Low Back Pain - American University of Beirutwebthera/downloads/presentations... · Low Back Pain Mansour Dib MD Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation

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

Disc diseaseDisc diseaseDisc diseaseDisc disease

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 painSacroiliac joint painSacroiliac joint painSacroiliac joint pain

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)

Multifidus atrophyMultifidus atrophy

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


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”


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


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

Supine BridgingSupine BridgingSupine BridgingSupine Bridging

Side BridgingSide BridgingSide BridgingSide Bridging

“Dog Bird” exercise“Dog Bird” exercise“Dog Bird” exercise“Dog 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



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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Low Back Pain - American University of Beirutwebthera/downloads/presentations... · Low Back Pain Mansour Dib MD Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation