Exercises for Lumbar Instability: Difference between revisions

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Search Strategy[edit | edit source]

In pubmed: Instability AND low back pain
Instability AND lumbar spine
transversus abdominis
physiotherapy and lumbar instability
transversus abdominis low back

In physiopedia: lumbar instability
anatomy back
spinal stabilisation
core stability
exercises back
therapy low back pain
feedforward

Definition/Description[edit | edit source]

Low back pain can be defined as pain or discomfort in the lumbar region. This can be unilaterally of bilaterally. In 85% of the patients low back pain is non-specific. That means that there is pain without a specific medical diagnosis.
People with weak muscle strength and endurance have a great risk at low back pain. It has been shown that weak trunk extensors may lead to chronic low back pain.
Some study’s claim that overweight is also a risk factor, but not every study can prove this.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Low back pain is usually due to lumbar (segmental) instability. Lumbar instability is one of the subgroups of non-specific low back pain. Implications of instability are pain, functional disability and reduced muscle endurance.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Patients with lumbar instability also show a condition of loss of spinal motion segment stiffness in with normal external loads may cause pain, spinal deformity or damage to the neurological structures. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Not all patients show a loss of the feedforward mechanism. But if the feedforward mechanism does not work well, the patients will have more pain. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
In lumbar motor control training you find more information about the feedforward mechanism.
Therapy exercises for lumbar instability is hard to define. Not only the lumbar region, but also the surrounding anatomical structures must be trained, like the abdominal muscles and some muscles of the lower extremity. The kind of exercises depends on the status of the patient.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Clinically Relevant Anatomy
[edit | edit source]

Clinically Relevant Anatomy of the low back.

Muscles of the low back:

Stabilizing and mobilizing muscles that affect the low backCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Indications for exercises[edit | edit source]

It has been showed that there are different reasons why we should give exercises to patients with lumbar instability. The most important considerations are; which are our goals and is the patient likely to benefit. An important study by Hicks et al, shows that during the examination of lumbar instability positive and negative determinants can be found indicating whether a subject will benefit from a low back stabilization program.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
There are indications that stabilization exercise programs are used to improve the strength, endurance, and/or motor control of the abdominal and lumbar trunk musculature. Stabilization exercise programs exist of general exercises, educational and workplace-specific back school classes, increase of workload tolerance, psychological interventions and segmental stabilization exercises. The stabilizing exercises focus on the re-education of a precise co-contraction pattern of local muscles of the spine.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
It had been showed that stabilizing exercises with routine exercises in reduction of pain intensity increasing the functional ability and muscle endurance. It is recommended to use stabilizing exercises in treatment of patients with lumbar segmental instability.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
This is the guideline about the implications for practicing the local muscle system:
• Develop the skill of an independent contraction of the local muscle synergy;
• Decrease the contribution of the overactive global muscles;
• Use a motor relearning approach to reteach the skill of developing a “corset” action of transverses abdominis and multifidus in response to the cue to draw in the abdominal wall.
• Use specific facilitation and feedback techniques to ensure each segment of the multifidus muscle is activated;
• Use specific feedback techniques to develop kinaesthetic awareness of local muscle contractions;
• Develop ability to hold the “corset” action tonically over extended periods of time
• Use repeated movements of lumbopelvic region, in non-weightbearing positions initially, to improve position sense.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Implications for practice of the local muscle system with the global muscle system
• Training the local and weightbearing muscles is likely to reverse impairments in the non-weightbearing muscles;
• Initially use specific facilitation techniques for the dysfunctional weightbearing muscles, with emphasis on increasing weightbearing load cues;
• Use optimal weightbearing postures to re-establish recruitement of both the local and weightbearing muscles;
• Weightbearing muscles should be trained under the stretch from gravity in flexed and more upright postures;
• Use static weightbearing postures with increasing holds and/or very slow and controlled weightbearing exercise to enhance the feedback mechanisms;
• Increase gravitational load cues gradually, ensuring local and weightbearing muscles are responding to the increases in load;
• At a later stage it may be necessary to add in specific muscle-lengthening techniques for non-weightbearing muscles, especially if the muscle tightness is in the passive rather than the active elements of the muscle.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The segmental stabilization model for the prevention and treatment of low back pain Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The three stages of the exercise model form the building blocks for the development of the joint protection mechanisms, for both low- and high-load functional situations. Each stage includes clinical assessments of the level of impairment in the joint protection mechanisms, followed by the suggested exercise techniques.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Exercise techniques[edit | edit source]

The guidline to follow before starting with exercises is to use the stabilizer. A stabilizer has come into general use for stabilization exercises for all parts of the body. A stabilizer is a pressure biofeedback unit and consists of an inelastic, three-section air-filled bag, which is inflated to fill the space between the target body area, a firm surface and a pressure dial for monitoring the pressure in the bag for feedback on position. The bag is inflated to an appropriate level for the purpose and the pressure recorded. Quite simply, movement of the body part off the bag results in a decrease in pressure, while movement of the body part into the bag results in an increase in pressure. Its use in assessing the abdominal drawing-in action has become its most important use in relation to the treatment of problems for the local muscle system in patients with low back pain. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

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The patient must be placed in an initial position lying on the back with the hips and knees flexed. The feet remain flat on the floor and the arms must be held alongside the body. The stabilizer is positioned under the low back and there it measures the movements of the spine. During exercises the spine cannot make any movements. The transversus abdominis muscle must be in contraction while doing exercises and this muscle keeps the spine in the right position. On the picture below the woman is holding the feedback machine. Thereon she can see when her spine moves.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

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A. Foundation movements
1) Contracting transversus abdominis muscle.
Goal: Learns to contract the transversus abdominis muscle without contraction of the overlying abdominal muscles.

How to do?
The person pulls his belly in and up at the navel without moving the rib cage, the pelvis or the spine.
Contraction intensity: 30 to 40% of the maximum voluntary contraction ( MVC).
Building:
1) Start with a small contraction.
2)Build up the duration of the contraction.
Only when the patient can control contraction of the transversus abdominis muscle with minimal muscle intensity ( 10 repetitions each 30-40%) over a period of time , the progress should lead to more advanced exercises. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A movie of this exercise is shown in spinal stabilization.

The action of the transverses abdominis : (a) relaxed abdominal wall, (b)The drawn in abdominal wall.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Normally the transversus abdominis muscle is in contraction always while standing and sitting. Contraction of this muscle creates a good posture. In normal conditions the transversus abdominis muscle contract by itself, but in patients with low back pain the muscle doesn’t happen naturally. This can lead to an unstable core, which is a risk factor for low back pain.
The goal is that patients with low back pain learn to contract the transversus abdominis muscle in al times (except in lying position).
After a time the muscle shut contract naturally. It is very important in patients with low back pain that they have a good posture, that’s why they have to learn to contract the transversus abdominis muscle.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

2) Contract of the M. multifdus
The mucle is the most important stabilizer of the spinal extensor group. People with low back pain often lose the ability to contract this muscle and they do not regain the ability spontaneously.
How to do?
First the person learn to recognize what is feels like to tense and relax the muscle.
Second focus not only on the multifidus but also on the lateral abdominals. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

3) Control of the pelvic muscles
This is important to move confidently into a neutral lumbar position. People with low back pain have not the ability to perform pelvic tilting. You can see excessive flexion laxity but limited, or bloked extension.
The ability to dissociate lumbar movement form pelvic movement is therefore important, and correction of faulty lumbar-pelvic rhythm is vital. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

4) Diafragma
The muscles are also reduced in asociation with rapid limb movement and support surface translation while global muscle activity is increased. It may be predicted that people with respiratory disease may have increased incidence of low back pain. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Prone kneeling Lumbar-Pelvic Rythm Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Facilitate active pelvic tilt. Prone kneeling with shoulders directly above the hands and hip above the knees Phase 1(a): no lumbar or pelvic movement should occur Phase 2(b):posterior pelvic tilt and hip flexion occur Phase 3(c) :Lumbar flexion and some thoracic flexion finish the action (d): Faulty lumbar-pelvic rhythm often shows up when lumbar flexion and posterior pelvic tilt occur immediately. Building: 1) The patient learns the tilting 2) The tilting has to be rhythmic Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title The control of the pelvic muscles is important to move confidently into a neutral lumbar position. People with low back pain don’t have the ability to perform pelvic tilting. They exhibit also a limited excessive flexion laxity or bloked extension. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title The ability to dissociate lumbar movement from pelvic movement is therefore important and the correction of faulty lumbar-pelvic rhythm is vital. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
High(two-point) kneeling (assisted) hip hinge action Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Use a pelvic tilt action to move the spine forward and backward. Once you can perform pelvic tilting well, you should combine it with classic hip in a hinge action where the trunk moves on the hip in a hinge action and the spine remains straight. Avoid any increase or decrease in lumbar lordosis! Draw the abdominal muscles and maintain this minimal contraction throughout the movement! Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Sitting pelvic tilt using gym ball Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Teach anterior-posterior pelvic tilt control. Sit on the ball with knees apart and feet flat on the floor. Both hips and knees should be flexed to about 90°. Tilt pelvis alternately in both anterior and posterior directions, making sure the shoulders and thoracic spine remain inactive. Start with small ranges of movement. Gradually work up to larger ranges. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Prone lying Multifidus contraction Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Teach clients to learn to use the multifidus at will and seperately from other muscles. The multifidus is the most important stabilizer of the spinal extensor group. People with low back pain often lose the ability to contract this muscle and do not regain the ability spontaneously. Prone-lying position Therapist palplates the multifidus. Bulge the muscles beneath the fingers of the therapist and differentiate between erector spinae contraction(more lateral) and multifidus contraction(more central). To differentiate between the multifidus muscle and the erector spinae muscle, it’s recommended to contract the erector spinae muslce by hyperextend the trunk. To contract only the multifidus muscle, the patient may not hyperextend the trunk.Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title A movie of this exercise is shown inspinal stabilization.
Sitting Multifidus contraction Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Encourage your client to contract the multifidus and lateral abdominals simultaneously. Client sit on the edge of a bench with his feet on the floor. Lumbar spine in neutral position. Therapist palpates the multifidus. Client performs abdominal hollowing If the therapist feels the contraction, the client can self-palpate and continue the action for 10 repetitions, aiming to hold each for 10 s while breathing normally. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Forward stride(walk) standing multifidus contraction Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Encourage your client to contract the multifidus and lateral abdominals simultaneously. Stand with one foot in front of the other Self-palpate the L4-L5 level by placing the thumbs on the lower lumbal spinosus process and moving them outward slightly into the spinal tissue. Place the weight onto the front leg and then onto the back leg alternately. Feel the muscles beneath the thumbs switching on and off. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title

B.Progressing stability training

Heel Slide – Basic Movement Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Place minimal but progressive limb loading on the trunk. Slowly straighten one leg with the heel resting on the ground. The moment the pelvis anteriorly tilts and the lordosis increases, you must stop the movement and draw the leg back into flexion. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Leg Lowering Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	This exercise is described in core stability. ‘Leg extensions’
Prone-Lying Gluteal Brace Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: co-contract trunk stabilizers with gluteals. Patient has to lie down and dorsiflex the toes. Flex than the knees ( 10°) and the hip (10°). After that contract the gluteal muscles. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Bridge from Crook Lying (Shoulder Bridge) Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	This exercise is described in core stability. ‘Dynamic leg and back’
Bridge with leg lift Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: progress from bridge from crook lying. The patient starts in crook lying ,then he lifts one leg. Avoid : allow the pelvis to fall toward the unsupported side! Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Four-point Kneeling Leg movement Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	This exercise is described in core stability. ‘Hamstrings raising’.
Four- point Kneeling arm and leg lift (full bridge) Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	A movie of this exercise is shown in lumbar spine fracture. ‘Bird dog’
Side-Lying spine lengthening Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: control the quadratus lumborum and lateral fibers of the oblique abdominals. Start position: strong co-contraction of the abdominal muscles. Lie on one side, thighs in line with your body and flex the knees 90°. Upper body supported on the same side elbow. Straighten your spine against the force of gravity, leaving the body supported on the forearm of the underneath arm and hip. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Side-lying hip lift Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	A movie of this exercise is shown in low back pain and pelvic floor disorders. ‘Oblique abdominals’
Side-lying body lift(Side bridge) Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: progress from side-lying spine lengthening. Start position: side-lying spine lengthening. Lift the hips, leaving the body supported on the forearm of the underneath arm and the knees only. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Pelvic shift with leg lift Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: teach pelvic control and stability in single-leg standing. Shift the pelvis to the left, lift slowly the right leg. The supporting leg supports the pelvis and the pelvis supports the back. Raise the knee no more than 45°.Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Sitting knee raise Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: maintain pelvic positon against the pull of the hip flexors. Raise one knee, about 8 cm. Unload the limb by lifting the heel. If he is able to maintain good alignment, have him lift the entire leg. Avoid: posterior pelvic tilt! Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title

C.Unstable base

Rapid Displacement in sitting Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Develop muscle reaction speed for back stability. The patient sit on a chair with her spine optimally aligned. A partner stands behind the person and press on the shoulders in multiple directions; flex, extend and laterally flex the spine. The patient needs to be able to rapidly stabilize his spine. That patient needs to relax the trunck muscles between repetitions. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title [1]
Throwing and catching on a mobile surface Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: develop rapid-onset back stability. Throwing and catching a bal on a mobil surface while you try to stabilize it.The aim is to align the lumbar spine optimally. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Sitting pelvic tilt, progressing to balance board Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: advanced control of pelvic tilt. The patient needs to sit down on a wooden bench with the feets on the floor. Than hold the pelvis alternately in the anterior and then posterior direction. The aim is to isolate the pelvis and lower lumbar spine from the thoracic spine and the shoulders from the upper lumbar spine. Maintain the position of the shoulders and thoracic spine. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Neutral position maintenance Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: build stability reaction speed in sitting. The patient has to try to balance his body while a person knock the patient. The patient sits in a neutral position on a wobble board. Work gradually up the pressure. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title

D.Gym ball

Sitting knee raise on gym ball Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	This exercise is described in low back pain and pregancy.
Lying trunk curl with leg lift Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: strengthen upper and lower abdominals. Start position: lying trunk curl over ball. The patient should lift one leg while maintaining the stable position. ! lying over the ball is a good way to stretch the whole spine! Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Bridge with therapist pressure Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Strengthen hip and trunk stability muscles by challenging stability with continuously variable overload from multiple directions. Start position: the standard bridge, his feets on a ball. The therapist pushes the patient against his pelvis from above and below and side to side. Rapid pushes will decrease muscle reaction time, training the muscles to contract more quickly without loss of intensity. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Basic superman Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: strengthen the spinal and hip extensors. The patient has to lie down with her abdomen on the ball and her feets astride and flat against a wall. Tight the abdominal muscles to form a firm surface pressing against the ball and retract the head. The patient retracts and depresses her shoulders to draw the arms downward and back and extend the thoracic spine to bring the chest off the bal. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Reverse bridge Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Strengthen back and hip muscles while increasing leg motion control. Start position: high position of the reverse bridge movement. The patient has to roll the ball toward herself by flexing her knees and hips and roll it away by extending her legs again. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title
Wall sit Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	Goal: Prepare the body for lifting while strengthening the legs to provide power for the lift. Start position: ball between back and wall. 1) Sitting position while rolling the ball down the wall. When he achieves 90° hip and knee flexion, the patient needs to hold the position. 2) Single-leg wall sit, straightening on leg at the knee. Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title

E.Building back fitness and resistence training for Core Strength

Bent knee sit-up Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	This exercise is described in core stability. ‘Crunches’
Gluteal Stretch Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title	The patient sits on the floor with his legs extended. The patient then crosses one leg over the still extended other leg The patient can push with his/her elbow against the lateral side of the knee twist his/her trunk away to get more stretch.
	Other possible exercises that we only mention -wall bar hanging leg raise Goal: strengthen the lower rectus and providing traction for the lumbar spine -Basic crunch Goal: Work the abdominal muscles in general, with increased emphasis on innerrange activity of the upper abdominals. -Side crunch Goal: Strengthen the oblique abdominals while also working the rectus abdominis -Machine exercises (fitness) Cite error: Invalid `<ref>` tag; name cannot be a simple integer. Use a descriptive title

Lower extremity muscle exercises
It is possible that lumbar instability is not only limited to the lumbar spine and the anatomical structures complementing it. Sacro-iliac joint instability for instance plays also a part and can be the cause of low back pain. Studies have found that a big contributor to this sacro-iliac joint instability and low back pain is the malrecruitment of the m. gluteus maximus and m. biceps femoris.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The patient has to perform a few slow hip extensions. The physiotherapist places one hand on the M. gluteus maximus of the patient and one on the hamstring muscles. The therapist gives feedback with his hand. The patient has to activate his gluteus maximus first and if he does this correctly he pushes the hand on his gluteus maximus muscles away first, before he does the same with his hamstring muscles.

It has been showed that there is a relationship, especially in muscle coordination, between the muscles that stabilize the lumbar spine and the muscles in the lower extremity, so these muscles has to be trained too, to further achieve coordinated activity between all muscles within a balanced muscular system.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThe quadriceps muscles play a part in this relationship also. A study has found that patients with low back pain have deteriorating function of the quadriceps muscles. Endurance and feedforward in the patients quadriceps muscles tend to be weak. The study found that this is due to reduced quadriceps activation after localized lumbar paraspinal fatiguing isometric exercise . Exercises aimed at localized fatigue of the lumbar spine extensors have shown an immediate response in the lower extremity including reduced quadriceps central activation ratio deteriorated balance and response to a balance perturbation. Furthermore they describe a quadriceps fatigability during maximal effort isokinetic knee extension contractions.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The two main functions of the quadriceps are extension of the knee and flexion of the hip.

Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The patient starts with both his feet on the ground. The patient then straightens one leg and holds this position for about 10 seconds. Then the patient switches legs. To make this exercise a loaded exercise, the patient can do this exercise with weights( for instance on a leg extension machine). Ask the patient to hold for 1-3 seconds.

Exercises for patients who are braced

It has been showed that patients who are braced for lumbar instability benefit from some of the exercises, that are described above. Braced, in this case, means that the patients who were braced were wearing orthesis A study found that patients who are braced and did the following exercises had a decreased level of pain.
- Gluteal and ischiocrural stretching exercises performed in an unloaded way.
- Contraction exercises of the lumbar stabilizing muscles, in particular the m. transverse abdominus.
- Exercises for trunk stabilization on ever more reduced supporting surfaces and finally on unstable surfaces.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Key Research[edit | edit source]

Fritz et al. examined the predictive validity of lumbar segmental mobility in patients with LBP. It is possible that patients with segmental hypermobility were more likely to achieve clinical success with stabilization exercises compared with patients without hypermobility.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

It has been showed in the research of Hides et al. that the Lumbar Multifidus muscle remained atrophied after a 10-week period when patients with acute LBP did not exercise. But this muscle was recovered to normal size in patients who received a stabilization exercise program that stressed deep abdominal and isolated the Lumbar Multifidus muscle contractions.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

In the study of Richard A et al. some patient groups demonstrated hypertrophy of the Lumbar Multifidus muscles with low-load stabilization exercises. There are indications that the Lumbar Multifidus muscle is inhibited in patients with LBP and the retraining of the muscle to contract may be the major importance during stabilization training. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

There are also indications that many exercises commonly used by physical therapists in LBP rehabilitation require low to moderate muscle activity of the Lumbar Multifidus and Longissimus thoracicus muscles. To increase the activity of these muscles during exercise, active or resisted lumbar extension is required. Resisted lumbar extension at the end range tends to maximum activity of these muscles.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

It has been showed that segmental stabilization exercise was more effective than placebo intervention in symptomatic lumbar segmental instability.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

It also has been showed that specific muscle stabilization retraining is more relevant for patients with either gross spinal symptoms or pronounced side to side differences in the size of the multifidus muscle than for patients that have no signals of instability. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The mode of action of stabilization retraining still remains unclear. It has not been shown to be capable of mechanically containing an unstable segment, even upon improvement of muscle activation. No direct long-term effect of stabilization exercises on the status of the local stabilizing muscles has been demonstrated. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The commission advises of a study that evaluated the effect of unstable and unilateral resistance exercises on trunk muscle activation revealed that, regardless of stability, the superman exercise was the most effective trunk-stabilizer exercise for back-stabilizer activation. The side bridge was the optimal exercise for lower-abdominal muscle activation. Thus, the most effective means for trunk strengthening should involve back or abdominal exercises with unstable bases. Furthermore, trunk strengthening can also occur when performing resistance exercises for the limbs, if the exercises are performed unilaterally.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Resourses[edit | edit source]

There’ re some video’s on physiopedia which show how to perform the exercises described on this page. It’s interesting seeing video’s because it’s easier to understand what you have to do. They are a capital gain to this page.

Clinical Bottom Line[edit | edit source]

On this page there are a lot of exercises. To be sure the patients stays motivated it’s important to take care of variation in the exercises you give. It’s possible using this page to variate your therapy for patients with low back pain.

Recent Related Research (from Pubmet)[edit | edit source]

Prospective study of a new dynamic stabilization system in the treatment of degenerative discopathy and instability of the lumbar spine.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

References[edit | edit source]

see adding references tutorial.

Exercises for Lumbar Instability: Difference between revisions

Revision as of 20:08, 30 December 2013

Contents

Search Strategy[edit | edit source]

Definition/Description[edit | edit source]

Clinically Relevant Anatomy
[edit | edit source]

Indications for exercises[edit | edit source]

Exercise techniques[edit | edit source]

Key Research[edit | edit source]

Resourses[edit | edit source]

Clinical Bottom Line[edit | edit source]

Recent Related Research (from Pubmet)[edit | edit source]

References[edit | edit source]

Physiopedia

Content

Legal

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 <sup>[[Image:Phy3.jpg]]<ref name="6" /></sup><sup></sup><br>
-The patient must be placed in an initial position lying on the back with the hips and knees flexed. The feet remain flat on the floor and the arms must be held alongside the body. The stabilizer is positioned under the low back and there it measures the movements of the spine. During exercises the spine cannot make any movements. The transversus abdominis muscle must be in contraction while doing exercises and this muscle keeps the spine in the right position. On the picture below the woman is holding the feedback machine. Thereon she can see when her spine moves.<ref name="20">http://protherapysupplies.blogspot.be/2010/11/pro-therapy-supplies-carries.html (Level of evidence 5)</ref>, <ref name="21">Rossi DM et al.; Antagonist coactivation of trunk stabilizer muscles during Pilates exercises; Jounal of Bodywork &amp;amp;amp;amp; Movement Therapies; Elsevier; 2013 (Level of evidence 1B)</ref>
+The patient must be placed in an initial position lying on the back with the hips and knees flexed. The feet remain flat on the floor and the arms must be held alongside the body. The stabilizer is positioned under the low back and there it measures the movements of the spine. During exercises the spine cannot make any movements. The transversus abdominis muscle must be in contraction while doing exercises and this muscle keeps the spine in the right position. On the picture below the woman is holding the feedback machine. Thereon she can see when her spine moves.<ref name="20">http://protherapysupplies.blogspot.be/2010/11/pro-therapy-supplies-carries.html (Level of evidence 5)</ref>, <ref name="21">Rossi DM et al.; Antagonist coactivation of trunk stabilizer muscles during Pilates exercises; Jounal of Bodywork &amp;amp;amp;amp;amp; Movement Therapies; Elsevier; 2013 (Level of evidence 1B)</ref>
 [[Image:Phy4.jpg]]<sup><ref name="20" /></sup>
@@ Line 44: / Line 44: @@
 [[Image:Phy5.jpg]]<br>
 [[Image:Phy6.jpg]]<br>
 ''The action of the transverses abdominis&nbsp;: (a) relaxed abdominal wall, (b)The drawn in abdominal wall.<ref name="4" />''
@@ Line 67: / Line 67: @@
 [[Image:Phy7.jpg]]
 <ref name="1" />
+<br>
 | Goal: Facilitate active pelvic tilt.<br>Prone kneeling with shoulders directly above the hands and hip above the knees<br>Phase 1(a): no lumbar or pelvic movement should occur<br>Phase 2(b):posterior pelvic tilt and hip flexion occur<br>Phase 3(c)&nbsp;:Lumbar flexion and some thoracic flexion finish the action<br>(d): Faulty lumbar-pelvic rhythm often shows up when lumbar flexion and posterior pelvic tilt occur immediately.<br>Building:<br>1) The patient learns the tilting<br>2) The tilting has to be rhythmic <ref name="1" /><br>The control of the pelvic muscles is important to move confidently into a neutral lumbar position. People with low back pain don’t have the ability to perform pelvic tilting. They exhibit also a limited excessive flexion laxity or bloked extension. <ref name="5" /><br>The ability to dissociate lumbar movement from pelvic movement is therefore important and the correction of faulty lumbar-pelvic rhythm is vital. <ref name="5" /><br>
 |-
 | High(two-point) kneeling (assisted) hip hinge action<br> [[Image:Phy8.jpg]]<ref name="1" />
 | Goal: Use a pelvic tilt action to move the spine forward and backward.<br>Once you can perform pelvic tilting well, you should combine it with classic hip in a hinge action where the trunk moves on the hip in a hinge action and the spine remains straight.<br>Avoid any increase or decrease in lumbar lordosis!<br>Draw the abdominal muscles and maintain this minimal contraction throughout the movement! <ref name="1" /><br>
 |-
 | Sitting pelvic tilt using gym ball<br> [[Image:Phy9.jpg]]<ref name="1" />
 | Goal: Teach anterior-posterior pelvic tilt control.<br>Sit on the ball with knees apart and feet flat on the floor. Both hips and knees should be flexed to about 90°.<br>Tilt pelvis alternately in both anterior and posterior directions, making sure the shoulders and thoracic spine remain inactive.<br>Start with small ranges of movement.<br>Gradually work up to larger ranges. <ref name="1" /><br>
 |-
 | Prone lying Multifidus contraction<br> [[Image:Phy10.jpg]]<ref name="1" />
 | Goal: Teach clients to learn to use the multifidus at will and seperately from other muscles.<br>The multifidus is the most important stabilizer of the spinal extensor group. People with low back pain often lose the ability to contract this muscle and do not regain the ability spontaneously. <br>Prone-lying position<br>Therapist palplates the multifidus.<br>Bulge the muscles beneath the fingers of the therapist and differentiate between erector spinae contraction(more lateral) and multifidus contraction(more central).<br>To differentiate between the multifidus muscle and the erector spinae muscle, it’s recommended to contract the erector spinae muslce by hyperextend the trunk. To contract only the multifidus muscle, the patient may not hyperextend the trunk.<ref name="1" /><br>A movie of this exercise is shown in[http://www.physio-pedia.com/Spinal_Stabilization#Description spinal stabilization].<br>
 |-
 | Sitting Multifidus contraction<br> [[Image:Phy11.jpg]]<ref name="1" />
 | Goal: Encourage your client to contract the multifidus and lateral abdominals simultaneously.<br>Client sit on the edge of a bench with his feet on the floor.<br>Lumbar spine in neutral position.<br>Therapist palpates the multifidus.<br>Client performs abdominal hollowing<br>If the therapist feels the contraction, the client can self-palpate and continue the action for 10 repetitions, aiming to hold each for 10 s while breathing normally. <ref name="1" /><br>
 |-
 | Forward stride(walk) standing multifidus contraction<br> [[Image:Phy12.jpg]]<ref name="1" />
 | Goal: Encourage your client to contract the multifidus and lateral abdominals simultaneously.<br>Stand with one foot in front of the other<br>Self-palpate the L4-L5 level by placing the thumbs on the lower lumbal spinosus process and moving them outward slightly into the spinal tissue.<br>Place the weight onto the front leg and then onto the back leg alternately.<br>Feel the muscles beneath the thumbs switching on and off. <ref name="1" /><br>
 |}
@@ Line 95: / Line 95: @@
 {| border="1" cellpadding="1" cellspacing="1"
 |-
 | Heel Slide – Basic Movement<br> [[Image:Phy13.jpg]]<ref name="1" />
 | Goal: Place minimal but progressive limb loading on the trunk.<br>Slowly straighten one leg with the heel resting on the ground. The moment the pelvis anteriorly tilts and the lordosis increases, you must stop the movement and draw the leg back into flexion. <ref name="1" /><br>
 |-
 | Leg Lowering<br> [[Image:Phy14.jpg]]<ref name="1" />
 | This exercise is described in [http://www.physio-pedia.com/Core_stability#Physical_therapy_management core stability]. <br>‘Leg extensions’<br>
 |-
 | Prone-Lying Gluteal Brace<br> [[Image:Phy15.jpg]]<ref name="1" />
 | Goal: co-contract trunk stabilizers with gluteals.<br>Patient has to lie down and dorsiflex the toes. Flex than the knees ( 10°) and the hip (10°). After that contract the gluteal muscles. <ref name="1" /><br>
 |-
 | Bridge from Crook Lying (Shoulder Bridge)<br> [[Image:Phy16.jpg]]<ref name="1" />
 | This exercise is described in [http://www.physio-pedia.com/Core_stability#Physical_therapy_management core stability].<br>‘Dynamic leg and back’<br>
 |-
 | Bridge with leg lift<br> [[Image:Phy17.jpg]]<ref name="1" />
 | Goal: progress from bridge from crook lying. <br>The patient starts in crook lying ,then he lifts one leg. <br>Avoid&nbsp;: allow the pelvis to fall toward the unsupported side! <ref name="1" /><br>
 |-
 | Four-point Kneeling Leg movement<br> [[Image:Phy18.jpg]]<ref name="1" />
 | This exercise is described in [http://www.physio-pedia.com/Core_stability#Physical_therapy_management core stability]. <br>‘Hamstrings raising’.<br>
 |-
 | Four- point Kneeling arm and leg lift (full bridge)<br> [[Image:Phy19.jpg]]<ref name="1" />
 | A movie of this exercise is shown in [http://www.physio-pedia.com/Lumbar_Spine_Fracture#Physical_Therapy_Management_.28current_best_evidence.29 lumbar spine fracture].<br>‘Bird dog’<br>
 |-
 | Side-Lying spine lengthening<br> [[Image:Phy20.jpg]]<ref name="1" />
 | Goal: control the quadratus lumborum and lateral fibers of the oblique abdominals.<br>Start position: strong co-contraction of the abdominal muscles. Lie on one side, thighs in line with your body and flex the knees 90°. Upper body supported on the same side elbow. Straighten your spine against the force of gravity, leaving the body supported on the forearm of the underneath arm and hip. <ref name="1" /><br>
 |-
 | Side-lying hip lift<br> [[Image:Phy21.jpg]]<ref name="1" />
 | A movie of this exercise is shown in [http://www.physio-pedia.com/Low_Back_Pain_and_Pelvic_Floor_Disorders#Physical_Therapy_Management low back pain and pelvic floor disorders].<br>‘Oblique abdominals’<br>
 |-
 | Side-lying body lift(Side bridge)<br> [[Image:Phy22.jpg]]<ref name="1" />
 | Goal: progress from side-lying spine lengthening.<br>Start position: side-lying spine lengthening. Lift the hips, leaving the body supported on the forearm of the underneath arm and the knees only. <ref name="1" /><br>
 |-
 | Pelvic shift with leg lift<br> [[Image:Phy23.jpg]]<ref name="1" />
 | Goal: teach pelvic control and stability in single-leg standing.<br>Shift the pelvis to the left, lift slowly the right leg.<br>The supporting leg supports the pelvis and the pelvis supports the back. Raise the knee no more than 45°.<ref name="1" /><br>
 |-
 | Sitting knee raise<br> [[Image:Phy24.jpg]]<ref name="1" />
 | Goal: maintain pelvic positon against the pull of the hip flexors. <br>Raise one knee, about 8 cm. Unload the limb by lifting the heel. If he is able to maintain good alignment, have him lift the entire leg. <br>Avoid: posterior pelvic tilt! <ref name="1" /><br>
 |}
-<br><br>
+<br><u>C.Unstable base</u><br>
-== Exercises  ==
+{| border="1" cellpadding="1" cellspacing="1"
+|-
+| Rapid Displacement in sitting<br>[[Image:Phy25.jpg]]<ref name="1" />
+| Goal: Develop muscle reaction speed for back stability.<br>The patient sit on a chair with her spine optimally aligned. A partner stands behind the person and press on the shoulders in multiple directions; flex, extend and laterally flex the spine. The patient needs to be able to rapidly stabilize his spine. That patient needs to relax the trunck muscles between repetitions. <ref name="1" /><br>[http://www.physio-pedia.com/Low_Back_Pain_and_Pregnancy#Exercises: ]
+|-
+| Throwing and catching on a mobile surface<br>[[Image:Phy26.jpg]]<ref name="1" />
+| Goal: develop rapid-onset back stability.<br>Throwing and catching a bal on a mobil surface while you try to stabilize it.The aim is to align the lumbar spine optimally. <ref name="1" /><br><br>
+|-
+| Sitting pelvic tilt, progressing to balance board<br>[[Image:Phy27.jpg]]<ref name="1" />
+| Goal: advanced control of pelvic tilt. <br>The patient needs to sit down on a wooden bench with the feets on the floor. Than hold the pelvis alternately in the anterior and then posterior direction. The aim is to isolate the pelvis and lower lumbar spine from the thoracic spine and the shoulders from the upper lumbar spine.<br>Maintain the position of the shoulders and thoracic spine. <ref name="1" /><br><br>
+|-
+| Neutral position maintenance<br>[[Image:Phy28.jpg]]<ref name="1" />
+| Goal: build stability reaction speed in sitting.<br>The patient has to try to balance his body while a person knock the patient. The patient sits in a neutral position on a wobble board. Work gradually up the pressure. <ref name="1" /><br>
+|}
-Before we can start teaching the patient how to use the correct muscles needed for holding the lumbar spine in a neutral position, it is important that the patient has sufficient postural awareness of the neutral lumbar position. The patient needs to maintain this neutral lumbar position during all the following exercises. These exercises can prevent problems in the lumbar region like: [http://www.physio-pedia.com/index.php5?title=Lumbar_Instability Lumbar instability], spondylosis, spondylolisthesis, LBP. There are two main muscles, M. Transversus Abdominis and Mm. Multifidi, which control the shape of the spine and give lateral and sagital stabilization to the spine<ref>P. Vaes, Onderzoek en Behandeling Deel IIA p.103</ref> . These two muscles have connections through the thoracolumbar fascia an also have an attachment to the lumbar vertebrae. With the connection between the vertebrae, the TA and MF control the fine-tuning of the positions of adjacent vertebrae. This is also known as segmental stabilization<ref>Stevens VK et al, The influence of specific training on trunk muscle recruitment patterns in healthy subjects during stabilization exercises. 2007 A2</ref> .<br>
+<u><br></u>
-''<u>Contracting M. Transversus Abdominis</u>''
+<u></u><u>D.Gym ball</u>
-The first step is teaching the patient how to contract the transversus abdominis muscle by performing abdominal hollowing. In abdominal hollowing the patient pulls his belly in at the umbilicus without any movement of the rib cage, the pelvis or the spine. When you palpate closely medial of both the anterior superior iliac spines you should feel the transversus abdominis muscle contract under your fingers. When the patient has trouble contracting the correct muscle, ask him to contract his pelvic floor. This can be instructed to the patient by asking to hold his pee. Many patients will automatically contract their transversus abdominis muscle when contracting their pelvic floor. It is important that the patient does not hold his breath, but just keeps breathing in a normal way when contracting the transversus abdominis muscle <ref name="Richardson CA et al, 1995">Richardson CA, Jull GA. Muscle control-pain control. What exercises would you prescribe? Manual Therapy 1995; 1,2-10</ref>. Ask the patient to count out loud while doing the exercises.
+{| border="1" cellpadding="1" cellspacing="1"
+|-
+| Sitting knee raise on gym ball<br>[[Image:Phy29.jpg]]<ref name="1" />
+| This exercise is described in [http://www.physio-pedia.com/Low_Back_Pain_and_Pregnancy#Exercises: low back pain and pregancy].
+|-
+| Lying trunk curl with leg lift<br>[[Image:Phy30.jpg]]<ref name="1" />
+| Goal: strengthen upper and lower abdominals. <br>Start position: lying trunk curl over ball. The patient should lift one leg while maintaining the stable position. <br>! lying over the ball is a good way to stretch the whole spine! <ref name="1" /><br>
+|-
+| Bridge with therapist pressure<br>[[Image:Phy31.jpg]]<ref name="1" />
+| Goal: Strengthen hip and trunk stability muscles by challenging stability with continuously variable overload from multiple directions.<br>Start position: the standard bridge, his feets on a ball. The therapist pushes the patient against his pelvis from above and below and side to side.<br>Rapid pushes will decrease muscle reaction time, training the muscles to contract more quickly without loss of intensity. <ref name="1" /><br>
+|-
+| Basic superman<br>[[Image:Phy32.jpg]]<ref name="1" />
+| Goal: strengthen the spinal and hip extensors. <br>The patient has to lie down with her abdomen on the ball and her feets astride and flat against a wall. Tight the abdominal muscles to form a firm surface pressing against the ball and retract the head. The patient retracts and depresses her shoulders to draw the arms downward and back and extend the thoracic spine to bring the chest off the bal. <ref name="1" /><br>
+|-
+| Reverse bridge<br>[[Image:Phy33.jpg]]<ref name="1" />
+| Goal: Strengthen back and hip muscles while increasing leg motion control. <br>Start position: high position of the reverse bridge movement. The patient has to roll the ball toward herself by flexing her knees and hips and roll it away by extending her legs again. <ref name="1" />
+|-
+| Wall sit<br>[[Image:Phy34.jpg]]<ref name="1" />
+| Goal: Prepare the body for lifting while strengthening the legs to provide power for the lift. <br>Start position: ball between back and wall.<br>1) Sitting position while rolling the ball down the wall. When he achieves 90° hip and knee flexion, the patient needs to hold the position. <br>2) Single-leg wall sit, straightening on leg at the knee. <ref name="1" /><br>
+|}
-When the patient is able to correctly activate his transversus abdominis muscle, he should build up muscle endurance. This can be achieved by contracting the TrA muscle at low intensity with many repetitions.
+<u></u>
-The subgoal is to:
+<u>E.Building back fitness and resistence training for Core Strength</u>
-• perform contractions with an intensity of 60% to 70% of the maximum voluntary contraction;
+{| border="1" cellpadding="1" cellspacing="1"
+|-
-• hold each contraction for 10 seconds;
+| Bent knee sit-up<br>[[Image:Phy35.jpg]]<ref name="1" />
+| This exercise is described in [http://www.physio-pedia.com/Core_stability#Physical_therapy_management core stability]. <br>‘Crunches’<br>
-• perform 10 repetitions
+|-
+| Gluteal Stretch<br>[[Image:Phy36.jpg]]<ref name="17">http://www.ibodz.com/exercise/gluteal-stretch. Consulted on 30-11-2013 (Level of evidence 5)</ref>
-The final goal is to:
+| The patient sits on the floor with his legs extended.<br>The patient then crosses one leg over the still extended other leg<br>The patient can push with his/her elbow against the lateral side of the knee twist his/her trunk away to get more stretch.<br>
+|-
-• reduce the intensity till 30% to 40% of the maximum voluntary contraction;
+|
+| Other possible exercises that we only mention<br>-wall bar hanging leg raise<br>Goal: strengthen the lower rectus and providing traction for the lumbar spine<br>-Basic crunch<br>Goal: Work the abdominal muscles in general, with increased emphasis on innerrange activity of the upper abdominals.<br>-Side crunch<br>Goal: Strengthen the oblique abdominals while also working the rectus abdominis<br>-Machine exercises (fitness) <ref name="1" /><br>
-• maintain the hollow abdomen position for 30 seconds.
+|}
-<br>
-Holding the contraction of the M. Transversus Abdominis is one of the best exercises to train the TA. To increase the effect of the exercise it is important that the TA will be trained isolated. This means that there can’t be compensatory movements of the chest or pelvic<ref>P. Vaes, Onderzoek en Behandeling Deel IIA p.109</ref>. <br>Abdominal hollowing can be performed in different starting positions depending on flexibility, weight, injury, .. of the patient. It appears that performing Abdominal hollowing maneuver in standing position and supine position can be effective on TA training<ref>Farideh Dehghan Manshadi et al. Abdominal hollowing and lateral abdominal wall muscles’ activity in both healthy men &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; women: An ultrasonic assessment in supine and standing positions. Journal of Bodywork &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Movement Therapies 2011. B</ref>:
-• Four-point kneeling position: Holding the contraction is easiest in this position due to the facilitory stretch of the deep abdominal muscles resulting from the forward drift of the abdominal contents.<ref name="Richardson CA et al, 1995" /> The patient is placed on hands and knees, with the hip directly above the [http://www.physio-pedia.com/index.php5?title=Knee knee] and the [http://www.physio-pedia.com/index.php5?title=Shoulder shoulder] directly above the hand. Both hands and knees are shoulder-width apart. The lumbar spine is in a neutral position. The patient’s head is looking towards the floor, with the ears horizontally aligned with the glenohumeral joint. This position is comfortable for patients with low back pain or for pregnant women.
-• Standing position: patient stands with his back against a wall and his feet 15 centimeters from the wall. By using a wall spinal movement can be reduced. This position is suitable for obese patients, but is not for patients with discal pathology due to the higher compression forces acting on the intervertebral discs.
+<u></u>
-• Sitting position: patient sits on a chair with a correct alignment by sitting tall. This is a useful exercise because patients can practice throughout the day. But this exercise can exacerbate low back pain in some patients. These patients will have more benefit with the four-point kneeling position.
+<u>Lower extremity muscle exercises</u><br>It is possible that lumbar instability is not only limited to the lumbar spine and the anatomical structures complementing it. Sacro-iliac joint instability for instance plays also a part and can be the cause of low back pain. Studies have found that a big contributor to this sacro-iliac joint instability and low back pain is the malrecruitment of the m. gluteus maximus and m. biceps femoris.<ref name="7">Hossain M, Nokes LDM. A model of dynamic sacro-iliac joint instability from malrecruitment of gluteus maximus and biceps femoris resulting in low back pain. Medical Hypotheses.2005; 65: 278-281. (level of evidence 3A )</ref>,<ref name="8" /><br>
-• Prone-lying position: in prone-lying the patient pulls the abdominal wall away from the floor against the force of gravity. This is thus an exercise for those who are already able to perform abdominal hollowing. This position is not suitable for obese patients or pregnant women.
+[[Image:Phy37.png]]
-• Supine-lying position: in this position the patient is able to perceive his abdominal contraction. This exercise is also a good start for the heel slide exercise which is a more advanced exercise.
-<br><u>''Contracting Mm Multifidi''</u>
-The second step is teaching the patient how to contract the multifidus muscles in the back. This can be done with the patient in prone-lying position. While palpating paravertebral of the L4 and L5 vertebrae, ask the patient to lift up his leg or anterior tilt his pelvis. This will activate the multifidus muscles, which can be felt as a bulging underneath your fingers. Instruct the patient to focus on this contraction and memorise it. After this step, the patient should try to activate the multifidus muscles with an isometric contraction (without any movement). To achieve this, the patient needs to imagine himself performing the movement and contracting the multifidus muscles without doing the actual movement. When the patient has succeeded this exercise, he is able to tense and relax solely the multifidus muscles. The multifidus muscles should then be trained in the same way as the transversus abdominis muscle with a final goal to maintain the contraction with an intensity of 30% to 40% of the maximum voluntary contraction.
+The patient has to perform a few slow hip extensions. The physiotherapist places one hand on the M. gluteus maximus of the patient and one on the hamstring muscles. The therapist gives feedback with his hand. The patient has to activate his gluteus maximus first and if he does this correctly he pushes the hand on his gluteus maximus muscles away first, before he does the same with his hamstring muscles.
-<br>The next step is co-contraction where the local stabilizers contract at the same time to form a tight trunk. This co-contraction will then be implemented in more complex exercises with movement of the limbs. It is important that the patient learns to contract these muscles before the initial start of a movement (feedforward control).
+<br>It has been showed that there is a relationship, especially in muscle coordination, between the muscles that stabilize the lumbar spine and the muscles in the lower extremity, so these muscles has to be trained too, to further achieve coordinated activity between all muscles within a balanced muscular system.<ref name="8" />The quadriceps muscles play a part in this relationship also. A study has found that patients with low back pain have deteriorating function of the quadriceps muscles. Endurance and feedforward in the patients quadriceps muscles tend to be weak. The study found that this is due to reduced quadriceps activation after localized lumbar paraspinal fatiguing isometric exercise . Exercises aimed at localized fatigue of the lumbar spine extensors have shown an immediate response in the lower extremity including reduced quadriceps central activation ratio deteriorated balance and response to a balance perturbation. Furthermore they describe a quadriceps fatigability during maximal effort isokinetic knee extension contractions.<ref name="10">Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil. 2005;86:1745–1752 (level of evidence 2C)</ref> The two main functions of the quadriceps are extension of the knee and flexion of the hip.<br>
-The lumbar multifidus muscles&nbsp;are&nbsp;most active during prone lumbar extention with a full ROM and with resistance applied,&nbsp;<br>prone lumbar extension to neutral, resisted lumbar extension while sitting and prone extension with the upper and lower<br>extremities lifted (Superman exercise).&nbsp;The M. Multifidus is less active&nbsp;in bridging exercises<ref>RICHARD A. EKSTROM et al. Surface Electromyographic Analysis of the Low Back Muscles During Rehabilitation Exercises. journal of orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp;amp; sports physical therapy. December 2008. (Level 1b)</ref>.&nbsp;&nbsp;
+[[Image:Phy38.jpg]]<ref name="18">http://physiotherapy-sumedha.blogspot.be/2011/01/exercises-for-knee-strength.html. Consulted on 26-11-2013 (Level of evidence 5)</ref>
-The exercises for the&nbsp;M. Multifidus&nbsp;are trained at an intensity of 30% to 40% of the maximum voluntary contraction, so the bridging exercises are good exercises for the therapy for lumbar instability. When the exercises are done with an extra resistance.<br>
-• Bridging: in bridging the patient lies on the floor with the hands by their sides and the knees bend for 90°. First the patient needs to contract the TA, then tilt the pelvis into a "neutral" position and raise the pelvis off the floor. There must be a straight line through the knees - hips – shoulder.<br>• Bridge leg-lift: return to the bridge position and raise one leg bridging the foot off the floor.<br>• Bridge leg-extension: return to the bridge position and extend one leg outwards until the knee is fully extended.
-<br>All back muscles contribute in a similar way to control spine positions and movements<ref>Veerle K Stevens et al, Trunk muscle activity in healthy subjects during bridging stabilization exercises. BMC Musculoskeletal Disorders 2006. B</ref><ref>Cholewicki J, Van Vliet JJ 4th. Relative contribution of trunk muscles to the stability of the lumbar spine during isometric exertions. Clin Biomech (Bristol, Avon) 2002. B</ref>. It is important that the patient continue breathing during the exercise, maintains slow and controlled movements of the limbs, avoids excessive low back extension during exercises and avoids pelvic twisting during the exercises.<br><br>
+The patient starts with both his feet on the ground. The patient then straightens one leg and holds this position for about 10 seconds. Then the patient switches legs. To make this exercise a loaded exercise, the patient can do this exercise with weights( for instance on a leg extension machine). Ask the patient to hold for 1-3 seconds.
-These stability exercises seem to have promising results. In patients radiologic diagnosed with [http://www.physio-pedia.com/index.php5?title=Lumbar_Spondylosis spondylosis] or [http://www.physio-pedia.com/index.php5?title=Spondylolisthesis spondylolisthesis] stability exercises seem to have statistically significant reductions in pain and disability at a 30-month follow-up in comparison to a control group receiving usual care.<ref>O’ Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercises in the treatment of chronic low back pain with radiologic diagnosis of spondylosis or spondylolisthesis. Spine 1997; 22:2959-67 (Level: A2; Pedro score: 7/10)</ref>
+<br><u>Exercises for patients who are braced</u>
-Controlling the lumbar neutral position is a specific form of exercise with potential for prevention of recurrent nonspecific low back pain an disability among middle aged working men.<ref>Suni J, Rinne M, Natri A, Pasanen Statistisian M, Parkkari J, Alaranta H. Control of the lumbar neutral zone decreases low back pain and improves self-evaluated work ability. Spine 2006 Volume 31, Number 18, pp E611-E620 (Level: A2; Pedro score: 7/10)</ref>
+<u></u><br>It has been showed that patients who are braced for lumbar instability benefit from some of the exercises, that are described above. Braced, in this case, means that the patients who were braced were wearing orthesis A study found that patients who are braced and did the following exercises had a decreased level of pain.<br>- Gluteal and ischiocrural stretching exercises performed in an unloaded way.<br>- Contraction exercises of the lumbar stabilizing muscles, in particular the m. transverse abdominus.<br>- Exercises for trunk stabilization on ever more reduced supporting surfaces and finally on unstable surfaces.<ref name="2" /><br>
-Pilates-Based Therapeutic Exercises seem to have good results in individuals with low back pain. There is a significantly lower level of functional disability (P = .023) and average pain intensity in individuals who practice these exercises.<ref>Rochenda Rydeard et al. Pilates-Based Therapeutic Exercise: Effect on Subjects With Nonspecific Chronic Low Back Pain and Functional Disability: A Randomized Controlled Trial. Journal of Orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy. July 2006. (Level B1)</ref>
+== Key Research ==
-In the&nbsp;research article of Roberto Gatti are some pictures of exercises used for Individuals With Chronic Low Back Pain.
+Fritz et al. examined the predictive validity of lumbar segmental mobility in patients with LBP. It is possible that patients with segmental hypermobility were more likely to achieve clinical success with stabilization exercises compared with patients without hypermobility.<ref name="10" />
-&nbsp;
+It has been showed in the research of Hides et al. that the Lumbar Multifidus muscle remained atrophied after a 10-week period when patients with acute LBP did not exercise. But this muscle was recovered to normal size in patients who received a stabilization exercise program that stressed deep abdominal and isolated the Lumbar Multifidus muscle contractions.<ref name="11">Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996;21:2763–2769 (level of evidence 1B)</ref>
-== Key Research&nbsp; / Evidence  ==
+In the study of Richard A et al. some patient groups demonstrated hypertrophy of the Lumbar Multifidus muscles with low-load stabilization exercises. There are indications that the Lumbar Multifidus muscle is inhibited in patients with LBP and the retraining of the muscle to contract may be the major importance during stabilization training. <ref name="12">Richard A et al.; Surface Electromyographic Analysis of the Low Back Muscles During Rehabilitation Exercises; Journal of Orthopedic &amp; sports physical therapy; 2008 (Level of evidence 3B)</ref>
-'''''Hayden JA, Van Tulder MW, Malmivaara AV, Koes BW. Meta-Analysis: Exercise Therapy for Nonspecific Low Back Pain. Ann Intern Med. 2005;142:765-775.'''''<br>
+There are also indications that many exercises commonly used by physical therapists in LBP rehabilitation require low to moderate muscle activity of the Lumbar Multifidus and Longissimus thoracicus muscles. To increase the activity of these muscles during exercise, active or resisted lumbar extension is required. Resisted lumbar extension at the end range tends to maximum activity of these muscles.<ref name="12" />
-This review ment to evaluate the effectiveness of exercise therapy in adult nonspecific acute, subacute, and chronic low back pain versus no treatment and other conservative treatments.
+It has been showed that segmental stabilization exercise was more effective than placebo intervention in symptomatic lumbar segmental instability.<ref name="13">Senthil P Kumar et al.; Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain: A randomized placebo controlled crossover study.; N Am J Med Sci.; October 2011 (Level of evidence 1B)</ref>
-In total 61 randomized, controlled trials were evaluated in this review. (11 acute, 6 subacute and 43 chronic low back pain).
+It also has been showed that specific muscle stabilization retraining is more relevant for patients with either gross spinal symptoms or pronounced side to side differences in the size of the multifidus muscle than for patients that have no signals of instability. <ref name="14">George A. Koumantakes; Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain; physical therapy; March 2005 (Level of evidence 1B)</ref>
-The evidence suggests that exercise therapy is effective in chronic back pain relative to comparisons at all follow-up periods.
+The mode of action of stabilization retraining still remains unclear. It has not been shown to be capable of mechanically containing an unstable segment, even upon improvement of muscle activation. No direct long-term effect of stabilization exercises on the status of the local stabilizing muscles has been demonstrated. <ref name="14" />
-Some evidence suggests effectiveness of a graded-activity exercise program in subacute low back pain in occupational settings, although the evidence for other types of exercise therapy in other populations is inconsistent.
+The commission advises of a study that evaluated the effect of unstable and unilateral resistance exercises on trunk muscle activation revealed that, regardless of stability, the superman exercise was the most effective trunk-stabilizer exercise for back-stabilizer activation. The side bridge was the optimal exercise for lower-abdominal muscle activation. Thus, the most effective means for trunk strengthening should involve back or abdominal exercises with unstable bases. Furthermore, trunk strengthening can also occur when performing resistance exercises for the limbs, if the exercises are performed unilaterally.<ref name="15">Behm DG et al.; Trunk muscle electromyographic activity with unstable and unilateral exercises; J Strength Cond Res.; February 2005 (Level  of evidence 4)</ref>
-In acute low back pain, exercise therapy and other programs were equally effective.
+== Resourses ==
-<br>
+There’ re some video’s on physiopedia which show how to perform the exercises described on this page. It’s interesting seeing video’s because it’s easier to understand what you have to do. They are a capital gain to this page.
-Roberto Gatti et al<ref>ROBERTO GATTI et al. Efficacy of Trunk Balance Exercises for Individuals With Chronic Low Back Pain: A Randomized Clinical Trial. journal of orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; sports physical therapy. august 2011. (level 1b)</ref>. showed that trunk balance exercises combined with flexibility exercises are more effective than a combination of strength and flexibility exercises in reducing disability and improving the physical component of quality of life in patients with chronic low back pain. There was&nbsp;a significant difference in scores on the Roland-Morris Questionnaire (P = .011) and the physical component of the 12-Item Short-Form Health Survey (P = .048) were found in favor of the experimental treatment. The experimental treatment group performed trunk balance exercises in addition to standard trunk flexibility exercises. The control group performed strengthening exercises in addition to the same standard trunk flexibility exercises.
+== Clinical Bottom Line ==
-<br>
+On this page there are a lot of exercises. To be sure the patients stays motivated it’s important to take care of variation in the exercises you give. It’s possible using this page to variate your therapy for patients with low back pain.
-== Resources <br>  ==
+== Recent Related Research (from Pubmet) ==
-Christopher M. Norris. Back Stability: Integrating Science and Therapy.
+Prospective study of a new dynamic stabilization system in the treatment of degenerative discopathy and instability of the lumbar spine.<span style="line-height: 1.5em;" /><ref name="16">Zagra A, et al., Prospective study of a new dynamic stabilisation system in the treatment of degenerative discopathy and instability of the lumbar spine. Eur Spin J. 2005;21:83-89. (level of evidence 2B)</ref><span style="line-height: 1.5em;" />
-== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
-<div class="researchbox">
-<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1tyP_Q3NRDkxDTz2n9CqJoy-eTRq__mqeGx6jtgZGegHmONQ8n|charset=UTF-8|short|max=10</rss>
-</div>
 == References  ==

Exercises for Lumbar Instability: Difference between revisions

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