Pro-Motion Physical Therapy incorporates evidence-based treatment into your
Lower Back Pain program whenever possible.

Low back pain is a growing problem that places an increasing burden on healthcare budget. (Indahl – 1995) The incidence of back pain in a lifetime ranges from 60% to 80%, most episodes subsiding within 2-3 months – recurrence rates are reported common. Of major concern are the 5% to 10% of low back pain patients who become disabled with chronic low back pain that accounts for 75% to 90% of the cost. (Indahl – 1995)

A large number of pathological conditions give rise to low back pain. However, 85% of the population is classified as having “non specific low back pain” (Dillingham -1995)

To identify effective treatments physical therapists need to define sub-groups within the low back pain population (Bogduk – 1995) who are most likely to respond to a specific treatment approach.

Lumbar spine instability represents one of these sub-groups and the specific training of lumbar spine muscles whose primary role is considered to be the provision of segmental control and dynamic stability is the specific treatment approach.

Panjabi (1992) defined spinal instability as: “a significant decrease in the capacity of the stabilizing systems of the spine to maintain intervertebral neutral zones within physiological limits to avoid major deformity or incapacitating pain”

The neutral zone is an area within the normal movement of the spinal motion segment where minimal resistance occurs.

Muscle contraction/ tone in control of the neutral zone provide the link to clinical situations. A decrease in muscle contraction / tone, due to fatigue or injury, may lead to spinal instability. The lumbar spine muscle system has the ability to compensate for instability by increasing contraction / tone of the lumbar spine motion segment and decreasing the size of the neutral zone, thereby decreasing pain.

What muscles can do this?

Bergmark (1989) identified 2 muscle systems that maintain spinal stability. The “global muscle system”) that acts on the trunk and spine without attaching to it. These muscles are seen to balance external loads and include Rectus abdominus and Iliocostalis lumborum. The global muscles do not have direct control of the spine.

Global Muscle System	Rectus Abdominus	Iliocostalis Lumborum

The “local muscle system” consists of muscles that directly attach to the lumbar spine and are responsible for providing segmental stability by controlling the lumbar segments. These muscles include lumbar spine multifidus and transverse abdominus.

Local Muscle System	Lumbar Spine Multifidus	Transverse Abdominus

A growing body of evidence has emerged that shows the activation of the transverse abdominus muscle and the lumbar spine multifidus muscles are adversely affected by acute and chronic low back pain with a loss in the functional segmental control. (Hodges and Richardson – 1996)

What can be done to restore the function of these muscles? (Motor Relearning Model)

Physical therapy management of this sub-group of low back pain patients is to specifically retrain the local muscle system in isolation. This method of motor learning occurs in three stages:

Stage 1 – train the specific co-contraction of transverse abdominus and lumbar multifidus with low levels of contraction. The co-contraction must be in isolation of global muscle activation.

Stage 2 – encouraged to perform the co-contraction in more upright positions as sitting, standing and walking, this must be done pain free. Patients are then encouraged to perform tasks that were previously pain producing. This is essential so the patterns of co-contraction will become automatic.

Stage 3 – the co-contraction of the lumbar multifidus and transverse abdominus becomes automatic while performing the functional demands of activities of daily living or sports related tasks. (Stages of Rehabilitation)

Evidence for the efficacy of this approach has grown through clinical trials. The studies of Hides (1996) and O’Sullivan (1997) (Hodges and Richardson-1996) have shown the motor relearning model and its effect on the low back pain sub-group of lumbar spine segmental stability has good outcome. The studies showed a significant decrease in pain and disability with use of the motor relearning model as compared to general exercise. These improvements were maintained at the 3 year follow up. The recurrence rate at 3 years was 35% in the motor relearning group as compared to 75% in the general exercise group.

The physical therapists at Pro-Motion Physical Therapy have had advanced training in the motor relearning method used to treat the low back pain sub-group of lumbar spine segmental instability.

References:

Bergmark A 1989 Stability of the lumbar spine. A study in mechanical engineering.
Acta Orthopaedica Scandinavia 230(60)(Supp):20-24

Bogduk N 1995 The anatomical basis for Spinal Pain Syndromes. Journal of Manipulative and
Physiological Therapeutics 18(9): 603-605

Dillingham T 1995 Evaluation and management of low back pain and overview.
State of the Art Reviews 9(3): 559-574

Hides J, Richardson C, Jull G 1996 Multifidus recovery is not automatic following resolution of acute first episode
of low back pain. Spine 21(23): 2763-2769

Hodges PW and Richardson, A 1996 Inefficient muscular stabilization of the lumbar spine associated with low
back pain; a motor control evalutaion of Transversus Abdominis.Spine 21(22): 2640-2650

Indahl A, Velund L, Reikeraas o 1995 Good prognosis for low back pain when left untampered.
Spine 20(4): 473-477

O’Sullivan P, 1997 The efficacy of specific stabilizing exercise in the management of chronic low back pain
with radiological diagnosis of lumbar segmental instability. PhD Thesis, Curtin University of Technology,
Western Australia

Panjabi, M 1992 The stabilizing system of the spine. Part 1 and Part2. Journal of Spinal Disorders 5(4): 383-397