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Low Back Pain Low Back Pain Mansour Dib MDMansour Dib MD
Physical Medicine and RehabilitationPhysical Medicine and RehabilitationMansour Dib MDMansour Dib MD
Physical Medicine and RehabilitationPhysical Medicine and RehabilitationPhysical Medicine and RehabilitationPhysical Medicine and RehabilitationPhysical Medicine and RehabilitationPhysical Medicine and Rehabilitation
Pain generatorsPain generatorsPain generatorsPain generators
DiscDiscDiscDisc
Posterior elementsPosterior elementsPosterior elementsPosterior elements
SacroSacro--iliac jointiliac jointSacroSacro--iliac jointiliac joint
Education - Spine PositioningEducation - Spine PositioningNeutral Extension FlexionNeutral Extension Flexion
Discogenic low back painDiscogenic low back painDiscogenic low back painDiscogenic low back pain
AxialAxialMay radiateMay radiateAxialAxialMay radiateMay radiateyy
lower extremities, groin, lower abdomenlower extremities, groin, lower abdomenExacerbating factors:Exacerbating factors:
yylower extremities, groin, lower abdomenlower extremities, groin, lower abdomen
Exacerbating factors:Exacerbating factors:ace bat g acto sace bat g acto ssitting, riding in a car, Valsalva, bending, sitting, riding in a car, Valsalva, bending, lifting, prolonged positioninglifting, prolonged positioning
ace bat g acto sace bat g acto ssitting, riding in a car, Valsalva, bending, sitting, riding in a car, Valsalva, bending, lifting, prolonged positioninglifting, prolonged positioning
Relieving factors: Relieving factors: walking, lying downwalking, lying down
Relieving factors: Relieving factors: walking, lying downwalking, lying down
Posterior elements painPosterior elements painPosterior elements painPosterior elements pain
Back +/Back +/-- leg painleg painwith standing +/with standing +/-- walkingwalking
Back +/Back +/-- leg painleg painwith standing +/with standing +/-- walkingwalkingrelieved by sitting, grocery cart relieved by sitting, grocery cart pain immediately upon wt. bearingpain immediately upon wt. bearingrelieved by sitting, grocery cart relieved by sitting, grocery cart pain immediately upon wt. bearingpain immediately upon wt. bearing
Arthritic painArthritic painmorning stiffnessmorning stiffness
Arthritic painArthritic painmorning stiffnessmorning stiffnessbetter with activity, heatbetter with activity, heatbetter with activity, heatbetter with activity, heat
Sacroiliac joint dysfunctionSacroiliac joint dysfunctionSacroiliac joint dysfunctionSacroiliac joint dysfunction
Often after a fall directly on to buttocksOften after a fall directly on to buttocksalso pregnancy, ankylosing spondylitisalso pregnancy, ankylosing spondylitis
Often after a fall directly on to buttocksOften after a fall directly on to buttocksalso pregnancy, ankylosing spondylitisalso pregnancy, ankylosing spondylitis
Low back/PSIS painLow back/PSIS paincan radiate can radiate -- posterior thighs, groinposterior thighs, groin
Low back/PSIS painLow back/PSIS paincan radiate can radiate -- posterior thighs, groinposterior thighs, groinp g gp g g
Painful transitions Painful transitions sit to stand, getting in/out of car, stepssit to stand, getting in/out of car, steps
p g gp g gPainful transitions Painful transitions
sit to stand, getting in/out of car, stepssit to stand, getting in/out of car, steps, g g , p, g g , pturning in bed, putting socks onturning in bed, putting socks on
, g g , p, g g , pturning in bed, putting socks onturning in bed, putting socks on
Why exercise ?Why exercise ?Why exercise ?Why exercise ?
Treatment for back pain can vary from Treatment for back pain can vary from medications, to injections, to surgery…medications, to injections, to surgery…Treatment for back pain can vary from Treatment for back pain can vary from medications, to injections, to surgery…medications, to injections, to surgery…
One common pathway for ALL One common pathway for ALL One common pathway for ALL One common pathway for ALL p yp yCAUSES: muscle retraining (exercise)CAUSES: muscle retraining (exercise)
p yp yCAUSES: muscle retraining (exercise)CAUSES: muscle retraining (exercise)
How does exercise work in back pain ?How does exercise work in back pain ?How does exercise work in back pain ?How does exercise work in back pain ?
Spine stability (Panjabi model)Spine stability (Panjabi model)Spine stability (Panjabi model) Spine stability (Panjabi model)
Bone and ligamentsBone and ligamentsBone and ligamentsBone and ligaments
Muscles surrounding the spineMuscles surrounding the spineMuscles surrounding the spineMuscles surrounding the spine
Neural control system coordinating periNeural control system coordinating peri--spinal muscular contractionspinal muscular contractionNeural control system coordinating periNeural control system coordinating peri--spinal muscular contractionspinal muscular contractionspinal muscular contraction spinal muscular contraction spinal muscular contraction spinal muscular contraction
Bones and LigamentsBones and LigamentsBones and LigamentsBones and Ligaments
An intact spine from An intact spine from which muscles have which muscles have been removed willbeen removed will
An intact spine from An intact spine from which muscles have which muscles have been removed willbeen removed willbeen removed will been removed will buckle under 9 kgs buckle under 9 kgs !! (Cisco, Panjabi !! (Cisco, Panjabi
been removed will been removed will buckle under 9 kgs buckle under 9 kgs !! (Cisco, Panjabi !! (Cisco, Panjabi ( , j( , j1992)1992)
( , j( , j1992)1992)
MusclesMusclesMuscles Muscles
Main stabilizing systemMain stabilizing systemMain stabilizing systemMain stabilizing system
Deep perispinal muscles:Deep perispinal muscles:Deep portion of multifidusDeep portion of multifidus
Deep perispinal muscles:Deep perispinal muscles:Deep portion of multifidusDeep portion of multifidusDeep portion of multifidusDeep portion of multifidusTransversus abdominis (TA)Transversus abdominis (TA)Quadratus lumborumQuadratus lumborum
Deep portion of multifidusDeep portion of multifidusTransversus abdominis (TA)Transversus abdominis (TA)Quadratus lumborumQuadratus lumborum
MultifidusMultifidusMultifidusMultifidus
Deepest of the Deepest of the posterior musclesposterior musclesSh tSh t
Deepest of the Deepest of the posterior musclesposterior musclesSh tSh tShortShortSegment to Segment to segment stabilitysegment stability
ShortShortSegment to Segment to segment stabilitysegment stabilitysegment stabilitysegment stabilityPrimary slowPrimary slow--twitch twitch (endurance) muscle (endurance) muscle
segment stabilitysegment stabilityPrimary slowPrimary slow--twitch twitch (endurance) muscle (endurance) muscle ( )( )fibersfibers( )( )fibersfibers
Transversus abdominisTransversus abdominisTransversus abdominisTransversus abdominis
Deepest of the Deepest of the oblique musclesoblique musclesDeepest of the Deepest of the oblique musclesoblique muscles
Activated separately Activated separately from otherfrom otherActivated separately Activated separately from otherfrom otherfrom other from other abdominal musclesabdominal musclesfrom other from other abdominal musclesabdominal muscles
Acts like a natural Acts like a natural corsetcorsetActs like a natural Acts like a natural corsetcorset
Quadratus lumborumQuadratus lumborumQuadratus lumborumQuadratus lumborum
Important for lateral Important for lateral stabilitystabilityImportant for lateral Important for lateral stabilitystability
What makes the spine “unstable”What makes the spine “unstable”What makes the spine “unstable”What makes the spine “unstable”
“Big Movers”“Big Movers”Rectus abdominisRectus abdominisObliObli
“Big Movers”“Big Movers”Rectus abdominisRectus abdominisObliObliObliquesObliquesBig proximal limb Big proximal limb musclesmuscles
ObliquesObliquesBig proximal limb Big proximal limb musclesmuscles
Neural control systemNeural control systemNeural control systemNeural control system
Stabilizers contract before big movers (deltoid, hip Stabilizers contract before big movers (deltoid, hip abductors) in response to a visual stimulusabductors) in response to a visual stimulus
I h lth i 10% f i l t ti iI h lth i 10% f i l t ti i
Stabilizers contract before big movers (deltoid, hip Stabilizers contract before big movers (deltoid, hip abductors) in response to a visual stimulusabductors) in response to a visual stimulus
I h lth i 10% f i l t ti iI h lth i 10% f i l t ti iIn healthy spine: 10% of maximal contraction is In healthy spine: 10% of maximal contraction is needed for stabilizationneeded for stabilization
Stabilization is carried throughout the wholeStabilization is carried throughout the whole
In healthy spine: 10% of maximal contraction is In healthy spine: 10% of maximal contraction is needed for stabilizationneeded for stabilization
Stabilization is carried throughout the wholeStabilization is carried throughout the wholeStabilization is carried throughout the whole Stabilization is carried throughout the whole movementmovement
This response is altered in LBP the stabilizers firingThis response is altered in LBP the stabilizers firing
Stabilization is carried throughout the whole Stabilization is carried throughout the whole movementmovement
This response is altered in LBP the stabilizers firingThis response is altered in LBP the stabilizers firingThis response is altered in LBP, the stabilizers firing This response is altered in LBP, the stabilizers firing late or quickly fatiguedlate or quickly fatiguedThis response is altered in LBP, the stabilizers firing This response is altered in LBP, the stabilizers firing late or quickly fatiguedlate or quickly fatigued
Effect of Injury or PathologyEffect of Injury or PathologyEffect of Injury or PathologyEffect of Injury or Pathology
Pain inhibitionPain inhibitionChange in sensory input to the musclesChange in sensory input to the musclesPain inhibitionPain inhibitionChange in sensory input to the musclesChange in sensory input to the musclesg y pg y p
with ligamentous or capsular damagewith ligamentous or capsular damageReflex inhibitionReflex inhibition
g y pg y pwith ligamentous or capsular damagewith ligamentous or capsular damage
Reflex inhibitionReflex inhibitione e b t oe e b t oappears to affect small, monoappears to affect small, mono--joint joint muscles moremuscles more
e e b t oe e b t oappears to affect small, monoappears to affect small, mono--joint joint muscles moremuscles more
Significant muscle inhibition noted in Significant muscle inhibition noted in acute LBP patientsacute LBP patientsSignificant muscle inhibition noted in Significant muscle inhibition noted in acute LBP patientsacute LBP patients
InstabilityInstabilityInstabilityInstability
Evidence shows serious dysfunction of Evidence shows serious dysfunction of the stabilizing system in LBPthe stabilizing system in LBPEvidence shows serious dysfunction of Evidence shows serious dysfunction of the stabilizing system in LBPthe stabilizing system in LBP
Multifidus atrophies in patients with LBP Multifidus atrophies in patients with LBP (Laasonen et al 10(Laasonen et al 10 30% smaller on the30% smaller on theMultifidus atrophies in patients with LBP Multifidus atrophies in patients with LBP (Laasonen et al 10(Laasonen et al 10 30% smaller on the30% smaller on the(Laasonen et al. 10(Laasonen et al. 10--30% smaller on the 30% smaller on the painful side)painful side)(Laasonen et al. 10(Laasonen et al. 10--30% smaller on the 30% smaller on the painful side)painful side)
Switch from type 1 (endurance) to type Switch from type 1 (endurance) to type 2 (quick firing) muscle fibers2 (quick firing) muscle fibersSwitch from type 1 (endurance) to type Switch from type 1 (endurance) to type 2 (quick firing) muscle fibers2 (quick firing) muscle fibers(q g)(q g)(q g)(q g)
Instability’s vicious cycleInstability’s vicious cycleInstability’s vicious cycleInstability’s vicious cycle
InstabilityInhibition and weakness of stabilizers yof stabilizers
Back pain
Increased lordosis Increased lordosis Neutral Neutral spine spine
Increased lordosis Increased lordosis Neutral Neutral spine spine
Break the cycleBreak the cycleBreak the cycleBreak the cycle
Specific “core strengthening” targets the Specific “core strengthening” targets the deficient muscles (multifidi, TA)deficient muscles (multifidi, TA)Specific “core strengthening” targets the Specific “core strengthening” targets the deficient muscles (multifidi, TA)deficient muscles (multifidi, TA)
Reestablish the proper neuromuscular Reestablish the proper neuromuscular Reestablish the proper neuromuscular Reestablish the proper neuromuscular p pp psequence = sequence = stabilizers contract before stabilizers contract before big movers big movers
p pp psequence = sequence = stabilizers contract before stabilizers contract before big movers big movers
Goals of Physical TherapyGoals of Physical TherapyGoals of Physical TherapyGoals of Physical Therapy
Stabilize the spine during activities of daily Stabilize the spine during activities of daily livinglivingStabilize the spine during activities of daily Stabilize the spine during activities of daily livingliving
Improve muscles strength, endurance Improve muscles strength, endurance (multifidi, TA, etc.)(multifidi, TA, etc.)Improve muscles strength, endurance Improve muscles strength, endurance (multifidi, TA, etc.)(multifidi, TA, etc.)
Change muscle activation patternsChange muscle activation patternsChange muscle activation patternsChange muscle activation patterns
Goals of Physical TherapyGoals of Physical TherapyGoals of Physical TherapyGoals of Physical Therapy
Increase lumbar segmental stiffnessIncrease lumbar segmental stiffnesswithout interfering with trunk movementwithout interfering with trunk movement
Increase lumbar segmental stiffnessIncrease lumbar segmental stiffnesswithout interfering with trunk movementwithout interfering with trunk movement
Tonic low grade contraction of Tonic low grade contraction of supporting muscles for joint protectionsupporting muscles for joint protectionTonic low grade contraction of Tonic low grade contraction of supporting muscles for joint protectionsupporting muscles for joint protectionReRe--establish effective automatic motor establish effective automatic motor patternspatternsReRe--establish effective automatic motor establish effective automatic motor patternspatterns
ExercisesExercisesExercises Exercises
Exercises vary according to the pain Exercises vary according to the pain generatorgeneratorExercises vary according to the pain Exercises vary according to the pain generatorgenerator
“Unload” the pain generator“Unload” the pain generatorE t i bi d l b t bili ti fE t i bi d l b t bili ti f
“Unload” the pain generator“Unload” the pain generatorE t i bi d l b t bili ti fE t i bi d l b t bili ti fExtension biased lumbar stabilization for Extension biased lumbar stabilization for disc paindisc painFlexion biased for facetogenic painFlexion biased for facetogenic pain
Extension biased lumbar stabilization for Extension biased lumbar stabilization for disc paindisc painFlexion biased for facetogenic painFlexion biased for facetogenic painFlexion biased for facetogenic painFlexion biased for facetogenic painStrengthening of SIJ stabilizers: hip Strengthening of SIJ stabilizers: hip abductors…abductors…
Flexion biased for facetogenic painFlexion biased for facetogenic painStrengthening of SIJ stabilizers: hip Strengthening of SIJ stabilizers: hip abductors…abductors…
ConclusionConclusionConclusionConclusion
Pain generator may varyPain generator may varyPain generator may varyPain generator may vary
Pain from whatever cause leads to lumbar Pain from whatever cause leads to lumbar “instability” by muscle inhibition“instability” by muscle inhibitionPain from whatever cause leads to lumbar Pain from whatever cause leads to lumbar “instability” by muscle inhibition“instability” by muscle inhibition
Retraining stabilizing muscles is essentialRetraining stabilizing muscles is essentialRetraining stabilizing muscles is essentialRetraining stabilizing muscles is essential
Low Back Pain and exercise Low Back Pain and exercise
Evidence shows no effect of exercise on Evidence shows no effect of exercise on intensity or duration of acute episode of intensity or duration of acute episode of Evidence shows no effect of exercise on Evidence shows no effect of exercise on intensity or duration of acute episode of intensity or duration of acute episode of LBP (Hayden et al.)LBP (Hayden et al.)LBP (Hayden et al.)LBP (Hayden et al.)
Decrease in recurrence and intensity of Decrease in recurrence and intensity of LBP (mechanical and radiculopathy) LBP (mechanical and radiculopathy) Decrease in recurrence and intensity of Decrease in recurrence and intensity of LBP (mechanical and radiculopathy) LBP (mechanical and radiculopathy) (Hides et al.)(Hides et al.)(Hides et al.)(Hides et al.)
What exercise program ?What exercise program ?What exercise program ?What exercise program ?
Dynamic Lumbar Stabilization Dynamic Lumbar Stabilization Dynamic Lumbar Stabilization Dynamic Lumbar Stabilization
Promoted in the 1990’s by Hodges and Promoted in the 1990’s by Hodges and Richardson (Queensland physio group)Richardson (Queensland physio group)Promoted in the 1990’s by Hodges and Promoted in the 1990’s by Hodges and Richardson (Queensland physio group)Richardson (Queensland physio group)( p y g p)( p y g p)
Concept not so new ( Pilates in 1920’s)Concept not so new ( Pilates in 1920’s)
( p y g p)( p y g p)
Concept not so new ( Pilates in 1920’s)Concept not so new ( Pilates in 1920’s)Concept not so new ( Pilates in 1920 s)Concept not so new ( Pilates in 1920 s)Concept not so new ( Pilates in 1920 s)Concept not so new ( Pilates in 1920 s)
Dynamic Lumbar StabilizationDynamic Lumbar StabilizationDynamic Lumbar StabilizationDynamic Lumbar Stabilization
Most recent trend in physical therapy Most recent trend in physical therapy and athletics and athletics Most recent trend in physical therapy Most recent trend in physical therapy and athletics and athletics
Back painBack painIncrease in performanceIncrease in performanceBack painBack painIncrease in performanceIncrease in performanceInjury preventionInjury prevention
Y T i Chi Pil t ll t t “Y T i Chi Pil t ll t t “
Injury preventionInjury prevention
Y T i Chi Pil t ll t t “Y T i Chi Pil t ll t t “Yoga, Tai Chi, Pilates: all target “core Yoga, Tai Chi, Pilates: all target “core strength”strength”Yoga, Tai Chi, Pilates: all target “core Yoga, Tai Chi, Pilates: all target “core strength”strength”
Dynamic Lumbar StabilizationDynamic Lumbar StabilizationDynamic Lumbar StabilizationDynamic Lumbar Stabilization
SynonymsSynonymsCore strengtheningCore strengthening
SynonymsSynonymsCore strengtheningCore strengtheningNeuromuscular retrainingNeuromuscular retrainingNeutral spine controlNeutral spine controlNeuromuscular retrainingNeuromuscular retrainingNeutral spine controlNeutral spine controlMuscular fusion Muscular fusion Trunk stabilizationTrunk stabilizationMuscular fusion Muscular fusion Trunk stabilizationTrunk stabilization
Training the Transversus Training the Transversus gAbdominis
gAbdominis
Bracing technique: patient supine, Bracing technique: patient supine, draws in lower abdomen, tightens pelvic draws in lower abdomen, tightens pelvic Bracing technique: patient supine, Bracing technique: patient supine, draws in lower abdomen, tightens pelvic draws in lower abdomen, tightens pelvic floor, slight anterior pelvic tiltfloor, slight anterior pelvic tiltfloor, slight anterior pelvic tiltfloor, slight anterior pelvic tilt
Training the TATraining the TATraining the TATraining the TA
Biofeedback for proper TA activation:Biofeedback for proper TA activation:Therapist experienceTherapist experience
Biofeedback for proper TA activation:Biofeedback for proper TA activation:Therapist experienceTherapist experiencePressure device placed beneath lumbar Pressure device placed beneath lumbar spinespinePressure device placed beneath lumbar Pressure device placed beneath lumbar spinespineReal time ultrasound to visualize TA Real time ultrasound to visualize TA contractioncontractionReal time ultrasound to visualize TA Real time ultrasound to visualize TA contractioncontraction
Training the TATraining the TATraining the TATraining the TA
Progress from supine bracingProgress from supine bracingProgress from supine bracingProgress from supine bracing
StandingStandingStandingStanding
SittingSittingSittingSitting
Bracing during lumbar motionBracing during lumbar motionBracing during lumbar motionBracing during lumbar motion
Dynamic Lumbar StabilizationDynamic Lumbar StabilizationDynamic Lumbar StabilizationDynamic Lumbar Stabilization
Supine bridging: activates multifidiSupine bridging: activates multifidiSupine bridging: activates multifidiSupine bridging: activates multifidi
Side bridging: quadratus lumborumSide bridging: quadratus lumborumSide bridging: quadratus lumborumSide bridging: quadratus lumborum
Dog bird exerciseDog bird exerciseDog bird exerciseDog bird exercise
Prone bridgingProne bridgingProne bridgingProne bridging
Physical Therapy:ProgressionPhysical Therapy:ProgressionPhysical Therapy:ProgressionPhysical Therapy:Progression
Unstable surface (soft mattress, physio Unstable surface (soft mattress, physio ball)ball)Unstable surface (soft mattress, physio Unstable surface (soft mattress, physio ball)ball)
External challenges ( throwing and External challenges ( throwing and External challenges ( throwing and External challenges ( throwing and g ( gg ( gcatching a ball)catching a ball)
g ( gg ( gcatching a ball)catching a ball)
Advance to sport or activity specific Advance to sport or activity specific exercise with “core stabilized” exercise with “core stabilized” Advance to sport or activity specific Advance to sport or activity specific exercise with “core stabilized” exercise with “core stabilized”
Efficacy of DLSEfficacy of DLSEfficacy of DLS Efficacy of DLS
Hides et al. Exercise program reversed Hides et al. Exercise program reversed multifidi atrophy and reestablished multifidi atrophy and reestablished Hides et al. Exercise program reversed Hides et al. Exercise program reversed multifidi atrophy and reestablished multifidi atrophy and reestablished symmetrysymmetrysymmetrysymmetry
O’Sullivan et al. Core strengthening O’Sullivan et al. Core strengthening group showed significant improvement group showed significant improvement O’Sullivan et al. Core strengthening O’Sullivan et al. Core strengthening group showed significant improvement group showed significant improvement in pain and function in pain and function in pain and function in pain and function
Efficacy of DLSEfficacy of DLSEfficacy of DLSEfficacy of DLS
Multiple studies showed significant pain Multiple studies showed significant pain improvement in spondylolysis and improvement in spondylolysis and Multiple studies showed significant pain Multiple studies showed significant pain improvement in spondylolysis and improvement in spondylolysis and spondylolisthesisspondylolisthesisspondylolisthesisspondylolisthesis
Reduces the intensity and recurrence of Reduces the intensity and recurrence of chronic, recurrent LBP (Hides et al. chronic, recurrent LBP (Hides et al. Reduces the intensity and recurrence of Reduces the intensity and recurrence of chronic, recurrent LBP (Hides et al. chronic, recurrent LBP (Hides et al. 2001)2001)2001)2001)
Practices to avoidPractices to avoidPractices to avoidPractices to avoid
Classic “sit ups”: excessive Classic “sit ups”: excessive compression forcescompression forcesClassic “sit ups”: excessive Classic “sit ups”: excessive compression forcescompression forces
Heavy strengthening of the extensors: Heavy strengthening of the extensors: loads are typically too heavyloads are typically too heavyHeavy strengthening of the extensors: Heavy strengthening of the extensors: loads are typically too heavyloads are typically too heavyloads are typically too heavyloads are typically too heavy
Avoid spinal exercises in the first hourAvoid spinal exercises in the first hour
loads are typically too heavyloads are typically too heavy
Avoid spinal exercises in the first hourAvoid spinal exercises in the first hourAvoid spinal exercises in the first hour Avoid spinal exercises in the first hour of the morning: high hydrostatic of the morning: high hydrostatic pressure inside discspressure inside discs
Avoid spinal exercises in the first hour Avoid spinal exercises in the first hour of the morning: high hydrostatic of the morning: high hydrostatic pressure inside discspressure inside discspppp
Goals of DLSGoals of DLSGoals of DLSGoals of DLS
Increase lumbar segmental stiffnessIncrease lumbar segmental stiffnesswithout interfering with trunk movementwithout interfering with trunk movement
Increase lumbar segmental stiffnessIncrease lumbar segmental stiffnesswithout interfering with trunk movementwithout interfering with trunk movement
Tonic low grade contraction of Tonic low grade contraction of supporting muscles for joint protectionsupporting muscles for joint protectionTonic low grade contraction of Tonic low grade contraction of supporting muscles for joint protectionsupporting muscles for joint protectionRelearn motor skills required for joint Relearn motor skills required for joint supportsupportRelearn motor skills required for joint Relearn motor skills required for joint supportsupportReRe--establish effective automatic motor establish effective automatic motor patternspatternsReRe--establish effective automatic motor establish effective automatic motor patternspatterns
Transversus AbdominisTransversus AbdominisTransversus AbdominisTransversus Abdominis
Controlled independently of other Controlled independently of other abdominal musclesabdominal musclesControlled independently of other Controlled independently of other abdominal musclesabdominal musclesActivated prior to other abdominal Activated prior to other abdominal musclesmusclesActivated prior to other abdominal Activated prior to other abdominal musclesmusclesActivation is not directionActivation is not direction--specificspecific
opposite occurs in back pain patientsopposite occurs in back pain patientsActivation is not directionActivation is not direction--specificspecific
opposite occurs in back pain patientsopposite occurs in back pain patients
Role of Transversus AbdominisRole of Transversus AbdominisRole of Transversus AbdominisRole of Transversus Abdominis
Proposed mechanisms of actionProposed mechanisms of actionConversion to a rigid cylinderConversion to a rigid cylinder
Proposed mechanisms of actionProposed mechanisms of actionConversion to a rigid cylinderConversion to a rigid cylinderRestriction of interRestriction of inter--segmental motionsegmental motionInterInter--segmental compressionsegmental compressionRestriction of interRestriction of inter--segmental motionsegmental motionInterInter--segmental compressionsegmental compressionRotatory control of interRotatory control of inter--segmental motionsegmental motionHelps stabilize the sacroiliac jointHelps stabilize the sacroiliac jointRotatory control of interRotatory control of inter--segmental motionsegmental motionHelps stabilize the sacroiliac jointHelps stabilize the sacroiliac joint
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