Core stability and low back rehabilitation

Supportive texts and readings Stuart McGill, PhD - Professor University of Waterloo Internationally recognized expert in spine function and injury prevention and rehabilitation
Low Back Disorders 2007 (Human Kinetics)

Outline Introduction Anatomy and Neutral Pelvis Assessment Conditioning Prescription guidelines
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Introduction
Low back and abdominal exercises are prescribed primarily for
rehabilitation of injured low back Prevention of injury As a component of fitness training programs

Goal is to stress both damaged and healthy supporting tissue to promote tissue repair
while avoiding further excessive loading that can exacerbate existing structural weakness ACSM chapter discusses the science of understanding loading forces and revisits some common practices in abdominal and low back training

Most effective
train motor control system to activate spine stabilizers Progress to endurance training Finally enhance strength and flexibility

 Stabilizing muscles - act to support muscle action by providing rigid base of support for movement Core stability provided by muscles in the torso connecting the spine, rib cage and pelvis When standing the pelvis and lumbar spine are oriented for maximal stability fig 1 Goal of training is to maintain this neutral spine orientation throughout dynamic movement
Lumbosacral angle ~ 41 degrees

Core Stability

Stabilizing exercise are ones that groove motor patterns and ensure a stable spine during activity
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Anatomy of the Core

No one muscle is the most important muscle for stability varies with movement pattern
For athletes a conflict of stability and rhythmic contraction/relaxation of forced breathing exists

Abdominal Group
In addition to stabilization each muscle group contributes to trunk movement

Transverse abdominus
Forced expulsion

Internal obliques
Lateral flexion, rotation to same side and flexion of trunk

External obliques
Lateral flexion of trunk to same side, rotation to opposite side and flexion of trunk

Rectus abdominus
Flexion of trunk

Anatomy of the core

Back Muscles Erector Spinae
Trunk extension

Multifidus
Lateral flexion, extension and hyperextension of the spine

Quadratus lumborum
Highly involved in lumbar spine stabilization - largely isometric

Latissimus dorsi
Role as spine stabilizer enhanced by pulling to chest in lat pull down exercise
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Assessment
Muscular endurance closely related to spinal stability and risk of low back pain
Balance of muscular endurance among torso flexors, extensors and lateral musculature is most important in reducing injury risk

All tests evaluated on time to failure and compared to normative data for overall time and ratios between test scores Lateral musculature test
Test performed on both sides of the body Lying in full side bridge, legs extended, top foot in front subject supported on one elbow and feet while lifting hips off the floor to create a straight line over their body length Uninvolved arm placed across the chest with hand on opposite shoulder Failure occurs when person loses the straight-back posture and hip returns to ground
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Assessment (cont)
Flexor endurance test
Begins with person in a sit-up posture with the back resting against a jig angled at 60 degrees Knees and hips flexed at 90 degrees Arms folded across chest Hands on opposite shoulders Toes are secured by examiner or toe straps Test begins by pulling support back ten centimeters Failure occurs when subject falls back and touches jig

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 Back extensors test

Assessment (cont)

Upper body cantilevered over the end of test bench - hands across chest Time to failure - drop from horizontal CPAFLA - similar test described in detail

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Interpreting scores
Tests just described have reliability coefficients of .98 or greater Normative data is presented in Table 12.1 of Mcgill - Low back disorders (2002)
Data gathered from healthy men (n=92) and women (n=137) with a mean age of 21

Interpreting absolute endurance is secondary to interpreting the relationship among the three muscle groups (flexors, lateral, and extensors.) The following discrepancies in ratios of time to failure suggest unbalanced endurance R / L side bridge > .05 away from unity Flexion / Extension > 1.0 Either Side bridge / extension > .75
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Training for core stability and low back health

Variable effectiveness has been found for training and rehabilitation programs for low back in different studies Variability may be due to prescription of inappropriate exercises caused by a lack of understanding of tissue loading
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Training for core stability and low back health

S McGill evaluated exercises with respect to tissue loading injury criteria, not solely for maximized muscle activity General Role for exercise in low back health
Stimulates hypertrophy Slows (reverses?) degenerative conditions Enhances nutritional benefits to spine More effective than surgery, bed rest or flexibility training

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Exercise Training
Focus on progressive exercise that emphasizes muscle contraction with the spine in neutral position
Spine posture determines interplay between ligament and muscle forces Extensor muscles activated in neutral position reducing load on spine Fully flexed spine fails at about 20-40% lower compressive load than with neutral position
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Relative loads on the third lumbar disk for living subjects

Upright standing depicted as 100%

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The line of gravity shifts further ventrally during relaxed unsupported sitting (B) as the pelvis is tilted backward and the lumbar lordosis flattens (this creates a longer lever arm). When sitting erect (C) the pelvic backward tilt is reduced and the lever arm shortens (still longer than when standing (A).
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Exercise Training
Several exercises are required to train all of the muscles of the lumbar torso
Individual fitness level, training goals, history of spinal injury should influence prescription

Exercises should avoid loading spine throughout ROM post injury Elite athletes may achieve higher performance levels by using full ROM in exercises

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 Teaching Abdominal bracing

Abdominal Bracing and Neutral Spine

co-contraction of abdominal wall muscles for spinal stability

1. Demonstrate joint stability in peripheral joint through flexor/extensor co-contraction

have subject palpate demonstrator then themselves

2. Identify core musculature - cough with hand above hips - palpate abdominal wall during contraction

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 Teaching Neutral spine 1. lying on back, knees bent - place fingers between lumbar spine and floor
hyper lordosis - increase gap from floor hypo lordosis - flatten back onto fingers Can utilize blood pressure cuff and observe rise and fall in pressure with same movements.

Abdominal Bracing and Neutral Spine

2. Put subject through lifting exercise or simulated work situations

Place long stick across lumbar, subject must maintain contact across lumbar, avoiding trunk flexion throughout motion.

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 All endurance exercises should last up to seven to eight seconds Progression in program should come from adding more repetitions rather than adding duration Utilize normative data from assessments to develop client goals Curl ups reduce spinal compression compared to sit ups and leg raises Press heel sit-ups - recent evidence advanced them as beneficial However, active hamstrings actually stimulate psoas activity and higher compressive penalty on spine
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Core Exercises

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 Partial Curl ups Focus on rectus abdominus

Abdominal Exercises

Distinct upper and lower rectus abdominus do not exist in most people training can be accomplished with a single exercise

Retain neutral spine, do not flatten back to floor Beginner

Supine with hands supporting lumbar spine One leg bent at 90 degrees Lift thoracic and cervical spine as one unit, no cervical motion should occur (chin poking or chin tucking) Leave elbows on floor, contract rectus and lift head and shoulders off the floor

Intermediate
lift elbows slightly off floor

Advanced
place fingers lightly on forehead 28 Head and neck must move as unit, maintaining rigid block position on thoracic spine

 Horizontal Side bridge

Abdominal Exercises

Challenge lateral obliques and quadratus lumborum Low lumbar compressive load Variable demand on rectus and others with progressive stages of exercise Remedial
Standing 45 degrees and leaning to wall Lying on floor and raising legs Utilize back extension bench at 45 degrees and support from side

Beginner
Lateral support on knees bent at 90 degrees and elbow, maintain torso straight Top arm across chest with hand on shoulder

Intermediate
Legs straight with top foot in front Variation - incorporate longitudinal rolling of the torso forward and backward

Advanced
Transfer from one elbow to the other while maintaining abdominal bracing
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 Traditional extensor exercises - high spinal loads due to ext applied loads from weights of resistance machines

Extensor exercises

Fig 13.9 bird dog

Remedial
Raise a hand or knee slightly off floor

Beginner
Single leg raise on hands and knees

Intermediate
Simultaneous contra-lateral arm raise with leg raise - increases extensor challenge Hold six to eight seconds when parallel

Advanced
Do not rest by placing the and and knee on the floor after each holding repetition Sweep the floor with hand and return out

Common errors include hiking hips and not achieving neutral spine exercise lying prone and lifting legs is contraindicated for anyone at risk for low back injury due to hyperextension
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 athletes can incorporate forced breathing cycles into all exercises Labile surfaces - exercise ball, wobble boards
Increase co-contraction, doubling spinal load in many exercises Fig 14.1 and 14.2 (Mcgill - 2002)

Advanced exercises

Not recommended until subject has achieved spinal stability and sufficiently restored load-bearing capacity
Can delay improvements by causing exacerbating spine loads if adopted early in rehabilitative program
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 Ball Exercises

Advanced exercises

Table top spine Forward ball roll Total body flexion Curl up Push up

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Advanced exercises
Squat and Power cleans
Great for developing power

Form is more important than weight being lifted as injury is likely

Europeans, practice technique for years before adding weight

Recommend beginning from elevated position if not a competitive weight lifter McGill recommends athletes use medicine ball in the same motion pattern to avoid high stress of lifting bar from ground
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Aerobic exercises
Evidence supporting positive role of aerobic exercise in reducing incidence of low back injury and in the treatment of low back patients Walking
Low levels of support tissue load Mild, prolonged activation of supporting musculature

Study comparing elderly engaged in a variety of lifelong activities

Runners - no detrimental changes in low back health Weightlifters and soccer players - more disc degeneration and bulges
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Flexibility
Flexibility of the spine has yet to be shown to improve outcomes of low back exercise programs or reduce risk of future injury in healthy populations Flexibility of hip has shown to be important Avoiding end of ROM during athletic and daily activities can reduce risk for several types of injuries Limit training to unloaded flexion/extension Fig 13.4 cat stretch - full ROM recommended only for athletes who have never had a back injury Hip and knee flexibility should be performed with neutral spine
Fig 13.5 and 13.6

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Exercise Prescription
Recommendations Low back exercise most beneficial if performed daily No pain, no gain does not apply Inclusion of general exercise (aerobic) is most effective Unwise to perform full ROM of spine early in the morning - Disc more hydrated in morning Emphasis should be endurance over strength, for low back health Training objectives must be identified individually in terms of
injury risk, optimizing health or maximizing athletic performance

May take 3 months to observe inc function and pain reduction

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