THE Eutic: Exercise Fo Lumbopelvic Stabilization [PDF]

Citation preview

SECOND EDITION



THE EUTIC EXERCISE FO LUMBOPELVIC STABILIZATION A Motor Control Approach for the reatment and Prevention of Low Back Pain CAROLYN RICHARDSON PAUL HODGES JULIE HIDES



,/j)CHURCHIU :u



lIVINGSTON�



SECOND EDITION



THERAPEUTIC EXERCISE FOR LUMBOPELVIC STABILIZATION A Motor Control Approach for the Treatment and Prevention of Low Back Pain



Therapeutic Exercise for Lumbopelvic Stabilization (previously entitled Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain) is based on the evidence from research undertaken by the authors over a number of years. The significance of these findings to the treatment and prevention of low back pain are now widely acknowledged, not only among researchers but also, and perhaps more importantly, among practitioners concerned with the management and prevention of back pain. In this new edition they have taken the opportunity to extend the scope of the book to accommodate the most recent evidence, which has emerged since the first edition was published in 1999. Key Features •



Written by three of the foremost researchers in the field of musculoskeletal dysfunction



•



Incorporates the very latest research from key workers in the field



•



Demonstrates the clinical relevance of the research findings to the student and busy practitioner



•



Presents a new, problem-solving approach to back pain assessment and management based on the latest understanding of the anatomy, physiology and biomechanics involved



•



Suggests future directions for clinical management and future research



•



Extensively illustrated with line diagrams and photographs.



Therapeutic Exercise for Lumbopelvic Stabilization presents the latest information on the muscle systems involved in the prevention and management of musculoskeletal pain and dysfunction, and introduces a unique approach to clinical management and prevention based on that research. It is an important book in that it not only presents the evidence but also gives practical guidance on how the findings may be applied in everyday practice. The first edition was widely welcomed and acc,laimed by researchers and clinicians alike. This new



/



This product is appropriate for.



edition will continue to provide an indispensable practical



•



manual therapy



reference source for all those working in the field of



•



physiotherapy



musculoskeletal pain and dysfunction.



•



chiropractic



•



osteopathy



•



orthopaedics



•



pain management



•



primary care



/�\ �� :u



CHURCHILL LIVINGSTONE



An imprint of Elsevier Ltd



Visit our website for additional outstanding products ELSEVIER



www.elsevierhealth.com



ISBN 0-443-07293-0



II



9 7804 4 3



r



7 2 9 32



Therapeutic Exercise for Lumbopelvic Stabilization



For Churchill Livingsione: Commissioning Editor: MalY Law /Saxena Wolfaard Project Development Manager: Mairi McCubbin Project Manager: Samantha Ross Dec;ign: Judith Wright



Thera pe u ti c Exercise for Lumbopelvic Stabilization A Motor Control Approach for the Treatment and Prevention of Low Back Pain SECOND EDITION Carolyn Richardson BPhty(Hons) PhD Associate Professor and Reader, Division of Physiotheropy, School of Health and Rehabilitation Science, University of Queensland, Brisbane, Australia



Pau I W. Hodges BPhty(Hons) MD(Neurosci) PhD NHMRC Senior Research Fellow and Associate Professor, Division of Physiotherapy, School of Health and Rehabilitation Science, University of Queensland, Brisbane, Australia



Julie Hides BPhty MPhtySt PhD Clinical Supervisor, The University of Queensland/Mater Hospital Back Stability Clinic, Brisbane, Australia



This book has been endorsed by the MACP



ma aD



MANIPULATION ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS



/�\ """ �



CHURCHILL LIVINGSTONE



-



EDINBURGH LONDON



NEW YORK OXFORD PHILADELPHIA ST LOUIS



SYDNEY TORONTO 2004



CHURCHILL LIVINGSTONE An imprint of Elsevier L imited



f) Harcourt Brace and Company Limited 1989 �) H a rcourt Publishers Limited 1999 G�) Elsevier Limited 2004. All rig hts rese r v ed. The right of Caro l y n Richardson, Paul Hodges and Julie Hides to be identified as



a uth o rs of this work ha s been asserted by the m in accordance with the Cop y r ight, Designs and Patents A ct 1988 No pM t of thi s publication m ay be reproduced, stored in a re tri eval system, or transmitted in any form or by any means, electronic, m echani c a l, photocopying, r e cord ing or otherwise, wi th out either the p r io r p ermiss ion of the publishers or



a



licence permitting restricted c opy ing in the United K ingd om issued b y the Copyright Licensing Agency, 90 Tottenham Court Road, Lo nd o n WIT



4LP.



Permissions may be sou gh t directly from Elsevier's Health Sciences Rights



Department in Philadelphia, USA: phone: (+1) 215 238 7869, fax: (+1) 21.5 238 2239, e-mail: [email protected]. You may also comp lete yo ur re qu e s t



on-line v i a the Elsevier homep a ge (http://www.elsevier.com). by selecti ng 'Customer Support' and then O bt ain ing Permissions'. '



First e di t io n 1999 Second edition 2004



[SBN 0443 07293 0 British Library Cataloguing in Publication Data



A c a talogue record for this book is ava i lable from the British Library Library of Congress Cataloging in Publication Data



A catalog record for this boo k is available from the Library of Cong res s Notice Kn o wledge and best pr act i ce in th i s field are constantly changing. As new research and experience broa den our knowledge, changes in pr a ctice, treatment



and d ru g therapy may become necessary or appropriate. Re aders check the mos t current iJl for m a tion provided



are



a dv i sed to



(i) on p roced ures featured or (u) by



the manufacturer of each p roduct to be administered, to ver i fy the recommended d ose or formula, the method and dur a tion of administration, a nd contraindica­ tions. [t is the responsibility of the practitioner, relying on their own experience



and knowledge of the pa tient to make diagnoses, to d e termi ne dosages and the ,



best treatment for each individual patient, a nd to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the author 110r



the MACP assume any lia bi li ty for any injury and/or d amage.



The Publisher your source for books, journals and multimedia in the health sciences



www.elsevierhealth.com



The Publish.r"s policy is 10 use paper manufachJred trom sustainable forests



Printed in China



I



v



Contents



Preface



VII



Acknowledgements



6. The role of weightbearing and non­ weightbearing muscles



ix



93



Carolyn Richardson



SECTION 1



Introduction



SECTION 3 Impairment in the joint



--_ ...._--= ...



1. The time to move forward



protection mechanisms: concepts



3



Carolyn Richardson



7. The deload model of injury



103



105



Carolyn Richardson



8. Joint injury



SECTION 2 The joint protection mechanisms



9. Pain models



PART 1



Introduction



119



Julie Hides



9 11



129



Paul Hodges



2. Lumbopelvic stability: a functional model of the biomechanics and motor control



13



SECTION 4 Impairments in the joint



Paul Hodges



protection mechanisms in low back pain



PART 2 Specific joint protection of the spinal segments



29



3. Abdominal mechanism and support of the lumbar spine and pelvis



orientation and weightbearing



59



75



77



Carolyn Richardson and Julie Hides



163



SECTI.ON 5 Treatment and prevention



PART 3 The antigravity muscle support



load transfer



149



Carolyn Richardson



Julie Hides



5. Stiffness of the lumbopelvic region for



Paraspinal mechanism in low back pain



12. Impairments in muscles controlling pelvic



4. Paraspinal mechanism and support of the



system



141



Paul Hodges



Julie Hides



Paul Hodges



lumbar spine



10. Abdominal mechanism in low back pain



11.



31



139



of low back pain



173



13. Principles of the 'segmental stabilization' exercise model



175



Carolyn Richardson, Julie Hides and Paul Hodges



14. Local segmental control



185



Julie Hides, Carolyn Richardson and Paul Hodges



15. Closed chain segmental control



221



Carolyn Richardson and Julie Hides



16. Open chain segmental control and progression into function



233



Carolyn Richardson and Julie Hides References Index



265



247



vii



Preface



Over the past decade a major focus of rehabilitation



Clinical studies have also conlirmed the presence



has turned to exercise to improve the stability of the



of muscle dysfunctions involving the deep muscle



lumbar spine and pelvis. There are a variety of clin­



system in pelvic pain syndromes. Other develop­



ical and research opinions in this area and many



ments include greater understanding of the mech­



methods have become popular in both the clinical



anisms for control and coordination of this system



arena and fitness industry. This book provides an



and the effects of unloading, and pain and injury.



overview of our interpretation of the field based on



Our recent research involving microgravity envi­



our research and clinical practice. While the first



ronments is providing the opportunity to evaluate



edition provided an introduction to our new



the effects of extreme environments that are likely



models of exercise and the state of knowledge at



to have an impact on functional environments on



that time, this second edition provides



Earth. An additional area that is continuing to



an



updated



view that integrates the burgeoning research in this field and the clinical advances. In relation to therapeutic exercise in low back pain, we believe that the focus of exercise inter­



expand is in the assessment of muscle control in



lumbopelvic pain. In this field we have made major advances in non-invasive methods to assess this system.



ventions by physiotherapists and other health



As research physiotherapists in the area of thera­



professionals should be designed to establish the



peutic exercise for low back pain we have chosen to



optimum interaction of muscles necessary to con­



investigate, in the first instance, the neurophysio­



trol and protect the joints, during the performance



logical mechanisms involved in joint protection



of a great



of the lumbo-pelvic region and the dysfunctions



variety of functional body movements.



In our first edition, we focused on the system of



which can occur. Even though many of the ideas



deep muscles that our research and clinical evi­



and hypotheses presented have not yet undergone



dence suggest are vital in control of the lumbar



rigorous scientific scrutiny, we feel that we have an



segments: the multifidus, transversus abdominis,



obligation in a text book on therapeutic exercise to



diaphragm and the pelvic floor muscles. So how



provide details of the new ways to approach exer­



over the last 5 years?



cise prescription as well as providing hypotheses for



Several key aspects have progressed. For instance



why certain exercise techniques traditionally used



long term follow-up data now indicates that the



by physiotherapists are likely to be very effective.



has our research progressed



interventions described in the first edition led to



Thus the research findings plus argued hypothe­



reduction of low back pain recurrence rates. Our



ses in this text have been used to give some insight



biomechanical studies have confirmed the import­



into therapeutic exercise techniques which are likely



ant contribution of the deep muscle system to con­



to be effective and also to develop non-invasive



trol of not just the lumbar spine , but also the pelvis.



measures which will reflect the problems in the



viii



PREFACE



musculoskeletal system in relation to joint protec­



using therapeutic exercise as a preventative meas­



tion. The principles presented can be applied to any



ure and to promote



region of the body.



as a t reatmen t after problems have occurred. This



One of the main aims of our past as well as our future research is to demonstrate that the pre­ scribed



therapeutic



exercises



are



resulting



in



is a



major



a



c h a n ge in l i fe sty le, not only



focus for our ongoing work.



We hope that you find reading the second edition of this textbook thought provoking and enjoyable.



improvement in the joint protection systems, and



We are excited that the work continues to evolve



hence demonstrate that c h an ges in the se mecha­



and grow in



nisms are closely linked to the resolution and even



will be useful to clinicians, students and researchers



prevention of painful symptoms. As



a



final note,



we also would like to emphasize the importance of



new



directions. We hope that this book



alike, and may stimulate new ideas which will ultimately help those w ith lumbopelvic pain.



ix



Acknowledgements



to first of all acknowledge the Jull whose excep ti ona l knowledge of physio therapy rehabilitation have made a si gni fica n t contribution to this book.



The authors wish



of a neutral spine pos ition for both the testing and



past efforts of G wend olen



treatment of spinal and trunk muscles



With



the



ex pansion



of



the



research,



each



.



Thanks to the staff, clinicians and students of the Joint Stability Research Unit Warren Stanton, Alison Grimaldi, Ruth Sapsford, Sally Hess, Chris



researcher has their own group of people to thank.



Hamilton, Daniel Belavy, Nathan Stewa rt, Quentin



Caroline and Julie extend their thanks to the



Scott, Helen Flem ing, Sue Roll, Sue Kelley, Jan



p r imary overseas research collaborator, Professor Chris



Snij ders



from



Erasmus



University



in



Rowena Topp enberg,



Smith, Mark Comerford,



Heidi Keto and the staff at the Back Stability Clinic



Hol land, whose biomechanical models blended



for their



well with their therapeuti c exercise models for low



exercise model.



contribution to the development of the



pain. In addition it was Professor Snijders



The editors' knowledge an d expertise in real­



who invited them onto the Topical Team for Low



t i me ultr a sound i maging has onl y d e v eloped and



Back Pain,



evolved with the assistance of Dr D a v i d Cooper,



back



an



initiative of the European Space



Agency (ESA).



an obstet r i ci an and gynaecologist who specializes



Thanks also to Benny Elmann Larsen, Senior



in ultrasound im aging His encouragement and



Physiologist for ESA, and Richard Lilmehan, NASA



guida nce have been in v a luable Int roduc ing some­



astronaut, who h a ve given Caroline and Julie the



thing n ew into a profession is never easy, and evi­



confidence to purs ue the ideas on the 'Deload



dence of the success of th e medium can



Model of Injury'. Dr Steve Wilson and Daniel



it develops into



Belavy deserve special mention with their excep­



tion and assessment tool in many physical therapy



tional expertise in instrument and sof tw are devel­



practices around the world.



.



.



being



a



b e seen as



routinely used rehabilita ­



opment for the measures used for the University of Queen slan d's contribution to ES A's Berlin bed rest



study at the Free University in Berlin.



A S PECIAL THANKS TO OUR FAM ILIES



The coll aborative research with Dr. Joseph Ng,



Caroline thanks her husband, Bren, for his never



of the Hong Kong Poly technic U niversi ty , has led



failing s upport with this very difficult but e xcitin g



to new discoveries of



the dysfunc tions present in trunk mu scles of low back pain p a tients and assisted with the development of t he exercise



task of writing



the



Europe with her to meetings and conferences.



model. It was phy siothe r apist, Christine Hamilton



Damian,



who alerted us, many y ears ago, of the imp orta nce



Cameron for their



a



book and his numerous trips to



Julie sends speci a l thanks to her husband, and



ch ildren



Emma,



Jonathon



and



p atien ce and en c o uragemen t



.



Without the support of her parents, Jill and David



of the neural control of the spine. They have



Cooper



taught him the rigor of scientific endeavour.



(and provision of extensive childcare



assistance) she never would have completed the



Thanks particularly to the international col­ laborators. The team in the Biomechanics and



'last ya rds'.



motor control laboratory of the Department of Neuroscience



PH



at



Karolinska



Institute



(Alf



Thorstensson, Andy Cresswell, Karl Daggfeldt



Paul thanks the collaborators in Australia and



and Anatoli Grigorenko) have provided important



overseas for their contribution to this work. At the



guidance in biomechanics and motor control and



University of Queensland he thanks the team of



stimulated Paul's pursuit of a second doctorate, in



the Human Neuroscience Unit ( Mi chel Coppieters,



neuroscience. On the other side of Sweden the



Catharina Bexander, Andrew Chapman, Rebecca



collaborators



Mellor,



Hospital (Allison Kaigle Holm, Sten Holm, Lars



Angela



Chang,



Sallie



Cowan,



Paulo



at



the



Sahlgrenska



University



Ferreira, Manuela Ferreira, Joanna Knox, Linda­



Ekstrom, Tommy Hansson) have provided an



Joy Lee, David McDonald, Nicola Mok, Steven



unrivalled opportunity to test the mechanisms of



Saunders,



Michelle



Smith,



Richard Yang) for their



Donna



s timulating



Urquhart, debate and



spinal control when the methods go beyond the limits of human experimentation.



contribution to the work presented here. In partic­



He would also like to thank his collaborators at



ular, thanks to Lorimer Moseley who has con­



the University of Melbourne (Kim Bennell, Sallie



tributed significantly to the work dealing with



Cowan, Kay Crossley) for giving him the opportu­



pain and its effect on the motor system. TIUs work



nity to be involved in tes ting the model of motor



is providing new insights in to the possible reasons



learning, albeit in another part of the body. This



for development of recurrent pain.



research is providing a foundation for under­



He is also grateful to his colleagues at the Prince



standing the mechanisms for efficacy of exercise.



of Wales Medical Research Institute in Sydney



Finally, he thanks his family (Merryn, Freya,



(Simon Gandevia, Jane Butler, Janet Taylor) who



Finn and Sofia) who have provided unrelenting



opened his eyes to the delights of neuroscience



support, despite the fact that Paul has been away



and challenged him to test the limits of human



often



eXDerimentation to gain a greater understanding



outcomes.



to



undertake



researd1



and



present



the



SECTION 1



Introduction



SECTION CONTENTS 1. The time to move forward



3



3



Chapter



1



The time to move forward Carolyn Richardson



INTRODUCTION



CHAPTER CONTENTS Introduction



3



Emphasis on motor control problems as a basis 3



of exercise



Exercise based on impairments in the neurophysiological mechanisms of j oint 6



protection The future



7



problems such as pain cont ri bute significantly to morbidity in the general popul a tion and form a maj or part of the high costs of health care in the industrialized world. Ironically, back pain is very pr ev a lent in the



Painful musculo-skeletal health low back



general 'health-focused' population who exercise to prevent



health problems i.n



tem, and it is also train



a



the cardiovascular sys­



major problem for those who



and compete at a



high level in sports and



ath­



letic events. Until



re c entl y,



the prevention and treatment



of insidious-onset mechanical low back pain



have



relied on the premise that the cause of mechanical low back pilin is



a



graduill breakdown



(i.e. 'wear



a.nd teilr') of the j oin t structures and associated soft tissues over periods of time. Biomechanicill and



focuse d on the spine and till' value of such



ergonomic research has successfully



ways



of minimizing



high



forcl�s on



has highlighted to the community



fa ctor s as safe working postures and furniture design in the prevention of low bilck pain.



EMPHASIS ON MOTOR CONTROL PROBLEMS AS A BA S IS OF EXERCISE The first edition



of this book addressed,



for the first



time, the deep muscles close to the lumbar spine and



pel vis,



their possible function i.n protecting



the joints from



injury and their



dysfunction in low



back pain. Front this new information,



a



new



pMa­



digm of exercise was devised that addressed the motor control problems in the muscles and focused



4



INTRODUCTION



on improving the mechanical support of the spinal



always been considered important concepts in the



joints through specific deep-muscle contraction exer­



development of mechanical low back pain. The



cises. This 'segmental stabilization training' tech­



complexity of this mechanism through the bones,



nique aimed at relieving the pain that had resulted



muscle and soft tissue has attracted the interest of



from irritation of pain-sensitive structures, subse­



many researchers. Load transfer has been shldied in



quent to tissue injury. This i.nitial breakthrough



relation to biomechanical models dealing with the



was possible because of astute clinical observation



stresses across the bones of the pelvis (Dalstra and



1995); other biomechanical models predict (e.g.



of patients with low back pain and through novel



Huiskes



research approaches, which allowed the morph­



that muscle forces and associated soft tissues



ology and control of the deep muscles to be inves­



fascias and ligaments) have a stabilizi.ng effect on



tigated scientifically for the first time. We also



load transfer and decrease the stress on the pelvic



explained the clinical tests that could be used to



joints.



assess the problems in the deep muscles in patients with low back



pain.



Some models have focused more on the way muscles protect the spine for weightbearing in terms



deep muscle function and



of their effect on neutral spinal curves in relation to



dy sfunction, and the ty pe of exercise required for



the pelviS. The biomechanical models of Keifer



This new paradigm of



(1997, 1998), which defined spinal stability in



the management of low back pain, was developed



et al



with recognition of the close relationship between



terms of the compressive load-bearing capacity of



muscle function and the biomechanics of spinal



the spine, included pelvic rotation in the model of



stability. The models of the sp.inal stability are



neutral postures. This model has contributed to our



overviewed in detail in Chapter 2.



understanding of ho"v a lordotic posture enhances the compressive loading of the spine. In addition,



Widening understanding of joint protection mechanisms in relation to exercise for the prevention and treatment of low back pain An expanded model for therapeutic exercise for



it demonstrated that the global muscles



are



suffi­



cient to stabilize and maintain equilibrium for small sagittal movements, although the addition of the local muscles, most importantly multifidus, could decrease the forces in the global muscles and fur­ ther enhance stability.



the prevention and treatment of low back pain has



It has been the extensive biomechanical model­



evolved through a deeper understanding of the



ling and anatomical studies from Erasmus Univer­



joint protection mechanisms from two different



sity in the Netherlands that has alerted researchers



but essential perspectives. Chapters 2, 3 and 4 dis­



in low back pain to innovative ideas of the role of



cuss, based on research findings, the role of the



muscles and associated soft tissues in decreasing



local muscle system in the support of the spinal



stress on the structures of the lumbopelvic region



segments, and its role in complex functions where



during load transfer. Snijders and colleagues



the control of the spine must be matched to the



(review),



demands of internal and external forces. To pro­



the important interaction between gravity, muscle



vide



forces, load transfer and the stability of the sacro­



a



further basis for exercise to promote the



integration of the local and global muscle systems



(1995 1998) have carried out many studies on



iliac joints.



into function, another aspect of the joint protection



Erasmus University also pioneered the load



mechanisms is introduced in this edition. This



transfer concept by studying the loading patterns in



aspect is related to the role of the antigravity muscle



terms of the effect on the posterior layer of the tho­



support system.



racolumbar fascia (Vleeming et al



1995) and the



effects of the loading patterns on the ligaments of



The antigravity muscle support system and joint protection



the pelvis, which are often painful in low back pain (Vleeming et



aI1996). These models and anatomical



studies highlighted the importance of particular



Wcightbearing mechanisms and the way load is



muscles, not only the transverses abdominis and the



specifically transferred through the pelvis have



erector spinae but also the large superficial muscles



The time to move forward



that attach to the fascia. Gluteus maximus and



More convincing scientific support for the delin­



the contralateral latissimus dorsi are considered



eation of skeletal muscle function into these two



important in the mechanism of load transfer diag­



categories has been



onally from arms to legs. These models have pro­



in microgravity (space) research. The microgravity



p rovid e d by our involvement



vided the impetus for strengthening programmes



environment, with minimal gravitational load cues



for patients with low back pain, involving a tnmk



present but where body movement remains import­



extension-rotation action (Mooney et al



2001).



While all these models for weightbearing func­



ant, provides the ideal model to test the theories of the delineation of muscle function into functional



tion of muscles are important in our understand­



categories. Results of animal and human research



ing of the biomechanical action of muscles, it is



to date strongly support the concept that lack of



our contention that the way in which the central



information to the body about



and



affects the



peripheral



neural



system



links



specific



muscles from each segment of the kinetic chain to give



a ntigr a v i ty



g r avi ty differentially



(one-joint) muscles, which



change their patterns of use, and disp l ay changes in



effective antigravity support system forms



physiology. Opposite changes occur in the multi­



a basis for optimal exercise for the integration of



joint, multifunction muscles, which experience



an



and global muscles within the framework



increased use in the microgravity environment;



of an effective prevention and rehabilitative exer­



this results in a lack of atrophy and indications are



cise programme for low back pain.



that they may even increase their levels of recruit­



the local



For an understanding of the antigravity muscle



ment. This change in muscle physiology occurs



support system, it will be argued that skeletal



through a process known



muscles can be classified, from a neurological point



ticity, where the physiological structure of muscles



of view, into weightbearing and non-weightbearing



is determined by the pattern of neural



categories. This delineation of skeletal muscle fw1C­



delivered to it.



as



neuromuscular pl