Re:Spinal stabilization. part 3. training. Craig Liebensons DC

[문형철]

척추 안정성을 위한 트레이닝

크레이그 리벤슨의 탐구

panic bird..

Introduction

Reactivating spine pain patients is a key to early recovery from acute and subacute episodes (Malmivaara et al., 1995; Indahl et al., 1998), prevention of recurrences (Hides et al., 2001), and treatment of chronic pain, disability, and failed

surgery syndrome (Fordyce et al., 1986; Lindstrom et al., 1992; Manniche et al., 1991; O’sullivan et al., 1997; Timm, 1994). 

The first part of this series described the role of instability in low back problems (LBP) as well as specific types of

biomechanical advice to prevent low back irritation. The second part described an assessment of the stability system. This third and final part will describe a step-wise approach to patient reactivation from simple introductory exercises with wide margins of safety/stability to advanced functional performance training with much smaller margins of

safety/stability.

Safe back principles have emerged from rigorous analysis of biomechanical and kinesiological aspects of spinal function (McGill, 2001; Liebenson, 1999). The goals shared with the patient are to offer palliative care, spare the spine (see part one), and then to stabilize the spine. Spine stability training includes 3 distinct levels of care. 

First, introductory exercises to find a patient’s functional range should be given. Second, low-load endurance  training of stability patterns is emphasized (Hides et al., 1996 ; Timm, 1994 ; O’sullivan et al., 1997 ). Third, such stability patterns should be trained in functional activities to enhance performance during activities of daily living (ADLs), sport or work demands.

Sport psychology and behavioral medicine 

 Behavioral medicine or sports psychology tenets of ‘‘paced activity’’ and the relationship between hurt and harm should be discussed with the patient. Many low back pain (LBP) patients have excessive fear avoidance beliefs or catastrophizing behaviors which promote a passive, symptom-driven approach, excessive pathoanatomic diagnositic testing,

and a poor prognosis (Linton, 2002 ). At the other end of the spectrum are individuals who are overly aggressive which can lead to a ‘‘boom or bust’’ mentality.

The middle path is best exhibited by the modern emphasis on quota-based ‘‘graded exposures’’ to feared stimuli (Linton, 2002 ). This operant conditioning model successively demonstrates to patients that hurt does not necessarily equal harm, and that activity— contrary to the patients beliefs— is actually beneficial. The activities chosen should be mutually agreed upon and at most have only slight mechanical sensitivity (MS). The exercises should be designed to improve the abnormal motor  control (AMC) identified in the eval‎uation (see Part two). Regular re-eval‎uation of activity intolerances (AI), MS, and AMC is necessary to prove to the patients that their fear is unfounded.

Training

 Prior to initiating low back exercise training biomechanical advice about how to avoid low back irritation during ADLs— spine sparing strategies—-  should be taught (see Part one).

A step-wise approach to reducing activity intolerances and restoring function has been developed. Once advice has been given about how to spare the spine during ADLs, and the safety exercise discussed, then a progressive approach beginning with exercises with a wide stability/safety margin are prescribed to quota. The goal is to improve motor control by emphasizing coordination during simple movements designed to stabilize the back (i.e. hip hinging). Such introductory exercises are then progressed by adding low-load endurance challenges.

Finally, exercises are progressed to include functional or performance components which mimic as closely as possible the actual ADL, work or sports demands that the individual faces (see Table 1 ) 

Introductory training—graded exposures to grooved stability patterns

 In level one training postural control, muscle

balance and pain reduction or centralization is

the focus. The goal is to ‘‘groove’’ motor patterns

with safe, low-load activities. This requires an

emphasis on the cognitive-kinesthetic awareness

stage of motor control (Shumway-Cook and Woollacott,

1995 ). Most patients have poor kinesthetic

awareness of how to produce and/or control motion

of their problem area. The patient learns to ‘‘discover’’

how to move and ‘‘centrate’’ an important

region such as the lumbo-pelvic, scapulo-thoracic,

or cervico-cranial. They acquire the skill to perform

the movement and then to limit it to a ‘‘pain-less’’

or pain centralizing functional range.

When a patient has a lot of MS with normal

ranges of motion, especially if there is referred or

radicular pain, the McKenzie approach of prescribing

movements which centralizes referred pain and

avoiding movements which peripheralize the symptoms

is strongly recommended. In disc patients

these movements often involve end-range positions

such as extension. The key is to regularly recheck

the patients MS to confirm‎ that the patient’s overall

functional range is expanding.

Behavioral principles/sport psychology are essential

to exercise training. It is important to

initiate exercise training with exercises that have

a large safety/stability margin. Such exercises

should be mutually agreed upon with the patient.

They should be carried out to a quota even if mildly

uncomfortable. In chronic pain patients the expectancy

of re-injury is typically based on an

activity avoidance belief or catastrophizing tendency

and not an actual experience (Crombez et

al., 1998 ). Graded exposures  to feared stimuli are

an excellent way to operantly condition pain

patients, and thus prevent deconditioning and

initiate functional reactivation. Pacing is important

with any exercise prescription so that both too

little or too much activity is avoided (Harding and

de Williams, 1995 ; Harding et al., 1998 ; Butler and

Moseley, 2003 ).

Exercises prescribed should be those with wide

margins of safety/stability. Generally, loads under

3000 N of force are considered safe for acute/

subacute exercise training. Routine ADLs involve

about 2000 N and the NIOSH limit for repetitive

tasks is 3300 N (see Part one). Table 3 shows the load

profiles for a variety of low back exercises. They

should be performed after limbering up and not

immediately upon arising or after prolonged sitting

(Snook et al., 1998 ; Green et al., 2002 ; Wilder et

al., 1996 ). Good form or coordination is a prerequisite

for such training (O’sullivan et al., 1997 ).

Finally, trunk muscle co-activation (e.g. abdominal

bracing) is recommended to increase the stability

margin (Cholewicki and McGill, 1996 ; McGill, 2002 ;

Granata and Marras, 2000 ; Stokes et al., 2000 ).

The cat– camel is an ideal way to warm-up the

spine. It is not a stretch and teaches the coordination

to move and position the spine through an arc

of motion. 8– 10 repetitions of gentle limbering

without stretching is appropriate.

  Limbering— cat– camel (see Fig. 1 ). 

 The quadruped leg reach teaches ‘‘neutral’’

spine control during distal extremity motions. The

key is avoiding spinal torsion or lumbar hyperextension.

8– 10 slow repetitions with brief isometric

holds is the goal.

  Quadruped leg reach (see Fig. 2 ).

 Abdominal bracing involves co-activation of

muscles in 3601  around the lumbar spine. It is a

light contraction 5– 10% of MVC similar to being

tickled or bearing down slightly (McGill, 2002 ;

McGill et al., 2003 ). However, the key is that the

breath is not held during the brace, nor is

abdominal contraction entrained to a certain phase

of respiration. If a patient holds the quadruped

position and the clinician attempts to gently push

the torso to and fro bracing will automatically be

facilitated. The same can be done in other positions

or exercises such as the dead bug or side bridge.

Often mobility of surrounding regions is restricted

thus increasing load on the spine. One

example, would be reduced mobility in the midthoracic,

hip, knee and ankle during a squat or

lunge resulting in poor maintenance of lumbar

lordosis and thus disc overload. In such cases

flexibility training such as of the mid-thoracic or

hip flexors will help to spare the spine

  T4– 8 stretch (see Fig. 3 ).

  Psoas stretch (see Fig. 4 ).

Once the patient learns to move and position their

spine in fundamental ways then a progression to

more complex exercises and functional activities can

occur. There are always two aspects to the decision

of whether or not a patient is ready to progress or

not. The first is concerned with MS and the second

with AMC. The sooner in the program actual

functional activities are trained the better but, it

is necessary at each step that (a) mechanical

sensitivity is not increased, and (b) that motor

control is re-educated. MC involves functional

centration or ‘‘neutral posture’’ of key joints, normal

respiration (i.e. no breath holding), and avoidance of

abnormal patterns of muscle substitution (Richardson

et al., 1999 ). If for instance, an exercise

increases MS by either peripheralizing symptoms or

increasing painful ROMs on post-exercise auditing

then the correct introductory training has not been

achieved. Similarly, even if mechanical sensitivity is

decreasing but the patient is not learning how to

perform simple movement patterns with good form

they are not ready to progress.

Isolation of specific stability patterns

 The goal of the second level of stability training is

to build endurance into the new spine sparing

motion patterns. This requires that the intensity of  training be increased. McGill and colleagues have

demonstrated that both muscle output and spinal

load can be measured for a variety of exercises

(McGill, 1995 ; McGill et al., 1996 ; Axler and McGill,

1997 ). Muscle output is determined as a percentage

of maximum voluntary contraction ability (MVC)

and spinal load as a measure of spinal compression

and shear forces. Ideal exercises are those that

have a high ratio of muscle challenge to spinal load.

Such analysis gives surprising data about common

exercises which are prescribed for low back pain.

For instance, spinal load is not different during situps

with knees bent or straight. In either case the

load is over 3000 N and therefore should not be

prescribed in the low back recovering population!

(Axler and McGill, 1997 ; McGill, 1995 ). There are

safer back exercises (see Table 2 ).

Besides using exercises with acceptable load

profiles and maintaining core stability a number

of traditional exercise science principles should be

followed so results can be maximized. These relate

to training with the appropriate intensity, frequency,

and duration. Motor control or stability

training requires an emphasis on endurance rather

than strength (McGill, 1998 ; Richardson et al.,

1999 ). For this reason the intensity  of training is

sub-maximal. As an example a typical prescription

would involve three sets using a reverse pyramid

approach (12/8/6 repititions). Each exercise is

performed slowly with a prolonged isometric hold

time (5– 10 s/repetition or about 2 breaths). A

frequency  of twice a day with a duration  of up to

3 months is often required to remediate chronic

spinal pain (Manniche et al., 1991 ).

Learning to coordinate breathing and bracing is

one of the key skills taught. As long as an

abdominal brace is held during an exercise such

as a side bridge while simultaneously taking

several breaths this coordination can be learned.

It can be challenged further by adding heavier

breathing such as might occur when one is

aerobically challenged.

There are certain stages of motor learning that

patients go through as they develop this stability

skill. These are kinesthetic-conscious awareness,

associative learning, and autonomous control

 (Shumway-Cook and Woollacott, 1995 ). Patients

do not comply well if they have to be hypervigilent.

Therefore, it is important to minimize the conscious

awareness stage and find something which is

easy for the patient to succeed with. This is termed

‘‘attacking success’’ or ‘‘finding the positive

slope’’. The astute clinician guides the patient

effortlessly through these stages with the help of

encouraging and facilitory cues, contacts, resistance,

commands, etc.

McGill has developed the concept of ‘‘the big 3’’

in isolating and training stability patterns for the

low back region (McGill, 2002 ). Such training

encompasses low-load exercises for the anterior,

lateral and posterior musculature.

The quadruped position is used to train the back

muscles. Once the quadruped single leg reach is

mastered then movement in the opposite arm can

be added.

  Quadruped opposite arm+leg reach (see Fig. 5 ).

The side bridge is an excellent, safe way to

‘‘groove’’ the hip hinge and train the lateral

oblique musculature. It can be progressed from

knees to ankles. Then an added challenge is add a

rolling movement while maintaining the spine

stable in a plank position.

  Side bridge on knees (see Fig. 6 ).

The abdominals can be trained with the supported

dead bug (isometrically) and then progressed

to a partial curl-up with spinal neutral

control (slight lordosis).

  Trunk curl-up (see Fig. 7 ). 

 The supported dead bug is an alternative lowload

way to initiate abdominal training and

coordinate ‘‘neutral’’ spine control with reciprocal

arm/leg patterns of motion. The unsupported dead

bug is a more advanced progression

  Dead bug supported (see Fig. 8 ).

  Dead back unsupported (see Fig. 9 ).

The decision about advancing beyond stability to

functional exercises is a simple one. If the patient  can easily perform a sets of 10– 12 slow repetitions

with good form they are ready to move on. For

example,

Move on :

  Quadruped opposite leg/arm reach with ‘‘neutral’’

spine control.

Don’t move on :

  Quadruped opposite arm/leg reach with lumbosacral

hyperextension or trunk rotation.

Integration—functional integrated training

(FIT)

 Functional stability training is goal oriented. Nonfunctional

positions such as recumbent may be used

as stepping stones to isolate and ‘‘groove’’ stability

patterns. However, as soon as possible ‘‘core’’

stability must be trained in exercises mimicking the

demands the patients face in their home, occupational,

and recreational activities.

The sooner in the program actual functional

activities are trained the better. But, it is necessary

at each step that the movement is in the patients  functional range— reducing mechanical sensitivity

and abnormal motor control while being as functional

as possible.

Unless, functional training occurs there is no

guarantee that the individual will be stable during

‘‘real world’’ challenges. Examples of functional

training include squats, lunges, pushing, pulling,

catching, carrying, etc. For more fit individuals and

to enhance performance or prevent injury in

demanding sports or occupations stability patterns

may be further challenged by the addition of

unstable surfaces such as balance boards and

gymnastic balls. This provides enhanced proprioceptive

stimulation which facilitates motor learning.

A patient’s ‘‘functional range’’ should be identified

for each functional training exercise. For

instance, to train for lifting, rising from a chair,

throwing, pushing, or pulling activities squatting

should be analyzed and trained. Typical findings of

dysfunction with squats are poor control of the

lower quarter (medial collapse— knee valgosity,

subtalar hyperpronation, Trendelenberg hip position

or patello-femoral shear) or lumbo-pelvic

(stooping substituting for squatting) regions.

A simple squat exercise is the squat with back to

the wall which automatically facilitates hip hinging.

  Squat with back to wall (see Fig. 10 ).

Troubleshooting for medial collapse can include

single leg stance balance exercises.

  Balance reaches (see Fig. 11 ).

Functional stability during activities such as

walking, climbing or descending stairs, rising from

the floor, kneeling, throwing, pushing, or pulling

can be re-educated with an exercise such as the

lunge. A typical dysfunction or faulty movement

pattern with forward lunging is excessive hip and

trunk flexion. A simple exercise that is usually

within the patient’s ‘‘functional range’’ is to

perform a forward lunge while raising the arms

overhead. This will usually re-educate ‘‘neutral’’

lumbo-pelvic posture automatically.

  Forward lunge with arms overhead (see Fig. 12 ).

If the forward lunge occurs with subtalar hyperpronation

and excellent way to ‘‘attack success’’ is

to attempt an angle lunge with an arm reach (see

Fig. 12 ), this will typically ‘‘drive’’ the foot into

supination automatically! Whatever is the most

challenging functional activity the patient can

perform with appropriate stability should be the

one selected for exercise.

  Angle lunge with an arm reach (see Fig. 13 ).

Common movements such as pushing and pulling

require the patient to make simple multi-planar

weight transfers . Pushing is part of functional

activities such as a tennis forehand, throwing,

boxing punch, pushing a shopping cart or vacuum

cleaner. Pulling is part of functional activities such

as a tennis backhand, golf swing, throwing a

frisbee, lifting a grocery bag out of a car or a baby

out of a crib. Pushing and pulling can be trained

with simple pulley or exercise tubing exercises.

  Core twist— push (see Fig. 14 ).

  Pull (see Fig. 15 ).

 Reactivation progressions should continue until

the patients’ ‘‘functional range’’ includes their

home, sports, occupational demands. Athletes will

require high-level performance training which will

also include strength/power, agility, and speed

challenges. These would be superimposed on the

3 levels of training already described. A frequent

training error in programs designed for highly fit

individuals is the performance of trunk or spine

exercises with high-level strength or agility demands,

without proper motor control. A step-wise

approach built upon a foundation of conscious

kinesthetic awareness of appropriate motor control

is the best guarantee of injury prevention when

performing high-level activities with a narrow

safety/stability margin.

Conclusion

 Safe back training in the acute stage should reduce

fear of movement, reduce or centralize the

patients pain, and ‘‘groove’’ appropriate movement

patterns for basic ADLs. In the subacute

recovery stage training should build endurance in

progressively more challenging and functional

movement patterns. Exercise should be prescribed

in a goal-oriented manner with the patient’s active

collaboration. In most instances, a realistic goal is

to teach patients better spinal awareness during

ADLs to spare their spine, and then to give them a

few simple exercises to stabilize their spine.

Patients engaged in higher level functional activities

or with chronic problems will require more

challenging exercises.