Exercises for Lumbar Instability

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Exercises

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,...

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.

Abdominal hollowing can be performed in different starting positions depending on flexibility, weight, injury, .. of the patient:

• 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).

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.

Key Research

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.

Resources

Christopher M. Norris. Back Stability: Integrating Science and Therapy.

Clinical Bottom Line

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