Spine Stabilization Concepts J. Scott Bainbridge, MD Denver Back Pain Specialists .

Spine Stabilization ConceptsSpine Stabilization Concepts

J. Scott Bainbridge, MD

Denver Back Pain Specialists

www.denverbackpainspecialists.com

History of “Spine Stab”History of “Spine Stab”

1924 Von Lackum proposes that much back pain is caused by instability of spine

1944 Knutson notes that intervertebral disk degeneration leads to abnormal motion which he terms “segmental instability”

HistoryHistory

1980s “Neutral spine” concept introducedPosition of comfort where muscular support

reduces stress on painful structures (disc, facet, nerve, etc.)

1990 “dynamic stabilization” developed to be more functional – interest increased after Joe Montana returns to football after LB surgery

HistoryHistory

1996 – current: Back stabilization continues to evolve and become more sport and work specific

Quality research and educational efforts by Hodges, Richardson, Hides, Jull, Comerford and others

Popularization of ball, pool, Pilates, pulley and other exercise systems

MOTION SEGMENTMOTION SEGMENT

vertebral bodies intervertebral disc facet joint spinal canal foramina transverse process spinous process

FACET JOINTFACET JOINT

NEURAL STRUCTURESNEURAL STRUCTURES

cauda equina dura sheath DRG nerve root medial branch

Movement SystemMovement System

Articular

NeuralMyofascial

Connectivetissue

Pain MechanismsPain Mechanisms Nociceptive

– mechanical & inflammatory

Sensitisation– peripheral– central

autonomic

Behavioural / Psycho-social

PhysiologicalPhysiological Considerations Considerations The motor unit consists of

the neurone and the muscle fibres it innervates

All muscle fibres in a single motor unit are of the same fibre type

The maximal contraction speed, strength and fatigability of any muscle depends on the proportion of the three fibre types

(Vander et al. 1994)

The Motor Unit

Motor Unit FunctionMotor Unit FunctionFUNCTION SLOW MOTOR UNITS

(tonic)FAST MOTOR UNITS

(phasic)

Load Threshold easily activated requires higher stimulus

Recruitment primarily recruited at low %of MVC (< 25%)

increasingly recruited athigher % of MVC (40+ %)

Role fine control of posturalactivity & low load activity

rapid or ballistic movement& high load activity

Muscle SpindleMuscle Spindle

Afferent feedback for motor control

Regulation of muscle stiffness

Gamma system strongly influences recruitment of SMU

Local Stability MusclesLocal Stability MusclesFunction

muscle stiffness to control segmental translation

no or minimal length change in function movements

anticipatory recruitment prior to functional loading provides protective stiffness

activity is continuous and independent of the direction of movement

(review: Comerford & Mottram 2001)

Global Stability MusclesGlobal Stability MusclesFunction

generates force to control / limit range of movement

functional ability to (i) shorten through the full inner range of joint motion (ii) isometrically hold position (iii) eccentrically control the return

low threshold eccentric deceleration of movement (rotation)

activity is non-continuous and is direction dependent

Primal Pictures

(review: Comerford & Mottram 2001)

Global Mobility MusclesGlobal Mobility MusclesFunction

generates force to produce range of movement

concentric acceleration of movement ( sagittal plane: power)

High load shock absorption activity is especially phasic

(on:off pattern) and is direction dependent

Primal Pictures

(review: Comerford & Mottram 2001)

Local stability segmental Local stability segmental controlcontrol

The segmental stability of the spine is dependent on recruitment of the deep local stability muscles

The spine will fail if local activity is insufficient even if the global muscles work strongly

1 –3 % MVC muscle stiffness significantly increases stability

25% MVC = optimal stiffness & stability(Cholewicki & McGill 1996, Crisco & Panjabi 1991,

Hoffer & Andreasson 1981)

Local Muscle System Local Muscle System DysfunctionDysfunction

There are changes in motor recruitmentresulting in a loss of segmental control

local inhibition

Dysfunction inDysfunction in Local Stability SystemLocal Stability System

Motor control deficit associated with delayed timing or recruitment deficiency

(Hodges & Richardson 1996)

Reacts to pain & pathology with inhibition(Stokes & Young 1984, Hides et al. 1994)

Decrease in muscle stiffness and poor segmental control

Loss of control of joint neutral position

Vastus Medialis ObliqueVastus Medialis Oblique

60 ml knee effusion significantly inhibits all of the quadriceps

40 ml effusion (sub clinical) inhibits VMO selectively

(Stokes & Young 1984)

Transversus AbdominisTransversus Abdominis Activates prior to movement of

the limbs or trunk to stiffness and stability of the spine

Its activity is independent of the direction of trunk movement or limb load

(Cresswell 1992, 1994)

(Hodges and Richardson 1995, 1996)

Transversus AbdominisTransversus Abdominis A motor control deficit is present

in subjects with low back pain

Activation of transversus is significantly delayed

The timing delay is independent of the type or nature of pathology

(Hodges & Richardson 1995 1996)

Transversus AbdominisTransversus Abdominis

AD

TrA

IO

EO

RA

MF

-0.2 -0.1 0 0.1Time (s)

PD

TrA

IO

EO

RA

MF

-0.2 -0.1 0 0.1Time (s)

MD

TrA

IO

EO

RA

MF

-0.2 -0.1 0 0.1Time (s)

Flexion Abduction Extension

NLBP

(Hodges & Richardson 1996 Spine 21: 2640-2650)

Transversus AbdominisTransversus Abdominis

-0.2 -0.1 0 0.1Time (s)

AD

TrA

IO

EO

RA

MF

-0.2 -0.1 0 0.1Time (s)

MD

TrA

IO

EO

RA

MF

-0.2 -0.1 0 0.1Time (s)

Flexion Abduction Extension

PD

TrA

IO

EO

RA

MF

(Hodges & Richardson 1996 Spine 21: 2640-2650)

LBP

Lumbar MultifidusLumbar Multifidusasymmetry of cross

sectional area of multifidus in back pain subjects

(Stokes et al. 1992)(Hides et al. 1994, 1995)

( Richardson et al. 1998, Hides et al. 1995, 1996)

dysfunction does not correct automatically when pain resolves & specific training can correct dysfunction and recurrence

Dysfunction inDysfunction inGlobal Mobility SystemGlobal Mobility System

Myofascial shortening which limits physiological and / or accessory motion

Overactive low load or low threshold recruitment

Reacts to pain and pathology with spasm

DYSFUNCTION:DYSFUNCTION:What comes 1What comes 1stst ? ?

Global dysfunction can precede and contribute to the development of pain & pathology

Pain & pathology are not a necessary consequence of global dysfunction

Local dysfunction does not precede the development of pain and pathology but rather is due to pain & pathology

Pain & pathology do not have to be present (may be related to distant history)

‘‘Motor Control’ Stability Motor Control’ Stability versus versus

‘Core’ Stability‘Core’ StabilityMotor control stability

= low threshold recruitment of local and global stability muscle system

– Well supported by the research literature

Core stability = high threshold recruitment of proximal trunk &

girdle muscles

Multifidus Muscle Recovery Is Multifidus Muscle Recovery Is Not Automatic After Acute Not Automatic After Acute

First Episode LBP First Episode LBP Hides, Richardson, Jull. SPINE 1996:21Control(n=19) medical management/

activitySpecific ex.(n=20) +med manage/ activityMultifidus ex. 2x/wk x 4 weeksUltrasound image: smaller multifidus on

painful side in all at start

ResultsResults

Multifidus CSA at most affected vertebral level painful side difference corrected in ex group but not in controls at 4 and 10 weeks.

P<0.0001 at both timesPain and Disability scores same in groups

(pain and disability resolved at 4 wks in 90%)

Long Term Effects of Long Term Effects of Stabilizing Exercises for First-Stabilizing Exercises for First-

Episode LBPEpisode LBPHides, Jull, Richardson. SPINE 2001:26Control(n=19) medical management/

activitySpecific Ex(n=20) +med manage/ activity Multifidus ex. 2x/wk for 4 weeks

ResultsResults

1 year recurrence: control=84%, ex.=30%P<0.0013 year recurrence: control=75%, ex.=35%P<0.01 (3 controls lost at 3 year)

Therapeutic Exercise for Therapeutic Exercise for Spinal Segmental Stabilization Spinal Segmental Stabilization

in LBPin LBPScientific Basis and Clinical ApproachRichardson, Jull, Hodges, and HidesChurchill Livingstone 1999

Cervical muscle dysfunctionCervical muscle dysfunction

RCPMaj & RCPMin show atrophy and fatty degeneration in chronic neck pain

(Hallgren et al 1994, McPartland et al 1997)

Anterior neck muscles show slow fast fiber transformation in chronic neck pain

(Uhlig et al 1995)

Noxious meningeal stimulation neck and jaw EMG activity

(Hu et al 1995)

Deep cervical flexor Deep cervical flexor dysfunctiondysfunction

Pressure biofeedback: incremental lordosis flattening pressure during active upper cervical flexion

EMG: activity in anterior neck mobiliser muscles

• (Jull 1994)

Deep cervical flexor Deep cervical flexor dysfunctiondysfunction

Control Can control greater

range of 2mm Hg increments (up to 28 from baseline of 20) than WAD

Less superficial muscle activity

WAD Can only control low

increments (from baseline of 20 up to 23)

Less consistent duration of hold

More superficial muscle activity

Jull 2000

Deep cervical flexor Deep cervical flexor dysfunctiondysfunction

identified in different pathological situations– Whiplash Associated Disorder (Jull 2000)

– Post-concussional headache (Treleaven et al 1994)

– Cervical headache (Watson & Trott 1993,Jull et al 1999)

– Mechanical neck pain (Silverman et al 1991, White & Sahrmann 1994, Jull 1998)

A Randomized Controlled A Randomized Controlled Trial of Exercise and Trial of Exercise and

Manipulative Therapy for Manipulative Therapy for Cervicogenic Headache Cervicogenic Headache

Jull, Trott, Potter, et. al.SPINE: Vol. 27, No. 17, pp. 1835-1843

Inclusion CriteriaInclusion Criteria

1 + HA/week for 2mo. – 10 yrCervicogenic headache (not MT or

Migraine)

MethodsMethods

Randomized: Control, Manual Therapy (Maitland), Exercise (motor control), or Exercise and Manual Therapy

6 weeks of treatment (8-12 visits)Outcome Measures: 7weeks, 3,6, and 12mo.Change in HA frequency (intensity and

duration were secondary measures)Physical assessments

Results: % of Subjects with Results: % of Subjects with 50% and 100% Dec. in HA 50% and 100% Dec. in HA

Frequency – Week 7Frequency – Week 7 50% 100%MT+Ex 81% 42MT 71 33Ex 76 31Control 29 04

The meaning of Life ?The meaning of Life ?

The control of stability The control of stability dysfunction !dysfunction !