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Journal of Bodywork and Movement Therapies (2004) 8, 8084

Journal of Bodywork and Movement Therapies

www.intl.elsevierhealth.com/journals/jbmt

SELF-HELP: CLINICIAN SECTION

Spinal stabilizationFan update. Part 1Fbiomechanics$

Craig Liebenson DC*
10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA

Introduction
The concepts of stability and instability are integral to modern musculoskeletal care. There are two distinct types. One is the whole body stability/ instability and pertains to whole body equillibrium. Whereas the other is segmental or relates to an individual joint and pertains to its stiffness. According to Panjabi three subsystems work together to maintain spine stability (Panjabi, 1992). They are the central nervous subsystem (control), an osteoligamentous subsystem (passive), and a muscle subsystem (active). He says The neural subsystem receives information from the transducers, determines specic requirements for spinal stability, and causes the active subsystem to achieve the stability goal. The spine or any joint becomes injured or irritated by end-range overload. This can involve either macrotrauma or repetitive microtrauma. Two main factors involved in whether or not extrinsic end-range overload will result in injury or irritation are intrinsic motor control and tness level. Motor control is a key component in injury prevention. Impaired motor control consists of failure to control a joints neutral range usually by a dysfunction or incoordination of the agonist antagonist muscle co-activation. The eminent researcher Pr. Stuart McGill states that evidence from tissue-specic injury generally supports the
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Spinal stabilizationFan update. Part 1Fbiomechanics

notion of a neutral spine (neutral lordosis) when performing loading tasks to minimize the risk of low back injury. (McGill, 1998). Injury or irritation occurs when the tissues threshold is surpassed by external load. The threshold is dependent on the individuals level of tness. Therefore, injury or irritation can occur with either high levels of external load in a normal system or low levels in a compromised one. The bottom line is that a history of too little or too much external tissue load will create an environment conducive to tissue failure (see Fig. 1). Motor control can be trained. The process focuses on neuromuscular re-education of patterns of agonistantagonist muscle co-activation during low-load manoeuvres. These are progressed to more functional tasks to ensure stability during activities of daily living (ADL), sport or work demands.

Biomechanics of low back injury

The spinal column devoid of its musculature has been found to buckle at a load of only 90 N (about 20 lb) at L5 (Crisco and Panjabi, 1992; Crisco et al., 1992). However, during routine activities, loads 20 times this are encountered on a routine basis. Load proles of various activities are shown in Table 1. Panjabi (1992) says, This large load-carrying capacity is achieved by the participation of well-coordinated muscles surrounding the spinal column. Surprisingly, the motor control system functions well when under load. Muscles stabilize

This paper may be photo copied for educational use. *Tel.: 1-310-470-2909; fax: 1-310-470-3286. E-mail address: cldc@ash.net (C. Liebenson).

1360-8592/$ - see front matter & 2003 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2003.12.003

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Spinal stabilizationFan update. Part 1Fbiomechanics joints by stiffening like rigging on a ship (see Fig. 2). But, when load is at a minimum, such as when the body is relaxed or a task is trivial, the motor control system is often caught off guard and injuries are precipitated. Low back injury has been shown to result from repetitive motion at end range. According to McGill, it is usually a result of a history of excessive loading which gradually, but progressively, reduces the tissue failure tolerance. (McGill, 1998). Coordination of agonist and synergist muscles, not strength, plays a pivotal role in resisting injury. Sparto et al. showed that spinal loading forces increased during a fatiguing isometric trunk extension effort as substitution by secondary extensors such as the internal oblique and latissmus dorsi muscles occurred to maintain a constant strength (Sparto et al., 1997). This demonstrates the 81

limitations of strength testing as an indicator of normal function. When synergist substitution occurs spinal load increases, even without a compromise in power or strength (i.e. torque output). According to Cholewicki and McGill (1996) spine stability is greatly enhanced by co-contraction of antagonistic trunk muscles (e.g. abdominal and extensor muscles). Co-contractions increase spinal compressive load, as much as 1218% or 440 N, but they increase spinal stability even more by 3664% or 2925 N (Granata and Marras, 2000). This mechanism is present to such an extent that without cocontraction the spinal column is unstable in upright postures! (Gardner-Morse and Stokes, 1998). In particular, these co-contractions are most obvious during reactions to unexpected or sudden loading (Lavender et al., 1989; Marras et al., 1987). Stokes et al. (2000) have described how there are basically two mechanisms by which this

0 0 Too litttle History of tissue stress Too much

Figure 1 Relationship of injury to history of tissue load. (Adapted from McGill SM 2000. Clinical biomechanics of the thoracolumbar spine. In Zeevi Dvir (ed) Clinical Biomechanics. Churchill Livingstone, Philadelphia.)

Figure 2 Spinal stability depends on co-activation of muscle in 3601 around the spinal column.

Table 1
* * * * * * *

Lumbar spine load proles for common activities.

Without muscles the spine buckles at 90 N (Crisco III and Panjabi, 1990) Routine activities of daily living involve E2000 N (Panjabi, 1992) According to McGill recommended subacute exercise training o3000 N (McGill, 1997) National Institute for Occupational Safety and Health (NIOSH) limit for repetitive tasksF3300 N (McGill, 2002) NIOSH work demand limitF6400 N (Gardner-Morse and Stokes, 1998; Gordon, 1991; Stokes et al., 2000) 7000 N (1568 lb) begins to cause damage in very weak spines(Adams and Dolan, 1995) Tolerance of average healthy young male spine approached 12,00015,000 N (26883660 lb) (Adams and Dolan, 1995) Competitive weight lifters manage loads in excess of 20,000 N (4480 lb) (Cholewick et al., 1991)

Spinal stabilizationFan update. Part 1Fbiomechanics

Tissue injury

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82 C. Liebenson

co-activation occurs. One is a pre-contraction to stiffen and thus dampen the spinal column when faced with unexpected perturbations. The second is a sufciently fast speed of contraction of the muscles to react quick enough to prevent excessive motion that would lead to buckling following either expected or unexpected perturbations (Carlson et al., 1981; Cresswell et al., 1994; Lavender et al., 1989; Marras et al., 1987; Stokes et al., 2000; Thelen et al., 1994; Wilder et al., 1996). Wilder et al. (1996) concluded in a study of bodys reaction to sudden, unexpected loads that muscles will respond rapidly to stabilize the body, i.e., they will try to maintain balance and posture. This has also been veried by Radebold et al. (2000, 2001) and Cholewicki et al. (2000a, b) in a series of studies. Inappropriate muscle activation sequences during seemingly trivial tasks (only 60 N of force) such as bending over to pick up a pencil can compromise spine stability and potentiate buckling of the passive ligamentous restraints (Adams and Dolan, 1995). This motor control skill has also been shown to be compromised under challenging aerobic circumstances (McGill et al., 1995). When a spinal stabilization and respiratory challenge is simultaneously encountered the nervous system will naturally select maintenance of respiration over spine stability. An example of this occurs when during repetitive bending or lifting activities the back becomes vulnerable due to poor aerobic tness even if the motor control system is well trained. Good abdominal strength is not sufcient to maintain spine stability. Lack of proper coordination between the abdominals and diaphragm will lead to spine instability during challenging aerobic activities (Hodges et al., 2000; OSullivan et al., 2002). Prospective studies have shown that decreased enduranceFnot strengthFof the trunk extensors can predict recurrences and 1st time onset of LBP in healthy individuals and increased likelihood of future recurrences (Biering-Sorensen, 1984; Luoto et al., 1995). Hodges and Richardson reported that a slow speed of contraction of the transverse abdominus during arm or leg movements was well correlated with LBP (Hodges and Richardson, 1998, 1999). OSullivan et al. found that synergist substitution of the rectus abdominus for the agonist transverse abdominus during an abdominal drawing in manoeuvre strongly correlated with chronic back pain and that specic rehabilitation which improved this dysfunction was superior to a more general exercise approach (OSullivan et al., 1997).

The multidus in the low back has been shown to be atrophied in patients with acute low back pain. (Hides et al., 1994). The acute patients atrophy was unilateral to the pain and at the same segmental level as palpable joint dysfunction. Recovery from acute pain did not automatically result in restoration of the normal girth of the muscle (Hides et al., 1996). However, it has been demonstrated that segmental spinal stabilization exercises can prevent multidus muscle atrophy in acute LBP subjects (Hides et al., 1996). Recent research has demonstrated that such exercises have a secondary preventive effect by reducing recurrences (Hides et al., 2001).

Biomechanical advice
Karel Lewit recommends the rst treatment is to teach the patient to avoid what harms him. LBP patients are generally vulnerable in the morning, when sitting for prolonged periods of time, and during lifting. Specic activity modication advice is therefore needed during these circumstances. Certain times of day are the most vulnerable for the back. For instance, in the rst hour after awakening or after prolonged static full exion such as sitting or stooping the body is at greatest risk. (Adams et al., 1987). Therefore, it is wise to avoid full trunk exion early in the morning (Snook et al., 2002). Prolonged sitting is one of the most deleterious activities for LBP patients. It has been shown that

Spinal stabilizationFan update. Part 1Fbiomechanics

Figure 3 Standing overhead arm reach.

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Spinal stabilizationFan update. Part 1Fbiomechanics after just 20 min of full exion of the spine ligamentous creep or laxity occurs which persists even after 30 min of rest! (McGill and Brown, 1992). In a porcine model just 2 min of full exion has been shown to lead to a substantial loss of the normal spinal ligamentous stiffness (Gunning et al., 2001). Therefore, regular micro-breaks involving standing and elongating the spine are recommended for every 2040 min of sitting (see Fig. 3). Suggestions to teach workers to lift with their knees not their backs are overly simplistic. Most workers have learned various techniques to avoid injury which are inconsistent with this advice. Better advice is consistent with the following principlesFpre-contract the trunk muscles (bracing); maintain slight lordosis; rotate jobs to vary loads; allow frequent rest breaks; and keep loads close to the spine (McGill and Norman, 1993). 83

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