Indeperpedent Subsystems With Low Back Pain
Panjabi et al. proposed a concept for understanding spinal stability, injury, dysfunction and recovery, asserting that there are three interdependent subsystems that function to stabilize the spine: the passive, active and neural subsystems:
- The passive musculoskeletal subsystem includes the spine and its vertebrae, disks and ligaments. The spinal column is the load-bearing unit and the source of passive stiffness for stabilizing the spine.
- The active musculoskeletal subsystem comprises the muscles attached to, or influencing the spinal column. These muscles are the source of active stiffness via their stored elastic energy and their level of activation or force.
- The neural control subsystem is the controller. This system uses feedforward control to generate active stiffness and uses feedback control to to augment the stiffness.
These three subsystems are interdependent and work together to maintain spinal stability and intervertebral motion in a healthy and unhealthy state. Damage or dysfunction in one subsystem requires the other two to compensate. For example, an injury such as disc degeneration affecting the passive musculoskeletal subsystem may decrease the inherent stability of the spine and alter segmental motion patterns. Enhancement of the neural and active musculoskeletal subsystems could then help compensate for this loss and partially restore stability of the area of the spine.
- Panjabi MM: Clinical spinal instability and low back pain. J Electromyogr Kinesiol 13:371-379, 2003
- Panjabi MM: A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur Spine J 15:668-676, 2006
- Panjabi MM: The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord 5:383-389, 397, 1992
- Panjabi MM: The stabilizing system of the spine. Part II. Neu tral zone and instability hypothesis. J Spinal Disord 5:390-397, 1992
- Panjabi M, Abumi K, Duranceau J, Oxland T: Spinal stability and intersegmental muscle forces. A biomechanical model. Spine 14:194-200, 1989
- Panjabi MM, Krag MH, Chung TQ: Effects of disc injury on mechanical behavior of the human spine. Spine 9:707-713, 1984
Lumbar Spine With Low Back Pain
A wise man once said “if you know where you come from, then you know where you are going.” In other words “if you know your past, you know your future.” Both quotes are definitely applicable for those dealing with clients to prevent or treat low back pain. So, where is this exercise rational coming from?
In the 1980’s Bergmark undertook a mechanical engineering approach to the study of the lumbar spine. He wanted to assess the role of the trunk musculature in providing stabilization for the lumbar spine and the specific forces applied to it by different muscles. Using this approach, he divided the musculature acting on the lumbar spine into two groups: local and global muscles. The global muscles such as the erector spinae and rectus abdominus was felt to transfer load between the thoracic spine and pelvis. The local muscles act directly onto the spine and are attached directly onto the vertebrae (eg. multifidi).
Functionally, the global musculature was felt to balance the outer loads on the body, while the local muscles controlled the loads within the lumbar spine.
Kinetic Integrations respects pain as pain makes us change to way we move and stabilize our body; in fact, pain creates movement dysfunctions. Now, for normal movement to return not only pain but also the behaviors it effects must be resolved.
What is Pain?
Pain is essentially an early warning sign that alerts us that damage to tissues is happening and without this warning, serious bodily harm could happen. Actually, KI believes that this reflexive response to noxious stimuli is a major evolutionary drive for survival and plasticity of the nervous system as it helps us to detect and remember danger. Just imagine if we would not learn from our painful experiences and thereby not avoid past and present dangers? Personal survival would be short-lived, wouldn’t it?
Pain is often initiated by specialized sensory nociceptor fibers innervating peripheral tissues such as the skin. A couple things happen almost simultaneously when this response kicks in gear:
- Nociceptor fibers cause a sensory flow activates neurons in the spinal cord which projects it to the cortex in the brain, eliciting pain.
- Nociceptive input activates reflex withdrawal, an increase in arousal as well as an emotional, autonomic and neurohumeral responses.
Often I see fear in working with clients that return to simple activities such as stepping down from a stool. Do you see similar responses with your populations?
Vibration Training Concepts
The moment I got introduced to our PowerPlate whole body vibration (WBV) equipment I got hooked on it. I wondered why doing just a simple stationary squat exercise made my legs tired after just 60 seconds of exposure and why some of my inflexible clients could magically touch their toes when reaching forward although they could not do that when not standing on the plate. The most amazing response I saw though was a client with diabetic peripheral neuropathy causing pain and loss of sensation in her feet for years. In fact she had to wear special shoes or otherwise she was unable to walk with a normal gait pattern. After a one session 5 minute exposure her pain magically disappeared and normal gait restored for two hours. In sum, exposure to WBV can dramatically change somebodies function and lifestyle.
Lets explore of what happens when our body gets exposed to WBV. The body’s natural stretch reflex kicks into high gear when exposed to it as if it is trying to resist being thrown around at a very high rate. This is done reflexively (unconsciously) to maintain the body in an upright position. The predominant muscles involved here are the fast-twitch muscle fibers of the postural musculature. This is actually believe to occur at higher levels that during most strengthening exercises.
Return to Functional Movement Training
Although the body seems to be made up out of different parts and that muscles seem to have independent actions, all of these assumptions go out the window when we move. While I am not suggesting that you should not learn about the body through its parts and muscle actions, those isolated concepts fail to make you understand how the body actually transfers itself from one position to the next.
With origins linked to sports performance training, neuroscience and rehabilitation, Kinetic Integrations emphasizes that in order to return, continue or progress functional movement we need to train the body and mind specifically to obtain those demands. This approach emphasizes the importance of coordinating the complex interactions between the neural and muscular components related to these activities. Specifically KI is interested in the neural components of training as it enhances optimal movement patterns through the nervous system neuroplasticity.
No matter how old we are, the central nervous system is capable of learning and relearning so function maintains or improves. Through changes in our physical demands and repetition of those demands, the ability to carry out activities with greater accuracy and speed emerge – functional movement improves as a result.
Questions For You
- When was the last time that somebody accomplished anything by flexing and extending their biceps muscle?
- Are you applying neuroplastic concepts to your population or yourself?
Is Core Stability Just a Myth?
For a few decades now, the terminology “core stability” has been accepted as synonymous to good health. It is common knowledge that optimal core stability resolves low back pain and increases performance. A whole industry grew out of this stability model with gyms and clinics teaching the “abdominal hollowing” or “trunk bracing” exercises to prevent or treat low back pain. The question is though, is core stability for real or is it just a myth that has developed into a life of its own?
During the 1990’s the term “core stability” became popular through the studies on trunk muscle onset timing in back injury and chronic low back pain. However, these findings combined with the general belief about the importance of strong abdominals to create a strong back as well as the influences from Pilates have promoted several assumptions prevalent in core stability training:
- Certain muscles are more important for stabilization of the spine, in particular the transverse abdominis (TrA).
- Weak abdominal muscles lead to back pain.
- Strengthening abdominal or trunk muscles can reduce back pain.
- There is a unique group of “core” muscles working interdependently of other trunk muscles.
- A strong core will prevent injury.
- There is a relationship between stability and back pain.
The Abdominal Hollowing method to stabilize the spine is based on the Richardson philosophy of trunk stabilization. Often rehabilitation and exercise specialists will use this method of stability as they feel that trunk stabilization retraining should start with reestablishing local lumbar stability first.
To instruct your client to perform the Abdominal Hollowing technique follow the following directions:
- Let your client lay down on the floor or on a treatment table in a supine hook-lying position.
- Stand next to the client.
- Ask the client to put both of their hand on their lower abdominal region at he level of their belly button.
- With permission from the client put your hand on top of their hand as if covering their belly button. Note: if you stand on their right side, use your right hand. If on their left side, use your left hand.
- Instructions: “Breath in and out normally for a few breaths until relaxed. To accomplish Abdominal Hollowing, draw your belly button towards your spine at about 30% intensity – hold this position for 10 seconds. Now, relax and repeat this maneuver.
- Cues: “Try to suck in your belly button as if you walk on the beach in a bathing suit”.
The Abdominal Bracing method to stabilize the spine is based on the McGill philosophy of trunk stabilization. Often heavy weightlifters will use this method of stability as they feel they can exert maximum force out of this position.
To instruct your client to perform the Abdominal Bracing technique follow the following directions:
- Let your client stand in front of you with the lumbar spine in neutral.
- Stand behind the client
- With permission from the client touch them with the palms of your hands on the lateral abdominal region so that your thumbs are on the client’s inferior rib cage region and the 4th and 5th fingers are touching their iliac crest.
- Instructions: “Breath in and out normally. To accomplish Abdominal Bracing, stiffen your abdominal muscles, trying to lock your rib cage on your pelvis”. Now, relax and repeat this bracing maneuver.
- Cues: “Try to start to engage your abdominal muscles as if somebody is going to punch you in the gut”.