Avtor: Boris Milikič

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The main purpose of this paper is to design a comprehensive exercise program for development of core strength and stability in patients with lumbago. I conduct an extensive and thorough analytical literature review of the existing research on the topic and developed the exercise program that helps to reduce and in some cases eliminate the pain in the lower back region.

We provide explanation of muscles important for low back and low back pain relief. Next we explain pelvic floor muscles, that take care of the correct position of the pelvic organs, and at the same time stabilize the spine.

Lastly, in developing my own exercise program, the program is methodically divided into three consecutive segments. For each segment, we propound a basic and a more advanced set of exercises in order to account for the differences in physical fitness level of the patients.

1.0 Low back pain

According to some estimates, between 60% and 80% of people experience back pain at least once in their lifetime. Most of these pains occur in the lower or lumbar spine. Due to back problems and pain, on average, each worker loses three working days a year.

To summarize some research in McGill (2007), they say that people with past lower back pain and problems have been associated with increased waist circumference, decreased muscle capacity, especially core muscles, decreased hip mobility in extension and internal rotation, and deficient motion control. In his book, McGill (2007) also summarizes in vitro testing for the causes of injuries, proposing that a reduction in specific tissue damage can be achieved with the following recommendations:

1. elimination of stressors that cause damage to the lumbar spine,
2. implementation of activities for healthy supporting tissue,
3. the ideal sitting posture is one that is constantly changing but still prevents the tissue from too burdened;
4. there are two types of risk factors that people have a predisposition to develop lower back problems:

• these are those factors that are related to the person (e.g., a person’s muscular endurance or lack of endurance) and those
• that are related to the requirements of the task we need to perform (e.g., lifting weights, loading a load, etc.).

Low back pain needs to be addressed from several perspectives. A distinction must be made between

• acute lumbalgia lasting less than six weeks,
• subacute lumbalgia lasting between six weeks and twelve weeks and
• chronic lumbalgia lasting more than twelve weeks.

Low back pain needs to be addressed from several perspectives. A distinction must be made between acute lumbalgia lasting less than six weeks and chronic lumbalgia lasting more than twelve weeks. The causes of most acute, short-term low back pain are mechanical or nonspecific, especially minor injuries to the spinal muscles and ligaments, unphysiological position in the workplace, poor posture, excessive sports and other loads, congenital and acquired spinal anomalies. Acute low back pain usually passes quickly, especially after the removal of triggers (Kos, Golja, 2001).

The eternal question is also whether to rest during the pain in the upper or lower back or to move rather. There has long been a belief that the best treatment and recovery for low back pain is prolonged rest or lying down. However, lying in bed for more than two days only harms the situation as the bones and muscles become weaker, the body becomes stunted, loses physical strength, the person may fall into depression and the muscles become weaker, the pain increases even more and each time it is even harder for the person to get back on their feet and function normally forward (Waddell, 2006).

No wonder this method is no longer functional, except in the case of unbearable acute pain and inability to move. Then we are forced to rest for a day or two, but the most important thing in all this is to start moving as soon as possible. Walking is enough to start with, followed by cycling (stationary bike) and swimming (Waddell, 2006).

Figure 1. The site where lumbar back pain may occur.

Retrieved from http://www.advancedhealthcareofthepalmbeaches.com/back-pain/

Our entire movement requires the participation of the spine, and problems with the spine are in most cases the result of multiple wrong loads. The injuries occur over years or even decades, and are influenced by many factors. People are too unaware of how important their spine is. They pay no attention to it, as the pain in it usually only shows up after a few years or decades. Although we are sometimes aware of the problem, we do not do much for our spine. They are not aware of the burdens of irregular movement patterns and the consequences this can have on our lives.

1.2 Core stabilizers and low back pain

Research shows that weak core stabilizers can cause lumbar spine pain. However, people who experience pain can reduce or eliminate the pain with the help of core strengthening exercises. Activating core stabilization muscles is even more effective with later strength and endurance exercises.

1.3 Core stabilizers

Bergmark (1989) divided core muscles into two groups and described them with a clinically applicable concept of local and global muscles. The muscles that run between the pelvis and the chest and attach to the vertebrae at least at one end are counted to the local system. These are mainly deeper lying muscles whose job is to maintain the mechanical rigidity of the spine and control movement between adjacent vertebrae. Global muscles include larger muscles that cross more moving segments and lie more superficially.

Core stabilizers are one of the most important muscles in our body. We are often not even aware of how important they are in our daily activities. Core stabilizers take care of our posture, allow the core to bend and stretch, and take care of the stability of the spine in everyday life (Cao, Schoenfisch, Tan, & Wang, 2013). Strong core stabilizers allow us to distribute the force caused by loads, while protecting our spine from injury. We divide them into local and global muscular system.

The core stabilizers consist of the back muscles, the abdominal muscles (front and side) and the pelvic floor muscles (PFM).

According to Kisner and Colby, stabilizer muscles are defined by role and position.

The characteristics of the superficial and deep muscles of the core are shown above. It is presented where they are located, what their job is and what these muscles are called.

Figure 2: Abdominal muscles Figure 3: Back muscles

Images obtained from https://mojaxis.si/stabilizatorji-trupa/

The transverse abdominal muscle (M. transversus abdominis) is the deepest muscle among them and is especially important for maintaining posture. In addition to this muscle, others in this area are shown: the abdominal muscle (M. rectus abdominis), the external oblique abdominal muscle (M. obliquus externus), the inguinal ligament (Inguinal ligament) and the internal oblique abdominal muscle (M. obliquus internus); which has the middle layer removed so that the transverse abdominal muscle can be seen.

Figure 4 shows the pelvic floor muscles. They take care of the correct position of the pelvic organs, and at the same time stabilize the spine.

Figure 4. Pelvic floor muscles

Image retrived from https://www.continence.org.au/about-continence/continence-health/pelvic-floor

Core stabilizers have a dynamic control role and are responsible for transmitting large forces from the lower and upper extremities across the core to achieve maximum efficiency and to achieve proper biomechanics of movement ( Sharrock et al., 2011).

Some researchers have described core stabilizers as a double-walled cylinder with the diaphragm at the top, with the abdominal muscles at the front, with the spinal muscles and glutes at the back, and the pelvic floor and hip muscles, which represent the bottom of the cylinder (Richardson, Jill, Hodges, 1999).

The hip and pelvic floor muscles are the foundation of all stabilizers. Hodges (2003) states that core stabilization synergy arises from the pelvic floor muscles and core muscles. The hip muscles, which cover a fairly large area, are involved in stabilizing the core as well as in generating the forces needed to move the lower extremities during sports movement. The imbalance of all the muscles of the above core stabilizers (agonists – antagonists) has a decisive effect on the stability of the core.

1.4. Core stabilizers and sport

Core stability has received considerable attention in recent years in both research and exercise. Thus, most of you, at least recreationally engaged in sports, have probably come across recommendations for strengthening core muscles or often called core stability exercises.

The stability of the corer allows athletes to control body position, create optimal strength and transmit force along the kinetic chain. Core stability is often required for rotational movements or bending, which is required by almost every sport. Research suggests that Core stabilization exercises may be effective in treating back pain due to spinal instability and other clinical diagnoses. Due to the high loads on the lumbar spine during athletic competition and exercise, athletes are likely to be more susceptible to pain due to instability or spinal injury (Joshua Johnson).

What is the difference between core strength and stability? By definition, “power” is the ability to create force at a given motion. The strength of the core thus creates a force during movement, such as getting up or stretching the back, while we speak of the stability of the core when all the muscles of the tcore are statically tense to resist unwanted movements.

2.0 Exercise to strengthen core stabilizers

An exercise program for the strength and stability of the lumbar spine and core can be used as a preventative program or as a rehabilitation program if you are recovering from low back pain or spinal cord injury. (Princeton University, Athletic Medicine, Lumbar / Core Strength and Stability Exercises)

The program includes a section for the stability of local stabilizers, a section for the stability of surface stabilizers and a section for power. Stability training should be done at least five times a week and strength training should be done 3-4 times a week. The program is divided into three levels:

• easy,
• medium and
• difficult.

It is advisable to start with “easy” exercises and complete them before moving to “medium” and these before moving to “Difficult”.

2.1 Instructions and levels of stabilizer training

The quality of the exercise is more important than the amount of exercise performed. This means that the practitioner performs only as many repetitions as he is able to do in the correct technique. The practitioner can move on to a more difficult modification of a particular exercise only when he is able to maintain stability and complete neuromuscular control during the current exercise, which means that the movement is controlled and coordinated. The goal of any workout is to improve intervertebral stability, pelvic stability, and effective movement. The patient has adequate stability of the pelvis and lumbar spine when complex movement patterns such as case squats and lunges, can be performed without excessive movement in the spine. Core stabilization training must be systematic and progressive.

The first phase is called core stabilization by the author (O`Sullivan, 2001) of the article. In the beginning, we need to focus primarily on small movements of the spine and pelvis that improve neuromuscular efficiency and intervertebral stability. The first phase is the cognitive phase, which requires a high level of self-awareness during the performance of exercises with the aim of shrinking only the local part of the stabilizers, without the involvement of global stabilizers. The goal of the first phase is to achieve harmonious contraction and cooperation of the transverus abdominis and multifidus muscles, controlled breathing and a neutral body position.

In the second phase, which the author (O`Sullivan, 2001) cites as core strength, we can already include eccentric and concentric movements of the spine throughout the range of motion. The second phase is the associative phase, where the emphasis is on improving certain movement patterns. Depending on what kind of back pain the practitioner has, certain movement patterns are divided into several component repetitions, which the practitioner performs in a large number of repetitions. It is very important to keep the spine in a neutral position and control the pain. If the practitioner has his spine in a neutral position and there is no pain, the practitioner can also perform movements such as sitting, getting up, lifting and walking. The speed and complexity of the movement should be gradually increased to such an extent that the practitioner can control the complex pattern of movement without pain. The practitioneris also encouraged to do regular aerobic exercise, such as walking, as this will give the muscles a certain tone. This phase of training can last from 8 weeks to four months. At the end of this program, the patients are able to perform complex movements in a controlled manner without any pain.

In the last, third phase, called core force, dynamic stabilization and rotation (Clark, Luccet, Sutton, 2011) can also be included in training. The third phase of training is about automating movements. At this stage, a very low level of attention is required to perform proper motor tasks. The third phase is actually the goal of the entire program. In it, practitioners use dynamic stabilization both in training and in life in everyday tasks.

Figure 5. All three stages of back stabilization training

LMS – local muscles system (O`Sullivan )

In Figure 5, we can see the first, second, and third phases of back stabilization training. The inner circle represents the cognitive phase and its exercises, the middle ring shows the exercises in the associative phase, and in the third or outer ring we can see which tasks in everyday life people use dynamic stabilization. Before each exercise, the practitioner must know exactly what is required of him. We can use the pictorial material to illustrate the exercises. Proper demonstration of the exercise is also highly recommended, where the practitioner can observe the correct execution of the exercise. We have to adapt the explanation of each exercise to each patient. In case of incorrect performance of the exercise, we immediately interrupt it and show the patient the correct version again. If the patient is not able to achieve it, the trainer must find an easier modification of the desired exercise. The conversation between the patient and the trainer is also of great value. Only in this way can the trainer get to know the well-being and feelings of the patient during the implementation of an individual exercise or the entire training program. Here he must pay particular attention to any pain that occurs in the patient.

2.2. Methodology for power development of core stabilizers

In the chapter exercise for developing the strength of core stabilizers, we will describe in three stages exercises that will improve the strength of our stabilizers, and consequently we will be able to reduce or eliminate back pain. We will step up the exercises according to the difficulty, and at the same time add pictorial material.

The first stage or phase involves the activation of local stabilizers. Activation of local stabilizers in the first phase, we focus on the technique of activating the abdominal muscles and developing the strength of the pelvic floor muscles (exercises from 1a to 1d). The absence of pain is very important.

It is followed by the phase of activation of surface stabilizers including static and dynamic exercises. Activation of surface stabilizers in the second phase, we develop the power of the surface muscles, while controlling the local muscles (inner). The exercises are mostly static and are performed in several planes. In the certain exercises, we achieved a small dynamic. The last phase is the stabilization and strengthen of the core during slow and controlled movement.

The eccentric and concentric contractions are performed in all three planes. Movement is slow and controlled. We also used gadgets in the third stage (ball).

2.2.1 Activation of local stabilizers

The first phase is aimed at activating local stabilizers. Since people with low back pain are still unable to withstand the loads required by heavier exercises during this period, this phase is designed to properly activate the muscles of the indoor unit. We will strive for a neutral position of the spine, minimal activity of superficial muscles, and above all, we must ensure the absence of pain.

Figure 6. Three methods to activate the stabilizing musculature in lumbar spine.

Most mentioned techniques for activating abdominal muscles:

(A) drawing-in maneuver in which the patient hollows the abdominal region (“draws” the belly button toward the spine )

(B) abdominal bracing which setting the abdominal muscles results in flaring laterally around the waist

(C) posterior pelvic tilt in which the pelvis is actively tilted posteriorly on the lumbar spine flatness

Retrived from Colby Lynn,Allen Kisner Carolyn: Therapeutic exercises (2012)

Figure 6 shows all three abdominal muscle activation techniques. The drawing-in maneuver also functions to increased intra-abdominal pressure by inwardly displacing the abdominal wall. Because of this the drawing-in is recommended for stabilisation trening (Kisner and Colby ) The patient should first perform it in a lying position (as in the knee 70-90 degrees), and later he should also perform it in a sitting and standing position. The patient should exhale first, then inhale and pull the navel towards the spine, while maintaining tension in the abdominal region. The goal is to increase intra-abdominal pressure, with minimal or even no contraction of the internal oblique.

Figure 7 Checking before a drawing-in maneuver	Figure 8. Execution of a drawing-in maneuver in a supine position
Figure 9. Execution of a drawing-in maneuver in the sitting position	Figure 10. Execution of a drawing-in maneuver in the kneeling position

Figure 7 shows the checking if there is a space for the outstretched fingers of one hand between the low back and the base before the execution of the drawing-in maneuver. Figure 8 shows the execution of the drawing-in maneuver in the supine position. Figure 10 also shows the use of the rod. Only this serves to help us achieve a neutral posture of the spine.

The main purpose of drawing-in maneuver (ADIM) is to strengthen a deep muscles, such as the transverse abdominal muscle, the internal oblique muscle, and the external oblique muscle. ADIM is an exercise method that increases abdominal pressure by pulling the abdominal walls inward, allowing the transverse and oblique abdominal muscles to contract. Due to the increased abdominal pressure, training for lumbar core stability is effectively performed.

Patient position

The training may be easiest in lying position in order to use effects of gravity on the abdominal wall. Hook-lying (with 70 to 80 degrees and feet resting on an exercise mat), prone-lying or semireclined position may be used if more comfortable for the patient.

It is important to progress training to sitting and standing position as soon as possible,

Figure 11. Palpation of the transversus abdominis (TA) muscle.

The TA feels like a tense sheet (a bulge is the internal oblique) when performing a gentle drawing-in maneuver.

Retrived from Colby Lynn,Allen Kisner Carolyn, 2012

Procedure

Have the patient assume a neutral spine position and attempt to maintain it while gently drawing in and hollowing the abdominal muscles. Patient have to breath in, breath out, then gently draw the belly button in toward the spine to hollow out the abdominal region . When done properly, there is minimal to no movement of the pelvis (posterior pelvic tilting) , no flaring or depression of the lower rips, no inspiration or lifting of the rib cage, no bulging out of the abdominal wall, and no increased pressure throw the feet.

Abdominal drawing-in maneuver (ADIM) is the main for the strengthening of the deep muscle such as transverses abdominis, internal oblique; and external oblique. ADIM is the exercise method which increases the abdominal pressure by pulling the abdominal walls to the inside that Tra and oblique abdominal are contracted. Because of the increased abdominal pressure, lumbar trunk stability training is effectively accomplished. Also, it induces the muscle contraction that excessive lordosis and tilts of the pelvis are reduced which is effective for the LBP (Kisner and Colby, 2012).

2.3 Exercises for core stabilization

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Detail description of exercises. Page is password protected. You get password when you purchase My Low Back on Google play.

3. Conclusion

Back pain is one of the more common problems of modern society. The number of people who experience pain in any part of the spine at least once in their lives is increasing. One of the most common is certainly pain in the lumbar region of the back. Today’s lifestyle, where we sit a lot and at the same time have very little time to devote to exercise, is certainly one of the main causes of these pains. Depending on the way of life nowadays, however, these pains will become more and more frequent. Although there are more and more people with low back pain, too few people are still involved in prevention.

Reference

1. Cao, L., Schoenfisch, W., Tan, S., Wang, J. (2013). Investigation of core muscule function through electromyography activities in healthy young men. Journal of exercise physiology, 16(1), 45-52. Pridobljeno iz http://www.asep.org/asep/asep/JEPonlineFEBRUARY2013_Wang.pdf
2. Clark, A. M., Lucett, C. S., Sutton, G., B. (Eds.). (2011). NASM Essentials of personal fitness training. United States of America: National Academy of Sports Medicine.
3. Comerford, M., Jull, G., Richardson, C.G. Toppenberg, R. Techniques for active lumbar stabilisation for spinal protection: a pilot study. Australian Journal of Physiotherapy, 38(2), 105-112.
4. Kisner C. in Colby L.A., (2007). Therapeutic exercises. Philadelphia: F.A. Davis Company. 38
5. Kos Golja, M. (2001). Bolečine v križu z revmatološkega vidika. V M. Ivanuša (ur.), Bolečina v križu. (str. 8–11). Novo mesto: Krka.
6. dr. Robert Košak, dr. med. UKC Ljubljana, Ortopedska klinika ,2010

7. McGill, S. (2007). Low back disorders. United states: Human kinetics
8. O`Sullivan P. (2001). Variation in progression of specific back stabilizing exercises. Manual teraphy, 6(1). 3-14. Pridobljeno iz: http://www.back-exercises.com/back-stabilizing-exercises.html
9. Pori, P., Pistotnik, B., Dolenec, A., Tomažin, K., Štirn, I., Majerič, M. (2013). Športna rekreacija. Ljubljana: Športna unija Slovenije, Fundacija za šport.
10. Richardson, C.A., Jull, G.A. in Richardson, B.A. (1995). A dysfunction of the deep abdominal muscles exists in low back pain patients. V: Proceedings of World Confederation of Physical Therapists, Washington.
11. Sharrock C, Cropper J, Mostad J, Johnson M and Malone T. A pilot study of core stability and athletic performance: Is there a relationship? The International Journal of Sport s Physical Therapy,
12. Waddell, G. (1999). The back pain revolution. Edinburgh: Churchill Livingstone.