Nonsurgical Management of LBP: Static Stabilization or Dynamic Exercise for the Back: Which One Do I Choose?

1
Nonsurgical Management of
LBPStatic 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 1Stability 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

• 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

• 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

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 al20when 3 following are found efficacy
  improves
• lt 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.
• OSullivan 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 al 50 154 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 multifidus vs 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 cant effectively train or
  target the correct muscles
• Principles of stabilization
• Isometric contraction segmentally they stabilize
  and dont 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 gt24 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 gt6 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 lt 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 /- 6 weeks, 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 errector spinae
  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 gt 100 sec)
• Train endurance gt 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_at_xceltherapy.com

50
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