Lumbar Rehabilitation

Lumbar Rehabilitation Stability is the key to rehabilitation Once we have ‘normal’ mobility we need to stabilise within this new range This emphasises the need for manual therapy techniques to restore mobility

Mobility Before Stability Bilateral Lumbar Paraspinals Bilateral Hip Flexors

Mobility Before Stability Abdominals Glutes

Mobility Before Stability Left Lumbar paraspinals Left Hip Flexor Left TFL Right QL Right Groin

Mobility Before Stability Left Posterior Pelvic Tilt Left adduction/ IR Left Oblique Right External Rotation

Stability What is it? Functional Exercise? Motor Control? Isolated strengthening?

Static vs Dynamic Stability Static Stability Osseous configuration Capsules and Ligaments The knee is greater static stability than the shoulder Someone sitting in lumbar flexion relies on static stabilisers for stability, hence creep of tissues and therefore pain Dynamic Stability Muscle function Dynamic Ligament Tension Force Couples Joint Compression Neuromuscular Control

Dynamic Stability Muscles contracting to provide stability Dynamic Ligament Tension Muscles blending with fascia, capsules and ligaments Muscles contract and tighten the static stabilisers E.G Glutes and Lats attach into thoracolumbar fascia E.G External and internal oblique attaches into aponeurosis Joint Compression Muscle Co-Contraction compress the joint into its neutral zone A 360° contraction increases the stiffness of a joint

Dynamic Stability Muscles contracting to provide stability Force Couples Muscle working together to move or position a joint Agonistic Force Muscles work together in the same direction E.G Internal and External Obliques to provide rotation E.G Glutes and Rectus Abdominis to produce posterior pelvic tilt People will compensate in one over another E.G Over active Rectus vs Gluteals

Dynamic Stability Muscles contracting to provide stability Force Couples Muscle working together to move or position a joint Antagonistic Force Muscles work together in opposite directions E.G Rectus abdominis and paraspinals If one is over active joint position will change E.G Increase tone paraspinals vs Rectus causes anterior pelvic tilt

Dynamic Stability Neuromuscular Control Motor Response to a Sensory Input Proprioception Understanding where you body is in space Kinaesthesia Understanding where your body is MOVING in space

Dynamic Stability What can reduce Dynamic Stability Muscle Weakness Muscle Fatigue Muscle Imbalances Injury

Dynamic Stability What do we need to do to train Dynamic Stability A complete rehabilitation programme includes the following Motor Control Teach the body/muscles to move/contract in the order/way they are supposed to E.g delayed firing diaphragm, trans abs, multifidus Isolated Strengthening Endurance Neuromuscular Control Exercises are progressed to become more challenging

What’s Wrong with Current Core Programmes Sit Ups, Crunches, Russian Twists etc Based upon the ‘ACTION’ of a muscle Not based upon its true role Sit up creates 320 Kg force through lumbar spine Twisting the lumbar spine- Discs don’t like rotational shearing forces Abdominal Hollowing Notoriously difficult to teach Diane Lee reports she uses Ultrasound for 30 mins until a correct contraction occurs Isolating Trans abs does not provide 360° stability Isolated strengthening, if needed, Yes, but must transfer into 360° contraction (Bracing)

What’s Wrong with Current Core Programmes Glute Bridges “Lifting a vertebrae at a time” Promotes posterior pelvic tilt Most lumbar spine patients report flexion as an aggravating factor

Lumbar Spine Pain Delayed onset transversus abdominis Decreased and delayed multifidus Delayed diaphragm Fatigue back extensors Lumbar spine buckles in a certain plane at without 360° muscular co contraction

The Core More of a Tent than a corset Includes the diaphragm and pelvic floor Includes the obliques, rectus abdominis Includes Quadratus Lumborum If this muscle doesn’t work you CANNOT walk

The Core- The Principles Provide 360° stability THEN endurance Start with Motor Control and Isolated Strengthening Hold for 8-10 seconds, Progress endurance by increasing reps NOT length of time held Holding longer causes oxygen deletion, lactic acid build up and alters muscle properties Add controlled external force (Perturbations) Peripheral movement NO perturbations Peripheral movement ADD Perturbations Unstable surface Unstable Surface ADD Perturbations Unstable Surface ADD Peripheral movement NO Perturbations Unstable Surface ADD Peripheral Movement ADD Perturbations Transfer to Sport Specific if Required

Isolated Core Focus On Anterior Core (Anti Extension) Posterior Core (Anti Flexion) Lateral Core (Anti Side Flexion) Anti Rotational Core (Anti Rotation)

Before Isolated Strengthening Every exercise starts with the same Neutral Lumbopelvic position (Pain Free) Diaphragmatic Breathing Bracing

Core Categories Anterior Core (Anti Extension) Dead Bug Plank ASLR Posterior Core (Anti Flexion) Glute Bridges Hip Thrusts Bird Dog Lateral Core (Anti Side Flexion) Clam Shell Side Plank Anti Rotational Core (Anti Rotation) Plank Bird Dog Wood Chop Advanced Turkish Get Up Deadlift Squat

Anterior Core (Anti Extension) - Dead Bug

Anterior Core (Anti Extension) - Plank

Anterior Core (Anti Extension) - ASLR

Posterior Core (Anti Flexion and Anti Extension) - Glute bridges

Posterior Core (Anti Flexion and Anti Extension) - Hip Thrusts

Posterior Core (Anti Flexion) - Bird Dog

Lateral Core (Anti Side Flexion) - Clam Shell

Anti Rotational Core - Wood Chop

Advanced - Deadlift

Advanced - Turkish Get Up

Misc - 90/90 Hip Lift with Balloon