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Article: Miller ER, Schnek RJ, Karnes JL, Rousselle JG. A comparison of the. McKenzie approach to a specific spine stabilization program for chronic low back pain. Journal of Manual and Manipulative Therapy 2005; 12(2):103-12. Clinical Bottom Line: Based on the study performed by Miller et al., stabilization exercises that. May 7, 2013 - 15 min - Uploaded by RosePhysicalTherapySpinal Stabilization program from Dr. Stuart McGill.

Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. In physiopedia: lumbar instability anatomy back spinal stabilisation core stability exercises back therapy low back pain feedforward Definition/Description Low back pain can be defined as pain or discomfort in the lumbar region.

This can be unilateral of bilateral. In 85% of patients, low back pain is non-specific, meaning there is no specific medical diagnosis for the pain. People with weak muscle strength and endurance are at greater risk for low back pain. It has been shown that weak trunk extensors may lead to chronic low back pain. Being overweight is also a suggested risk factor but some studies do not support this. Low back pain is often due to lumbar (segmental) instability. Is one of the subgroups of non-specific low back pain.

Download Safari For Mac Os X Mountain Lion Iso. Implications of instability are pain, functional disability and reduced muscle endurance. Patients with lumbar instability also show loss of spinal motion segment stiffness in with normal external loads may cause pain, spinal deformity or damage to the neurological structures. Not all patients show a loss of the but in those where the mechanism is not working well, the patients will have more pain.

Therapy for lumbar instability must address not only the lumbar region but also the surrounding anatomical structures such as the muscles of the abdomen and lower extremities. The kind of exercises depends on the status of the patient. Clinically Relevant Anatomy of the low back.

Stabilizing and mobilizing muscles that affect the low back Indications for exercises There are different reasons why we might give stabilisation exercises to patients with lumbar instability. The most important considerations are our treatment goals and the likelihood of a positive response to treatment. An important study by shows that during the positive and negative determinants can be found indicating whether a subject will benefit from a low back stabilization program. 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. Stabilisation 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. It had been shown that stabilizing exercises along with routine exercises help with the reduction of pain intensity while increasing functional ability and muscle endurance. Stabilizing exercises are therefore recommended in the treatment of patients with lumbar segmental instability. The segmental stabilization model for the prevention and treatment of low back pain 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. Exercise techniques Optimal spinal stabilization can be achieved by strengthening the deep back and abdominal muscles.

These include the transversus abdominus (TrA), quadratus lumborum, oblique abdominals, multifidus and erector spinae. Exercises targeting these specific muscles should be done in a progression, usually beginning with TrA which provides the patient with initial stabilization that is helpful during subsequent exercises and daily activities.

Basic Activation Depending on treatment findings, a patient may need to start with some basic muscle activation. 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. 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. Foundation Movements 1) Contraction of TrA without contraction of the overlying abdominals Normally TrA should be in a state of continual contraction whether in standing and sitting, facilitating good posture.

In patients with low back pain, TrA can become deactivated, leading to an unstable core but additional global musculature may also be co-contracted in an effort to regain some control. The goal of this exercise is that patients with low back pain learn to contract TrA at all times (except when lying). After a time the muscle should return to its natural state of continuous contraction.

It is very important for patients with low back pain to have good posture which will be assisted by retraining TrA. Technique: The patient pulls his belly in and up at the navel without moving the rib cage, pelvis or spine.

Contraction intensity: 30 to 40% of the maximum voluntary contraction (MVC). Progression: Gradually build up the duration of the contraction. Only when the patient can activate TrA with minimal muscle intensity (10 repetitions each 30-40%) over a period of time, should more advanced exercises be added. 3) Control of the pelvic muscles This is important to move confidently into a neutral lumbar position.

People with low back pain do not have the ability to perform pelvic tilting. You can see excessive flexion laxity but limited or blocked extension. The ability to dissociate lumbar movement from pelvic movement is therefore important and correction of faulty lumbar-pelvic rhythm is vital. 4) Diaphragm The activity of the diaphragm is also reduced in association with rapid limb movement and support surface translation while global muscle activity is increased. People with respiratory disease are predicted to have increased incidence of low back pain. Prone kneeling Lumbar-Pelvic Rhythm.

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 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 blocked extension. The ability to dissociate lumbar movement from pelvic movement is therefore important and the correction of faulty lumbar-pelvic rhythm is vital. High(two-point) kneeling (assisted) hip hinge action 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!

Sitting pelvic tilt using gym ball 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.

Prone lying Multifidus contraction 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 palpates 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 muscle by hyperextend the trunk. To contract only the multifidus muscle, the patient may not hyperextend the trunk. A movie of this exercise is shown in. Sitting Multifidus contraction 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. Forward stride(walk) standing multifidus contraction 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 lumbar spinous 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.

B.Progressing Stability Training Heel Slide – Basic Movement 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. Leg Lowering This exercise is described in. ‘Leg extensions’ Prone-Lying Gluteal Brace 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. Bridge from Crook Lying (Shoulder Bridge) This exercise is described in.

‘Dynamic leg and back’ Bridge with leg lift 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! Four-point Kneeling Leg movement This exercise is described in.

‘Hamstrings raising’. Four- point Kneeling arm and leg lift (full bridge) A movie of this exercise is shown in. ‘Bird dog’ Side-Lying spine lengthening 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. Side-lying hip lift A movie of this exercise is shown in.

‘Oblique abdominals’ Side-lying body lift(Side bridge) 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.

Pelvic shift with leg lift 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°. Sitting knee raise 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!

The following videos are examples demonstrating progressions of spinal stabilization exercises that can be used for patients requiring this technique. They can and should be modified according to specific patient needs, preferences, or functional demands. The physical therapist should remember to consistently stress the importance of maintaining a neutral spine when performing these exercises. Unstable Base Rapid Displacement in sitting 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. Throwing and catching on a mobile surface 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.

Sitting pelvic tilt, progressing to balance board 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. Neutral position maintenance 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. Gym Ball Sitting knee raise on gym ball This exercise is described in. Lying trunk curl with leg lift 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! Bridge with therapist pressure 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. Basic superman 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. Reverse bridge 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.

Wall sit 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.

Building back fitness and resistance training for Core Strength Bent knee sit-up This exercise is described in. ‘Crunches’ Gluteal Stretch 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) Lower extremity muscle exercises It is possible that lumbar instability is not only limited to the lumbar spine and its associated anatomical structures.

For instancee, sacro-iliac joint instability also plays 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 gluteus maximus and biceps femoris. The patient has to perform a few slow hip extensions.

The physiotherapist places one hand on gluteus maximus of the patient and one on the hamstrings for feedback. If done correctly, the therapist will feel the hand on gluteus maximus being pushed away before the hamstrings are activated. It has been shown that there is a relationship, especially in muscle coordination, between the muscles that stabilize the lumbar spine and the muscles in the lower extremity.

These muscles therefore should be trained as well in order to further achieve a balanced and coordinated muscular system. The quadriceps also play a part in this relationship. A study has found that patients with low back pain have deteriorating function of the quadriceps, with reduced endurance and feedforward compared to normal. 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.

The two main functions of the quadriceps are extension of the knee and flexion of the hip. The patient starts with both his feet on the ground. The patient then straightens one leg and holds this position for about 10 seconds before switching 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 shown that patients who are braced with an orthosis for lumbar instability benefit from some of the exercises described above. A study found that patients who were 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 TrA. • Exercises for trunk stabilization on ever more reduced supporting surfaces and finally on unstable surfaces. Key Research 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. 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. 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. 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.

It has been showed that segmental stabilization exercise was more effective than placebo intervention in symptomatic lumbar segmental instability. 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. 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. 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. Resources Clinical Bottom Line 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 vary your therapy for patients with low back pain. Recent Related Research (from ). References • ↑ Davarian S. Et al.; Trunk muscles strength and endurance in chronic low back pain patients with and without clinical instability; Journal of Back and Musculoskeletal Rehabilitation; 2012 (Level of evidence 1B) • ↑ Javadian Y et al.; The effects of stabilizing exercises on pain and disability of patients with lumbar segmental instability; J Back Musculoskelet Rehabil.; 2012 (Level of evidence1B) • ↑ C. Norris; Back stability: integrating science and therapy; p.

63, 130, 131, 132, 133, 134,135, 140,146,149,158-161,168-171, 173,175,177,180, 181, 185, 190, 194, 196, 197, 200,205, 207, 210, 211, 215,236,242,243; 2008 (Level of evidence 5) • ↑ Celestini M, Marchese A, Serenelli A, Graziani G. A randomized controlled trial on the efficacy of physical exercise in patients braced for instability of the lumbar spine. Eura Medicophys.

2005;41: 223-231. (level of evidence 1B) • ↑ Hicks GE., Fritz JM., Delitto A., McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program, Arch Phys Med Rehabilitation 2005; 86; 1753-1762 (level of evidence 1B) • ↑ Rackwitz et al.; Practicability of segmental stabilizing exercises in the context of a group program for the secondary prevention of low back pain. An explorative pilot study; eura medicophys; 2007 (Level of evidence 3B) • ↑ C. Richardson et al.; Therapeutic exercise for lumbopelvic stabilization: A motor control approach for the treatment and prevention of low back pain; p. 177-178, 180-181, 186; Churchill Livingstone; 2004 (Level of evidence5) • ↑ (Level of evidence 5) • online video,, last accessed 6/2/09 • online video,, last accessed 6/2/09 • ↑ Lamounier Sakamoto AC, et al. Muscular activation patterns during active prone hip extension exercises.

Journal of Electromyography and Kinesiology. (level of evidence 2B) • online video,, last accessed 6/2/09 • online video,, last accessed 6/2/09 • ↑. Consulted on (Level of evidence 5).

The next few exercises are examples of some basic stabilization exercises that aid in low back pain relief. Having strong midline support is critical to decreasing the stresses placed upon the lumbar spine (lower back) and pelvis. It should be noted, however, that often muscles that appear to be weak may actually be inhibited by an antagonist muscle (muscle on the opposite side of the joint) or by faulty lumbar facet joint mechanics. • See Generally, an inhibited muscle will not respond to resistance training.

Therefore, if low back pain or hip pain is being experienced, it is important to first see a spine therapist in order to screen for muscle inhibition. Attempting to strengthen an inhibited muscle may cause a substitution pattern that only reinforces a painful movement pattern.

In general, it is advisable to see a spine specialist who specializes in back pain prior to beginning any exercise program. In addition, unlike, it is important to take a few days off per week from strengthening exercises to allow the body to rest and build strong muscles. Windows Server 2008 Iis Configuration Pdf File on this page.

A licensed physical therapist can help design a strengthening exercise program to fit an individual's specific needs and help with pain relief. In general, a usually includes strengthening the abdominal muscles in the front and the gluteal muscles in the back. Many people think of performing abdominal crunches or situps to. While 'six pack abs' look nice to some, it is more important to work the Transversus Abdominis (TVA) through abdominal exercise to achieve spinal stability.

When retraining the TVA, it is important to maintain a neutral lumbar spine (don't try pushing the back all the way into the floor). The back is most often in a neutral spine position, so it makes less sense to strengthen the back in a flexed or extended position. Lie on one's back with the knees bent.

Knees and feet should be shoulder width apart. Draw the belly button toward the spine while maintaining a neutral spine. Upon exhalation, reach toward the ceiling as if trying to grab a trapeze overhead.

Then raise the head and shoulders off the floor, just to the point where the shoulder blades are barely touching the floor, and hold 1-2 seconds. Inhale upon return and repeat at the end of the next exhalation. Continue until it is not possible to maintain a neutral spine or when fatigued. (See ) • Hold 1-2 seconds • Repeat until fatigued • 1 time per day • 4-5 days per week. • • Strengthening Exercise Program for Low Back Pain Relief • Gluteus Maximus Muscle Strengthening (Buttock Exercise) To strengthen this muscle, lie on the stomach with the hips and legs off the end of a table or bench.

Tighten the buttock on one side and extend the leg up toward the ceiling while maintaining a neutral spine. Movements should be slow. Initially, it is common to only be able to perform a few repetitions at a time. • Hold 5 seconds • 4-10 repetitions per side • 1 time per day • 4-5 days per week. Gluteus Medius Muscle Strengthening (Hip Abductor Exercise) This muscle (the hip abductor) is used to raise the leg laterally at the hip and also supports the pelvis when standing on one leg (single leg stance). If this muscle is weak or inhibited, the opposite pelvis will drop when single leg stance is performed. Functionally, single leg stance is performed whenever someone walks.

A weak gluteus medius will result in the opposite hip dropping during the gait cycle and can cause an increase in low back pain and hip pain with walking. To strengthen the gluteus medius, lie on one's side with the back against the wall.

Draw the belly button in while maintaining a neutral spine. Raise the upper leg with the toes slightly pointed toward the ceiling and the heel maintaining contact with the wall.

Perform slowly with a 2 second hold at the top. (See ) • 10 repetitions per side • 1 time per day • 4-5 days per week Optimizing Exercise Programs for Pain Relief.