Nonsurgical Management of LBP:Static Stabilization or Dynamic Exercise for the Back: Which One Do I Choose?

Benjamin L. Kolly DPT, OMPT, ATCXcel Physical Therapy, PLC

Clinical Relevance•Different approaches between clinicians?

▫Competence, Clinic Preference, Results

•Is one option better than the other, what does the evidence suggest?

•Should we use one or multiple stabilization models?▫May depend on outcomes, patient

experience, exposure, severity

Outline

•What is Stabilization•Continuum of Dynamic vs. Static

▫What is dynamic▫What is static

•Review of Literature•Key concepts•Suggested Implementation

Spinal Stabilization

•Definition: ▫Kinesthetic awareness of posture and the

ability to modulate spinal stiffness during functional activities

▫To transfer loads, disassociate limb movements from the spine, and make movements effortless.

•Barr et al 1:“Stability is a dynamic process that includes both static positions and controlled movement”

Stabilization Mechanisms•Panjabi described spinal stability as 3

interdepedent parts2

Bone and ligaments- most stability to passive restraint at end ROM

Muscles- support forces encountered daily Negatively affected by disuse 3

Pain and injury can negatively affect these muscles through pain and reflex inhibition 4

Neural control- coordinates mm activity to imposed demands (anticipatory and non-anticipatory)

Stabilization of other joints

•Muscle system can minimize aberrant joint displacement and act as strain absorber 5

•Muscle spindles may regulate mm stiffness by contracting the slow twitch tonic muscles 6

•Low load contractions (25% MVC) can provide maximal joint stiffness 7

•CKC activity may increase antagonist co-contraction & reduce shear forces. 8,9

Muscles• Complex system responsible for 1) stability and 2)

movement 10

• 1) Deeper muscles: thought to control stiffness and segmental stability▫ I.e.: TA, multifidus

• 2) Superficial or global system: torque generators or movers of the spine and responsible for dissipating external loads to the spine.▫ Contribute to stability in direction specific

movements and carrying weights11

▫ Comes at a price of increasing compressive load on the spine-possibly un-wanted in some conditions

▫ Limited control of shear forces (too far from axis of mvmt)

Dynamic Stabilization•Dynamic: a continuum of movement that

replicates functional activities; varies between authors and studies.

•Dynamic Exercise: purposeful, more often closed kinetic chain, movement with the intent of replicating normal functional activities of daily living, recreation, and sporting. Activation of the Larger, more superficial muscles of the trunk.

Static Stabilization•Static: A theory of tightening the

torso/trunk to minimize motions occurring through the trunk during physical activity or therapeutic training

•Static Exercises: commonly thought of as isometric, table or mat exercises emphasizing the deeper muscles

•Also known as motor control or specific stabilization exercises.

Stabilization TheoriesStatic Dynamic

• Required to restore atrophy of multifidus and TA

• Prevents compensation or substitution patterns in painful-weak muscles problems 12

• Generates a trunk extensor moment and reduces tensile loading, compression, and shear loads of the spine .12-16

• Proper technique and repetition of mm activation will transition into functional use and thereby spinal stability.17

• Lumbar spine function can improve without isolation of TA and multifidus

• To return to activity dynamic exercises need to be emphasized

• Isometric static holds increase intra-abdominal pressures and not practical

• Functional• Aids in restoring confidence

Efficacy• Philadelphia Panel Evidence Based Clinical Practice

Guidelines for Nonspecific LBP18

▫ Clinical benefit on pain relief function and perception for sub acute and chronic LBP with Therapeutic Exercises

• 2005 Cochrane review by Hayden et al examined 6 RCT : spinal exercise is particularly helpful in the healthcare settings.19

• Hicks et al20:when 3 following are found efficacy improves:▫ < 40 years old▫ SLR greater than 91 degrees▫ Positive prone instability test▫ Aberrant motion present during sagittal plane AROM

67% chance they would have significant improv (success) with meeting ¾

Transverse Abdominus• Primarily slow twitch type I fibers (low load, endurance

mm)• Theorized to act bilaterally as a corset or tensioning of

thoracolumbar fascia sometimes referred to as increasing intra-abdominal pressure 21

• TA may be activated in a feed forward mechanism contributing to stability, stiffness.

• Some authors have been unable to validate this concept22,23

• Found to contract before upper or lower extremity movements (anticipatory manner) preventing unwanted mvmt in subjects without LBP whereas in patients with LBP there was a delay in the contraction.24-29

• Teyhen et al found R to L side thickness of the TA was equivalent between those with and without LBP but there was a 21% greater change in girth within the asymptomatic group side to side from rest to contraction30

Training of the TA• Patients can retain TA contractions up to 1

week b/w sessions31 • 5 min instruction effectively maintain neutral

spine and minimize segmental spinal motion during biceps curl, hip flexion, and hip extension.32

• Some subjects with chronic LBP took 4-5 weeks of training to develop this co-contraction effectively33

• Subjects with LBP less effective at performing TA contraction than asymptomatic individuals 34

Allison, Morris, Lay in examination of the TA (2008)35

TA was not found to stabilize the spine during bilateral extremity movement

TA does not act as a corset nor does it reflect normal motor patterns seen in ballistic movement

Multifidus• Primarily slow twitch type I fibers (low load,

endurance mm)• Likely more responsible for resisting or

monitoring segmental rotation• Largest contributors to intersegmental

stability; found to contribute more than 2/3 of the stiffness at L4-5 segment 36

• Evidence of atrophy in chronic LBP 37

• Rich in mm spindles, attaches to facet joints, functions as proprioceptors or kinesthetic sensors 38,39

Repositioning accuracy reduced in subjects with LBP

Evidence of Multifidus Atrophy• Paraspinal mm 10-30% smaller on affected

side of unilateral post-operative LBP patients 42

• Chronic LBP patients have weak spinal extensors and/or multifidus 40-42

• Asymptomatic patients had a 3% +/- 4% side to side difference whereas unilateral pain patients demonstrated 31% +/- 8% difference. 43

Multifidi training44,45

•RCT 39 subjects 1st occurrence of unilateral LBP

•Both groups near full resolution of symptoms at 4 wks

•Standard care Group multifidus size unchanged at 4 and 10 wk

•Treatment Group multifidus CSA restored 4 weeks

•3yrs post study Standard Care Group had 9X greater likeliness of pain

Multifidus Training in Elite Cricket Athletes46

•13 week training camp, 26 young males (10 with hx of debilitating LBP)

•6 wk stabilization lieu of lifting weights in gym

•Results▫CSA increased and asymmetry reduced in

subjects with Hx LBP▫50% decrease in pain scores

RCT of Static Stabilization• Hides et al 45 : 45 subjects 1st occurrence of LBP

received standard medical care vs. multifidus/TA stabilization ▫ Short term (4 wks) no sig difference in rate of recovery

from acute pain ▫ Long term (2 and 3 year f/u) showed reduced

reoccurrence rates ▫ Standard Care 12 x more likely experience recurrent

LBP in the first year and 9x more likely in years 2-3. • O’Sullivan et al 33 : compared TA stabilization and

general management who underwent 1x/week x 10 weeks ▫ Post treatment and 2.5 year f/u showed greater

reductions in pain and disability in the stabilization approach.

RCT (Cont)• Goldby et al 47: 213 subjects over 10 weekly sessions received

spinal stabilization, minimal care, or manual therapy. All 3 groups 3hr back school which included advise on back exercise. ▫ No significant differences in pain, disability, QOL, and medication

between groups at 3,6,12,24 months although there was within group changes from baseline.

• Ferreira et al 48 : 223 subjects, 12 treatments in 8 weeks received general exercise, stabilization, or manual therapy. Both exer groups received cognitive behavioral therapy and encouraged to do HEP. ▫ Stabilization and manual therapy had SLIGHTLY better short term

pain and perceived functional outcomes but all groups had similar outcomes at 6 and 12 months and there was no statistical difference b/w groups.

• Cairns et al 49 : 97 patients with hx LBP received max 12 sessions in 12 weeks; randomized into conventional tailored PT or stabilization of multifidus and TA ▫ No significant differences in outcomes (pain, perceived disability,

QOL, and psychological distress) were detected after 12 weeks, 6 mo and 1 year follow up

RCT (cont)•Costa et al 50 : 154 patients with chronic

LBP divided into stabilization or placebo underwent 12 sessions in 8 weeks. ▫Small clinical improvements in stabilization

group seen at 2 months and generally maintained at 6 and 12 months

▫12 months significant pain reduction in stabilization

•Stuge et al (2004) 51 : TA stabilization demonstrated long term (2 years) positive outcomes in decreasing pain and disability

Systematic Review of Motor Control (Static Stabilization)52

• Better than minimal intervention (short term, intermediate, long term) and disability (long term)

• Better than manual therapy for pain, disability, QOL (intermediate)

• Better than other forms of exercise (5 RCT) in reducing disability short term

• Overall Motor Control may be effective in reducing pain and disability in nonspecific LBP but not superior to other forms of exercise

General vs. Specific Trunk Stabilization53

• Koumantakis et al: 67 subjects grouped into Stabilization of TA and multifidus vs general stabilization approach focusing on large mm groups (obliques and paraspinals)

▫ General group examples: crunches, prone trunk extension, pelvic tilting sitting/lying/standing positions, bridges, tilt with heel slides, lower abdominal crunches, 4-point kneeling, lateral planks, alt arm-leg movements, swiss ball exercises

▫ Specific trunk stabilization exercises: quadruped TA, multifidus manual palpation, co-contraction sit to stand, isolated movements of hip and thoracic spine, sitting on unstable base, aggravating postures, bridges with co-contraction, unstable base (swiss ball), functional co-contractions

• Results: no significant difference between the groups at 8 and 20 week examination

Examples of Static

•Richardson & Hull•Sahrmann•Hodges

Richardson & Hull Exercise Theory55

• Extremely difficult to determine if TA/Multifidus mm working when larger more active global mm are firing and as such you can’t effectively train or target the correct muscles

• Principles of stabilization:▫ Isometric contraction segmentally they stabilize and

don’t move▫ Prolonged low level contractions slow twitch endurance

mm and relatively low load required for stabilizing Begin 4 pt kneeling or prone where body weight supported Progressing holding time and reps before body weight loads

▫ Co contraction train in neutral with both TA and multifidus co contraction

Sahrmann56

•Training of the deep lumbar muscles with concurrent extremity movements (beginning with mat exercises) critical to establish safe functional movements of the legs.

•Lumbar extension during active hip extension occurs as a result of decreased abdominal control to counteract anterior pelvic tilt during manuever.

Paul Hodges

•Palpate isometric contraction of multifidus by having patient swell multifidus into hand

•Essentually have to make a conscious contraction out of a subconscious muscle

Examples of More Dynamic

•PNF•Pilates•Gary Gray•Gambetta•McKenzie•BET

PNF 57

•RCT 108 subjects with LBP >24 weeks underwent 4 weeks of intervention 5d/wk divided into 3 groups: alt trunk flexion-extension isometric contractions; alt concentric and eccentric contractions; C group normal daily living /avoid structured exercise.

•PNF exercises significantly increased spinal ROM and endurance but no significant difference between groups for disability ratings

Pilates Based58

•RCT 55 subjects with LBP >6 weeks or reoccurrence at least twice/year grouped into Pilates based or control for 12 sessions in 4 weeks

• Statistically lower level of self reported disability and pain intensity over control

•Maintained for up to 12 months post intervention

Gary Gray Functional Exercise

•Early pioneer in closed chain-functional exercise

•Little documentation and no RCT•Key Concepts: a) we never use our muscles

in isolation during real world movements so we should not create exercises that tease out functional movements; b) rehabilitate the body the way it functions in the real world; c) begin with isolated integration and move towards integrated isolation

Vern Gambetta

•Rehabilitation and strengthening of athletes and individuals involves training:▫Movements not muscles▫Fundamental skills before whole specific

task▫Use body weight before external loads▫Joint integrity before mobility

•Incorporate functional movements 

McKenzie method• Petersen et al compared McKenzie to

strengthening exercises in subacute –chronic LBP. McKenzie favored over strengthening but little statistical difference 59

• Miller et al compared McKenzie to stabilization exercises in chronic LBP. No significant differences were seen between the groups 60

• Long et al compared McKenzie to nonspecific or exercise groups in subacute – chronic LBP. McKenzie statistically better than both groups in the short term 61

RCT of Dynamic Stabilization 54

•Prospective study 42 patients post microdiscetomy; 3 groups (Williams – McKenzie exercises, dynamic stabilization, control group)

•Stabilization group showed significant improv in all parameters (P < 0.0001-0.0004)

•Williams – McKenzie moderate improvement in all parameters (P 0.0001 - .05)

• Parameters (pain, perceived functional capacity, depression, spinal mobility, weight lifting capacity, body strength)

Dynamic Stabilization Effectiveness•Gambetta, Gray, Pilates, PNF outcomes

not well studied or documented•Make sense functionally•Follows many motor control theories•Allows for dissipation of loads•Possibly allows for better co-contraction

Importance of Static & Dynamic• Panjabi: effective control of BOTH the deeper

muscles responsible for intervertebral stability AND the larger muscles responsible for movement across multiple levels are responsible for efficient stabilization and alterations in these neuromuscular control or loss of normal spinal mobility will cause pain 62

• Dynamic important to effectively stabilize the spine during real life experiences

• Static beneficial where hx of poor mvmt patterns or fxnal deactivation

Combined Static and Dynamic

•BET•Paris

BET (Back Education and Training)63

▫Utilizes principles of good BOS, efficient alignment for mm recruitment, sequencing of weight shifting

▫Progress volitional bracing (stable safe lumbar spine position) to automatic synergistic trunk activation. Early Rehab: Therapists assisted, therapist

resisted mat, or table exercises self bracing Mid Rehab: dynamic stabilization and pertubation

training, ball and rollers Late Rehab: active standing from weight shifting to

squats, to reaching and functional movements▫Final phase of training is no longer active

bracing but rather functional movements that involve kinesthetic awareness

Stanley Paris64

• Stabilization and integration an eclectic approach• Stabilization as 2 types:

▫Static stiffening spine, holding in neutral, minimize stress on sensitive tissues. Also referred to as muscular fusion Bridges, bridges with leg raise, pelvic tilt with leg

mvmts, TA seated, prone multifidus (opp SLR), quadruped UE /LE, Lunge with TA…

▫Dynamic spinal movement safely and under control, avoid outer limits of range and sustained postures or overloads. Also referred to as Neuromuscular control Quadruped (with or without UE / LE) with examiner

pertubation, resisted arm movements in standing, diagonal lifting

Motor Learning : Skill Acquisition • How individuals learn new tasks or exercises• Several Theories, Basic Principles65

▫Feedback give early in learning, allow person to adjust self latter

▫Whole task training might be better unless break down into naturally occurring elements (weight shift in walking not prone hip extension)

▫Transfer (how training transfers to a new task or new environment): Depends on similarity of task/environment (ie if

doing table exercises likely will not transfer to work demands unless practice in those environments)

Who benefits from stabilization?•Sub-acute and chronic18,19

•Stabilization programs may be beneficial in reducing reoccurrence rates 44

•Candidates with hypermobility tend to respond more favorably than those with hypomobility68

•Patients with ¾ of the characteristics in the CPR 20

What does all of this mean?

•Stabilization appears effective• Patients with LBP seem to have alterations in

mm pattern, sequencing, activation, and tone 25,44,66,67

•No scientific evidence to support any 1 concept over another

•Little if any evidence on dynamic stabilization (difficult to study)

•Success is likely dependant on multiple variables

How do we then implement program• Phase 1 (1-2weeks , 2 session/week)

▫ KISS Theory▫ Educate re injury and recovery, teach and practice

techniques for accuracy, implement self mgmt strategies, introduce positive outlook, allow for some natural healing, avoidance of pain maneuvers

▫ Progress from 10 sec to 3 minute intervals before phase 2

• Phase 2 (2 +/- 6 weeks, 3 session/week)▫ Progress stabilization towards functional restoration▫ Incorporate larger movements

• Phase 3 (6-12 months)▫ Continue exercises independently, f/u with clinician

for goal setting, guidance, and exercise progression…

Phase I▫ Teach pain free movement patterns and exercises: low compressive

loads▫ Reduce overload/over-activity of errector spinae mm; Wake up the

smaller mm▫ Emphasize conscious awareness of pelvic positioning / identify neutral

position and movement with and without extremity movements▫ Abdominal drawing in maneuver (ADIM) quadruped to prone,

biofeedback (start at 70mmHg and have them lower 6-10mmHg for 10 +sec) May not be better than other forms of stabilization but may have role in

motor control, safe exercise, reduced intradiscal pressures, allow patient to see changes and improvements

▫ Initiate co-contraction of multifidus with TA using palpation▫ Devel core awareness: activating multifidus and TA during functional

positions of sit, SDLY, prone, stand, supine▫ Teach concepts in isolation then utilize and practice movements in

more functional positions ▫ Chronic progress faster than acute▫ Goals: noticeable relief, activation of approp mm, hold ADIM 30 reps x

30+ sec, understanding of self mgmt, standing/sitting tolerances, walking tolerances, fxnal tasks

Phase II▫ Build on Phase I if very acute

Unloaded trunk ROM (quadruped), hip flexibility, aerobic exercise, ADIM supine with heel slides/leg lifts, bridging, 4 point, 4 point on roller/unstable surface, sitting/standing/walking, standing rows

Quadruped multifidus unilateral arm lifts, leg lifts, ADIM in horizontal side support

▫ Progress stabilization to functional restoration▫ Break down fxnal tasks into components to increase accuracy and

minimize fear avoidance Ex: Bending over to p/u object first teach pain-free deep knee

bends or lunges then incorporate rotation of the hips and ankles with the bend, and lastly add resistance

▫ Challenge spine in daily activities and movements (squatting, bending, lifting); incorporate basic body-mechanic applications

▫ Modify speed of movements, direction, and external loads in preparation for discharge

▫ Diagonals / PNF▫ Goals: Restricted RTW or sport, increasing workloads, discharge

to self

Phase III• Continue exercises independently, f/u with

clinician for goal setting, guidance, and exercise progression▫Prevention of future injuries▫Sports enhancement through core strengthening▫High level activities/recreation/sport while

stabilizing the spine▫Distraction exercises (ball tosses, extreme

reaching) while keeping co-contraction, simulated work/recreational activities, lifting OH

▫Functional drills on unstable surfaces (rocker board/balls)

▫Goals: address functional limitations, fears, enhancement

Important Considerations• Aerobics / Cardiovascular Endurance• Cognitive Behavioral Strategies (Fear Avoidance)• Body Mechanics• Teach ADIM, Pelvic Tilt in isolation and with

movement• Train extensors (Sorenson Test > 100 sec)• Train endurance: > 3 min per rep • Improv neural processing to fire in nml efficient

manner• Consider activity and specificity of activity• Fear avoidance habits – Graded exposure• Train proprioception• Train pertubation / anticipatory /functional activities

Take Home•Combine treatment approaches•Movement may be just as important as

stiffness to dissipate forces (reduce loads), reproduce practical movements, and minimize energy expenses

•Choose approaches based on patient tolerances and fear

•Modify treatment based on functional outcomes

•What works for the Goose may not work for the Gander

Questions

•Ben can be reached at bkolly@xceltherapy.com

References• 1. Barr KP, Griggs M, Cadby T: Lumbar stabilization: Core concepts and current literature, part 1. Am J

Phys Med Rehabil. 2005;84:473-480.• 2. PanjabiMM: The stabilizing system of the spine: Part I. Function, dysfunction, adaptation, and

enhancement. J Spinal Disord 1992;5:383-89.• 3 Richardson CA, Jull GA. Concepts of rehabilitation for spinal stability. In: Boyling JD, Palastanga N (eds)

Grieves modern manual therapy of the vertebral column 2nd ed. Churchhill Livingstone, Edinburgh. 1994: 705-720.

• 4 Baugher WM, Warren RS, Marshall JL, Joseph A. Quadriceps atrophy in anterior cruciate deficient knee. The Amer J of Sports Med. 1984;12: 192-195

• 5. Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D’Ambrosia R. Muscular activation. The role of the antagonist musculature in maintaining knee stability. The Amer J of Sp Med. 1998; 16(2): 113-122.

• 6. Johansson H, Sojka P. Pathophysiological mechanisms involved in genesis and spread of muscular tension in occupational muscle pain and in chronic musculoskeletal pain syndromes: a hypothesis. Med Hypotheses. 1991; 35: 196-203.

• 7. Hoffer J, Andreassen S. Regulation of soleus muscle stiffness in premamillary cats. J of Neurophysiology. 1981; 45:267-285.

• 8. Kvist, J., and J. Gillquist. Sagittal plane knee translation and electromyographic activity during closed and open kinetic exercises in anterior cruciate ligament- deficient patients and control subjects. Am. J. Sports Med. 2001; 29:72– 82.

• 9. Fleming, B.C., P.A. Renstrom, G. Ohlen, R.J. Johnson, G.D. Peura, B.D. Beynnon, and G.J. Badger. The gastrocnemius muscle is an antagonist of the anterior cruciate ligament. J. Orthop. Res. 2001; 19:1178 –1184.

• 10. Bergmark A. Stability of the lumbar spine: A study in mechanical engineering. Acta Orthop Scand Suppl 1989;230:1-54.

• 11 Kuukkanen TM, Malkia EA. An experimental controlled study on postural sway and therapeutic exercise in subjects with low back pain. Clin Rehabil 2000;14:192-202

• 12. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for spinal segmental Stabilization in Low Back pain. Edinburgh, Scotland Churchill Livingstone; 1999

• 13. Daggfeldt K, Thorstensson A. The role of intraabdominal pressure in spinal unloading. J Biomech. 1997; 30: 1149-1155.

• 14. McGill S. Normal and injury mechanics of the lumbar spine. In: Low back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, IL, Human Kinetics, 2002, pp87-136

• 15. Gardner-Morse MG, Stokes IA. The effects of abdominal muscle coactivation on lumbar spine stability. Spine. 1998;23:86-91.

• 16. Axler CT, McGill SM. Low back loads over a variety of abdominal exercises: searching for safest abdominal challenge. Med Sci Sports Exer. 1997;29:804-811.

• 17. Stevens J, Green Haal K. Motor skill acquisition strategies for rehabilitation of low back pain. J Orthop Sports Phys Ther 1998;28:165-7.

• 18. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back pain. Phys Ther. 2001; 81:1641-1674.

• 19. Hayden JA, van Tudler MW, Malmivaara Akoes BW. Exercise therapy for treatment of nonspecific low back pain. Cochrane Database Syst Rev. 2005; 3: CD00035.

• 20. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary dvelopment of a clinical prediction rule for determining which patients with low back pain will respond to stabilization exercise program. Arch Phys Med Rehabil. 2005; 86:1753-1762.

• 21. Barker PJ, Guggenheimer KT, Grkovic I, et al. Effects of tensioning the lumbar fasciae on segmental stiffness during flexion and extension: Young Investigator Award winner. Spine. 2006; 31:397-405.

• 22. Allison GT, Morris SL. The influence of fatigue on trunk mm responses to sudden arm movements, a pilot study. Clin Biomech (Bristol Avon). 2002;17:414-417.

• 23. Hodges PW, Cresswell A, Thorstensson A. Preparatory trunk motion accompanies rapid upper limb movement. Exp Brain Res. 1999;124(1): 69-79

• 24. Hodges PW, Changes in motor planning of feed forward postural responses of the trunk muscles in low back pain. Exper Brain res. 2001; 141:261-266.

• 25. Hodges Pw, Richardson A. Inefficient muscular stabilization of the lumbar spine associated with low back pain: A motor control evaluation of transverse abdominus. Spine. 1996;21:2640-2648.

• 26. Cresswell AG. Responses of intra-abdominal pressure and abdominal muscle activity during dynamic trunk loading in man. Eur J Appl Physiol Occup Physiol. 1993;66:315-320.

• 27. Hodges PW, Richardson CA. Delayed postural contraction of transverse abdominus in low back pain associated with movement of the lower limb. J Spinal Disord. 1998;11:46-56.

• 28. Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehabil. 1999; 80:1005-1012.

• 29. Hodges PW, RichardsonCA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77:132-42.

• 30 Teyhen DS , Bluemle LN, Dolbeer JA, Baker SE, Molloy JM, Whittaker J, Childs JD. Changes in lateral Abdominal Muscle Thickness During the Abdominal Drawing-in Maneuver in those with lumbopelvic pain. J of Orth Sports Phys Ther 2009; 39:11:791-798.

• 31. Karst GM, Willett GM. Effects of specific exercise instructions on abdominal muscle activity during trunk curl exercises. J Orthop Sports Phys Ther 2004;34:4-12.

• 32. Kavic N Grenier S, McGill SM. Quantifying tissue loads and spine stability while performing commonly prescribed low back stabilization exercises. Spine 2004; 29:2319-29.

• 33. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22:2959-2967

• 34. Richardson CA, Hides JA, Wilson S. Stanton W, Snijders CJ. Lumbopelvic joint protection against antigravity forces: motor control and segmental stiffness assed with magnetic resonance imaging. J Gravit Physiol. 2004;11:P119-122.

• 35. Allison TA, Morris SL, Lay B. Feedforward Responses of Transversus Abdominis Are Directionally Specific and act asymmetrically: Implications for core stability theories/ J Orthop Sports Phys Ther. 2008;38(5):228-237.

• 36. Wilke HJ, Wolf S, Claes LE, Arand M, Wiesend A. Stability of the lumbar spine with different muscle groups: A biomechanical In Vitro study. Spine 1995;20(2):192-198.

• 37. Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw EE, De Cuyper HJ. CT imaging of trunk muscles in chronic low back pain patients and healthy control subjects. Eur Spine J. 2000; 9:266-272.

• 38. Bogduk N. Clinical anatomy of the lumbar spine and sacrum. Edinburgh, Churchill Livingstone, 1997.

• 39. Brumagne S, Cordo P, Lysens R, Verschueren S, Swinnen S. The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine 2000;25:989-994.

• 40. Ebenbichler GR, Oddsson LI, Kollmitzer J, Erim Z: Sensory-motor control of the lower back; implications for rehabilitation. Med Sci Sports Exer 2001; 33:1889-98.

• 40. Ebenbichler GR, Oddsson LI, Kollmitzer J, Erim Z: Sensory-motor control of the lower back; implications for rehabilitation. Med Sci Sports Exer 2001; 33:1889-98.

• 41. Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehabil. 1999; 80:1005-1012

• 42 Laasonen EM. Atrophy of sacrospinal muscle groups in patients with chronic, diffusely radiating lumbar back pain. Neuroradiology 1984; 26:9-13

• 43. Richardson C, Jull G, Hodges P, et al. Traditional views of the function of the muscles of the local stabilizing system of the spine in: Therapeutic Exercise for Spinal Segmental Stabilization in Low back pain: Scientific Basis and Clinical Approach. Edinburgh, Chur chill Livingstone, 1999 pp21-40

• 44. Hide JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996; 21:2763-9.

• 45. Hides JA, Jull GA, Richardson CA. Long term effects of specific stabilization exercises for first-episode low back pain. Spine 2001;26:E243-8.

• 46. Hides J, Stanton W, McMahon S, Sims K, Richardson C. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J of Orthop Sports Phys Ther. 2008; 38(3):101-108.

• 47. Goldby LJ, Moore AP, Doust J, Trew ME. A randomized controlled trial investigating the efficacy of musculoskelatol physiotherapy on chronic low back disorder. Spine 2006;31:1083-1093

• 48. Ferreira ML, Ferreira PH, Latimer J, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic, low back pain: a randomized trial. Pain 2007; 131:31-7.

• 49. Cairns MC, Foster NE, Wright C. Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine. 2006;31:E670-681

• 50. Costa Leonardo OP, Maher CG, Latimer J, Hodges PW, Herbert RD, Refshauge KM, McAuley JH, Jennings MD. Motor Control Exercise for chronic low back pain: A randomized placebo-controlled trial. Phys Ther 2009; 89(12):1275-1291.

• 51. Stuge B, Veierod MB, Laerum, E, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a two year follow-up of a randomized clinical trial. Spine. 2004; 29:E197-203.

• 52. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor Control for persistent, nonspecific low back pain: A systematic review. Phys Ther. 2009; 89(1):9-25.

• 53. Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther. 2005; 85:209-225.

• 54. Yilmaz F, Yilmaz A, Merdol F, Parlar D, et al. Efficacy of dynamic lumbar stabilization exercise in lumbar microdiscectomy. J Rehabil Med 2003; 35: 163-167

• 55. Richardson CA and Jull GA. Muscle control – pain control. What exercises would you prescribe? Man Therapy 1995;1:2-10.

• 56. Sahramm, SA. Diagnosis and Treatment of movement impairment syndrome. St Louis MO Mosby: 2002.

• 57. Kofotolis N, Kellis E. Effects of two 4-week proprioceptive neuromuscular facilitation programs on muscle endurance, flexibility, and functional performance in woman with chronic low back pain. Phys Ther. 2006; 86:1001-1012.

• 58. Rydeard R, Leger A, Smith D. Pilates-Based therapeutic exercise: Effect on subjects with nonspecific chronic low back pain and functional disability: A randomized controlled trial. J Orthop Sports Phys Ther. 36(7): 472-484.

• 59. Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S. The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: a randomized controlled trial. Spine; 2002;27:1702-9.

• 60. Miller ER, Schenk RJ, Karnes JL, Rouselle JG. A comparison of the McKenzie approach to a specific spine stabilization program for the chronic low back pain. J Manipulative Ther. 2005;13:103-12.

• 61. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized controlled trial of exercise for low back pain. Spine 2004;29:2593-602.

• 62. PanjabiMM. Clinical spinal instability and low back pain. J Electromyogr Kinesiol. 2003;13:371-379.

• 63. St John, Karen. The Institute of Physical Art, Inc. Back Education and Training (BET). 2004

• 64. Paris, Stanley. Spinal Instability Whole Spine Stabilization. University of St Augustine for Health Sciences. 2003.

• 65. Shumway –Cook A and Woollacott MH. Motor Control Theory and Practical Applications. 2nd Ed. Lippincott Williams and Wilkins Philadelphia 2001. Ch 1 Theoretical Framework. Pp1-162.

• 66. Moesley GL, Nicholas MK, Hodges PW. Pain differs from non-painful attention-demanding or stressful tasks in its effect on postural control patterns of trunk muscles. Exp Brain Res. 2004;156:64-71

• 67. O’Sullivan P, Twomey L, Allison G et al. Altered patterns of abdominal muscle activation in patients with chronic low back pain. Aust J Physiother. 1997;43:91-8.

• 68. Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil 2005; 86:1745-5.