1 Principles of Exercise Therapy Lower Back Pain 1. Facet joint pain 2. Spondylolysis & Spondylisthesis 1. Exercise Therapy turns the patient into an active participant and not just a passive recipient of therapy, making possible a natural and gradual transition from treatment to exercise. 2. The responsibility for his or her own health is transferred to the patient, forming the basis for his or her own mastery, a precondition for permanent improvement. Rectus abdominis Obliquus abdominis 1 Global muscles (motor muscles) Local muscles (stabilizers) Transversus abdominis Multifidus Psoas, posterior Erector spinae Quadratus lumborum Bergmark 1989 Global muscles vs Local muscles Global muscles those connecting the pelvis with the thorax ex) Rectus abdominis, Erector spinae Local muscles those directly attached to the lumbar vertebrae ex) Transversus abdominis, Multifidus, Psoas (posterior fibers) Sensory motor function Kinesthesia Afferent impulses CNS Efferent impulses Research in Spine Rehabilitation Sensory input (Proprioception) Neuromuscular response 1
O Sullivan P.B., Twomey L.T. Method and Classification Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis Spine 24:2959-2967, 1997 44 patients randomized in two groups Training for 10 weeks Group 1: Trained transversus abdominis and multifidus Group 2: Conventional physiotherapy including training Training in Group 1 Stabilizing exercise ; Pulling-in navel 1) Initially Training in non pain-inducing positions 2) Later Training in static positions that were previously pain-inducing 3) After that Training in functional activities Training in Group 2 - Strengthening exercise + Conventional treatment Follow-up after 30 months Conclusion Group 1 (Transversus abdominis + multifidus) significant pain reduction significant improvement of function Group 2 (Conventional treatment) No significant pain reduction No significant improvement of function Low-graded training of the stabilizing musculature of the lumbar spine reduces pain and improves function O Sullivan 1997, Hides 1996 2
Facet Joint Pain Facet joint pain 15~40% of chronic LBP 80% patients Prior disc disease Lumbar facet joint sprain Pathomechanics & injury mechnism Lumbar extension; aggravate Lumbar flexion; relief Sprains may occur in any of the ligaments in the lumbar spine The most common sprain involves lumbar facet joints Facet joint sprain typically occurs when bending forward & twisting while lifting or moving some object Sudden acute & chronic repetitive stress Avoid Exercises Pathomechanics & injury mechnism Lumbar Extension Exercises Shearing Exercises Strength Exercises for Abdominal / Back Muscles Early Hamstring Stretching General Stretching Exercises for Low Back Pain Located centrally or lateral to the spinous process areas & is deep Local symptoms Vertebra is moved passively with a posteroanterior or rotational pressure 3
Spondylolysis Spondylolysis & Spondylisthesis Avoid Exercises Classification Lumbar Extension Exercises Shearing Exercises Strength Exercises for Abdominal / Back Muscles Early Hamstring Stretching Grade I 25% of the body slipping ant. Grade II 50% Grade III 75%: 초기이후는수술 General Stretching Exercises for Low Back Grade IV 100% Therapeutic Exercises Applications Type I - Low Extremity Exercises with Pelvic Stabilization Exercises Early Running Type II GB Stabilization Exercises PNF Exercises Late Walking and S&R Running Type III - GB Stabilization Exercises Pathomechanics Hypermorbility of the low back Spondylolysis Degeneration of the vertebrae Defect in the pars interarticularis of the articular process of the vertebrae 선천적인 weakness Might symptoms unless a disk herniation occurs Sudden trauma such as hyperextension Begins unilaterally 4
Pathomechanics Spondylolisthesis Complication of spondylosis Highest incidence with L5 slipping on S1 Goal of treatment Pain relief Arrest of slip progression Minimizing deformity Type 1 Type I is called dysplastic spondylolisthesis and is secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra Type II A Type II A is sometimes called Lytic or stress spondylolisthesis and is most likely caused by recurrent micro-fractures caused by hyperextension. It is also called a "stress fracture" of the pars interarticularii and is much more common in males. Type II B Type II B probably also occurs from microfractures in the pars. However, in contrast to Type II A, the pars interarticularii remain intact but stretched out as the fractures fill in with new bone. Type II C Type II C is very rare in occurrence and is caused by an acute fracture of the pars. Nuclear imaging may be needed to establish diagnosis 5
Type III Type III, is a degenerative spondylolisthesis, and occurs as a result of the degeneration of the lumbar facet joints. The alteration in these joints can allow forward or backward vertebral displacement. This type of spondylolisthesis is most often seen in older patients. In Type III, degenerative spondylolisthesis there is no pars defect and the vertebral slippage is never greater than 30%. Type IV Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis. Type V Type V, pathologic spondylolisthesis, occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases. Principles of Exercise Therapy with Spondylolisthesis Patient Stabilization Exercises for Low Back Balance Exercises Strength Exercises for Abdominal / Back Muscles ; M. Strength + M Endurance Regaining Stable Posture Low Extremity Exercises Stretching Exercises for Hamstrings & Gcn Maintaining Improved Posture through PNF Principles of Exercise Therapy with Spondylolisthesis Patient Anterior lordotic abdominal strengthening exercises Pelvic Stabilization or proprioception exercises Aggressive flexibility exercises of the hip rotators, hamstrings, hip flexors, lumbosacral fascia, ligaments, and muscle-tendon units 6
Risk Sports Activities Exercise-stretching Running / Jumping / Squatting Bending / Twisting / Hyperextension Gymnastics Contact sports Weight Lifting Tennis / Ski / Basketball / Volleyball Initial exercise-strengthening Initial Mobilization Ankle pump Standing with Ball between Your Low Back and the Wall Pelvic Tilt & Mobilization in Quadruped Initial exercise-strengthening Advanced exercise-strengthening 7
Advanced exercise-proprioception 8