convex surface, the facies pelvina and the facies dorsalis, and an apex. It consists of a series of 3, 4, or 5 fused sacral vertebrae. On the anterior surface of the sacrum the superior and inferior edges of the vertebral bodies correspond as transverse ridges. Between these ridges lays the lumbosacral disc that connects the lumbar spine with the sacrum.
Before we can start teaching the patient how to use the correct muscles needed for holding the lumbar spine in a neutral position, it is important that the patient has sufficient postural awareness of the neutral lumbar position. The patient needs to maintain this neutral lumbar position during all the following exercises. These exercises can prevent problems in the lumbar region like: Lumbar instability, spondylosis, spondylolisthesis, LBP. There are two main muscles, M. Transversus Abdominis and Mm. Multifidi, which control the shape of the spine and give lateral and sagital stabilization to the spine . These two muscles have connections through the thoracolumbar fascia an also have an attachment to the lumbar vertebrae. With the connection between the vertebrae, the TA and MF control the fine-tuning of the positions of adjacent vertebrae. This is also known as segmental stabilization .
Contracting M. Transversus Abdominis
The first step is teaching the patient how to contract the transversus abdominis muscle by performing abdominal hollowing. In abdominal hollowing the patient pulls his belly in at the umbilicus without any movement of the rib cage, the pelvis or the spine. When you palpate closely medial of both the anterior superior iliac spines you should feel the transversus abdominis muscle contract under your fingers. When the patient has trouble contracting the correct muscle, ask him to contract his pelvic floor. This can be instructed to the patient by asking to hold his pee. Many patients will automatically contract their transversus abdominis muscle when contracting their pelvic floor. It is important that the patient does not hold his breath, but just keeps breathing in a normal way when contracting the transversus abdominis muscle . Ask the patient to count out loud while doing the exercises.
When the patient is able to correctly activate his transversus abdominis muscle, he should build up muscle endurance. This can be achieved by contracting the TrA muscle at low intensity with many repetitions.
The subgoal is to:
• perform contractions with an intensity of 60% to 70% of the maximum voluntary contraction;
• hold each contraction for 10 seconds;
• perform 10 repetitions
The final goal is to:
• reduce the intensity till 30% to 40% of the maximum voluntary contraction;
• maintain the hollow abdomen position for 30 seconds.
Holding the contraction of the M. Transversus Abdominis is one of the best exercises to train the TA. To increase the effect of the exercise it is important that the TA will be trained isolated. This means that there can’t be compensatory movements of the chest or pelvic.
Abdominal hollowing can be performed in different starting positions depending on flexibility, weight, injury, .. of the patient. It appears that performing Abdominal hollowing maneuver in standing position and supine position can be effective on TA training:
• Four-point kneeling position: Holding the contraction is easiest in this position due to the facilitory stretch of the deep abdominal muscles resulting from the forward drift of the abdominal contents. The patient is placed on hands and knees, with the hip directly above the knee and the shoulder directly above the hand. Both hands and knees are shoulder-width apart. The lumbar spine is in a neutral position. The patient’s head is looking towards the floor, with the ears horizontally aligned with the glenohumeral joint. This position is comfortable for patients with low back pain or for pregnant women.
• Standing position: patient stands with his back against a wall and his feet 15 centimeters from the wall. By using a wall spinal movement can be reduced. This position is suitable for obese patients, but is not for patients with discal pathology due to the higher compression forces acting on the intervertebral discs.
• Sitting position: patient sits on a chair with a correct alignment by sitting tall. This is a useful exercise because patients can practice throughout the day. But this exercise can exacerbate low back pain in some patients. These patients will have more benefit with the four-point kneeling position.
• Prone-lying position: in prone-lying the patient pulls the abdominal wall away from the floor against the force of gravity. This is thus an exercise for those who are already able to perform abdominal hollowing. This position is not suitable for obese patients or pregnant women.
• Supine-lying position: in this position the patient is able to perceive his abdominal contraction. This exercise is also a good start for the heel slide exercise which is a more advanced exercise.
Contracting Mm Multifidi
The second step is teaching the patient how to contract the multifidus muscles in the back. This can be done with the patient in prone-lying position. While palpating paravertebral of the L4 and L5 vertebrae, ask the patient to lift up his leg or anterior tilt his pelvis. This will activate the multifidus muscles, which can be felt as a bulging underneath your fingers. Instruct the patient to focus on this contraction and memorise it. After this step, the patient should try to activate the multifidus muscles with an isometric contraction (without any movement). To achieve this, the patient needs to imagine himself performing the movement and contracting the multifidus muscles without doing the actual movement. When the patient has succeeded this exercise, he is able to tense and relax solely the multifidus muscles. The multifidus muscles should then be trained in the same way as the transversus abdominis muscle with a final goal to maintain the contraction with an intensity of 30% to 40% of the maximum voluntary contraction.
The next step is co-contraction where the local stabilizers contract at the same time to form a tight trunk. This co-contraction will then be implemented in more complex exercises with movement of the limbs. It is important that the patient learns to contract these muscles before the initial start of a movement (feedforward control).
The lumbar multifidus muscles are most active during prone lumbar extention with a full ROM and with resistance applied,
prone lumbar extension to neutral, resisted lumbar extension while sitting and prone extension with the upper and lower
extremities lifted (Superman exercise). The M. Multifidus is less active in bridging exercises.
The exercises for the M. Multifidus are trained at an intensity of 30% to 40% of the maximum voluntary contraction, so the bridging exercises are good exercises for the therapy for lumbar instability. When the exercises are done with an extra resistance.
• Bridging: in bridging the patient lies on the floor with the hands by their sides and the knees bend for 90°. First the patient needs to contract the TA, then tilt the pelvis into a "neutral" position and raise the pelvis off the floor. There must be a straight line through the knees - hips – shoulder.
• Bridge leg-lift: return to the bridge position and raise one leg bridging the foot off the floor.
• Bridge leg-extension: return to the bridge position and extend one leg outwards until the knee is fully extended.
All back muscles contribute in a similar way to control spine positions and movements. It is important that the patient continue breathing during the exercise, maintains slow and controlled movements of the limbs, avoids excessive low back extension during exercises and avoids pelvic twisting during the exercises.
These stability exercises seem to have promising results. In patients radiologic diagnosed with spondylosis or spondylolisthesis stability exercises seem to have statistically significant reductions in pain and disability at a 30-month follow-up in comparison to a control group receiving usual care.
Controlling the lumbar neutral position is a specific form of exercise with potential for prevention of recurrent nonspecific low back pain an disability among middle aged working men.
Pilates-Based Therapeutic Exercises seem to have good results in individuals with low back pain. There is a significantly lower level of functional disability (P = .023) and average pain intensity in individuals who practice these exercises.
In the research article of Roberto Gatti are some pictures of exercises used for Individuals With Chronic Low Back Pain.
Key Research / Evidence
Hayden JA, Van Tulder MW, Malmivaara AV, Koes BW. Meta-Analysis: Exercise Therapy for Nonspecific Low Back Pain. Ann Intern Med. 2005;142:765-775.
This review ment to evaluate the effectiveness of exercise therapy in adult nonspecific acute, subacute, and chronic low back pain versus no treatment and other conservative treatments.
In total 61 randomized, controlled trials were evaluated in this review. (11 acute, 6 subacute and 43 chronic low back pain).
The evidence suggests that exercise therapy is effective in chronic back pain relative to comparisons at all follow-up periods.
Some evidence suggests effectiveness of a graded-activity exercise program in subacute low back pain in occupational settings, although the evidence for other types of exercise therapy in other populations is inconsistent.
In acute low back pain, exercise therapy and other programs were equally effective.
Roberto Gatti et al. showed that trunk balance exercises combined with flexibility exercises are more effective than a combination of strength and flexibility exercises in reducing disability and improving the physical component of quality of life in patients with chronic low back pain. There was a significant difference in scores on the Roland-Morris Questionnaire (P = .011) and the physical component of the 12-Item Short-Form Health Survey (P = .048) were found in favor of the experimental treatment. The experimental treatment group performed trunk balance exercises in addition to standard trunk flexibility exercises. The control group performed strengthening exercises in addition to the same standard trunk flexibility exercises.
Christopher M. Norris. Back Stability: Integrating Science and Therapy.
Recent Related Research (from Pubmed)
- The use of trigger point dry needling and intramuscular electrical stimulation for a subject with chronic low back pain: a case report.
- [Decompression of lumbar lateral spinal stenosis: full-endoscopic, interlaminar technique].
- Clinical presentation and physiotherapy treatment of 4 patients with low back pain and isthmic spondylolisthesis.
- The effects of stabilizing exercises on pain and disability of patients with lumbar segmental instability.
- Trunk muscles strength and endurance in chronic low back pain patients with and without clinical instability.
- Association between history and physical examination factors and change in lumbar multifidus muscle thickness after spinal manipulation in patients with low back pain.
- Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain: A randomized placebo controlled crossover study.
- Core stability exercises in individuals with and without chronic nonspecific low back pain.
- The progression of paraspinal muscle recruitment intensity in localized and global strength training exercises is not based on instability alone.
- Lumbar microdiscectomy: a clinicoradiological analysis of outcome.
- ↑ P. Vaes, Onderzoek en Behandeling Deel IIA p.103
- ↑ Stevens VK et al, The influence of specific training on trunk muscle recruitment patterns in healthy subjects during stabilization exercises. 2007 A2
- ↑ 3.0 3.1 Richardson CA, Jull GA. Muscle control-pain control. What exercises would you prescribe? Manual Therapy 1995; 1,2-10
- ↑ P. Vaes, Onderzoek en Behandeling Deel IIA p.109
- ↑ Farideh Dehghan Manshadi et al. Abdominal hollowing and lateral abdominal wall muscles’ activity in both healthy men &amp;amp;amp;amp;amp;amp;amp;amp; women: An ultrasonic assessment in supine and standing positions. Journal of Bodywork &amp;amp;amp;amp;amp;amp;amp;amp; Movement Therapies 2011. B
- ↑ RICHARD A. EKSTROM et al. Surface Electromyographic Analysis of the Low Back Muscles During Rehabilitation Exercises. journal of orthopaedic &amp; sports physical therapy. December 2008. (Level 1b)
- ↑ Veerle K Stevens et al, Trunk muscle activity in healthy subjects during bridging stabilization exercises. BMC Musculoskeletal Disorders 2006. B
- ↑ Cholewicki J, Van Vliet JJ 4th. Relative contribution of trunk muscles to the stability of the lumbar spine during isometric exertions. Clin Biomech (Bristol, Avon) 2002. B
- ↑ O’ Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercises in the treatment of chronic low back pain with radiologic diagnosis of spondylosis or spondylolisthesis. Spine 1997; 22:2959-67 (Level: A2; Pedro score: 7/10)
- ↑ Suni J, Rinne M, Natri A, Pasanen Statistisian M, Parkkari J, Alaranta H. Control of the lumbar neutral zone decreases low back pain and improves self-evaluated work ability. Spine 2006 Volume 31, Number 18, pp E611-E620 (Level: A2; Pedro score: 7/10)
- ↑ Rochenda Rydeard et al. Pilates-Based Therapeutic Exercise: Effect on Subjects With Nonspecific Chronic Low Back Pain and Functional Disability: A Randomized Controlled Trial. Journal of Orthopaedic &amp;amp; Sports Physical Therapy. July 2006. (Level B1)
- ↑ ROBERTO GATTI et al. Efficacy of Trunk Balance Exercises for Individuals With Chronic Low Back Pain: A Randomized Clinical Trial. journal of orthopaedic &amp;amp;amp;amp;amp; sports physical therapy. august 2011. (level 1b)