Role of Lumbar Stabilization Exercise and Spinal Manipulation in Low back pain. Dr. PICHET YIEMSIRI

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1 Role of Lumbar Stabilization Exercise and Spinal Manipulation in Low back pain Dr. PICHET YIEMSIRI

2 Lumbar Stabilization Exercise

3 Spinal stability Static stability Dynamic stability Stable of the back

4 The stabilizing system of the Spine Control Subsystem Nervous Passive Subsystem Ligament&Bone Active Subsystem Muscle Panjabi MM. J Spinal Disord 1992;5(4):390 6.

5 Exercises in low back pain management Exercise is one of the few clearly effective treatments for chronic pain (evidence-based). It improves body function, activity, and overall health. Systematic review located a limited number of head-to-head comparisons of various exercise program

Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain Conclusions Both lumbar stabilization and dynamic strengthening exercise

6 Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain Conclusions Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP. Lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP

7 The Core Concept : A cylinder of deep muscles surround the spine providing stability 29 pairs of muscle

8 The Core Concept :

9 Core Muscles : Global muscle system (fast-twitch) : Superficial layer, long with large level arms, produce large amount of torque and gross movements, transfer and balance load between thoracic spine and pelvis. Key global muscles : Erector spinae, external oblique, rectus abdominis and quadratus lumborum. Local muscle system (slow-twitch) : Deep, shorter, controlling inter-segmental motion and responding to changes in posture and extrinsic loads, maintain force control within the spinal structures. Key local muscles : Transversus abdominis, multifidi, internal oblique, deep transversospinals, and pelvic floor. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl 1989;230:1 54.

10 Normal Co-Contraction Healthy patients Transversus Abd & Multifidus contract 30 ms before shoulder movement and 110 ms before legs movement

Major motor deficit Loss of gluteal strength and size Erector spinae, hamstring dominance when lifting and rising from a chair Gluteal amnesia Good

11 Major motor deficit Loss of gluteal strength and size Erector spinae, hamstring dominance when lifting and rising from a chair Gluteal amnesia Good gluteal for GOOD BACK McGill S. Low Lack Disorders: Evidence-Based Prevention and Rehabilitation, 2nd Edition. Champaign: Human Kinetics, 2007:

12 Primary Core Stabilizer Transverse Abdominis (TrA) Multifidus

Origin: inner surface of cartilages of lower 6 ribs, interdigitation with diaphragm, thoracolumbar fascia, anterior ¾ of internal lip of iliac crest, and lateral 1/3 of

13 Origin: inner surface of cartilages of lower 6 ribs, interdigitation with diaphragm, thoracolumbar fascia, anterior ¾ of internal lip of iliac crest, and lateral 1/3 of inguinal ligament Insertion: linea alba (broad aponeurosis), pubic crest, and pecten pubis Nerve Innervation: T7-T12, L1 (iiiohypogastric and ilioinguinal) Transverse Abdominis

14 Multifidus Origin: Sacral region: posterior surface of sacrum, medial surface of posterior iliac spine & postero-sacroiliac ligaments. Lumbar, thoracic, & cervical regions: transverse processes of L5-C4 Insertion:Spanning two to four vertebrae, inserting onto spinous process of one of vertebra above from last lumbar to axis (second cervical vertebra Nerve Innervation: Spinal

15 Functions of TrA & Multifidus Deep Multifidus and TrA provide intersegmental spinal stability Deep fibers of Multifidus control intervertebral motion Superficial fibers of Multifidus control spine orientation

16 A Core exercise program Individualize for patient Done in stage with gradual progression Correct any existing muscle imbalances. Adequate muscle length and flexibility. Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

17 A Core exercise program Isometric contract relax exercise

18 A Core exercise program Flexibility section Quadriceps Stretch Hamstring Stretch Adductor Stretch Dynamic Hamstring Stretch Sidelying ITBand Stretch

19 A Core exercise program Clamshell exercise isolate gluteus medius

Beginning : Cat - Camel Start on all fours A

abdominal and reach chin towards ceiling.

20 Beginning : Cat - Camel Start on all fours A Core exercise program Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked Camel- Exhale and lower abdominal and reach chin towards ceiling. Tuck chin and sit back into Prayer position Repeat 5 to 10 times

21 A Core exercise program Isometric contraction activate the abdominal wall musculature Contraction in 30% maximal voluntary contraction Re-education in upright positions Richardson ; 1999

A Core exercise program Drawing-In Manuever Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall Increases cross sectional area of TrA tighten like a corset and

22 A Core exercise program Drawing-In Manuever Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall Increases cross sectional area of TrA tighten like a corset and most likely improves stability of lumbo-pelvic region Patient starts in hook-lying position and assumes a neutral spine position & attempts to maintain it while drawing in and hollowing the abdominal muscles Subtle posterior pelvic tilt & flattening of lumbar spine

23 A Core exercise program Abdominal Bracing Occurs by setting the abdominals and actively flaring out laterally around the waist It has been shown to activate the oblique abdominal muscles

24 A Core exercise program Posterior Pelvic Tilt Activated more in Rectus Abdominis Awareness of the movement of the pelvis and lumbar spine Activated the patient to find neutral spine position

25 A Core exercise program High Bridging Start End

26 Stage 2 PROGRESSING A CORE STRENGTHENING PROGRAM Big 3 Curl-up Side Plank (side bridge ) Bird dog (quadruped position with alternate arm/leg raises) McGill, S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, IL: Human Kinetics, 2002.

27 A Core exercise program Curl up (A) (B)

28 A Core exercise program Side-Plank alignment of the ribcage and pelvis so that the spine is in a neutral posture Advanced side plank

29 Bird-dog A Core exercise program

30 A Core exercise program Bird-dog advance

31 A Core exercise program Superman

32 Stage 3 A Core exercise program Focus on Endurance Repetitions not durations Isometric holds in BIG 3 (7-8 Sec;oxygen consumption) Do as much as you can while you are as fresh as you can be maintaining sufficient oxygen levels

33 Take home massage But! Exercise... Relieve pain, symptoms Restore function Prevent recurrence (by local muscle) Don t forget aerobics exercise

34 Spinal Manipulation

range Thrust: High velocity, low amplitude therapeutic movement within or at

35 Spinal Manipulation Definitions A passive movement that tends to nudge the components of a joint or group of joints beyond their usual physiological range Thrust: High velocity, low amplitude therapeutic movement within or at end range of motion. Nonthrust: Those manipulations that do not involve thrust.

36 Spinal Manipulation Goals of treatment Relieve and prevent physical disability. Treatment on loss of mobility and pain. Discontinue use of manipulation when mobility is restored and symptoms are resolved

37 Spinal Manipulation Lumbar Spine Gapping Manipulation

38 Spinal Manipulation Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

39 Spinal Manipulation Side lying Lumbar Rotation with locking Manipulation To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation.

40 Spinal Manipulation Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med Jun 3;138(11): RCTs were identified Conclusion There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.

41 Spinal Manipulation Giles LG, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine Jul 15;28(14): ;discussion Conclusion In patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication. The data do not strongly support the use of only manipulation, only acupuncture, or only NSAIDS for the treatment of chronic spinal pain.

42 Spinal Manipulation Bronfort G,Haas M, Evans RL,Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J May-Jun;4(3): RCTs CONCLUSIONS: the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. there have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.

43 Spinal Manipulation Cochrane Database Syst Rev Feb 16;(2):CD doi: / CD pub2. Spinal manipulative therapy for chronic low-back pain. Rubinstein SM 1, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Included 26 RCTs CONCLUSIONS: High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.

$equina syndrome spinal epidural hematoma disc herniation fracture and$

44 Spinal Manipulation Take home massage Complications : Rare but cauda equina syndrome spinal epidural hematoma disc herniation fracture and dislocation

45 Thank you

ACE s Essentials of Exercise Science for Fitness Professionals TRUNK

ACE s Essentials of Exercise Science for Fitness Professionals TRUNK Posture and Balance Posture refers to the biomechanical alignment of the individual body parts and the orientation of the body to the