Contents at a Glance

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1. STABILIZE: The Essential      Exercise For Low Back Pain      Why Stabilize?      Back & Abdominal Muscles       Control The Spine To       Prevent Injury        The PROBLEM      The SOLUTION!

2. Science of Back Exercises

3. Spinal Segmental                  Stabilization

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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STABILIZE brochure

   
Transversus Abdominis Re-Activation for Back Pain Relief!
by Howard A. Knudsen, PT
Doctor of Physical Therapy

 Why Stabilize With Transversus Abdominis?

Transversus abdominis is the key, but let's review the problem... First we know that low back pain will affect 80% of the population.   And, although the pain may go away after 4 to 6 weeks, the deep stabilizing (inner core) muscles of the lower back will remain impaired.  Impaired deep stabilizing muscles provide poor segmental stiffness, and this predisposes your back to re-injury and an eventual return of lower back pain.

A study of people who recently injured their back showed excellent long-term results for those who performed specific back exercises for transversus abdominis guided by ultrasonography.  In fact, the control group that did not perform specific exercises were 12.4 times more likely to have a return of low back pain during a three year follow up.  Scientific research reveals no other treatment with comparable results.  Only these specific back exercises have been shown to dramatically reduce recurrence of lower back pain.  To understand the problem and the solution, you first have to know how the muscles work in a healthy system.


 Back & Abdominal Muscles Control The Spine
    To Prevent Injury  
The brain normally has independent control over the inner and outer core muscles that surround the spine (see figure).  In a healthy system (with no history of low back pain), the brain normally activates inner core muscles first when low loads are placed on the spine during daily activities.  The brain is programmed to contract these deep stabilizing muscles to provide stiffness between individual segments of the spine.  The most important inner core stabilizing muscles of the lower back are the deepest layer of the lateral abdominal muscles, Transversus Abdominis, and the deepest of the muscles in the lower back, Lumbar Multifidi.  These muscles work at all times during body movement, even when the movement is of a body part a long way from the spine, such as the shoulder.  These muscles are much smaller and deeper, and do not generate great forces.

As moderate to high loads are placed on the spine, the brain recruits outer core muscles more aggressively.  These are large, strong, movement-producing muscles that may visibly ‘bulge out’ under the surface of your skin when contracted. 

The inner core controls the individual segments or parts of the lumbar spine & pelvis, whereas the outer core is only capable of controlling the whole spine in this region.  The inner core muscles contract in a "tonic" manner when properly activated during light activities.  The contraction produces a sustained, low-grade force that remain continuously active over long periods.  Whereas, contraction of outer core muscles is typically "phasic," or in other words it turns on and off much quicker, like a “lightning strike" during more aggressive activities.


 The PROBLEM
After a back injury or significant degenerative changes of the spine and subsequent low back pain, the inner core muscles become impaired.  Studies show segmental muscle atrophy of multifidus at the same side of lower back pain.  Other studies show that the brain no longer uses separate control strategies for the inner and outer core muscle groups.  Instead, the brain uses a simplified strategy of muscle control.

To help illustrate the differences in a healthy system vs. an injured system, let’s compare the brain’s strategy of muscle control to a light switch that controls multiple lights in a living room.  The healthy system may be compared to a sophisticated “rotary dimmer dial” light switch with separate “joystick” controls.  First, the brain gradually increases the inner core’s intensity level for control of low to minimal loads (similar to a dimmer dial).  Then, as more spine stability is needed, specific muscles of the outer core are added depending on direction of forces (joystick control) combined with intensity level (dimmer dial control).  The injured system is more like a single “on/off” light switch.  After first episode of low back pain, the brain does not seem to be able to differentiate between light and heavy loads and there is not separate control of inner and outer core muscles groups.

With an impairment of the inner core muscles after injury, the outer core muscles become excessively active in a compensatory attempt to stabilize the spine.  The brain’s new strategy results in spasm of outer core muscles and torso rigidity during painful periods.  Transversus abdominis seems to just follow the lead of over-active outer core muscles of the abdominal wall (i.e., rectus abdominis, external oblique, and internal oblique).  It also contracts in a phasic manner (lightning strike) instead of tonic (cold molasses).  And, the segmental portion of multifidus at the level of injury tends to waste away (muscle atrophy) and does not contract during activities that place low to minimal load on the spine.

The final piece of the puzzle gives us a clear picture of the problem.  The brain’s muscle control strategy of the “injured system” does not automatically return to the previous two strategies of a “healthy system” once the low back pain goes away and you return to performing normal activities.  The inner core muscles remain impaired and provide poor segmental stiffness, and this predisposes your lower back to re-injury and a return of low back pain.


 The SOLUTION
In the first stage, we reprogram the brain to use a separate strategy for control of inner core muscles.  These muscles are retrained to contract in a “tonic” manner (low-grade, slow developing, continuous recruitment).  You may also need to focus on reversing segmental muscle atrophy in the deep multifidus muscles.  “Drawing in” of the lower abdominal wall shown in the diagram below is one of the tasks performed.

We use facilitation and feedback techniques during this initial stage of rehabilitation.  These specific exercises are performed under the guidance of sonography, which is used as a biofeedback tool and to assess progress.  The depth of the stabilizing muscles makes them difficult to accurately assess without this technology, so diagnostic ultrasound scans are the key to success and they also help to shorten recovery times.  In the medical community, sonography is recognized as a safe, non-invasive technique of visualizing internal structures.   Sonography allows for precise muscle control to be visualized which is beneficial to both the patient and practitioner.  Once a patient has a clear understanding of the precise muscle contraction, the task is performed independently thousands of times.  Why?  Because research shows that control of deep stabilizing muscles is directly proportional to low back pain control.

"Muscle control = pain control!"

As muscle control improves, patients are progressed to performing exercises in more functional and demanding positions. The second stage of treatment involves pre-contracting the inner core muscles, then integrating normal outer core movement control with advance stabilization exercises. Patients who experience difficulty in stage two, often benefit from using the STABILIZER Pressure Biofeedback. The STABILIZER helps monitor movement of the lower back during exercise.  This precise feedback let the patient know if they are performing the exercise correctly.  This lessen mechanical stress to the spine during exercise which should in turn reduce exercise-induced low back pain.

"The key to back exercise is targeting the right muscle for the right function."
 

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Last update:
 Saturday April 21, 2007