SI Joint Pain & Dysfunction. Do U Have It?

The sacroiliac or SI joint is the articulation between the bone at the base of the spine called the sacrum and the bones on both sides of the pelvis called the ilium. Refer to the picture below.

Over 22 years of physical therapy, I have treated many patients with low back and buttock pain who were diagnosed with an SI joint dysfunction. The difficulty with diagnosing an SI joint dysfunction is that the SI joint has no specific distribution pattern of pain.  Pain directly over the SI joint does not necessarily mean that the joint itself is involved. SI joint pain can very often be referred pain from other structures such as the disc, nerve root, or facet joints of the lumbar spine. Many physical therapists or physicians attempt to diagnose an SI joint dysfunction through palpation of bony landmarks as well as assessment of SI joint mobility. There is only a very small amount of motion in the SI joint i.e. 2-3 mm or 2-3° of gliding or rotation thereby making an accurate diagnosis very difficult. In addition, evidence based research refutes the reliability and validity of accurately assessing bony landmarks and SI joint mobility. McGrath et al has published an article, entitled Palpation of the sacroiliac joint: an anatomical and sensory challenge in which the concept of SI joint palpation is scrutinized. Freburger and Riddle performed a literature review looking at our ability to perform SI joint motion testing. They found poor inter-tester reliability, low sensitivity, and low specificity in several commonly performed tests. Inter-rater reliability is essentially the ability for multiple practitioners to come to the same diagnostic conclusion. If you have multiple individuals perform the same test, the results should be the same. Riddle and Freburger in another study noted that the ability to detect positional faults of the SI joint also has poor reliability. At present, the only acceptable method of confirming or excluding a diagnosis of a symptomatic SI joint is a fluoroscope guided intra-articular anesthetic block ie an injection directly into the SI joint. (Laslett et al) So how can I, as your physical therapist, assist in the diagnosis of an SI joint dysfunction?  The answer: SI joint provocation tests!

Two recent studies by Laslett et al and Van der Wurff et al have demonstrated that there isn’t just one key or ideal SI joint provocation test. However, by performing several tests together, you can increase your sensitivity and specificity of detecting an SI joint dysfunction. Both studies reported that the accuracy of detecting SI joint dysfunction is increased if least 3 of the 5 tests are positive. Furthermore, if all 5 tests are negative, you can likely look at structures other that the SI joint. Van der Wurff et al reported that if at least 3/5 of these tests were positive, there was 85% sensitivity and 79% specificity for detecting the SI joint as the source of pain.  Interestingly, another study by Kokmeyer et al agreed with the previous findings, but also noted that the thigh trust test alone was almost as good at detecting SI joint dysfunction as the entire series performed together.

Combining the two studies, there are 5 provocation tests to perform when attempting to diagnose SI joint pain:

  1. Thigh thrust/Femoral Shear test
  2. SI Distraction Test
  3. SI Compression Test
  4. Gaenslen’s Test
  5. FABER / Patrick’s test

The following video will demonstrate these tests. I would like to thank Mike Reinold, PT for his blog information that was used to complete this explanation of SI Joint dysfunction.  Check out the video below!!

CORRECTION:  I would like to clarify the SI distraction test as described in Laslett. I believe that he considers the direct posterior shear of the innominates as a distractive force of the ilium away from the sacrum. I initially interpreted this test as a compression of the SI joint via a distraction of the ASIS’s. I guess it depends on HOW you apply the force to the ASIS’s.  Also, the sidelying “compression” test needs to be performed in a straight, linear fashion as well in order to compress the SI joint. It is important to place a towel roll under the lumbar spine in women in order to prevent sidebending stress t the lumbar spine. In OMT, we use the sidelying position to “distract” the SI joint using more of a rotational force on the lateral edge of the ilium in order to “open up” and distract the SI to get a feel for joint play. As you can see, these tests are not definitive for exactly HOW they stress the joint but they are specific for a stressing maneuver TO the SI joint.

 

Nerve Mobilization Techniques

I would like to highlight one of the unique treatment techniques that we offer at OrthoWell.  As many of you know, we spend a lot of quality time during our biomechanical evaluation trying to “figure things out”. This is the reason that several of our referring physicians call us “THINKERS”.  We pride ourselves in determining your functional diagnosis. This diagnosis is what we use to develop your plan of care and to educate you in how to alleviate your pain or dysfunction. Many of our patients have seen several physicians or therapists before hearing about us. For this reason, we offer specialized evaluation and treatment services that our patients may not have heard of and that may be appropriate to alleviate symptoms that have been unresponsive to prior interventions.  One of these is Nerve Mobilization or NeuroMobilization. So what is it?

What is NeuroMobilization?

NeuroMobilization or Nerve Mobilization is a technique that we utilize to treat nerves that may be adhered, irritated, or compressed.  Many patients that have been unresponsive to other physical therapy and present with a chronic history of referred symptoms like pain, numbness, or tingling into the arms or legs may respond to NeuroMobilization.  Every patient that presents with referred symptoms or pain that has been unresponsive to localized treatment receives a complete neural tension evaluation.  Neural tension testing is a way for your therapist to determine the extent of nerve involvement.  By mobilizing a nerve, we can determine, in combination with manual traction and sensitizing maneuvers, whether your pain is originating from the spine or the periphery.

NeuroMobilization Techniques

We can then perform NeuroMobilization techniques utilizing controlled neural tension maneuvers to mobilize the nerve up and down.  David Butler,PT, has been at the forefront of these techniques for over 20 years.  Although we still do not completely understand the exact mechanism, he proposes that NeuroMobilization (what David Butler calls Neurodynamics) can accelerate nerve healing and quiet down what he calls an “altered impulse generating system (AIGs)”.  These AIGs may respond to the oscillations of NeuroMobilization by enhancing circulatory exchange or ion transfer in and around the nerve.  You can read more about the techniques and science in David Butler’s book The Sensitive Nervous System.

Here is a video that highlights a sciatic nerve tension test and Neuromobilization.

 

What Happened To My Arch??

I cannot count the number of times over the past 22 years that patients have told me “I USED to have an arch, but not anymore”.  Is it true that you can actually lose your arch as you get older?  The answer: YES.  So what happens?  Many doctors attribute a loss of your medial arch height to a condition labled posterior tibialis tendon dysfunction or PTTD. Your posterior tibialis muscle lies deep under your calf and it’s tendon inserts into your midfoot.  It is responsible for turning your ankle inwards and “reinforcing your arch height.”

PTTD typically presents as a progressive increase in tendonitis pain which can lead to partial or complete rupture. The loss of PTT integrity has been hypothesized to produce a gradual change in the alignment of your foot. However, recent evidence shows that a partially torn or ruptured PTT is NOT the definitive reason for an adult acquired flatfoot.  Let me show you. A study by Yeap et al   followed 17 patients who underwent a surgical transfer of the PTT to a different part of the midfoot in order to control a drop foot. At a 5 year follow-up, none of the patients had a clinical flatfoot deformity. In other words, “losing” the PTT tendon by attaching it to a different part of the foot did NOT cause a flat foot.  In light of this one study, there is sufficient evidence to rebuke the PTT as the sole reason for an adult acquired flatfoot.

Another study by Deland et al   attempted to produce an adult acquired flatfoot in cadaver models by cutting the PTT. This produced only a minimal drop in height. It wasn’t until they severed the ligaments and plantar fascia on the underside of the arch that a complete arch collapse was achieved. Researchers Chu and Myerson confirmed the results of this study as well. So the evidence is here. A major contributing factor to the loss of arch height as we age is the loss of ligamentous integrity in the foot.

Did you know that women are 3 times more likely to be diagnosed with PTTD? It is most frequently found in women in their 50’s.  Although a definitive hormonal link has not been established, PTTD appears to peak during the perimenopausal period. An interesting study performed at USC in 2011  found that women with PTTD compared with a control group had significantly decreased endurance and strength of hip muscles. Strengthening your hips may help to strengthen your arch. More evidence that everything is connected!

Can you raise your arch by strengthening the muscles in your feet? Did you know that there are 18 muscles in the arch of your foot? What does the research tell us? In my previous article on running technique, I mentioned an article by Robbins who showed radiographic changes in arch height after runners ditched their shoes and started walking and/or running barefoot. This should be a very slow process, but many coaches and therapists advise walking barefoot on grass or sand as a starting point. Two other studies by Fiolkowski et al  and Headlee et al also show that when muscles in the arch weaken, the arch falls.

So what, specifically, can you do about your fallen arches?

Number 1 :  Custom Foot Orthotics. You need to control the pain and unload the injured structures first. We are attempting to control some of the mechanical imbalances by fabricating foot orthotics that “hug” your midfoot. We utilize both rearfoot and forefoot posting (angling of the orthotic) in combination with motion control shoes to control your excessive motion.  For more severe cases, some research shows better control of the twisting or internal rotation of the leg using braces such as ankle-foot orthoses.  The Richie Brace is one example.

Number 2:  Exercise!! Yes, it is very important. The articles above prove it. In order to “raise” your arch height with exercise, you need to be very consistent and compliant with your program.  I have mentioned HOW to exercise in a previous post. I want to emphasize that, if you have flat feet, your arches will fall every time you stand or take a step if you don’t train yourself to prevent it. This means using the appropriate intrinsic muscles in your arch in combination with active joint repositioning. If you can master this, you will be in a constant state of muscle retraining and joint stabilizing while bearing weight on your feet.

You could then add barefoot walking on grass or sand as an adjunct to your program. My next post will highlight the research on the muscle training effects of minimalist shoes such as the Nike Free.  Stay Tuned! Now, check out my videos on foot intrinsic training and an effective hip strengthening exercise called Clams.

Life is Sometimes “A Pain in the Neck!”

I think that most of you would agree that life is sometimes a “pain in the neck”!  The source of the pain is usually multi-factorial and may include such things as emotional stress, muscle weakness, history of trauma, arthritis, herniated discs, and/or poor posture, let alone the screaming child (or boss!)  thrown on top of that. Yikes!!  Of course, as many of you have experienced, there are many different physical therapy and medical approaches to treating neck pain.  So what does the research tell us about the most effective physical therapy treatments?  In 2002, a systematic analysis of studies (performed up to that date) showed that passive physical therapy modalities such as ultrasound, heat, electrical stimulation were ineffective in the treatment of chronic neck pain in the long term. Basically, only temporary relief.

Can 2 minutes a day of exercise decrease your neck pain?  How many of you experience neck or shoulder pain after using your computers? A study in Denmark evaluated 198 office workers with chronic neck and shoulder pain. The subjects were randomly assigned to either a non-exercising control group, a 2-minute exercise group, or a 12-minute exercise group. The exercise groups performed a lateral raise in the scapular plane to 90 degrees with elastic tubing. The exercises were performed 5 days per week for 10 weeks. After 10 weeks, both exercise groups significantly reduced their neck/shoulder pain and tenderness, and significantly increased their strength compared to the control group. The interesting thing about this study is that there were no differences between the 2 min and 12 min groups.  The conclusion is that only 2 minutes (to failure) of the prescribed exercise could control your neck pain.

A Finish researcher by the name of Jari Ylinen has performed many controlled studies on neck pain.  He is definitely the GO-TO guy for this research!  He notes that several studies have been performed that show an improvement in neck pain within 5-11 weeks of rehabilitation, but that the results usually disappear 2-3 months later. So what he did was demonstrate how YOU, the neck pain sufferer, could maintain the desired results over a 12 month period. One of his studies in 2003 compared 180 female office workers with chronic, non-specific neck pain.  They were randomized into two different strengthening groups, one consisting of 4-way isometric neck exercises with Tband at 80% effort, and a control group. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. All groups were advised to do aerobic and stretching exercises 3 times a week and were educated in proper posture principles. At a 12 month follow-up, neck pain and disability decreased in both groups, yet maximal isometric neck strength had improved 69-110% in the isometric group, only 16-29% in the other strengthening group, and just 7-10% in the control group. Previous studies have shown either no or only temporary gains with active neck training and this study emphasizes the importance of performing your program at least 2x/wk for a solid year to achieve the described results.

For those of you who have a tendency for finding short cuts, read on!  Ylinen in 2008 performed another study comparing the same active neck strength training exercises in the 2003 study to a control group that only performed neck stretches.  At a 12 month follow-up, he found NO statistical differences in neck pain or disability between the groups and only minor changes in strength and mobility. Why? The big difference in this study?  Patient compliance with the strength training decreased to only 1x per week!!  Sound famliar from my Pump You Up post?

So how do you put this all together into a neat package for the BEST  approach to neck pain?  Education is the key.  Number 1, evidence-based exercise will fail if you continue to assume poor posture. Number 2, you need to make time with the time you have. That means choosing the BEST exercises that can be done in a timely fashion and to continue your program 2 times per week. An interdisciplinary group of researchers and clinicians in 2009 reviewed the research to develop a ‘toolkit’ for clinicians to apply the best evidence for treating neck pain. The “Cervical Overview Group” created a clinical practice guideline that includes a therapeutic home exercise program for neck pain. You can view it HERE after signing up for free. In the next four videos, I would like to present 4 evidence-based exercises that incorporate isometric cervical strength training, scapular stabilization exercise, and functional retraining.  Do these and you will take control of your neck pain once and for all!

CERVICAL ISOMETRICS

SCAPTION

ROWS

“W” SQUATS

PUMP YOU UP!!

So how important is resistance training? I have had the privilege of working with one of my peers, a fellow PT, and strength and conditioning specialist, Mike Stare from Spectrum Fitness in Beverly, both professionally as well as personally. Mike helped to redirect MY fitness program while I was recovering from my knee injuries 1.5 years ago. Mike is on top of his game from a fitness training standpoint. He has devoted a lot of time and resources in developing an evidence-based approach to fitness and weight loss in ALL age groups. You can see this for yourself at his website. It is important for clients in a fitness program as well as our patients in physical therapy at OrthoWell to understand HOW to strengthen muscles.

The physiological principle of “overload” is what makes the difference between strength gains and stagnation. Resistance training is hard work! I tell my patients “If it’s easy, then you’re doing something wrong!” Is it true that people will lose 5-10% of muscle strength in every decade of life after the age of 40? Studies have shown that people can retain 100% of their muscle mass and strength from age 40 through their 80s with exercise! (Wrobelski, A. et al. The Phys and Sports Med, Sept 2011) You can read more on the Anti-Aging movement at Mike’s BLOG as well.

However, during exercise, you need to challenge your muscles physiologically. You need to provide a “load” that goes “over” your muscles comfort zone. In order for a muscle (including the heart) to increase strength, it must be gradually stressed by working against a load greater than it is used to. So how do you do this? There are many books and magazines such as Muscle Fitness that advocate all kinds of strategies for maximizing strength and muscle mass. Strength gains can be accomplished by performing a one-repetition maximum as well as via the typical 10 rep set approach. My approach, with the fine-tuning of Mike, is to instruct my patients in 2-3 sets of 8-12 repetitions per exercise. The most important factors to consider are the utilization of proper technique in order to isolate the specific muscle as well as to use the idea of the “loss of technical form” as your maximum output point. By the time you reach the 8-12th rep you should be tiring and on the verge of a loss of technical form. You should not work to fatigue as this will compromise your technique and become a safety concern. Regarding the frequency of strengthening exercise, studies show that strength gains are maximized at a frequency of 2-3x per week. The American College of Sport Medicine (ACSM) recommends working out a MINIMUM of 2x per week at an intensity that is equal to 70-85 percent of your one rep maximum (maximum weight you can use for one rep) for 8-10 reps and 1-3 sets. A program that comprises repetitions over 12 is considered endurance training. For cardiovascular benefits, the ASCM recommends exercising for a frequency of 3-5 times per week, at an intensity equal to 60-85 percent of your maximum heart rate for a time of 20-60 minutes. Research has shown that you’ll get the same beneficial results by exercising at 50-60% of your maximum heart rate that you would get exercising at an intensity 80% of your maximum heart rate.

At OrthoWell, as part of your physical therapy, we get you started on a strengthening program that targets your problem area. Finding the right practitioner to design a complete, individualized fitness program can be a very rewarding thing and Spectrum Fitness is definitely one of our choices. As Mike points out, “If there is one thing to do to improve the quality of life as we age, strength training would be it.”

For our athletes and runners, don’t forget that strength training has been PROVEN to enhance athletic performance. Read the following to get the facts!

-A University of Alabama meta-analysis of the endurance training scientific literature revealed that 10 weeks of resistance training in trained distance runners improves running economy by 8-10%.  For the mathematicians in the crowd, that’s about 20-24 minutes off a four-hour marathon – and likely more if you’re not a well-trained endurance athlete in the first place.

-French researchers found that the addition of two weight-training sessions per week for 14 weeks significantly increased maximal strength and running economy while maintaining peak power in triathletes.  Meanwhile, the control group – which only did endurance training – gained no maximal strength or running economy, and their peak power actually decreased (who do you think would win that all-out sprint at the finish line?).  And, interestingly, the combined endurance with resistance training group saw greater increases in VO2max over the course of the intervention.

-Scientists at the Research Institute for Olympic Sports at the University of Jyvaskyla in Finland found that replacing 32% of regular endurance training volume with explosive resistance training for nine weeks improved 5km times, running economy, VO2max, maximal 20m speed, and performance on a 5-jump test.  With the exception of VO2max, none of these measures improved in the control group that just did endurance training.  How do you think they felt knowing that a good 1/3 of their entire training volume was largely unnecessary, and would have been better spent on other initiatives?

-University of Illinois researchers found that addition of three resistance training sessions for ten weeks improved short-term endurance performance by 11% and 13% during cycling and running, respectively.  Additionally, the researchers noted that “long-term cycling to exhaustion at 80% VO2max increased from 71 to 85 min after the addition of strength training”

Headaches!! Aspirin or Exercise?

 

One of the most common types of stress-related headaches is called a cervicogenic headache. This type of headache is the result of referred pain from boney or soft tissue structures in the neck. When your upper trapezius goes tense from stress and one of the attachment sites of the trapezius is the base of your skull, what do you think the end result could be? That’s right. A cervicogenic headache. When it comes to special testing such as XRays or MRI, there is no clear relationship between degenerative changes of the discs or cervical vertebrae and headaches (Ylinen et al 2010). As a result, most of our assessment comes from functional and palpation testing of the cervical joints and soft tissue. Conservative management of neck and headache pain often includes passive therapies such as the many specialized soft tissue techniques that we offer at OrthoWell Physical Therapy. But what does the research say about exercise-based interventions? Do neck exercises help cases of cervicogenic headache? According to Ylinen et al 2010, they certainly do. The strength group performed one set of 15 reps (in four directions) of cervical resistance training using rubber bands, upper extremity dumbbell exercises, and neck stretches 5x/week in combination with 4 hands-on physical therapy treatments. The control group performed only daily neck stretches, cardio 3x/week, and no physical therapy. What they found, at a 12 month follow-up, was that headache pain decreased by 69% in the strength group and only 37% in the control group. A more detailed analysis of the study can be found at the Theraband Academy website. In conclusion, the evidence-based combination of hands-on physical therapy, exercise, and patient education would be the best approach to resolving cervicogenic headaches.

Why does your knee keep on hurtin’?

As the adage goes “ The more treatments we have for something, the more we don’t understand the cause”, it seems that anterior (front) knee pain or patellofemoral (kneecap) dysfunction would fall into that category. We understand that a torn meniscus or torn anterior cruciate ligament requires surgery. So how about that nagging, chronic pain in the front of your knee. The kind of pain that returns on a whim and makes you think twice about returning to your break-dancing hey day at your nephew’s wedding. The kind of “twinge” that shrinks your confidence on the 18th hole of your company’s summer, for-boasting-rights golf outing. The reason—not as obvious. So here’s one for you, for boasting rights, of course. In Dye et al (AJSM 1998), the lead researcher decides that he would be the guinea pig in a “mapping” of pain responses during arthroscopic probing, WITHOUT anesthesia, of his anterior knee and patellofemoral joint. Ouch!! The authors rated the level of conscious awareness from no sensation to severe pain. They also subdivided the results based on the ability to accurately localize the sensation. So what did they find? They found that palpation to the anterior synovial linings and capsule (front aspect of the inside of the knee joint), retinaculum (ligament on either side of the knee cap), and fat pad (underneath the patellar tendon) produced moderate to severe pain. The most interesting thing about this study, besides the masochistic aspect, is that NO sensation was detected on the patellar articular cartilage (the underside of the kneecap) even in high level “chondromalacia” or arthritis of the undersurface of the kneecap. The implication of this study is that anterior knee pain is NOT caused by the patellofemoral or kneecap joint.

To take it a step further, Faulkerson et al (Clin Orthop 1985) reported a direct relationship between the severity of pain in the anterior knee and the severity of neural damage within the lateral retinaculum (ligament on the outside of the kneecap). They found that patients presenting with moderate to severe pain were found to have the highest degree of change in the neural tissues of the lateral retinaculum. Very interesting! I’m sure you would agree.

What this means for your therapy is that we can utilize manual therapy and taping strategies to address the neural and soft tissue changes in the lateral retinaculum.  KinesioTaping techniques can produce a “proprioceptive override” effect in which the stimulation of the tape on the skin can override and cancel out the pain receptors. This, of course, is an adaptive process that occurs through consistent intervention and compliance with a home exercise program. Let us show YOU how to get back control of your knee pain.

Foam Rolling Technique

As most of you know, a very important part of our practice is the treatment of soft tissue dysfunction. This may be in the form of a muscle “knot”, chronic scar tissue, or post-surgical stiffness. We have many names ie “the doctors of knotology” and “the Marquis de Sade” to name a few. In spite of the many terms of endearment, at OrthoWell, we get our patients better- Faster! because of our approach. A very important part of your recovery has to do with your home program. Every conditioning program should include stretching, strengthening, cardio, and a close fourth should be self-massage and/or self-mobilization. Many of you have experienced “the twins” (my double tennis ball massager) as well as the foam roller. It is important to address your chronic “knots”, scar tissue, and muscle sensitivities in order to promote optimal tissue dynamics and to prevent future pain syndromes related to poor tissue dynamics.

The following video highlights our foam rolling strategy for your lower extremities. Each muscle group should receive 5-10 passes along the foam roll. The amount of weight you impart upon the roll will be dictated by your tolerance. Yes, this should hurt! Only mild to moderate pain, nothing severe. Use your arms and opposite leg to control the pressure being applied. Try to identify key areas along the way that may need additional passes. Yes, over time, the pain will subside and your pressure will increase. Consistency is the key. Ideally, stretching and self-massage should happen daily. Here is a run down of what is happening in the video.

1. In the first part of the video, I am treating the quadriceps. Longer muscles need more attention. Perform 5-10 passes each at the upper end, middle, and lower end of the muscle.

2. Turn 45 degrees and perform the same treatment at the junction between the quadriceps and iliotibial band(ITB). Pay close attention to the lower end near your patella.

3. Turn another 45 degrees and, in the same manner, treat directly along all three aspects of the ITB.

4. Next, turn over and treat your upper glute area. Cross one leg over the other as shown. The leg that is crossed is the side you are treating. Perform 5-10 passes.

5. Move down to the hamstrings and treat the upper, mid, and lower ends. Place your opposite leg on top of the treatment leg in order to impart more pressure.

6. Next, treat the calf muscle. Place the opposite leg on top for more pressure. Treat the entire length of the calf. You can also perform an up/down ankle movement in order to help glide the stiff tissue while imparting pressure onto the roll.

7. Finally, treat the inner thigh or adductor muscle group. It may be easier to use the 6” roll to treat this area effectively. You can purchase a white 6” roll which is the same material as the 4” or you may purchase the black roll which is firmer than the white.

Keep on rollin’

 

 

Low Back Pain – Part 3 – BEST Evidence-Based Core Exercises!

So what are the BEST evidence-based Core exercises?  

Evidence from random controlled trials of people suffering from low back pain show that core stabilization exercises result in significant improvements in pain and function(5,7) . However, the most effective combination of which muscles to target and which stabilization methods to utilize are still debated(1-11).  One technique that has been suggested is abdominal hallowing or “drawing-in” your navel to activate the transversus abdominis (TrA) muscle.  This technique has been shown to increase the cross-sectional area of the TrA(10), however, many exercise scientists are now advocating a method called “abdominal bracing”(demonstrated in my last post) in which ALL the abdominal muscles are recruited instead of just one(11). It should be the goal of core exercises to activate as many torso muscles as possible in order to ensure spinal stability and to prepare our bodies for the dynamic and often complex movements that occur during our daily activities.  So what does the research say about which exercises activate which muscles the best?

Numerous studies have used EMG to determine the greatest electrical activity of torso muscles during various core stabilization exercises.  In Escamilla et al(3), they used surface or skin electrodes to compare exercises such as traditional crunches, sit-ups, reverse crunches, and hanging knee-ups using straps to exercises using an Ab Roller/ Power Wheel and a device called the Ab Revolutionizer. What they found was that the activation of the upper and lower rectus abdominis(the “washboard” muscle) as well as both the internal and external obliques was the greatest with Power Wheel roll-outs and hanging knee-ups with straps.  Because research indicates that the internal obliques are activated in the same manner(within 15%)  as the tranversus abdominis(3), we can assume that these results apply to the TrA as well. The activation was least with a traditional sit-up!   In Okubo et al(8), they used both surface electrodes and intramuscular fine-wire to compare curl-ups, side planks, front planks, bridges, and bird dogs.  What they found was that the TrA was activated the greatest during front planks with opposite arm and leg raise and that multifidus activation was greatest with bridging.  Although core stabilization exercises should be performed in multiple planes of motion, these two studies highlight the enhanced activation that occurs during “face down” exercises such as front planks and roll outs.

The functional progression of exercises as well as training in all planes of motion are important aspects of OrthoWell’s core stabilization program. Our program will uncover your weaknesses and maximize your strength by progressing through successive levels of difficulty in all directions of movement ie anterior, posterior, lateral, and rotatory. Optimal development of the “local” system ie your functional neutral position and bracing technique(my last post) should occur before attempting to train the “global” or big muscle system.  Unfortunately, most people over-train the global system and need to be re-educated. So be patient as we take you by the “core” and steer you in the BEST, evidence-based direction.

The following videos are examples of some of our functional progressions for each plane of motion(sorry for the  occasional “sideways” view).  I demonstrate a particular exercise and then follow with an exercise of progressive difficulty. Functional progression is very individualized and requires skilled observation to determine competency.  Many thanks to two of my peers, Mike Reinold,PT and Eric Cressey for being very helpful in this regard.

Anterior Core Stabilization Exercises

Anterior/Posterior Core Stabilization Exercises

Posterior Core Stabilization Exercises

Lateral Core Stabilization Exercises

Rotatory Core Stabilization Exercises

1.  Allison GT, Mo4444rris SL, Lay B. Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: Implications for core stability theories. JOSPT. 2008; 38: 228-237.

2. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. JOSPT. 2007; 37: 754-762.

3. Escamilla RF, Babb E, Dewitt R. Electromyographic analysis of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Physical Therapy. 2006; 86: 656-671.

4. Faries MD, Greenwood M. Core Training: Stabilizing the Confusion. Strength and Conditioning Journal. 2007; 29: 10-25.

5. Hall L, Tsao H, MacDonald D. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of Electromyography and Kinesiology. 2007; 19:763-773.

6. Hides J, Stanton W, McMahon S. Effect of stabilization training of multifidus muscle cross-sectional area among young elite cricketers with low back pain. JOSPT. 2008; 38: 101-108.

7. Hodges P, Kaigle A, Holm S. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In Vivo porcine studies. SPINE. 2003; 28: 2594-2601.

8. Okubo Y, Kaneoka K, Imai A. Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. JOSPT. 2010; 40: 743-750.

9. Stanford M. Effectiveness of specific lumbar stabilization exercises: A single case study. Journal of Manual and Manipulation Therapy. 2002; 10: 40-46.

10. Critchley, D. Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing. Physiother. Res.Int. 7:65–75. 2002.

11. Kavic, N., S. Grenier,  S.M. McGill. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 29:1254–1265. 2004a.

 

Low Back Pain -Part 2- Getting Down To The “CORE”

Getting down to the CORE!!

What is your Core?

It is defined as the center or “core” of your body.  It is the “powerhouse” around which all limb movement is performed. It consists of 29 pairs of muscles as well as boney, ligamentous, and discs structures that support the lumbo-pelvic-hip complex in order to stabilize the spine, pelvis, and kinetic chain during functional movements.  In short, it’s pretty important!

 What is the function of the Core?

The core functions to provide both stability and mobility.  It can generate forces in order to complete a sit-up as well as provide spinal stability as you reach your arms overhead.  The muscles that are most important in providing core stability can be divided into two groups:  the primary stabilizers and the secondary stabilizers.  The primary stabilizers are the transversus abdominis in the deep abdominal region and the multifidus muscles which are deep in your back and attach directly to each vertebrae in the spine.  The secondary stabilizers are the obliques in the front, the quadratus lumborum & lumbar paraspinals in the back, the pelvic floor muscles at the bottom, and the diaphragm at the top.

So what does the research say about the Core muscles?

Current research has promoted the transversus abdominis (TrA) and the multifidus as the primary stabilizers of the spine.(1,4,6,8,9)  The TrA is the deepest of the abdominal muscles and, when contracted, it increases tension of the thoraco-lumbar fascia, it increases intra-abdominal pressure, and increases spinal stiffness in order to resist the forces that act upon the spine(4,7) The multifidi span from 1 to 3 vertebral levels and attach one vertebrae directly to another.  As a result, they provide the largest contribution to inter-segmental stability.(4,9) The TrA and multifidus have been found to activate prior to limb movement in order to prepare and stabilize the spine(1,4,9) and it has been shown that the EMG activity of the TrA may be delayed in patients suffering with chronic low back pain (LBP).(7)  The TrA is activated regardless of the direction of trunk or limb movement(4) and this is the reason why performing spinal stabilization exercises in multiple planes of motion can be so effective. A significant reduction in the cross-sectional area ie atrophy of the multifidi as well as poor motor control of the TrA has been associated with patients with acute or chronic LBP.(6.9) Patients with LBP who did not receive exercises specific for the multifidi continued to have atrophy of the multifidi even after 6 weeks of being painfree as compared to the increases in multifidi cross-sectional area in those that performed the exercises.(6,9)  In other words, just because your pain is gone does not mean that your muscles are functionally recovered.  One of our primary objectives in physical therapy is to prevent FUTURE episodes of LBP!  So how do we do it?

How do we test the Core?

Unfortunately, there is not a research-proven, valid testing regimen for core stability.  However, Shirley Sahrmann has proposed a test called the Sahrmann Core Stability Test which is the most common test of function.  It involves the use of a pressure cuff placed under the lumbar spine to measure one’s ability to maintain pelvic neutral while performing five exercises of progressive difficulty.  The chart is included below.

 

How do we perform spinal stabilization exercises?

In physical therapy, we utilize the concept of a neutral spine while performing spinal stabilization exercises.  Every joint has what we call a  “resting” or “open-packed position”. It is the position of a joint when the joint spacing is maximized and the resistance from boney or ligamentous structures is the least. These are the fundamentals of Orthopedic Manual Therapy.  In the following video, we will review the concept of the Functional Neutral Position as well describe how to activate the transverses abdominus and multifidi muscles in mutiple positions.

 

 

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So what are the BEST evidence-based, core stabilization exercises? 

 

1.  Allison GT, Morris SL, Lay B. Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: Implications for core stability theories. JOSPT. 2008; 38: 228-237.

2. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. JOSPT. 2007; 37: 754-762.

3. Escamilla RF, Babb E, Dewitt R. Electromyographic analysis of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Physical Therapy. 2006; 86: 656-671.

4. Faries MD, Greenwood M. Core Training: Stabilizing the Confusion. Strength and Conditioning Journal. 2007; 29: 10-25.

5. Hall L, Tsao H, MacDonald D. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of Electromyography and Kinesiology. 2007; 19:763-773.

6. Hides J, Stanton W, McMahon S. Effect of stabilization training of multifidus muscle cross-sectional area among young elite cricketers with low back pain. JOSPT. 2008; 38: 101-108.

7. Hodges P, Kaigle A, Holm S. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In Vivo porcine studies. SPINE. 2003; 28: 2594-2601.

8. Okubo Y, Kaneoka K, Imai A. Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. JOSPT. 2010; 40: 743-750.

9. Stanford M. Effectiveness of specific lumbar stabilization exercises: A single case study. Journal of Manual and Manipulation Therapy. 2002; 10: 40-46.