Benjamin L. Kolly DPT, OMPT, ATC Xcel Physical Therapy, PLC

1. Nonsurgical Management of LBP:Static Stabilization or Dynamic Exercise for the Back: Which One Do I Choose? Benjamin L. Kolly DPT, OMPT, ATC Xcel Physical Therapy, PLC

2. Clinical Relevance • Different approaches between clinicians? • Competence, Clinic Preference, Results • Is one option better than the other, what does the evidence suggest? • Should we use one or multiple stabilization models? • May depend on outcomes, patient experience, exposure, severity

3. Outline • What is Stabilization • Continuum of Dynamic vs. Static • What is dynamic • What is static • Review of Literature • Key concepts • Suggested Implementation

4. Spinal Stabilization • Definition: • Kinesthetic awareness of posture and the ability to modulate spinal stiffness during functional activities • To transfer loads, disassociate limb movements from the spine, and make movements effortless. • Barr et al 1:“Stability is a dynamic process that includes both static positions and controlled movement”

5. Stabilization Mechanisms • Panjabi described spinal stability as 3 interdepedent parts2 • Bone and ligaments- most stability to passive restraint at end ROM • Muscles- support forces encountered daily • Negatively affected by disuse 3 • Pain and injury can negatively affect these muscles through pain and reflex inhibition 4 • Neural control- coordinates mm activity to imposed demands (anticipatory and non-anticipatory)

6. Stabilization of other joints • Muscle system can minimize aberrant joint displacement and act as strain absorber 5 • Muscle spindles may regulate mm stiffness by contracting the slow twitch tonic muscles 6 • Low load contractions (25% MVC) can provide maximal joint stiffness 7 • CKC activity may increase antagonist co-contraction & reduce shear forces. 8,9

7. Muscles • Complex system responsible for 1) stability and 2) movement 10 • 1) Deeper muscles: thought to control stiffness and segmental stability • I.e.: TA, multifidus • 2) Superficial or global system: torque generators or movers of the spine and responsible for dissipating external loads to the spine. • Contribute to stability in direction specific movements and carrying weights11 • Comes at a price of increasing compressive load on the spine-possibly un-wanted in some conditions • Limited control of shear forces (too far from axis of mvmt)

8. Dynamic Stabilization • Dynamic: a continuum of movement that replicates functional activities; varies between authors and studies. • Dynamic Exercise: purposeful, more often closed kinetic chain, movement with the intent of replicating normal functional activities of daily living, recreation, and sporting. Activation of the Larger, more superficial muscles of the trunk.

9. Static Stabilization • Static: A theory of tightening the torso/trunk to minimize motions occurring through the trunk during physical activity or therapeutic training • Static Exercises: commonly thought of as isometric, table or mat exercises emphasizing the deeper muscles • Also known as motor control or specific stabilization exercises.

10. Stabilization Theories Static Dynamic • Required to restore atrophy of multifidus and TA • Prevents compensation or substitution patterns in painful-weak muscles problems 12 • Generates a trunk extensor moment and reduces tensile loading, compression, and shear loads of the spine .12-16 • Proper technique and repetition of mm activation will transition into functional use and thereby spinal stability.17 • Lumbar spine function can improve without isolation of TA and multifidus • To return to activity dynamic exercises need to be emphasized • Isometric static holds increase intra-abdominal pressures and not practical • Functional • Aids in restoring confidence

11. Efficacy • Philadelphia Panel Evidence Based Clinical Practice Guidelines for Nonspecific LBP18 • Clinical benefit on pain relief function and perception for sub acute and chronic LBP with Therapeutic Exercises • 2005 Cochrane review by Hayden et al examined 6 RCT : spinal exercise is particularly helpful in the healthcare settings.19 • Hicks et al20:when 3 following are found efficacy improves: • < 40 years old • SLR greater than 91 degrees • Positive prone instability test • Aberrant motion present during sagittal plane AROM • 67% chance they would have significant improv (success) with meeting ¾

12. Transverse Abdominus • Primarily slow twitch type I fibers (low load, endurance mm) • Theorized to act bilaterally as a corset or tensioning of thoracolumbar fascia sometimes referred to as increasing intra-abdominal pressure 21 • TA may be activated in a feed forward mechanism contributing to stability, stiffness. • Some authors have been unable to validate this concept22,23 • Found to contract before upper or lower extremity movements (anticipatory manner) preventing unwanted mvmt in subjects without LBP whereas in patients with LBP there was a delay in the contraction.24-29 • Teyhen et al found R to L side thickness of the TA was equivalent between those with and without LBP but there was a 21% greater change in girth within the asymptomatic group side to side from rest to contraction30

13. Training of the TA • Patients can retain TA contractions up to 1 week b/w sessions31 • 5 min instruction effectively maintain neutral spine and minimize segmental spinal motion during biceps curl, hip flexion, and hip extension.32 • Some subjects with chronic LBP took 4-5 weeks of training to develop this co-contraction effectively33 • Subjects with LBP less effective at performing TA contraction than asymptomatic individuals 34

14. Allison, Morris, Lay in examination of the TA (2008)35 TA was not found to stabilize the spine during bilateral extremity movement TA does not act as a corset nor does it reflect normal motor patterns seen in ballistic movement

15. Multifidus • Primarily slow twitch type I fibers (low load, endurance mm) • Likely more responsible for resisting or monitoring segmental rotation • Largest contributors to intersegmental stability; found to contribute more than 2/3 of the stiffness at L4-5 segment 36 • Evidence of atrophy in chronic LBP 37 • Rich in mm spindles, attaches to facet joints, functions as proprioceptors or kinesthetic sensors 38,39 • Repositioning accuracy reduced in subjects with LBP

16. Evidence of Multifidus Atrophy • Paraspinal mm 10-30% smaller on affected side of unilateral post-operative LBP patients 42 • Chronic LBP patients have weak spinal extensors and/or multifidus 40-42 • Asymptomatic patients had a 3% +/- 4% side to side difference whereas unilateral pain patients demonstrated 31% +/- 8% difference. 43

17. Multifidi training44,45 • RCT 39 subjects 1st occurrence of unilateral LBP • Both groups near full resolution of symptoms at 4 wks • Standard care Group multifidus size unchanged at 4 and 10 wk • Treatment Group multifidus CSA restored 4 weeks • 3yrs post study Standard Care Group had 9X greater likeliness of pain

18. Multifidus Training in Elite Cricket Athletes46 • 13 week training camp, 26 young males (10 with hx of debilitating LBP) • 6 wk stabilization lieu of lifting weights in gym • Results • CSA increased and asymmetry reduced in subjects with Hx LBP • 50% decrease in pain scores

19. RCT of Static Stabilization • Hides et al 45 : 45 subjects 1st occurrence of LBP received standard medical care vs. multifidus/TA stabilization • Short term (4 wks) no sig difference in rate of recovery from acute pain • Long term (2 and 3 year f/u) showed reduced reoccurrence rates • Standard Care 12 x more likely experience recurrent LBP in the first year and 9x more likely in years 2-3. • O’Sullivan et al 33 : compared TA stabilization and general management who underwent 1x/week x 10 weeks • Post treatment and 2.5 year f/u showed greater reductions in pain and disability in the stabilization approach.

20. RCT (Cont) • Goldby et al 47: 213 subjects over 10 weekly sessions received spinal stabilization, minimal care, or manual therapy. All 3 groups 3hr back school which included advise on back exercise. • No significant differences in pain, disability, QOL, and medication between groups at 3,6,12,24 months although there was within group changes from baseline. • Ferreira et al 48 : 223 subjects, 12 treatments in 8 weeks received general exercise, stabilization, or manual therapy. Both exer groups received cognitive behavioral therapy and encouraged to do HEP. • Stabilization and manual therapy had SLIGHTLY better short term pain and perceived functional outcomes but all groups had similar outcomes at 6 and 12 months and there was no statistical difference b/w groups. • Cairns et al 49 : 97 patients with hx LBP received max 12 sessions in 12 weeks; randomized into conventional tailored PT or stabilization of multifidus and TA • No significant differences in outcomes (pain, perceived disability, QOL, and psychological distress) were detected after 12 weeks, 6 mo and 1 year follow up

21. RCT (cont) • Costa et al50 : 154 patients with chronic LBP divided into stabilization or placebo underwent 12 sessions in 8 weeks. • Small clinical improvements in stabilization group seen at 2 months and generally maintained at 6 and 12 months • 12 months significant pain reduction in stabilization • Stuge et al (2004) 51 : TA stabilization demonstrated long term (2 years) positive outcomes in decreasing pain and disability

22. Systematic Review of Motor Control (Static Stabilization)52 • Better than minimal intervention (short term, intermediate, long term) and disability (long term) • Better than manual therapy for pain, disability, QOL (intermediate) • Better than other forms of exercise (5 RCT) in reducing disability short term • Overall Motor Control may be effective in reducing pain and disability in nonspecific LBP but not superior to other forms of exercise

23. General vs. Specific Trunk Stabilization53 • Koumantakis et al: 67 subjects grouped into Stabilization of TA and multifidusvs general stabilization approach focusing on large mm groups (obliques and paraspinals) • General group examples: crunches, prone trunk extension, pelvic tilting sitting/lying/standing positions, bridges, tilt with heel slides, lower abdominal crunches, 4-point kneeling, lateral planks, alt arm-leg movements, swiss ball exercises • Specific trunk stabilization exercises: quadruped TA, multifidus manual palpation, co-contraction sit to stand, isolated movements of hip and thoracic spine, sitting on unstable base, aggravating postures, bridges with co-contraction, unstable base (swiss ball), functional co-contractions • Results: no significant difference between the groups at 8 and 20 week examination

24. Examples of Static • Richardson & Hull • Sahrmann • Hodges

25. Richardson & Hull Exercise Theory55 • Extremely difficult to determine if TA/Multifidus mm working when larger more active global mm are firing and as such you can’t effectively train or target the correct muscles • Principles of stabilization: • Isometric contraction segmentally they stabilize and don’t move • Prolonged low level contractions slow twitch endurance mm and relatively low load required for stabilizing • Begin 4 pt kneeling or prone where body weight supported • Progressing holding time and reps before body weight loads • Co contraction train in neutral with both TA and multifidus co contraction

26. Sahrmann56 • Training of the deep lumbar muscles with concurrent extremity movements (beginning with mat exercises) critical to establish safe functional movements of the legs. • Lumbar extension during active hip extension occurs as a result of decreased abdominal control to counteract anterior pelvic tilt during manuever.

27. Paul Hodges • Palpate isometric contraction of multifidus by having patient swell multifidus into hand • Essentually have to make a conscious contraction out of a subconscious muscle

28. Examples of More Dynamic • PNF • Pilates • Gary Gray • Gambetta • McKenzie • BET

29. PNF 57 • RCT 108 subjects with LBP >24 weeks underwent 4 weeks of intervention 5d/wk divided into 3 groups: alt trunk flexion-extension isometric contractions; alt concentric and eccentric contractions; C group normal daily living /avoid structured exercise. • PNF exercises significantly increased spinal ROM and endurance but no significant difference between groups for disability ratings

30. Pilates Based58 • RCT 55 subjects with LBP >6 weeks or reoccurrence at least twice/year grouped into Pilates based or control for 12 sessions in 4 weeks • Statistically lower level of self reported disability and pain intensity over control • Maintained for up to 12 months post intervention

31. Gary Gray Functional Exercise • Early pioneer in closed chain-functional exercise • Little documentation and no RCT • Key Concepts: a) we never use our muscles in isolation during real world movements so we should not create exercises that tease out functional movements; b) rehabilitate the body the way it functions in the real world; c) begin with isolated integration and move towards integrated isolation

32. Vern Gambetta • Rehabilitation and strengthening of athletes and individuals involves training: • Movements not muscles • Fundamental skills before whole specific task • Use body weight before external loads • Joint integrity before mobility • Incorporate functional movements 

33. McKenzie method • Petersen et al compared McKenzie to strengthening exercises in subacute –chronic LBP. McKenzie favored over strengthening but little statistical difference 59 • Miller et al compared McKenzie to stabilization exercises in chronic LBP. No significant differences were seen between the groups 60 • Long et al compared McKenzie to nonspecific or exercise groups in subacute – chronic LBP. McKenzie statistically better than both groups in the short term 61

34. RCT of Dynamic Stabilization 54 • Prospective study 42 patients post microdiscetomy; 3 groups (Williams – McKenzie exercises, dynamic stabilization, control group) • Stabilization group showed significant improv in all parameters (P < 0.0001-0.0004) • Williams – McKenzie moderate improvement in all parameters (P 0.0001 - .05) • Parameters (pain, perceived functional capacity, depression, spinal mobility, weight lifting capacity, body strength)

35. Dynamic Stabilization Effectiveness • Gambetta, Gray, Pilates, PNF outcomes not well studied or documented • Make sense functionally • Follows many motor control theories • Allows for dissipation of loads • Possibly allows for better co-contraction

36. Importance of Static & Dynamic • Panjabi: effective control of BOTH the deeper muscles responsible for intervertebral stability AND the larger muscles responsible for movement across multiple levels are responsible for efficient stabilization and alterations in these neuromuscular control or loss of normal spinal mobility will cause pain 62 • Dynamic important to effectively stabilize the spine during real life experiences • Static beneficial where hx of poor mvmt patterns or fxnal deactivation

37. Combined Static and Dynamic • BET • Paris

38. BET (Back Education and Training)63 • Utilizes principles of good BOS, efficient alignment for mm recruitment, sequencing of weight shifting • Progress volitional bracing (stable safe lumbar spine position) to automatic synergistic trunk activation. • Early Rehab: Therapists assisted, therapist resisted mat, or table exercises self bracing • Mid Rehab: dynamic stabilization and pertubation training, ball and rollers • Late Rehab: active standing from weight shifting to squats, to reaching and functional movements • Final phase of training is no longer active bracing but rather functional movements that involve kinesthetic awareness

39. Stanley Paris64 • Stabilization and integration an eclectic approach • Stabilization as 2 types: • Static stiffening spine, holding in neutral, minimize stress on sensitive tissues. Also referred to as muscular fusion • Bridges, bridges with leg raise, pelvic tilt with leg mvmts, TA seated, prone multifidus (opp SLR), quadruped UE /LE, Lunge with TA… • Dynamic spinal movement safely and under control, avoid outer limits of range and sustained postures or overloads. Also referred to as Neuromuscular control • Quadruped (with or without UE / LE) with examiner pertubation, resisted arm movements in standing, diagonal lifting

40. Motor Learning : Skill Acquisition • How individuals learn new tasks or exercises • Several Theories, Basic Principles65 • Feedback give early in learning, allow person to adjust self latter • Whole task training might be better unless break down into naturally occurring elements (weight shift in walking not prone hip extension) • Transfer (how training transfers to a new task or new environment): • Depends on similarity of task/environment (ie if doing table exercises likely will not transfer to work demands unless practice in those environments)

41. Who benefits from stabilization? • Sub-acute and chronic18,19 • Stabilization programs may be beneficial in reducing reoccurrence rates 44 • Candidates with hypermobility tend to respond more favorably than those with hypomobility68 • Patients with ¾ of the characteristics in the CPR 20

42. What does all of this mean? • Stabilization appears effective • Patients with LBP seem to have alterations in mm pattern, sequencing, activation, and tone 25,44,66,67 • No scientific evidence to support any 1 concept over another • Little if any evidence on dynamic stabilization (difficult to study) • Success is likely dependant on multiple variables

43. How do we then implement program • Phase 1 (1-2weeks , 2 session/week) • KISS Theory • Educate re injury and recovery, teach and practice techniques for accuracy, implement self mgmt strategies, introduce positive outlook, allow for some natural healing, avoidance of pain maneuvers • Progress from 10 sec to 3 minute intervals before phase 2 • Phase 2 (2 +/- 6weeks, 3 session/week) • Progress stabilization towards functional restoration • Incorporate larger movements • Phase 3 (6-12 months) • Continue exercises independently, f/u with clinician for goal setting, guidance, and exercise progression…

44. Phase I • Teach pain free movement patterns and exercises: low compressive loads • Reduce overload/over-activity of errectorspinae mm; Wake up the smaller mm • Emphasize conscious awareness of pelvic positioning / identify neutral position and movement with and without extremity movements • Abdominal drawing in maneuver (ADIM) quadruped to prone, biofeedback (start at 70mmHg and have them lower 6-10mmHg for 10 +sec) • May not be better than other forms of stabilization but may have role in motor control, safe exercise, reduced intradiscal pressures, allow patient to see changes and improvements • Initiate co-contraction of multifidus with TA using palpation • Devel core awareness: activating multifidus and TA during functional positions of sit, SDLY, prone, stand, supine • Teach concepts in isolation then utilize and practice movements in more functional positions • Chronic progress faster than acute • Goals: noticeable relief, activation of approp mm, hold ADIM 30 reps x 30+ sec, understanding of self mgmt, standing/sitting tolerances, walking tolerances, fxnal tasks

45. Phase II • Build on Phase I if very acute • Unloaded trunk ROM (quadruped), hip flexibility, aerobic exercise, ADIM supine with heel slides/leg lifts, bridging, 4 point, 4 point on roller/unstable surface, sitting/standing/walking, standing rows • Quadruped multifidus unilateral arm lifts, leg lifts, ADIM in horizontal side support • Progress stabilization to functional restoration • Break down fxnal tasks into components to increase accuracy and minimize fear avoidance • Ex: Bending over to p/u object first teach pain-free deep knee bends or lunges then incorporate rotation of the hips and ankles with the bend, and lastly add resistance • Challenge spine in daily activities and movements (squatting, bending, lifting); incorporate basic body-mechanic applications • Modify speed of movements, direction, and external loads in preparation for discharge • Diagonals / PNF • Goals: Restricted RTW or sport, increasing workloads, discharge to self

46. Phase III • Continue exercises independently, f/u with clinician for goal setting, guidance, and exercise progression • Prevention of future injuries • Sports enhancement through core strengthening • High level activities/recreation/sport while stabilizing the spine • Distraction exercises (ball tosses, extreme reaching) while keeping co-contraction, simulated work/recreational activities, lifting OH • Functional drills on unstable surfaces (rocker board/balls) • Goals: address functional limitations, fears, enhancement

47. Important Considerations • Aerobics / Cardiovascular Endurance • Cognitive Behavioral Strategies (Fear Avoidance) • Body Mechanics • Teach ADIM, Pelvic Tilt in isolation and with movement • Train extensors (Sorenson Test > 100 sec) • Train endurance: > 3 min per rep • Improv neural processing to fire in nml efficient manner • Consider activity and specificity of activity • Fear avoidance habits – Graded exposure • Train proprioception • Train pertubation / anticipatory /functional activities

48. Take Home • Combine treatment approaches • Movement may be just as important as stiffness to dissipate forces (reduce loads), reproduce practical movements, and minimize energy expenses • Choose approaches based on patient tolerances and fear • Modify treatment based on functional outcomes • What works for the Goose may not work for the Gander

49. Questions • Ben can be reached at bkolly@xceltherapy.com

50. References • 1. Barr KP, Griggs M, Cadby T: Lumbar stabilization: Core concepts and current literature, part 1. Am J Phys Med Rehabil. 2005;84:473-480. • 2. PanjabiMM: The stabilizing system of the spine: Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord 1992;5:383-89. • 3 Richardson CA, Jull GA. Concepts of rehabilitation for spinal stability. In: Boyling JD, Palastanga N (eds) Grieves modern manual therapy of the vertebral column 2nd ed. Churchhill Livingstone, Edinburgh. 1994: 705-720. • 4 Baugher WM, Warren RS, Marshall JL, Joseph A. Quadriceps atrophy in anterior cruciate deficient knee. The Amer J of Sports Med. 1984;12: 192-195 • 5. Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D’Ambrosia R. Muscular activation. The role of the antagonist musculature in maintaining knee stability. The Amer J of Sp Med. 1998; 16(2): 113-122. • 6. Johansson H, Sojka P. Pathophysiological mechanisms involved in genesis and spread of muscular tension in occupational muscle pain and in chronic musculoskeletal pain syndromes: a hypothesis. Med Hypotheses. 1991; 35: 196-203. • 7. Hoffer J, Andreassen S. Regulation of soleus muscle stiffness in premamillary cats. J of Neurophysiology. 1981; 45:267-285. • 8. Kvist, J., and J. Gillquist. Sagittal plane knee translation and electromyographic activity during closed and open kinetic exercises in anterior cruciate ligament- deficient patients and control subjects. Am. J. Sports Med. 2001; 29:72– 82. • 9. Fleming, B.C., P.A. Renstrom, G. Ohlen, R.J. Johnson, G.D. Peura, B.D. Beynnon, and G.J. Badger. The gastrocnemius muscle is an antagonist of the anterior cruciate ligament. J. Orthop. Res. 2001; 19:1178 –1184. • 10. Bergmark A. Stability of the lumbar spine: A study in mechanical engineering. ActaOrthop Scand Suppl 1989;230:1-54.