Managing LumbarInstability –a Physical Therapy Perspective ...

9/17/21

L. Russek, Clarkson University 1

Managing Lumbar Instability – a Physical Therapy Perspective

Leslie Russek, PT, DPT, PhD, OCSClarkson University

St. Lawrence Health SystemPotsdam, NY

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Who Am I?• Professor Emeritus, Physical Therapy Department,

Clarkson University• Staff PT, St. Lawrence Health System, Potsdam NY

• Clinical specialties: hypermobility, fibromyalgia, headaches, temporomandibular disorders

• Frequent presenter to professional and patient groups at national conferences

• Author of multiple review and research articles on hypermobility

• Author of ”Chronic Pain” chapter in Physical Rehabilitation textbook for PT students

• [email protected]• https://webspace.clarkson.edu/~lrussek/

I do not have any conflicts of interest to report

Russek: Lumbar Instability 2

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mailto:[email protected]

https://webspace.clarkson.edu/~lrussek/

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ObjectivesAt the end of this presentation, participants will be able to:1. Summarize anatomy and biomechanics of lumbar instability

• Spondylolisthesis: anatomical instability• Functional segmental instability

2. Identify evidence-based tests used for assessing lumbar instability

3. Outline evidence-based physical therapy management of lumbar instability

Note: I will not be discussing sacroiliac instability, as that is an entirely different, very complex and controversial topic


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Anatomy and Biomechanics

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Neuroanatomy of the Lumbar

Spine


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Mobilizer vs. Segmental Spinal Muscles


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Other Stabilizing Muscles


The Psoas

The Pelvic Floor

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Core Stabilization Concept

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Stabilizing muscles are often very small and very deep, but don’t ignore them!

(picture from https://www.physio-pedia.com/images/d/dd/Ms_systems.jpg)

Russek: Lumbar Instability

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https://www.physio-pedia.com/images/d/dd/Ms_systems.jpg

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Proprioceptive Role of Muscle• Deep stabilizing muscles provide substantial

proprioception for the spine• Multifidi layers perform different functions

• Deep fascicles optimized for proprioception• Intermediate fascicles control intersegmental motion• Superficial fascicles can contribute to mobility• Multifidi provide 2/3 of all spinal stiffness

• Russo, 2018

• Rotatores muscles have 4-7x as many muscle spindles as multifidi Nitz, 1986• Rotatores have poor leverage for force production

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https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rotatores-interspinales-and-intertransversarii/ Russek: Lumbar Instability

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Mobilizer vs. Stabilizer Muscles• Local stabilizer

• E.g.: transversus abdominus, multifidi, psoas• Increases segmental stiffness, almost isometric, proprioception• Tonic activity to provide stability

• Global stabilizer• E.g.: internal & external obliques, spinalis, glut med• Controls ROM, often eccentrically• Phasic: active when stability is needed

• Global mobilizer• E.g.: rectus abdominus, iliocostalis, piriformis• Generate torque to produce ROM, usually concentric• Phasic: active when motion is needed

(Gibbons, 2001)10Russek: Lumbar Instability

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https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rotatores-interspinales-and-intertransversarii/

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Mobilizer vs. Stabilizer Dysfunctions• Local stabilizer

• Motor control deficit• Responds to pain and pathology with inhibition• Leads to decreased stiffness and poor segmental control

• Global stabilizer• Eccentric control deficit• Fails to stabilize• Leads to length/strength imbalance through weakness/lengthening

• Global mobilizer• Myofascial shortening requires compensations elsewhere• Responds to pain and pathology with spasm• Leads to length/strength imbalance through spasm/shortening

(Gibbons, 2001)11Russek: Lumbar Instability

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Proposed Exercise/Pain Relationship


Increased Activity/Exercise

PainOptimal Activity/ Exercise

Instability pain

Overuse pain

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Potential Pain Generators


• Zygapophyseal (facet) joint capsule• Lumbar, sometimes non-dermatomal referral• Relieved at rest• Kemp’s extension-rotation test• New lumbar facet sign (Gómez Vega , 2019)

• Dura:• The dura is highly innervated• It is attached to the posterior longitudinal

ligament• Pain tends to be diffuse and is NOT

dermatomal (Ombregt, 2013)

• Nerve roots in the cauda equinaDura picture: L. Ombregt, A system of Orthopaedic Medicine, online at https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000338_web.pdf

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Spondylolisthesis vs. Lumbar Instability

Spondylolisthesis• Excessive movement between

vertebrae (instability) away from neutral

• One or more subluxed vertebrae• Subluxation visible on imaging• Associated with either disc

degeneration or pars fracture• Might or might not have symptoms• Pain lumbar, referred into lower limbs,

and/or radicular signs

Functional Lumbar Instability• Excessive movement between

vertebrae (instability) near neutral• Vertebrae may be properly aligned• No subluxation visible on imaging

• Might or might not have pathology visible on imaging

• Poor motor control• Pain in mid-range movements• Pain is often sudden, “catching”• Pain is often localized to the low back


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https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000338_web.pdf

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Spondylolisthesis

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Spondylolisthesis• Frank slippage of one vertebral body on

another• Contributing factors:

• Degenerative spondylolisthesis: • Degeneration of intervertebral disc, degeneration

of facet joints• Typically older individuals

• Isthmic spondylolisthesis:• Pars interarticularis (isthmic) fracture

(spondylolysis)• Typically younger/adolescents• Overuse or trauma

• Weakness of stabilizing muscles• Radiological spondy is poorly correlated to

painVanti, 2021


Diagram of isthmic spondylolisthesishttps://orthoinfo.aaos.org/en/diseases--conditions/spondylolysis-and-spondylolisthesis/

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https://orthoinfo.aaos.org/en/diseases--conditions/spondylolysis-and-spondylolisthesis/

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• Radiological spondylolisthesis is poorly correlated to pain

• Most people with radiological spondylolisthesis have NO symptoms (>75%)

• Symptoms, when present, include:• Buttock and posterior thigh pain• Muscle spasm• Radiculopathy: compression of nerve root

• Typically worse with standing upright, walking, lumbar extension• Cauda equina syndrome: saddle paresthesias, bowel/bladder, acute pain

Vanti, 2021

Spondylolisthesis


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vero

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Dur

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http://www.annenamocatcat.com/2019/01/post-accident-injuries-of-lumbar-spine.html

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Clinical Tests for Spondylolisthesis*

• Alignment test:• Step-off sign/midline sill sign

• Provocation/alleviation tests:• Posterior Shear Test/Segmental

Spring Test• Prone Instability Test• Passive Lumbar Extension Test• Active Straight Leg Raise• Lumbar Rocking

• Motor control tests:• Aberrant Movements Test• Gower sign

• Stabilizing strength tests:• Supine Bridge Test• Prone Bridge Test• Side Bridge Test

* Symptomatic spondylolisthesis• Vanti, 2021


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http://www.annenamocatcat.com/2019/01/post-accident-injuries-of-lumbar-spine.html

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Lumbar Instability Tests

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Lumbar Spine Instability Questionnaire1. My pain is usually worse with prolonged or static positions2. I have had this problem a long time3. I experience pain when I change positions (eg, sit-to-stand or stand-to-sit)4. I have frequent bouts or episodes of symptoms5. I have difficulty sitting without a back support (such as a chair) and feel better with a supportive back rest6. My pain increases with quick, unexpected, or mild movements7. I have had a back injury OR trauma in the past8. I am sometimes fearful to move because of my pain9. It seems like my condition is getting worse over time (eg, shorter intervals between bouts)10. When I bend forward it hurts, but returning to standing is usually worse11. In the past, my back catches or locks when I twist or bend my spine12. I have many occasions when I get muscle spasms in the back13. I feel like my back is going to “give way” or “give out” on me14. I feel the need to frequently pop my back15. I get temporary pain relief with a back brace or corsetHowever – this tool does not meet requirements for an interval-level scale. Best used as a symptom checklist. Saragiotto, 2018It appears to predict which patients are likely to benefit from motor control exercises or graded activity Macado, 2014


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Tests for Lumbar Instability• Step-off sign/midline sill sign (spondy only):

• Sn=81%, Sp=89%, ppv=78%,

• Posterior Shear Test/Segmental Spring Test• Low inter-tester reliability: kappa=-0.02=0.27• Sn=17-46%, Sp=48-95%, LR+=0.96-9.0

• Provocation tests• Prone Instability Test (Sn=72%, Sp=58%, LR+=1.7)• Passive Lumbar Extension Test (Sn=70-93%, Sp=82-95%, LR+=8.8)• Lumbar Rocking (Sn=95%, ppv=93%)• Active Straight Leg Raise (Sn=71%, Sp=91% for nonspecific lumbopelvic pain)

• Vanti, 2021; Esmailiejah, 2018; Ferrari, 2015


• SpPIn: High Specificity –Positive test rules In dx

• SnNOut: High Sensitivity –Negative test rules Out dx

• Likelihood Ratio: scores >5 (+) test is moderate predictor

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Motor Control Tests

• Aberrant Movement Patterns Cluster (Sn=18-26%, Sp=72-88%)• Painful arc in flexion• Painful arc returning from flexion• Instability catch• Gower sign• Inversion of lumbo-pelvic rhythm

Vanti, 2021; Ferrari, 2015


SpPIn: High Specificity –Positive test rules In dxSnNOut: High Sensitivity –Negative test rules Out dxLikelihood Ratio: scores >5 (+) test is strong predictors

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Recommended Instability Tests

• Prone Instability Test• Passive Lumbar Extension• Aberrant Movement Pattern

• (Ferrari, 2015)

• Lumbar Rocking • (Rathod, 2019)


Lumbar Rocking, Rathod, 2019

Prone InstabilityFerrari, 2015

Prone Lumbar ExtensionFerrari, 2015

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Muscle Strength Tests• Stabilizing muscle strength:

• Supine Bridge • Prone Bridge• Side Bridge

Vanti, 2021; Ferrari, 2015; McGill, 1999

• Motor control testing• Pressure biofeedback (low evidence)


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Clinical Prediction Rule for Benefit from Lumbar Stabilization Exercise

• Predicting Benefit from Lumbar Stabilization Exercises

• (+) Prone Instability Test• (+) Aberrant movement• Straight leg raise > 91º• < 40 years old

Hicks, 2005

• Predicting NO Benefit from Lumbar Stabilization Exercises

• (-) Prone Instability Test• No aberrant movement• Fear Avoidance Beliefs Physical

Activity score < 9• No hypermobile Spring Test


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Treatment of Lumbar Instability


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Impaired Motor Control and Instability

Russek: Lumbar Instability 27Im

paire

d in h

EDS

Russo, 2018, based on Panjabi

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General Approach

• Establish a therapeutic relationship• Establish trust and positive expectations• Minimize use of tissue-damage terminology

• Patient education• Posture, body mechanics, importance of activity & appropriate exercise• Self-efficacy for pain management

• Pain control• Decrease central sensitization• PT modalities only short term, if needed, to facilitate exercise and normal activity

• Exercise…Vanti (for symptomatic spondylolisthesis), 2021


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Exercise Progression• Proprioception and body awareness

• External feedback• Posture & breathing awareness

• Motor control• Selectively activating stabilizing muscles• Decrease muscle guarding and overuse of superficial muscles• Breathing control• Maintaining stability while moving limbs• Restoring normal spinal movement patterns

• Dynamic core strengthening• Gradual progression of challenge

• Functional & endurance training• (O’Sullivan, 2000; Toprak Celenay, 2017)


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Proprioception Training Options

Russek: Lumbar Instability 30https://youtu.be/fLtNIQyZXiU

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https://youtu.be/fLtNIQyZXiU

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Cognitive Phase

• Activate of stabilizing muscles:• Multifidi• Transversus abdominus• Diaphragm• Pelvic floor

• Decrease activation of superficial global muscles• Correction of breathing patterns• External feedback is beneficial


Fortin, 2021

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Progress Challenge Gradually

Russek: Lumbar Instability 32Vera-Garcia, 2020

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Functional Exercises


Saner, 2016

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Comparing Types of Exercises

• Core stabilization was more effective than general strengthening, treadmill walking

• Core stabilization using unstable surfaces was more beneficial• Addition of diaphragm strengthening improved benefits

• Inspiratory training during exercise is better than expiratory training• Strengthening the gluteus maximus with core improved outcomes• Pilates and core stabilization are of similar benefit

(Frizziero, 2021, non-specific CLBP)

• Tai Chi and core stabilization are of similar benefit• Yoga had the most adverse events of mind-body arts (Zou, 2019 , non-specific CLBP)


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Some Final Points…

• People with HSD often start exercising much weaker than non-hypermobile individuals• It may take weeks to progress to the ‘basic’ exercises• They benefit from external feedback to supplement proprioception• Optimal training frequency 20-30 minutes/day, 3-5x/wk (Mueller, 2020)

• Diaphragmatic training can help• Resisted inhalation during stabilization exercises increased diaphragm,

transversus abdominus, and multifidus thickness (Finta, 2018)


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In Summary…

• Radiological spondylolisthesis is not the same as functional lumbar instability• Provocation tests can identify functional segmental instability• Motor control tests can identify contributing factors

• Don’t forget the diaphragm!• Motor control exercises are better than generic exercise• Proprioception is essential• Zebras may start very weak, and may need ‘pre-exercises’


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References• Esmailiejah AA, Abbasian M, Bidar R, Esmailiejah N, Safdari F, Amirjamshidi A. Diagnostic efficacy of clinical tests for lumbar spinal instability. Surg Neurol Int.

2018;9:17. doi:10.4103/sni.sni_359_17

• Ferrari S, Manni T, Bonetti F, Villafañe JH, Vanti C. A literature review of clinical tests for lumbar instability in low back pain: validity and applicability in clinical practice. Chiropr Man Therap. 2015;23:14. doi:10.1186/s12998-015-0058-7

• Ferrari S, Vanti C, Piccarreta R, Monticone M. Pain, disability, and diagnostic accuracy of clinical instability and endurance tests in subjects with lumbar spondylolisthesis. J Manipulative Physiol Ther. Nov-Dec 2014;37(9):647-59. doi:10.1016/j.jmpt.2014.09.004

• Finta R, Nagy E, Bender T. The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain. J Pain Res. 2018;11:3031-3045. doi:10.2147/jpr.S181610

• Fortin M, Rye M, Roussac A, et al. The effects of combined motor control and isolated extensor strengthening versus general exercise on paraspinal muscle morphology and function in patients with chronic low back pain: a randomised controlled trial protocol. BMC Musculoskelet Disord. May 22 2021;22(1):472. doi:10.1186/s12891-021-04346-x

• Frizziero A, Pellizzon G, Vittadini F, Bigliardi D, Costantino C. Efficacy of Core Stability in Non-Specific Chronic Low Back Pain. J Funct Morphol Kinesiol. Apr 22 2021;6(2)doi:10.3390/jfmk6020037

• Gibbons SGT, Comerford MJ. Strength versus stability: Part 1: Concept and terms. Orthopaedic Division Review. 2001;March / April: 21-27.

• Gómez Vega JC, Acevedo-González JC. Clinical diagnosis scale for pain lumbar of facet origin: systematic review of literature and pilot study. Neurocirugia (Astur : Engl Ed). May-Jun 2019;30(3):133-143. Escala de diagnóstico clínico para dolor lumbar de origen facetario: revisión sistemática de la literatura y estudio piloto. doi:10.1016/j.neucir.2018.05.004

• Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. Sep 2005;86(9):1753-62. doi:10.1016/j.apmr.2005.03.033

• Macedo LG, Maher CG, Hancock MJ, et al. Predicting response to motor control exercises and graded activity for patients with low back pain: preplanned secondary analysis of a randomized controlled trial. Phys Ther. Nov 2014;94(11):1543-54. doi:10.2522/ptj.20140014

• McGill SM, Childs A, Liebenson C. Endurance times for low back stabilization exercises: clinical targets for testing and training from a normal database. Arch Phys Med Rehabil. Aug 1999;80(8):941-4. doi:10.1016/s0003-9993(99)90087-4

• Mueller J, Niederer D. Dose-response-relationship of stabilisation exercises in patients with chronic non-specific low back pain: a systematic review with meta-regression. Sci Rep. Oct 9 2020;10(1):16921. doi:10.1038/s41598-020-73954-9


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References• Nitz AJ, Peck D. Comparison of muscle spindle concentrations in large and small human epaxial muscles acting in parallel combinations. Am Surg. May 1986;52(5):273-

7. • O'Sullivan PB. Lumbar segmental 'instability': clinical presentation and specific stabilizing exercise management. Man Ther. Feb 2000;5(1):2-12.

doi:10.1054/math.1999.0213• Ombregt L, “The dural concept”. A system of Orthopaedic Medicine. Elsevier, 2013. Accessed 9/8/21. Available at

https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000338_web.pdf• Rathod AK, Garg BK, Sahetia VM. Lumbar rocking test: A new clinical test for predicting lumbar instability. J Craniovertebr Junction Spine. Jan-Mar 2019;10(1):33-38.

doi:10.4103/jcvjs.JCVJS_5_19• Russo M, Deckers K, Eldabe S, et al. Muscle Control and Non-specific Chronic Low Back Pain. Neuromodulation. Jan 2018;21(1):1-9. doi:10.1111/ner.12738• Saner J, Sieben JM, Kool J, Luomajoki H, Bastiaenen CHG, de Bie RA. A tailored exercise program versus general exercise for a subgroup of patients with low back pain

and movement control impairment: Short-term results of a randomised controlled trial. J Bodyw Mov Ther. Jan 2016;20(1):189-202. doi:10.1016/j.jbmt.2015.08.001• Saragiotto BT, Maher CG, New CH, et al. Clinimetric Testing of the Lumbar Spine Instability Questionnaire. J Orthop Sports Phys Ther. Dec 2018;48(12):915-922.

doi:10.2519/jospt.2018.7866• Toprak Celenay S, Ozer Kaya D. Effects of spinal stabilization exercises in women with benign joint hypermobility syndrome: a randomized controlled trial. Rheumatol Int.

Mar 30 2017;doi:10.1007/s00296-017-3713-6• Vanti C, Ferrari S, Guccione AA, Pillastrini P. Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment. Arch Physiother. Aug 9

2021;11(1):19. doi:10.1186/s40945-021-00113-2• Vera-Garcia FJ, Irles-Vidal B, Prat-Luri A, García-Vaquero MP, Barbado D, Juan-Recio C. Progressions of core stabilization exercises based on postural control challenge

assessment. Eur J Appl Physiol. Mar 2020;120(3):567-577. doi:10.1007/s00421-020-04313-9• Zou L, Zhang Y, Yang L, et al. Are Mindful Exercises Safe and Beneficial for Treating Chronic Lower Back Pain? A Systematic Review and Meta-Analysis of Randomized

Controlled Trials. J Clin Med. May 8 2019;8(5)doi:10.3390/jcm8050628


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9/17/21



Thank You!

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