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.
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.
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
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
Full HTML article:
The Evolution of Spinal Stability in the Physical Therapy Field
F. Kermode (who performs research on the deep stabilizing muscles
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
too advanced for low back pain patients prior to
tonic holding capacity and isolated co-contraction of
multifidus and transversus abdominis.
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
Overview of Concepts of
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
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
To cognitively activate the deep stabilizing muscles of the inner
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).
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.
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
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
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.
Here is a Summary of Keys
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.
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.
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,
Mental imagery is used to focus your attention on the specific motor
learning task. Most patients have poor body awareness, especially in the
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.
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.
Strategies for the facilitation of inner unit muscle
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.
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.
Examples of Visual Feedback
Sonography. The University of
Queensland group has pioneered the use of
diagnostic ultrasound for
testing, and retraining deep stabilizing muscles for spinal
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.
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.
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
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
Pressure Biofeedback Unit during specific abdominal and back exercises.
Assessment of Deep
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.
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.
Click link for more information about
Variations in the progression of specific exercises.
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
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.
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
disability. (The control group had no significant change.)