LUMBOPELVIC STABILITY

ROLE OF ABDOMINAL AND PARASPINAL MUSCLES

STABILITY


THE CONDITION OF REMAINING UNCHANGED EVEN IN THE PRESENCE OF FORCES THAT WOULD NORMALLY CHANGE THE STATE OR CONDITION

STABILIZATION


THE ACT OF MAKING SOMETHING STABLE

DYNAMIC STABILIZATION


AN INTEGRAL FUNCTION OF THE NEUROMUSCULAR SYSTEM REQUIRING MUSCLES TO CONTRACT AND FIXATE THE BODY AGAINST FLUCTUATING OUTSIDE FORCES, PROVIDING POSTURAL SUPPORT WITH FINE ADJUSTMENTS IN MUSCLE TENSION.

PARAMETERS OF SPINAL STABILITY



CONTROL OF SPINAL ORIENTATION WHICH RELATES TO MAINTAINANCE OF OVERALL POSTURE OF THE SPINE AGAINST IMPOSED FORCES AND COMPRESSIVE LOADING. CONTROL OF INTERSEGMENTAL RELATIONSHIP AT THE LOCAL LEVEL (LUMBAR SEGMENTAL CONTROL), IRRESPECTIVE OF CHANGES IN THE OVERALL ORIENTATION OF THE SPINE.

CORE


Human core is described as low back-pelvicback-pelvic-hip complex with its governing musculature. Core is important because it is the anatomical location in the body where the centre of gravity is located, where the movt starts.

MAINTAINANCE OF SPINAL STABILITY

3 ELEMENTS OF SPINAL STABILITY:STABILITY:-

PASSIVE SUBSYSTEM
OSSEOUS AND ARTICULAR STRUCTURES FACET JOINTS PEDICLE LAMINA IV DISCS PARS INTERARTICULARIS CONTROL SEGMENTAL MOVEMENT NOT ONLY AT THE END RANGE BUT AROUND THE NEUTRAL JOINT POSITION ALSO  SPINAL LIGAMENTS OFFER MOST RESTRAINT TOWARDS THE END RANGE OF MOVEMENT BUT DO NOT PROVIDE SUBSTANTIAL SUPPORT IN THE NEUTRAL JOINT POSITION


NEURAL CONTROL SUBSYSTEM



CONTROL OF SPINAL MUSCLES FOR SPINAL SUPPORT MUSCLES NEED TO BE PROGRAMED IN RESPONSE TO THE FEEDBACK IN ORDER TO ADJUST TO ANY CONDITION AT ANY POINT OF TIME, SO THAT THE APPROPRIATE MUSCLES ARE ACTIVATED TO APPROPRIATE LEVEL.

ACTIVE SUBSYSTEM


REFERS TO THE FORCE GENERATING CAPACITY OF THE MUSCLES WHICH PROVIDE THE MECHANICAL ABILITY TO STABILIZE THE SPINAL SEGMENT.

MUSCLES QUADRATUS LUMBORUM ABDOMINALS HIP GIRDLE MUSCULATURE PARASPINALS

PARASPINALS

ERECTOR SPINAE LONGISSIMUS - ILIOCOSTALIS

ROTATORS INTERTRANSVERSARII MUTIFIDUS

LOCAL AND GLOBAL STABILIZING SYSTEM



BERGMARK 1989 CATEGORIZED THE TRUNK MUSCLES INTO LOCAL AND GLOBAL SYSTEM BASED ON THEIR ROLES IN STABILIZATION.

LOCAL STABILIZING SYSTEM

       

GLOBAL STABILIZING SYSTEM

     

INTERTRANSVERSARII INTERSPINALES MULTIFIDUS LONGISSIMUS THORACIS PARS LUMBORUM ILIOCOSTALIS LUMBORUM PARS LUMBORUM QUADRATUS LUMBORUM MEDIAL FIBRES TRANSVERSUS ABDOMINIS OBLIQUUS INTERNUS ABDOMINIS

LONGISSIMUS THORACIS PARS THORACIS ILIOCOSTALIS LUMBORUM PARS THORACIS QUADRATUS LUMBORUM LATERAL FIBRES RECTUS ABDOMINIS OBLIQUUS EXTERNUS ABDOMNIS OBLIQUUS INTERNUS ABDOMINIS

LOCAL SYSTEM
DEEP MUSCLES OR PARTS OF DEEP MUSCLES WHICH HAVE ATLEAST 1 ATTACHMENT TO THE LUMBAR VERTEBAE THEY CONTROL STIFFNESS , INTERVERTEBRAL RELATIONSHIP OF THE SPINAL SEGMENTS, POSTURE OF LUMBAR SPINE

GLOBAL SYSTEM


LARGE AND SUPERFICIAL GROUP OF MUSCLES THEY CONTROL:CONTROL:MOVEMENT OF SPINE DIRECTLY TRANSFER LOAD FROM THORACIC CAGE TO THE PELVIS

FUNCTIONAL SIGNIFICANCE OF LOCAL SYSTEM



 

THEY ARE CLOSER TO CENTER OF ROTATION OF SPINAL SEGMENTS HAVE SHORTER MUSCLE LENGTHS HENCE IDEAL FOR CONTROLLING INTERSEGMENTAL MOTION

LUMBAR MUSCLES
 

BACK MUSCLE ACTING BILATERALLY- MAINLY BILATERALLYEXTENSORS LONGISSIMUS & ILIOCOSTALIS -CAN ASSIST LATERAL FLEXION ACTING UNILATERALLY MULTIFIDUS, LUMBAR LONGISSIMUS & LUMBAR ILIOCOSTALIS CONTROL ANTERIOR ROTATION AND TRANSLATION RETURN TO UPRIGHT MULTIFIDUS INDUCES POSTERIOR SAGITTAL ROTATIONCONTRIBUTES ROTATION 20% OF TOTAL EXTENSOR MOMENT -LUMBAR ERECTOR SPINAE CONTROLS POSTERIOR SAGITTAL TRANSLATION 30% -THORACIC ERECTOR SPINAE 50%

FEATURES SUPPORTING A TONIC HOLDING FUNCTION



PARAVERTEBRAL MUSCLES
 NO.OF TYPE I FIBRES > TYPE II FIBRES  THORACIC ERECTOR SPINAE-70% TYPE I SPINAE LUMBAR ERECTOR SPINAE-58%-69% SPINAE-58%-

 

SIZE OF TYPE I FIBRES > TYPE II FIBRES LARGE CAPILLARY NETWORK

 MULTIFIDUS- 4-5 CAPILLARIES/MUSCLE CELL MULTIFIDUS-

HIGH CONCENTRATION OF OXIDATIVE ENZYMES HIGH ENDURANCE CAPACITY

ROLE OF MUSCLES FOR STABILITY



KAIGLE ET AL 1995 TRANSECTED THE PASSIVE STRUCTURES OF THE SPINES OF 33 PIGS AND CARRIED OUT STIMULATION OF THE MUSCLES AROUND THE SPINE- THIS SPINERESULTED IN INCREASED STABILIZATION OF THE SPINE AND DECREASED ABNORMAL MOTION IN NEUTRAL ZONE

GOEL ET AL 1993 IN THEIR STUDY (INVOLVING INTERSPINALES, INTERTRANSVERSARII, LUMBAR MULTIFIDUS, QUADRATUS LUMBORUM) DEMONSTRATED THAT INTRODUCTION OF MUSCLE FORCES IN AN UNSTABLE SPINE, DECREASED AP TRANSLATIONS & ANTERIOR ROTATIONS

WILKE ET AL 1995 SHOWED THAT MUSCLE FORCES STIFFEN THE MOTION SEGMENT STRONGEST INFLUENCE MULTIFIDUSMULTIFIDUS- RESPONSIBLE FOR 2/3rd OF INCREASE IN SEGMENTAL STIFFNESS & DECREASE IN ROM

Mc.GILL 1991 CONCLUDED THAT THE UNCHANGING GEOMETRY OF THE MULTIFIDUS THROUGH THE RANGE OF POSTURES INDICATES THAT PURPOSE OF THIS MUSCLE WAS TO FINELY ADJUST VERTEBRAE WITH SMALL MOVEMENTS.

ROLE OF DIFFERENT FASCICLES

QUADRATUS LUMBORUM


Mc.GILL ET AL 1996 PROVIDED EVIDENCE THAT IT PLAYS AN IMPORTANT ROLE IN STABILITY OF THE SPINE (SYMMETRICAL BUCKET HOLDING TASK) ANDERSON ET AL 1996 FOUND THAT THERE WAS NO ELECTRICAL SILENCE OF QUADRATUS LUMBORUM EVEN IN FULL FORWARD FLEXION THUS IT HAS A STABILITY FUNCTION

OBLIQUUS INTERNUS ABDOMINIS



CONTRIBUTES TO FIXATION OF PELVIS DURING LEG MOVEMENTS IT ACTS AS A PART OF LOCAL SUPPORT SYSTEM OF THE LUMBAR SPINE - BERGMARK

PELVIC FLOOR MUSCLES THEY ARE ACTIVE DURING LIFTING TASKS  ACTIVATION OF PUBOCOCCYGEUS INCREASES THE ACTIVATION OF ABDOMINAL MUSCLES AND VISE VERSA THUS HELPING IN STABILITY


TRANSVERSUS ABDOMINIS CONTRACTION RAISED INTRAINTRAABDOMINAL PRESSURE - TENSION ON THORACOLUMBAR FASCIA STUDIES SUGGEST ITS ROLE IN BOTH; PRODUCING ROTATION RESTRICTING ROTATION


SPINAL INSTABILITY


A SIGNIFICANT DECREASE IN THE CAPACITY OF THE STABILIZING SYSTEM OF THE SPINE TO MAINTAIN THE INTERVERTEBRAL NEUTRAL ZONES WITHIN THE PHYSIOLOGICAL LIMITS WHICH RESULTS IN PAIN AND DISABILITY (Panjabi) NEUTRAL ZONE INCREASES WITH INSTABILITY

NEUTRAL ZONE AND INSTABILITY

ACCORDING TO PANJABI THE LOAD DEFORMATION BEHAVIOR OF THE SPINAL SEGMENT IS NON LINEAR AND IS HIGHLY FLEXIBLE IN THE VICINITY OF THE NEUTRAL POSITION THIS IS CALLED AS THE NEUTRAL ZONE. MOTION OCCURS IN THIS REGION AGAINST MINIMAL INTERNAL RESISTANCE, WITH LIGAMENTOUS STRUCTURES PROVIDING RESTRAINT IN THE ELASTIC ZONE TO LIMIT END ROM.

WHAT CONSTITUTES INSTABILITY?

LOSS OF JOINT STIFFNESS, INCREASE IN MOBILITY, ABNORMAL SPINAL MOTION, CHANGES IN THE RATIOS OF SEGMENTAL ROTATIONS AND TRANSLATIONS PANJABI IDENTIFIES CONTROL OF INTERSEGMENTAL MOTION AROUND THE NEUTRAL ZONE AS A MAJOR PARAMETER OF SPINAL INSTABILITY (as in definition)

REASONS FOR INSTABILITY



INJURY TO ANY OF THE STABILIZING STRUCTURES REPETITIVE LOADING OF THE INFERIOR ARTICULAR FACETS WITH EXCESSIVE LUMBAR FLEXION & EXTENSION COMPRESSIVE & SHEARING LOADS TO THE IV DISC MUSCULAR WEAKNESS

MODEL OF ASSESSMENT
- 3 TIER SYSTEM

DIAGNOSTIC MEASURES

CLINICAL MEASURES

SCREENING TESTS

FIRST TIER


NON INVASIVE VOLITIONAL TESTS:

-TESTING TRANSVERSE ABDOMINIS

(ABDOMINAL DRAWING-IN ACTION) DRAWING-

-TESTING SEGMENTAL LUMBAR MULTIFIDUS -TESTING CONTROL OF LUMBOPELVIC POSTURE (LEG LOADING)

ABDOMINAL DRAWING-IN ACTION DRAWING

INSTRUCTION: DRAW THE LOWER PART OF ABDOMEN TO THE SPINE WHILE KEEPING THE SPINE & PELVIS STABLE - DISSOCIATE IT FROM BREATHING - SLOW & CONTROLLED CONTRACTIO - TAUGHT IN CROOK LYING - PRESSURE BIOFEEDBACK IS USED (CENTER OF CUFF AT THE NAVEL) - HOLD 10 sec, MAX 10 reps

SUCCESSFUL TEST
REDUCTION IN PRESSURE BY 6-10mm Hg 6-INDICATES THAT THE PATIENT IS ABLE TO CONTRACT THE TRANSVERSUS ABDOMINIS INDEPENDENTLY POOR TEST  DROP LESS THAN 2mmHg  NO CHANGE IN PRESSURE  INCREASE IN PRESSURE -INDICATES INABILITY TO ACTIVATE TRANSVERSUS ABDOMINIS SUFFICIENTLY -CO-CONTRACTION OF GLOBAL MUSCLES CO-SUBSTITUTION BY RECTUS ABDOMINIS OR OBLIQUUS EXTERNUS


TEST FOR SEGMENTAL LUMBAR MULTIFIDUS INSTRUCTION: GENTLY SWELL OUT YOUR MUSCLES UNDER MY FINGERS WITHOUT MOVING YOUR SPINE OR PELVIS HOLD WHILE BREATHING NORMALLY CLINICIAN PALPATES AND COMPARES SIDE-TOSIDE-TO-SIDE OR WITH UPPER AND LOWER LEVELS

RESULTS


DEEP DEVELOPMENT OF TENSION IN THE MUSCLE ACTIVATION OF MULTIFIDUS AT THAT SEGMENT ABILITY TO HOLD THE CONTRACTION MUSCLES TONIC HOLDING CAPACITY LITTLE OR NO TENSION INABILITY TO ACTIVATE SEGMENTAL MULTIFIDUS RAPID AND SUPERFICIAL DEVELOPMENT OF TENSION USE OF ONLY SUPERFICIAL FIBRES CAUSING EXTENSION - USE OF TENDON OF THORACIC PORTION OF ERECTOR SPINAE

LEG LOADING


DETERMINES THE ABILITY OF THE TRUNK MUSCLES TO HOLD THE LUMBOPELVIC REGION IN A STEADY POSITION DURING PROGRESSIVE LEVELS OF LEG LOADING (Sahrmann 1987) POSITION: CROOK LYING PRE CONTRACTION- DRAWING IN OF THE CONTRACTIONABDOMINAL WALL PRESSURE BIOFEEDBACK PLACED UNDER THE LUMBAR SPINE TO DETECT ANY MOVEMENT OF THE LUMBOPELVIC REGION (INFLATED TO 40mmHg

 

LEG LOADING PROGRESSION

LEVEL1: SINGLE LEG SLIDE, CONTRALATERAL LEG SUPPORT


(LEFT) LEG SLIDE WITH HEEL SUPPORT TO FULL EXTENSION AND RETURN (RIGHT) SUPPORTED LEG SLIDE- HEEL HELD 5cm FROM SLIDETHE SUPPORTING STRUCTURES

LEVEL2: SINGLE LEG SLIDE, CONTRALATERAL LEG UNSUPPORTED



(LEFT) LEG SLIDE WITH HEEL SUPPORT TO FULL EXTENSION AND RETURN (RIGHT) UNSUPPORTED LEG SLIDE- HEEL HELD 5cm SLIDEFROM THE SUPPORTING STRUCTURES

SECOND TIER


DETAILED NON INVASIVE VOLITIONAL TESTS PRESSURE BIOFEEDBACK & EMG BIOFEEDBACK OBSERVATION OF BODY CONTOURS & BREATHING PATTERN.

THIRD TIER


EMG WITH FINE WIRE ELECTRODES INSERTED INTO DEEP MUSCLES IS USED FOR INVASIVE TEST
&/OR

NON INVASIVE VOLITIONAL ASSESSMENT

Jeffreys I Developing a progressive Core Stability Program. Strength Cond J 2002;24:652002;24:65-66.

CORE STRENGTHENING - SOME EXERCISES

ABDOMINAL CRUNCH

BRIDGING

SINGLE LEG ABDOMINAL PRESS

SINGLE LEG ABDOMINAL PRESS MODIFIED

DOUBLE LEG ABDOMINAL PRESS

DOUBLE LEG ABDOMINAL PRESS MODIFIED

SEGMENT ROTATION

QUADRUPED

MODIFIED PLANK

MODIFIED PLANK 2

SIDE PLANK

SUPERMAN

CORE STRENGTHENING
-WITH SWISS BALL

SQUAT AND REACH

BALL SIT - BACK

BRIDGE ON BALL

BRIDGE HEEL DIG

BALL PLANK

FORWARD LEAN

BALL RAISE

BALL ROTATION

TRUNK EXERCISE

REVERSE CRUNCH

REFRENCES
       

GOEL ET AL A COMBINED FINITE ELEMENT OF LUMBAR SPINE, SPINE, 18, 1993,1531-1541 1993,1531MANOHAR ET AL STABALIZING FUNCTION OF TRNUNK FLEXORS, SPINE,1997, 22, 2207- 2212 2207CRESSWELL ET AL OBSERVATIONS OF INTRA ABDOMINAL PRESSURE, ACTA PHYSIOL SCAND1992, 144, 409- 418 409JOHANNE ET AL MUSCLE ACTIVATION EXERCISES APMR, 2000, ACTIVATON OF PARASPINAL MUSCLES AM J PHYS MED REHAB 2002 BACK AND ABDOMINAL FUNCTION APMR 2001 CORE STRENGTHENING APMR 2004 THERAPUTIC EXERCISES FOR SPINAL SEGMENTAL LBA RICHORDSON