Current Concepts in Lumbar Spine

8/18/2019 Current Concepts in Lumbar Spine

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© Physioseminars 2009

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Anatomy of the Spine

Concentric layers of annulus fibrosus.

Surrounding incompressible nucleus pulposus.

Nucleus acts to distribute pressure evenly.

It behaves hydrostatically.

Post-lateral annulus is the weakest, not as firmly

attached to vertebral end plate, no cover of PLL(Edwardset al 2001)

Anterior compression caused by flexion squeezes thenucleus backwards, and conversely extension forces itforwards.


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Flexion Extension

Inter vertebral disc iscompressed anteriorly.

Size of the vertebral canaland IV foramen

Displacement of nucleusposterior.

Intra pressure is

Spinal cord & nerve rootsare stretched.

Inter vertebral disc iscompressed posteriorly.

Size of the vertebral canaland IV foramen

Displacement of nucleusanterior.

Intra discal pressure is Spinal cord & nerve roots

are stretched.

Nucleus pulposus

Annulus fibrosus

Facet joints

Ligaments

Muscles Nerve

Synovium


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On loading, fluid is expelled from the annulus fibrosis andgoes into the nucleus pulposus

Centripetal fluid shift


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Intradiscal mass displacement-non physiologicaldisplacement of tissues within the disc.

Protrusion-The displaced material causes a bulge in the intactwall of the annulus .(Hydrostatic Mechanism intact)

Extrusion-the disc material is displaced through the rupturedannular wall .(Hydrostatic Mechanism not intact)

Sequestration- a discrete fragment of disc material is forcedthrough the ruptured annular wall into the spinal canal.(Hydrostatic Mechanism not intact)


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Age/Occupation

Functional Disability /Base lines measures

Where is the location of the pain? (body Chart)

Duration

Is the pain constant or intermittent?

Onset

What positions or movements increase/decreasethe pain?

Past history of back pain

Diagnostics Sleep position and patterns, seated positions and

postures

Assessment of the Spine (History/ Interview)


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Bladder /bowel involvement, Saddleanaethesia,sciatica⇒ Cauda equina

Unexplained weight loss, Nocturnal pain H/O ofcancer⇒ Cancer

Trivial trauma in individual with osteopenia⇒Fracture

Systemically unwell ,febrile episodes⇒Spinal Infection

Exacerbations and remissions, marked morning

stiffness,raised ESR ,Persisting limitation allmovements⇒ Ankylosis Spondylitis

Waddell signs: Presence of nonorganic signssuggesting symptom magnification and

psychological distress◦ Superficial or nonanatomic distribution of tenderness

◦ Nonanatomic or regional disturbance of motor or sensoryimpairment

◦ Inconsistency on positional SLR

◦

Inappropriate/excessive verbalization of pain or gesturing◦ Pain with axial loading or rotation of spine.

◦ Give-away weakness: Inconsistent effort on manualmotor testing with “ratcheting” rather than smoothresistance


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C/o pain in back&neck


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1.Active Movements

A) Flexion

B) Extension

C) Lateral Flexion

D) Rotation Side glide

2.Repated Movement testing by McKenzie system.

3.Palpation

–muscles and fascia for increased tone andtrigger points.

4.Special Tests

a) Straight leg raise/slump test

b) SI joint test-Should be tested after ruling out L-Spine

c) Neurological examination

5.Muscles sling assessment.

6 Muscle imbalances Use Kendall’s guidelines


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Straight Leg Raise◦ Indication-C/o of pain and other symptoms in the

posterior & lateral aspect of the lower quarter.◦ Test -Hip Flexion with a straight knee

Structural VariationProximal symptoms-use dorsiflexion

Distal symptoms-Hip flexion producing distal symptoms.

Active neck flexion not recommended.

Sensitizing movements

1) Internal rotation and adduction of hip.2) Dorsiflexion/eversion (tibial Nv bias)

3) Dorsiflexion/inversion (sural Nv bias)

4) Plantarflexion/inversion (peroneal Nv bias)

Slump Test

Indications-Headaches, pain in spine or pelvis &lower limbs.

Test

1. Thoracic & lumbar flexion

2. Cervical flexion

3. Knee extension

4. Dorsiflexion

Structural differentiationProximal symptoms-use dorsiflexion

Sensitizing Movement

1)C/L lateral flexion

2)Hip Internal Rotation & adduction

3) Foot movements for each nerve


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Indication of the endurance of key muscle groups Bridge test are functional, they assess strength, muscle strength,

and ability of the athlete to control the trunk by the synchronousactivation of many muscles.

4 Tests-

1) Prone Bridge

2) Lateral Bridge

3) Flexion Endurance test

4) Extension Endurance Test


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Men Women

Extension 161 185

Flexion 136 134

Right side bridge 95 75

Left side bridge 99 78

Flexion/extensionratio

.84 .72

◦ FABER tests

FABER or Patrick’s test is used to assess hip or SI joint dysfunction


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Iliotibial BandStretch Test◦ Test will often

provoke pain inthe contralateralPSIS areaindicating and SIproblem

◦ SI dysfunction canlead to a

shortening of theIT-Band and aperpetuation orreoccurrence ofthe problem

Neurological Exam◦ Sensation Testing

If there is nerve root compression, sensation canbe disrupted


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◦ Reflex Testing

The two reflexes to be tested in the lower extremityare the patellar tendon and Achilles tendonreflexes

Used to assess the L4 and S1 nerve root respectively


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Indahi A,et al: Good prognosis for low back pain when left untampered. Arandomized clinical trail. Spine 20:473-477,1995

Van den Hoogen HJM,et al :The prognosis of low back pain in generalpractice.Spine 22:1515-1521,1997


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Boden SD,Wiesel SW:the multiply operated low back patient. In The Spine (ThirdEdition ). Eds : Rothman RH, Simone FA, W.B. Saunders Co., Philadelphia,1992

In a study on blue collar workers, isometric lifting strength was of no

predictive value for the future reports of the low back pain across thesexes, and in male workers, greater strength was actually associatedwith more frequent reports of low back pain (Batte M,et al :Spine

14;851-856,1989)


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FALSE: Comparison of patients with herniated lumbar discs to controls found no difference inexercise history during the time preceding onset of injury (Brennan G: Spine 12:699-702,1987)

In another study , frequent physical exercise actually showed borderline significance as a riskfactor for sciatica (Riihimaki H: Spine 19 138-142,1994)

-Mechanical Diagnosis& therapy (McKenzieSystem)

-Movement impairment syndromes- Sarhman

-Motor control impairment –O’Sullivan &

Dankaerts-Muscle imbalance- Janda

-Quebec Task Force-pain patterns


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DerangementSyndrome

Other

Posture SyndromeDysfunctionSyndrome

ScoliosisLumbar canal stenosisSpondylolisthesis

SI joint Vs L-spine Vs HipFacet joint syndromeChronic pain state


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Long A, Donelson R,Fung T:Does it matter which exercise ?A randomizedcontrolled clinical trail of exercise for low back pain.Spine 29:2593-2602,2004


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Most prevalent of the McKenzie’s mechanical subgroups.

Derangement means some disruption in joint articulation.

Characteristic signs are that of rapid changes in both jointsmechanical behavior and its symptoms.

Rapidly reversible LBP-Ron Donelson

One direction makes pain better and the opposite direction oftesting aggravates the pain e.g. lumbar flexion worsens thelumbar symptoms, extension testing will usually centralizeand abolish the same pain.

Clinical presentation includes worsening or peripheralisationof the symptoms in response to therapeutic loading

strategies Clinical pattern is variable

May have history of previous episodes

Signs and symptoms may be either somatic ,radicular or acombination. Patients with sciatica ,including many withneurological loss attributed by nerve root compression from aherniated disc, typically fall in this group

Symptoms may be constant or intermittent

May more proximally or distally

Repeated movements cause symptoms to increase/decrease,centralize /peripheralise,produce/abolish

Mechanical presentation always includes reduced ROM oracute deformity in a either forward (kyhotic) or lateral/Lateralshift (Scoliotic) direction.

Loading Strategies can cause lasting changes

Treatment-Reductive forces applied to reduce, abolish orcentralize symptoms


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Intermittent pain that is reproduced only when patient movesto their lumbar end range in a specific direction

It is consistent with the presence of painful, adaptivelyshortened tissues that are a result of contracture or scarringfrom the prior injury or surgery

Repeated movement will produce symtoms,which do notpersist after testing

Midline LBP without radiation and painful restriction of theend range

Present for atleast 6-8 weeks

Treatment-Remodelling program consists of stretchingexercises several times per day over several weeks tolengthenand remodel them so they they no longer limitmovement.

Smaller subgroup

Intermittent pain limited to LBP, no radiation

Produced only with prolonged positioning and loading of thespine at, or near end- range, usually in flexion

Prolonged slouching is by far the most common cause of thispain

Pain abolished by patient moving out of that end-rangeposition.

Repeated movement testing- No loss of lumbar motion, nodeformity and no pain with any direction of testing.

Treatment –Education and posture correction


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Centralization

It is a clinical phenomenon frequently observed duringmechanical evaluation of patients with low back painsyndromes. Centralization as defined by McKenzie, describesa situation in which the pain arising from the spine and feltlaterally from the midline or distally is reduced andtransferred to a more central or near midline position ,itoccurs in response to repeated movements or sustainedpostures.(23)

Useful for patient classification.

Prognostic value for identifying patients who will respondfavorably to conservative rehabilitation.

Directional Preferenceis the direction of the movement orposture (Flexion , Extension , or side-glide/rotation) thatproduces the centralization phenomenon.

Long et al demonstrated that patients with a mechanically

determined directional preference achieved superior

outcomes when the exercises and evidence-based advice

matched the individual’s directional preference compared to

exercise protocols unmatched to directional preference and

evidence-based advice.(24,25)

McKenzie introduced the concept of direction- specificexercises aimed at producing an analgesic effect for personswith LBP


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C/o of pain on the right side of back and buttock

Same day after shift correction –pain reduced


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History: Sudden, partial or complete loss of voluntary

bladder function due to massive disc impingementon spinal nerves

Saddle Anesthesia

Urinary retention and bilateral sciatica

Treatment: Surgical Emergency- decompression is mandatory

for prevention of irreparable / irreversible bladder

damage 12 hoursis the maximum time prior to irreversible

changes

Disease of older people

Caused by bone( facets,osteophytes) or soft tissues(bulgingdisc, ligamentam flavum enlargement)

Neurogenic Claudication,Numbness and tingling

Trial of conservative,nonsurgical treatment.

If intolerable ,MRI/CT and possible Laminectomy

Two directional subgroups

1) Pain improved when seated or spine is flexed.

2) Pain improved with performing end-range Lumbarextensions.


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Spondylolysis: Anatomic defect in the bony pars interarticularis

within the lamina

May uni- or bilateral

Can be congenital or induced

Usually without clinical symptoms with incidentalfindings on radiographs

Spondylolyisthesis

Progression of spondylolysis with separation Grades assigned I-IV for level of translation

Most common levels are L5-S1 (70 ) and L4-L5 (25 ) May be asymptomatic, but can result in

Spondylosis/DDD/Radiculopathy

Rule out Lumbar Spine

Is it SI joint – presence of at least three out of fivepain provocative SIJ tests (Mark Laslett , Aprill2003,Australian journal of physiotherapy)

Yes No

Treat Assess Hip


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Gaenslen’s test

Compression test

Distraction test

Thigh thrust test

“Based on our review, there are fewdata to support the use of symmetry ormovement tests in the identification ofwhat has been considered SIJdysfunction. In addition, the results ofradiographic studies suggest that the

motion at this joint is too small toaccurately assess with visualestimation and palpation.” Conclusionwas to use the above pain provocationtests to identify SIJ dysfunction.

Ferburger, Janet, Riddle ,Daniel, “UsingPublished evidence to guide theexamination of the SI joint region",Physical Therapy,81,5 ,May 2001

Sacral thrust test


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Pain generating mechanism influenced by psychologicalfactors or neurophysiologic changes peripherally or centrally

Persistent widespread pain

Aggravation with all activity

Exaggerated pain behavior

Inappropriate beliefs and attitudes about pain

Young S, Aprill C: Characteristics of a mechanical assessment for chronic lumbarfacet joint pain .J Manual and Manipulative Therapy 8: 78-84,2000


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THE McKENZIE METHOD CATEGORIZESPATIENTS INTO MEANINGFUL

SUBGROUPS

FOR THE PURPOSE OF PRESCRIBINGAPPROPRIATE THERAPEUTIC

INTERVENTIONS

Danish Institute for Health Technology Assessment. Low Back Pain. Frequency, Managementand Prevention from an (sic)HTA Perspective.Danish Health Technology Assessment 1999 1 (1)


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2)Movement Impairment syndromes(Sahrmann)

Lumbar rotation-extension syndrome

Lumbar extension syndrome

Lumbar rotation syndrome

Lumbar rotation-flexion syndrome

Lumbar flexion syndrome

3) Motor Control impairment (O’ Sullivan)

Flexion pattern

Flexion/lateral shifting pattern

Active extension pattern

Passive extension pattern Multidirectional pattern


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Provocative movements :Flexion , slump sitting. Pain relief: Standing, Prone lying , lean forward at hips

Tests

-Forward bend-↑ pain , most movement at spine

Impairments

-↑ stiffness of hamstrings , abdominals(RA)

-↓ stiffness of paraspinal

Treatment

-Correct posture

-Move at hips rather than spine

-Train control of paraspinal muscles

Provocative movements: Lumbar extension

Pain relief : Flattening of lumbar spine,↓ Hip flexor activity

Tests: ↑ pain during tasks involving extension

-Forward bending-↓symptoms

-Return from flexion-↑symptoms-ext early

-Supine-↓symptoms with knee bend

-Quadruped-Forward ↑ pain

Impairments- ↑ stiffness of hip flexors and ES

- ↓ stiffness of abdominals and gluteus maximus

Management

Correct and control lumbar lordosis

-Improve abdominal muscle control of rotation

-Improve hip flexor length


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Pain relief: Prevent lumbar rotation/LF

Tests:-Lateral Flexion-asymmetric

-Single leg stance-poor truck control

-Rocking back in quadruped

Impairments

-More flexible into rotation/lat flexion at lower segments than upper

Provocative movements: Rotation +/-lateral flexion

-↑stiffness of paraspinal ,Hip abductors

-↓stiffness of abdominal

Management

-Prevent rotation in low lumbar spine

-Identify tasks that include rotation

-Maximise rotation at hips

-Train control during movement tasks-quadruped control rotation

Provocative movements: Lumbar extension and rotation and limbmovement that produce these movements .

Pain relief: Flexion( eg stand with spine against the wall) Tests-Forward bending- Reduces pain, but extended early on return-Lateral flexion,rotation,single leg stance-asymmetric and poor

control.-Hip extension in prone Impairments

-Spine flexible into extension & rotation- ↑ stiffness of hip flexors ,hip abductors, lat dorsi- ↓ stiffness of abdominal muscles.- Dominant activity of extensor and hip flexor muscles- Oblique abdominals may be weak. Treatment-Control extension of lumbar spine• Improve abdominal control• Reduce tightness of hip flexors


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Provocative movements: Flexion & rotation-sitting(slump),bending,twisting

Pain relief: Prevention of flexion/rotation, prone lying

Tests:

-Forward bend-most movement of lumbar spine-pain

-Rotation-asymmetric

Impairments

-Hang on OE in sway back

-↑ stiffness of hamstrings

-↓stiffness of back extensors

Treatment

- Improve abdominal muscle control of rotation- Improve paraspinal to control lordosis

Key Components & Progressions1)Education

2)Posture Management-Ergonomics

3)Mobilization/Manipulation/Neuralmobilization

4)Specific Exercise- Directional Preference5)Core Stability

6)Specific Stretch and Strengthening

7)Prophylaxis


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Outcome

Treatment

Diagnosis

Assessment

Subjective pain ratings

Duration/Pain location/Severity

Back and leg pain Intensity

Oswestry score

Roland-Morris

Return to work status

Medication used Activity Interference

Lifting capacity

Return to work status

Self rated improvement-In %

Nottingham health profile


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Centralization (McKenzie)

Appears to identify a substantial subgroup ofspinal patients.

It is a clinical phenomenon that can be reliablydetected, and is associated with a good prognosis.

Negative Extension Sign (Herbert Alexander) A positive extension sign was defined as an

increase in radicular pain on attempted passive

lumbar extension

Alexander AH et al: Nonoperative management of herniated nucleus pulposus : patientselection by the extension sign .Long-term follow –up.Orthop Rev 21:181-188,1992


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STAGE 1 – Reducing the derangement

Posture education

Core muscle recruitment

Stretching of the shortened tissues

DURATION – 1-4 WEEKS

STAGE 2

MAINTAINENCE OF DERRANGEMENT

IMPROVING THE CORE STABILITY

POSTURE MAINTAINENCE

DURATION 2-4WEEKS


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Office of Horrors

http://e/My%20Documents/Safety%20talk%201.ppthttp://e/My%20Documents/Safety%20talk%201.ppt


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Monitor -20-40” Monitor height-

eye level. Keyboard Mouse Chair Desk Telephone Lighting


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There are a variety of exercises that can beperformed


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Should be routinely incorporated into therehab program

Used to reinforce pain-reducing movementsand postures

Extension exercises◦ Should be used when pain decreasing w/ lying down

and increases w/ sitting◦ Backwards bending is limited but decreases pain --

forward bending increases pain

◦ STLR is painful

Flexion Exercise◦ Used to strengthen abdominals, stretch, extensors

and take pressure off nerve roots

◦ Pain increases with lying down and decreases withsitting

◦ Forward bending decreases pain

◦ Lordotic curve does not reverse itself in forward

bending PNF Exercises

◦ Chopping and lifting patterns can be used tostrengthen the trunk, re-establish neuromuscularcontrol and proprioception


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Must re-educate muscles to contractappropriately

Stabilization exercises can help minimize thecumulative effects of repetitive microtrauma

Core/Dynamic stabilization

◦ Control of the pelvis in neutral position

◦ Integration full body movements and lumbarcontrol

◦ Incorporation of abdominal muscle control iskey to lumbar stabilization


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•Pelvic Floor muscles•Transversus Abdominis•Multifidus•Diaphragm

Attachments

-Lateral raphe of the the

thoracolumbar fascia

-Lateral 1/3 of the inguinal

ligament

-Iliac crest-Lower 6 costal cartilage

interditating with the costal fibers

of the diaphragm


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Role

Contraction increases intra-abdominal pressure.

Assists with spinal mobility.

Aids in increasing the stiffness value of the thoracolumbar fascia by itscontraction thereby allowing effective transference of the force through thespine.

Stabilizes the sacroiliac joint through tension generated in the posteriorsacroiliac ligaments( Lee,D.1999).

Provides a “hoop effect” around the midsection of the body.

Allows primary muscles for lumbar stability.

Is active in all planes of movement.

Pubococcygeus

Puborectalis

Ilicoccygeus

Ischiococcygeus

Role of the Pelvic Floor(Snapsford,1998)

-Unloading the spine

-Pelvic-Spinal stability

-Increased intra-abdominal pressure

-EMG studies show a correlation between pelvic floorand abdominal muscle contraction(Snapsford,Hodges,Richardson,1998)


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Coativation Pattterns -Pubococcygeus w/

Transversus Abdominis

-Puborectalis w/RectusAbdominis

-Iliococcygeus &Ishiococcygeus w/Obiliques.

Note

-Ischiococcygeus inserts

sacrospinous ligaments

-It is a dynamic stabilizer ofthe posterior sacroiliac joint.

Note:The fillingthe fascialenvelop’ effects stiffens thethoracolumbarfascia,contributing to the“hoop effect of the

transversus”


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Largest and most medial muscle of the lumbar muscles.

Polysegmental with separate bands which receive their owninnervation.

A study (Hives,1994) found evidence of lumbar multifidus localinhibition at the pathological segment with acute and subacute lowback pain.

The contraction of the multifidus adds to the stiffness value of thethoracolumbar fascia by filling up the fascial envelop formed betweenthe spinous process and the transverse processes on either side.

Although it is primarily an extensor of the lumbar spine,in standing itprimarily acts to resist anterior shear and flexion.

The multifidus and the psoas major form a force couple to square thelumbopelvic unit in the sagittal plane (Porterfield,Derosa 1991)

Similarly the multifidus and pelvis floor muscles act as a force coupleto check sacral nutation and counternutation in the sagittal plane(Lee,1998)

Sternal origin-Xiphoid Process

Costal origin-Last six ribs and costal cartilages.

Lumbar origin-1st ,3 or 4 lumbar vertibrae

All inserting radially on the central tendon

It is interesting to note that the crura of the diaphragm blendinto the psoas major inferiorly.

The TA interdigitates with the diaphragm as well.

The TA and the pelvic floor muscles work in a synergy.

It also acts as a passive restraint when increases in intraabdominal pressures as in weight lifting push the abdominalcontent superiorly.

It is interesting to note that the diaphragm significantlycontributes to the lumbarspine stability via the cruralattachments,during the sustained loading of the spine(Hodges2000)


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Lateral System

1. Ipsilateral Hipabductors

2. ContralateralHip adductors

Left side lying to test rightlateral sling .Abduct theright leg.

Insufficient recriutment ofthe gluteus medius

The posterior fibers ofgluteus medius arepalpated during the lateralloading of the leg inabduction and externalrotation.


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Deep LongitudinalSystem

1. Biceps Femoris2. Sacrotuberous

Ligaments3. Thoracolumbar

Fascia

4. Deep ErrectorSpinae


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AnteriorObilique System

1. IpisilateralExternalObiliques

2. ContralateralInternal Obiliques

3. Abdominal Fascia4. Contralateral Hip

adductors

A Sequenced curl up tests the

oblique abdominal portion of

the anterior oblique slings

bilaterally.

Bilateral overactivation of the

obilque abdominals will narrow

the infrasternal angle.


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PosteriorObilique System

1. IpsilateralLatissimus Dorsi

2. ThoracolumbarFascia

3. ContralateralGluteus Maximus

Test for lower part of

posterior oblique sling

Concentric action of

Gluteus maximus

Test for upper part of

posterior oblique sling

Test for Lat Dorsi and Right

post oblique sling


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Muscles that can adversely affect the biomechanics of thelumbo-pelvic region

Lattismus Dorsi

Errector Spinae

Oblique Abdominals

Hamstring

Psoas Major

Rectus femoris

TFL

Short and long adductors Piriformis/Deep external rotators of the hip

Progression of stabilization exercises shouldmove from supine activities, to proneactivities, to kneeling and eventually toweight-bearing activities

Stabilization exercises must be thefoundation and should be incorporated intoeach drill