LBP & Pilates

Acute Low back pain and Core stability

A summary and explanation of the rationale behind core stability training for acute low back pain.  Introduction Low back pain (LBP) is a common disorder, with 80% percent of the population likely to experience LBP at some stage (Walker, 2000., Ihlebaek, et al., 2006). The causes of low back pain appear to be complex and due to many factors (Laird et al., 2012), and as such, management plans put in place to improve patient outcomes must reflect this notion. Whilst we know there are particular structures that in the case of injury or tissue damage can contribute to pain, what actually led to the initial painful sensation is difficult to determine, even with the use of modern day imaging (i.e MRI scanning) (Koes, et al., 2006).  Despite this anomaly, there are significant bodies of research that indicate people with low back pain demonstrate changes in two major core stabilizing muscles, the Transverse Abdominus (TrA) and Lumbar Multifidus (LM) (Wong et al., 2014). Compared with individuals with no back pain, patients in pain have been shown to display reduced TrA & LM muscle activity during contraction, delays in anticipatory contraction (body’s natural stabilizing mechanism before moving the outer extremities) and reduced cross-sectional area of muscle. There is a lack of agreement between researchers about how exactly these deficits in stabilizing muscles (TrA, LM) cause LBP however we know they play important roles in spinal control of each vertebra and thus are likely to affect the risk of recurrence of patients pain (Wong, et al., 2014).  Structure & function Core stability exercise training can be loosely defined as the restoration of the ability of the nerve and muscle system to control and protect the spine and its associated structures (nerves, ligaments, joints etc) from injury or re-injury (Hodges, 2003). Both the TrA and LM are targeted by the types of exercises provided by therapists here at Physiohealth and have received special attention in the literature. TrA is a broad sheet like muscle with attachments to the lumbar (lower back) vertebra, and to the pelvis and rib cage. This forms a corset like structure which controls pressure inside the abdominal cavity and stiffness of the spine (Hodges, 2003). LM is a deep muscle lying parallel on each side of the spine which contributes largely to the control of spinal segments whilst the body is in motion (Cholewicki, 1997).  Rationale Several studies have reported changes in the brain’s control of these local stabilizing muscles in LBP (Hodges, 2003). Once the initial muscle spasm and pain of an acute back pain episode has subsided through the use of several manual therapy techniques, a priority is to implement strategies that prevent recurrence and thus promote future wellbeing. Specific stabilization exercises, aka core stability training programs are now initiated. These programs follow an evidence-based learning model that stipulates motor learning occurs in three distinct phases (Magill, 2001). Now don’t get caught up in the fancy detail but its worth understanding what the goal of each phase is, which would make a lot more sense to your recovery in the case of acute LBP.
  1. Stage #1: i.e. Contract TrA (deep, small muscle) lying on the back with knees bent and feet flat on the bed.
    1. Here the patient is provided with a simple sequence, given clear, plain instructions and uses repetition to get the hang of the contraction.
  1. Stage #2: i.e. Refine the ‘static contraction’ learnt @ Stage #1.
    1. The patient will here be provided with advancements to progress their newly learnt ability to activate the deep core muscles. Upper limb and lower limb movements can be added to complicate the movement challenging your ability to maintain control of your posture/balance.
  1. Stage #3: i.e. Achieved with practice and experience!!!
    1. The final stage is all about transferring your newly learnt skill into your activities of daily living. The day you walk in the door we as Physiotherapist’s at Physiohealth are planning your return to normal function. This phase specifically involves applying the learned muscle skill to actions and movements (e.g. lifting, typing, sitting up, getting into the car, sports) you use to feel pain doing.
Whilst specific stabilization exercises have been shown to be ineffective with respect to alleviating pain in an acute low back pain episode (Ferreira et al, 2006), there is evidence that these types of exercises are effective in reducing the recurrence after an acute episode (Ferreira et al, 2006). This you will find is the basic rationale behind their introduction in a clinical setting at Physiohealth. The benefit of such core training programs is that under the guidance of a Physiohealth practitioner the patient can work through exercises in their own home environment after acute symptoms have been relieved. Thus working towards a happier, healthier and more active lifestyle.  Where does Pilates fit in? Pilates training is a form of movement retraining that conditions the deep core stabilizer muscles of the body. Is it a low impact technique that focuses on controlling the core whilst performing sequenced movements of the upper and lower limbs. The complexity of the exercises is increased as you improve control of the key postural muscles. At Physiohealth we offer 30min one-on-one consultations (perfect for the beginner) and 1 hour class packs, for those with the basics under control. Physiohealth conducts Pilates classes out of our Williamstown, Footscray and Mount Waverly practices. Further details of the specifics of the Pilates classes can be found under the services tab on the Physiohealth website. Don’t be hesitant to visit us at Physiohealth with any queries or concerns about these types of exercises or Pilates. References: Ihlebæk C, Hansson TH, Lærum E, Brage S, Eriksen HR, Holm SH, Svendsrød R, Indahl A: Prevalence of low back pain and sickness absence: A ‘‘borderline’’ study in Norway and Sweden. Scand J Public Health 34:555-558, 2006  Walker BF: The prevalence of low back pain: A system- atic review of the literature from 1966 to 1988. J Spinal Dis- ord 13:205-217, 2000  Laird, R., Kent, P., and Keating, J., 2012. Modifying patterns of movement in people with low back pain – does it help? A systematic Review. BMC Musculoskeletal Disorders 13(169).  Koes, B., Van Tulder, M., and Thomas, S., 2006. Diagnosis and treatment of low back pain. British Medical Journal, 332(7555).  Wong, A., Parent, E., Funabashi, M., and Kawchuk, G., 2014. Do changes in transverse abdominus and lumbar multifidis during conservative treatment explain changes in clinical outcomes related to nonspecific back pain? A systematic review. The Journal of Pain, pp: 1-35.  Hodges, P., Moseley, L., Gabrielsson, A., Gendevia, S. 2003. Experimental muscle pain changes feedforawrd postural responses of the trunk muscles. Exp Brain Res 151: 262-271.  Magill, R., 2001. Motor learning: concepts and applications. New York: McGraw Hill.  Cholewicki J, Panjabi MM, Khachatryan A. Stabilizing function of trunk flexor– extensor muscles around a neutral spine posture. Spine 1997;22:2207–12.            
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