1. Lumbar Rehabilitation

2. 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

3. Mobility Before Stability
Bilateral Lumbar Paraspinals
Bilateral Hip Flexors

4. Mobility Before Stability
Abdominals
Glutes

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

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

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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

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

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

22. 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

23. Anterior Core (Anti Extension) - Dead Bug

24. Anterior Core (Anti Extension) - Plank

25. Anterior Core (Anti Extension) - ASLR

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

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

28. Posterior Core (Anti Flexion) - Bird Dog

29. Lateral Core (Anti Side Flexion) - Clam Shell

30. Anti Rotational Core - Wood Chop

31. Advanced - Deadlift

32. Advanced - Turkish Get Up

33. Misc - 90/90 Hip Lift with Balloon