| | Masterclass Muscle control - pain control. What exercises would you prescribe? C.A. Richardson and G. A. Jull Department of Physiotherapy, University of Queensland, Australia SUMMARY. A very specific type of exercise has been devised which is proving to provide effective pain relief for chronic and recurrent back pain sufferers. The exercise approach focuses on retraining a precise co-con- traction pattern of the deep trunk muscles, the transversus abdominis and lumbar multifidus. The approach is based on the knowledge of how muscles provide stability for the spine in normal situations. It has been fur- ther developed according to research evidence which has demonstrated dysfunction in the deep trunk muscles in patients with back pain. The mechanism for pain relief with this specific exercise approach is believed to be through enhanced stabil INTRODUCTION poy ‘Therapeutic exercise encompasses many well known exercise strategies such as rehabilitating the functional ‘demands of the muscle system, enhancing cardiovascu- lar fitness or improving joint and muscle flexibility. Exercise can also be used to assist in pain relief through several local or general physiological effects (McArdle et al 1991). Our particular interest has been in the use of exercise for pain control in spinal pain patients. Itis our hypothesis that control of back pain and prevention of its recurrence can be assisted by enhancing muscle con: {rol of the spinal segment. The aim is to improve active segmental stabilisation thereby protecting the joints from painful strains and reinjury. In recent times, several different exercise pro- {grammes have been proposed to promote lumbar stabil isation (Robison 1992, Saal & Saal 1989). The ability Of such programmes to improve stabilisation of the lum: bar spine has been difficult to evaluate because of a lack of appropriate measurement methods. Current pro- grammes consist of a variety of general trunk and girdle exercises and, for the most part, they seem to have some suecess (Saal & Saal 1989). However, within these gen- eral programmes, itis difficult to ascertain which partic- ular features of the exercise tasks or facilitation tech- niques are responsible for the more successful outcomes in some patients compared to others. Therefore it is (CA. Richardson BPhiy(Hons) PAD, Senior Lecturer. G_A.Jull MPhty, Grad Dip Manip Ther, FACP, Senior Lectures, Department of Physiotherapy, The Universi of Queensland, (94072, Austria Correspondence and requests for offprints to CAR, of the lumbar spine segments. sometimes difficult for the clinician to know where to place the emphasis in their retraining of a back pain patient. ‘Our work with spinal pain patients both in the clinic ‘and in the laboratory has led to the development of some quite specific exercise techniques for the rehabilitation of lumbar segmental control. Research is beginning to vindicate these approaches. In presenting these particu- lar exercise techniques, itis appropriate to consider sev- eral issues. These include the mechanisms involved in providing muscle support for the lumbar motion seg- ‘ment and why muscle control is needed to enhance seg- ‘mental stabilisation in back pain patients. It is also nec- essary to understand which muscles are vital for segmental stabilisation as well as those which demon- strate dysfunction in back pain patients. This provides a basis for identifying features to consider in exercise design for specific methods of rehabilitation of active lumbar segmental control. MECHANISMS FOR MUSCULAR SUPPORT OF ‘THE LUMBAR MOTION SEGMENT. The muscle system in its function of stability, provides protection to articular structures. It can help minimise unwanted joint displacement, aid stress absorption and generally prolong the ‘cartilage serving time’ of the joint Baratta et al 1988), ‘The development of active joint stabilisation has been atributed to several muscle recruitment strategies. ‘One strategy is the early pre-programmed recruitment of particular muscles. Specific muscles are recruited ‘before an action is commenced to ensure that the joint issupported prior to a given movement. For example, during a jumping task, the leg extensor muscles are recruited prior to ground contact in preparation for the forces of landing (Golthofer & Kyrolainen 1991). ‘The regulation of muscle stiffness is also important for the stabilisation of joints (Johansson et al 1991). A ‘mechanism for increasing joint stability through enhanced muscle stiffness is co-contraction of agonist and antagonist muscles which lie each side of a joint (Andersson & Winters 1990). Recruiting muscles in co- contraction is considered to provide support and joint stabilisation even when contractions occur at very low levels. Hoffer & Andreassen (1981) contend that con- tractions as low as 25% maximum voluntary contraction (MYC) are able to provide maximal joint stiffness. In addition, feedback from the joint and ligament afferents, via their effects on the gamma spindle system, may help regulate muscle stiffness (Iohansson et al 1991). This ‘occurs through the gamma system’s influence on the alpha motorneurones which control the tonic, slow ‘twitch muscle fibres (Johansson & Sojka 1991). It ‘appears that the tonic motor units are those most closely related to the control of joint stabilisation. This is com- ‘mensurate with the proposed antigravity postural sup- porting role attributed to these motor unit ‘A major advance in our understanding of how mus- cles contribute to lumbar stabilisation came from recog- ising the significant functional difference between local and global muscles. Bergmark (1989) in his disser- tation on lumbar spine stability proposed a difference ‘between local and global muscles. Global describes the large torque producing muscles linking the pelvis to the thoracic cage. Their role is in providing general trunk stabilisation. Such muscles balance external loads and. in that way help minimise the resulting forces on the spine. Local muscles refer to those attaching directly 10 the lumbar vertebrae. These muscles are considered 10 be responsible for segmental stability as well as control ling the positions of the lumbar segments Lumbar segmental stability Lumbar segmental stability is provided by osseous, lig- amentous and muscle restraint. Injury and degenerative disease can affect any structure of the motion segment and can result in both abnormal segmental movement and muscle dysfunction. Panjabi (1992) considers the segment’s neutral zone is the sensitive region. This, the small range of displacement around the segment’s neutral position where litle resistance is offered by pas- sive spinal restraints. The subtle movement in this region may increase with injury, disc degeneration and. weakness of the muscles (Panjabi 1992), Logically it is the muscles of the local system which have direct attachments to the lumbar vertebrae that hhave the greatest capacity to affect segmental stiffness through control of the neutral zone (Crisco & Panjabi 1990). The contributions of several of the back muscles Muscle contol ~puin control 3 to active segmental stabilisation have been investigated in in vitro studies (Goel et al 1993; Panjabi et al 1989; Steffen et al 1994; Wilke et al 1995). The lumbar mul fidus in particular has been shown to contribute to the control of the neutral zone. Wilke et al (1995) in a biomechanical study demonstrated that the multifidus provided more than two-thirds of the stiffness increase at the Ly.s segment. This stabilising role of multifidus hhas been recently verified in vivo in animal research (Kaigle etal 1995), ‘The abdominal muscles are often ascribed an impor- ‘ant role in the treatment of back pain. A muscle which could be described as part ofthe local system and which hhas not been studied extensively to date, is the transver- sus abdominis. Its possible importance in lumbar stabil- isation was first addressed by Cresswell et al (1992). ‘These researchers studied the muscles of the back and. abdominal wall using fine wire EMG. They demon- strated that transversus abdominis had direct links with the development of _intraabdominal pressure, Furthermore it contracted with all trunk movements regardless of the primary direction of movement and it was recruited prior to all other abdominal muscles with sudden perturbations of the trunk. Recently, more concrete evidence has emerged ‘demonstrating the importance of transversus abdominis in the motor control associated with lumbar stabilisa tion. Fine wire and surface EMG were used to stud) each abdominal muscle during three movements of the upper limb, flexion, abduction and extension (Hodges & Richardson 1995a). The onset of EMG activity for transversus abdominis occurred prior to any limb move- ment. Additionally the pattern of onset was similar for each of the three directions of arm movement. This was different to the activity pattern of other abdominal mus- cles. The rectus abdominis, external and internal oblique muscles rarely preceded limb movement and the onset of their activity varied with the movement direction. The authors concluded that in regard to stabil- isation ofthe lumbar spine, this study provided evidence for a functional differentiation between the abdominal muscles The local muscle system has a primary responsibility for segmental stability. It appears that both multifidus and transversus abdominis are important components of this system. Dysfunctions in the local muscle system ‘The stabilisation function of any antigravity trunk mus- cle is likely 10 be affected in low back pain patients. ‘Their tonic fibres have an important antigravity, postu- ral supportive role. These fibres can be affected by dis- use (Richardson & Jul 1994) and by the reflex and pain inhibition associated with lumbar pain and injury (Baugher et al 1984), The nature of this dysfunction impacts on the type of exercise required to restore this stabilising or supporting role.4 Manual Therapy A link has been established between dysfunction in the local muscles and back pain. Several researchers have demonstrated dysfunctions in the multifidus mus- cle of back pain patients. Hides et al (1994) reported 3 significant reduction in segmental multfidus cross sec- tional area in patients with acute, first episode, unilateral back pain. It was proposed that this phenomenon was & result of pain and or reflex inhibition of the muscle. Rantanen etal (1993) demonstrated ‘moth eaten’ Type I ‘muscle fibres in the multifidus muscle of patients with chronic back pain. Further evidence comes from Biederman et al (1991) who found that multfidus demonstrated greater fatiguability relative to other parts of the erector spinae in chronic back patients compared toa normal population. Dysfunction of the transversus abdominis muscle has also been clearly shown in back pain patients Hodges and Richardson (1995b) demonstrated a motor control deficit in the transversus abdominis muscle. In their EMG experiment analysing the onset of activity of the muscles ofthe abdominal wall in response to arm movements, the timing of onset of transversus abdomi- nis was delayed in chronic low back pain sufferers compared with individuals who had never experienced back pain, Notably no significant change was detected between the two groups in any other muscle of the abdominal wall. The delayed action of transversus abdominis compared to its early recruitment prior to limb movement in normal individuals, has made a sig- nificant contribution to knowledge of the mechanisms involved in poor lumbar stabilisation associated with low back pain, The results are even more significant when one considers that the problem appears to be lim- ited to the muscle which forms the deepest layer of the abdominal wall. Evidence of the importance of the local muscles in stabilisation of the lumbar spine as well as their proven dysfunction in the back pain population, has led us to focus on these muscles in the rehabilitation of active sta- bilisation of the lumbar spine. Indeed, a completely new type of therapeutic exercise has been developed aimed at reversing the dysfunction known to occur in the local muscle system. EXERCISE DESIGN In the process of developing a new concept in therapeu- tic exercise to enhance lumbar stabilisation, each facet of the exercise was reasoned on a knowledge of stabili- jon as well as a knowledge of the muscle dysfunction found in back pain patients. Several decisions had to be made to design the most suitable exercise. These included the type of muscle contraction (i.e. concentric, eccentric, isometric), the body position, the level of resistance or load, the number of repetitions and subse- quently the methods of progression. These decisions ‘were based on extensive work in the clinic as well as a number of EMG studies (Jull et al 1993, Richardson et al 1990, Richardson et al 1992, Richardson et al 1995). ‘Type of muscle contraction Functional differences between the global and local muscle systems help direct which type of muscle con- traction is needed in re-education of the local system. ‘The length-tension relationships of these muscles differ uring trunk movements. The global muscles span the lumbar area and they shorten or lengthen eccentrically as they produce the torque to move the trunk. The local muscles attach from vertebra to vertebra and are respon- sible for maintaining the position of the lumbar seg- ‘ments during functional trunk movement. McGill (1991) confirmed their primary segmental stabilisation role ina study of the geometry of the multifidus muscle. He showed thatthe operational length of multfidus was virtually unchanged through a range of trunk postures. ‘These functional demands indicate that isometric exercise is most beneficial for re-educating the stabilis- ing role ofthese deep local muscles ofthe lumbar spine. ‘Ata later stage, isometric exercises for these deep lum ‘bar muscles can be combined with dynamic functional exercise for other parts ofthe body. Exercise involving co-contraction of the deep abdominal and back muscles is also in line with stabili- sation. Co-contraction of agonist and antagonist has been considered by several researchers in relation to joint stabilisation strategies (Andersson & Winters 1990). This type of muscle activity is linked to increas- ing joint stiffness and support independent of the torque producing role of muscles (Carter et al 1993). A simul- taneous isometric co-contraction of transversus and rmultifidus, while maintaining the spine in a static neu- tral position, should help re-educate the stabilising role of these muscles As argued previously, the tonic motor units are those most closely related to control of joint stabilisation. In addition, both disuse and reflex inhibition are likely to affect the slow twitch or tonic fibre function within the muscle. Therefore a prolonged tonic holding contrac~ tion at a low level of MVC would be most effective in retraining the stability function of these muscles. In summary, the evidence presented indicates that a programme for the transversus abdominis and multi- fidus is required for specific lumbar segmental stabiisa~ tion training. It should include activating an isometric o-contraction of these muscles and training the patient to hold a low level tonic contraction. There is one other factor in exercise design. There are patients in whom the tmore active global muscles such as rectus abdominis, «external oblique or thoracic erector spinae predominate i gencral exercise techniques. In these patients it is almost impossible to detect if local muscle activation is ‘occurring during general exercise. Therefore specific exercises which isolate the local muscles as much as Possible from contraction of the global muscles have