This document discusses evidence and perspectives on lumbar spine rehabilitation and functional instability. It questions conventional approaches and dogma, advocating instead for individualized exercise based on context and motor skill training. Specific muscles are not singled out as most important for stability; rather, coordinated muscle activation through motor patterns is key. Low levels of co-contraction can provide adequate stability without undue load.
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Convention versus Evidence
1.
2. Lumbar Spine Functional Instability
Rehabilitation
Convention or Evidence?
Paul Schoonman, DC
Schoonman Chiropractic and Rehab
Health Science Advisory Board, Merrimack College
Andrew Cannon, MHS, PT, SCS
Dir., Sports Medicine, NRHN
Team PT, Lecturer, Merrimack College
4. Critical consumers of dogmatic
approach to lumbar spine care
and exercise
Disc location
5. Trunk Performance
No such thing as truly
functional exercise
Function is context and
individual specific
GPP, SPP
Input versus outcome?
Motor skill in, stability
out!
Ankle sprain, MDI
Like the trunk, ROM is
poor indicator of overall
ability
6. Shoulder any different?
Phases of Rehabilitation for Shoulder Instability
Phase I
Rest and immobilization
Pain control with nonsteroidal anti-inflammatory drugs and ice applied to the shoulder
Phase II
Isometric strengthening
Isotonic strengthening
Begin exercises with shoulder in adducted, forward- flexed position, progressing to
abducted position
Phase III
Endurance building along with strengthening exercises
Goal: the patient reaches 90% strength in the injured shoulder compared with the uninjured
shoulder
Phase IV
Increase activity to sport- or job-specific activities
7. What is best for people with acute
low back pain with or without
radicular symptoms to do?
8. Bed rest for acute low-back pain and sciatica
People with acute low-back pain who are advised to rest in bed have
more pain and are less able to perform every day activities, on
average, than those who are advised to stay active.
As many people get some relief from low back pain and sciatica (pain
down the back and leg) by lying down, bed rest is often recommended.
However, this review found that, for people with acute low-back pain,
advice to rest in bed is less effective in reducing pain and improving an
individual's ability to perform every day activities than advice to stay
active. For people with sciatica, there were no important differences in
the effects of advice to stay in bed compared with advice to stay
active.
Page 106
Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and
sciatica. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.:
CD001254
9. Williams flexion exercises
I have not been able to find one shred
of evidence that they are better than
any other form of exercise or that
specifically they are indicated over other
therapeutic exercise interventions
11. Evidence says pre-exercise does not
Not pre-exercise 3x day does
– 20 seconds, 5-7 reps, comfortable
– Frequency is key
– Limited value in spine care relative to spine
stretching
12. Finally, separate out
what is indicated to do
what seems good to do, “clinical wisdom”
what other people do
what the patient wants to do
what you have time to do
what their parents/employer want them to do
What the insurer will pay you to do
16. What patient is this new path for?
Acute? No. Sub acute and beyond, Episodic
Can they be radicular? Yes!, non progressive,
stable, neurologically improving, weakness
decreasing, reflexes increasing
Change from victim to patient
Pain versus function
17. Neuromuscular Function in Athletes Following Recovery
From a Recent Acute Low Back Injury,
Cholewicki et al, jospt vol. 32 #11, 11:2002
Chronic LBP, delay in shut off of agonist , switch on antagonist with
fewer # of trunk muscles responding
Varsity athletes with hx 1 episode of LBP, >6 months prior
@injury pain 4.4/10, FVAS 30/100, min. 3 days OOP
@testing, avg. 56 days post, pain 0/10, full participation
A shutting off of a fewer number of agonists with an increased latency
as well compared to matched controls
18. Stability
Synergistic coordination
of neuromuscular
system to provide a
stable base for
superimposed
functional movement or
activity
Shoulder MDI and hand
placement
But, the trunk??
19. What Do We Know About Lumbar Spine
Segmental Instability?
Clinical instability is a sagittal plane translation of >
3mm or 9% of vertebral body width on either an
flexion or extension radiograph, and/or sagittal plane
rotation >9 degrees for lumbar motion segments
Clinical instability is a deficit in the end of range
passive restraints
Functional instability is a decrease in the capacity of
the stabilizing system of the spine to maintain the
spinal neutral zones within physiological limits so
that there is no neurological deficit, no major
deformity and no incapacitating pain
Functional instability is a failure of the neural and
contractile units to guide normal segmental motion
within the neutral zone.
20.
21. Cause or Effect??
Functional instability
can be both the cause
of and the result of
injury
Not just tissue based
Motor control aspects
– Coordinated contraction
stiffens the joints and
ultimately determines
functional (in)-stability
22. How much load/shear is too much?
Shear tolerance of vertebral motion segment of
2000-2800N one time loading
Repetitive shear loads may be more likely 500N
The osteoligamnetous spine buckles at 20N!
How do muscles that compress make the spine
more functionally stable?
Luca d e al. Stability of the ligamentous spine. Technical Report #40, Biomechanics Laboratory, San Francisco, University of California
23. So what is stability from a spine
perspective?
Potential energy = PE= mass x gravity x height
Stable equilibrium prevails when the PE of the system is
minimum
A ball in a bowl is stable. At the bottom of the bowl it is at
minimum potential energy
The deeper the bowl, the steeper the sides the more stable
the system
Bergmark A (1989) Stability of the lumbar spine: A study in mechanical engineering. Acta Orthop. Scand 1989; 60:3-53.2
24. The Continuum of Stability
Slope of sides = stiffness
of passive tissues =
mechanical stop/end
point
Width of the bottom of
the bowl = joint laxity
Bergmark A (1987) Mechanical stability of
the human lumbar spine. Doctoral
dissertation, Department of Solid
Mechanics, Lund University, Sweden
25. how many sides does the bowl
need?
Spinal joints can rotate in 3 planes, along 3 axes
Requires a 6 dimensional bowl for each 6 lumbar
spinal joints = 36-dimensional bowl
If the height of the bowl is decreased in any one
of these 36 dimensions, the ball rolls out!
A single muscle having inappropriate force or a
damaged passive tissue can cause instability
26. Potential energy as stiffness and
storage of elastic energy.
stiffness = (k)
deformation = (x)
so stretching a band with stiffness x a
distance x will store energy (PE)
27. Elastic PE = .5 * k * x
Stretching a band with
stiffness (k) a distance (x)
with store energy (PE)
Increase in k = increase in
side of the bowl
Stiffness creates stability to
support larger loads (P)
Most important is stiffness
is balanced
Increased stiffness of just 1
spring will lower PE in one
direction and decrease
ability to bear load
28.
29. Symmetrical Stiffness
Active muscles act like a
stiff spring
Modest levels of muscle
activation create
sufficient stiff and stable
joints
Motor control system
modulates stiffness
therefore stability
through coordinated
muscle co- activation
30. How Much Stability is Enough ?
What is Sufficient?
Too much stiffness and muscle
coactivation imposes a load
penalty/prevents motion
Muscular stiffness necessary for
stability with a modest extra for
margin of safety
How hard do the muscles need to
work to provide adequate stability in
the neutral zone?
5%-20% MVC with ADL to athletic
activities
Strength or endurance?
Remember the bowl needs all its
sides!!
31. Is a single muscle most important
Inappropriate application of “Queensland”
research, did not say tva and mf “more”
important
Was any single string more important?
All muscles play a role in stability, roles vary
based on task at hand and resources
available
33. You need a strong
trunk to protect your
back
10% of MVC abdominal
wall cocontraction
Endurance over strength
Proper daily motion is
“endurance training”
34. What are stabilization exercises
An exercise repeated in a
way that grooves motor
patterns and ensures a
stable spine
Consider loading as to
how good an exercise is
An athlete requires a
stable spine during c-v
demanding, complex
motor skill.
It is not whole body
stability, balance
35. What is the most important muscle
Which wire is most
important to the tower
standing
How can
wires/muscles that add
compression,
decrease
compression?
36. Upper and lower rectus
There is no functional
separation of the rectus
abdominis
Is a separation of neural
drive, rarely!
Once activated, function
as a cable throughout its
length
If you mean, lower abs,
could be TVA, that would
be the lateral ‘V’
37. We give patients lumbar stability
exercises
Input or output?
We train motor skill
They get stability