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1. STABILIZE: The Essential
     Exercise For Your Back
2. Science of Back Exercises
3. Spinal Segmental               spinal segmental stabilization Stabilization
therapeutic exercise Introduction To Spinal
  Segmental Stabilization
exercise prescription For Lower Back pain... Which
  Exercises Would I Prescribe?
deep stabilizing muscles Overview of Concepts of
  Segmental Stabilization
retraining core stability Here is a summary of keys
  to success...
visual feedback Examples of visual
  feedback techniques
exercise progression Exercise Progression
prognosis Prognosis and Expected
  Treatment Times
4. Ultrasound Imaging Of
     Deep Stabilizing Muscles
5. Integration of Inner &
     Outer Units
6. Roman Chair Back
    Exercises For Strengthening
7. Functional Exercises For
     Your Back
8. Back Stiffness: Exercises
    And Stretching
9. Inversion Tables For
     Vertebral Distraction


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multifidus forward shift back exercise   
 SPINAL SEGMENTAL STABILIZATION:
 Specific Exercises For Deep Stabilizing Muscles
 Of The Back & Abdominal Wall
by Howard A. Knudsen, PT
Doctor of Physical Therapy

lower back pain recurrence  Introduction to Spinal Segmental Stabilization

The concept of spinal segmental stabilization has been one of the most exciting advancements in the field of physical therapy.  Specific back exercises that focus on deep stabilizing muscles have proven to reverse motor control deficits that occur after back injury or degenerative change.  The most significant finding thus far is that people who do not retrain their deep stabilizing muscles are 12.4 times more likely to have recurrence of back pain within 3 years. 

THERAPEUTIC EXERCISE FOR SPINAL SEGMENTAL STABILIZATION IN LOW BACK PAINMuch of the concept development and research performed has been conducted at the University of Queensland by Paul Hodges, PT, PhD, Julie Hides, PT, PhD, Carolyn Richardson, PT, PhD, and Gwen Jull, PT, PhD.  They published most of their studies in THERAPEUTIC EXERCISE FOR LUMBOPELVIC STABILIZATIOn, 2nd Edition.  Other prominent clinical researchers include Mark Comerford, PT and Peter O'Sullivan, PT, PhD. 

Specific exercises for the deep stabilizing muscles for the back and abdominal wall have been promoted in the United States by Pete Emerson, PT, MMTC who is the owner of Back & Sports Injury Physical Therapy in Denver and owner of Manual Therapy Seminars of Colorado and the UK.  He has introduced the physical therapists in the U.S. to experts from Australia and United Kingdom like Paul Hodges, PT, PhD and Mark Comerford, PT who have presented continuing education seminars here on a yearly basis. 
 

lower back pain exercises  For Lower Back Pain... Which Exercises Would I Prescribe?

Most rehabilitation specialists prescribe therapeutic exercise for low back pain that aims to use larger, superficial musculature in an attempt to stabilize the spine.  These exercises have recently evolved into functional capacity training.  Although this may be appropriate in later stages of rehabilitation (especially for athletes and those who perform heavy-labor), it is not the optimal starting point.

Many physical therapists mistakenly believe that strength is the key to lumbar spine stability.  We now know that motor control coordination is actually the key to stability.  Precision, not strength.  Other experts agree with this assertion...

Pete Emerson, PT, MMTC states: "Conventional therapy has dictated that strength is synonymous with stability and that more is better. This is not to say that strength training is not appropriate. When a patient requires rigidity under load, they must be trained to function under those conditions, but the vast majority of patients who experience low back pain need an intrinsic (inner unit or a deep stabilizing muscle) retraining program first to ensure control of the joint neutral position.  Although this intrinsic system can be more time consuming and difficult to teach at first, the system cannot be ignored any longer as the future in exercise rehabilitation." 
spinal stability Full HTML article: The Evolution of Spinal Stability in the Physical Therapy Field

F. Kermode (who performs research on the deep stabilizing muscles using real-time ultrasound imaging at a physiotherapy clinic in Western Australia) reports that typical back exercise programs, like gym-based rehabilitation program, pool therapy, and Pilates are too advanced for low back pain patients prior to retaining the tonic holding capacity and isolated co-contraction of multifidus and transversus abdominis.

Kermode states that "With many programs, the stabilising muscle activity tends to be trained in a phasic pattern, which does not lead to improvement in tonic holding capacity of the deep muscles."
real-time ultrasound imaging Full PDF article: Real-time ultrasound assessment of abdominal stabilisation muscles

Well, if you haven't guessed by now...  The back exercises I would prescribe for lower back pain are spinal segmental exercises.  An excellent resource of these exercise is available on a new DVD-ROM called Rx Tools.
 

segmental stabilization  Overview of Concepts of Segmental Stabilization

Goal.  In the first stage, you need to reprogram the brain to use a separate strategy control of the inner unit muscles.  You will be retraining these muscles to produce continuous, low-grade forces over long periods of time.  You may also need to focus on reversing muscle atrophy, if present in the deep back muscles.

Aim.  The focus of segmental stabilization retraining is to protect and support the individual segments of the spinal column from re-injury by re-establishing and enhancing muscle control.  Specific exercises have been developed to retrain the deep stabilizing muscles of the back and abdominal wall.  They directly address the motor control impairments identified in the inner unit.  In the clinic, we expect to teach the patient that "motor control = pain control." 

Ideal Response.  To cognitively activate the deep stabilizing muscles of the inner transversus abdominis contractionunit as independently as possible from unwanted superficial muscle activation of the outer unit.  "Drawing in the lower abdominal wall" is the specific motor learning task for the transversus abdominis (see diagram below).  multifidus contraction"Swelling the deep muscle fibers on either side of the lumbar spine" is the task for the lumbar multifidus.  Contraction of transversus abdominis must be independent of other abdominal muscles (rectus abdominis, external oblique, internal oblique).  Contraction of deep fibers of the multifidus must be independent of erector spinae muscles and deep muscles fibers of multifidus are emphasized over superficial.

transversus abdominis activity

Obstacles to success.  From clinical experience, we know that achieving the ideal response (although easily mastered by individuals with no history of lower back pain) is practically impossible and for patients with a history of back injury or degenerative changes.  Research has shown that the brain develops a dysfunctional movement-coordination programming strategy after a back injury or degenerative changes.  The inner unit muscles are impaired and no longer have tonic-holding capacity; they follow the lead of the outer unit with a phasic contraction pattern related to movement.  On the contrary, the outer unit muscles are excessively active during low-loading on the spine.  "The result, preferential recruitment and earlier firing of overactive phasic muscles and a neurological (motor control) system biased against the recruitment of inhibited stabilizing muscle groups."  There is no question that this non-functional activity can be very frustrating for the patient, but it can also be frustrating for a practitioner who who has little experience with this exercise program.  (I felt like giving up on numerous occasions as a self-treating patient and as a novice practitioner.)

Keys to success.  An assessment by a physical therapist or physician with specialized training, who would then prescribe specific exercises with individualized facilitation & cognitive techniques, optimal positioning, neutral orientation of the spine, and feedback.  Another key to success is practice, practice, practice.  Clinical guidelines suggest that a patient should perform 2-3 exercise sessions each day.  It is also recommended that this skill be practiced at least one time (for 10 seconds) each hour in functional positions.

Another key to success... the not-so-secret weapon!  All of the prominent clinicians who have published research on these specific exercises use diagnostic ultrasound imaging.  Sonography is used by a physical therapist to verify his or her assessment and measure progress.  The patient uses real-time ultrasound imaging as a visual biofeedback tool, and this has been found to be extremely successful in isolating transversus abdominis.  The patient can view the isolated contraction of transversus abdominis independent of internal oblique.  Precise feedback is also given for the deep back muscles, this ensures that the patient is activating the multifidus at the affected segment... including the deep fibers, and the ability to hold the contraction can also be monitored. 
 

cure lower back pain  Here is a Summary of Keys to Success...

Focus on one muscle at a time.  Break up the complex orchestration of movement-coordination into the individual parts and practice until you have an "ideal response."  Initially it is best to focus on one deep stabilizing muscle at a time during formal motor skill training. 

Use instructions.  This may includes pictures, written materials, audio tapes and verbal instructions.  An explanation of the specific exercise, function of the muscle, and anatomy is critical. 

Demonstrate the exercise action.  A physical therapist or physician should show what the contraction should look and feel like by demonstrating the specific activation to the patient. 

Body position.  A secret to relaxing the superficial (outer unit) muscular system while performing an isolated contraction of the transversus abdominis or deep multifidus is identifying an appropriate position.   Body position may also be used to promote a facilitation strategy, like "gravity stretch" on the abdominal wall in 4-point kneeling or side-lying.  Of course, the most symptom-free position is preferable.

Neutral orientation of spinal column.  Spinal curves with normal lumbar lordosis and thoracic kyphosis tend to promote relaxation of excessively activated outer unit muscles.  Obviously, this will help to activate the inner unit muscles, independently.

Cognitive strategies.  Mental imagery is used to focus your attention on the specific motor learning task.  Most patients have poor body awareness, especially in the lower back.

Visual feedback.  Viewing a real-time ultrasound image of the muscle activity is an excellent form of biofeedback.  Visual feedback may include using a mirror to see a muscle's activation or a movement involved with a facilitation strategy.  The STABILIZER Pressure biofeedback was developed specifically for these back exercises.  EMG machines may also be used to detect unwanted global activity of superficial muscles. 

Tactile feedback.  Palpation (touching with fingers or thumbs) is used for tactile feedback while attempting to contract one of the deep stabilizing muscles.  There are also spots to palpate to check for unwanted outer unit substitution.  Muscles are palpated through different rehab strategies to ensure proper firing patterns without substitution of the phasic system.

Facilitation strategies.  Strategies for the facilitation of inner unit muscle contraction.  Facilitation strategies have been described by various authors.  Co-activation of the pelvic floor or posterior fasciculus of psoas with transversus abdominis or multifidus are examples. 

Relaxation strategies.  Strategies for the relaxation of unwanted outer unit muscle activity are necessary.  For example, it is imperative (at least initially) to be in a quiet room that is conducive to relaxation with no distractions or disturbances.  Verbal instructions should be given in a slow, relaxed manner. 

An excellent reference to this summary of keys to success is found in BACK TRAINER Prescription Tools (Rx Tools). This new book reviews the different techniques used to facilitate transversus abdominis, multifidus, and posterior fasciculus of psoas.  Once the motor control of the local system is restored then training is aimed at the integration of the local and global systems.  Rx Tools also contains a broad range of examples of these type of specific exercises.
 

sonography  Examples of Visual Feedback Techniques

Sonography.  The University of Queensland group has pioneered the use of diagnostic ultrasound for ultrasound imaging physical therapyevaluation, testing, and retraining deep stabilizing muscles for spinal segmental stabilization.  Real-time ultrasound is used as an evaluation tool by physical therapists to objectively measure the contraction of transversus abdominis, multifidus, and pelvic floor muscles.  Ultrasound imaging is a way to measure firing patterns, endurance times, view the consistency of the muscles, as well as measuring cross-sectional area.  Physical therapists are also using this technology during retraining as a method of visual biofeedback for the patient during attempted contraction of local stabilizing muscles.  This helps speed up the rehabilitation process.  Click here for more information about the use of real-time ultrasound imaging.

biofeedback for unwanted global muscle activationSurface electromyography (sEMG).  sEMG may be used to monitor unwanted activity of the superficial muscles of the outer unit.  An example of the proper use of sEMG is monitoring the external obliques or erector spinae for feedback to the patient of unwanted activity.  Because of the depth of the inner unit, sEMG is not reliable and validity is poor for monitoring deep stabilizing muscles.  Click here for more information about the use of the EMG Retrainer during specific abdominal and back  exercises.

STABILIZER Pressure Biofeedback Unit.  The STABILIZER was developed by physical therapists at the University of Queensland to provide indirect feedback on positional changes of the abdominal wall, lower back and stabilizer pressure biofeedbackpelvis.  This device may be used while assessing the maintenance of the holding patterns during spinal segmental stabilization training.  It has been found that the stabilizer may be best used after the initial phase of retraining, when an attempt is made to integration of the local and global systems.  Click here for more information about the use of the STABILIZER Pressure Biofeedback Unit during specific abdominal and back exercises.
 

assessment of deep stabilizing pictures  Assessment of Deep Stabilizing Muscles

Clinical skills are imperative to the success of this exercise program.  Physical therapists have the training and background to learn how to assess the deep stabilizing muscles for their role in spinal segmental stabilization. A thorough history is taken, observations are made, and then the abdominal and back muscles are palpated to check for impairments of the inner unit and excessive activity of the outer unit.  Objective measurements of cross sectional area of muscles and firing patterns may be noted using real-time ultrasound imaging.  You may also use sEMG for biofeedback on unwanted recruitment of outer unit muscles. 

Observation and palpation
Physical signs of unwanted outer unit muscle activity include aberrant movement, contour of the abdominal wall, and breathing patterns.  Palpation of muscles using finger tips or thumbs is used to assess independent contraction of deep stabilizing muscles.

There are ways to suspect deep multifidus and transversus abdominis dysfunction without the use of advanced ultrasound imaging.  With the prevalence of an altered movement-coordination programming strategy, the patient will most likely excessively recruit his or her erector spinae muscles (when attempting to contract the deep multifidus).  This is viewed and/or palpated in the thoracolumbar area.  The patient will also excessively recruit his or her superficial abdominal muscles (when attempting to contract the transversus abdominis).  This is viewed and/or palpated in the abdominal wall. 
 

back exercise progression  Exercise Progression

Various authors have recommended their personal philosophy for progressing through the stages of this specific exercise program.  I will provide a review of some a few of these programs. 

Peter O'Sullivan, PT, PhD.  He uses a motor learning model to describe his exercise progression.  Early training starts with the cognitive stage.  Associative stage is the second phase, where the focus is on refining a particular movement pattern.  Finally, the third stage is the autonomous stage where a low degree of attention is required for the correct performance of the motor task. 

Paul Hodges, PhD, PT.  He also describes a motor learning model starting with the cognitive stage, then and the associative stage, and finally the automatic stage (instead of O'Sullivan's autonomous stage).  He states that the "level of feedback changes as the rehabilitation progresses through stages."

Mark Comerford, PT.  He suggests FOUR PRIORITIES.  Although similar to
O’Sullivan’s three stages, Comerford brings new insight into the progression of
these specific exercises. 

Variation of back exercise progression Click link for more information about Variations in the progression of specific exercises.
 

Prognosis for back pain  Prognosis and Expected Treatment Times

The best data on prognosis and expected treatment times come from specific studies.  All research to date is being conducted by physical therapists who are using ultrasound imaging for assessment and visual feedback of correct recruitment of isolated muscle contraction. 

Acute, first-episode low back pain.  The prognosis is good for patients who receive training after first-episode lower back pain.  In fact, people who receive no retraining of deep stabilizing muscles are 12.4 times more likely to have recurrence of back pain within 3 years.  Those without previous history of lower back pain who present with acute lower back pain needed only 4 weeks of training for a 70% chance of no recurrence

Chronic, recurrent low back pain.  Another study was performed on people with chronic lower back pain (onset of LBP was at least 3 months prior to the study) with a radiologic diagnosis of spondylolisthesis or spondylolysis.  They received 10 weeks of training with statistically significant positive results.  Specific back exercise training resulted in a decrease in pain intensity and disability.  (The control group had no significant change.) 

  back exercises diagram
 

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