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.a