Integration of Inner and
Outer Units
This section will focus on the integration of inner and outer units
of stabilizing
muscles during the specific exercise progression. I will read
summaries from the writings of three prominent physical therapists who are considered master class
experts in this type of rehabilitation. They have published
their rehabilitation programs in scientific literature and teach
courses on this topic. I
recommend that if the reader is a rehabilitation specialist that you
also read specific reports by the authors and also attend
their courses on specific exercise for retraining spinal
stabilization.
Paul Hodges: 3 Stages / 8 Steps
Cognitive stage.
The cognitive stage consists of formal
motor skill training. This is the time when the patient is improving
the perception of the skill. He or she needs to understand the task
and know what it feels like. The physical therapist needs to provide
instructions, visual cues, mental imagery, optimal body positions or postures,
and various facilitation/feedback techniques to help produce the ideal response.
It is also necessary to provide or use various techniques including feedback to
decrease over-activity of global muscles. Next, we work on improving
precision of the skill.
Associative to automatic
stages. The associative stage is where the patient has
"got the idea," so he or she needs repeated practice of the skill
for thousands of repetitions to develop a motor program and thereby progress to
the automatic stage. The idea is to decrease the
facilitation/feedback techniques as one progresses toward the automatic stage.
We also start with a simple, non-functional task in unloaded positions and
gradually progress to complex, functional, upright tasks while gradually adding
load and speed. The following are the eight steps of progression he
lists...
Steps of progression.
1. Independent activation of transversus abdominis and multifidus.
2. Independent co-activation of transversus abdominis and multifidus.
3. Improve precision.
4. Co-ordination of breathing.
5. Function: static tasks
6. Function: Light dynamic tasks.
7. Local and global co-activation.
8. Specific functional retraining.
Reference: 2003 seminar notes by Paul Hodges.
Peter O'Sullivan: Cognitive,
Associative, Autonomous
First stage of training.
The first stage of training is the
cognitive stage. During this initial training stage, a high level of
cognitive awareness is demanded of patients. This is necessary in order
to isolate the co-contraction
of the transversus abdominis and multifidus without substitution of the global muscles
(e.g., rectus abdominis, external & internal obliques, thoracic
portion of erector spinae). "The aim of the
first stage is to train the specific isometric co-contraction of transversus
abdominis with lumbar multifidus at low levels of maximal voluntary contraction
and with controlled respiration, in weight bearing within a neutral lordosis."
Second stage of training.
O'Sullivan calls the second phase of motor learning the associative stage.
In this stage, the
focus is on refining particular movement patterns which have been found to be
faulty and pain provocative. The aim is to identify two
or three of these movement patterns during examination
and then during rehabilitation they can be broken down into component movements
and perform for high repetitions. The patient is taken through these
component movements while isolating the co-contraction of
the local muscle system. Initially exercises are performed while maintaining the spine
in a neutral lordotic posture and later patients progress to normal spinal movement.
O'Sullivan states that: "At all
times segmental control and pain control must be ensured." Some of the
movement patterns identified during examination may be sit to stand, walking, lifting, bending, twisting, extending, etc. The
patients are prescribed independent exercises that focus on the movement components.
These are performed on a daily basis with pain control emphasized. They
are progressed as speed and complexity of the movement pattern is increased.
Eventually, these movements should be performed in a masterfully controlled manner.
He also encourages his patients to perform regular aerobic exercise like walking while
maintaining correct postural alignment, low level transversus abdominis and
multifidus
co-contraction and controlled breathing pattern. The key to pain control
is focusing on muscle control (performing the co-contraction) during movement
patterns throughout the day that a patient would typically anticipate resulting
in lower back pain and instability. O'Sullivan says that this is
fundamental so the co-contraction during these movement patterns becomes automatic.
Once this stage is finished, then formal specific exercise is no longer
necessary. From his experience, he suggests that this stage can last from
between 8 weeks to 4 months. Rehabilitation time depends on motivation and
compliance of the patient along with intensity of practice. Obviously, it
also depends on the degree and nature of the pathology.
Third
stage of training. The final stage is the autonomous stage
where the participant only requires a low degree of attention for the correct
performance of the motor task. O'Sullivan states: "The third stage is the
aim of the specific exercise intervention, whereby subjects can dynamically
stabilize their spines appropriately in an automatic manner during the
functional demands of daily living." Multiple studies show that changes to
automatic patterns of muscle recruitment can be achieved. The result of
the training is long-term show positive outcomes for subjects. The key is
a decrease in recurrence of symptoms and better functional outcome.
LMS = local muscle system
Reference: Manual Therapy (2000) 5(1), 2-12.
