Core Exercises: Current Treatment of Low Back Pain November 13, 2014 Monica Rho, MD Assistant Professor Director of Women’s Sports Medicine Program Spine.

Core Exercises: Current Treatment of Low Back Pain

November 13, 2014

Monica Rho, MD

Assistant Professor

Director of Women’s Sports Medicine Program

Spine & Sports Rehabilitation

Rehabilitation Institute of Chicago

Northwestern University Feinberg School of Medicine

Overview

• Review the links of core strength to low back pain (LBP)

• Highlight the evidence on core strengthening treatment for LBP

Core Muscles in Low Back Pain

• Loss of anticipatory function– Transversus abdominus (TA)

(Hodges 1996, Hodges 1997)

• Weakness and decreased endurance– Multifidi and back extensor

muscles (Hides 1994, Hides 1996, Jorgenson 1987)

• Decreased spine proprioception

Transversus Abdominus

• TA is first muscle contracted during ventral trunk loading to prevent unwanted trunk movement with limb movement (Cresswell 1994)

• TA is not the first responder in upper limb movements of patients with LBP (Cresswell 1994)

• TA shows decreased ability to contract in patients with recurrent LBP during lower extremity tasks (Hodges 1997, Ferreira 2004)

Multifidi

• Multifidi atrophy in patients with chronic LBP– Post-op pt with unilateral LBP – 10-30% smaller paraspinals on

affected side compared to unaffected (Laasonen 1984)

– Unilateral acute/subacute LBP vs control : side to side difference was 3% in controls and 31% in LBP (Richardson 1999)

Back Extensors

• Decreased endurance of extensors compared with controls (Jorgensen 1987, Ebenbichler 2001)

• Abnormal flexor to extensor strength ratios (McGill 2002, Siolie 2001)

Jorgensen 1987

Spine Proprioception

• Postural control is altered in patients with chronic LBP (Ebenbichler 2001)

– Single leg stance balance– Postural stability tests (Mok 2004)

• Unexpected balance challenges– Trunk perturbation (Wilder 1996)

• Difficult repositioning back to neutral spine posture (O’Sullivan 2003)

• Proprioception comes from deep fibers of Z joint capsules and multifidi (Bogduk 1997, Hides 2004)

HOW DO WE TREAT LOW BACK PAIN WITH CORE

EXERCISES?

Abdominal Hollowing/Abdominal Draw-in

• Contemporary culprit of low back pain– Activity of TA contributes to spinal control

(Cresswell 1992, Hodges 1999)– Dysfunction of the muscle occurs in

people with LBP (Hodges 1996, 1998, 2001)

• Activated by abdominal draw-in maneuver (Richardson 1999, Jull 1995, Hodges 1996, Urquhart 2005)

• “Breath in and out. Gently and slowly draw in your lower abdomen below your navel without moving your upper stomach, back or pelvis” (Urquhart 2005)

Abdominal bracing

• Lateral flaring of abdominal wall (Kennedy 1980)

• Increase of intrabdominal pressure (Kennedy 1980)

• Greater external oblique activity than other abdominal muscles (Urquhart 2005)

• “Breath in and out. Gently and slowly swell out your waist without drawing your abdomen inwards or moving your back or pelvis” (Urquhart 2005)

Posterior pelvic tilting

• Reduction of lumbar lordosis (Vezina 2000)

• Muscle activation patterns are not clearly defined with or without LBP (Vezina 1998)– Great activity of internal oblique than rectus abdominus (RA) and external

oblique (EO) (Urquhart 2005)– Greater RA activity compared to lateral abdominals (Richardson 2005)– Greater EO than RA (Vezina 2000)– Similar IO and RA (Flint 1965, Carman 1972)

• “Breath in and out. Gently and rock your pelvis backwards” (Urquhart 2005)

Can we change low back pain with stabilization exercises?

• Improvement in the activation multifidi improves pain in acute and chronic LBP (Hides 1996, O’Sullivan 1997)

• Inconclusive evidence that proprioception can improve with lumbar stabilization program (Kavcic 2004)

• Spinal Segmental Stabilization Training (Richardson 1999)– Re-training the co-contraction of the transversus abdominis and lumbar

multifidus– Drawing in the abdominal wall – causes activation of deep transversus

abdominis in co contraction of the deep fascicles of lumbar multifidis (Jull 1999)

– Eventual incorporation of these skills into functional task• Abdominal bracing training

– Stiffens the spine and improves stability (Grenier 2007)– Immediately more functional maneuver

Role of Breathing

Summary

• Muscles of the core are affected in patients with low back pain

• Re-training these muscles does improve function and outcome in low back pain

• Methods of re-training these muscles are varied and there is controversy as to which is the “best” method

• Breathing patterns has an affect on the activation of core muscles

Laughter is the Best Medicine

References

• Laasonen EM: Atrophy of sacrospinal muscle groups in patients with chronic, diffusely radiating lumbar back pain. Neuroradiology 1984;26:9–13

• Richardson C, Jull G, Hodges P, et al: Traditional views of the function of the muscles of the local stabilizing system of the spine, in: Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain: Scientific Basis and Clinical Approach. Edinburgh, Churchill Livingstone, 1999, pp 21–40

• Rantanen J, Hurme M, Falck B, et al: The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine 1993;18:568–74

• Cresswell AG, Oddsson L, Thorstensson A: The influence of sudden perturbations on trunk muscle activity and intraabdominal pressure while standing. Exp Brain Res 1994;98: 336–341

• Hodges PW, Richardson CA: Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther 1997;77:132–42; discussion, 142–34

• Ferreira PH, Ferreira ML, Hodges PW: Changes in recruitment of the abdominal muscles in people with low back pain: Ultrasound measurement of muscle activity. Spine 2004;29:2560–6

• Ebenbichler GR, Oddsson LI, Kollmitzer J, et al: Sensorymotor control of the lower back: Implications for rehabilitation. Med Sci Sports Exerc 2001;33:1889–98

• Jorgensen K, Nicolaisen T: Trunk extensor endurance: Determination and relation to low-back trouble. Ergonomics 1987;30:259–67

• McGill S: Normal and injury mechanics of the lumbar spine, in: Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, IL, Human Kinetics, 2002, pp 87–136

• Sjolie AN, Ljunggren AE: The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents. Spine 2001;26:2629–36

• Mok NW, Brauer SG, Hodges PW: Hip strategy for balance control in quiet standing is reduced in people with low back pain. Spine 2004;29:E107–12

References

• Bogduk N: Clinical Anatomy of the Lumbar Spine and Sacrum. Edinburgh, Churchill Livingstone, 1997• Hides J: Paraspinal mechanism and support of the lumbar spine, in: Richardson C (ed): Therapeutic Exercise for Lumbopelvic

Stabilization, ed 2. Edinburgh, Churchill Livingstone, 2004, pp 59–74• Hides JA, Richardson CA, Jull GA: Multifidus muscle recovery is not automatic after resolution of acute, first-episode low

back pain. Spine 1996;21:2763–9• Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain: a motor

control evaluation of transversus abdominis. Spine 1996; 21:2640-50• Hodges PW, Richardson CA. Feedforward contraction of transversus abdominis is not influenced by the direction of arm

movement. Exp Br Res 1997; 114:362-70• Wilder DG, Aleksiev AR, Magnusson ML, et al: Muscular response to sudden load: A tool to evaluate fatigue and

rehabilitation. Spine 1996;21:2628–39• O’Sullivan PB, Burnett A, Floyd AN, et al: Lumbar repositioning deficit in a specific low back pain population. Spine

2003;28:1074–9

Thank You