Michele Sheets, Physical Therapist, Physiotherapy
Associates
As
the physical therapy profession has advanced, treatment emphasis has
gone from passive modality oriented treatment to more active exercise
oriented programs. Spinal
stabilization has become the standard treatment for spinal dysfunction
or back pain. What exactly
does that mean? When you
send your client for one of these programs, what should you expect to be
addressed?
Spinal
stability is the ability of the spine to distribute the normal stresses
that pass through it evenly to all of the segments.
This is accomplished by maintaining proper postural alignment
with activities throughout the day.
Treatment to reach this goal should include education on proper
positioning, and strengthening or retraining specific muscles that
surround the spine. These
muscles include transversus abdominis, the multifidi, gluteus maximus,
and gluteus medius.
In
years past, treatment has focused on strengthening the superficial
abdominal muscles, the rectus abdominis and obliques.
More recent research has shown the importance of the deep
horizontal muscle, the transversus abdominis.
It works with the pelvic floor muscles and multifidi to form a
protective cylinder around the spine to insure that any stresses through
the spine are distributed evenly amongst all the vertebrae versus being
translated to just a few vertebrae.
As with any machine, the weakest link is the one that gives
first, transferring stress to the already unhealthy spinal segment.
Evening the load is of utmost importance.
The
above stabilization muscles can become weak like any other muscle, and
can be affected by reflex inhibition through repetitive or traumatic
injury, or the normal trauma associated with surgery surrounding them.
The multifidi can be observed to have noticeable atrophy in
individuals with spine dysfunction.
It is important to insure that these muscles resume their normal
function after any of the above occurrences.
In
addition to the muscle groups above, the gluteal muscles play an
important role in spinal stabilization. The gluteus medius originates as a fan shaped muscle on the
outside of the ilium or pelvic bone.
It fans over to attach to the trochanter of the femur. It serves to help stabilize and compress the SI joint.
When it is not functioning correctly, the hip flexors, IT band,
or quadratus lumborum can be forced to compensate leading to further
dysfunction in these muscles. The
extra forces or trauma on the SI joint can also lead to SI instability
and pain.
The
gluteus maximus works to extend the hip.
With proper spinal stability it will function independently.
With weakness or poor neuromuscular function of glut max, the
lumbar paraspinals will be forced to help with hip extension.
This can lead to unnecessary stress at the individual spinal
segments, further degeneration or damage to the vertebrae and
surrounding structures, and eventually pain.
The
role of physical therapists is to identify muscles that are working too
hard and muscles that are not working hard enough.
Treatment should focus on reeducation of the muscles to play
their primary role. There
are many popular exercise programs that address spinal stabilization
such as those developed by Shirley Sahrmann, the San Francisco Spine
Institute, Vladimir Janda, or the Watkins Protocol.
Proper function of these muscles along with education on proper
biomechanics should be introduced before a strenuous work hardening or
work conditioning program, or further abnormal stresses to the affected
joints can continue to occur, resulting in increased pain and
dysfunction. The sooner these imbalances are addressed, the quicker the
recovery process can begin to occur.
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