This document discusses evidence and convention regarding lumbar spine rehabilitation and functional instability. It questions the dogmatic approach to lumbar spine care and exercise, noting that function is context-specific. True functional exercise does not exist, and motor skill training is more important than focusing on stability alone. The document advocates moving from isolated to integrated and slow to fast exercises based on the principle of specificity of adaptations to imposed demands (SAID).

2. Lumbar Spine Functional Instability
Rehabilitation
Convention or Evidence?
Paul Schoonman, DC
Schoonman Chiropractic and Rehab
Health Science Advisory Board, Merrimack College
Andrew Cannon, MHS, PT, SCS
Dir., Sports Medicine, NRHN
Team PT, Lecturer, Merrimack College

3. CONVICTION!!

4. Critical consumers of dogmatic
approach to lumbar spine care
and exercise
Disc location

5. Trunk Performance
 No such thing as truly
functional exercise
 Function is context and
individual specific
 GPP, SPP
 Input versus outcome?
 Motor skill in, stability
out!
 Ankle sprain, MDI
 Like the trunk, ROM is
poor indicator of overall
ability

6. Shoulder any different?
Phases of Rehabilitation for Shoulder Instability
Phase I
 Rest and immobilization
 Pain control with nonsteroidal anti-inflammatory drugs and ice applied to the shoulder
Phase II
 Isometric strengthening
 Isotonic strengthening
 Begin exercises with shoulder in adducted, forward- flexed position, progressing to
abducted position
Phase III
 Endurance building along with strengthening exercises
 Goal: the patient reaches 90% strength in the injured shoulder compared with the uninjured
shoulder
Phase IV
 Increase activity to sport- or job-specific activities

7. What is best for people with acute
low back pain with or without
radicular symptoms to do?

8. Bed rest for acute low-back pain and sciatica
People with acute low-back pain who are advised to rest in bed have
more pain and are less able to perform every day activities, on
average, than those who are advised to stay active.
As many people get some relief from low back pain and sciatica (pain
down the back and leg) by lying down, bed rest is often recommended.
However, this review found that, for people with acute low-back pain,
advice to rest in bed is less effective in reducing pain and improving an
individual's ability to perform every day activities than advice to stay
active. For people with sciatica, there were no important differences in
the effects of advice to stay in bed compared with advice to stay
active.
Page 106
Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and
sciatica. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.:
CD001254

9. Williams flexion exercises
I have not been able to find one shred
of evidence that they are better than
any other form of exercise or that
specifically they are indicated over other
therapeutic exercise interventions

10. Does Stretching Decrease
Injury?

11.  Evidence says pre-exercise does not
 Not pre-exercise 3x day does
– 20 seconds, 5-7 reps, comfortable
– Frequency is key
– Limited value in spine care relative to spine
stretching

12. Finally, separate out
 what is indicated to do
 what seems good to do, “clinical wisdom”
 what other people do
 what the patient wants to do
 what you have time to do
 what their parents/employer want them to do
 What the insurer will pay you to do

13. New Path

14. Simple --- Complex
Isolated --- Integrated
Slow --- Fast

15. SAID
 SPECIFIC
 ADAPTATIONS
 IMPOSED
 DEMANDS

16. What patient is this new path for?
 Acute? No. Sub acute and beyond, Episodic
 Can they be radicular? Yes!, non progressive,
stable, neurologically improving, weakness
decreasing, reflexes increasing
 Change from victim to patient
 Pain versus function

17. Neuromuscular Function in Athletes Following Recovery
From a Recent Acute Low Back Injury,
Cholewicki et al, jospt vol. 32 #11, 11:2002
 Chronic LBP, delay in shut off of agonist , switch on antagonist with
fewer # of trunk muscles responding
 Varsity athletes with hx 1 episode of LBP, >6 months prior
 @injury pain 4.4/10, FVAS 30/100, min. 3 days OOP
 @testing, avg. 56 days post, pain 0/10, full participation
 A shutting off of a fewer number of agonists with an increased latency
as well compared to matched controls

18. Stability
 Synergistic coordination
of neuromuscular
system to provide a
stable base for
superimposed
functional movement or
activity
 Shoulder MDI and hand
placement
 But, the trunk??

19. What Do We Know About Lumbar Spine
Segmental Instability?
 Clinical instability is a sagittal plane translation of >
3mm or 9% of vertebral body width on either an
flexion or extension radiograph, and/or sagittal plane
rotation >9 degrees for lumbar motion segments
 Clinical instability is a deficit in the end of range
passive restraints
 Functional instability is a decrease in the capacity of
the stabilizing system of the spine to maintain the
spinal neutral zones within physiological limits so
that there is no neurological deficit, no major
deformity and no incapacitating pain
 Functional instability is a failure of the neural and
contractile units to guide normal segmental motion
within the neutral zone.

21. Cause or Effect??
 Functional instability
can be both the cause
of and the result of
injury
 Not just tissue based
 Motor control aspects
– Coordinated contraction
stiffens the joints and
ultimately determines
functional (in)-stability

22. How much load/shear is too much?
 Shear tolerance of vertebral motion segment of
2000-2800N one time loading
 Repetitive shear loads may be more likely 500N
 The osteoligamnetous spine buckles at 20N!
 How do muscles that compress make the spine
more functionally stable?
Luca d e al. Stability of the ligamentous spine. Technical Report #40, Biomechanics Laboratory, San Francisco, University of California

23. So what is stability from a spine
perspective?
 Potential energy = PE= mass x gravity x height
 Stable equilibrium prevails when the PE of the system is
minimum
 A ball in a bowl is stable. At the bottom of the bowl it is at
minimum potential energy
 The deeper the bowl, the steeper the sides the more stable
the system
 Bergmark A (1989) Stability of the lumbar spine: A study in mechanical engineering. Acta Orthop. Scand 1989; 60:3-53.2

24. The Continuum of Stability
 Slope of sides = stiffness
of passive tissues =
mechanical stop/end
point
 Width of the bottom of
the bowl = joint laxity
Bergmark A (1987) Mechanical stability of
the human lumbar spine. Doctoral
dissertation, Department of Solid
Mechanics, Lund University, Sweden

25. how many sides does the bowl
need?
 Spinal joints can rotate in 3 planes, along 3 axes
 Requires a 6 dimensional bowl for each 6 lumbar
spinal joints = 36-dimensional bowl
 If the height of the bowl is decreased in any one
of these 36 dimensions, the ball rolls out!
 A single muscle having inappropriate force or a
damaged passive tissue can cause instability

26. Potential energy as stiffness and
storage of elastic energy.
 stiffness = (k)
 deformation = (x)
 so stretching a band with stiffness x a
distance x will store energy (PE)

27. Elastic PE = .5 * k * x
 Stretching a band with
stiffness (k) a distance (x)
with store energy (PE)
 Increase in k = increase in
side of the bowl
 Stiffness creates stability to
support larger loads (P)
 Most important is stiffness
is balanced
 Increased stiffness of just 1
spring will lower PE in one
direction and decrease
ability to bear load

29. Symmetrical Stiffness
 Active muscles act like a
stiff spring
 Modest levels of muscle
activation create
sufficient stiff and stable
joints
 Motor control system
modulates stiffness
therefore stability
through coordinated
muscle co- activation

30. How Much Stability is Enough ?
What is Sufficient?
 Too much stiffness and muscle
coactivation imposes a load
penalty/prevents motion
 Muscular stiffness necessary for
stability with a modest extra for
margin of safety
 How hard do the muscles need to
work to provide adequate stability in
the neutral zone?
 5%-20% MVC with ADL to athletic
activities
 Strength or endurance?
 Remember the bowl needs all its
sides!!

31. Is a single muscle most important
 Inappropriate application of “Queensland”
research, did not say tva and mf “more”
important
 Was any single string more important?
 All muscles play a role in stability, roles vary
based on task at hand and resources
available

32. Myths, Legends,
Misconceptionsn

33. You need a strong
trunk to protect your
back
 10% of MVC abdominal
wall cocontraction
 Endurance over strength
 Proper daily motion is
“endurance training”

34. What are stabilization exercises
 An exercise repeated in a
way that grooves motor
patterns and ensures a
stable spine
 Consider loading as to
how good an exercise is
 An athlete requires a
stable spine during c-v
demanding, complex
motor skill.
 It is not whole body
stability, balance

35. What is the most important muscle
 Which wire is most
important to the tower
standing
 How can
wires/muscles that add
compression,
decrease
compression?

36. Upper and lower rectus
 There is no functional
separation of the rectus
abdominis
 Is a separation of neural
drive, rarely!
 Once activated, function
as a cable throughout its
length
 If you mean, lower abs,
could be TVA, that would
be the lateral ‘V’

37. We give patients lumbar stability
exercises
 Input or output?
 We train motor skill
 They get stability

38. WELL??