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List of Tests and Exercises ix

Preface xi
Acknowledgments xiii
Photo Creel its xiv
Why and How You Should Read This Book XV

PART I Scientific foundation 1

CHAPTER 1 Introduction to the Issues 2
Legislative Landscape: The Unfortunate Adverse Impact on Bad Backs J
Deficiencies i n Current Low Bilek Disorder Diagnostic Practices 3
Is It True That 85% of Back Troubles Are of Unknown Etiology? 5 • Diagnosis by
Hypothesis Testing .5 • Is IL True That Most Chronic /Jack Complaints Are Rooted
in f'sychologie<tl factors? 6 • Does Pain C1use Activity Intolerance? 7
Inadequacies in Current Care and Prevention oi low Back Disorders 7
J/l·lldvised Rehabilitation Recommendations 8 • Can /Jack Rehabilitation /Je
Completed in 6 10 12 Weeks? 10 • Should the Prim,lfy Co.1f of R('habilitatio"
Be Restoring !he Range of Motion? II • What ArP BeltP.r AltemJtives in Dealing
With Painful Backs? II
Mechanical loading and the Process of Injury: A Low Back Tissue Injury Primer 1 1
A Final Note 14

CHAPTER 2 Scientific Approach Unique to This Book 15

In Vitro Lab 15
In Vhv Lab t 6
/-low the Viflual Spine Works 16 • Development of the Virtual Spine 21

CHAPTER 3 Epidemiological Studies on Low Back Disorders (LBDs) 22

Multidimensional links Among Biomechanical, PsychosociaL and Personal Variables 22
fhrcc Important Studies 23 • Do Workers Fxpcricncc LBDs Bc>eausc They Arc
/>aid to Ac! Disabled? 24 • Does Pain /-lave aJl Organic Basis-Or Is It All in the
Head> 25 • Are Biomechanical Variables and Ps)•chosocial Variables Distinct? 28
• What Is the Significance of First·Time Injury Data ior Cause anc/l>revention? 28
How Do Biomechanical Factors Affect lBD? 29
Mechanical Loading and LBO: field-Based Risk factors 29 • What Are the Lasting
PhysiOiogieal, Biomecil<Jnical, and MotOr Changes 10 Which lnjur)• J.e,7ds? 30 • What
Is the Optiinal Amount of Loading for a I-lea/thy Spine? J 1
What Are the Links Between Personal Factors and LBD1 32
What the Eviclcnce Supports 33

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vi Contents

CHAPTER 4 Functional Anatomy of the Lumbar Spine 35

Basic Neur.)l Structure 35
Vascular Anatomy 36
The Vertebrae 36
Vertebral Architecture and load Bearing 36 • Posterior Elements of the Vertebrae 4 I
Intervertebral Disc 44
t.nad-Bearing Abilities 44 • Progres>ive Disc Injury 44
Muscles 47
Muscle SiT.e 48 • Muscle Groups 49 • Abdominal Muscles 56 • Psoas 60 • QuadralllS
Lumborum 6 I • Muscle Summary 62
Ligaments &2
t.nngitudinal JJgaml'lliS 6} • Interspinousand Supraspinous Ligaments 63 • Other ug.1mems
in the Thoracolumbar Spine 65 • 1\'ormal Ligament Mechanics and Injury Mechanics 65
Lumbodorsal Fascia ILDF) 66
A Quick Review of the Pelvis. Hips. and Related Musculature 67
Clinically Relevant Aspects of Pain and Anatomic Structure 70
Tissue-Specific Types of Pain 70 • can l"din Descriptors Provide~ Reliable Diagnos;s? 11
A Final Note 71

CHAPTER 5 Normal and Injury Mechanics of the Lumbar Spine 72

Kinematic Properties of the Thoracolumbar Spine 72
Kinetics and Normal Lumbar Spine Mechanics 76
Loads on tile /.ow BKk During Functional Movemetlts 76 • Loads on th~ Low Back
During Various Exercises 87
Dubious Lifting Mechanisms 91
Intra-Abdominal Pressure 92 • Lum()odorsal Fascia 94 • Hydraulic Amp/iller 95
• Ill/~ LOG and Hydraulic Amplifier: II Summary 95
Other Important Mechanisms of Normal Spine Mechanics 95
Biomechanics of Diurnal Spine Changes 96 • Spinal Memory 96 • Anatomical Flexible
Beam and 1russ: Muscle Cocontraclion and Spine Stability 97
Injury Mechanisms '18
Summary of Specific Tissue Injury Mechanisms 98 • Injury Mechanics Involving the
Lumbar Mffhanism 99 • Staying Within the • 8iomf•Chanical Fnvc•lope' 99
Biomechanical nod Physiological Ch~nges Following Injury 108
Tissue Damage P<Jthogenesis, Pain, and l'erformance /08 • Injury Process: Motor
Changes 109 • Specit/c Patterns of Muscle Inhibition Following Injury 110 • The
Crossed-Pelvis Syndrome and Gluteal Amnesia 110

CHAPTER 6 Myths and Realities of Lumbar Spine Stability 113

Stability: A Qualitative Analogy 113
Quantitative foundation of Stability 114
Potential Energ)' as a Function of Hetght 115 • Pownlial F.nergy as a Function ofStitlnC'ss
and Elastic Energy swage 111 • Muscle.~ Create Force and Stiffness 118 • Suificient
Stabilit)' 119
Stobility Myths, Facts. and Clinical lmr>licaMns 119

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PART II Injury Prevention 123

CHAPTER 7 LBO Ri sk Assessment 124
llric( Review ol the Risk Factors lor LBO 124
NIOSH Appmach to Risk ASsessment 125
1981 Guideline 125 • 1993 Guideline 126
Snook Psychophysical Approach 12 7
Lumbar Motion Monitor (LMM) 12 7
Ergowatch 128
Biological Signal-Driven Model Approaches 130
The Marras Model and the McGill Model 130 • EMG-Assisted Optimization 13 I
• Simple or Complex Models? 13 7
The Challenge Before Us 131

CHAPTERS Reducing the Risk of low Back Injury 133

Lessons From the Literature 133
Compensation 13oard SUltistics- an Artifact? I34 • Ergonomic Stvdies 734 • l<eh.ab and
Preventio" Stvdies 134 • Studies on the Connection Betwt>en Fimess and Injury
Disabilily 135 • Beyond Ergonomics: Is// Time to "Modify" the Worker? IJS
LllD PrfVfnti on for Workers 136
Should Workers A1'0id End Range ofSpine Motiotl During Exertion? 136 • What Are lfle
Way.s to Reduce the Reaction Moment? 131) • Should One Avoid Exertion lmmediaJely
After Prolonged Flexion? 143 • Sltould tmra·Abdominal Pressure (lAP) Be Increased
During Lifting? 744 • Are Twisting an(/ Twisting Lift.s P;micularfy Dangerous? 745
• Is Lifting Smootflly and N01 jerking the Load Always Best? 145 • Is There Any Way to
Make Seated Workless Demanding on 111e8ack? 148 • SomeShort-AnswerQueslions/50
LBO Prevention for Employ~'<S 152
Injury Prevenlion Primer 154
A Note for Consultants 157

CH APTER 9 The Question of Back Belts 158

Issues of the Back Belt Question 1 58
Scientific Studies 159
Clinical Trials 159 • Biomechanical Studies 161 • Studies of Belts, /-/earl Rille, and
Blood Pressure 162 • Psychophysical Studies 163
Summary of Prescription Guidel ines 163

PART Ill low Back Rehabilitation 165

CHAPTER 10 Building Better Rehabilitation Programs for
low Back Injuries 166
Our Five·Stage Back Training Program 166
Finding the Best Approach 167
Stages of Patient Progression 169
Stage 1: ~teet and Correct Perturbed Motion and Motor Patterns 169 • SUlge 2: Eswblisll
Stability Through Exercises and Education /81 • Stage 3: Develop Endurance 182

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viii Contents

Guidelines for Developing the Best Exercise Regimen 183

Developing a Sound Basis for Exercise Prescription 183 • Basic Issues in low Back
Exercise Prescription 184

CHAPTER 11 Evaluating the Patient 189

The Most Cru ciaI Element in Evaluation 189
Firsl Clinician- Patient Meeting 190
Some Provocation Tests 192
A Note on MotiOil Palpalion 198 • DisOnguishing8etween Lumbar and flip Problems 198
Some Functional Screens 199
The 'Stiff' Spine 203 • Cnncrol of TorMonal Motion 203 • Testing for Aberrant Cross
Lumbar MoUon 204
Testing Muscle Endurance 2 10

CHAPTER 12 Developing the Exercise Program 213

Philosophy of Low Back Exc.,cise Design 113
Clinical Wisdom 214
Sparing the Back While Stretching the f-lips and Knees 2 I 4 • Flossing the Nerve Roots
for Tl>ose Wi(/l Accompan)•ing SCi,1lica 216
Identi fying SMe and Effective Exercises 217
Incorporating and Palleming the Muscles 218 • Eliminating UnS<lfe Exercises 218 • SelecUng
Saff!,1Jld Effective Exercises 220
Beginner's Program for Stabilization: A Sample 22 I
Exercises That May Be Used in a Stabilization Program 222

CHAPTER 13 Advanced Exercises 230

Safely Increasing Challenges 23 1
Labile Sur1;1ces and Resistance Training Machines 231 • Safely Progressing Back
Exercises Z33
Occupational and Athletic Work r; ardening 2J b
low Back Exercises for High-Performance Workers or Athletes 236 • Low Back Exer-
cises Only for Athletes 238
Looking Forward 241

Epilogue 243
Handouts for Patients or Clients 244
Appendix 268
Glossary 274
References and Ad<litional Readings 276
Index J Ol
About the Author 312

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Introduction to the Issues

here is no shortage of mauua1s and lx)()ks offering wisdom on low back heal th. Authors
T range from tbose "'ith fonual medical or rehabi~tation training to laypeople who ha,•e fow1d
an approllch to allevi:1re their own back troubles and become self-proclaimed low b:1ck heakh
prophetS. Their intentions are honorable 1 but their advice is rarely hased on a soue1d sciencifit
foundat1ort. Too many of these ;luthors offer inappropriate recommendations or even harmful
suggesr.ions. Years ago, as 'J began to develop scientific investigations into various aspects of low
back problems, I would ask my graduate srudents to find the sciend6c foundation for many of
dle "comntonscnse'" recommendations I was hearing both in dtc clinic and in indusuial settings.
'lo my surprise they often reported that the literat-ure yielded no. or ve1y rhin, evidence (note
that I choose my srudcnts carefully and that tht'Y are very competent and reliable). Examples of
suc.:h thinJy supported "commonsense" recommendations include the folJowing:
• BeJJd the knees to pcrfonn a sit-up.
• Bend the knees and keep rhe back smtighr ro perform a lift.
• Take )'O!fJ and Pilates classes-cltcy are good for the back.
• Reduce the load being handled in orde1· ro ,·educe the risk of back troubles.
• Stretch the hamso·ings if you have a had back and leg pain) and so o n.
ln fuct~ each of these recommendations may be appropriate in some simations hur1 as will be
shown, not in all.
'llte famo\Jsecooontisrj ohn Kennetb QllbJ'aith was well known. for demOJJSU":Iting- tim actions
based on common wL'irlom. ar Jeasr in economic renns, were often doomed ro fail. He stared rhat
conunon wisdom is &rencraiJy neither common nor v.ise. Galbraith eloquently expressed exactly
what I had experienced wit!J "c~ni cal wisdom" pertaining to the low l>atk. Many atrempts at
~weventing low back troubles and rehabilitating symptomatic ones have failed simply he~-ause
they relied on ill-conceived clink-al wisdom. T his hisrory of fi1iled attempts is part:icularly un-
fortunate b(.'Gluse it has lent credence to the assertions of a number of increasingly well-known
'\1urhorities" that low back inj\1ry prevention 41nd rehabilit:.uion programs are a waste of resources.
These authorities ch1im that the majority of low back problems are not org·anic ott all-that,
for example, most of these difficulties have materialized lx.;cause workers are paid too much for
inju1y compensation, have been subject to psychosocial influences, or crave sympathy. These
tJjsmissals of back injury are not justified. Back injury prevention and reh:lbilitarion programs
with stroug scientific foundations, cx_t'(;utiOilS, and foJJow-up can he effecti,·e.
Having stated rhis, I must acknowledge that justif)•ing improved practice on scie~ttific evi-
dence is a dynamic process. \iViffi new evidence, the foundation will change. To accQunr for such
inevitable slufu<, Thave developed a balanced approach iu these p a~o<es, rcvic.wing cl>c assets and
liabiljties and opposiog views of an argument where appropriate. llut fuir waroiHg! As you read

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Introduction to the Issues 3

this book, be prepared to chaU~nge current thoughts and rethink currently acccpred practices
of injury prevention and appro;lches to rehabiliwtion.
This chapter will F.unHiadze you with some of the debatable issues regarding lo\\r hack
function, together with some opinions that rehabilitation professionals hold about patients,
diagnosis, comp~nsation, and disability. It will <1lso explore the circumstances that lead to back
injury and discuss the need to apply knowledge to improve low back injury prt...•·vention and

Legislative landscape:
The Unfortunate Adverse Impact on Bad Backs
Although most legislation and leg<1l acti\ity involving bad backs are enacted "ith good inten-
cions, mucll is counterproductive. A good example is the issue of spine range of motion (ROi\'1).
The American Mectical i\ssocoation (AMA) guidelines (1990) fur quantil)·ingthe degree of back
disability a·re based mosdy on loss of spine ROM. La")•ers and compensacion boards dm need
numbers fo r the pw-pose of defining disability and rewarding compensation have h1rcbcd onto
spine RO~·t :1s an objcc.ctivc and easily me:burcd factor. to the leg.1l arena, du:rapy is considered
successful when the R0,\1 has been restored or at least improved.
Scientific e\ridence suggests, however, that after hack injury, many people do nor do well with
an t:mphasis on cnhandng spine mobiljty. ln some cases, back prob1cnlS arc actu:UJy cx<Jcer-
hated by tllis approach. In fact, evideo1ce shows t:bat many back injul'ies improve \lith
approaches-motor control training, enhancement of nmsde endurance, and training \\;th the
:.pine in a neutral position (Saal and Sa all t989, may be c.xmsiclcrcd tbc classic work). Our most
recem work has shown that three-dimensionallow back R01VI has nocoo'l'elation to ftmctional test
scores or e\'en the ability ro perform occup"rional work (Park.< et al., 2003). In rhe !:>est practice,
spine flexibility may not be cmphasi7.<:.d until the very late stages of rchabWmrion, ;(ever.
1-!ow, then, ctid d1is idea of flexibility as the best measure of successful rebauiliration become
so entrenched? The cun em rnen·ic for detemljning di.sabiliry appea rs ro have been chosen
for legal convenience rather thao for a positive: impact on l.o w back troubles. T he current
landscape creates a reward system for therapy that at·gu:obly ltinders optima l rebabilita-
rion. Perh:1ps rhe criteria for clererminlng disahilicy need ro he reasses~e<l tlnd jtsstified wir,h
stierstific e,;dence.
Another example illustrates the perverse impact of well-intended equity legislation. vVe all
have equal rights under rhe law, hur we are nor physical equals. Although individual v,1riance
is present in every {,,-oup, different populations within society demonstrate qui te diftCrent
capabilities. For example, the dat:o of] ager and colleagues ( 1991), compiled from nwty studies,
clearly showed d'lat young men can tole111te mo1·e compressive load down their lumbar spines
than canolder men, and simil~rly, men can tolerate about an additional third more load than <.~n
won1en when matched t()r age. Yet buman rights ltgislation, which is designed to create fairness
and equity by discouraging distinctions among groups, ;~crual ly puts older fem;tles at g>'eateo·
risk than younger meo. By not allowing a 64·year...old osteoporotic woman to be t:reated (and
protected} differently &om a 20-yc;or-old, fit, 90 k~ (200 Ib) male in terms of tolerating spine
load, t:be legislation presents a major barrier fot· intelligently implementing tolerance-based
guidelines for protecting workers.

in Current low Back Disorder Diagnostic Practices
[tis currently popular for many authori ties to suggest that back trouble is not a me>dical concti-
rion. 'll1ey assert d•at ph)'Sicalloading has little to do with low back injury compensation claims;
rather, they believe workers complain of hack rrohlems in order co benefit from overly f,rener·
ous compcn));ttiOu packages or to couvinc.:c physicians they arc sick. Ac.:corcliug to this view, any
biomechallically based injury prevention or rehabili.nnion program is useless. Variables within

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the psychO:Social sphere dominate any biologic;tl or mechanical vari"ble. If this is true, then this
hook is of no value-it should he about psychosocial intervention.
T ho.s.e who (.•ontend thar psychosocial factors dominate low back issues arc well-pohlished sd-
enri~-rs and physicians. Forex:.unple, Professor Richard Deyo ( 1998)summarized a common view:
"C.)IIsider the following paradox. The American economy is increasingly postindustrial, with
less beavy labor, more automation and more roboUcs, a.nd medkinc has consistently impro"ed
diagnostic imaging of the spine ;md developed new forms of Slll'gical ;md nonsurgical therapy.
But work disability caused by back pain has steadily risen." This line of ,·easoning assumes that
modem work (i.e., more repetitive, more sedentary) is healthier for the back than the predomi-
nantly physical labor of past generations. The C\·idence suggests, however, that the r<~pecitivc
motions required by some specialized modern work, or the sedentary n.tture <:h"
others, produces damaging biomechanical srressors. In fact, the nriety of work perfonned by
our gre~n-grandparenrs may hHve been far healthier chan our own. Oeyo also seenl s to assume
that nonsurb>ical therapy has been appropriateJy chosen for eacb individual, whereas! suggest
that inappr-opriate ther<1PY prescriptions remain quite cornmon.
Furthcnnorc: a1thuugh I agree- that th<~rc is more re(jam:<: on rnc-dieal irnag1ng, 1 suspect

that this reliance has resulted in a loss in the mechanically based diagnostic skills that are a
crucia l facror in accurate diagnosis. Interestingly, magnetic resonance imaging (M Rl) has bee11
documented ro find-among other fettures·-cHsc bulges, trophic facer joints~ and "degenera- 1

cive di."c d~SC<lse,'' yet these have little relationship to wherher the individual has or not.
Gibson and colleagues ( 1980) present '"1dcncc rcg.mling plain film rndiogr"phs; and McGill
and Yingling ( 1999) and Zhao and colleagues (2005) cliscuss why such images are compromised
in showing actual damage. Savage and coworkers ( 1997) sbo"'ed there is little li nk between
the image :and the pacient~~ symptoms. VVithout question the images are of great value for the
surgeon who must "'cut out the pain hut only if the image finding corrohorares the .specific

clinic.-al symptonts of the patic:nt.

Professor Alf Nachemson ( 1991) wrote that "mosc case control sn1dies of crosssecr.ional
design that have addressed the mecbaniCll I and psychosocial factors inAuencing LB-P Qow b>~ck
pain), indttding joh sarisF.1ction, ha\•e concluded tbar the latter play a more irnporntnt role tl1an
tl1e e.xrensiveJ); studied mechanical factors." Yet none of the several references cited to support
this opinion made reasonable quantification of the physical job demands. Generally, these stud-
ies showed that psychosocial variables were related ro low back trouble,;, but in the absence of
measuring mechanicalloadiJlg, they had no chance to e'' aluate a loading rclationsllip.
Finally, Dr. Nortin Hadler (200 I) has been rather outspoken, staring, for example, m•" "iris
unclea rwhether there is any meaningful association he tween task content and disabl:ing regional
musculoskeletal tJjsorders for a wide range of ph)rsicaJ disorders" aud that ''on the other h:md,
nearly all muJtivariate cross settionaJ and longitudinal studies designed to probe for associa-
tions beyo<1d the physical demand of msks, detect associations with the psychosocial c;omext of
Recent evidence dearly shows that, although psychosocial Factors can be iunportant in
u1odulating patient behavior, biomechauical components are io1pormJlt in leading to low back
disorders and in their pre.•ention. The position that biomechanics plays no role in back health
and activity tc)lerance can be held only hy those who have never performed physical labor and
have llOt experienced firsthand the work methods that must be emplo)•Cd to avoid disabling
injuty. While tbe scientilic evidence is absolutely necessaty, it will only confim1the obvious to
those who have this experience. I 6nd it perverse)}; satisfying when physicians tell nne that they
are now, after missing work as a result of a nasty back episode related to physical work, able to
relate to rheir patients. Perhaps experience with a va,·iety of heavy work and with disabling pain
should be Jie.quired for some medics!
lt is, then, c-.sscntiaJ to irwcstigate and understand the links among loading~ tissue <.hunagc
or i•·,·itarion, psychosocial factors, and performance to p1-ovide cJt,es for the design and imple-
mentation of better prevention :mel rehahilimtion strategies for low back trouble~. Founded on
this mbri<:,. chapter 7 will strcn!,'thcn the case for performing provocative testing to disc.:<>vcr the
cause of a patient~ pain and v.ill pro,~de an algorithm to guide that approach. In rbe following
section.< 1 \.\111 address several commonly held beliefs ahour back injmy.

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Introduction to the Issues 5

Is It True That 85 % of Back Troubles

Are of Unknown Etiology?
Low back injury reports often mention the s~atistic that85% oflow back rroublcs are of unknown
etiology. This has led to the popu lar belief that disabling back troubles a•·e ioevitable and just
happen, a statement t hat defies the plethora of Jite rarure lin k-in g specific mecb anicaJ scenar ios
to specific tissue damage. S<lme ha~·c argued that this statement is simply the product of poor
ctiagnosis---or of clinicia•1s •·e~chi ng the end ol' their expertise (e.g., !<inch, 1999). [ n fitirness r
m ust point our that d iag nosis often depends on the profession of the diagnostician. Eac-h g roup
attempts to identify the primary dysfunction ac.:conling to its particular l)rpC of trL.""aUoent. For
e.xample, a physical therapist will :mempt diagoosis to guide decisions reg.1rding manual d1crapy
appro<lches, whi le a surgeon may finrl a diagnosis direcred ro. .vard making surgical decisions more
helpful. Some clinicians (surgeons, fo r example) seek a specific tissue as a pain <.:and.idate. From
tlli.s pe•·spective, oerve block procedut·es have sbowo conclusive pain source diagJ'osis io well
over 50% of cases (e.g., Bogdul< ct al., 1996; Lord eta 1., 1996; Finch, 1999). T his has prompted
research in co which tissues are innen•atecl a ncl are candidates as pa in gene rators. Biomt.oc h anist.~
often argue that this may be irrelevam since a spine wid1 altered biomechanics has altered tissue
stresses. Thus a damaged rissue may caose overloo:~d on another tissue, causing whether the
damaged tissue is inn ervated or not.
This is why other dinicians employ sl<illed provocative mechanical loadi"g of specific tissues
co reveal chose th~H hurt, or at lease ro reveal loading ll:ltrems or motion pacrerns that cause
pain. These <ype.< of functional diagnoses are helpful in desib~ung therapy and in developing
less painfu l motion patterns, but the process of functional diagnoses will be hindered by a poor
understanding of spine biomechanics. Furthermo•-e. those with a thorough undersronding of
the hiomcchanics of tissue damat,re c<1n be guided m a genera l diagnosis h)' reconsuucring the
insci.g ating mechanical scenario. An ~1dditiouaJ benefit of this approach is that once the t'auSc
is undet·srood, it can be removed or reduced. Unfortunately, many patients continue to have
rroublessimply because they continue to engage in the mechanical t-ause. Familiarity wirhspine
mc'Chanics wiU dispel d1i' myth of undiagnosable back trouble aud reduce tlte percentage of
those with back troubles of no lo1o,vn cause.
£,.,.en whh ::l cissue...hased d iagn osis, the p raccice of creating all patients who have a specific
diagnosis "ith a sin&'Uiar tl1erap)' has not proven productive (Rose, 198 1)). For example, suc'C{'SS
rates wir.h rnany car1cer dlet·apies greatly improved with the combi11acion of chemotherapy and
radiotherapy. Optimal hack rehabilitation requires removal of the cause and the addition perhap,;
of stability, manual soft tissue therapy, or something else depending on the patient. Few patients
fall uno a "oomplete !it" for ftu1ct:iooal diagnosis where a singalar approach will yield optimal
resulrs. Bor.h for interprer.arion ofrhe 1iteramre and for d init-al de<::ision making. it would appe;tr
prudent to question the tliagn(>scic criteria needed before a briven diagnosis is assign ed.
Limitations in tissue-based diagnosis should not be used to suggest thatdeterroinU1g the cause
nf hack (roubles is in eJevant or rh;:~t t he manual o r medical ( l'eatrnenc in some cases is fruitless,
leaving psychosocial approaches to prevail by default. Even given the t-urrent l.i1n itations, the
diagnostic approach is productive for guiding prevention and rehabilitation approaches. But
what is meant by t his llapproach"? Read on~

Diagnosis by Hypothesis Testing

GeoA' Maitland (1987), the Australian physiotherapist, years ago promoted the concept of
examining the patient a nd fonning a working hypocl1esis. The h}l>othesis was us..ed to guide
u·eatmcnt and project the prognosis. 1l1e hypothesis was tbeo te.lted ;uld relined as rehabilita-
tion progr-essed. Our approach, which incorponltes a strong biomechanical foundation and
blends expertise from various biomedical and psychosocial disciplines, is strongly a lif,rtted wit h
_M.aidand's proposition. An initial intprcssion is fonru:d from the first lllcttiogof !Xtticnts in t he
waiting 1'oom- f1·om obsel'Ving their sitring J>OStore, how rhey rise from the ch air, their in.i rial
gairpartern , and so on. T hen a history is taken m look for possible candidate injury mechanisms
as well as perceived pain cxaccrhators ami O bServation continues during some basic

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motion patterns as the evaluation process proceeds, delviJlg further into the medla1>ics aJHI
narure of t h e symp to ms. ' fhen provoc::1t ive tesrs are performed ro either strengthen o r weaken
clu! hypo thesis. J\'lotion and moto r p atterns that are wlcratcd are identified. All informatio n is
used to formulate the phm for correctin: exercise and the. starci11g dosage of tolerable therapeutic
exercise. The progression concludes with functional sc,·eens and tests that are chosen based on
informatio.n o btain ed in t he preceding process. In this way a fi mctional diagnosis is ensured rh at
is sufficient for considering exercise choice and rates of subsequent progression. The cause has
been identified toged>er "i th symptoms of <1bnom13l motion and motor patcem s. T he course
of pre \'enci.on and re habilitation now has some q uantitative b11.1idiug par.uneters.

Is It True That Most Chronic Back Complaints

Are Rooted in Psychological Factors?
Whi.le there is no dotJbt that many cbronic back cases have psychological overlays, the signifi-
cance of psyd>ology for hack problems is often greatly exah'Sera ted. Dr. Ellen T hompson (IY97)
coined the phrase "bankrupt expt.rtise" when referring to spine docs wbo are unable to guide
improvement in their patients and default to blamiJlg the patients and tbei; psychoses. These
physicia ns either dismiss rnecha nic<ll causation o r assume ch:tt mech an ical causadon has heen
adequately addressed.
At our uJtiversity d i•>ic I see patients who have been referred by physicians for coo suit. These
are either e lite performers or the very difficu lc chronic bad backs who have failed with all othe,·
appro ac hes. In spite o f the fa<..' t that these people have ret:eived very t horough att~ntion, I am
continually heartbroken to hear about the minimal notice paid to ongoing back stressors and
abo11t the exercises that these "basket CllSC backs" have been prescribed that have only exacerbated
their condition. T he day before I wrote this section, I saw a classic example.
A wonhll1 b<1d suffered for five years on diS<lbilit)' and had seen no Fewer th<u• 12 specialists
from a variecy of disciplines. Although seve1-al had acknowledged that she had ph~'Sica l concems,
her troubles were largely attributed to mental depression. She consistently reporred being
unable to tolerate specific a<:tivitics while b d ng a ble to tOlerate o the rs. Some provot'::ativc tcst-
ingconfim>ed her report together with uncovering a previously undiagnosed ardt•~ric hip. For
years she had heen faithfully following the instructions of ber health care providers to perfom1
pc.hrk tilts knC('S-tO-chcst st retches first thing ln the morning, and sit-ups; to take h cr large dog

fo1· walks; and so on. All of these ill-chosen suggestions h<1d p1·e,•enred he•· posterior disc (w1th
sciatica)-hased trouhles from imprm1ng. As we will see later, these rypes of troubles typically do
not recover witb At.·xion-bascd approaches-pa rticularly first thing in the morn ing. Nlo re.ovcr,
the lead-imposed torsio1tal loads d1at she e.\'])CJ'ienced every time she walked her dog e.xceeded
her tolerance. Alt ho ugh she reported vacuuming as a major exacerbator o f her trouble~, her
health care pro\•iders had n (-vtr shown h c.r how to vacuum her honlc in a wa ~r tO spare her b-ack.
I suggested that removing these daily activities a11d replacing the tle>:ion stretches with ueutral
spine position awareness training and isometric rorso challe nges would likely sr:.trr a slow, pro -
gressive rtcovc1y pattern. I believed that her psychologkal concerns would probably disapl""'r
with ber back symptoms if sbe fell into the typical pattern. Tltis patient, with this typical story,
has a reasoll:lhly good chance to enjoy life once 3h'llin. (Nore: T his patient was hack ro work and
off her antidepressan t medication at the time of proofing this manuscript.)
None of tl1e "experts" t.l>is woman had seen- including physical therapist~. ch iropractors,
p>ychologists, physiatrists, neurologists, and orthopods-add,·essed mechanical concerns.' f'his is
not to condemn the-~'*! professions but rather to suggest that shari ng expericnc~ <tnd approach es
wiU hd p us to be more successful in helping bad backs. Perhaps these professionals we re unaware
of the principles of spine function, the !)>pes of loads that a1·e imposed on the spi ne tisslles during
cerrain activities: rutd how these -activities and sp in e postures can be changed to greatly reduce
th e loads- in o ther words, the biolllt.'th anil:al C()mponcnts.
T his book is an anempt to heighten the aw<~reness 311d potential of this<:"' l app1-oach .
While ir sounds very harsh, I have found relatively few e.'perts who appear wi!Ung to adequately
address tile causes of uack tn)UUle$ while working to find the nl<l.'tt appropri ate therapy. My
)'ears of laboratory-based work, combined with collaboration in ,·ecent years with my clin.ical

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colleagues, h•we provided me with wtique insight. As a result, l am not so quick to blame tbe
chronic patient.

Does P:ain Cause Activity Intolerance?

E'1dcoce t.lhat mechanical tissue overload causes damage is c-ondusi,·c. But does the damage cause
pain, and does the chronic JY<~ in cause work intolerance? Several, bullimited numhersof, studies
ha,,.e documented the mechanical or c hemical stimulation of tissues to reproduce clinical pain
patterns. (The absence of definitive, large-scale studies is due to tbe ethical issues of performing
invasive procedures and probably not to lack of scientilic merit in such srudies.) ~':or example,
the pioneeoi ng work of Hirsch and c"lleagues ( I963-64) documented pain from rhe injection of
hypertonic saline into specific spine tissues thought to be c-andidates for damage. Subsequent w
dus work, several other studies suggested the link between mechaniC;![ stimulation and pail>, lor
example, the work of Hsu and colleagues ( 1988) documenting pain in damaged dis-cs.
There is irrefumble evidence that ''trtebral disc e nd-plate fractures arc \'cry common and
result only ft'Oilt mechanical overload (Bt1nckmano, Biggemann, and Hjlweg, 1989; Guotning,
Callaghan, and McGill, 200 1). That these ITacrures are alw found in necropsy specimens dtat
were subjcL~ed to whiplash (Taylor, 'l'vomcy, and Corker, 1990) also •~rclrtgthcns another fJcet
of this relationship. Hsu performed discograms (iJtjections or radio contrast) into 692 discs, of
which 14 demonstrated leakage inro the verrebrol body, confirming an end-plate fr=-cntre. Four
of the$e discs (28%) produced severe pain, nine (64%) produced fully concordant pain, and
one produced mildly discordant paiu. IJI contra.<t, only II% of the remaining 678 discs witb
no end-plate disruption produced severe pain, 31% concordant pain, 17% mild p:1in, and 41 %
no pain. This evidence provides suong support for tbe notion that loading causes rlamage and
damage causes pain.
Fven though pain c:m limit nonction and activity in other areas of t.he bod)•, some still sug-
gest that these are not linked when a bad back is at issue. 1easell (I997) provided an interesting
perspective when he argued d1at in S):)()J"t.S medid.JIC, as opposed to occupational medicine, it is
well accepted that some injuries J-equil'e months of therapy or ca n even cause t'etirement from
rhe acriviry. He nore.d that athlercs receh•ing speciali7...ed sporrs me.dicine c.-are are all interest·
ing group to consider since m<my <1re highly motivated, are- in top phys-ica.l conditjon, are well
paid, h,tve access to good medical care, and are tully compensated even whi le injured. Their
injuries and pain can cause ahsence from phl)' for suh!>tamial amounts of time and <::an even end lucrative c.:arcers. ]Cascll rcrn.inded us that not all long·tC.rm chronic pain is an entirely
psychosocial concern, as implied b)' some cijnicians. T1>ese clinicians' dismissal of the useful-
ness o( physical approaches simply hecau~e rhey have not heen successful in rechacing long-te.nn
troubles is a dissc.rvitc ro the patient.

Inadequacies in Current Care

and Prevention of low Back Disorders
i\1any back patients can tc.stif)' that the care d1ey have received for their rrouble.s is not satis-
factory. Wl1at are some uf the fuctors that conti1bute to the inadequacy of their experience?
Cerrninly one fgcwr is rhe facr [har [he epidemiological evidence on which many professionals
base their neannent rt.'Commcndations can be quite confusing. Following are some examples
of the is.o;ues th:n cause confusion.
• Plethom of :rtudi«S on "backache." Nonspecific "backache" is nearly impossible to
quantify and, even if it could be qu~mti t1ed, offers no guid1n1ce for in(ervention. As S\JCh, any
study of treaonent intenrencions on nonspecific.· backache is of lirtle use. Some backs suffer with
discogen.k problems, for c.xawple, and will respond quite differently from those wi tb ligmnen-
tous damage or l\1cet-based problems. Efficacy srudies that do not subcb ssiJY bad l>acks end up
with nonspecific ''average" responses. This has led to dte belief that norhing works-or that
everything docs, but to a limited degree. i\riorc stmlics on nonspecific backache tn:armcnt will
not be helpful, not· will the l:trge epidemiological re•'iews or these studies offe•· real insight.

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In contrasr, patients with treatUlent matched to the condition experience greatcc short- aJH.I
long-rem1 reductions in dis~thilit)' th<m those receiving unmatched o·enmems (llrenn:m et al.,
• U·s-baped ]/merion of lotuling tmtl resulting i1tjury •-isk. Like many he>llth-related
phenomena, the relationship of low hack tissue loading to inju ry risk appears to fonn a u. .
.shaped function-not a monotonically rising line. For example, virrually cvCLT nutrient will
cause poisoning "ith excessive dosage levels, but health suffers in tbeir absence; thus, there is a
moderate optimum. In the case with low b·ack loading~ evidence sngge$ts that two regions in the
U-shapcd relationship are problematic-too much and too little. Porter ( 1987) su&,>ested that
heavy work is good for the back-but how does one de6ne heavy? Porter was probably referring
ro work of sufficient challenge ancl variability to reach rh e hoo:om of rhe U ancl hence lower
symptoms. From a hiologicaJ pers:perti\'C., sufficient loading ts necessary to cause strengthening
and tougbening of tissues, bur excessive levels wiJI result i.n lack o f <:oosensus
in the lirer<lture reg"J rding the. measurement of exposure has heen prohlenutic (l\1-a.rras et al.,
2000). A more advanced understanding i ~ required.
• Relatumsbip ofintensity, tlurtt!Wn oflotuliug, 0'1111 rest periud<. f\s Ferguson and Marra;
( 1997) pointed out, some studies SU!><gesr that '' cerrain type of loading is not rela ted ro 1min,
injury, or disability. while others subrgest it is, dependiug on how the e~l)Osure wa.s mea~ured
and where tire moderate optimum for tissue health resides for the experirnenral population. The
subjectivity of such studies is further unde•·scored when we consider tbe question of whether
there is a difference berween tissue irrit<ltion and cis11ue damage. Loading e:o..v eriments
on human anJ animal rissuc.s to produce damage. revea.l the "ultinlatc col(~rablc load'' beyond
which injuries C3use biomecha•1ical changes, pain, ;md gr.oss failure to su"Ucrures. IJ1 real life, any
of u~ could irritate ri~sues to produce tremendou~ pain ar loading level~ well helow the L-adal'·
cridy dctcnnincd rolcr.mtc l>y repeated and prolonged loading. In fact, evidence presented l>y
Videtna!l and colleagl•es ( 1995) suggests Lllal the progressive development of oonditioos such
as spinal stenosis results from years of specific snhfailure ~cr.ivity. The tlmclamental question is
'"Could such conditions be avoided by evidence-based prevention str.ttcb.-ies that ind ude optimal
loadutg, rest periods, and control~ng the duntion of exposure?"

Ill-Advised Rehabilitation Recommendations

These f.tilurcs to frame research and its results appropriately have resu lted in 111any ovc.r-
simplificacions ahoot low back tre:.lrment, which ha"e in turn led to some inadequace treatment
practices and reL'Ommenclations. A few of the most l'f>mmon recommendations for back health
arc here.
• Strengthen 11tuJ'cles in the tonm to protect tbe back. Despite the clinical emphasis on
increasing 'Ua<.:k mu~de strength, several studies ha,·c shown that musdc sttcngth cannot prcdkt
who will lta•e rut\lre hack troubles (Biering-Sorenson, 1984). On the other hnnd, Luoto and
colleagues (1995) have shown that muscular endurance (as opposed to strength) is prmeccive.
\¥by, dten, do many therapeutic programs continue to emphasize strenb'tb and ucglctt endur-
ance? Perhaps it is a holdover i,tUuent-e from the athletic world in which the goal of training
is to enhance perfom1ance. Perhaps iris an influent"e from rhe pervasive use of bodybuilding
approaches in rehab ilitation. ~ will be shown, optimal cxerdse thcrnpyoccurs when the cmphasi~
>hifts awa)' from the enltancement of performance and toward the establishment of impr<wed
health. ln cases rhe two are murually exclusive!
• Bmtl the Jmees when perfonning sit-ups. Cli•1icians widely recommend bending the
knees during a sir·Ul), but on wlm evidence? A frustrating lite•·arure search suggests that this
perception may be the result of "clinical wisdom." Inrerestingl)•, Axler and McGill (1997)
demonstr3!ted that there is little ad\'antagc to one knee position O\'Cr the other, and in F.t<.:t
the issue is pi'Obably moor because there are far better ways to challenge the abdom inal muscu-
lature and lower lumbar spine loads (uaditional sir· ups cause spine loading <:onclition.s
that greatly elevate the risk of injury). ·n1is issue is one of many that will be challenged in this

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• Perfo•~>tiug sit-ups will int"Ttfl>'t b11ck berrlth . ls this a true statement or att artifact of
expe1imencal methodology? Despite what many would like ro helie,·e. there is onI)' mild liter:mn·e
support for- the belief tJ1at people who are fit have less hack trouble. (although positive evidence
is increasing, for e.umple, Stevenson et al., 200 1). lnterestingly, many of the studies attempting
to evaluate the role of lncreased 11tncss in back health actually included e.xerdses that have been
k.t1o,vn to cause back troubles in many people. For exau1ple, ma11y have ane.npted to enhance
abdominal strength with sit-ups. After examining the lumly.u· compression that results from
performing sit-ups with full flexion of the lumbar spine, together with excessive d isc annulus
stresses, it :is clear that enough -sit-ups wiU cause damage in most people. E.ach sit-up produces
low back compression levels close to the National hlStitute for Occupational Safety and Health
(NIOSH) action limit, 'md repeatedly compressing the spine to levels higher than the NIOSH
action limit has been shown to increase the 1·isk of back disorders (Axle,· and McGill, l997).' I'hus,
reaching a oeondusion over the ,·ole of fitness !i·om the published literawre has been obscured by
iJI~chosen exercises. £ncreased fitness does have support, hut the way in which fimess is increased
appears to l.>c t:ri tk~d .
• To avoid /Jt7ck injmy wbeu lifting, beud the knee.r, not the bnck. Probably the most
cummo n advice given hy die clinicit~n ro the patient who must lift is to bend the knees and keep
the back strJight. In addition, forms the foundation for virtually every set of ergonomic
guidelines provided to reduce the risk of work-related injury. Very few jobs can u<: pcrfonncd
this way. Fmdter, despite the resea ,·ch that has compared stooping and squattiog styles of
lifting, no cooclusiol1 as to is better has been ,·cached. The issue of wheth er to stoop
or squat cluring a lifr depends on the dimen.sions :md properties of the load. the characteristic.-;
of the lifter, the number of times the lift is to be repeated, and so fonh, and there may in fJct
lie safer tcdmiqucs altogcth<-r. Much more justifiable guidclin.:s will lie developed later in th~
• "1ight" hamstrings 11n1l le-11gth /em/ to b·ou.bles. It would seem intui-
tive tbat shortened or 'ltight" hamstrings would -apply deleterious torque to the pch~s -and k-acl
to back u·oubles. A similar :orgument could be mounted for unequal leg lengths, \Vhicb wotdcl
tilt the pelvis and impose bending stresses on the lumb.r spine. This line of reasoning appears
ro have driven popu lar clinical practice. tnterestingly, there is Uttle support for rhese notions. A
longitudinal studyof young men over their military sen~ce did not reveal any link betvteen current
back pain and hip flexi<m restrictions (Hdlsing, 1988). Neid1er could funu·c pain be predicted
in tl1is study or in the weU -conducted study of Biering-Sorenson (1984). An interesting study by
t\.<bmcll and colleagues (1996) suggested that while reduced hip flexion may llot be associated
\\oith b:.tckpain, a~)'lllmetry bel·ween $ides may he. Interestingly many high~performa nee athletes
who run anti jump have "tight" halwitrings that cluy use as ".sprinbrs·" Unequal leg lenf,rtb has
been shown to have a link with back pain in only the mo~L extreme of lenhrth discrepancies;
even cases -of a 5 em (2 in.) difference r:1rely develop chronic pain (Grundy and Roberts, 1984).
further, there does not seem to be a significam lin k between leg length inequality and lumbar
scoliosis, •tl~st for inequalities of I em (0.4 in.) or less (Hoikka, \'likoski, and 1311 roth, 1989).
All of this suggests caution when one is flssessing patients and attributing symptoms. Perfom1
the provocative res~ and discover whether these posmral variables are ITUe exacerbators in the
individual and thus are justifiable targets for tl1crapy.
• A single e:xo·cise or back Jtability trragram is tulequntefirr all c11ses. It is currently popular
co promote the tr:1lnlng of single muscles to enhance spine stability. VVhilc the original research
was motiv.tted by the intention tO reeducate perturbed motor patterns that were documented to
be the resuIt of injtu)', others have misinterpreted the dat".t and are promotiog exercises to train
muscles the)' believe the most imporcanr stabili>.ers of the spine. Unforrunately, tbey did no1
quaociJY stability. T he proces-< of <ltuntifying the conrribution of cl1e anaromical component<
ro ~tabilit.y reveals that ";mtally aU muscles can be important, but their importance continually
chan~cs with tbc dcrnauds of the activity and task. It is true that da1nagc to any of the spinal
tissues frOin mcchani<:-:tl overload results in utt.Stabtc joint behavior. Because of Uiomcchanical
cbanges to !he join~ however, the pen:u.rbed tissue is rarely linked to the symptomatology in a
simple way. .More likely other tissues hecome involved and which ones are invol\•ed v.rill result

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~I_, Back OiS<lr<lers

in differen~ accompanying motor disturbances. Tltis variety in possible etiologies mearu; that
a single, simple rehabilitation approach often will nm work. Ls mobility to be restored at the
expense of normaJ joint stability? Or is stability to he e$tablished first, with enhaoced mohiUry
as a seeoncb ry deh1yed rehabilitation goal? Or is the clinical picture wmplex, fur example, in a
situation in which spine stability is needed but conic psoas activity causing chronic hip Re,1.rc
necessitates hip mol>ilizacion? This example, one of many that could have been chosen, illus.-
trates the c hallenge of ensuring sufficient stabiU~· for the spinal tissues. No simple, or single,
approach will produce the best ,·esttlts in all cases. '!'he description and ch1111 prese nted in this
book wilJ bel p bruicle the fom1ulation of exercises rhat ensure spine srahility.

Can Back Rehabilitation Be Completed in 6 to 12 Weeks?

Some have suggestc<.l that damaged tissues should heal within 6 to I 2 weeks. In fact, many
have used chis argumenc co support the notion that work intoler:wce exceed ing tltis period bas
nn parhoanatomical h;~sis (e.g., Fordyce, 1995) hur srems from psychosocial issues. Further,
S()me have sum,rcsted that pacienr recovery would be better ser ved by redirct'ting rehabilitative
efforts away from physical approaches. Tltis posicion can be re.futed by data and indica res a otis·
unclersrandingofthe complexities of spine p:n-homechanics. ·T he (.'Oncept tha[ rissues he.1l within
6 to 12 weeks appears co be orib~ na lly based on animal studies (reviewed iu Spitzer, I 993). How·
ever, not all human patients get better so quickly (Mendelson, 1981), and the follow-u p studies
from some defined disorders such as whiplash are (.'Ompelling in rhe supporr of lingering cissuc
disruption (e.g., Radanov ct al., J 994).
Evidence will be presented in later chapters of both mechanical and neurological cbauges
rhat linger for yearssuhseq\lentto inJury. ~rhis includes loss of,ra,·ious motor conrrol p;.lrnmeters
cogether v.dth documented asy-1nmetric muscle atroph}• and other disorders. Thi~ suggests that
vostiojury .changes are n.ot a sirnple 1H:1tter of gross damage "hea)jng." Following are only a few
of the types of damage that can be long-term indeed:
• Specific tissues such as ligament'S, for example, have been shown to take >rtat"S to rt.'Cover
from rei:Jtively minor insult (Woo, Gome?., and Akeson, 1985).
• 11te interven ebral mocion units fonn a complex mechanism involving inrric:ue interplay
among the parts sucb that damabrc tO one.:_part changes the biom<."<:hanic:s a11d loading on another
part. Fro1t> the perspective of pathomechanirs, man)' reports h:we docomenred the cascade of
biomechanical change associared wkh inicial disc damage and subsequent joint instal>Wl)' and
secondary orthricis, which may take years to prOh'I'C.'>S (e.g., Bri.nckmann, 1985; Kirkaldy·\oVUiis,
• Vid eman and colk>a!,'ltes (1995) docwnented that vertebral osreophytes were most higbly
associ:Lted with end-plate il'rcgulat'ities and disc llulging. Osteophytes are generally accepted to
be second~ry to disc and encl- plate trauma but take )'ears ro develop.
Thus, to sugge~'t that back troubles arc nor mechanicaiJy based if they Jing(;r Ionge r t han a few
mootbs onJy dcmonscr~tes a !inured expertise.
Another question is ''C:m these hack rrouhles linger for a lifetime?" ln. this connecrion, it is
interesting that elderly people appear to complain aiKmt bad backs less than younger people.
\'.1lkenburgand Haanen (I 982) showed that back troubles are more frequent during the younger
years. Weber (1983) provided further insight by reporting on patients JOyears after disc hernia-
tions (some of them had had surgery while others had not} who were engaged in strenuo us daily
attiv i~'-yet all were still r<.-cei,·u1g total disability nenclits! It would appear that the cast~1de of
changes rcsolring from some forms of tiSStle damage can t:•ke years, bur generally not Ionge''
chan I 0 years. Although the bad news is that tbe affecred joints sti_ffen during the cascade of
rhangc:, the goc:xl news is that eventually the: pain is gone-.
To summari1.e, the expectation that damaged low back tisst1es should heal within a matter
of week~ has no foundation. ln face, longer-tenn rroubles do ha,,e a 511bsranrial biomechanical
or pa t hoanatomic~~f basis. On the other hand, croublesonu: ba<.:ks arc. generally not a Ufc sen-

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Introduction to the Issues 11

Should the Primary Goal of Rehabilitation

Be Restoring the Range of Motion?
Research has shown mat an increased R0}.·1 in the spine can increase me risk of furtll"C hack
troubles (e.g., Battie ct al., 1990; Bicring-Sorenson, 1984; Burton, Tillotson, .md Troup,
1989). Why then does increasing the ROM remain a ,·ehabilitation objective? The first
reason, discussed e;~rl ier, is rhe need ro quantify reduced disahili<)• as de fined hy the AMA.
Second, there is a holdover philosophy from the ath letic woriJ that increased ROM enhances
performance. This may be u·ue for some activities, but it is untrue for others. As wiU be
shown, this philosophy may work for other joinrs, hut ir generally does nor work for the hack.
[n fact. successful rehabilitation for the back is genen1J iy rCt.Jrded when athletic principles a re

What Are Better Alternatives m Dealing With Painful Backs?

Painhd hacks are the resulr of different causes; this hook proposes app1~1aches to identify the
cause in the indjviduaJ. Under:,t'.tntHng the spct:ific <.:ausc., or cxac.:crbator, in each indiv:idual directs
effo11s w remove the cause, >1nd ensures that the cause is not replicated in the tber.,py. T issues
in the back become irritared wirh repeated loading. Consider lighdy hitting the th1m1b with a
h:unmcr rCpc'JtCCU}r-cventually the slightest touch causes pain. This is symptom m:.1guification
because the tissues a!'e hypersensithed-not because of psychosocial modulators. Reduction
of hypersensirhrity in rhe rhumb only occnrs fo llowing a snhsnmria l amount of time a.Jter t he
hammc.ring has stoppe<l. Tissues in the back arc concinuaUy "hit wid1 the hammer" because of
tl1e abeJ'fatlt motion or motor patterns. Fo1·example, people with Oexion bending in toletance of
rhe spine may replicne this CVCI) ' time they rise !'rom a chaiT. CoiTCCt this movement hmlr and
"take the hanuner <~way.., T hen the tissues bt"COme less sensitized, the repertoire of pain-free
tasks increases, and mot1on returns . .t\•fotion returns once tbe pain ~tOes away. Resist "resroring
f\1ncrion" with a mohilirJng :-1pproach too soon. This often rero1rcls prQbrress.

Mechanical Loading and the Process of Injury:

A low Back Tissue Injury Primer
Any clinici:m completing n worker or patient compensation form is requjJ·ed to identity rhe event
dlat caused dte injllr)l. Very few back injuries, however~ resuJr from a single event. ·This section
documents the more conunon cumulative trauma pathways lc:.1ding tO the t'Ulminatlng evc~nt
of a back injury. Because the cuJminating event is fulsely presuJlled to be tlle cause, prevention
efforts are focused on mar event. ' This misdirection of effort.< fails to de<> I with the r·eal cause of
the cumulative trauma.
lll'hile a generic scenario for i11jury is presented here, chapter 5 oAers a more i11-<leptb dis·
cu,~<ion of injury from repeared and prolonged lo>1ding ro specific ris-<ne. The pnqJOse of thi<
section is oo promOtf! consideration of the many factors that modulate the risk of tissue failure
artd to encourage probing to generote app.-opri>~te hypotheses about injury etiology.
l.njury, o r failure of a tissue, occurs when the •pplied load exceeds the l'ailure role"mce (o1·
strength of the tissue). For me purposes of this discussion, injury will be defined"' me hill con-
tinuutn from the JOOSt minor of tissue i1Titatlon (but nticrotrauma nonetheless) to 'lhe grossest
of tissue fa ilure~ for example. ve~tebral fr:.tcn.ue or lig;unent avulsion. YVe will pro-ceed on {he
premise ~t such damage generates llain.
Obviously, a load that exceeds tl>e fuilure tolerance of the tissue, applied once, produces
inj'ury (see tigure I .lb, i n which a Canadi3n snowmobiler airborne and nbour to expe1·ience
an axial impact witb the spine full y tlexcd is at risk o f posterior disc herniatioo upon land-
ing). This injury process is depicted in figu re , where a m:argin of s:afCt),. i~ observed in
the f> 1-st C)'cle of subfa ilu1·e load. ln rhe second loading cycle, the applied load inc1·eases in
magninuie, simuiL1neously decreasing the margin of safety to zero, at which point an injury
oc.:curs. Vlhilc this dc.scr1ption o f low back iojury is common, particuJarly among medical

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FaJlure to lerance

Margin of


Figure 1.1 (a) A nwgin of safety is observed in the first cycle of subfailure load. In the seco11d loading cycle. the applied
load increases in magni tude, sirnult(lneously decreasing the 1nargin of safety to zero, a1 which po int an injur)' occurs. (b)
Tit~ Canadian snowmobile driver (the author in 1his case, \vho should know better) b. about to experitonce an axial corn-
prC$sivc iml>act load 10 a fully flexed spine. A on<t-li m~ application of load c.Jn reduce the margin oi safety to zero as 1he
applied load exceeds I he weng1h or failure toler,, nee oi the suppMing tissues.
to.~ i Rtf>fim~lttom /(Jwfl.l/ oi 6i<Ntw d toJfl(CS, :w(5;, S.M. ,\ 1(;(iil1. ~IIWJIE'd p.tjJe~ . 8iOOk••:h.uti<;s. uf low b .tc.k l.nj\lf)': lmf) 'ls. Ull ~o-uu cn~ Jtf.t<.tioo and d\1" (.l;nlc,"
456-<415, 1997, wiih f.'tYtl'us.sion frOitd£15-e\'lt:• Science.

practitioners who otre required to identify an injury-causing event when completing fi-,rms fur
workt~rs' <:o:mpcnsation reports, roy expcricnc:c suggests th<1t relativd y few low back injuries
occur in this manner.
1\1ore<.Y>mmonly, injury cluringotx·upational and athletic endeavc,rs irwo1ve.s cumulative trauma
froul repctith·e subfailurc magnitudt loads. In such t~sc.s, injury is the result uf a.c.'Cumulated
rn uma produced byeitber the repeatetl application of relatively low lond or the <~!>plication of
a sustained load for a long duration (as in a sitting task, for example). An indh<idual lifting boxes
onto a pallet who is rc1>eatedly loading the tissues of the low back (several tissues could be at
risk) ro a subfailu•·e level (see figu •·e 1.2, n-b) experiences a slow degradntion of failure toler-
anc't? (e.g., vcn ehrae, Adams •md H utton, 1985; T!linckmann, Jliggemann, and 1-lilweg, 1989).
A.1 cissucs fatib'''" with each cycle of load and correspondingly the failure tolerance lowers, the
margin of safety evemually approaches u ro, ar which point this indi vidual will e>p er ience low
hack injmy . Ohviousl)', rhe accumulation of cramna is more rapid with higher lo::1ds. Carrer and
Hayes (197i) noted that, at least with bone, fatigue f.tilurc occurs witb fewer repeticion.l when
the applied load is closer to the yield strength .
Yet anorher wa}' to produce injury with n suhfnilure load is ro sustain sr:resses con.stantly over
a period of time. T he rodm~n shown in figu re l.3n, wjrh their spines fully flexed for ;;1 prolonged
period Of Ume, are loading tllC posterior p:ISSive tiSSues and are UUtiating time-<Jependent Changes
in disc mec hanics (figure 1.3/J). Under sustained loads these ,;scoelastic tissues slowly deform
and creep. T he sustained load and resultant creep cause a probrressive reduction i11 the tissue
su·ength. Correspondingly, the margin of s;tfety "lso declines unci! injury occurs at a speci lic
percentage of tissue m<tin (i.e., at the breakillg strain of that particular tissue). Note that these
wor kers are noc lifting a heavy load; simply staying in chis posrllre long enough win I evennaaUy
ensure injurious dalllagc. '1l1e injury n1ay involve a singfe cissuc, or a complex picture may emerge
in which several tissues become iowolved. For esample, the prolonged stooped posrure imposes
loacl; on th.e posterior ligaments of the spine ancl posrelinr fibers of the intervertebral disc. T he
associated <:rct.p deformation that ultimately produces mic.:rofailure (e.g., Adauls, Ilutton, an.d
Stott, I 980; McGiII and Brown, 1992) n1;oy initi.ate another chain ofevents. Srretcbed ligamems

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Introduction to the Issues 13

Margin of safety


Figure1.2 I•J Rcpc.w"l subfailure loads le.1d to tissue fatigue, reducing the f•ilure tolerance, l eading to (b) failure on
the N th repetition of lo<1d, or box lift in this cx.-wnpt~.
(;,J Keptln!cd fr.xn /Ottiii.JI of Sioo.eclMJ'NCS, 10 <S). S.M. o\'\4..Clll, ~'ll'l... lte..l [';)~~·- s.omoch.:t•li<S oi luw b.l(k inlwy: lll'lpi M:.ulun~ CHI ("UfleN pwaloo .uid d~ d inlt.,M
'IS6-ol75, 1997, with permis>iOf) from tkio~·ll.'t' ~eoce.

Margin of safely


I Applied load

a b

Figure 1.3 (a )These 10donen with full)• flexed lumbar spines are loading posterior passive tissues ior a long duration, (b)
reducing the failur.. tol<!rance leading to failure at the Nth% of tissue strain.

iJ1Crtasc jo int laxity, wb.ich can lead ro hypcrflc.xion injury (to the disc) and ro t bc following
sequence of evems:
1. L<x:al instability
2. Inj1.11'Y of unisegmental strucn1res
3. £ver-increasing sheating and bending loads on the neural arch

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4 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Back OiS<lr<lers

This laxity remains for" subsr:mrial period after rhe

prolonged stoop.
Tolerance Understanding the process of tissue damage in
this way emphasizes why simple injury prevention
approaches often fail. i\1ore effL~tlve injlll)' lnterven~
tion strategies recognize and address the complexi-
ties of rjssue O''erload.
Avoidance of loading altogether is u ndesirable.
'T1te ohjl.'Ctive of injury pre,,emion strategies is to
Applied load
ensure that tissue adaptation stimulated from e'llO-
sure to load keeps pace with, and idea.lly exceed~,
d1c accumulated tissue drunage. Thus, exposure to
Rest load is necessary, bur in the process of 3CCunl\llation
of microtrauma, the applied loads must be removed
(with rest) to allow the he-aling and adaptation
pi'Ocess to gt'lldua lly increase the fu ilure tolerance
to a higher level. vVe have already seen how tissue
Joadil1g anti injury risk fonn an optimal U-shapcd
Figure 1.4 Loading is necessary (or optimal tissue
relationship of nor too much and not too linleload.
heallh. When loading and the subsequent degrada-
tion of tolerance are followed by a period of rest, an Determining the optima I load for he• lrb encom-
p~sse~ both che art and sc..:ienccof medicine and ti s~;ue;:
adaptive tissue respo n se increases 1olerJnce. Tissue
"'tra in i ng~~' results from the optimal blend of art and
biomeeha11ics. Figure 1.4 prescJJts a final load-time
science in medicine and 1jssue biomec.h.1nics. history to demonstrate [he links among loading, resr,
and adaptive tissue tolerance.
In summat·y, the injury process may be associated either with vet)' ltigh loads or with relatively
low loads {ha~; are repe:ued or Sl.ISt:-llned. This ei\her/or ca\lsation ne<;essit:ates 1i gorm1s examina-
cion of injury ami tissue loading history for substantial periods of time prior to the culminating
injmy event. It is importtut to recognize that simply focusing on a single \'1\fiable such as one-
time load magnitude may not result in a succ~ful index of risk of injury, particularly across a
wide va riety of activities.

A Final Note
The sci("Ct(.'d controversic.'S introduced in this <.:haptcr illustrate the need for the ~~idcnct: pre-
sented io the rest of rhe test and the relevance of rbe discussions chat foiJow. Resisc the urge to
assume that conventiomll wisdom is correct: First consider d1e evidence and then form your
own o pinions.

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Sci·entific Approach
Unique to This Book

his book conn1 ins many 11onu·adition~l

viewpoints on how the spine functions and becomes
T damaged. of these perspectives have emerge.(l from a unique hiomechanic<~Jiy ha$ed
mctl10dological approach. This chapter wiU FJ1niliarizc you with tl1e unique gcnc.ral appn)'JCh
taken fo•· o brai1tiog much of che d"t" in this text and will help )' OU understand both che Jimit~­
cions and the unique insightS provided by such an approach.
A~ spine biome<:hanists, our methods of inquiry arc.: ~imiJar to those used by mcrhanita1 or
civil engineers. Fo1· example, a ci>"i.l engioeer charged with the task of building a bridge needs
three types of infonnation:
• 'Traffic to be acoom.modared, or the design load
• Soucrure to he used (e.g., space m a$S or roman arch), a$ each archirecntre posse.,o.;ses
specific mechank-al traits and features
• Charat'teristics of Jli'Oposed "'"rerials that will affect s!Tengrh, endurnnce, stabili ty, resis-
tance t<) srrucrural fatigue, and so o n

Our approach to uwestig11t:ing spine function Js similar to tl1at of our engineering coUeagucs.
We begin with the following relationship to predict the risk of tissue d:1mage:
Applied load > tissue strength = tissue failure (injury)
Recall from the ci.ssuc injury primer at tbc end of chapter I that tissue strength is reduced by
repeated aud prolonged loading bur is increased with !mbsequeot rest and adaptation. Analyz-
ing cissue f.t_ilure in rhis way requires two distinct methodolo£,rical apprO<lches. 111is is why we
dcvdoped two quite distinCt laboraror:ies, which Jed to much of the progress dcx·umcntecl
.. in
chis book. (Please note that the "we" used in tbis chapter includes my rese"rch ream of gradu-
ate smdenrs, visiting scholars, and technicians.) Our first lab is equipped for in vitro testing of
spines, in wbich we pufJKJsefully try w create herniated dist~, dama~d end plates, ami other
tissue-specific injuries. "r1>eserond lab is the in vivo lab, where living people (both oonnals and
patients) are rested for their response ro stress and loading. fndh•idual tissue loads are obtained
from sophi stkat{!{l modeling prot't.XIures.

In Vitro Lab
T he in vitro lab is Cl)uipped with loading mt~chiues~ an acceleration rack, tissue secdc)ning equip-
lllent, and ~m X-r:•y suite. to tlo<.:urnent progressi"c tissue damage. For c..xawplc, by pcrfonning
discograms "' ith radio-opaque ooorrast liquids, we can document cl1e mechaniesof progressive
disc herniation. t..Ve investigate any other injury mech;misms in tbe same way-that i$, b;' applying

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physiological loads and motion pattents and then docwnenting r:he damage with appropriate
Since many technique issues c:111 atTect the experimemal results, the decisioll to use one over
another is governed by d1e specific research question. For example, since a marched set of human
''Pine-s to run a t'Ontrollcd failure rest ca1tnot he obtained, animal models mwt he used. Here,
control is e;xercised over genetic homogeneity, diet, physical activity, and so forth to comrast
an experimental cohort \\~th a marched ser of control spines.
O f tuursc. the results must be v~1lida ted and interprered for them to be relevant to hwnans.
In addition, identifying tl1e limitations fo1· relevance i.u interpretation is critical. Some hypotll-
eses thar dem;md the use of human material " e compromised hy the lack of available young,
healthy, undegenerated specimens. Having healthy specimens is. critical beccmse bic)mechani<."s
and injlU'y mechanisms radically change with age. Other major methodological issues include
d1e way in which biological tissues are loaded, perhaps at specific load rates or at specific rntes
of displacement. The researcher must decide which has the mo..••t relevance to the is.sue at hand.
Devising tti1ese exper-iments is not a trivial task.

In Vivo Lab
The in vivo lab is unique in its approach in attempdng to documenr the loads on rhe many
lumbar tissues ju vivo. TI:Us knowledge Jen<.ls powerful insight into spine met·haJtks, both of
1\onnaJ functioning and of fuilure mechanics. Si11ce traosduct:rs ~IUlOt be routinely implanted
in the tissues ro measure fo rce, noninvasive merhods <lre necessa1y. The intention of the b:tsic
approach is to create a virrual spine. This virtual model must accurately represent tbe anatomy
dlal responds dynamicaUy to the three-dimensional motion patterns of each test subject or patient musr Jllimic the muscle activation JXHterns chosen by rhe individual. Jn so doin;g-, it enables
us to evaluate subjects' wUque motor patterns and the consequences of their choices and slill.

How the Virtual Spine Works

Wl1ik two groups (the MatTas group [e.g., Granata and Marras, 19931 and tl1e McGill group)
have de,·oted much effort to the development of biologically d•·i,•en models, the McGill
model will be described here given irs familiarity to the author. The model-<t d)'!amic, three-
duncnsiona l, anatomically complex, biologically dri,·en approad 1to prcdkting indivi dual lumoar
tissue loads-is composed of two distinct pans: a linked-seb"nent model :md a hig hly detailed
!>lJine model that derem1ines tissue load~ :and spine stability.
• ''11le r,rst pan oftbe McGill model is a three-di meusion;~llinked-segmenr representation
of rhe hody using a dynamic load in the hands as input. 1\vo or more video cameras <lt- 30 Hz
record joint displaccrncnts to reconstruct the joints and body sct:,'lncnts in three dintensions.
Working through the ;~rm and trunk liokage usi11g linked-segmem mechanics, rea~tion forces
and moments are compuced abour a joint in the low hack (usually JA.-LS) ~>reviously described
in i\kGill and Norman, 1985) (sc.c fib'lll'C 2.1 a). Using pcl"ic ami spiuc markers, the three reac-
tion moments are co•wet~ed into moments about the thJ'ee orthopedic axes of the low back
(J1exion ..extension, lateral bend, anci axial twist)~
• TI1e second part of the McGill model enables the partitioning of tbc reaction moments
obtained fi·om the 1inked ..segment model inco the subst.anrial restorathre moment components
(supporting ri.ssues) using an anatomically derailed three-dimensional representatioJJ of the skel~
eton, musc les, ligaments, nonlinear elastic imc"·ertebral discs, and so on (sec 6gure 2.l.b). This
part of the model was Rrs< desc1ibed by tvlcG ill and Norman ( 1986), with Full three-dimensional
med>Ods described by McGill (1992)and cl1e m<:><t rocenr updare provided br Cholewicki and McGill
(1996). In total, 90 low back,Uid torso muscles m·c represented. Very briefly, fit1>t the passi"e tissue
forces at-e predicted by assuming srress-srn1in or load defom>ation relationships for the individual
rass.ive tissues. Defo.m1acions are modeled &om the three . .dimensional lumbar l..1nemactcs r.neasured
from the subje-ct, which drive the vcrtc.bral kinematics of cl'lC mO<Id. Passive tissue SttCSS('S arc caU-
brated tor rhe differences in flexibiliry of e<1ch subject by I\Oonalizing tbe stress-stra in cuJ"Ves to

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Figure 2.1 The tissue load prediction approach requires two models. (a} The (irst i:s a dynamic
threeAd imen s i on allinked ~segmen t model
to obta in the three reaction moments about th e low back.
(b ) The second model partitions the moments into tissue force. (muscle forces 1-18; ligaments
19~26; a nd moment contribLltions from deformed disc, gut, and skin in bending).

the passive rangt: of motion of the !ruhject. Electromagnetic in.'itrumentation, which monitors the
rdarive lumbar angles in three dimensions, detects the jsoJatcd lumbar motion. The rcnulining
moment is rhen parririoned :)mong the many fa~icles of muscle based on their activation
profiles (measured from electromyography [EMGJ) and their ph)'Siological cros.s-sectioual
area. The. tnornent is th e n modulated with known relat ionships for instanl:'.tncous muscle
length of e_id>er sho1'tening or lengthening velocity. Suc11110 and McGill (1995) desc1·ibed the
m ost recent improvemen~ of rhe force-velociry relarionship. In this way, rhe modeled spine
moves according w the movements o f the suUjectS s pine, and the virtual muscles arc activated
according w the activation measured di,·ectly from t he subject (see ligures 2.2, a-b. and 2.3).
Using biological signals in this fashion to solve the indetennimcy of multiple load-bearing
tissues facilirares t he assessm en t of t he many ways that we c hoose co support loa cis. Such aJ1
assessment is net:.c ssary for evaluatin g injury mcth anisms ami fonnulat:iug injtrry-avoidan ce
iniciat.ives. From tl clinical perspecUve, cbjs abiJicy l O mimic individuaJ spine Illations and
mti$cle activation patterns enables us to evalu<lre t he consequence$ of a chosen motor control
strategy. For e.xa.mple, we can see th:n some people ar e able to stabilize t heir backs and spare
their lwnbar tissues (rom ovel'ioad when pcrfonning specific msks. Conversely, we are able to
evaluate the consequences of poorly chosen motor srn>tegies. l n chis way we can id-entil)' those
indh ridua)s with pemtrbe:d motOr patte ms and devise spc-"<.ific ther:~pies to rebrr<)()ve healthy motor
patterns clut ensure sufficiellt spine stability and spare their tissues from damaging load.
Our challenge has been to ensu re sufficient biological fidelity so that estimations of tissue
force-S are valid a nd rt.)hust over a wide varietv of cH..'tivities. The three-dimensional anatomy is
represented in computer m emory (n1usdc a;eas are provided in <1ppendi;\; A. I). On occasiOn,
if the expense is wa iT-Jnred, we create a vi renal spine of an individ u~l1 ti·om a rhree-dimension~ll
ret.'(msrruca:ion o f .senal magnetic resonance imabring (MRJ) slices from t he hlp t rochanter to T4
(sec figure 2 .2b). T his <omponcut of the modeling process is well documented for the interested
reader in NtcGill and Norman ( 1986) and McGill ( 1992). A lis10f the large lllunbe,·ofassociared
research papers pe rtaining to the many detailed aspecrs of the process is provided i.n a separate
reference section at the end oftbis book. Sec figures 2.4 and 2.5 for a flowchart and cxmnplc
of the modeling process.

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Figure 2.2 (a) Subject monitored with EMG ele<..'trodes and e i~Cir01 nagnetic instrumentation to directly mea·
sure three-dimensional lumbar kinematics and rnusele at1ivity. (b) The modeled spine {partially reconstructed
for illustration purposes,. although for the purposes of a nalysis it remains in mathematkill form ) moves in
accordance with the subject's spine. The virtua l m uscles are .activated by the EMG signals recorded from the
subject's muscles.

Figure 2.3 In this historical photo on the right, an insuumented subject simulates the co.mplex three·
dimensional t.Jsk of tossing an object.. The instrumenta tion includes three-dime nsio nal video to
capture body segme nt kinematics, a recording of the three.dimensional force vector applied to the
hand, a 3-SPACE e lccwomagnetic device to record isolated three-dimensional lumb;:~r mol ion and
assist in partitioning the passive tissue forces, ~1nd 16 channels of EMG e lectrodes to capture muscle
aclivation patterns. A more modern dat;a collection is shown on the left.

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Video - - - - - - - - - -----.

Body !oint
! Spinal model: partitioning reaction
moment into individual tissues

Kinematic portion: l
Orientation of rib cage and pelvis determined (3-SPACE) I·
Hamd force
Estimate lumbar vertebral position I
1 +
~ I
EMG Linked-segment model Estimate center of rotation disc
dynamic + StO<ed spacial matrices:
Initial estimate of crude compression Pelvis
R . t
eactlon moment / / and shear at L4/LS Ribcage
Each vertebra
about L4/LS disc
Orient vertebrae according to estimate

Calculate muscle and ligament len~hs
and velocity of length change (dU )

Kinetic portion:

·I Cak::ulate d~ moment
•I Calculate ligament stress and contribution to restorative moment I
Predicted muscle moments equal to sum of muscle moments?
AID converted '>t>s
- ~
L.E. Compute total disc compression·shear using disc model
EMG to force
Compare all stresses (muscular. ligament, skeletal) to tolerance data

Muscle length and load time histories and flag tissues close to failure
velocity parameters

Calculate stability index and elgen values

Figure 2.4 The rnodcl input and output are illustrated in this flowchart up to the point of C.l lcularion of moments
t~nrf tissue loads. Spine stability is c.-tlcul<lted with an additional module.

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0.<40. , - - - - - - - - - -- - - - - ,

1 -- 035


bend -026
!I 0.20

0 IS


0 2 4 6 8 tO 12 14 It o~ +-~-~~-~~-~-T~
0 2 4 6 8 10 12 14 18
8 Tome(•)
b Time(s)

1,500 AklaJ oomprt~~~ion


lncemal longssimus / \''
t .. t
' ' I '
0 -···· ..........
E)[ternal obllqvt

2 • 6 8 10 12 1-t 18
~ ~oL--r
z --~.r-~.--~ar--,~o~-,~2--,~.--~,.
Twne(s) rvne (a)
c d

Figure 2.5 VartOtrs stages oi model OOII)UI in thi~ ('xomplc of a whj«l Hexing. picking up,, •~l'ighl, and""'""''·
ing: ldl lumbar mol ion abou1 the 1hfee axe.-flc""''""'"·'nsron, lateral OOnd, and axiallwist; fbllcng1hs of a r.,.,
St'l('(l('(l muse: I~ throughout lhc motron; ( C) some mu«.lc IO<<~; l di L4-L5 joint forces or COfnJl<I'S~ion olnd shear;
I<•) Slabiloly rndex, where larg<>< positive numbe" hogher s1abilily and a zero 0< negat iw mornb<~ would
sugg<.>sllhollun ;lo~bl e l)('!,.vior is possible.

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Scientific ~£_;1£11 Unique to This Book._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _:2:..:_

1\ of the Virtual Spine
T he development of che virtual spine

10 •
I approach has been an c'•olutiona ry
process spanning 20 years. bt that
rime we have h:ul to confro nt several
spet:ificissue.s, namtly. of valida-
tion a.t1d how to hancUe deep ntuscles

rhat are i naccessihle w~ th surface
EMG electrode-<. Briefly, ~I though we
have tried intramuscular electrodes

10 .
"' in highly selected conditions, rhis is a
limiting invasive pn>cedure. C:ri!.nerally,
we cstim:ue tbc deep rnusde activm.ion
arnplirudes fi'Orn movement synergists
(NicGili,Juker, and Kropf, 1996). T his
method is limited, however, bct"ause it
requires a prior knowledge of muscle
patterns for a given mmnent com-
bination in a specific task. \ 1\le try to
incotlJOrate the highest level of content
valicUty by using deL1iled representa·
tions of the anatomy and physiol<'>',;ical
0 2 6 8 10 12 t4 18 CI'Oss-sectional areas, recording stress-
e so-ain relationships~ and incorporating
knom1 modulators of musdc fore..:! such
Figure 2.5 as length and velocity. One of our vali-
dation exercises is to compare dte three
measured reaction momentS ";th the ~um of iJ1dividual tissue mome-nts predicted by the \rirtual A close outch sugge.cs that we have succeeded iJt accurately represeming force.
Over the ~>ast ten ye<~rs this approach for predicring indil·iduallumbar risst.te load$ has evolved
to e nable us to document s pine stability. In this way, we can evaluate an individual~ motor pat-
terns and identify strategies that ensure safety and those that could reswti.u iJtjW)'· Tltis is not a
rrivi41l n1sk. It requires converting tissue forces to stiffness and using convergence algorithms to
separate those force$ needed to c reate the torque~ that sustain postures and movement': ti·om the
additioMI forces needed to ensure stability. Potential energy-based amtlyses are tlten employed
to identify the "stability index" in e.1ch degree of freedom of the joim, which in turn reveals the
joines abili ty ro survive a given loading scenario. T his level of modeling represents. th e highest
level of sophistication currently available. ft has enabled us to challenge concepts p-ertaining to
spine stabi1ity- mo•·e on this in chapters 6 and 12.

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Epidemiological Studies
on low Back Disorders

efinj tfcve exper:imenrs a1·e ra1·e in the fields of science and medicine. rnsr;-ead, conclusions
D generally emerge from the integra cion and syntbesis ofe,~clencc from a variety o f sources.
Using a s.irnilar approach, lawyers arbruc GJ.Ses io which each pic<.:c of e.,;ocm:c is considered dr-
Instanda I in che hope tbat ev-entually the ci t'Cumsum LiaI evidence will l:>ecome overwhelming.
Like lawyers, scientific gather and regather drcumstanti:d evidence from several
pcrspC(:tivcs with the b'<Y.IIof understanding cause and effect. By studying the rdations hips among
l':lriables amd investigating mechanisms, they a•-e able ro fo1·m perspectives that are robust and
pbusihle. '11>is t)1le of research work, together with longirudinal studies, tesrs the causative
factors idcmtifil'd in thc.mcc.:ha.nisric ~rudie~.
Other chapters i•l this book are dedictted to investigating d1e various mechanisms within
the low back and their links with good health and disability. This chapter foctJSC.< on rhe study
of associations of variables through varjous cpitlemiologitaJapproaches. Some readers wilJ find
dus a boring cltapter~o my stude11rs inform me. You may choose to skip tl1is chapt~r. But
those wishing a fuller understand ing of rhe challenges thar lie in building a strong founda -
tion for the \•ery best injury prevention and rehabilitation prohrrams are e ncouraged to read
on. Doing so will enable you to appredate the epidemiological perspective, to have a more
complete (..'Omprehension of the positions t.1ken in the rext :1s a whole to reduce the e<;onomic
impa<.'t of low back disorders, and to understand certain subsequent approaches fi">r prevention
and rehabilitation.
Several sections in this chapter will help you undei'Stand the risk factors for low back
rrouble-~l>edficalJr, the changes in personal factors -and whether tbey cause h<lck troubles
or are a consequence of ha,· dtcm. For the purpose of this revi<.:'''! purported disabljng low
back uouhles and possibly related work intolerance will be referred to collectively as low back
disorders (LBDs). Furthermore, the term pmo11alJitttot1 can include anthropometric and 6tness
variaOics, as wcU as motor control ability, injury history, and so forth.

Multidimensional Links Among Biomechanical,

Psychosocial, and Personal Variables
t\s noted in chapter 1, several pronunem people have declared thllt psychosocial ''ariables are
the most significant factors in L.BI). T hi.s is an important issue since effective intef\rention mtast
address tht' real catt.~e and consequence of hack tcouhles. ln this section we will see that "irru~
ally all studies that properly measured or caklllated the physical demands of rasks showed d>:lt
JleOJlle subjected to specific mechllnical stressors are at higher risk of LBD than others btlt rim
there also appear to he .some mitibrating is!o;ues.

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§:>ldemiologic~l Studies on Low B~c~-~isordffi tLBD
;:os:!.)- - - - - - - - - - - - - - - - - - - - - - - . ;2.3

Three Important Studies

The following thrt':C studies: arc reviewed here bl.'Cau.seof their past inAuC11tc and futurt:. ilnpH-
• Bi1,ros rm4 collertgrUJr. In 1986 Bi0>0S :md c-olleagues J>erfomlcd a lugl~y quoted study-one
th;n h~s beer'l vel'y influential .i n shaping opinion rega1·ding inju ry prevention and l'ehabilita-
tion- ar tbe Boein g plant in VVashington State in the U nited Sr:Jres. 'l"his retrospective inves·
riga cion analyz.ed 4,645 injuries (of which 900 were to the low hack) over a 15-month period in
1979-1980. 'Ilw auti101'S reported a cun·elation between the incidence of back injury and poor
appmisal ratings of employees perfonncd by t heir supervisors within ~ix mouths !Jlrior to t he
reported injury. The aud>o,·s considered d>e poor ratings to ,·epresellt a psychosocial factor.
lo 1991 Bigos and colleagues conducted a longitudinal pt-ospective study of 3.020 employees
at Boeing, during which there were 279 reporred low back injuries. T he researcher$ collected
pcrsoualiLy inventories -as well as questionnairc·s regarding family and coworker support and job
satisfaction. They also analyzed personal factOrs such as isometric stren0•th, nexibility, aerobic
capacity, heighc, a1\d weight. The authors concluded that psychosocial measw·es-panicularly
those related to job enjoyment-had the strongest in!lueJlce of all the variables analyzed. 1Jl fact,
those workers who stared they did not enjoy their job were 1.85 times more likely to r·eport a back
injury (odds ntio = 1.85). job satisfuction counted for less than 15% of the variance as 311 injury
risk factor, Dll>:aning d1at more than s; % o f tltc V"J.riancc was unaccounted for. [n other words>
psychosocial factors failed to account for 85% of the causation ofLBDs. The authors concluded
"that the statistically signincallt, though cliJucally mode<t, predictive power of work perceptions
and psychosocia l factors for reports of acute l:>ack pain among industrial workers argues against
rhe exclusive use of >m injury model ro e.\'(lhtin such problems." This is a f.~ir snmmaty of me
im.plkottions of theii work. It do<.~ not mean t hat m~chanical loadjng i.s unimportant. Yet, this
study isoft:ell quoted to support the 1·iewpoiot that psychosocial fuctors are the most important
causes of bark disorders. Interestingly, Marras and colleagues (1993) also found similt11· odds
ratios for joh satisfaction ( 156) in a massive study of 400 repetitive industrial lifting jobs across
48 industries.
Very few epidem io logically l:>ased stud ies have Odds Ratios
employed reasonably robust quantifications of biome-
chanic:al, psychosodaJ, -and personal factors. 1\vo impor- Perhaps the most lu-cid delinition ol an
tant studies meet this requirement. odds ratio can be ad>ieved through an
example. If smokers have three times the
• Mn>YfiS tmtl colleflgucs. 11>e first impot~anr study
nsk <;>I developing lung cancer that non-
was reported hy i\hrn>s an<l ~-olleagues (1995), who smokers do {perhaps 6 out of 10 smokers
surveyed over 400 industrial lifting jobs across 48 differ· as opposed to 2 out o.fl 0 in nonsmokers),
ent il>dustries. Thev eKllmioed medical records ill these they have an odds ratio of 3. Thus, an odds
indu>uics to classifY each type ofjob as l:>eing either low, ratio greater than 1 suggests an inGreased
medium, or high risk for causing LBO. They documented risk irom a specific factor.
-a variety of mechanical variables as weU as reporting job
satisfaction. T he most powerful single ,,.riable for pre-
dicting those jobs with LBO was ma.<timum low back moment. This resulted in a pre-.dictive odds
ratjo of +.04 between low- and medium-risk groups and a ratio of 3.32 between the low- and
high-risk groups. Other single variables produced impressive odds ratios, for example, s;~gittal
crunk velocity (odds ratio • 2.48) for the low- and high-risk t'lmparison and 2.42 f()r maxirmun
weight htUJdled between the low- and high-risk groups. Job satisf.ction produced an odds ratio
of 1.48 between the low- and high-risk groups and of Ul between the low- and nnedhun-1·isk
groups. The researchers entered the single variables into a mt~ciple logistic regression mO<Iel.
The. group of various nH!'JSurcS sck.-cted by d11! rnodcl described tbc risk index well between the
low- and high-riskgro11ps ;tnd also between the low- and medim11-risk groups. Suiwbl)' var)'ing
the five measures chosen by the regression process (maximum load moment, maxinmm lateral
rrunkan&ru~ar vdodty, avcmgc trw1k tw-isting velocity, lifting fr(~qucnty, and the maximum sagittal
trUJik angle) ~ ecreased the odds of beiJ>g a melllber of lhe high-risk LBD group ove1· I0 times

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(odds ratio = I 0.6). This was an unpormnr study for specifyiJlg certain physical characteristics
ofjoh de,;ign that redut-e the risk of LBO and linking epidemiological findings with quantitative
biomecha1tical analysis ami psychosocial fuctors aCn)sS a large working population.
• N(frmnn am/ mll•ngnes. The second important study co Stlccessfully integrate biome-
chanical, psychosocial, and personal factors was conducted hy Nonnan and colleagues ( 1998),
who examined injuries that occurred in an auto assembly plant rl1at cmpJoycd more than 10.000
houJ'ly p;lid workers. During a two-year pe1·iod of obsen•ation io the plant, the authors reported
analyses on 104 cases and no r.1ndomly selected controls. Cases were people who reporred
low b-Jck r ain (LBP) to a nursing station; controls were people randomly selected! from com-
pany rosters who did llOt report pain. '1llis is a notable study because the authors attempted to
obtain goo-d-quality psychosocial, pers<>nal, and psychophysical dar~ on allpm;icipant.s fmm an
intervicwen--assisred questiormairc. as welJ as good-quality. direcdy rnG'ilsurcd biomt"<..· hanical data
on the physical deo1ands of tbe jobs of all participants. (.Kote that the psychophysical approach is
based on wQrker self· perceived stresses.) The snuly revealed that seven1l independent ancl highly
signili c~ur biomcchanical, psychosocial, and psydmph)"ical factors (identified as ,;sk factors)
esisted in t.hose wbo reported LBP. The personal risk factors cl1at were included wet·e much less
import:~nt. After adjusting for personal risk facwrs, the statistically independent biomechanical
risk factors that emerbred were peak ltunl)ar shear force (conservatively estimated odds rat io
lwnbar disc compression integrated over the work shift (odds rotio = 2.0), and peak
= 1. 7),
force on the hands (odds ratio = 1.9). T he odds ratios for the independent JlSychosocial
risk factor:s, from among many srudjed) were worker perceptions of poore r workrllace
socia l eovironment (2.6), hightr jolJ satisfaction (not Jower, as shown in the Boeing study)
(1.7), higher coworker support (1.6), and perception of being more highly edu cated (1.2).
Perceptions of higher physit-al exertion, " psychophysical factor, resulted in an odds ratio
of 3.0, which is possibly related to the t'Jpacity of the worker relative to tbc jo'b demands.
Nea l'ly 45'% of the total V<lfiance was accounted for by the>e risk factors, with approximately
12% accounted for by the p>)'chosoci<ll factors and 31% hy the hiomechankal factors. These
re>ults are very consistent with those reported by Marr-Js and colleab"lltS (1995) <tnd by Pun-
nell and colleagues ( 1991). Only a few of the pet·sonal l~ctOI'S were associated with reporting
LBP: bod)' mass inde.' (odds r<1tio ~ l .O) and p•ior compensation d <1im (odds nltio = 2.2). This
casc-txmrrol study is of high quality because it used a battery of many of d1c best m easurcmcnt
methods avaihble for field use to assess many psychosocial, biomecbanical, :Uld personal fact'Ors
on all participant.< in tbe data pool.
The evi dence from the comprehensive studies sugge>ts that borh psychosocia l and biome·
chanica ! V<lriable). are important risk factors for LBO. 1n partit•tdar twnulative loading, joint

momems, and spine shear fort-es are importaJLt. Those claiming that only psychosocial factors
are import:mr or that only physic:llloading !1tctors are important c:mnot monnr a creditahle,
data-based defense, as it appears that the data they t[UOte fail to measure properly either physical
or psyc::llosocial variables or bot!L.

Do Workers Experience LBDs

Because They Are Paid to Act Disabled?
Some papers in the literature :1ppear to dismiss the link between pain and disability. ,\ 1ost of these
papers clea:rly state chat r:his notion is restricred co unonspec-i 6c bac:k pain," noting th<tt specific
diagnoses do it'n()3ir the ability ofa worker to perform a demanding·job. I lowcver, some authors
base thei•· arg>1111etlt on the concept that low back tissue injury heals in 6 to 12 weeks, wh ile
others base their argumenL5 on a heha\'ioral model of chronic pain that is not rotally consistent
with the findings of other sdentific approaches. A short discussion of the: issues and evidence
related to physician djag1.1osis, cornper1s:uion. tisst.1e damage, and pain is necessar)r.
The pos-ition that chronic pain and dis.."lhility are a function of r.·ompensarion {and n()r mechani·
cal facr:ors). is contradktcd by evidence that low back troubles continue after legal St:ttlcmcnt of
injury compensation (Mendelson, 1982). Hadler (199 1) believes that the conte>t between the
patient and the medical officer charged with determining the compensatory award causes tbe

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patient to act disabled aJ>d thwarts any illcentive to act well. Teasell and Shapiro (1998) shared
this opinion in a review of several differem clwonic pa in disorders, as did Rainville and colleagues
(1997) in mother very nice study that specifically addressed chronic LDP. Hadler has taken the
posicion that mechanical FJctors are~ for the mosl part. of Jitdc importal\ce in cither causing
or rehabilitating bad backs when ~-ompared with the psrchosocial modu lators (e.g., Hadler.
200 I). H is sela-rive citation of the literature excludes evidence linking mechanical overload to
cissue dam:age and ignores several important intervention studies. _For e;\-ample, VJ'ernckc and
Hatt (2001) showed chat pain ~>atrerns upon pacient presentation, specifically whether the pain
~<~L-entralizes" or not, <lre mnch more powerfuJ predictors of chronkit)' than the psychosocial
variables they studied.
Of the several parties i1wolved in the compensation system, all wish fo1· a healthy patient.
Howe\'er,.seve.ral Factors consrire m militate against an optimal process and exped ence for all.
Some w1forrunate patients arc rejected from the "cmn p" system l>ct~use they fJil to get better,
or actually get worse, and are labeled noocompliam. This is large!)' because the comp S)'Stem
usually employs a rehab approach thar blings finality to rhe case. T his approach is o ften known
as •'work bard(·ning'• and is characte.riz.c.d by physical tasks that have a systcmacic .schedule
lor increased challenge. Some claim that the type of challenge OJ' e.ercise or worl< task is not
important---only thilt-it be performed. Patients are encouraged ro work: rho ugh the :pain. There
is no question cl1at maoy patients: thrive under this approach anti arc successfuJI)r discharged
as employed workers. However, this appmach is not for every patieut. Tj·pically these sorrs of
programs lh:we signific:a.nt dropout rates. T he comL1 system usually label$ these individuals :t'i
lot noncompliant" and they are dismissed from payoutS. PsychosociaJ _ issues art usually gi\•en as
reason for their inability to tope. My opinion is different. Many of these individuals have backs
rhat: may be unst:lble, and che work ha rdening program in<;orpora[eS the injt.u y mechanism
as part of the treatment and makes them worse. lludcr (e.g., 1991, 2000) has documented for
years that cenrra1 sensitization medtoulisms and secondary hyperalgesia are basljd on measur-
~ble ch~nges in nen10\IS su·uctures ~md th~n more p3in dtn·ing movement only heightens the
syndrome. Det.":luse corrective e.\:ercise has not been prcsc.:ribed, the tissues are htrther damaged,
or at least pre1•cnted from healing. for these patients we work to elllninate cl1e camse of their
pain and erosure pain-free therapeutic exercises, specifically designed to address their deficits and
the actual cause Qf tissue overload. Even with the most disabled of hacks, those cases that have
been classified as failures aud labeled with no hope for recovery (i.c., 0% chance of reruming
to work), this approach gets about 35% back to work.
T hus, although the topic of <.xnnpensation is impor[antt it is irrelevant in discussions of the
links betwt:cn loading and LBO. Compensation issues should not be used to argue again>t the
existence of a mechan_icaJ Ii ok between injury 3nd work toJel'ance OL', worse yet, to suggest that
d1e removal of compensation wiiJ eJimin;tte the cause of tissue damage.

Does Pain Have an Organic Basis-Or Is It All in the Head?

Much has been written ahout the apparent absence of an organic basis for chronic low back dis-
ability (:md other chronic pain S)'lldrome.,). As noted in chapter I, as high as 85 % of di..a hling
LBO cases. are cla imed to ha1·e no definitive pathoanatomical ctiagnosis (\•\1>ite and Gordon,
1982). ' li"o conclusions have been protx>sed:

• Many LBD patients presem 11<1t:h "nonorganicsigos" ~uggestiog psycl>ological dist11Jbance

as th e <."a use of their cQndicion.
• Poot diagnostic techniques, either fmm inadequately trained doctors or fi·om limit-ations
of widely available diagnostic rechnolog)', have precluded the making of many solid cliagnoses.
T he first conclusion sugb'-esto,; that the correct cou rse of accion in these ('·undhgnosed'' cases is
to ignore pl•y>ioloj,-ital issues and address only psycholob.;cal or psychosocial factors. The S<..>cond
conclusion suggests that one should not ignore clle poss.ibilities that more thorough diagnostic
[echniques could unearth physical cause5 and that rehabilitatioo hased on that assumption could
be more effective than rehabilitation for psychological disturbance alone. Let's Cl'amine C'.tth
of these" t-gumeots.

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Does Absence of Diagnosis Imply Psychological Cause?

Waddell amd colleagues wrote many manuscripts and guidelines (e.g., 1980, 1984 , 1987) on
nonorganic signs in patients to .support the notion of psychologicaJ clh;ntrhance overrlding any
patlloonaromical tissue dtl.lllage (bee.-,. usc nunc was diag-nosed). Yet 111any of tlicse "nonurg:mic..
signs <J re po·ecisely what we will use clinically to detect hypeo·sensicivity to loads that cause pain.
For examp.le, a compressive injury often c reates pain under very mild compression when the
pe.rson is in a flexed or slouched posture. Light touch and reported pain in a paiuful region may
indicate a highlycentraJiy sensitized patient. While the nonorganic signs maybe ve~y helpful in
defining risk for sw·hrical candidates, we take the posicion that they do not indicate psychological
overlay-iEJ fact the behavior may be physiologically based. Only a rigorous anti complete exam
that ;,,eludes provocative testiogcould provide e'•ideJ1ce w support the di;1gnostic h)1'10thesis.
Teasell Shapiro ( 1998) wro te a 11ice summary of an exr.ensive e>..veriment.,tl Jiterarure
Sllb"gcSting that these pain SYJI'Iptoms may indeed ba\re a pbysiologica.1 basis. The::y r<·vicwcd
the recent scie11ce on the spread of net.ron excirubility and sensitization of adjacemneurons
ro e.\:plain the sensation of radiating p<tin in chronic conditions. Changes in neuroanatomy are
coupled with biochemicaJ c.:hanges with <·hronic: pain. For example, in fibrumyalgia patients,
lllllllerous Studies have showo levels of substance "P" in the cerebrospinal 0 llid elevated tWO tO
rhree times over that in controls (reporrecl in a review by Teasell, 1997). While rhe nnnorganic
signs des-cribed in \ V.1dddiS pat~rs are impo rtant <:onsidcrntions ln many ca.sf.~ and are a con-

tribution co clinical practice. strong e\o'idence suggests that many nonorga.n.ic signs may not be
exdushre of a pathonnaromica1 mechanism that has eluded di:lgnosis.
Some have argued that no link exists ben,·e.en pain and rissuc.damabre and accivity imole.111nce.
[n the abset1ce of no direcl evidente} some groups have simply assumed that nociteptive pain tbat
is nor surgically correccohle or that has not improved within six weeks should not be reb" o·ded
as disabling (e.g., Fordyce, 1995). Io fact, the Fordyce mon<'!,O'llph initiated much discussion,
including several letters (e.g., Thompson/MerskeyfTeaseU!Fordyce. 1996). For<lyce's 1996
sratements th~ll arhe co-urse we are presently on d'lre:nens disaster" and that "we change or go
broke" were particularly revealing. T he bigh msr of treatingchronk pain and disability appears
to have n'loti,·ated the elevation of the importance of tllt: psychosocial factors :,o in
this monograph. It is also interesting to obset'Ve the absence ol'any eminent biomechaoical e,, lleo·t
among rhe author list of the Fordyce report. The Canadian Pain Society stared rhat t he Fordyce
report literature review "is in<:omplctc and docs not rcAett the con t(~mporary understanding of
chronic low back" ( r hompson/Mer,;keyneaseii/Fordyce, 1996). Moreover, rhe Fot·dyce
repon Jarg(!ly ignored the evidence linking mechanicaJ ove.rlo<ld m measur-able ch:1nges in .spiJ1e
blomcchaults and spinal paio ncuromcchani<.--:tl mcchanisnl.S. Anodu:r assumption o f the report
was rhar most spine I. BDs a)'e nonspecific, meaning simply that a diagnosis WliS oot made.
Could Inadequate Diagnosis Be a Factor in Nonorganic LBP?
Bogduk and colleagues (!996) argued ct>at pain :u·ising from maoy spinal tissues can be attributed
ro a detectable p;.lintial lesion. !:'o r example, rhe f~cer join~ will produce pain upon stimul:ltio n
(McCall, Park, and O'Brien, 1979). Bugduk's point is ctrtainly c'O rre<:t. However, because not all
lesions at'C easily detectable, one callJlot 3Jb"t1C that if a lesion is not detected there is no organic
basis for pain. For example, fr:lcnares ancl meniscal tears thar h:we heen detected in postmortem
srodies ha,~e not shown radiolq,rically on planar X-ray (Jonsson e£ a1.1 t99lt Taylor, 1\vomey,
and Corker, 1990) or on computed tomography (CI) (Schwarzer et al., 1995). Nor l•ave fTeshly
produced fractures and articula•· damage been outwardly detect;~ble radiographically in animal
models (Yingling and j\'lcGill, 2000). Yet these are the typical diagnostic procedures use<!.
Interestingly, Bogduk and colleagues (1996) and Lord and colleagues ( 1996) showed d>at
injection of anesthetic (placebo-cono'OIIed diagnostic blocks) coowincingly demonstrates that
facet joincc; are often the site of pain oritrin. Funher, disc sn1dies exaJnining the pain response of
wdl 0\'Cr I 000 discs in over 400 pc'Ople undergoing discography by Vanharanta and colleagues
( 1987) (subsequently o·eappraised by M.oueta et al. in 1994 and reported by Bogduk et al. in t 996)
showed a clear and s£atistic.tll}r significan£ correlation he tween disc pain and b'Tade 3 fissures
of the artnulus 6brosi.s. Must physicians would probably not detect th('Sc deep fis:sures of the
anottlus.ln a rigorons and systematic study of diagnosis based on anesthetic blocks:. Schwaner

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ar1d colleagues (1995) were able ro diagnose over 60% of the LBD cases cited in t:he study by
f!ogduk and colle>g>1es ( 1996) as being internal disc disruption (39%), f:1cet joint pain (15%),
and sacruiliac pain (12%). Bogduk and tulleague' (1996) stared, "If inappropriate tests such as
EMG and imaging are used, nothing will be found in the majority of cases, falsely justifying
rhe impression rhat nothing can be ro,.nd." Clearly IVC must question the statement that 85%
of LBO cases are icliopathic or have no definitive pathoanar.omicaJ c;luse.
At d1c \Vorld Congress for Lumbopelvic Pain i11 I995, Professor .Bogduk proposed many
reasons to caution againsr defaulting ro a psychosocial cause of hack rroobles, which are most
d1ought pn.woking:
• Firsr con$ulr: 1"he usual pr:)ctice of :.l I 0-minute consolt is simply poor pr:lc-cice such rhat
thcrre is no chance for a full assessment of causal mechanisms.
• Evidence- based m:magement: Faith in IY.lSsh•e inrervenrions continues, lcaclin.g ro frustra·
cion by aU parties gi\•cu poor cffittH:y.
• Issue of certificate: Rathtr than cnga&ri.n g patients, uncovering C<lliSCs of their rroublcs,
aodso oo, a clinician tnakes the decree with the issuance of a certificate fot· t:itne off, (jght
duty, or :;o forth.
• \;vorl-place intervention: \.Vas the occupationaJJy related cause of the ba(.:k problem
• Cocrec:t tr(..-atmcut: Was the trcatmentapproprlarc or more a co11SCqucncc of convenience
or whar may be socially correct?
• l11vestig:nioos: Prolonged pain requires thorough investigation. False positives from tests
are an iatrogenic nighnnare and cheir possibili£Y must be considered in the.,tie cases.
• 'lfe:annent of chronic LBP: Simpl;' the wrong n·eatment or therapeutic exerc ise wa.s
• Lodb>ing a claim: Compensation board has made an incorrect decision .
• Lawyers: En('Ouragc rctainmenc of the disilbility fc)r maximal claim .
• Ex-pert \vimess:FaJsc witness claiming the t-ausc to be.pS}'ChosociaL
J must admit dtar I have had to de<ll with everyone of tht.>se points while working with patiencs,
mcdic.:al management groups, and the lcg-JI process. Tbcy arc important.

Helpful Strategies for Undiagnosed LBDs

Some physicians ilre clear!}' fru$trated wirh che delt~)led improvemenr of undiagn<)sed chronic
LBD patie11tS. This frustration, together "itb concern !Or d1e 6nantial health of the compen-
sation S)'Stem, may have motivated the Fordyce report to empbasite psychosocial modulators
rather dw1 organically ba~d variables to explain intolemnce ro certain types of •ctiviry. llut
dealing with frustration on the basis of false assumptions will not help the siruation. 'What, then,
are more useful approaches to undiagnosed chronic cases of LBD?
As nored earlier, many clinicians do not have the expertise or tools to diagnose back troobles at
a tissue-based level. Provocative testing will enable many physicians w identify painful motions
and loading. By imegraringbiomechanics with such testing, physicians may be aide-d in making
nmctiona l diagnoses.
ln a small srudy Delitto and colleagues ( 1995) suggested mat appropriately classified h<1ck
pain sufferers (doose with functional dassifications rather than tissue-specific diagnoses) do
better with. specilic treatments. ~\orrher, as patients progress rhrough the rehabilitarion proc-ess,
they seem to require different treannent approaches. For example, several studies suggest fiat
rnanipulation c-.n be benelicial for "cute short-tenn troubles, while physical tJtcra[Jy and exer-
cise approaches appear better for chronic conditions (Skargren, Carlssoll, and Oberg, 1998). A
major lim..iration o f these sntclies is that none has assessed progressive rreaonems: ·that change
as the patient progrcssc.; through the rchabilit<ttion process; ratJ1cr, d>cy :~I have assessed only
single treaanent :~ppro:~ches. ~\orure studies most assess the effica(:yof staged programs io1 which
categorized patienrs follow progressive treatment involving several sequenced approache.'i.

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In sumroary, the position suggesting that tl>ere is no derectable pathoanatomicall>asis for pai11
and activiL)' intolerance in some patients and thus that d>ese are nmctions of only psychosocial
variables does not appear to be defendable. Improved ci.ssue-based diagnosis, impro,~ed provoca-
tive te-sting and improved Fwtctional dingnosisl and better mldersrnndjng of the interactions of
psychological va1iables ";th patho;matomical va riables appe;H' to have promise fo,. helping to
impro,·e t reaone.nt o ntt." 'rncs.

Are Biomechanical Variables

and Psychosocial Variables Distinct?
Are biomechani<.:nl variahk.os and psychosodal variables distinct, or is there an interplay between
them t.h.a.t, jf understood, wouJd underpin a rnore evidenced-based intervention program?
Most reports have made a cbr separ•tion between psychosocia l and biomechanical f"ctors.
But is the re any evidence that psychosocial fattors could modulate muscuJoskeletal loading-or
vice versa? first, consider that hjghl)' respected pain scientists present volumes ofen1pirkal data
demonso·<lt ing rhar pain perception is modulated by sensory, neurophysiological, •nd psycho-
logical mechanisms, S"b'S"sting that the separncion of the two for analysis is folly (e.. g., Melzack
and \>Vall, 1983). Teasel! (1997) argued quite con,·inciugly that, while psychologiClll ·fJctors have
been cited as being causHive of pain and disability, in fact psychologicll l difficulries arise as rhe
cortsequence of chronic pain (see also Gatchel, Polatin, and Mayer, 19?5; Radanov et al., 1994)
and disappocar upon its resolution (see also Wallis, Lord, and Bogduk, 1997; llicks cr al., 2005;
Man1\ion eta!., 200 1). Interestingly, when dep,·ession is tracked as a variable, so1>1e evide,\ce
suggests that hack pain is a predictor of depression (e.!f., Curry and Wang, 20M), yet depression
can predispose pc'Oplc to pain (Lc·pinc amiBrik-y, 2004). The e>;dcntc is compcWng-pain and
psychological variables appe<lr to be linked it1 a bidirectional relationship.
Is there more direct evidence that psychosocial fActor' are ine.,tricably linked with biomechani-
cal factors' Marras and colleagues (2000) noted that ccnaio personality fa(~OI'S, t<>b<ctl>cr with
some psychosocial variables, appear to increase spinal loads by up to 17% in some personality
')~Jes via muscular coconaaction. This :1ppe:-lrs to occur at moclenlte levels of loading, while
l>iomt:c.:ban ical loading overrides ;my psyc.:hosotiaJ effects wtder larger task demands. This <.:on-
elusion was strengthened wirh a field study linking these general mechanistic observations with
reporred LllD in workers. Tn summary, LBDs "Pilear m he assodated with both Joading and
psychosociaJ fJl'tors, and thcst' fat'tors seem to be related and multifactorial. The same <.'Ondu-
sion ;1ppears to be valid for many types of chronjc pain conditiorts (Gamsa, 1990).
Consider this final tale and logic. My loving dog developed a painful knee. Simply my reaching
toward her knee caused her to sink her teeth into my ann as she recoiled. W.1s she disp laying
psychosocial disturbances causing her pain or a natural response to avoid mecbankal loading
rhat she knew would hurt her?

What Is the Significance of First-Time Injury Data

for Cause and Prevention?
One of the best indicators of fun1re back trouhles is a pre1rious history of hack troubles (Bigos
eta!., 1991; Burton, Tillotson, and Troup, 1989; Troup eta!., L987). This suggests that sn1die,,
of first-time back trouble episodes may be ([uite revealing lor causative factors. Burton, Tillot-
son, Symonds, and colleagues ( I\196) sn1died police officers in Northem Ireiand wearing >8 kg
( 18 Ih) of body armor in a jacket (this additional load was borne by the low back). This group
demonstrated a shorter perjod of time to their 11rst onset of pain when compared to officers in
an English force thar did not wear the f>ody ;1rmor. The authors also lound that spe nding more
chan 2 hoUJ-s per clay in a ve.hjcJe <.·onstitutcd a separate risk for 6rst-cime onset of LBP. Anothe1·
"'"'"Y (Troup, Maron, and Lloyd, 1981) noted tl>at fJlls among employees across" '"'riety of
industries were a comn.1on cause of fii'S£-rime onset and were associated with Jonger periods of
sick leave and :.1 greater propensity for recurrence than were injuries caused hy other mecha~
uisms. (Ligamentous damage r('Stllting from thls type ofl&dding is discussed in cha ptcr 4.) It is
"!so interesting m note that persona llactoi'S appea •· to play some nole in forst-time occurrence.

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Biering-Sorensen (1984) tested 449 men and 479 women for a variety of physical characteristics
and showed that d>ose with hrger amonnts of spine mobility ;md less lumbar exrensor muscle
endurance (independent factors) had an increased occurrence of first-time back troubles. Luoto
and colleaf,"UCS (I 995) reached similar conclusions. Muscular tndurance, and not anthropometric
variables, a ppears to be protective.
Some injuries just happen as the result of motor <:o nn·ol errors. ( fhh interesting mechanism
is introduced in chapter 5. where we describe witnessing a.n injury using videofluoroscopy to
view the spine.) These may be considered random events and may be more likely in people with
poor motor control S)'>'ten>S (Brereton and McGill, 1999).

How Do Biomechanical Factors Affect LBO?

Severa l approaches have provided evidence into the links between biomecbaJiical Factors and
LBO. A few are summari7.ccl here.

Mechanical Loading and LBO: Field-Based Risk Factors

Of tbe epidemiological sruclies that have focused on kinematic and linetic hiomechanical factors,
a few inves tigated loading of low back anatomical strucrurcs. These would be <.-onsidercd to bf!
the strongest evidence. Tile majority of the srudjc:,, howevc1·, assessed indirect measures that
are linked co spinal loading such as the presence of static work posnu-es, frequent torso bending
and twisting, lifting demands, pushing or pulling exertions, and exertion repetition. VVhile tissue
overload is the cause of tissue damage aod reL1ted batk troubles,the.<e indirc'Ct measures of load
merely act as S\IITogates. The attl'llcdon of using surrogate measures rather than direct rissue
loads per se for epidemiol<>f,'it'<l I study is that they are simpler to <lllantify and survey lo the field.
_Howc"er, trade-offs exist among •nethodologicaJutility, biological reality, and mbuswess. Risk
(lctors related to specific cissue-based injtuy rnochanisms at-e found in chapter 8.
Several issue.-;: should be kept in mind when one is interpreting this Litenlture. Virmally aJl
reviews of the epidemiological literature (e.g., Andersson, 1991; .Pope, 1989) have noted that
specil1c job> titles and types of work are associated with Lll )) (althot•gh LBD is defi ned di ffeJ-endy
in different smdies). In particu1ar, johs characrerized by manual handling of mareri:~~ls, sitting in
•ibrating vduclcs, and remaining sedentary arc all linked with LBD. llowev<:r, this t}'])C of data
does not reveal much about the links between specific characteristics of the work.and the risk of
suffering Lll 0 : specifically, a dose- response relationship has not heen elucidared. Furthermore,
a rt.-view of 57 papers that surveyed LBDs rc,·calcd no consistency between specific risk f-Jctors
and the development of those disotders (Ferguson and Marras, l997). Tltis review demonstrated
rhe large differences in the way surveillance was performed and in risk factor measurements. \-\'e
are rmni.ndcd once again that epidemiologieal approaches alone vtiU not eludc.larc the biological
pacl>way of the development of LBDs, a process rhar mlk~t be w>derstood to develop optimal
prevention and rehabilitation strategies.
As noted, the majorit:)<• of specitic risk factors that arc.addressed in the epidemiologit"<ll lit-
entturc (which is surprisingly sparse) are reaUy surrogate factors, or indirect measures, of spine
load. T hese surrogate facwrs are static work postures; seared work postures; frequent bending
and twisting; lifting, ptLUing, and pushing; and \~bration (especial!)• sear~d).
• Static work p(Jstures. Research h"s .sugbrest<:d that ''lurk charactt!rized by static postures
is an LBD risk lilctor. While many studies have suggested a link widl static work, the key paper
on this roric was presented by Punnerr and coworkers ( 1991), who reviewed 1995 b:<ck inju ry
cases from an auto assembly planr. Analyzing jobs for postural and lifting requirements, they
found that LBDs were asscx~iatcd with postures that required maintaining mild trunk tlcxion
(defined as the trunk fle8ed forward from 2 Io to 45°) (odds ratio= -1.9), posrures im·olving
maintaining severe rrunk flexion (defined as the trunk being flexed forward gTeater rhan
45°) (odds ratio= 5.7), and postures involving tntnk twisting or bending greater than
20° (odds ratio = 5.9). Their results suggested d1at d>e risk of back inj<"Y increased with
e.xposure ro rhese deviated posmres and wirh increased <luration of exposure. Oe\riated postures

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grcady incrt>ase low back tissue loading, particularly when they must beheld (t\Iarras eta!., 1993:
McGill, 1997).
• Seawl wt>rk posture.r. Kelsey (1975) linked the seated work rm<mre ro a grearer risk of
LBD. In a more recent study, Liira and colleasucs (1996) SU!fl;(CStcd that although white collar
(sedentary) wo•·kers who musr sit for long periods have a greate•· risk of low back troubles (8%
increase in odds risk), active blue collaY workers brain some prophylactic effect from sitting down
(14% rcdu~tion in odds risk). This Sllf,'gCSts that variable work, and not too much o f any single
activity, may have merit in •·educing mechaotically induced low back troubles.
• Fn,qumt hendingm1d I:"JJi.rtrng. T he U.S. Dep:irtmenrofLabor report ( I!lll2) and many
more studks (swnmarized by Andersson, 1981; Nlarras ct a!., 1995: Pun nett et al., 1-991; Snook,
1982) noted the increased risk of LBD from frequent bending and twisting. In iilct, Marras
documented in several studies the increased risk ofLBD with higher torso velocities (e.g., t\i;~rras
et al., 199):, 1995). (Note that this is isolated spi ne motion and not nonspecific to1-,;o motion.)
vVhile these srudies did not ex.1111ine a mechanism to explaiu a ~nk with LBD, the associated
motion wit hi n the spine v.ill be shown in ch<1pter 5 to fom1a parhomed1<mism for very specific
disabling LBDs.
• Lifting, pulling, ami pu.rbi11g. The National Institute for Ocr:uparional Safety and Health
report (NIOSJI, 198 1) provides a good review linking activities requiring lili:ing, pushing, and
pulling wit h increased risk of LB D.
• Viln·ati(m. J!i.nally, 'ribration, particularl)' seared vibration, is linked ro elevated rates of
LBD (e.g., Kelsey, 197 5; Pope, 1989).
• Gener-ation ofspine JWWer. T l1e concept of power (forte times velocity, or in the context
of the spine, spine bending velocity with simultaneous muscle force) has not been well fonmilated
heL':lUSe it is a variable that is calculated rather than dir cc:cly measured. However, it appears that
when the spine muscles are rcqwrcd to generate high forces, the motion needs to be very slow
or static to reduce the risk. On the other hand, if the bending velocity is high, then the muscle
forces need to be low. Eithe r way, low power is required to minimize risk T his is s:uhsrantiated
Uy professor i\1aiTas' work linking velocity and a<.:cclcration to higher risk.ln addition, in our
o""' laboratory w01·k we have begun expe ri men~< loading people's spilles isometrically and then
with d ifferem comb inations of load and motion. VVe had ro ahandon lhe expe riments dm? to
p-Jin generated when higher power lcvclo; were reached.
While a II of the risk factors noted here have been epidemiologkally linked with an increased
inddcm:eofLBD, a suUscqucm section on tissue damage wiU provide insight into the med Ja-
nisms linki ng mechattical overload, the onset of p:!in and disabilit)', and the narural histo•y of
d1ese in juries as rhey permin ro job performance.

What Are the lasting Physiological, Biomechanical,

and Motor Changes to Which Injury leads?
Tht: fo llo wting discussion of recent studies iJJust rates the substantiaJ literat ure documenting
s1x:cific performance deficits and >ubsequenr anatomical changes in LBP populations.
• Several studies have docurnented a change in rnuscubr function 3ftcr iniUJ'Y ( nicely sum-
marized in Sterling, J ull, and Wl"ight, 2001). T hese include, for example,
delayed onset of specific torso muscles during sudden even~ (Hodges and !Richardson,
1996, 1999) that may irnpair the spine's ability to achieve prowctivc stabllity during
s ituations such a~ sliiJS and fJlls;
- cbangt·s in torso at.ronist-antagooist activity during brait (Arcndt-Nidson ct al.)
- i nhibirion of back extensors in rhe presence of pain (Zedka et al., 1999); ~nd
- asyuunctric mustle output during isokinctic torso extensor efforts (Grabincr, Koh,
and Gltazawi, 1992) that alters spine tissue loading.

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• Anatomical changes following low hack injury inc1ucle asymmetric atrophy in the muJ-
tifitlus (Hides ct al., 1994) ami fiber change,; in the multifidta. even five years a:ftcr surgery
(Ranranen eta!., 1993). Further, in a very nice study of 108 patients with ltistoJies of chrOJtic
LBO ranging from four months to 20 years, Sihvonen ancl colleagues (IY97) noted tbat 50% had
disturbed joint motion and 75% of those witl1 nuH:ttingpain had abnormal eltttromyograms to
dte med ial spine e,,tettsor muscles.
• Finally, a rc..>cent!'.'tudyofthose witb a historyoflow lrdt:k troubles has shown a wide varie.ry
of lingeriJ>g deficits (McGill et al., 2003). The b<tck troubles were sufl'icie.nt to cause work loss,
hut the subjects had been back to work for an a''erage of 270 weel-s. Generallr, rhose with a
history of truubles were bea,~er and had disturbances in tbe flexor/extensor strength ratio and
the tlcxor/e;:xtensor cndur.uu.'C ratio together with the lateral bend eudurancc rntio, bad dimin-
ished gross nexion range of lumbar motion, and had lingering motor difficulties compromising
their ability t(> balance and hend down to pick up a light ohjccr. None of rhese ch:anb"'S t'Ould
be considered ~'Ood.
T he broad implication of rhis work is that a history of low hack trouble, even when a sub-
~tantial anwunt of time ha~ elapsed since the trouble, is associated with a variety of lingering
delicits such d1a t a multidiscipl ioary ime1venrion approach would be l'eq·uircd to diiJniJtish their
presence. This collection of evidence is quire powerful in documenring pathoneuromechanical
changes asso<:itncd with duonic LBO. These t:hanges arc lasting years-not 6 to 12 week..'i!

What Is the Optimal Amount of l oading

for a Healthy Spine?
Lucid inte•·pretation of <he dara in the epidemiological litenmore is limited by rhe f.lct thar rhe
lc\•cls at w hich tissue damage ()<:Curs remain obscure . .l\hny are concerned with the known
tissue damage th<lt occm'S with high magnitudes of load, repetition, and so on. For e,,ample,
Herrin and colleagues (IY86) found that musculoskeletal injuries were twice as Jikel)' if the
worker's hunhar spine was exposed to compressive forces that exceeded 6&00 N (predicted v.-ith
a biomcchanical model). On the other band, several of the er>ideJlliological studies ha,·e not
been able co support a link between heavy work, when crudely measured, and the risk of LllD
(e.g., Bigos et al., 1986; Porrer, 19S7). Mitig•ting factors appear to include repetition of similar
rno\•cments and variety in work.

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lo the d.iscussion of the U-shapod relationship between activity levels and LBD discussed in
chapter I. we saw that srress atoptimallevels strengthens the S)'Stem, while too little o r too much
i-s detrimenraJ to heal th. Kelsey ( 1975) demonstrated a !,'Teater than e.xpected increase in disc
prot:J·usions among sedentary workers. VVh.ile many t:on.s·ider sitting tl "low-loac.l" task, in filet it
creates damaging conditions for the disc-the mech:mism of which will be explaine-d in chapte1·
5. This has obscure.d the emergence o f a much clearer relationship :unong biomechanical load-
ing, disc herniation, d iniC'•I impressions, and the ability to perfun n demandi ng work. Furtl>er,
\ Todeman and colleagues ( 1990) studied a cross section or ''etired workers by comp31'ing their
LBD history with their magnetic reson:mce imaging(A<fRJ) ~.. ns. A historyof b<~ck pain and the
"isiblc parzuneters of spinaJ pathology were least prevalent in workers whose jobs had induded
moderate acrivity and most prevalent in workers with either sedentary or ltea''Y work.
J\t1any studies compare just rwo levels of work- for example, light ver-$n~ he;n'Y, lighr versus
tnoderate, or moderate versus heavy. Because any relationship other than a ~rraig:ln: line requires
more tha1\ two poiots (or levels or ac6viry O l' levels of loading), such studies cannot iJ iuso·ate
the U-shaped reladnnship. Consider the data compiled in a thorough epidemiologic;~! smdy
reported by Liiro and (X>Ilcagucs (1996) ofLBD prevalence and physical work cxposurL'S. Even
though the authors considered only the upper levels ol' escessive loadiug, they concluded that
one-quan er of excess back pain morbidity could be expla.ined by physical work exposures. T be
real possibjliry remainS: that this ls an underestimate.
Furthermore, the nature of LBD ap ~>ears to be affected by the type of work. Videman and
('OIIeagues ( 1990) noted a tendency among those wh11 had had sedentary careers to have marked
dist Uegeneration in later yeaTS, while thost who had pf!rformed heavy work (defined as not
on ly li lting but also requiri ng large truuk motions) tended to have classic arthritic changes in
rhe spine (srenosis, osteophytOsis, ere.). ln a similar stud)•, Bartie and colleagues ( 1995) reporterl
an apparent <.'onrriburlon of genetic fal"t.o rs to various age-related change.s in the .spine using
monoqgoric twill,;, given signi6cantly greater simi l aritie~ in spinal changes than would be
expected by ch;mce.
Porter ( 19H7, 1992) perfom1ed rwo studies furthering the nncion of an optimal loading level
for health. 'I11c 6rst study tracked miners and nonminers treated at hospitals for back pain.
VVhile significantly more miners reponed tOr back (rouble compared with nomnl1::.ers, signifi-
cantly fewer were diagnose.d with elise protrusions, while significantly more were reported to
have stenosis and n(·.rvc root cntrapulent (conditions associated more with the 2rtfuitic spine
according { 0 the data of Videman, Nurminen. and -n'Oup, 1990). The second sru<iy e1•aluared
questionn<~~ire results from J 96 p~tien ts with symptomatic disc prorrusion and 53 with root
cntrapmcn t syndrome. -Jlley were asked about their history of heavy v.rork between the ages of
15 and 20 years. Significantly n1ore subjeclll with disc protrusion had done no heavy physical
work in rhose early years. By contrast, more of those with nerve entrapmenr syndro1ne had clone
fiv(' full years of heavy work bcrwceo 15 and 20 years of age. These collective Jata ''Uggcst dtat
different work demands cause different spine conditions and perhaps that tbe optimum loadi11g
is different for different tissues. Nonetheless, the optimum activity appe::1rs to he varied work
at a mod tl~ te level betw~en stdcm:ary and heavy vmrk.
What constitutes an optimum load-a load that is not too much, nor too lirtle, not roo
repetitive1 :tnd not too prolonged? CtuTendy> we are in need ofassessment tools for detem1ining
optimum load to .s.ruide the intervention toward optimum bealth.

What Are the Links

Between Personal Factors and LBD?
Some persQnal factors such 2s muscle endurance (not strenbrth) and less spine rantre of motion
(not more) arc prophylactic for future back troubles. 'I11csc will be addressed in pa:rt ill, "Low
Bac.k Rebabilit'<ltion." A few other persona l fuctOJ'S are noted here.
A few specific personal factors appear to affet.'t spine cissue rolenmce according to the existing
literature; age and gender arc two cxruupk-s. Jager and colleagues (1991) compiled the available
literature on the tolerance of lumbar motion units ro bear compressive load that passed their

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inclusion crited a. Tbeir result'i revealed d>at when males and females were matched for age,
fem:~les were able to S\IStain only approxinurely two-thirds of the cx>mpressive loa<ls of males.
Furthc.rm()re, Jager and colleagues' data showe d that \\~thi n a g iven gender, the 60-year-old
spu>e was able to tolerate only about two-thirds of the load tolerated by the 20-year-old spi11e.
Keep in mind that age and gender are very simple factors.
lt appears that other personal factor!h such as poor motor t,•onttol system "fimess."' can lead
to a back u>jury during ordinarily benign tasks such as picking up a pencil from tl1c: floor. The
modeling da{ll of Cholewicki a11d McGill (1996) suggest that rhespi11e <:ll O easily IK>ckle during
such a task. \;v"hen the muscle forces are inherently low, a .small motor erro r can cause rorntion
ofa single spinal joint, placing all bending JtJOulent support responsibility on the passive tissues.
Such scen31ri_os do not COilStiturc e~cessive tasks, but patients often report them ro di nicians as
the event that caused the-ir injury. "fhis phenomenon will nor be found in the scientific lirer:-1nrre,
however. l\tfany medit"':tl personnel would no t record this cvcut a.'\ the cause of injury s-int-c in
many jul'isdictions it wo1lld 1\0t be deemed a compensable injurr. T hese types of injuries seem
to he more inflnent·ed by the flrness of an inclividual's motor control system than by factors
such as strength. McGill ami colleagues (1995) noted that people differ in their ability to hold
a load in thleir b.onds and breathe he:t~Tily. Tl1is is ve•·y signilkanr since the muscles required ro
be continuously active ro support the spine (and prevem hnckling) are also used ro bread1e by
rhythmitall)' tontra.<:ting. Those wbo must uSC! tJl(dr musdes to brcad1c in this way sacrifice
spine stabjHry. [nterestingly, we have measured ch:tnging Stnltegiesin those ,,~i rh compi'Omised
lung elasticity (smokers, emphysemics, ere.) who use rl1cir back e•'tensors to assist wirh lung
infla tion, resulting io the pervtrse effect of enhancing St<l bility at the e xpense of wearing dovm
tl1e endur3J1Cecapacity of their back muscles (Wanget al., ill p1·ess).I\Uof thesodeficiem motor
onnrrol mechanism.<will heighren biomechanical susceptibility to injul)' Ol' reinjury (Cholewicki
and Mc-Gill, 1996) and are highly variable personal cbaracteriscics.
Additional fuccors other than sim ple load magnitude apj)l>ar to modulate the nisk of tissue
damage. ' !.he mechanism of disc herniation provides an example. While disc herniatio"s have been
produced under controlled conditions {e.g.t Gord<m et al., 199 1)~they have not been prtx:luced
consi.stently. Our hb has been able to consistently produce disc herniations by mimjdci11g spine
motion and load patterns seen in workers(Callaghan and McGill, 20lll). Specifi~'ll lly, it appears
that only a very modesr amount of spine compres.ion IUrce is required (only 80()-1000 l'\'), hut
the spuoe specimen must be repeatedly flexed-mimicking repeated torso-spine flexion from
conrin1oal bending to a 1\.dly flexed posture. The main relevance for rhis issue is that rhe way in
which workers elect to mo,•e and bend will influence the risk of disc herniacion. T his highlights
the need to cxami1u.· how workers rnovc in standardized tests -at the Uc&rinning of thdr C'.trccrs
while d>ey sri II have "vit·gin" backs, making it possible to determine cause and effect. Recem
evidence suggests that those with a hisrory of back rrouhles are mnre likely ro Jill: flexing the
sputc amlnm the hips, increasing tlte risk of futmc hack damage (NicGill eta!., 2003).

What the Evidence Supports

Io swJuuary, it is interesting to consider why ooly some workers become patient~. -nere is no
question that damage to tissue can be ~':I used hy excessive loading, and damage causes J>ain. How-
ever1pain is a perception that is modulated by psychosocial variables ln addition to physiological
injwy. Clearly both psychosocial and biomecll3nical variables are associated with LBO and are
important in preventing low back injtuy and the ensuing chronicity; collectively the evidence
from seve:J--:.1! scientific perspectives is overwhelming. The relative importance of e.ithcr is often
diflic'Uit to compare across studies as the metrics for each are differem- biomechanical variables
are reported in newwns. newron·meters, numbers of cycles. and so fonh, while psycho..o;.oci~ll
variables are reported in ordinal .scales linked to perception (independenr risl: factors can be
compared u~ingodds ratios). Smnc inAucntiaJreports have ignored bjcnllcchanical evidence and
promoted psychosocial ''ariables as being more impomnt. However, no srody of psychosocial
variables has l)een ahie m <.'Cmclusively esmhlish cau.<rial links-only association. Some hioLnechani...
caJJy based .studicS1 together with the ehronic pain li terature, arc strongly ('Onviucing iu their
establisluneot of bod> association a11d causality. Thank goodness! We can now prot-eed.

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Back injury can begin with dam;lgeto one ussue, but this changes the biomechanical fwlG'tion
of rhe joint. T iss11e stresses change and other tiSSIJes become i1wolved, leading to progressive
deteJior<Jti()n with time. 11ssue damage do<.->s not aJways result from too high a load mabYJt.in1de.
Ll the case of disc herniation, repetitive motion, even in the absel\ce of large loads, seems to be
a significant Cllusative mechanism. T he notion that tissues heal within 6 to 12 weeks and mat
longcr-lascing work inwleram.-e has no parhoanatomical basis appears to be false; tissue injury
data and the science of chronic pain med1anisms strongly suggest otherwise.
Understanding the role of bi.omechanic:1l, psychosocial, and personal factors t<>gechcr with
their interrelationships will huj)d the foundation for hetter prevention in the future . The chal·
lcng-e is to develop variable tolerance guidelines, psychosocial guidelines, and higher-level
medical practice codes.
O n bala ot-e the evidence supports the following statements:

• Biomechanical f.tctors ore linked en both the incidence of first-time low bock troubles
and absenteeism, and subscqutnt episodes.
• Ps)'(;hosocial mctors appear to be important a$ well b1•t may he more related co episodes
alter the i.nitial back-related episO<le.
• Psychosocial <tnd biomcchanical factors appear to in Aucnce each othcr, in te<ms of both
causation of work absence and the coul'se of l'ecovery.
• 1rea ~ncnt to reduce b;lck pain oltcn leads to a reduction in psychosocial issues, not the
other way around. There is overwhelming evidence d>at 011ce patients C;l.n otrrai.o a sound
nigHtt's s.leep and can eliminate lcnv· level chronic pain, their psychological,ttion
and mental toughness rerum.
• Tit<' relat:ioushit> between loading and LBDsappears to be a U-sbaped function with the
optimal loading being at :1modernte level.
• Low hack tissue damage tau initiate a <:aSC<l dC:: of changes that may e;wsc pain and intol-
erance ro cerr~liJ) activiries, and {hese changes may be disrupdve for op to 10 years in an
unfQrtunare few.
• Many types of tissue damahre can esc~1pc lletection in vivo. E"cn b7foss dam;1ge visible
during dissertiou is often tlOt visible on med.ical images. T hus, nonspecific dia&'l>osis
does not rule our the presence of mechanical damage and must not he used to imply that
mechaniml fuctors are not related to LDD.

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Functional Anatomy
of the Lumbar Spine

he average reader of this book wiU have alread)' srudied hasic of the spine. This
anato n1y
T chapter begins by revisiting some anatomkaJ fcatur~s,
possibly in a way not con-
sidered. Then these fearures will be related to normal function and injury mechanics ro lay tbe
foundation. for the prevention and rehabilit·ation strategies mat follow. 1 believe that clinicians
and sc.:icntisrs alike wbo specialize in low back rrouble!t do out devore suffi<.:icnt eff<)rt to simply
considering d1e anatomy. T he answers tO many questions relevant ro the clinician can be found
within an :~~natomical frame\llOrk, wherein lies the nmech:mlcaln toundarion t'or preventing and
rehabilitating back troubles. The w1derstamling of injury mechanisms presented here will help
ensure that you do nor unknowingly include injtu·y-exacerbating maneuvers in therapeutic
exer<;ise prescriprions.

Basic Neural Structure

T he grcatcstath.l ctcs who arc elite performer~, and who avoid injury, arc verr wise in understand-
ing the po-ocess of activating muscles and groups of muscles. T hey ru·e masteo·s at using imageoy to
control the motor unir reCJ11ionent process. \Ve smdy rhese individuals ro lean1 their proce.'iseS
so mat we can ,,onpiO)' t!JCSC tct:hniqucs with pc"Oplc who have painful back.<. The oa.sics of what
)'Ou lleed to know abour neural integration, some of which are inu·oduced here, <'.111 be fotUid
in wonderful resourre.s such as Kandel, Schwm:z, and Jessell (2000).
Motion may oocur from a ('Onsciou.s thought in tht brain that in!; muscle:: activation,
or the activation may resuJ( from a n'lore subconscious process involving an encoded panem
thought to reside in the spi nal cord. Trmnnar:ic evems can re<:ode these parrerns to pertnrhed
States, as can chronic and acute pain. Rc-recoding these pe..rrurbed patterns back ro nonnal is
an issue addressed in the thiru sectioo of this book.
Better links hetween neuroanatomy, neurophysiology, and reh:lbilit:-lrion :.1nd rraining<.-an he
found in my textbook Ultimmr Back Fitmss rmd PeFfommna {2 006). Several relevant disc"ssions
Lllustmte. for example, why macb.incs carmor creare the many variations of forc.:c development
within a nruscle tostimuhue all motor units. In the torso. for example, rhe oblique m\lscles have
many neuromust·ular t.•ompartments that must be stimulated with demand. Slow and isolationist
approadtes t)'pical of bodybuilding do nor offer a rich l"·oprioceptive euviromuem 1>roviding
variable morion, balance, force projecrion, and direcrion challenges involving the full linkage.
Another a~pect for designing the best manual therapies is based in ncuroanaton1y. \.\'bile a
wonderful ncuroanatomical source is David Butk r's book Thr Seusitrvr Ncrvous S.)'stmt (2000),
an introduction to the conceiJtS is attempted hefe. Often, pain th~r is attributed to muscle
rurns out [0 he neurogenic pain . ''fhe tests descJibed later in this hook are fmmcled on several
principk'S. AnatonJically, the spinal cord and all ncn•ou) tissues linked in series (lumbar nerve
roots, the sci;>tic nen•e, etc.) c;~n be rensioned, o-eleased, mobitized, llOd llossed '"ith speci6c ru•d

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coordinated joint motions. Tensioning nerves only causes more pain-neurot;.renic pai11 cannot
be stretched away. Sadly, too mu ny patients with "light hamstrings" or sci.atic symptoms pursue
stretching programs that proclm;e only temporar}' relief. This relief resnlts from rhe activ.u:ion of
tht! stretch reflex in the back extensor muscles, bur it typically lasts only about 20 minutes. Tbc
pain and stifli1ess rerum. It is often possible to break the cycle by replacing the stretching with
neorll l ••mohilization. Butler describes well the benefits of mobilizing :1 nenre along its entire

rratt tobrct11er v.rith the mechanics that crt•:ate local tensions. \Vith c<x)rdinated coervical hip,

knee, and aJnklc-motion, the lumbar nerve roots. cauda equina, and sciatit tract can be mobilized
3nd Aossed without tensioning (shown in chapter 12). We have too many cases of inn'O nsigent
sciatica cnred \vith this approach to i!,.'l'l:Ore it.

Vascu Jar Anatomy

AU spinal tis.<u('S have a '"JScular supply with the exception of t11c disc. The implications of the
3\'llScu lar nucleus ue described ill the disc section of this chapter. The curious case of vertebral
veins is int roduced here. The veins lea•ing the vertebral bodies are the only veins in the body
known to lack valves, Venous valves prevent bac.:L.ilow o f blood. But as wiU be shuwn shortly
in the discussion of vertebral mechanics, this anatomic feature is critical. It appears that the
veins acr as a hydraulic outlet fi·om the ''ertebral body, enabling d1e expulsion of blood under
lUgb <.:omprc:ssive loading. In this way both the arte1ies and the vcins may provide a prott-ctivc
mechanism and the ultinl:lte hydraulic shock dampening syst~m.

The Vertebrae
As you uodoubtedly know, the spine has 12 thoracic aod r,,.e lumba1· venebrae. The construe-
cion of the. vertebral hodies themseh•es may be likened ro a barrel ,.;th round walls made of
relatively s.tiff tortit~d bone (see R&'Urc -1.1 ). The top and bottom of the barrel arc made of a
mote deformable emilage plate (e•ld plate) t.hat is approxin>ately 0.6 mm (0.002 in.) thick but
chinn.,;t iru the central reb-ion (l~obe.J'tS, Menage, and Urhan, 1989). The end plate is porous
for the transport ofnuaicnts sucb as oxygen and glucose, while the inside of the barrel is filled
witl1 c,u,cellous bone. T he tr"becular '"'nmgetnem within the cancellous bone is aligned with
the stress o-ajectorie$ that develop during activity. T hree orientations dominate--one vertical
and two oblique (Gallois and Japoit, 192 5) (sec figure 4.2).

Vertebral Architecture and load Bearing

The very special arcltirecwre of tl1e vertebral bodies determines bow they bear COllll)ressive load
and fail under excessive loading. The walls of the vertebrae (or sides of me barrel) remain rigid
upon compression, but the nucleus of the disc pressurizes (the classic work is by Nach<::.mson, l 960,
I966) and co uses the cartih1ginousend plates of the venebr.1e to bulge in""rd, seemingly to compress
the cancellous hone (Brinck111ann, lliggemann, and Hilweg, 1989). In filet, under compression the
('ant'ellous bone fJils first (Gwming, C1llat,>han, and McGill, 2001), making it the detenninant of
faihtre tolerance of the spine (at least when tlte spine is not positioned at the end range of motion).
It is difficult ro injure the disc annulus this way (annuklr failure will be discussed late,·).
Alth<>Ugb this notion is contrary to the t'Oncept that the ve.rrehrallx)dies <l re rigi d, the func ~
t.iona.l interpretation of this anatomy suggests a very dever shock-absorbing and load-bearing
system. Farfan (1973) pi'Oposed the notion th<lt the vertebral bodies act as shock absorbers of rhe
spine, alrhough he ba5ed this more on vertebral body fluid Aow tban on end-plate bu10-ing. He
suggested that the discs were not the major shock absorbers of the spine, to •-irtually any
textbook on the S11bject. Since the nucleus is an incompressible fluid, bulging end 1)1ares sugf,"CSt
fluid C>'Jlltlsion from the vertebral bodies, specifically blood mrough the perivertebral sinuses
(Roaf, 1960). ll1is mc(·hanism suggests a protective dissipation upon a:nd clynatnjc
compressive loading of d1e spine. T he case swdy literarw·e abow>ds with con>pression fractures
of the vertebral hody during dj'llamic loading where the disc remained intacr (for example, during

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Transverse process

_ _ _ Vertebral body---.,;;;:::;:d<~--

Transverse process ?
Inferior articular facet

- - - - - - - S pinous process-
------~, Inferior articular
Lamina"" process

< ~

figure 4.1 The parts of a typical lumbar vertebra.

lmilge CQUIIf:S}'Of Primill Pict1.11~ .

figure 4.2 The a rrangement of the trabeculae (first noted byGallois and japoit in 1925) is aligned with the domi·
11.1111 trajectories of stress. (a, b, c) The three trabecular systems.

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~ Back OiS<lr<iers

tobogganing and sledding !Kelly and Robinson, 20031). More vertebral bod)•-b.,sed shock-
ahsorhing mechanisms ~re rlocumented subsequently. ln summ:uy, the common statement found
in many teA'tbooks that the discs are the .shock absorbers of the spine now questionable;
nlther, the vertebral bodies appe:u· to play a clolllinant role in pertonning this function.
Deform able vertebrae is a new notion for many. How do the end plates bulge inwa ,·d into
seemingly rigid bone? The answer appears to be in the architecture of t he canceiJou~ bone. Ver-
tebral cancellous bone structure is dominated l>y a system of columns of bone (shown in figure
-t.2) that run vertica lly li·om end plate to end plare. The venical columns are tied together with
smaller rransverse trabec"lae. Upon axial compression, as cl1e end plates bulge into the \'Crtebral
bodies, these ("Olwnns c::xpcriCJKc.COil)prcssion and appear to bend. Under c.x«.:cssivc t:omprc~sive load,
the bending columns wiU buckle as the smaller bony mmsverse tcabeculae fracture, as documented
hy fyhrie ;tnd Schaffier ( I994) (see 6gure 4.3). [n cl1is way, the cancell01c< bone can rehound hack to
its ori!>~rml slmpc (at k ast 95% of the original unloaded shape) when the load is rernoved, even
after suffe,-ing fracn11·e and delamination of the u-ansvet'Se trabeculae. This architecture appears
to :1fford excellent elastic deformation, even after marked
damage, and then to regain i~ original srruetu rc. anJ func-
Understanding Vertebral tion as it heals. Da maged cancellous fractures appear to
Mechanics heal quickly, given the small amount ofosteogenic acti\;ty
necdtd, at least when compared with the length of time
To truly appreciate vet'1ebral behavior I
encourage you to ob1ain a vertebra from
needed to repair c-ollagenous tissues.
M icrofracotring of the craheculae can occur with
a butcher (bovine or porcine is ideal).
repetitive loading at levels well below the failure level
Hold the vertebra end plate to end
from a single cycle o f load. Lu and colleab"'e' (2001)
plate l>etween your thumb and finger
demonstr.ued that cyclic loading at I0% of ultimate
and squeeze. tf you have never done
this hefore, you will he amazed hy the failure load caused no damage or cb,wge in stiffness; but
defonnation and elasticity. The verte- wirh 20,000 cycles of load ar 20% to 30% of the ulrimate
bra experiences similar deformation as failure load, both stiffness •nd energy absorb-ed at failure
the incompressible nucleus of the disc were dl'creased. Highly repetlrive loads~ even at qui te low
presses over the central end plate during magnitudes, appear to cause 11ticrodamage.
spine compression in vivo. T he osteoporotic vertebra is characterized by mineral
loss and declining bone density in the trabecu lae. Beca\lse
tn1 nsverse (rn heculae ~1re far fewer in numbe r than lon·
!,~ntdi nal trabeculae and because they are generally of
smaJier di:u:ucter, the transverse trabec-ulae S(>t..--ci6cally are
the target for roechan_ica1oon'lprOlllise with osteoporotic
minel':l l loss (Sih'> and Gibson, 1997) (see fitn,te 4.-l).
Interestingly; the same ;,mchon; noted a higher tendency
for the n·ansversc trabeculae to in females with
brreater inddence than in males. This loss in mechanical
integrity of the transverse trabceuJac has a great influ-
ence on the compressive sr.rength of the vertebrae via
the mechanism described earl ier. Thus, the osteoporotic
vertebra begins to slowly collapse when exv osed co exces-
sive load~ with seriaJ huc:kling- of the column.-; of hone
ultimately dcvclo~ing the classic wedge shape.
lt is im:e t·esting ro coocrast the other e.u:reme of the
Figure 4.3 Under compressive loading, bulg- bone density specm1m. The transverse trabeculae h~r­
ing of the end plate causes buckling stresses in vesred from specimens who performed heavy work (in
the vertical trabeculae, which, w·h<m excessive, particular, weighilifter~) were thick and den se. [n addi-
cause damage in the transverse trabeculde. tion, where the tr:msn:rsc trabeculae inte.rsct..tcd with
Note Ia! the vertical (from com1>ressionJ and (b) the vertical ("Ohmms, the joints were. characterized by
horizontal (from tension} cracks in th ~ transverse
heavy booy gusseting, sirniJar w what a welder wouJd
weld ro stre ngthen <1 righr..angled joint. The t ransverse
R.~in l('fl (rom Br:ww, Vol tSi(l), fyh1iof and Srh<!trll'f. ~r..,nuro
1ne-:;;h,1n~-n~ in hvnl\m \-..'ftcbr,.11 01nccl'o~•"botw-," 105· 109. C'"t'fyt'·
trabc(u(ac appear to bL·.crut;al in dctcnniningcomprt~­
ught 19'9-1. with perruls~lul'l of El~ie• Scle.,oo-. sive strength.

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tu~~aromyof th~e~L~u~m~b~a~r~Sp~i~n~e--------------------------------------------------------~3~

Yet anotber observed fmlure mecha-

nism of rne "ertehral body is temled
the '1slow crush, 11 in which extensive
trabecular dan1<1ge is observed without
concomimnr lo~ of stiffness or abnapt
change in the load-deformation rela-
tionship (Gunning, Callaghan, and
McGill, 2001) (see fignre 4.5). Since
slope chanb"' in the loacl-clefonnation
relations Itip is often used tu identity the
yield point., or the initial tissue damage, a b
d1is injury can go unnotice-d. Interest-
ingly cnotl!gh, vertebrae failing under Figure 4.4 \'VIlh .aging. lhe transverse or horizo•'lallrabeculae lhin
ev-et·-increasing comp_ressive load will and ev(>ntually los(> their abilit)' to support the vertical trabeculae,
gradually increase in sri Aness, a testAl- which can then buckle, causing vertebral collapse. (a) A healthy
ment to the wonderful architecture of trabecui<Jr bone network from a 47 -yt-ar-old womcm. (b) P~orali on
the transverse and vertical lralx"'Culae. in a horizontal trabecula in an elderly woman.
Also interestillg is the load-rate depen- Rcprin~l (r(lm /hi(•, Vol. 21, MJ, Sil\'.-,,md U. Glmn, ~Modt'ling 1hr mt.'(hanfc:;ll lx>h.1'-"P
dence of bone strenb>th, as the end plate oh.,;,Mbr~ltfabeculat booo: eTecb d age-u~.lted cb."'fl.o/S in mloostruc:tucto," fW· 19 1- 199.
appears to fail first at low load rates COfYt••lsJ'It -1997, whh pe~mlssion (run) E.~vlet X•~l<e.
while the ''ertehral bony element.s fail at higher load rates (see fig~are 4.6).
Both tb e disc ami the vertebrae defonn while supporting spinal loads. Umlc!r exc-c,-<<ivc
compressive loading, the bulging of the end plates into the vertebra I bodies also C<lUS<.'s radial
stresses in the end plate sufficient to cau<e fracture in a stellate panem (see figure 4.7). T hese
fractures, o r cracb1 in the end plate are .somt:time.s sufficiendy large to allow tbe liquid nucleus
to squirt tbuough the end plate imo the vertebral body (McGill, !997) (sec figures4.8 and 4.9).
Sometimes a local area of hone collapses under the end plate to crene a pit oa· crater that goes
on to fonn the cla~'ic Schmorl's node (see fi!:,•lue 4.1 0, a-h). T his t)'pe of injury is associated with
rompres.sjon of the spine when the spine is within the neutrnJ .rnnge of motion (i.e.~ not Aexcd,
bent, or twisted). In my experience, this cype of compressive injury is vel")' common and often
misdiagnosed as a hemjated disc due to the flattened interd.iscaJ space .seen on planar X--rays.
However, mote that in end-plate-fractures, the annulus of the disc remains i11tact. It is siutply a
case of the nucleus le.wing the disc and progressing dlJ'Ough the end pl~te into the cancellous
core of the verrehra (sometimes referred to as a verticaJ hemiacion). Over the years we have
compr('Sscd over 400 spinaJ units in a nc!utral posture, and all Uut two resulted in end-plate.
fractul'es ns tbe prima.y tissue damage.


a b

Figure 4.5 (iJJ Massive lrabecular damage found during the dissection a•1d ,·emoval of marrov.• following an excessive
"siO\>\'Crush" compressive load. (b) l"'ligher magnification of the crush fracture. Even this massive fr.acture was not dear on
X~ray or any other examination method.
Rcp!'intf"d {r(lm Clinit·.•l DiQ;n('Ch.H•ic•. Vol. 16({>1t. GvnninR, ), ('o.1ll.-.ghan, i\rn:l S. M('GiU, "The 1(11(' of J>fiOf' t(:l.1ding hi<il()ry ;,nrl 'fHn.ll posn;m on Ill<' rompn;~~n,.,
ro!e•.u'M:e and t)'J* of Lnlure In d~e spu-.e uslog a pou:ioo lt.lufl'l,) model," 411--180. l~·•lght 2001, wltb I* •IYII»kln of tlsevil~.

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N = 14 N = 10 N = 14 N =6 N: S

80 -
1!: 80 -
.... 20 - 1----.

0 I I I r
100 1,000 3,000 10,000 16,000

Load rate (N/s)

0 Endplate
0 Vertebral body

Figure 4.6 Com1>ressio11 inju ri~ at different load rates. At lo\v rates of compressive load the end
plate appears to be the first structure to fail, but bone will fracture first under higher rates of load.

Figure 4.7 Ste llate-patterne d end~pfate fracture (ind icatt!d '"'' ith arrow) occurs as th e nucleus is
I:M'€Ssurized under com(Yessive load, vvhich causes it to bulge the end plate, imparting tensile ~1resses.

., .... u
. ..
.. ..
," ~
' • ..:.- £''"


End plate

..., ........ ...

Figure 4.8 Under compressive loading the nud eus pressurizesj causing the t'fld pJattt to bul g~ into the vertebral body.
With excessive radial-tensile stress the end plate will fracture and the viscous nucleus will squirt through the crack into
the vertebral body.
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!Y~~aromyof th~e~L~u~m~b~ar~S~p~in~e~---------------------------------------------------2
4 ~1

Figure 4.9 Following a more severe end- Figure 4.10 In ;.ddilion to end-plille fmcrures, o1her injul'ies
plate fr.,cture, a l)()rtion of Ihe nudeus has to the enrl plate unrler compressive load include (d) "pits:
squirted through into the vertebral body which occur as trabecular· bone fractures in small areas under
(shown at the tip of the scalpel and the the end plate. These go on to form Schmorl's nodes. lb) A
arrow). This is a porcine specim en. Schmorl's node is shown at the tip of th~ arro\~'-
Ad.,ptt'fl (c()m W I I, tcitk.ttcJy.Willis<tnd C.V. 8~0nrn,
Jfd eel. Cuj))"lght IIJ6), will\ perml~tl itom flsevlet.

End-Plate Fractur es
In my expe•ience, end-plate fracture with the loss of nuclear nuids through the crack into the vertebral body
(often formi ng Schmorl's nod~'$) is a very common compressive injury and perhaps the most misdiagnosed. loss
of the d isc nucleus results in a flattened interdiscal space that when seen on pl3n~r X-rays is usually diagnosed
as a herniated disc or "degenerated disc." 1·10\vever, the annulus of the disc remains It's simply a case
of the nucleus squi rting through the end-plate crack into the cancellous core of the vertebra. True disc hern•a-
tion requires very special mechanical conditions that will be descrihf)(l shortly. When compressing spines in
the lab, we hear aGl l)udible "pop" at the instant of end-plate fracture-.xactly what patients report when they
describe details of the event that resulted in their pain. I also strongly suspect that some fractures are sornewhat
benign in that no immediate severe pain occurs. Others, however, may be instant<ln<.'Ously acute; it depends
on the biomechani cal changes thai accompany the fracture. If there is substantial loss of the nucleus from the
disc (i.e., it is vertically herniated), then immediate loss of disc height and subsequent compromise of nerve
root space will result. At this point the end-plate fracture will mimic the symptoms of true herniation-.;nother
reason for U1e com moo misdiagnosis.

Posterior Elements of the Vertebrae

The posterior elemenrs of rhe verrebrae (pedides~ Jaminaet spinous proces..,o;e,o;, <lncl facet join t.o;)
have a shelJ of cortical bone but <:.'Ontain a t"an('eUous bony core in the thick sections . The trans-
verse pt·ocesses project latemlly together with a superior and an inferior pair of facet joims (see
figure 4.1). On the later<~ I S<rrfitce o f rhe hone char fom1s rhe superior f:K-ets are the acc-esso•y
and mamilh ry prot"t:sses d1at. together with the transverse prOC("Ss, are major attachment site$
of the longissimus and iliocostalis extensor muscle groups (described later). The f.>cet joints are
()1Jical synovial joints in that the artic·olating surfitces are covered with hyoline cor'tilage and arc
contained wit hin a capsule. Fibroadipose enb rgeme.nrs, or meni5toids, are fmmcl arnw1d th e
rim of the fi>cet, although mostly at the proximal and distal edges (Bogduk and Ellgel, 1'184),
which have been implicated as a possible struct:\l re that co1rld "bind " :md lock rhe facet joint
(see 6gure 4. I I, a-b).
T be neural arch in general (pedides and laminae) appt'O rS to be SOl>>owhat tlcx.ible. l.n faet,
Bed1.inski ( 1992) demonstrated llex.ibility of the pars internrticula•·is during lle~ion-e.,'tension of
cadaveric spines, while Dickey and colleagues (I996) documented up t() three-degree change< of

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The Posterior Elements of the Vertebrae Are Flexible

In "Understanding Verlebral Mechanics'' on page 38, I recommended obtaining a vertebro from the butcher.
Grasp the vertebral body in one hand and lhe whole neural arch in the other. Bend the arch up and down and
note the flexibility. This flexural displacement occurs in each cycle of ful l spine flexion-<:>xtension common in
events such as women's gymnastics (figure 4.1 2). If this cycling continues, the scress reve rsals will eventually
cause a fatigue cra<:k in the pars. Further repetition will cause the crack to pro1>agate through the ful l width of
the pars, eventually resulting in fractur<:.- -and in vivo. the condition of spondylolisthesis.

rhe right pedicle with respect t<> the left pedicle

during quite mild daily acth·irics using pedidc
screws in vivo. Failure of d1ese elea>eots together
with f.1cet d:unage, leading to spondylolisthesis, is
Interior sometirnt's blamed exclusively on anterior-poste-
articular rior shear forces. However, a c~tse could be .rnade

\ process
from epidemiological evidence in ath!leres s11ch as
gymnasts and Ausrralian cricket bow lers (Hard-
edge edge c-astle, 1\Jmear, and Foster, 1992) that the damoge
ro rhe.o;e posterior elements may also l:>e associated
a with full range o f mot ion. I.J1 fact t h e faster t he
bowler, the higher the risk of fatigue fracture
(Ranawat er al., 2003). The cyclic full spine tJe>;on
Fibroa.diposeLam,ina and exten sion in t hese sons of acrh..;ties fatib" 'e
Superior meniscoids the ardt with repeated stress reversals.
articular On the othet· hand, there is no dottbr that
process excessive shear fo rces cause injury to these pos·
tc1i 0r vertebral clementS. Posterior shear of the
superior vet1ebrae t'lln lead to ligl)mentous damage
Medial hut also failure in rhe vertebra itself>as the end
Lateral side plate often avt!lscs from cl1e n "'t of th e vertebral
side bocty (Yingling and McGiU, 1999b) (see figut·e
4.1 3). Jloth our lab observa>ions and discussions
with international colleagues have rei nforccd our
suspicioo that this type of tailw·e may be more
process common in the ado lescent a nd geri:)rric spine
process than in rhe young and middlt-aged adult spine.
b Further work is needed for confll'lnation.
Ct·ipton and colleagttes ( 1995) documented
Figur~ 4.11 (a) Lalc..-al view of lhc inferior articular that a11tcrior s ht.tar o f the supetior vertebra cause.s
process, ··cvealing the facet., the-fibroadipose meniscoids, pars and facet fr.lcture leading to spondylotistl1esis
and the adipose tissue pad, which have been implicated with a typical tolerance or ~m adnlt lumbar spine
in joint binding. (b ) Cros$ section of the f>OSterior vie\v of of approximately 2000 N. Although similar injury
the facet joint, showing the positions oi the fibroMiipose me<"hanisms and tolerance value..; were obsen·ed
meniscoids and lhe adipose tissue pads in the joint. in young porcine spine specimens (Yingling
Rte'j,.ifll(.'(l, I •~· f)(ofmi,.~inn, (r(wu R. JX'hnkr, 200'i, Kilwtk• .uwf'>luy.l cwi •'<I.
(Champ<u8f1, 1l: Hufi\M"l KtOE'1•CSJ, 127.
and McGiU, 1999a, 199%), d1e type of injury
appeaa'<l to be mo<lu~1 ted by lo-.<ting t-ate. Specifi-
cally, anterior shear fo,·ces pro<luced unden nabI.e soft tissue injmy at low load rate;; (I 00 N/s),
bur fracrur·es of the pars, fi1cet face, and venehral hody were observed at higher load rates (7000
N/s). Posterior shear forc('S applied at low load rates produced uodcfmablc >Oft tissue fi1ilurc
and vertebral body fracwre, while those fot-ces at higher load rat·es pt·oduced wedge fractures
ilnd facet d amage.
WllilC sh ear tolcnmcc of the vertebral motion unit appc:1rs to be in the range of 2000 to 2800
for one-tillle loading, Norm<111 and colleagues (I 998) noticed an increase in reported lY.Ick pain

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~~~aromyof th~e~L~u~m~b~a~

Figure 4.12 Repetitiv-e gymnastics moves such as this cause stress-strain Figure 4.13 SheM injuries include
reversals in the pars. In sufficient numbers lh~y will result in fatigue rrac- fracture of the facet base and, on
ture-leading to spondylolisthesis. occasion. end-plate avulsion from the

Neural Arch Fracture

Sj)Ondylolisthcsis and neural <~rch defects are endemic among female gymnasts and cricket bowlers, to name
a few. Patients with spoodyloli$the.sis generally do not do well with thernpeutic exercise that takes the spine
through the range of motion; rather, stability should be the rehabllitation objective. Ranawat and colleagues
(2003) have rna de a strong <:ase for conservative approachtos, which were successfult:wcn with cricket bowlers,
as only a few needed follow-up surgical intervention. I have been involved in litigation cases i n which clear
spondylolisthesis existed but was alleged to be related to a specific event (for example, il recently occurring
automobile accident}. In surgery, however, there was evidence ol substanti~l ostoogenic activity. suggesting that
the injury was quite old. In fao, these patients I former gymnasts) must have h~d this damage while competing
but were so fit and their spines were so stable that they were able to remain in competition. Following retire-
ment, having children, and losing fitness. a rather minor event became the instigator of their symptoms.

in vivo in j('>bs that exposed workers to repetitive shear loads brreater than 500 N . VVe consider
th~>se the tJ.est guidelines currently available.
A fin~l note is relev-Jnt for ,·epeaced and prolonged e'~ension posn~res and motions associ-
ated with the approach discussed later ln d1i.s hook. Some individuals bave "kissing
spines" in which adjac{·nt posterio_r spines collide in full e.xtension at one level. TI1e invoh•ed
level is usu all)' due to a simple case of anatomic Vtlriation. 'T'hese may become more frequent in
people with disc hei1,-ht loss where the posterior spine become< more approximated. Jim Taylor
(Twomey a.nd T.1ylor, 1987) has noted destructive ch•ngcs in the interspinous l.igaments as the)'
are repeatedly crushed at the kissing spi ne level. He described the changes as the development of a
"fibrocan:ilaj,.;nrmsct)\'ering on the colliding lxme and a hursa-likecm1ty>1lrrounded hy f•t lined \\ith
asynovial mcmbrnn ~. "There is no question rcb':l.fdingthc efficalyofthe .M.cKenzie extension routine.~
for some acute discogenic back patients. I am cautious about haviog people routinely ellgage in
these posrures following recovery from the acute. episode-the spine may pay a price.

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Intervertebral Disc
The imerve,·rebral disc has three major components:
the nucleus pulposus. :-lnnulu$ fibrosus) ilnd end
plates. T he nucleus has a h"'l-likc characwr with col-
lagen Gbrils suspended in a base of warer and various
mucopolys..ccharides giving it hoth vis~-osity and some
elastic response when perrurbed in vitro. At the risk
of sounding <:l'ude, the best way to describe a healthy
nuclells is that it looks and feels like heavy phlegm.
During in \':itro testing we have had it squin out tutdt'r
pressure and literally stick to the wall. Wl1ile there is
no djsrinct border between the nudeus and the annu-
lus, the lamellae of the annulus become more distinct,
1t10ving radially outward. The oollagcn fibers of each
lamina a•·e obliquely oriented (the obli qt~ i ty runs in
the opposireclirection in each concentric lameJia). 1l1e
Figure 4.14 Cross 5<!<1ion of the intervertebral disc. ends of the collagen lib<:rs ancbor into the vc.rtebral
Rf'juinc.t:<t hy!""'lmir.sion. ftom't.VC. Whiling<'!n(l R.F=. 7.4.'rn'""''· 199fJ, body wid1 Sharpey's fibe•·s in the outermost Jmnelb e,
BiOrtH->eh,wtcs ()( ,\fu~cufod.£-lr:wl llifury \O!.alnft.:.ign, It: l·lum.<ll'l
Kl:fM'!liCSI, 2<4 1.
while the inner 6bers attach to the end phne (the end
plate was discussed in a previous sc<.:tion). The discs
iJl CI'OSS section resemble a rotmded triangle in the thoracic region and an ellipse i1> the lumbar
region, suggesting anisotropic facilitation of twisting and bending (see figure -l. I4).

load-Bearing Abilities
The disc bt!haves as a hydrostatic strucn1re thar allows $ix degree-s of mocion bern·ee11 ven ebrae.
Its ability ro Jx....-load, however, depends on its shape and geometry. Due to the orientation of the
collagen fibers widlin the concentric rings of the annu Ius, with one-half of rllC fibers oblique to
the orher half, the annulus is able to resist loads when the disc is 1'\visted. However, only bal f of
the fibers are able to support this mode of loading, while the other halfbccu me disabled, result-
ing in a substantial loss of strength or ability to hear load. Tile annulus and dte nucleus work
together to supporr compressive load when the disc is ~;ubjected ro hending and compression.
Under spine compression the nucleus pressurizes, appl)'ing hydraulic forces ru the! end plates
vertically ;~nd to lbc ituler annulus laterally. This causes the amtulus collagen fibers to bulge
outward a~>d become tensed. Years ago, Markolf and Morris ( 19H) ele!!'Jndy demonstr:tted d~at
a disc with the nucleus removed lost height but preserved much of its properties of a.'{ial stiffnl.oss,
creep, and relaxation rates. The fact th<lt the nucleus appears neceSS;~ry to preserve disc height
has implications for f.tcer loading, shear stiffness, and li!!"ment mechanics.
lr is noteworth}' that disc damage is most often accompanied hy subdiscal bone damage
(Gunning, Call•ghan, and McGill, 200 1}. ln fact, Keller and (1993) noted the
interdependence of bone st<~ros and disc health. Recenr e\·idence also suggests that excessive
compression can lead to :.1lrered within the nucleus and increased rares of cell
death (apoptosis) (Lotz and Chin, 1000}. Thus, the cvidcncc.-u~ests that ml'llpressive loadinll'
involving lowe•· co•.npressive loads stimulates healthy bone (•lored as a correlate of disc health)
bur that excessive loading leads ro tissue hreakdown.

Progressive Disc Injury

Considerarion of progressh'e elise injury is in order here. A normaJ disc under compression
deforms mainly the end plat~'S vcrtkally together with lesser outward bulging of the annu-
lus (Brinckm<lltn, Biggemann, and Hilweg, 1988}. Ho"Tever, if little hrd •·ostatic p•·essu •·e
is present, as in the c-ase in which the nucleus h.-.s been lost rhrough end . . plare fracrure or
hernjation., the outer annulus bulges outward and the inner annulus bulges inward during
disc compression (see figure +. 15, a-b). This double conve.< bulging causes the laminae of

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Figure 4.1 5 (a ) In a h eilhhy joint with a contained nucleus there is minimal annulus deformation under compressive
load. (b) I( the nucleus loses pressure {due to an end ..plate fracture, for example), the annulus compresses, causing radi.-.1
bulging both outward <lnd inw.1rd (Jrrows) and producing delaminating stresses as the annulus la.yers are pulled apart.

the annulus to sepcuate, or delaminate, and bas been

bypothesiz.ed <lS a pathway for nuclear material to leak
through th.e lamellae layers and finally extrude, creating A Note on Twisting
a frank herniated disc (Adams and Dolan, 1995).
Anoth<'r interesting proposal has been recently put While we have not fJeriormed a lot of
forth by Professor Adams (personal communication). l-Ie research on the effect of !\\listing on the
has suggesred that a healthy disc builds interval pressures discs, il appears th<ll repeated twrsting
under con'lpressivt: loads that are so l1igh that no nerve or causes the annulustC> slowly delaminate.
vascular ' 'essel could survive. !Oollowing initial end-plate This is evidenc;ed by the tracking of the
damage, th.e disc can no longer build substantial pres.liure nucleus into the annulus in all directions.
•uch that nerve; and blood vt:SSds are able to invade the While we do not yet know the relation-
disc. T hese are more possibilities to e•plain the increased ship becween number oi cycles and loa(ls,
va.sculariza tion of "degenerated"discs ;mel cheir ahiliry to we do know that added torsion reduces
generate pain. the compressive strength of the join~ (Ault-
From :1 revjew of [he literature. one <:41 n rna ke fOur man et al., 2004).
general t'Oindusions abom annuJu.s injury and the result..
ing bulging or hernia cion:
• It " 'auld appear that the disc must be bent to tl1e full end •·ange of motion in ordet· to
hem iare (Adams and Hutron, 1982).
• Disc herniation is associated not onl)' with extreme deviated rx>srurc~ either fully flexed
or bent, but also with repeated loading in the neighborhood of thousands of times, high-
lighting rhe role of fatigue as a mechanism of injory (Gordon et al., 1991; King, 1993).
• Epi<lcmiological data link hemiation with sedentary occupations and the sitting posture
(Videman, Nul'lninen, and 'froup, 1990). In fact, Wilder and colleagues ( 1988) docu-
mente.d rumular tears io young calf .spines fn)m prolonged simuJated sitting postures and
cyclic (umprcssive Joading (i.e., simulated truck dri\·ing).
• Hemiations rend to occur in younger spines (Adams and Hutton, 1985), meaning those
with higher warer content (Adams ;md Muir, 1976) :md more hydraulic behavior. Older
splrnes do not appear to exhibit classic extrusion of nuclear matt!rial hut rather -arc char-
acterized by delamination of the annulus layer and radial cracks that appear to progress
wirh repe>ted loading (a nice review is provided by Goel, Monroe, et <1l., 1995).
A couple of years ago we soughr the most potem mechanism leading to disc hernia don. Given
that it was critical co create a homogeneous cohort of sped mens, we chose. a pig spine modd)

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COI\troUiJlg' diet, physical activity, genetic o>akeup, disc degen-

eration, and so forth. We found that repeated lle.'<ion motion
under simultaneous compressive loading was the easiest way
to ensme herniation. In facr. it tur-ned out that the numbers of
c):cles of Aexion motion were more important than c-he acrual
mabrnitude of compressive load. \;V'hile no hcmiations were
produced with 260 N of compressive load ;tud up to 85,000
Aex:ion cycles, herniations were produced "ith 867 N orload
and 22,000to 28,000cycles, and with 1472 N and only 5000 to
9500 cydes (Callaghan and i'vkGiJI, 200 l). Clearly, hcmiations
are a f\,nction of repeated 1\,11-Ae><.ion motion cycles with only
a modest leveJ of accompanying compressive load. fn fact. we
Figure 4.16 R~hahil i1 a1ion d evic<?s such mllnkkcd dJc lumbar motion anJ loadiHg of a rypic:tl spine
as this atlempt to isol ate lumbar motion rehabilitation machine where the seated patient belts down the
by extending against a resistance pad but pelvis to isolate th e lumbar sp ine an d then extends the torso
create slmuhar'let:•us lumbtlr compressio•'· reperiti\•dy aga.inst a re~istanc(~ over the midlratk. (Amazingly,
We found that replicating the full o·ange some people are trained on this type of machine, even those
oi motion from full flexion to neutral and with known disc herniations!) (See figure 4.16.) The time series
using the compressive loads of these devices radiOb'raphs (sec 6b'ltre 4. J 7) demonstrated the prOf,~·cssiun of
'"''en~ powerful combinations to produce the nuclear material trncking through the annulus with suc-
disc hernial iOl'L cessive motion cycles. The herniated disc appears to result
from tumuJative trauma: E:veo though we have t: rush ed well
0\1er 400 vertebl'al motion segments, we have only once or t...vicc observed a. hernjation wilhout
conoomirnnt flexion cycles. Note that we are including both frank hemiation and visible disc
bulges (sre figure 4.18) w1Jcr this cate-gory of injury mechanism.
Our most recent work on disc bcmiation w1covered the dependency of the location of the
herniating bulge on the axis of motion (Aultman et al., 2005). For example, in 20 motion s..-g-
menrsJ we flexed d1em repeatedly about an axis that was 30o- rotated from the pure flexion axis
(mostly flexion with some lateral bend). One spocimcn simply failed abn1ptly ftnd ""'s removed.

Figure 4.17 SeriJI radiographs showing the initial containment of the Figure 4.18 Repe;lted Rexion can result in
radiocontrast in lhe nucle us and, with repealed full·ilcxion motion (wilh a frank herniation or a bulge, shown here
i'lboul 1400 N of compressron), the progrcssfvc posterior tracking of the in a specimen w ith the lamina removed
contr<Jst until hernial ion. to expose t·he posterior disc, which can
K"1>11nted from <..I11'»Cill BtomochdfllCS, 16\1•• J.P. Ulltilghlll\ t~nd S).~. ,\~C1II, "'llltM'f'!leht.lJ d tSC impmgc on nerves causing symptoms. Note
hemiarion: S1ud~ on a po•dne model exposed to highty repedti\'(' (le"ionfe,i('ndnn mxion wit!)
thai the nucleus w.-1s injecJed wi1h a d ye so
foiY'~t 28-37. 2001, wuh pcm1~Si(lfl from Flwvicr Scicnc:e.
that the bulge is more visible larrow).

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Mechanisms of Annulus Failure (Herniation)

Damag€! to the annulus oi the disc (hemiation) appears to be associated with fully Oexing lhe spine
for a repeated or prolonged period of lime. In fact, herniation of the disc seems almost impossible
without full flexion. This has impl ications lor exercise prescription particul;~rly for flexion stretch-
ing and sit-ups or for activities such as prolonged sitting, all of which are char;~cterized by a flexed
spine. Some •·esisrance exercise machines that rake the spine ro full nexion •·epeatedly must be re-
considered lor those interested in sparing the posterior annulus portions of their discs. Furthermore,
the mechanism by which the process can be interrupted appears to be postural dependent, provid·
ing some more insight into 1he mechanism of the McKenzie approach.

L1 the rcJn<lining 19, the bemiati.on track was away

f•·om the axis of •·oration (see figu •·e 4.19).
~re have also been able to add more insight
into the McKenzie therapy approat·h, which is
based on extended poSt\ll'eS. The d>eory is that
an extended posture drives rhe nucleus forw:ml
within the disc. \~7e have found that the hcmia- ..._.111iation
tion process begins from failure in tbe inncmlOSL dmloiion
annulus rings and progresses rndi:~lly ourn•ard.
The layers of the :umulus delaminate ami fdl with
nucleus material. We now have proof that the
.......... --
exrended post:ure can drive rhe nndens material
that is in the delaminated pockets of the posterior
' "'JJending
nucleus back toward the centnll part of the disc "- /
(Scannell and •'vlcGill, 2005).
Also worth noti ng here is t he inrrigu ing
hypothesis ofBogdukand hi'On1ey, who havesug- Figure 4.19 Tilling the flexion axis 30• away from pure
ge~ted the possibility ofan annular ~·spr~•in" simi- ilexion caused the nucleus to track in a direction av~o'ay
lar to a sprain of the ankle ligaments (Bogdnk and irom Ihe axis (Auhman ct al .. 2005). This motion depen-
1\vomey, t991 ). T hey hypothcsiuxlthat rltc ourer ?<!Oce h,1S powerful potcnti.a l fo r the design of exercise
layers of the annuJus experience excessive S(rain 1n those wuh known postenor-later.ll d1sc hulgcs.
under torsion. Given that these authors htlVe presented evidence for the ru-esence of nen•e fibers
p-.trti(ularly in this region, cllc a1:1nulus appears to Uc a good l11.ndidatc for a source of pain.

lraditiooaR anatomical descriptions of the spine musculature have taken a posterior vanmge point.
Th is has hindered insight into the role of these muscles since many of the fttnctiona lly relevant
aspt:cts are better viewe.d in th tt sabrittal plane. (For a nice synopsis of the sagitta] pJane lines of

Clinical Relevance: Locat.i on of Disc Bulge and Designing Exercise

A posterior-lateral disc bulge is usually caused by ret:>e~ted flexion oi the disc about an axis Ct,Jl·
ti ng across the disc perpendicular to the herniating track. This is powerful knowledge for exercise
intervention, since further motion about Ihis axis would cxitcerb<ttc the herni<ltio n. We arc currently
inve,sligating whether extending about the same axis will reduce the tracking. Further, this knowledge
gives cl ues for better prevention. Look for a dominant motion pattern in a patient's daily routine
consistent with the bulge location and eliminate iL If the causative motion pattern is an element of
an athletic event in which the patient competes, major clecisio•1Swill need 10 he made. More motion
wil l only ensure the inevitable--can the technique be changed to e liminate the causative motion?

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ac-tion, see llogduk, 1980; Madntosh and Bogduk, 1987.) Fonhcrmore, many have developed
their unde.-srar>ding of n\llscle fw>ction by simply interpreting tbc liucs of action <>nd region of
anachment, assuming tl>at the muscles oct as straight-line cables. T his may be misleading.
U ndt!rstanding the function and purpose of each muscle requires two perspectives. First,
knowledge of static muscle morpl>Oiogy is esscnti•l, though it may change over a range of
motion. Second, know.ledge of activation-rime histories of the muscu13ture must lbe obtained
over a wide variety of movement and loading tasks. 1\1uscle-s creace force. but these forces play
roJcs in•noment production fr_)r movement and in stabilizing jointS for safety and perfonnance.
Further understanding of d>e motor control system stroregies chosen to suppo•t enern•llo:•ds
and maimain stability requires tbeinterpretacion of anacomy, mechanics, and activation profiles.
TI1is.sectiun will e nhance the distu~sion of anatotnkally based issues of the .spine musc-ulature
and will blend the •·est~ Its of various elecu·omyogl'llph ic (EMG) sn1dies to helpinterp rer fullction
and the functional aspects of motor control.

Muscle Size
'lltc physiologic cross-sectional area (PCSA)of muscle detenujnes the force-producing potenti31,
while the line of action and moment ann determine che effecr of t he force in mo menr pro due·
tion, stabilization, and so forth. It is en o neous to estimate muscle forte hased on musde volume
without accowuing for fiber architecture or by raking tr::msvcrse scans to measure anatomical
cross-sectional ll·eas (McGill, Parr, and Nonuan, 198B). lJsing areas direcdy obtained from
computed tomography (Cl) or magnetic re.s onance imabring (i\fRI) s1ices has led to errone-
ous force ~:stimates and interpretations of spine function. In ~"Ut.:h ~tses, since~~ large nwnber
of muscle t'ibers are not seen in a single tnlnsvei'Se scan of a pennated m\ascle, m\lscle forces
are underestimated . T hus1 areas o brained from !VfRI or Cf s<."::llls must he correcced for fi ber
architecture and sean plane obliquity (McGill, Santab'Uida, and Stevens, 1993).
In figure 4.20, transverse sans of one
suhjecr show the changing shape of the
torso musdcs over t he thoracoLumbar
regiol\, highlighting the need to combine
cransverse scan dara with data document a

lng fiber arcbitccturc ob~in cd from

djssection. In this example, the thorocic
e.x"tensors (longissimus thoracl$ and iJio---
tostaHs lwnborwn) se<:n at T9 provide
an exrensor momenc at L4, even though
they are not seen in rhe L4 sc:m. Only
their tendons overlie the U extensors. A
sagittal plane schematic shows u>e errors
in me<~soring muscle cross-sectional area
from a single transverse slice-which
bas caused some to underestimate t he
potentia l of the muscle.
Raw muscle PCSAI) and 1nomenr ;uws
(McGill, Sanraguida, and Stev<"ns, 1993)
are provided in appendix A. l. Areas cor-
Figure 4.20 Transverse scans of one subject tsupine~ at the levels rected for oblique lines of-action are shown
ol T9, Ll, L4. and 51, showing the m usculature in cross section. in rable 4.1 fOr some scle(tOO musdes at
Note that many muscles seen at more superior levels pass tendons
severol le1•els oftbe thoracolnmbar spine.
over the lower levels transmitting force. This illustrates the error in
Guidelines fo r esdmating t rue physia
simpl)' using a single sc-Jn to estimate rnusde force and momcnL
potential. ologid areas arc pr<widcd in MtGill and
R~l mcd i1om Clinic.. I Bklmecl\.;lflJC., 8~ S.M. ,\.\d.i\11, L. Sanw~ulda, and J, S4e\·c•~
colleagues ( 1988). Other recent sources of
MNitlffl of the !ttmk mu~culdti.Jfe from T6 ro LS using M RJ SC<' n5 oi l S )"'tmg m;f/es raw nn"cle geomerry ohtaine:d from MRI
con,.cr...U !nr r'w~c(f! fihr-r ,..,.,;('mouion 17 1 1993. wi1h pNmi.,sion from El<c..,•irr fur botb males and females ore fimnd in
Matms nnd colleagues (2001).

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Table 4.1 Corrected Muscle Cross-Sectional Areas

A fe-w examples of conected cmss.secrional areas. ante• iof/poster-ior nlOment am'ls, aod lal.cral momenl
arn1s perpendio.1lar to the muscle fiber line or action <.Ising ~he cosines fisted in McGill, Patt, and Nonnan
f 1988J. These a 1'C the values that should be u sed i n bioo1cchanical models rathc_r than the uncorrected
values obtained dir£><;ti)' (rom scan slic<..os.

Cross-sectional area Moment arms Momentanns

Muscle* (mm)' (anVpost) (mm) (lateral) (mm)
longissimus pars
lurnbon.11'n LJ.l4 644 51 17
Quadratus lumborum LH2 358 31 43
L2-l3 507 32 55
l3-l4 582 29 59
L4·L5 328 16 .39
External obl ique L3 ·L4 1121 17 110
Internal obli<.JUe L3· l 4 1154 20 89
•The:• l.lmll'loWol1c1ng•.,~,~~m~ p.u'!luml)(lfum ill l >~·t S 11"1.'1' 1WT.MJid h.lvt'l'l<.'f'l'l h~t~'fl hc•1r hy V'!rhJ<• of 1h1•1r <"(l~m<.,. hill Wt'fl' nol, '"
the~ could nCil be distlngul~he<l on .all scan ~~ ~.

Moment arms of the abdominal musculnture are generaII)•obtained fmm CT- or MRI-baserl
studies. Generally, sul>jects Ue supine or prone witbin the MRI or SCaJUler, and !the distance cr
from their spine to the muscle centroid is measurt.>d. Lying on d1eir backs in this posture causes
rhe ;~bdominal contents to collapse posteriorly under gravity (McGiii,Jt•ker, and Axler, 1996).
L1 real life and during standing, the abdominal muscles are pus hed away from the spine by
the visceral contents. Recent11•, research has shown t11at CT or MRI studies of the abdoutinal
muscle moment arms obt':linCd fTom suhjects in (he supine posture underestin1ated the tnJe
values by 30%.
In sumtnary, understanding the force and mech<lnlcal potential of musdcs requires an
apprecitltion fot· the cunring line of acr::ion. which is best obt:~ined in the anaromy lab. But.
unt(wtunarely, these specimens a re usua lly atrophied) elimin ating them a.s a St.>Ur<.-e for muscle
size estimates. i\iusclc obtained from various mcdica.l imo.1ging tL·thniqucs need to be cor-
rected ro account for fiber a•·chitecrure and contractile oom)X>nent< that do not appear in the
particular scan level (for example, onlr the tendon passes the level). l'un:ber, moment arms for
rnusdc lines of action from subjects who are-lying down need to be adjusted for applit"..ttion to
upright pos tures mainr:1i 1\ed io real life.

Muscle Groups
l ' his section describes specitic muscle groups from a functional pe•'Spective and introduces
SQme issues fundamenral for under-standing injury a\'oiclance and the c ho ice of appropriat:e
rehabiJicati:on approa<:h.

Rotatore.s and lntertransversarii

Many anatomical textbooks descril:>e the 1\mction of cl1e small rotator musdes of the spine,
which ana<:h to :1djacent vertebrae, as creating axial cwisring rorque. T his is consisrenr:: with
their nomenclature (rotatores). Similarly, d1e intertransversarii are o fte n assigned the ro le
of la teral Jkx.ion. Thc>e proposals h•ve several problems. First, these small <nusdcs (sec
figlll"e -1.2n) have such small I'CSAs that they can generate only a fe\v newtons of force,
and second, the}' work [brough SU<.·h a smaU momenr arm that their roraJ contribution ro
rotational axial twisti.n ~ and bending torque is miojmaJ. lior reasons, I bcljcvc tbcy
serve anot her l'uncrjon.

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lntertransverse ...2:::.---

lntertransverse ...::.:::::::_----it"-:


Figure 4.21 Shor! muscles of the spine: lcv.uor costarum longi, levator cos1arum brevi, inter.
transverse medialis, in1er1ransverse latcralis. rota1ores, and interspinalis. They have been described
Cl'roncously ilS creating axial twisl ing torque.
'""''j\'e' r.Otll'lc~r uf Pdmal Piau,.~~-

The rotatores 3rtd imcrtransversarii muscles are highly rich in muscle spin cUes, approximately
4.5 to 7.3 times richerthan the multifidt•s (Nicz and Peck, I986). This evidenc-e suggests rhat rhey
may function as lenbTtll transducers o r vertebral position sensors at every thoracic.· and l umba r
joint. In some EMG C<f>erimcnts we perfonned a number of years ago, we placed indwelling
electrodes very close ro rhe vertebrae. In one case we had a strong sus~1icion that the elecrrO<Ie
was in a rottltor muscle. The suhject attempted EO perfo nn isometric rwi~ting efforts with the
spine unt\\ristcd (or constra_ined in a neutral posture) in both direttions Uut prodm.:c::d no E.t\1G
activity li·01n dle rom tor-only dle usual activity in the abdomina Iobliques and so on. However,
when cl1e suhjecc ni ecl to twist in one direction (with minjmal muscular effo rt), tHlere was no

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Manual Therapy and the Function of the Rotatores and lnte rtransversarii
We now suspect that the rotatores and intertransversarii are actually length tran sducers and thereby
position scn:;ors, stnsing the positioning of each spinal motion unit. These structures are likely
affected during various types of manual therapy with the joint at end range oi motion (a posture
used in chiropractic technique, for example).

response, while in the orher direction there was major ~lctivity. 1 'his particular rotator seemed not
to be activated to create axial twisting torque but rather in re..\lJ<>nSe to twisted position c hange.
Thus, its activity was elicited as a fimction of twisted positioJl--which was uot consistent wlth
the role of creating torque to twist the spine. ' I1tis is stronger evidence th~t rhese muscles ;>re
not rotatc-ws at aU bur fu nccion as position transducers in the spine proprioception system.

Extensors: Longissimus, Iliocostalis, and Multifidus Groups

Th~ major· extensors of the thoracoluml>ar spine are the lonf,>iSSimus, i liocxJs tal is~ and multifi-
dus groups. Although tbe longissimus and iliocosrnlis groups are often separated in anatomy
books, it m:1y be more e nlightening in a functional conte~t to recognize t he thora,cic portions
()£both ( )f these nmsdes as one group and the lumbar portions as anotber f,'TOup. T he lumbar
<illd thoracic portions are architecturally (Bogduk, I980) and functionally different (McGill and
Nonnan, I 987). liogduk ( 1980) ~Y.trtitions the lumbar >llld thor:~cic portions of these muscles
in ro longissimus thoracis pars hunbo rum and pars thoradst and i)i(x:ostalis lwnhonun pars
lwnborum cu1d pars tJlOr<K:is.
T hese two 1\mcri.on~l groups (pars lumbonun, which attach to lumbar vertebrae, and pars
thoracis~ which attttc:h to thoracic verrebrae) fonn quhe a marvelous ar chitecture for several
rC~lSOn~ and arc discussed in a funt'ti<>nal L'Outcxt with this &stinctiou (i .e.~ pars ltumbormn vs.
pars thoracis). Fiber cypi,ng St\I<Ues note dilferences between the lumbar and dtOI'll<:ic sections:
The t horacic section.~ con rain approximately 75% slcm•·rv.itch fthers, while lumhar sections are
generally evenly mi.,ed (Sirca and Kostcvc, 1985). The pars thorncb components of these two
muscles au:ach to the ribs and vertebral components ;llld ha1•e t•elatively short conrracti.le fibers
with long renrlons that'"" parallel to the spine to their origins on rhe posterior Sllrfuce of the
~crum :Uld medial border of the iliac crestS (see figure +.22). Furthcnnorc, their line of action
over rhe lower thoracic and lumbar region is just wtderneath the fascia, sucb that forces in these
muscles h<:we the gretuest possible moment arm aod therefore produce t he great es:r amoum
of cxrcnsor moment with a m.inimwn of
colllpo·essi~e penalty to tlte spine (see figW'e
-!.23). 'When seen on a rr:msverse i\•1Rf or
cr sc.:an a t a lumbar level, pars thorads
tendons have tlle greatest extenso1· monlem
arm, overHying the lumbar bu lk- often
over ]() em (4 in.) (McGill, Parr, and
Nonnan, 1988; McGill, Santagtdd;t, aJtd
Stevens, 1993) (see fi!!'tre 4.2-l).
T he Jumbar compo nents ()fthese mus·
des (iliocostalis lwnborum pars lumbonun
and longissimus thoracis pars lumhonmt)
are very different anaromically and func~
tioually fron'l their thoracic namcsakt·.s.
l'heyconn:ect to che mamillary, accessory,
and t ransverse processes o f the lumhar
vertebrae and miginatc:, once again, over Figure 4.22 An isolated bundle of longissimus thoracis pars
dte posterior sacrum and medial aspect of thorads (inserting on the ribs at T6), wilh tendons lifted by probes,
the iliac crest. Each vertebra is connec[e<J course over the full lumbar spine 10 1hcirr sacral origin.l11cy have
t..ilatcrally with scparare laminae of t hese a very large extensor momcnl arm tiusl underneath the skin).

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::_S_::2_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Back OiS<lr<iers

-- -

Figure 4.24 (a, b ) The moment arrns of the pars lumborum

pof1ions of iliocostalis ancllongissimu). (c)TI1e large moment
arm of the pars thoracis iliocostalis and longissimus muscles
gives them their ability to create major lumbar extensor
Figur~ 4.23 l11is world-class powerlifter e•empfifies the mOillents. The lines of action of (c/) the pars lumbonrm portion
hr1:.ertrophied bulk of the ilioco;talis and longissimus of longissimus, (el the par-s lumborum portion of iliocostalis,
muscles seen in trained liiters. This muscle bulk is in tl1e and ({) the pars thoracis portion oi longissimus and iliocostalis
thoracic region1 but the tendons span the entire lurnb..u join at th4:!ir common point oi origin at the sacral spine. (g) The
spine. mechanical fulcrum or the axis about whkh musdt>:S create
moments is indicated by the diamond shape.

muscles (see fi£,'1Lre 4.25). Their line of action is not parallel to the compressive a'is of tbe spine
but rather has a postc:·rior and taudal direction cltatt:auscs them to generate posterior sheu forces
together with extensor moment on the superior vertebrae (see figure 4.26). T hese posterior shear
forces supporr <Hl}T anterior reacr.ion shear forces of rh e upper vertebrae rhat are produced as
the upper body is flexed forward in a typical Ufting posture. It is imporrunt to clarify that this
tlc.xion of the torso is accomplisl>ed through hip rorotion, not lumbar lle.xion. These muscles
lose their o blique line o f action and reorient to rhe compressive axis of rhe spine wirh lnmh:rr
flexion (McGill , Hughson, and Parks, 2000) so that a flexed spine is unable to resist damab>ing
shear forces (see ligure 4.27, a-tf). T his possible injW')' mechanism. together with activation
profiles during clinically relevant activities, is addressed in a lner section.
The multif:idus muscles perfonn quite a different function from tho se o f the longissimus
and iliocostalis ~'I'Oups, particularly in the l111\lbar region where they attach posterior spines of
adjacent vertebrae or span two or three segments (see figure 4.28). Their line of action tends
ro be ptlral'lel to the compressive axis or lo some cases n ms aoterlorly and caudal in an oblique
direc.:tion. 'T'hc lnajor rue<:hanically rclcvam ft <lturc of the lllulrifidU, however, is that since d~ey
span only a few joints, thei r for'Ces affect only local areas of the spine. T herefor-e, the tnultilidus
muscles are involved in producing extensor torque (together with very small amounts of twist-
ing and side-bending torque) but c.)nl)' provide the abi]jry for cOrrc<:tiOil.S, or moment support,
at specific joints that may be tbe foci of sttesses. lntetestingly, tile multi!idus Uluscl es appeal' ro

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Figure 4.25 lliocosra lis lumborwn pars lumhorum Figure 4.26 The oblique angle of ~1elumbar por-
;mel longissimus lhoracis pars lumbonrm origina!e tions of longissimus and iliocosta lis is seen in vivo
over 1he postel'ior surlace of rhc .s~crum, follow a in this MRI picture. Their line of force (F) is shown
very supe rf itinl pa1hway, • nd 1hen dive obliquely relative to the compressive axis (Q.
10 lheir ve-rtehra I auachme•'lts. Thisoblique orienta·
lion creates posrel'ior shear~$) forces a:nd extensor
rnornents on each successive superior vertebra. The
compressive axis <0 is indic(lted.

a b

Figure 4.27 n,e o blique angle of the lumbar portions or the iliOCOStdlis lumborum a nd longissimus thoracis
protects the spine agains-t large anterior shear !orct--s. However. this abil ity is a funttion of spine c ._1rvature. (a)
A neutral spine and ( b) the oblique angle of thr:,-se muscles as vie\\I(,"CC with an ultrasound imager. (c) The loss
oi this a ngle with spine flexion (d) so that .-.nte rior shear forces cannot be counteracted. This e n sures shear
stability and is a nother reason to consider adopting a neutral spine during flexed weight~hofding tasks.

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54 Low Back Disorders

have tluitc low musde spindle density~ertainly

less thao the iliocostalis or longissimus muscles
(Amonoo-Kuofi, 1983), T his may be due to their
more medial location and subsequ~nt smaJJer
length excursions (see table ~.2 for musde length
changes. which were :.1ssessed t1sing a number of
e.x'treme postures depicted in figure 5. 1 on page
74). An injury mechanism invoh•ing inappropri-
aie neural activati on signals to the multifidos is
propQS-ed in chapter 5, using an ex::lmple of injury
obscn •ed in the laboratory. It is also worth noting
here, given the recent emphasis on rnultifidtiS,
that some people h~ve considerecl more lateral
portions of the extensors to be rnulcifidus. This
has presented some problems in both f\loctional
Larn.erlaeof multilidus interpretation and rehabili'"tion.

A Note on Latissimus Dorsi

lliocoslalis Longissimus
Latissirnus dorsi is involved in lumllar extensor
momem generation and is ofren acting as a major
Figure 4.28 Multifidus is actually J series of laminae ]rs o rigin ar each lumbar spinous process
that can span one lo lhr-ce vertebral segments. Their lines
of action do nol suppon ~ntcrior shear of the superior
via t he lumbodorsal fascia .and insertion f.)n dtc
h \ lnleT\IS gives it a very large extensor moment
vertebrae but actually contribute to it. Examining their
cross·sectionJI area reveals that the multifidus is a reia · ann(<ee figure 4.29). During ptdling and lifting
lively small lumbar exrensor. motion, d1e latissimu!t is active (sec c.:haptcr 5),
which has implications for its role and how it is
trainer! for functional motion partems . It i~ often
the rnusdc ofchoice for "stoppiug" dtoracic and high lumbar ''hing"-s" in painful back'S aud isalso
very imponamto enhance torso extension in high per-formance situations (lvlcGill , 1006).

Exercise for the Extensor Muscles of the Low Back

Research has shown that the thoracic extensors (longissimus thoracis pars thoracis and
iliocostalis lumborum pars thoracis) that attach in th€ thoracic region are actually the most
eiiicient lumbar extensors si nee they have the largest moment arms as they course over
the lumbar region. For this reason, il is time 10 revisit the clinical practice of uisolatins
muscle groups," in thiscase the lumbar extensors for the lumbar spine. Specitkally, wh<•t
are referred to as the lumbar extensors !located in the lumbar region) contribute onl y a
portion of 1he total lumbar extensor moment. Training of Ihe lumbar extensor mechanism
must involve the extensors lhat attach to the thoracic vertebrae, whose bulk of contractile
fibers lies in the thoracic region but whose tendons pass over the lumbar region and have
the greatest mechanical advantage of all lumbar h1uscles. Thus, exercises 10 isolate Ihe
lumbar muscles cannot be justified from an anatomical basis or from a motor control
perspective in which all •players in the orchestra" must be challenged during training.
Anol her imporram clinical issue invol,•es the anatomical features of rhe extensors.
While Lhe lumbar sections of the longissimus and iliocoslalis muscles that attach to the
lumbar vertebrae cre;ne extensor torque, they also produce large poSterior shear forces
10 suppo11 1he shearing loac;ls that develop during torso flexion postures. Some therapists
unknowingly disable these shear force protectors by having patients fully nex their spines
during exercises, creating myoelectric cruiescence in these muscles, or by recommend-
ing Ihe pelvic tilt during flexing activilies such as lifting. Discussion of this funCtional
anatomy is critical for developing lhe strategies for injury prevention and rehabilitation
cfes<:ribed later in this book.

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Table 4.2 Muscle Lengths in Centimeters (Including Tendon Length) Obtained From
the Upright Standing Position and From Various Extreme Postures
Upright 25• lateral
standing 60q fle)iion bending 1 0"' twis t Combined11
R rectus abdominis 30.1 19.6. 27.4 30.0 17.7
L rectus abdomlnls 30.1 19 .a• 32.6 JO.S 22.9"
R external oblique I 16.7 14.4 12 .6" 15.5 13 .3
l external oblique 1 11>.7 14.4 2 1.3b 18.0 19.2
R external oblique 2 15.8 12.9 10 .7" 15.6 9.5•
l external oblique 2 15.8 12.9 2 1.o'> 16.2 18.2
R internal oblique 1 11.1 9.9 9.1 12 .2 7.6•
l internal oblique 1 11.1 9 .9 14 .1b 10.0 12.2
R internal oblique· 2 10.3 8.8 7.6• 11.2 6.9•
l internal oblique 2 10.3 8.8 13.2• 9.5 10.7
R psoas lumborum (l1) 15. 1 20.(1' 14.2 15.4 18.7
l psoas lumborum (ll) 15 .1 20.0 16.8 15 .7 20.7"
R psoas lumborllln (l2J 12.5 16.4" 11.8 12.9 15.6b
l psoas lumborum (l2) 12.5 16.4" 13.8 13.0 17.0'
R psoa> IUinborurn (l3) 9.9 12.9" 9.5 10.0 12.5"
l psoas lumborum (l3) 9.9 12.9" 10.9 9.8 13.3'
R psoas lumborum (l4) 7.5 9.4b 7.4 7.6 9.3•
l psoas lumborum (l4) 7.5 9 .4• 8.0 7.4 9 .>••
R iliocostalis lurnborum 23.0 29.7• 16.9 23 .5 26.4
l iliocostalis lumboru m 23.0 29.7" 25.5 22.6 3 1.8"
R longissimus thoracis. 27.5 33.7" 25.4 27.6 3 1.1
llongissimus thoracis 27.5 33.7" 28.6 27.4 34.8"
R quadratus lumborum 14.6 18.2" 11.9 14 .4 14.9
l quadratus lumborum 14.6 18.2 17.4 15 . 1 20.9"
R latissimus dorsi (l 5) 29.4 32. 1 2 6.8 29.8 29.0
llatissimus dorsi (LS) 29.4 32.1 31.5 29.1 34.6
R m ultifidus I 5.3 7.3" 5.2 5.1 7. 1•
l multifidus I 5.3 7.3• 5.4 5.5 7.5''
R multifidus 2 5.1 7.2'• 5.0 5.1 7.01 "
l multifidus 2 5.1 7.2• 5.2 $.1 7.2
R psoas (ll) 29.2 28.6 28.1 29.0 27.2
l psoas (LI J 29.2 28.6 10.2 29.5 29.6
R psoas !l2) 25.8 25.3 25 .1 25.7 24.4
l j)SU3S (l2) 25.8 25.3 25. 1 25.7 24.4
R psoas <UJ 22. 1 21.8 21.7 22.0 2 1.2
l psoas (l3) 22. 1 2 1.8 22.5 22.2 22.3
R psoas (l4l 18.7 18.6 18.6 18.7 18 .4
l j)SOOS (l 4) 18.7 18.6 18.9 18.8 18.9
fl~ ••m1:e 01 ~~~tlt'l'lW 1~es U">L>d to a~ letlglh chal'l&e & IUiblr.llOO In Ogu1e S.l oo P.lSe 1<1.
'Combinall0n!1 of (l(t> ilP.xion. l !t" ~~~hi lawral bend, 10' coum.e«:lock\"ise twlsL
"M\1'-f'il• lt-ngth~ di fi(•r h)• m l)«• th.ln 1Qo/.. ft(lm IIMJ\(l obt.lin('rl duri ng ~tiglll !>l~n(ling.

Kcptu\K'i.l, by pe. mis~loo, from S).'l. .\'\I:Clll, 1\IYl. "KincliC pott."tttial of tht: lutnbJ t lft.u\k muSC\JIJ turc ~ut d1tee '"'hog.o.~l Ollhop.a!.·dk axe In exttcn'IC f)C)iilli:on~;"'
S{Nf1~19\71: WJ·S IS~

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()------------------------------------'L,ow Back Disorders

Abdominal Muscles
Jn rhi~ seccion we will consider several impo rrnm aspecrs
of lumbar mcdhtnic.s in wltich the abdomin a] muscles a rc

Abdom inal Fascia

The abdo111inal fasci;l contains tl1e rectus abdom.inis anJ
connects laternlly to the aponeurosis of d1e layers of
the abdominal wall ]t.~ functional sib'Tlificance is 111<1cle more
im portant by oonnectio.ns of the aponeurosis with pectoralis
major, together with fnscial elements t hat cross the midline
to transmit force to the fascia (and abdominal muscles) on the
opposite side of the abdomen (Porterfield and DeRosa, 1998)
(see 6guo·e 4.30,,t-b). Such anatomical feamres unde•llin and
justify exercises (detailed later) cl>at integrate movement pat-
terns tbat sinlUit:anoously chaUcngc t he abdominaJ mu~lcs,
the spine, and the shoulder muscularure.

Rectus Abdominis
While manv classic anatomy texts consider the abdominal wall
to be an it~porrant flexor ('; f t he o-unk, the rocms abdominis
appears to be the major tnu\k flexor-and cl1e most active
during sit-ups and curl-ups (Iuker, Nk{~ill, and Kropf, 1998).
i\1usde acth~ rion ampHntdes obtained from hath i.ntramuscu-
lar and surFace electrodes over a v~rietv of tasks a.rc shown in
table SA (pages 78-79). It is interestio;g to consi<ieo· why the
rectu~ abrlo1ninis is partirioned into section.$ rathe:r t ban being
Lumbodoosal fascia !Latissimus dorsi a single long U'IUSclc~ given that tbe sections share a comnlOn
neove supply and that a single long muscle would have the
Figure 4.29 Latissim us dorsi originates advantage of broadening the force-length relationship over a
from each Iumlnv spi ,,ous process via greater range ofkngth change. Perhaps a single muscle would
the lumbodorsal fascia and inserts on the bulk upon shortening, compo·essing the viscem, or be stiff
h1.1merus to perform both lumbar extension and resistant to be ndi ng . 1\"or only does the set-"tioned rectus
and stabilization roles. alxJominis limit bulking upon ~hortcniug, but rhc sections
also have a bead effect, which allows bendi.og at each teodon
to fac:iHt<lte torso tlexion .. e:\!.tension or abdomina I di~reu.sion
or contraction as th e ,.;sceral contents chanbrc volume (Nl. Belanger, Uuiver~i ty of Quebec: at
Montteal, -personal communication, 1996).
T he " h ea dedn recn.'.s a lso performs ::mother role-the lareral transmission of fo rces
from the oblique muscles forming a continuous hoop around the abdomen (Ponertiel<l
and DeRosa, !998). The imcnnuscular tendons aod fascia prevent the fibers of rectus from
heing ripped apan; laterally from rhese hoop stresses. T his aspect of ahdnmina l mechanics
is clucidatt?d fu rther in the ne::xt section 1 whic h discusses the forc~s developed in the oblique
Another clini,-.1issue is the conn·oversy regordingupperand lower abdominal muscles. While
the:: obliques are regionally activated (and have functional separation herween upper and lower
regions), aJI sections of the rectus are activated together at similar levels during flexor torque
generation. A signific:~nt fuo\ctional separntion does not appear to exist between upper and loweo·
rectus (Lehman and McGill, 200 l) in most p<.'ople. Research reporting differences in cl>e upper
and lower ;rectus activation SOJilCtirucs suffers fro1n tht absence of nonnalization of the El\llG
signal dw·ing processing. l!rielly, resea o·chers have used raw amplinodes of lll)'Oclecrric activity
(in miJJivolts) to conclude that there is more, o r less, activity relative ro other sec tions of th e
musdc, Uut th e Dl3!;,'1lituclcs a rc affec ted by local condut tivitycbaractcristi<.:s. Tbus!' amplitudes
n1ust be normalized to a standardized contraction and exptessed as a percentage of thjs activity

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External abdominal
Aponeurosis of external oblique muscle
abdominal obliquo Anterior layer of rectus sheath
Aponeurosis of intemal
Internal abdominal
oblique musd e
abdominis muscle
abdominal oblklue

AponeurOSIS Of
I Linea alba Transversus
abdominus musde
transvorsus abdloll)i~ us

a Transversalis fascia

Rectus sheath

abdominal ~==--­
oblique muscle

Aponeurotic part lnternaJ oblique

of external abdominal
oblique muscle

Figure 4.30 The abdominal fascia connects the obliques of the dbdorninal wall wi\h (ct ) rectus
abdominis and, to a lesser extent, !b) pe<.'toralis major and ht'lps to transmit hoop stresses around
the abdornc;!n.
(b) M~pi.OO irom C.M. Nouis, :woo, 8.Jck t.MWiit,. !UMnqJ.l ign. ll.: Hum:m KineliC.S). Sb.

Ueper and lower Rectus

Although we have seen separation in neural drive between upper and lower sections of rectus
abdomi nis in a few Middle Ea.stern-style belly dancers (out of a larger cohorl), these abilities and
moves arc rare in cv()ryday life. (We nlade these observations only during very low-lcvcl contrac-
Uons in which the muscles were moved in the ahsence of substantial flexion torque or muscle load.)
In fact, a disti nct upper and lower rectus does not exist in most people. Once force is required, the
rectus appears to aetas a C<~blc with active tension along its entire length. Thus, tr~ining the rectus
for nearly every<me can be accomrlished with a single exercise. This is not true for the obliques, as
they have several neural comparlmeniS-Iareral, medial, upper, and lower.

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.::S.:: Back OiS<lr<iers

Unnormalized crunches
500 t..=:J




21 41 61 81 101 12-1 141 161 181 201 221 241 261 281 90 1 321 341 361 381 401

Normalized crunches
90 ~
~ so

& 30
" 20

Figure 4.31 (a) Studies that have repcu1ed an upper and lower rect\IS abdominisgenerally ev(lltJaled u•'•'ormalized
EMG signals-for example, in ~'e .study of men perfO<ming crunches. (b) ~l owever, when the signals are normalized
properly, the apparent difference disap1>ears. While th~re are regional•ctivation zones in the abdominal obliques.
the<e is Iiule evidence to suggest that a functional •upper and lowe<" rectus abdominis ex isiS in most people.
RtVIin!t:"dfumlV. h•hm.m ~nll S.M. MrGill, 1<199, "llle"influr11on•of d1ilnp•·•11i<: nMnipui.\licm o n lumiJ-.I.f l.:ill('flutk~.mrJ (MC •Ju•ing ~in1>letmcJ (umpl~x
la:sb.a case !il.udy," Jowml of Physio.bgkal Tllerapoolks, 21l9J. 576-581. COP)'figfu 1999.

(r~ther than in mlllivolts) (see figure 4.3 1). Res~rchers may also have inadvertently monitored
pyramidalis (;m optional muscle at the base of the rectus), which would ci<Yud interpretation.

Abdominal Wall
The rhree layers of rl1e >1bdominal wall (external ohliqne, internal obliqne, anci tr>1nsverse
abdominis) perform several functions. All thrt".C arc involved in flcx:ion and appcart<> have their
flexor potential cnhancx:d because of their atraclunenr to the linea sem.iluoaris (see figure ~ .32)
(McGill, 1996), which redirects the ohlique muscle forces down <he ''ectus she;1th to effectively
in(Tease the flexor moment ann. '"The oblique~ are involved in torso twisting (M.cGill, 1991 a,
1991 b) and lateral bend (McGlll, 1992) and ap1x:3r to ph>y a role in lmnb~r srabilization since
they increase rheir activity, to a small degree, when the spine is plac-ed under pure ax.i al compres-
sion ()uker, McGill, and Kropf, 199S). (This funccion>1l notion 11;11 be clevelop~d l>1ter in this
chapter.) The obliques are also involved in challenged lw>g ventilation, assisting with "active
expirarion" (Henke e< al., 1988). The impomnr funcrional impl ication of active e'v iration 11;11
he dis<..'1J.o;secl in <1 subsequent section.
Rcseard1crs have focused a lotofattcntion on the transverse abdorn.iujs for two reasons. First,
some bel ieve it is i•wolved in spine stability through its belttike conrainment of the abdomen
and also in the generation of im:ro-ahdomillal pressure (lAP). Richardson and mlle•gnes ( 1999)
nicdy dlc second reason for the focusccl attention on this musdt, suggesting that
uaosversus has a delayed <>oset of acti,•ation time in some with back troubles, prio r to a r:1pid

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~~~aromy ofth~e~L~u~m~b~a~

a1111 movement-the hypothesis being chat the trunk must fu-se be

made stiff and stable. lr appears rhat this is e\•idence rhar an aher·
rant motor pattern exists: in rapid activity. VVe cannot find evi:dt'nc:c.
dtat this motor pattern happens bilaterally, itnpl}1ng- that it has
lirde to do with stahility. The question remains as to wllerher this is
important in more nonna11y paced atcivities. Delayed onset: confirms
motor deficits. but a 10 to 30 ms onset delay wollld be irTClev.,nt
during a normal movement in which these muscles are cominually
<.'Ol'Ontrac:ted ro ensure sr.ahility. Contrary w what is commonly heard
in e.~ercise discussions, the e\~dence does not Sllb~est: that transverse
is not recruited. It is also interesting that, <tgain com:r:uy to poplllar
thought, the tran.;versu.~ and internal oblique are very similar in their

6bcr orientation. In our very limited imrnmuscular l:'.MG cle<."trodc
workQuker,NlcGiU, and Kropt; l99S)wesawa high degreeofcot1pling
hetween thec;e two muscles in a wide varietY pf nonOOllisric exertions
(no doubt some myud<"<.trit cross-talk c.<istc<[). ' 'Vc have been unable
to lind people who can or cannot activate transverse. Nonetheless,
several groups (Cresswell and colleagues, 1994, ond Hodges and
Rkhardson 1 J 996, arc the most C.lpericnccd) have n Ot(.~d tht extra
Figure 4.32 The obliqoomuscles (EO: activity of transversus when lAP is elevated, but also d:tat all of tbe
anterior porliQn of e)(tem;.l oblique; abdominal muse!~ show this acth~tv.1"he combination of n-ansverse
10 : anterior' portion of iotetnal obliqt.1e; activation (and almost aJways con~omitant oblique activity) with
T: Lransverse abdominisJ tr<•nsmil fore~ elevated lAP enhances stability, without quescion.ln fact, Cholewicki
along their fiber lengths and then redi- and collcogues (1999) recenrl)' cnncluded t har building lAP on irs
rect lor·ce along rectus abdominis via own a<lds spine stauiliry.
the ir attachment to the Iinea semilu- In cbe broader functional perspective, the components of the
naris to enhance their effective nexor ahdominalmuscles (rectus, ohliques, and mmsversus) work together
moment arm.
but also independently. While a '"'-riel}' of sources have provided
R.eprinted (,om Jouma( q{ Biom«h.-.nk.~. l9i71.
S.:..L M CGill, "A u~·i..ed .ln,U•'WIIi<.,ll nl(x.Jd of tiiC'!
myoelectric evidence fro1u a variety of tasks, an a.naroutital antl
J.Ld(lniitloill "'mculo•tu1c fUt torso ilexlw\ effort~;' function~! interpremtion i< needed. As noted earlier, the obliques
973·977, Copyrill,hl 199G, witt! pernN!iSion ftom differentially activate to create twisting torque and C'an enhance
EJSoe\•io:>r SdeflO! .
flexion torque. Rectus is primarily a flexor-in fact, those pc'Ople
who have a great deal of motor conlTOI in [he abdomi na l muscles can p1·eferentially activate
each muscle (see fib'ltre 4.33, JN/). Finally, some have suggested an upper and lower partition·
ing of the abdominal muscles. As prevu:Jusly lllencioned, this impression is probably an artifutt
resulting from f'OO'' EMG tecfu>ique; the,·e does not appear to be a fw>ctional upper and lower
rectus(Lehman and McGill, 2001; Vern-Garcia, Grenier, and McGill, 2000). On tl>c other hand,
rcgionaJ di.ffercntcs do cx;st in the obJitJucs; some sections can be preferentially recruitecl both
media!J)' and laterally tOgether with upper and lower portions. Fin.,lly, the obliques, together
with transverse al:xiominis, form a containing hoop around the entire abdomen, with d1e anterior
of rhe hoop (umposed of the abdominal f•scia and the posterior cOmpos<!d of the humbodorsal
fascia. The resulting "hoop stresses" and stiffness assist with spine stability.

Abdominal Muscle Exercises

The functional divisions of the abdominal muscles justiiy the need for several exercise techniques
to challenge them in all of their roles: moment generation, spine stability, af!d heavy breathing.
While the obliqu~'S are regionally <l<.<ivatetl, with sever~ I neural comp;trtmcnts, there appears to be
no functional sep;tration of up1:ler and lower rectus abdominis. TI>us, a curl-up exercise activates
all portions of the rectus abdominis. However, uppet and lower portions of the obiique abdominal
muscles are actiV<lted separately dependi ns on the demands placed on the to rso, Finally, detailed
examination of the fascial connections reveals force transmissiot1 among the shoulder musculature,
the spine, and rhe abdominal muscles, justifying exercises incorporating larger moveme01 panerns
for the advanced (J<ltients who can bear the higher loads.

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Figure 4.33 Some trained people have the ability to differentially Jctivate specific portions of the .abdominJI musculature.
TI1is sequence shows (.a} an inactive alxlominal wall, (b) the abdominal wall "balloonecl,N Jnd (c) contraction of tr.:.ns\terSe
abdominis, which draws and "hollowsNthe wall. (N ote that other muscles. musl rel ~l x-to do this, which compromises both stabil-
ily and strength./ (d ) Pla-cing the hands on the thighs and pushing a llows ,, flexor rnomc nt to develo p where good m uscular
c:onlrol is able to activate just the rectus abdominis with the previously activated lransvcrsc and lillie ohliquc <)Ciivity.

The psoas, a musdc that crosses the spine and bip, is wtique for many reasons. \~~>il c it bas be-en
cia imed tO be 0 major StabiJiu r 01' the lumbar Spine, J believe that this claim needs intellll'et"-
tion. AJthough the psoas complex attaches w Tl2 and to every lmubar vertebra on jrs course
over the pelvic ring (sec hb'llrC 4.34), its activa tion profile (sccjuke r, M(.-Gill, and Kropf, 1998;
.luker, NlcGill, Kropf, and Steffen, 1998; and Andersson et al., I995, for indwelling EMG data)
is nor consistent with that of a spine srahilize.r (in the purest sense) bur rather indicates that the
role of the psoas Js purely as a hip tlexor. Dw·in~; our work ro implant intramuscular clt<.:trodC!.
in this muscle, we performed the ir1sertion techniquesevet"l times on ourselves. 'l11e first time
the electrodes were-in rny own psoas, f rried se\'er:tl low hack exertions in an attempt tn activate
it (flexion, extension, side-bending, < ~Tone of these really caused the psoas to lire. Simply
raising the leg while standing, with hip flexion, c >used massive activation, clearly ind icuting that
<he psoas is a hip Aexor.

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After this pilot work, in a Larger study we

fouJid that any task •·equiring hip Oexion involved
t he p soas. Alrhou!,-h we obtained this impression
from studying the activation profile of tbe psoas,
other considerations sr:em from ics architecture.
Why does t he psoas cr:werse the e ntire lumhar
spine and, in fact, course. all the way to the lower
tl10rndc spine?\ Vhy not let tbe iliacus perfonn
h ip llexion ? If only the iliacus were to flex rhe
hip, the pdvis would he torqued into an anterior
peJvic tilt, forcing the lumbar spine inoo extension.
These forces are butt ressed by the psoas, which
adrls stiffness between t he pelvis anrl the lumbar
spine. In effect, it can be thought of as a spine
stabilizer but o nly in the presence o( significanc
h ip tl exor torque. Also, an activated a.nd sti ffened
psoas will contribute some shear stiffness ro the
lumbar motion segment-bur once again , only
when hip flexor torque is required. The fact is
that the psoas and iliacus arc two separate musdcs
Iliac Quadratus Psoas
crest lumborum major processes
(see Sanraguida and McGill, t995), fu ncriooatly,
architecturaJiy, and neurally. There is no such
Figure 4.:14 The psoas .JU.1ch cs 10 each lumbar vcr- thing as an iliopsoas muscle!
c~hra (late ral vcr1cbrat body a nd transverse proc~s) In addition, soo1e din ical discussion Ius been
where each of lhese lan1inac of psoas fuse .and form a centered amund the issue or whether t he psoas Is
common tendon thai c~u r$es dwough the iliopectineal an inwrnaJ or e.uemaJ rotator of the femur and
notch to the iemu1'. 1'he quadratus lumborum auaches hip. t\ lthough it has some arcb.iteCttl ml ad•-antage
each 1ransverse process with the 1ibs and iliac crest, ro e>1:ernally rotate the hip,)uker, McGill, Kropf,
iorming the guy wire support systern. and Steffen (I 998) obserred o nly sma II act ivation
fnM!\(' <:OUItf">'( l)f r. irn.1\ Pit;lut t;<$. bias during hip rotatioll tasks. Howe>·er, tltis may
have been due to the need for significant h ip sta-
bilization, resulting in substantial hi1) cocontrac-
Psoas Function tion. lu a recent study, we cxrunined a matched
cohort of workers-half of whom had a hisrorv
M)'Oelecrric evidence and a natomical analysis of disabling low hack troubles, while the oth.;r
suggest that the psoas major acts primarily to half had utvcr missed work. Thost who had a
create hip flexion torque, that its activacion is h istot')', but were asymptomatic at the rime of
minimally linked to spine demands, and chac the test, had a sign.ificam loss of hip extellsion
it imposes substan·tial lumba r spine compres- and hip internal rotation (but lllorc e¥.terna1 rota-
sion when activated. Caution is advised when tion). Th is is an inlel'esting obsecvatio11, g1ven
ltaining th is muscle due to the substanlial spine much clinical discussion regarding che ~~tight"
con1pression penalty that is imposed on the psoas. E.vcn thoug-h \1/C do not fully w1dcrst:md tlu:.
spine when the psoas is a~'tiva tcd. neuromechanics, this llluscle as a clinical concem
is word> srudying furrher.

Quadra tus Lumborum

The quadrntus lumborum (QL) is another special muscle for several reasons. First, t be archi -
tectu,·e of t h is muscle suits a stabilizing role by anaching to each lumhar ••crrebr<1, effectively
buttressing adjacenr vertebrae hilareraiJy, rogerJ1er with attachments ro the pelt-is and rib cage
(sec figure 4.34). Spccilic"lly, t he lilkrs of the QL cross-link the vertebrae and have a large lateral
momenr a n n via t he rnmsve1'Se pi'Ocess actachme nts. T hus, by its design the Ql. could buttress
shear instability and he effective in stabilizing all loading modes. l)'pically, under compressive
load t he fi r-st mode of buckling instability is lateral (Lucas and Bresler, 196 I); the QL can play a
significant role in local b reral buttressing. Also, the OL hardly cha1'1(es len gth during an y spin e

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motion (see table 4.2 on page 55 and McGill,

Quadratus Lumborum l991b), suggestiog that it contracts virtuillly
isomerrically. Further insight into its special
The Q L appears to be highl)' i nvolvcd fu nction t omes fro m an earlier o bservation
with stabilization of lhe lumbar spine, d1at the mutor control svstern involves this
together with other muscles. suggest- muscle together with the abdom inal wall
i ng that ~ cl inical focus on this muscle when stability is require d in t he absence of
is warranted. Exercises emphasizing m.ajor moment de1nands.
activation of the QL whi le sparing the T he muscle appears robe nctive during
spine are described in part Itt, ''Low Sack a varie£)' of flexion~domina nt, extensor-
Rehahil italion.•· dominant, and lateral bending tasks. (Note
that myoelectric access to the Q L is Q\1ite
n id-v, and ir is difficult co confirm where tbe inrramuscnlar electro des <1re wit hin the muscle.
Ccr~.inJy o ur tctimiqucs o n this muscle were not very precise. In addition) they tend co migrate
upon conm•crio''· funher doudiog interpt•et:ation of the signal.) Andersson and colleagues
( 1996) found rhat the Q L did not relax with the lmn b01 r extensors during d1e flex;oot· relaxation
phenomenon. The tlcxion-rda.xation phcnomtnon is an intcrcsting task since there are no
subsrantiallareral or twisting torques and the extensor torque "Ppeilrs to be supported p"ssively,
further suggesting some stabilizing role to r rhe Q L.
L1 another C.'-l ltriment (note abrain that our laboratory technique~ to o btain Q L activation
wel"C l"ilUler imprecise at the tillle), subjects sLood upright with " buclet it> each hand. vVe incre-
mentally increased rhe load in each bucker (resulting in progressively more spine compression).
Our datOl suggest that the QL int reased it> activation lcvd (together with the obliques} as more
stability W<lS required (McG;Ji, juker, and K1·opf, 1996b). This L-ask forms a special siLuaLion
since onl)' compressive loading is applied ro the spine in the absence of any hending moments.
In summary, the strcnbrth of the evidence from se\•eral perspectives )eaves one to conclude that
the QL perfonns a very special stabilizing role for the lumbar spine in a wide variety of tasks.

Muscle Summary
This section h_.. s provided :.m ovenriew of the roles of the musdes of the o-unk in supporting
postures an d moving and cltc lumbar spine. The posterior 1nusdc.s were presented
in four large functional gt·oups. The deepest group (the small rotators) appear to act as posi-
tion sensors r:1ther than as rorque generators. The more superficial exrensors (multifidus and
iliocostalis Jumbornm and longissimus thorads) faU into three C<ltt:goril'S to
• generate large e.A--rension moments over the entire lwnbar region,
• g¢neratc postetior shear, or
• affecr and control o nJy o ne o r two lumbar se&•Tuents.

T he roles or the abdomina.! muscles in trunk llexion and in trunk stabilization we,·e high-
lighted mgerh er with the roles of the psoas and QL. Clearly, many muscle< ph1y a large role in
protecting the low back from injury. Cha[ltCr 12 applies these findings to exercise r.Cb~mcns fur
incti,•iduals with low back pain.

VVhen the mumbar $pi ne is neither flexed nor extended (neutral lordosis) 1 only musd e contribu-
tions need hi"::' t-onsidcred in d1c '''ccha1Jic.:S to support the spine. L]owcvcr, as the spine flc:~cs,
bends, and twists, passive rissues are stressed; the resultant forces of those tissues change the
imerpre tation of injury exacerha tion, the discttssion of clin ical issues, o r hoth. For this reason,
I introduc..: the mechanks of passive tiS)'UCS in this section, followed by some examples i.Uustrat-
ing their effects on clinical mechanics. Also r,,scinating is the distribution ofmech"noJ"eceptors
documented in every lumbar ligamenr and fascia. Solomonow and colleag>.>es' (2 000) recent
cv:idcnce suggests a significant proprioceptive role for spinal ligaments.

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Longitudinal Ligaments
The venebn•e are joined w fom>the spinal colnmn by rwo ribbon-like ligaments, <he ;mrerior
lon{,rirudinal and the posterior longitmlinaJJjga.ments, which assist in restricting excessive flexion
and extension (see figure 4.3 5). 13oth ligament~ h:we bony attachments m the venebml bodies and
collageno\IS attachments w the annulus. Very lirde evidence exists for the presence of mechano-
receptors i.n these ligaments. Posterior w the spinal cord is the li!,ramentum tlavum, whicb is
characteriu:d by a t-omposition of approximately 80% elastin aJ1d 20% collagen, signifying a
very speci>l function for this ligament. It has been proposed rhar this highly elastic structu re,
which is under prett:nsion throughout all leve.Is of flexion, act'i as a banier to matt:rial that co uld
buckle and encroach OJ1 tl1e cord in some regions of the range of motion.

lntersp·inous and Supraspinous Ligaments

The interspinous and superspinous ligamenrs are often classed as a single structure in anaromy
texts, altho1..1gb functionaJly they appL'ar to have quite different roles. The interspinous ligamt'nt!,
connect adjacent posterior spi nes but are nor orie.nted parallel to the compressive agis of tbe
SJ)ine. Rath er, they have a large angle of obliqui l)', which has been a point of contem:ion. For
years most anatomy lx)()b have sbown these lihramcnts with an oblique angle that would t"'luSe

----- Ligamentum lla\'\Jm

Supraspinous ligament

- - - - lnte<S!)inous ligament
- - -- (dorsal)
~--- (middle)

Anterior longitudinal Po:ste•·ior longttudinal

ligament ligament

Figure 4.35 Major lumbar ligam@,f)IS. Note the controversy surrounding the inU:fspinousligament
in iigurcs 4.36 and 4.37.
Ad.ll)~l, ~, perl'uio>!>IOn, itom 1. W.'ltlinS;. l !l99, StruCtUie .ff~l funCtkJ() of tht< Mu~l'ulo'iJreft:o~.'ll S••)l('r)J, !Ch.etni),J!~n.. 11..: l·lun\.ln
l(lnetic:s1, I 49

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posterior shear of the SUp<!rior vertebrae (sec figure 4.36). This error is belit'Ved to have originated
around the turn of the century, with the hypothesis being that an artist held d>e vertebral section
upside down when drawing~ other artis~ simply copied the previous art r:lther t han looking at
a spine. This wa.s corrected by Heylings (sec fib'tlfe 4.37), nocing that indeed these li!f<1ment.<
have the obliquity to resist JXlsrerior shear of the sur erior vertebrae-but also impose amerior
shear forces during fitll tle,ion (Heylings, 197H). While many anatomy textbooks suggest rhat
d1is ligament serves to protect ag'3inst exct.-ssive tlexion (based o n erroneous anatomy}, I do not
believe this notion is t'Orrect. Heylings (1978) suggested that dte ligament acts like a collateral
ligament simil:tt• to those in the l'Tiee, whereby the ligament <:ono·ols the vertebra lroutcion as
it follows -an <1ft' throughout the flexion range. This in mrn helps the fact:t joints remain in
contact, gliding wit h rotation. Furthennorc, with jrs o blique line of action, the i oterspinous
lig-Jment J>I'Orects aga inst posterio1· sheal'i ng of rhe superior vercebr:1e and is implic<l ted in an
injury scenario discussed later in this chapter.
f11 contrast to the interspi nous Jig~ut1Cnt, the s-upcrspinous ligament is :tligncd uu.>rc or less
parallel to the comp1-essive axis of t he spine, COIU>ecting t he tips of the posterio1· spines. It
appears ro provide resistance against excessive forward flexion . .Finally, both supr-aspinous and
in terspinous ligaments h::We an extensive network of free nerve endings (type JV receptors)
(Yaltia, Newm"n, and Rivard, 1988) together with Ruffin i corpuscles and Pacin i;m corpuscles
(Y.1hia, Newman, and Rivard, 1988; J iang et al., ! 995). Yahia and colleagues (1988) and
Solomono.w and colleagues (2000) suggest a proprioceptive role for tbc ligaments to prevent
C$Ces.sive s train in fully flexed l><>Stures ;md-giventheir architecture-qu ite possibl)'when
under excessive shear lo<HI.


Figure 4.36 For most of the past I 00 )'ears many Figu re 4.37 The interspinous ligament
.;~natornica l artists have dr(hVI'l lhe inlerspinous runs obliquely to lhe compressive axis <ll'ld
Iigament upside down, as shown in this example. thus has limited capacity to check flexion
Such dr.awings hav~ caused the ligame•'lt (unc- rotation of thE! superior vertebrae. Rather,
tion to be rnisinterprt>ted as that of a supporter the interspinous ligament may act as a col-
of ant~rior shear, which is incorrect. The original lateral ligament, controlling vertebral rota-
figure of tlh is example, from J. Watkins, 1999, tion and imposing anterior sht>-a r forces on
Structure a nd FuncLion of the Musculoskeletal the superior vertebrae. (ZG) Zygapophyseal
System (Champaign, IL: Human Kinetics), was joint or facet joint, (L2). (LJj lumbar spinous
clrJwn correctly but has been a lte red to illustrate processes.
the incorrect rendering man}' a rtists have drawn AdapiO!<I, by permission1 fra.n l). 1-k>'t•l in~. 1978. ~s~r<~ ·
in the past. $.!)inocn .mrllntt"f'\J•in(1u.; lig.11utnt.. Qi IIW'- humlm luml).lf
!<pi'*," k.Mm l.ll of An.l tm rw I 1St II': 1l9. CC¥fright Bl •< k·
AdaptNJ, by ()('m'll!oSton. from 1. \\'<Jitl.u~, 1999. Juucwte and .,.,"t!JI PIA>Hshlng.
ft,mnion q~· lho.. MtN-(1/o •J..f'k'fo•f ~•-w·m (Ch<1111p-1ig.n, II : ll um.1n
Kinrlit:oJ, 149.

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In terspinous Ligament Architecture

The intetspinous Iigamenl appears 10 provide a collateral action as it guides the sliding motion of
the facet joints and checks posterior shear of the superior vertebra. The nip side of this funoional
role is tinat during lull flexion the superior vertebra is sheared <Interiorly. often adding to the reaction
shearforces produced in a forward bending posture. Therapeutic exercise recommending iull spine
flexion stretches must consider the resultant shearing forces imposed -on the joint by interspinous
I igamcnt strdin. Too often, even those patients with shear pathology-lor examp le, those with spon-
dylolisthesis-are prescribed flexion stretches. This appears to be ill-advised.

Other Ligaments in the Thoracolumbar Spine

Other lig:u:ncnts in the thoracolumbar spine include the intcrt rattS\•crsc ligaments a.nd the f..tcet
• lntertnmsvers~ ligllme-ntJ. Tlte.'ie ligaments span the transverse proc< an d have
been a11,>ued to be sheets of c'Onnective tissue rath''" than true ligaments (Bogtluk and Twomey,
1991). h>fact, Bogduk and 'J\vomey suggest that the intertr<lnsverse ligament membrane forms
a septum between the anted or and posterior mnscubn1re that is an embryological holdover
from the development of tl1ese tv.·o sc.ctions of muscle.
• Fnt-.:1mpsule. The facet capsu le consists ofconnective tissue with bands that restrict both
the joint flexion and the disr.raction of the facet ".trfaces that result from axial twisting. T he lib"'"
ments that fonn the (..'apsulc have been dcx:umcnttd tO be: rich in proprioceptive: org--•.ms--Pacin-
ian and Ru ffini corpuscles (Cavanaugh cr a!., 1996; McLain :tnd Pkbr, 1998}-and have been
observed to respond to multidirectional srress (Jiang et al., 1995), at least in cats.

Normal Ligament Mechanics and Injury Mechanics

Detennin.img the roles of ligaments h.1s invoh•ed qualitative interpretacion using their ;.Utttchment.s
and lines of accion together with fw1ctional tests in which successive ligam.erus were cut and
che joint 1notion. was re:1ssessed. Ead y Sl\ldies attempting w detenn ine the ~~moun t o f rei alive
contrihution of each ligament ro restricting Aexion were pe rformed on cadaveric preparations
t hat were not preconditioned prior to tl.."Sting. This usually entails a loading regimen so t hat the
cadavel"ic s.pecimens bener reflect in 1<ivo behaviot·. Specifically, the investigators did nor rake
into a<..x:ount che F.tct that upon dearh, discs being hydrophilic, increase their water content and

n msequently their bdght. The swollen discs in cad:ovetic spccimcus produced an arti6cial preload
on the ligaments closest to tile disc, inapwopriately suggesting that the ca psular and longitudinal
ligaments are more important in resisting tlexion than they acnraJiy are in vivo. For t his reason,
these early data describing thl· fum:tiooal roles of various ligament<; were incorrect. T he work
of Sharma atltl colleagues (1995) showed tbatthe major lig-~menL< fot· resistillg ne:..ion are the
supraspinous ligaments. Those e<irly Sl1Jdies showing thai rhe postetior longin.ICiinalligament
and the ca·psular ligaments arc important for re:o,isring Aexion tlid not employ the necessary
pret-onditiotting just discussed.
Mechanical failure of the lig;~ments is worth <:<.>nsidering. King (1993) noted that soft rissue
injmies ar~ common during high-e ncrbry, traumatic evenrs such as autOmobile coiHsions. Our
own observations on pig and human speci.tnens loaded at slow load n>res in bendil>g and shear
modes suggest that excessive tension in the longintdinal ligaments causes <lVulsion o r bony F.t il·
ore ncar the ligament attachmen t sire. No)'es and colleagues (1994) noted t hat slow strain rates
(0.66%/s) produced more ligament ftl'ulsion injw·ies, wlille fast struin mtes (66%/s) resulted in
more mid(jgame,uous fi> ilure, at least in monkey knee ligaments. The clinical resu lts of Ris-
,sane.n (1960), however, .showed tbar approximar.ely 20% of randomly select ed cadaverk spines
possessed visibly rupturtd lumbar imcrspinous Jig.lmcnts, while the dorsal an.d ventral portions
of the inteli'spinous ligaments and the st•praspin.ous ligaments were intact.

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These could be <unsidered tO represent

Patterns of ligament Injury the living pO]Julation. Given the o blique fibe1·
direction of the Interspino us complex (sec
Tom Sl>inal ligaments appear to he the figure4.3 7, page 64), a very likdyscenorioof
result of ballistic loading-particularly
interspinous ligament damage is f.. lling and
slips and falls or traumatic sporting
landing on one's hehind, driving the pehis
activity wilh the spine at its e nd range of forward on impact and <:rearing ~l posterior
motion. Those with recently developing
shearing of the lumb;.l l' joims V<1len the spine
spine symptoms and accomp;mying spine
is fi,lly flexed. The interspinous ligament is
instability can often recount prior inci· a major load-l.)(:mring tissue in tills example
dents i111 which the ligamenls could have of high-energy loading characteriz.ed b)'
been damaged. I( the traumatic event
anterior shear displacement comhined with
occurs at work but the. delayed sequellile fidl tlcxion. Considering the avaiLiblc data, I
develop later during an event at home, is belie,•e tbat da1nage to the ligallileots of the
this compensabl(l? Arguing these types of
spine, partic11larly che in[erspin<nts complex,
questions requires~ solid understanding is not likely during lifting or otb('r nonnal
of injury mechanisms.
occu pational activities. Rather, ligament
da mage seems co occur primarily d uring
muunaric evcmsJ as described c-..trlicr4 T be s-ubse<lUCnt joint la.Uty is well known to aL'Cclcratt!
arthritic changes (Ki.rbldy-\•\C,IIis and Burtoo, 1991). What has beCil said in reference to the
knee joim, "Ligament damage marks the beginning of the end," is also applicable ·co the spine
io terms of being the initiator of t be cascade of degene.r.ttive change.

Lumbodorsal Fascia (LDF)

While a ftu.>tti011al interpretanon of the ltuJlbodorsal !ilscia (LDI) (also called the thoracoltullbar
f:1scia by some) is provided later, a short anatomical description is b>iven here. Firsr, the mscia has
h<my attacbmcnts on t he tips o f the spinous process (except t he shorter L5 i n many individual<;)
and to the posterior-superior iliac spines (PSIS). Some fa.cial connections cross t he midline,
suggesting some force r.ransm ission, rhus completing che hoop around the abdomen with the
previously dest·rihed abdominal fascia anteriorly. The rrnn~ve~e abclomi nisand internaJ o blique
muscles oblain their posterior attathrt'Lent to the fasd~, as docs the latissimus dorsi over the upper
regions of t he fuscia. The fascia, in wrapping around the back, forms a compartment around !he
lumbar extenson; (multifidus and p:u-s lumhomm groups of iliocostalis and longissimus) and has
been implicated in oompartlnent syndrome::
(C11T er al., 1985; Sty(, 1987)(see figure4.38).
Recent smdie:s anriht1re various mechanical
roles tO rhe LD F. In fuct, some have recom-
mended lifting techniques based on Lhese
hypoth eses. I-fowever, are t he}" consistent
witb cxperimenta1 (·vide nce? C racovt!rsl-y
and colleagues (198 I ) originally suggested
that lateral forces generatecl by the internal
oblique and transverse musdes arc
tranSQ1itted to the LDF via their attachmellts
to the bteral horder, and thar rhe fascia could
suppo rt substantial exte.nsor moments. They
hypothesized that this lateral te,sion on the
LDF'increased longirudinal tension by virtue
Figure 4.38 Collag~n fiber arr•ngement in the LDF binds of the collagen fiher obliquity in the LD F,
the lumbar cxlensor m usclcs and tendons fron"' the thoracic C"..aus-ing the posterior spi110us process-es to
muscles tog<?ther as th ey course 10 rhe sacral anachmcnK move together, reSl11ting in lumbarexrension.
Thus. one of the funclions of the LDF app<:,ars 10 he ac1ing as This prC>posed sequence of event.s formed an
an extensor muscle retinaculum-and a natural abdominal- attractive proposition bo:c.use the LDF has
llack belt. rhe largest moment arm of all r he exteJlSOr

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tissues. As a result, anv t:stensor forces within

rhe LDFwould impose.the smallest compressive
penalty to vertebral components of t he spine.
However, three studies, all published about
the same time. collectively challenge the viabilicy
of tlus hn><>thesis: one by Tt>sh and colleague.>
(1987), who perfo rmed mechanical tests 011
cadaveric material; one by Macintooh and col-
leagues (1987), who remgoized tl>e anatomical
illcOnsistcndcs wit b the abdominal. activation;
and one IJy NlcG ill and NormaJl ( 1988), who
rested the viability of LDF involvement with the
latissimus dorsi as well as with the· abdomina(
muscles (see tigure 4.39). These collective works
show rhat [he LDF is not a significant active
extensor of the spine. Nonetheless, the LDF
is a strong rissue with a well-developed lattice
of collagen fibers, suggesting rhar ;rs function
may be that of an extcn..'ior muscle retinaculum
(llogduk and Ma6ntosh, 1984), or 11ature's back
Figure 4.39 Stress lin es in the LOF indicate that the belr. Jn addition, the fa>cia does contain borh
la tissimus dorsi is the d ominant fo rce activiltor--Jt least Ruffini and Pacinian corpuscles togethe•· with
in this example. diffuse i11nentation (Yahia, Newman, anJ Rivan.l,
1 99~). The rendons of longissimus rh01·acis and
iliocostalis lw11borum pas$ under rhe LDF to their S<~cral and iliac attachments. It appears that
tlte LDF 1nay provide a fonu of rctiltacular "srrappu1g" li>r the low back musculature. Finally,
the abdominal wall and the latissimus dorsi forces <1dd tension to the fuscia and stiffness to the
spine to prevent specific cypes of unstahle behavior and t issue damage (explained i n chapter 6
on spine stability).

l umbodorsal Fascia Anatomy: Nature's Back Belt

No evidence justifies specific lifting techniques to involve the LDF for extensio n of the spine. How-
ever, activation of the latissimus dorsi and the deep abdominal obliqu~ contribut~ sliffening (and
stabilizing) forces to the lumbar spine vii\ the fascia (guidelines for <~Ctivating these muscles are
provided in chapter 12). Furthermore, the LDF appears to act as a retinaculum and probably fulfills
a proprioceptive function. ll is part of a "hoop" around the abdomen, which consists of the l DF
posteriorly, the abdominal fasda anteriorly, and the active abdominal muscles later~lly; the three
together com1>lete the stabilizing corset (see figure 4.40). As noted earlier, this also appears to be an
important elastic energy storage-recovery device for ballistic athletes, tuned by the obl i qu~.

A Quick Review of the Pelvis, Hips,

and Related Musculature
A healthy back depends on proper ftmcrion in the pelvi$ ancll1ips for several 1·eason$. Power
is usually gc:nerated at the hipsl for both perfonnancc and .safety reasons. Further, t he pdv-is
acrs as the platform fo,· the spine. G iven the exercises that ensure optima l hip funcrion
with spine integration shown later in chis hook, a h rief overview of the re anatomy is
pro,idcd here.
T he pelvis is usually sectioned inro three regions, rhe il.i.wn, the ischium, and the pubis.
Arriculacio.n s and small mocions occur at the pu his anteriorly and at the sacroiliac joints (see
figure 4.41). Scvci"J! nerve block srudic.1 h<1vc shmm these to be potential c:nc<c>of pain. Probably

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"6"6- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --'L,ow Back OiS<lr<iers

Al>dominal lascia

..... -- ....... JJL-- ... _

... ---- ,.,.. ~... --- ....

Transverse External
abdominis oblique

l umbodorsal

Figure 4.40 1l1c abdom in~ l fasci.,, anteriorly, and the t l)~ postcriolly. arc passive parts of the
alxlominal hoop. The laleral active m usculature (primarily the larger internal oblique and e~<temal
oblique together with the smaller transverse alxlominis) serves to tension the hoop (dashed arrowsJ.

the most relevant factor for cxercisc-rtlated issues is tbe architecture of d1c muscles. Psoas
and iliacus have alread)' been described for their role in hip Oexion anti stabilization. Gluteus
maximus is primarily <1 hip exrensor and e.\'ternaJ roraror, whiJe g luteus medius and g lutens
mi.n imus are primar ily abdut t ors and thus tremendously important for any acthrity that requires
single-leg stance or gait with directiooal change. TI>ey assist the spine musculature (such as QL
and rhe obliques) w hold the pelvis up du,·ing single-leg suppcm :md thus are key players in
~-pine stability during gait. They also externally rotate t he femur, which is a fun<:ci<>nal fearu re
we will use to full advantage in the design of squat exercis.:s law· in this book There are other
"glute:~ l" muscles known as the deep six (piriformis, obturator internus and externus, gemellus
superior and inferior, and tluadrams femoris)~ whicb together assist in conrroUing internal and
external ro tation.
T he in the hamstring group (biceps ferno1·is, senlitendinosus, semimembranosus)
e.xtend the thigh~ flex d1e kn ee, and perform stabilizing roles over each of these joint-.. [n many
upright situationS 1 particularly walking and running, their most important ro1c is i11 "'Uraking"
'vitl> eccentric contraction. Yet in stooped posrures, particularly lifting, tbe hamstring groups
are ' 'ef)' importanr fo r their conuibutions m hip extension. T h e medial thigh muscle,-. adduct
the thigh. The quatli-iccps t'xtcnd the knee and provide a patdlar tendon mcking fu11ction. One
member of the "quads," rectus femo1·is, crosses tbe hip joiot a11teriody to create hip flexion.
"'Tigbt" h al11$tri ngs are often blamed fo r hack trouhles, hut as is noted severa l rimes in this book,
this blame is oltt:n misdirected. l11c. bulk of evidence supportS neither a lio.k between shorter
han>strings as a predictor of back nor the ide'l dm scretcl>ing enhances strength output

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n~e ________________________________________________________ 69


Ilium - ---\--\·
Sacro,liac jomt ---'~--.--:~c. ,.;..'-- - - Anterior supenor iliac spine

Anterior inferior iliac spine

Acetabular lemoml ----= -[--"", ~ ~~'-('



~ ~
Quadratus Gluteus
disc minimus


Adductor longus

Adductor magnus

Vastus latEoralis""

fiJlure 4.41 View of th e pelvis and hips. Togethe•·they f" nction to stabilize and create hip power.
t.t) K~t)riOt ~tl, by pe(tltbt>ion , fu>u1 S. Sh uhz. 1005, h.Wiin~liOfl of r'ml.•tull'>skelt>t.JI fn)Utl~$. :! ~uJ ed. lCh.ltupai~R, 11.: r 1um11n Kh'letiCSI, <177.
ri.J.cJ ReprJI\u....:l, by t>ctfl'lis•Jcnl, Ctom k. Bchoke• •!005, KlndJ.:. J1Mlotl1)•, 2nd ed. !O."u'(lo1iSft.. ll: Hun\.ln Kineuc.s>. I , 6.

(e.g., Fowles et al., 2000; A'•ela et al., 2003) and o ffe rs no prorecrive value against injury risk
(e.g., Black and Stevens) 200 1). Fmthcrrnorc, what is often attributed to "hamstring tightness''
is actually neural tension so that metchi•lg only worsens the back and radiating leg symptoms.
There is .some evidence to ~uggest t har hamstring trauma can le-ad to neural tension (Buder,
1989), ald1ough more often the source of the neural tension is associated with a lwnbar nen-c
root or central srenosis.

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Training the Hip Musculature

No single exerci$1!- can train all hip muscles, although there are some parti cularly good o ne$. For example,
the one-legged squat is particularly functional, since quadriceps are aclive for knee extension and IJatella
control. hamstrings for knee stability and hip extension. the glutcals for hip extension and hip abduction, and
the adductors and gluteal deep six for hip stabilization. Another clinical issue is the pe~il i n training hip flexion
power given the associated loading of the lumbar spine. This is usually reserved for those who no longer have
pain- training hip nexion onen retards progress t0W<1rd the elimination of pain. It is usually wise to build
extensive spine stability prior to progressions into building hip power.

Considering thc..llic muscles dcmonstrat('S the tremendous nmnOcr ofthem that cross the hip
i<>inr. Collectivel)> they are able to create significam po"·er, and they can direct force io a pow-
erful maraner in many directions. Ln many cases t hey are the m•1jor power source fo r functional
perfonnanec. Spcdfically, t he-y create and <lirect force wb.ilc c han ging length at rapid speed.
Many of them cross both rhe hit> and knee joint, indicati11g that fimctiolla l train.iJ1g must i•wolve
r:1sks that ch3llenge borh joints at d ifte re m ve.Jocities. Fnrrher>rJ1is trajning must incorpor;.ue
la teral motion and ro tationaJ motion in the transverse plane.

Clinically Relevant Aspects of Pain

and Anatomic Structure
Recall from rhe introduction m this book that tissue damage can alter the biot11echanics of a
spinal join t and that o nce t he bio mechanics have changed, any in nervated cissue can he the
n ndidatc for symptoms. Pain o riginates wlth the free nCI'YC endings o f the varlous J)tlJn recep-
tors that typically f(>nn small nef\•e fibers. As noted by Guyton ( I981), not al.l of the small fibers
o rigitute in pain receptors: Some oliginate in o rga ns sensirjve to tempe rature, pressure, o r o ther
"touching" sensations. Pain also may be initiated at higher levels in the pain pathway: I lowe and
colleagues (1977) demonsrrated that mechan.ical prcsstu·es on the dol'sal roor gangLion produce
discharges for up to 25 ntinutes foUowing t he removal nf d1e mechanical p ressure. ln addition~
O.vonaugh (1995) showed that nerve endings arc sensitive to ch(mical mediators released
during tissu e damage and i>tflammation. Some swdies have anempred to examine inflammatory
processes by the injection of va>ious chembls. For eXl!mplc, Ozakray and colleagues (19\H )
injeered ca rrageenan into the region of nen •e rcc<'ptors :.round t he facer joints <)f rabbitS and
reported that the discharge from the r ressure-sensitive neurons lasted for 3 hours. This finding
suggests rhat tisS\ae damage p roducing infhl mmatory processes may contribute to a ~ong..Jastin.g
muscle spa sm. In a rl!ccnt summary1 C avanaugh (1995} p resented e vidence m document the
possible role of various chemical mediators that sensitize v;~rious components along the pain
pathway so t hat pain is pro duced duri_ng evems dl3f a re no rmally nonno:\i ons. Nluch remains
robe understO<><I.
llogduk (1983) pro,•ided an e.'cd lent review of the innervation oflmnbar tissues. For example,
the facet is well innef\'atcd with a \':lrietyof low- and high-threshold nerves, suggesting borh pain
and nociceptive ftmctions. Free nerve endings also have been observed around t:he superfici:1l
layers of intervertcbra I discs.

Tissue-:Specific Types of Pain

J have had some personal experience with direct 01ecbanical irritation of specific low back tissues
and the resulrantpain. Admittedly, these results are limited, given the single subject (myself) md
the subjective nature o f the ohsen·acions, hut Lbelieve tbe.y are worth re portin g nnnet heless. J
o Utai ned tbese insights frorn indwelling EL\,I G experiments in which Decdles were used to imphmt
tine wire ~:MG elecrrodes in the psoas, QL, multifidus, and th•·ce layers of the abdom inal wall.
t\1any people have experie nced the hurning sens<ltion as the needJe rcne-tr:ltes the skin. This is
<..utant.'Ous p-ain, as the application of ice and a ho t material fc...-cJs similar. As t he u.,;<·dlc applies

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pressure to, and punctures through, the LDF, the pain is felt as a scrnping sensation and some-
times as an elccn1c current. The same sort or pain is felt as the needle progresses through the
different sheaths between the lavers of muscle of the abdontin al wall. It is interesting to note
that fibromyalgic patients sometimes report t!Us scn>tchy type of u>uscularly locatcci pain-it
is very consistent "~th epimysium and Fascia irritation. Once the needle was inside the moscle!
no pain wa_'i r>erceived~ just an occasional feeling of mechanical A~ the needle muched
the peritoneum of the abdominaJ cav1ty in any location, a general inresrjuaiJy sick rceting was
produced in the abdomin:1l region, focused nnteriody to a small area just he low the naval. As
the needle muched the hone of the verrehra, even with very light pressure, a vet); pointed and
"Uoring,. p:.Lin was produlx:..d, sitnilar to the pain c.xpcricnlxxi 011 being kicked in the shins. Once
again, the :reader must. reali~.e that tbese are the e~-pericnces of a single llecson. Nonetheless,
they do provide crude qualitative insight into me <)1lCS of pain produced in specific tissues.

Can Pain Descriptors Provide a Reliable Diagnosis?

P:lin L.;; cle:.lrly produced fronl tissue irritation, particularly mechanical overloacl Some have
argul'tl thar some tissues may or may not bet";jlfldidates for sourc(>s of pain on t be presence
or absence of nociceptive nerve endings. This may be a diversjonary argutnent. 1f t..he O\'erload
is 51.1fficien• to d:unage tissue and produce biomcchanica l cha nge in rhe joinr, then rhe loading
patterns oE other tissues are disturbed. Thus, even though one tissue may not be C<tpahJe of
producing pain, if it is damaged >ufficicmly to shift load to another suitably innervated tissue,
pain may result. For e.x:;tmple, in nervated annu lus and disc end plates may be sou r(.-es of pain
as a conse<;uence of encl~p late fracture or ammlar herniation. But end-plate fn1erure can cause
significant disc bdgbt loss, which can lead to nerve enti"Jplllcnt, complex joint instabilitj•, sub-
sequent fitcet ovcrlo"d, and so on. Once the biomcch,mics of the joinr have been altered, it is no
longer fruitful to attempt to diagnose specific tissue clamagei the picnLre is com pie.'\. Funcdonal
diagnosis is the option.

A Final Note
Tn this chapter, a rudimentary anatomical and hiomtX:hanical knowledge on the: part uf the reader
is assumed . Using this foundation, some anatomical features were reviewed tbat are not often
considered or discussed in d assic :mm::omical te~'tS. Serious dis<..·ussion of :macomv must itn•olve
function and1 hy extension, must consider biomechanics and motor control. i-lopefuUy, th e
ftutctionaJ discussions throughout this c h:~ pter have stimu.lated you to give more consi.deration
tO me arch.itecn~re of the ltnnb3r spine. The chal lenge for the scienrist and clinician alike is tO
become co:oversao£ witb the functional implications of the anatomy, which will f,'lljlle decisions
to develop the HlOSt appropriate pr(..·vcntion programs for tbe uninjured and the best treauucnts
for patieJ>ts.

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and Injury Mechanics
of the Lumbar Spine

hapter 4 described the tissues, or the anatomical parts, and rheir •'Ole in function; this chapter
C wiU describe t be normal mechanics of rhe wboJe lwnbar spine. Since most hiomechanic..~
texts provide descriptions of spim~ JttOtion,
1 will address that only hr:icfly here. ln.stead, I will
fOCUS 011 tbe f'<LilCiiOOal iropJicni.ons of th,lt lllOtion, which nre r.11• lllOfC imp01~ant. I 1\;U also
ex1)Jain injmry mechanisms: and the changes that foJiow injur)'· C'AJnrroversy remains as to whether
these changes arc a consequence of injury or iLl f.1ct play .a causative role.
Upon completion of d>is chapter, you will be able to explain the role ol' tissues in "arious tasks
and conse<tuendy identi~· back-sparing techniques. In addition, you 11.UI unclersrand rl1e changes
that follow· injury, which have an impa(t on Junctional abilioy ami rchabiliration dl'A.>sions.

Kinematic Properties of the Thoracolumbar Spine

The r:u•ges of thoracic and lun\bar segmental motion about tbc tllrce principal axes (shown i 11
tahle 5.I) demonstrate rhe gre~rer flexion, extension, and lateral hending capahilicyotfrhe lumbar
region and the relatively greater rv.risring capability of the thoracic region. VVhilc tb_e Soebi'Jnent<ll
ranges shown in the ~Jbl c are population averages, keep in mind tbat a large variability exists
among people, among age groui)S (McGill, Yingling. and Peach, 1999), and among segments
within an individual.
joint stiffness \''alues eorwcy the ~lrnount of translational and rotational deformation of a
spine section under the application of force or moment. Tbc average stiffness values (sho""
in table 5.Z t'Ompilerl hy A<hton-Miller anrl Schultz, 19ll8) document the mmslational stiffness
of the spine in a neutral posture: they inditt:atc greater stiffuess under compression than under

Motion Palpation-Pathology or Normal Asymmetry?

Stiffness. asymmetries during bending to the right compared to the left and during twis!i ng clockwise
compared to counoerclockwise al specific vertebral levels are not uncommon. This finding is of
greao impotlanc.e to tile clinician who may someoimes susp!lct pathology a1 a specific location but
is simply experiencing normal anatomical asymmetry.
Recent work by Ross a11d colleagues (1999) exemplifies the peril in assuming that a joint with
an asymmetric feel upon palpation is l)alhological. Clinicians "'ho hold to a typical motion palpa·
Lion philosophy will oflen identify an abnol'fTlal feeling at a specific spinal level as the target for
therapy. Sometimes the asymmetric~ I stiffness may simply be asymmetric skelcta I anatomy-p('rhaps
a single facet with a unique angular orientation. Obviously, such a joint would be resistive to any
"mobilizing" therapy.

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Normal '!_nd lnj~Mechanics of the lumbar ine 73

Tab le 5.1 Range of Motion of Each Spine Level (in Degrees)

Flexion and
extension Lateral
Level Flexion combined Extension bending Axial twill
T1 ·2 4 6 9
T2-3 4 6 8
T3-4 4 6 8
T4-5 4 6 8
TS-6 4 6 8
TC>-7 5 6 fl
Tl-8 (> 6 8
T6-9 6 & 7
T9-10 6 6 4
TI0- 1 I 9 7 2
Tl l- 12 12 9 2
Tl2-LD 12 8 2
Ll-2 8 5 6 2
1.2-J 10 3 6 2
1.3-4 12 I 8 2
1.4-5 13 2 G 2
LS -S I 9 5 3 5
' o .1nd
All dal.:l .,u:o fn:wn Whatt> ·o
P.\llf<'b' 11976J, e)(cepc delllon and elltt>ns.on lumbar, \"hl<:h a1e from Pro•cy ~ aL '· J 98-'1 .vd fleafcy

Table 5 ..2 Average Stiffness Values for the Adult Human Spirne
Spin<> lev-el Comp. Ant.fPost. Lat. Flex./E<I. lat. Axial torsion
Tl-T1 2 1250 86/87 101 1551189 172 149
l1-L5 667 145/143 132 80/166 92 395
l5-S1 1000 78172 97 1201172 206 264
Coolp...~e.~M ·t• ~l sht~.1f valo~ .ue gwc•n 11'1 1~r'l~ JX!• null111~ J nll ben~•~g .ti)IJ .lx1a iiMiOn u'l flt!wt<>•~·l'llett:tS. pe••
TI ·TI2 data frotn \.vhite ,1nd Panj~blt19i8>. ll-15 <btcl from Schultz ec.ill. t i979J and Bertson.. Nacheomwn, .md Shuh.( 11979/.
l5·Sl rJ;tl<l fr(ll"n ,\kGl.1sh•-n cl ~1. 11967t

shear loads. In rot<lrionaJ modes~ g reater stiftiless occ:urs during axial torsion than during rota-
tion about the flexion-extensioll and lateral bending axes. While ge!lerally the range of motion
decreases with age, certain injuries, particularly co the disc. can inc1·ease the range of motiOil in
bending and ~h ear translation (Spencer, Miller, and Schultz, 1985). Kirkaldy-Willis and llurcnn
(1992) implicated tlwsc large unst,.ble movctucms in fat:tt joint denmgcment. Recent cla~J have
quanti lied the increase in the rnnge of motion about all three spine a<es as elise degenel'1ltion
proceeds from grade I ro gr;~des ill and TV. Radial rears of the annulus are mosr prev•lent in
these stages. But tl1is extra motion is replaced by extreme losS of motion in grade V discs, whkh
are characcerized by collapse and osteophyte fom>ation (13naka et al., 2001 ).

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Low Back OiS<lr<iers

As the spine moves iu three duncnsions (llexion-e,tension, lateral be.nd, and twis~). the align-
menr of muscle vectors changes with respect to the vertehml orthopedic axes. T his causes the
role of rhe· various muscles to change. Sometimes their relative contribution to producing a
sped Be moment d1:mges aJong with the resultant jojn.r compression ;u\d shear. Nlu.sde lengths
and their moment potential as a funt-rion of spine post11re arc shown in table 4.2 (]:>:tge 55) and
rahle 5.3. A range of extreme posnares is .shown in fibrurc 5.l. Senne muscles close to the .spine
obviously do not wHiergo great length excursions.

Figure 5. 1 A range of extreme postures was chosen to assess m uscle length changes ltable 4.2) and their potential to
produce threc-dimensi onal moments (table 5.3]. Postures depicted are Ia) upright standing, (b) GO• flexion, (c) 25• R lateral
bending. (d/1 0° tWiSI, .1nd (e) combined.

Lumbopelvic Rhythm
Tht> t)'pic~l description of torso flexion suggests that the first 60' of torso flexion takes p lace in thc lumbi"
spine, while any further nexion is accomplished by flexion ~bou1 the hips (see figure 5.2). Although this
notion is very popular in ell nical
textbooks, we have never measure.'(]
this strict sequenct;! in anyone. In
fact, Olympic weightlilters auempt
to do the opposittl-thcy lock the
lumbar Sl>ine close to the neutral
posilion and rotale- almost enlirely
about 1he hips. When the lumbar
spine and hip interplay is<luantified
in mosl people, il is apparent I hal
torso flexion is accompli shed with
a combination of hip motion and Upright Spinal Spinal flexion
lumbar spine flexio n. In fact, given standing flexion and pelvic tihing
the ligament and annulus Sll'esses
associated with lumbar flexion,
avoidance of full spine flexion is Figure 5.2 The I<Jmbopelvic rhythn'i is the textbook descripti<Jil of how people
both prophylactic and therapeutic bend ove<, lhe 11rst 60' takes plaoo in the lum'b~r spine tfiexingJ, while further
for most patients. The bel icf that the ro~;~rion oi t~e tO<SO isaccomplished with rotation about tlile hip. We have ~er
lumbopelvic rhythm (with disti net measured th1s sequence en anyone-IC'Om proiess•onal athlete to back patu;nt.
separation ol spine and pelvic motion] is beneficial, as described in so many textbooks, appears to be a clinical
myth and nOI the product of quantified spine and pelvis motion.

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Table 5.3 Moment Potential (N · m) of Some Representati ve Muscles in Various Postures Shown in Figure 5 .1

Muscle (N) p 8' r• F 8 I T F I 8 T F 8 T F 8 T

R rectus abdomonis 350 - 28 17 6 -35 17 12 -28 21 8 -29 15 4 - 33 20 15

R e xternal oblique

JIS -7 27 9 -7 24 15 -7
I 28 I II -~ 28 6 I 20 22
n n
o R intemalobliquelll 280 ~ 15 19 -16 -9 8 -31 -13 18 -20 -14 17 - 18 -2 2 -33 o
~ ~
cii· R par> lumborum Ill I -IS> 36 23 9 35 23 8 36 24 9 3 24 5 38 23 7 cii·
~ ~
;- R pal'l luonb<>rum ll41 S9S 23 23 -7 23 24 -4 23 23 -8 23 22 -8 23 25 -6 ;-
~ ~

Ril io<.Osldli> lumho oum

R 1ongi<simus thorads
















-1 -


Only <1 porhon 01 ~f' mu~<:l('., •"· '£1_,,~r.-d: f« p~.lttlp&fo. rh4'll.lmln;w d ~oou toll ts. ~"" rarh« than the v.hole ~
~(lmhrn.111qn oi ~1 fll"\101'1. 1"" tij4hl i.1tt'l ,tt tl>l'f1ol1n~ ,mtl I 0 ("il\IOI('friOI. k~i..- 1wi"' in ni'W' fl(KI'IIf4": •r •ll('xion; ' fl. -1.1""".11 hfond: "T .. oni,.ll'•·,.i~l

~~n~. brtk.'fml•u.on. ffl.iltl ) ,M t\k(.ill. 1'1')1, " )..lnt~k po~rnt.JI ~ thfdu!Tb.u tnuli. muM.ul.&~ ..~:~out three~thclgoo.:all)rthop~ '"~ ~ t-lti!IIM;- P'l"hiOR!o • ~mw.• IIJ•1r. 80'1 815

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Kinetics and Normal lumbar Spine Mechanics

Interpretation of the function of the :matomical components of the lumbar spine r<Ujuircs
• analj•sis of rJ1eiFarcbiteerure and neurn l activation of muscles, and
• knowledge of forces in the individual tissues (both active and passive) during a wide
variety of tasks.
T hjs inFormation is cn•cial for understanding how tiss-ue overloadiJlg' and injuries occur and
:!Iso for opl~mizi ng treaunent strategies for specific spine injury. ' lable 5.4 and figure 5.3 provide
activation levels quantified with >'llrfuce and intramuscular electmmyography (EMG) for a v:ui ety
of torso musck-s and over a variety of activities. T hese will be referred to throughout this book.
This se<:rion will <Jddress several issues and contro,,ersies about the fun<..·tional interprenttioraof
rhe thoracolwnhar anatomy. Gh'en rhe inability of the c linid an and scient ist to m eaSUire indjvidttal
tissue forces in vivo, the onJy tenable o ption is to usc sophisticated measurement tochniqucs
to oollect various biological signals from living subjects and integrate tl1em with sophisticated
modeling approaches to estimate tissue loads. h1 chapter 2, 1described briefly the technique we
used to ass~oss the various issues in this ('hapter (the vlrtuaJ s pine).

loads on the low Back

During Functional Movements
Of cour:se, no one can avoid perfo rming countless functiona l movements everyday. And if your
patient~ fo rm is poor for any of those Jllovemeots, he is cxaccrbatins his low lY.u:k problems
simply by goiog about b is business. ' l'hus, you must be able to ana1)7A! how your patient mo,•es
in aU f.Qns o f ordinary siruacions so rhat you can identity ;md exp lain where his problems Ue1
and how to (.:'Orrect them.

Standing and Bending Forward

Several studies over d1c years have shown d1e tlcxion -rclaxation phenomenon, or the apparent
m~"Oelectric silence of tlle low back extensor muscles during a st,tnding-ro-fuii-Hexion maneuver.
The hypor.lhesis has been that. as fn ll flexion occu rs, e irher the extensors sh ut dO\A-'11 their neun1l
dril·c by reflex or the passive tissues simply take tl1e load as they strain under full Ocxioo. A
study by McGill and ((jppers (199-J.) using the virtual spine i!pproi!ch described i'l chapter 2
qu<t nt ified individua l tissue forces~ chns a dd ing more insight into the understanding of t his
ta$k. As on e bends forward~ the spine fle.xes a nd t he extensors un dt:rgo eccentr ic con trac-
tion . As full Jle.uoo is approacbcd, the passive tissues rapid ly take over moment production,
relieving the muscles of this role and accounting for lheir myoelectric s ilence. Figure 5.4
shows rh e relative contribution of t he muscles and the passive tissues (liga mt!nts, d isc, and
gu t) to the reaction moment throughout d\e movement, whJie taUle 5.5 documents the
distribt,tion of rissue forces and their rnoments and joint load consequence. lltterestingly.
the "relaxa.tion' 1 of the lumiMr ex1:ensor muscles tlppeared t<) <)ccur only in an elecnical sense
because they genemted substantial force elastically during full spine Bexion througil stretching.
Perhaps the tenn Rexion-relaxation is inapp,-opriaie, particularly for those who may be attemptine;
ro minimize forces in the muscle in clinical settings. Furt.hennore, d1e .shear loading is substantial
(st·c chapter 4 for a diSl1J~ion of the lig'dmtnt :md muscle directions a nd the los:t of shear support
in the extensors with full flexion) and would suggest caution lor d\Osc witb spondyloliS1hesis or
other moresuhcle shear instahiliries. C learly, straight-leg roe touches o r l11ees-tc>.chcststretche.~
would c.:ausc simi Jar conc:crn.

Loads on the Low Back During Lifting

lJt~ring lifcing, muscle and ligament forces required ro support the pos1we and fucilinl!e move-
ment impose mammo th loads o n the spine. T his ls why lifting technittue is so imJX)rntnt to
reduce low back moment demands and the risk of excessive loading. The followiJlg example
demoostrJ\es this concept.

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b Quiet standing

Bent·knee s~ ·u ps
~ Standing extended

Press~heel sit-ups
~ Standing lateral bend-
lett ' d
Bent·knee curt--ups ~ ~ Standing lateral bend·

Bent-knee leg rais>e ~ 4- Seated lateral bend·

moving left ,
Straight-leg raise
~ ~J' Seated lateral bend·
moving right

Isometric hand-to· knee

(I hand-r kne>elr hand·! knee)
~ Seated upright ' ~
Cross curl-up
(to r/1 shoulder)

- ~
Seated isometric twist

Isometric side bndge
(left side down)
Standing hip rotation

Dynamic side bridge
(lefl side down)
Seated hip rotation

Push-up lrom feet

~ Sitting upright
Push-up !rom knees
" \
Sitting slouched, relaxed

Symetric bucket hold

(20130/40/0 kg) Lifl light load (20 kg)
Lilt heavy load (50·1 00 kg)

Figure S.J Schem.11ic documcrlling V.<lrious lasks during which FMC signals wefe ()blaincd. n,ey ate lisred i n fable .5 JI.
l~pllntell, by pem\iS..k:lll. iro1n IJ. Iukes'. S.M. M<.G1II, S.M. Ktopt 1. S1df~l'l. 1998, .-Qu.u1111.11iv<! lfllf,lmuM.ubf I®O<dettlk , IGIIY d)' of lumb,\1 ponloni uf fl!>O:lS .u'ld
lhe abdominal wall during a wide v<Jrlety 01 Colsks," MC'didne oltl<l ScJen.ce In Spom an</ Exerr:Jse 300>: .JOt-j JO.

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Ta ble 5.4 Subject Averages of EMG Activation Normalized to That Activity Observed During a Maximal Effort
(100%)-Mean and (Standard Deviation in Parentheses)
Psoas channels, extemal obJique, mt('fn.ll obh~. and transverse- abdominis are intramuscular electrodes "hJie rectus .1bdomlnts~ r«tu'\ femoris. and erector spin.le are
!.Urfat.-e clt.'droc:""'-.

Task PsoAS 1 Pso.1s 2 EOi IOi TAi liAs Rfs ESs

Straight-leg sot-up 151;;12) 24 t:tT! 44 b:9J IS J:t15! II t:t9J 48 1;;181 161:101 4 t±ll

Bent-knee sot-up 17 t±Hll 18 t±7) 43 (±12) 16 1±14) 10 t±71 S5t:t11>1 I~ 1;;7) 61±9}
n Press-heel sit·up 28 t:t2ll 341±181 51t±14J 22 (±141 20 (;tIll 511t.l01 15t±l21 ~ l±ll n
0 0
.... Bent-knee wrl-up 71%81 10 1:<141 19 (±14) 14 (±10) 12 l:t'l) 62 l:t22) 8 (j; l2l 6t:<IOJ ~
.-. 12 (±7} !2 t:t20) 6 1.,8) CD
::r Bent-knee leg ra isc 24t:t15J 25 1:>8) 8 1±91 71:61 8 t>:SI ::r
Straight-leg raiSe lS 1±201 33 (±8) 26 (:>9) 9(±81 G 1±4) 37 i:t24) 2311:121 71±11 ) it
0. 0.
s: s:

lsom. hand-to-knee (left h~nd -+ right
knee, righl hand-+ left knt'<'J

Cross cud-up (right shoulder _.. auos"~


5 (:tJj
4 (:1;4)
68 (± 14)

23 (±20)
30 l:t28J
48 l:t23)

24 (:tl 4)
44 U:18)

20 (±11)
69 1:t18J
74 lt.25)
57 1±22)
8 lt7)
42 (:t29)

ICH± I'!)
5 (±4)


:::! •
left should~r -+ aerO>>) 5 l±ll 5 (:1:5) 24 (;t;17) 21 (:t16) 1> (±l.lJ 58 1±241 12 (:tl4) .. (:1:8)

lsom. side support (left side down) 211±17) '121±8) 43 (±13) 36 l:t29) 39 1±24) 22 (± 11) 11 (± 11) 24 (:tiS)

Dyn, side suppon (ldl sidt~ clown) 26(±18) 13 (;t;5) 44 (±16) 42 (±24) 44 (:tJJ) 41 (±20) 'I (:t7) 19 (;t;l7)

Push-up from fee l 241± 19) 12 (±5) 29 (±12) 10 1:tf4) 9 1±9) 29(z10) 10(±7) 3 (±4)

Push-up from knc>es 141±11) 101±7) 19 (±7) 71±9) 8 (.t81 19 It 11 ) 5 to:l) 3 (±4)

lift lighr lo,1d 120 ~gl 9 (±101 ) b:4) 3(±3) 6 (±7) 6 1±5) 141±211 6(:SI 37 (±13)
Lift heavy load (50-I I 0 kg) 1Htl8) 5 (:t6) 5 (±4) 10 (:t 11 ) 10 (xl!) 17 (:t2J) 6 (:t51 62 (±12)
Symme lric bucke< hold, 20 kg 144 Ib) 2 (;;4) I (:tI I 7 \;!;4) 5 (±Jj 5 (±1) 10 \±7) J 1*3) J (±b)
:1!1 kg (1>6 lb) 3 (±41 I I± I ) 9 (±5) 6 (±4 ) 6 1±1) 10 (±8) 3 \%3) 4 (±7)
40 kg (88 lb) 3 (:t5) 1 (:ti l 1()(;tl'>l 8 (:t6J 6 (:t2) 10 t±8) J (;:3) J (:t2)
0 kg 1 (:t2) 0 \:t l ) 2 \:t I I 2 (:t2) 2 (;t1) 10 (:t9) 2(:t 1) 2 (:t 1)

Seated isorn. twist CCVV 30 (±20) 17 (:15) 18 \±8) 43 (±25) 49 (±35) 17 1±22! 7 {±4} 14 (±6)

Seat<>d iso m. twist CW 23 (:!:20) 11 (:t8) 52 1±13) 15(±11 ) I 0 (±19) 13 (±10} 9 (:d0) 13 (:!:8)

$landing hip internal rotalit:m 21 \:t 18) 1Q(±9) 18 1±12) ~4 (;t23) 33!±20) 13 (>:9) 9 (:t7) 18 (:t6J
0 0
0 S1anding hip externa l rotation 27 1±20! 221>:19) 17(±13) 2 1 (± t!l) 3 1 (±17) 13 (±H) 19(±11 ) 171±9) 0
.... Sitting hip internal rotatio n 19 (±15) 2J 1±18) 36 (ot31 ) 30 (±30) 3'1 (±29) 18 (±8) 20 (±19 ) 1h• 8)
<0' <0'
Sitting hip external rotation 32 1±25) 25 \±20) 1'1 (±9) 15 (± 17) I G (±131 15 (±9) 16 (±13) 8t±8)
a. Sitting upright 12 (±7) 7 (:t5) 3 (±6) 3 (±3) 4 (:t2) 17 (±91 4 {±2) 5 (:t8) 0..
s:: 5 (;t8)
Silling slouchecllrelaxcd 4 (;t4) 3 l:tJI 2 (:t5) 2 (:t2) 4 (:t3) 17 (:tll ) 3 (;t2)
;· Quiet standing 2(±1) 1 (±1) 3(±4) 5 tr3J 4 (±2) 5(±5) 3 (:tl) 11 (.!: 11 ) ....

Standing extended 3 \±2) 2 (±1) 12 (±91 6 (±3) 5 (±3) 11 (±5) 4 (:tl) 7 (±8)
Standing late<al bend, lei1 9(:t10) 1 (:t2) 11 (#l) 18 (:t 14) 12 (:1:7) 13 (;t7) J (:tl) 11 (;t 13)

Sta nding lalera l bend, righl 6 (±5) 1 (±2) 19 (± 18) 18(±14) 25 (±20) 14 (±9) 3 (± I) 8(±8)

Se alecl la lera l bend, moving lelt 2 (±3) 1 I±H 21 \±'19) 7 (±7) 7(±11 ) 13 (±8) 4 (:tl) 6 (±7)

Seated latera l bend, moving right 18 1±12) 12 (:t2) 15 (±2 6) 10 (±7) 1Ht7) 17 l:t20) 5(±4) 5 (:t8)

Upl'igh1 14 (:t9) 8 (±4) 6(±11) 5 (±3) 5 (±5) 19 (±23) 5 (;tl) () 1±8)

Ke,)I\1\Wt.l, lly permlssiou, froon~ 0. Juke.-. ~.}.'\. ,\\I:C\11. S..M. )..•<Jf)t r. St.eff~t) 19!>8, "Qu.uuiutl\'i! ilm.m~u~ul..• t myoc..fecltie JICb.,.ll}' oi lumiJ.u p011i(l(b oi psoos .100 lht: .lLdo.nll'l.ll w.lll <ti.till~ •• wi<k -.<ui.ety ofl.~• sks."
Medldt~ednd Sc-1ooce in Spotts .wid fxerrl"F<e 30.2): Jot ..JIO

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e ~/
\ .································ -·····-..
100 . '\ ....~
::;; .\
..! \ -.......·-·-- .-·-·-·--- --·- . .;:
' '
: ..,/ '',
/ \
0 --~~~- ---- -- -- -- - ----- - -~~- -
0 3 6 9 12
lime (s)

Raw moment - - - DiscTq LigTq - · - MuscleTq GuiTq

Figure 5.4 O"ring standing to full ionvard flexion, then back to standing, the extensor muscles eccentrically contract but
transfer their moment supporting role (MuscleTq) to the passive tissu'"' at full flexion- the disc (OiscTq), the buckled g"t
tGutTq), and the ligaments (LigTq). Note that some force remains in the muscles with passive Stretching.

Table 5.5 lndiv·idual Muscle and Passive Tissue Forces and Moments During Full Flexion
1'he moment •was 17 l Nm l 38 Nm b)' muscle, 113 Nm by ligaments, and 20 Nm by passi\•e tissues, such as 'he disc, skin, and
buckled viscer.t}. Tile joi nI compression w.'ls 3145 N. .tnd shHar w:.s 102b N.


N Flexion I lateral I Twist N Anteroposterior I lateral
R rco us abdominis 11> -2 !5 s -4
l rectus alxlominis 16 -2 -! -1 15 5 4
R external oblique I 10 -I 8 7 ·3
L extern ~1 1 obl ique 1 10 -1 -1 -1 8 7 3
R external oblique 2 7 -1 1 0 6 2 -3
L ext~1nal oblique 2 7 -1 -I 0 6 2 3
R internal obl ique 1 35 0 3 -2 21 · 19 20
L inw nal oblique. 1 35 0 -3 2 21 -19 -20
R internal oblique 2 29 -2 2 -3 8 -17 21
L internal oblique 2 29 -2 -2 3 8 -17 -21
R pars lumborum (1. 1) 21 2 1 () 21 6 2
L pars lumborum Ill J 2! 2 -! 0 21 6 -2
R pars lumbo1·um (L2J 27 2 0 26 8 2
L pars lumborum 11.2) 27 2 -1 0 26 8 -2
R pars lumborum tl3J 31 0 29 -4 6
L pars lumborum (L3) 31 -I 0 29 -4 -6
R pars lumborum tl4) 32 0 30 -7 6
L pars Jumborum (l4J 32 -1 0 30 -7 -6

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N Flexion I lateral I Twist N Antero posterior I Lateral
MUSCLE (COntinued)
R iliocostalis lumborum 58 s 4 1 57 14 -I
I iliocostalis lumboru m 58 5 ~I -I 57 14 I
R longissimus thoracis 93 7 4 0 91 23 ·6
Llongissimus thoracis 93 7 -4 0 91 23 6
Rquadralus lumhorum 25 1 2 0 25 -I 1
L quad1-atus lumborum 21 I ·2 0 25 ·I ·I
R latissimus dorsi (l5) 15 I 'I 0 14 ·'I -6
Llatissimus dorsi (1.5} IS -1 1 0 14 • 'I b
R multifidus I 28 I 1 1 26 6 9
L multifidus 'I 28 I -I -1 26 6 ·9
R multifidus 2 28 1 1 0 28 6 0
L mull ifidus 2 211 1 -I () 28 6 ()

R psoas (Ll) 25 1 2 0 24 9 6
L psoas (ll ) 25 ·I ·2 0 24 9 ·b
R psoas (L2l 25 -I 2 0 24 9 6
L PSO<IS (L2) 25 0 -2 0 24 9 -6
R psoas tl3J 25 0 'I 0 24 9 7
L pSO<lS (L3) 25 0 -I 0 24 9 -7
R psoas {l4) 25 0 1 1 24 9 8
l pSOils (1.4) 25 0 ·I -1 24 9 ·8
Anterior longitudinal 0 0 0 0 () 0 -
Posterior lo•'lgitudino
ll 86 2 0 () 26 1 44 -
Lig~m entum (lavum 21 I 0 0 21 2 -
R intertransverse 14 0 0 0 13 3 -
L intcrtransverse 14 0 0 0 13 3 -
R a" icular 74 2 1 1 65 40 -
L articular 74 2 ·I ·I 65 40 -
R articular 2 103 3 2 2 84 -3 -
I arlic:.uiM 2 103 3 -2 ·2 84 .J -
Interspinous I 301 18 0 0 273 142 -
lntesspinous 2 345 14 0 0 233 268 -
lnlctspinous 3 298 1() 0 0 194 238 -
Supraspinous 592 41 0 0 59 1 79 -
R lumbodors-ill fascia 122 8 1 0 109 -1 -
L lumbodorsal fascia 122 8 -1 0 109 -1 -
Disc 9
Gut, etc. 11

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2- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 'L:::ow Back OiS<lr<iers

A man is lifting 17 kg (59 lb) held ir1 r.he hands usutg a squat lift style. This produces an
extensor re3ction moment in rhe low hack of 4.10 Nm (332 ft/lb). 'T'he forces in •he various
ci.s.sues that support this moment impt)Soe a compressive load on the lumbar spine of nver 7000 N
(1568lb). ,able 5.6 details tlte wntributions to the total extension momennnd to the forces
from dte muscular components. ' r1tCl<e forces and their effects are pr·ed icted using the sophis-
tic., ted modeling approach, which uses hio(ngk·al signals obtained d irectly fro m the sohject
(sec chapter 2). It shotLi d be noted here tl1at 7000 N (15681b) of compression begins to cause
darn age in very weak spines, akhough the tolerance of the lumbar spi ne in an aver"3ge healthy
young man prohahly approaches 12 to 15 kN (268R-3360 lb) (Adams and Dolan, 1995). In
cxtrernc t~ses, t'Oillpres.sivc loads on the spi.ncs of compctiti\·c wcightliftcrs ha\'Csa fely CXt:ccded
20 kN (+f80 Ib) (Cholewicki, A'IcGill, and No.,nan, 1991).
Undcrsrancling the individual muscle forces, tbeir conrrihution co supporting the low hack,
and thc:ir components of compression and shear furce dtat arc imposed on the spine is very useful.
u1r.his particu lar e.<;~mple, tl>elifter avoided fuJI spi!le flexjon byOe.ting at. the hip, minimizing
ligamenr and other p•tssive tissue tension and relegating me momem generation responsibiliry
w tbt mus.t:uJamrc. A.n cx.unple in which tht spin.: is tlcxcd is presented later in thi!t chapter.
t\.< described in chapter 4. the pars thoracis e•tensors are ver)' effective lumbar spine e.xtensol's,
given rheir large moment am1s. AJso, since the lifter's upper body is tlexed, larbre reaction shear
forces on the spine are produced (the rib cage is crying to shear forw;u d on tltC pc:kis). T besc
shear ro,.ces are suppoi~ed to a very large degree by tl1e pars lun>bor'Ulll extensor muscles. Fur-
rhermore. d1e -alxlomin:ll mu.,;cJes are activated but do nm produce movement. ~Vh)1 are they
active? These muscles are activated to stabilize the spinal colwnn, althmtgh this mild abdominal

Table 5.6 Musculature Components for Moment Generation of 450 Nm

During Peak loading for a Squat lift of 27 kg (59.5 Ib)
Muscle Force ( N) Moment (Nm) Compression (N) Shear (N)
Rectus abdominis 25 -2 24 5
External oblique 1 45 1 39 24
Exremal oblique 2 43 -2 30 31
lntemal oblique 1 14 1 14 -2
Internal oblique 2 23 -I 17 - 16
Longissimus thoracis pars lumborum L4 862 35 744 -436
longissimus thoracis pars lumborum L3 15'14 93 1422 - 518
Longissimus thoracis p.1rs lunlborum L2 1342 12 1 1342 0
l.ongissimus lhoracis pars lumhorum ll 1302 110 1302 0
Il iocostalis lumborum pars 1horacis J69 31 :\69 ()

Longissin'lus lhoracis pars lhort~cis 295 25 295 0

Quado·a ros lumborum 193 16 186 74
Latissimus dorsi l5 112 6 79 -2
Multifidus 1 136 8 '134 (8
Multifidus 2 226 8 189 124
Psoas Ll 26 0 23 12
Psoas L2 28 tJ 27 8
Psoas L3 28 I 27 6
P$0,1S L4 28 1 27 5

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Normal '!_nd lnj~Mechanics of the lumbar i ne 83

activity imposes a compression penalty to the spine. A more robust explanation of stabilizing
mechanics is presented in chl-lpter 6.
T he preceding example demonstrates how diffusely the forces are distributed and illustrates
lww proper clinical interpretation requires anatomically detailed free body diagrams that repre-
sent realiry (such as t:hose incorporated into the virtual spine model). I believe that ove•"Simpl ilied
free body d iagrams have overlooked the imrx)nant mechanical compressive and espedaJJy sh<..oar
oomponen~ of muscular force. This has compromised the assessrnent of injury mechanisms and
che formuJ ;uion of OJ>timal therapeutic exercise.
Loads on the Low Back During Walking
Thousands oflow-level loadiug (.)'d es are endured by the spine every day du ring wal.lcing. V:~1ik
tl•e srnallload>in the low back during walking suggest it is a safe and tolerable activity, clinicians
h3ve found that w;~ Iking pro,•ides relief to some individuals but is painful ro others. Hccenr work
has sugg·,.osred that v.ralking speed -affects spine mechanics aud 1113Y account for thes..e individual
differences. During walking. the compressive loads on the lumbar spine of <'PI>ro:<imardy 25
rimes body weight, together with the very modest shear forces, are well helow any known in
"itro failure load (see figure 5 .5). Srrolling reduces spine motion and produces a.lmoH static
loading of tissut'S, bowevC'r, while F.tster walking, with arms swiuging, causes tyd it.: loadiL1g of
tissues (Clllaghan, l'atla, and McGill, I999) (see figtll'e 5.6). This ch<~nge in motion may begin
ro " 'Plain the relief e>verienced by some. Arm swinging while walk; ng faster, \\ all other
fal.t:Ors con trolled, n.'Suhs
. in lower lumbar spine torques, muscle atti,~ty, and loading (see tigurc
5.7). ln fact, we have observed up to I0% reduction in spine loads from anu S\\'inging in some
individuals . This may be because swinging the anns F.tcilicates efficient storage ancl recovery of
clastic t nc.rgy, rcduting the need for eoncentric muscle eontra('tion and chc upper bod)r accel-
erations associated with each srep. lorercsti.ngly Ktibo and colleagues (2()06) reported higher
wrso stiffness wirh faster walking, which would further fucilirate efficient energy reco,•ery. Also
int(!rcst:istg is the FJct that fast walking has be('n shown tO be a positive c.:of.t('tor in prevention
of, and more successfult·ewvery from, low back troubles (l"urter, 1988).

Fast Walking
fJst walking is generally therapeutic (Nutter, t988). ScvcrJI mcchJnisms appear to account for this:
re<::iprocal muscle activation and tissue lo;1d sharing, gentle moti(>o, and reduced spine load$ with
energy conservancy from arrn swing. In contrast, these benefits do not occur during slow walking
or "mall strollinS," which exacerbates symptoms in many because of the static loading that results.
Finally, we have noted that peof)le with a pained hack exemplif)• lhe typical pained generalllexor
response in that they often tend to swing the am1s primarily about the elbows. This should be cor·
rected to arm swing about the shoulders to optimize the benefits of arm swing.

Loads on the Low Back During Pushing and Pulling

Our insigb ts into the mechanics of pushing and puHiJlg were obtained from our investigations
originally intended to set occupational limits fo•· :lllowable s.~fe loads (see Lert and McGill,
2006). Gotb "novice" (senior university students) and "expert" (firefighters) pushers/pullers were

Pushing and Pulling- Technique is Critical

The technique used in pushing and pulling i$ very dominant in det·ermining the load on the back.
The magnitude of the hand forces is almost irrelevant until extremely high pushing and pulling forces
are r('<luir~'<l. Specifically, when hand forces arc tlire~'ted through the low b<lck, they do riol ~reate a
moment and in this way muscle forces are not required to surpott a moment. For athletes like rugby
players or strongmen competitors pulling a bus, this same technique is used. Here the pushing or
pulling force is driven as close through the feet as possible to enhance the foot grip together with
ensuring minimal joint torque.

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4 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Back OiS<lr<iers

300 , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
100 - - - - - Fast
50 Normal
o +-.--.-..-.-.--.-.--.-.-.--.-.--.-.--F=T~==~~~
0 5 10 15 20 25 30 35 40 45 00 55 50 65 70 75 60 85 00 95 100
a Stride(%)

20 ~--~~----------------7'~----~==~==~
10 Slow

15 20
,g -5

~ -10
I> Stnde (%)

5 I


- 15
c Strid<> (%)

Figure 5.5 l oads on the Jumb;u spine lnormalized to body weightj during three speeds of w<:tlking a nd with normal
a nn swing. The c urves arc normalized for one stride lright heel contact to right heel contacl). (il) 1.4-LS compression, (b)
a nterior-posterior shear forces in which positive indicates anterior shear of the superior vertcbr~1e1 (c) late ral shear fo rce in
w hich posit ivc indicates r ight shear of the superior vertebrae.
Rqlllnted from 0/J)k\tf 8/ufrtedi.Jnh;.s. '14, J.P. C.dt.,~han. A.E. Rnl.t, ~nd S..M. Mc:CUI, "low I.Md: thf~Wil'M!n~iou;tlioi•" fOKes, klnCI'!\.1tlcs kh\l>cks •.h.ulng
walking." 20l-1 1G, 1999, ,,.<ifh petmissioo rrom Ehevi(>J' Sdenc(',

recruited. The expert firefighters e'petienced much lower spine forces. They cleverly used body
mecbanics witl1 body le11n to generate the driving for<'e and to direct the hand forces tl1rough
the low bad~ resulting in very small low back momems. 'T'he implication is th~t. mwe agajn,
the motion and motor ~lant·rns that the firefighters elected to use rl.osulted in their supe.rior
performan.:e and safety. Ln this way the magnitude of the push/pull loads became much less
important for the b<1ck. 'l Cchnique WO;lS dorninanr:!

Loads on the Low Back During Sitting

N achemson (1966), using intradiscal prt~sure measurements, documented tbe higher loads on
the discs it1 various sitting postures compared to the standing posture. Normal sitting causes

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Normal '!_nd lnj~Mechanics of the lumbar ine 85

ii!! .s
., 3 Fast
01 c 2 Normal
~ x" 1 Slow
c w 0
~E -1 !)• -10. IS 20 -.25
--- ---
~ ~-5
E -6
a Stride (%)

...e 1.50

0 .00
.... --:---------------··
E ~.50
5 10 60 ss 10 ~~/so ss 90 95 1
"' .. - 1.00


~-1.50 Fast
- 2.00 No<rnal

...$ s

-1 5 10 30 35 40 45 50 55
~ :c

"'jE"' l< -3
S1rida (%)

Figur~ 5.6 l.umbar motion during three speeds of walking foo · one noomal subject (normalized to RHC to RHC;: Ia) lumbao
flexioo>-e.cension in v.4nich extension is 1m itive, rb) lateral bend in which positive indicates bend to llw right. (c) axial twist
in which positive indic.ates the upper body twisting to the right.

flexion in the lumbar spine, and people, if left alone, generally sit in a variety or flesed postures
(Callaghan and McGill, 200 I b). Sin:ing generally involves lower ahdominal wall acti,~ty (jJarticu-
larly the deep abdominalinuscles) compared to standing> and generally higher txttnsor activity
with unsupported sitting (see Callaghan, J'atla, and McGiU, 1999, for walking and u llaghan
and McGil.l, 2001b, for sitting). Sirting slouched mi nimi7£S muscle activity, while sirting more
upright requires l1igher activation of the psoas and the "''tensors (Iuker, McGill, Kropf, and Stef-
fen, 1998). Full flexion increases disc attnulus stresses; this posture Ius produced cUsc herniatiorts
in rhe lah (e.g., Wik1er, Pope. and Frymoyer, 1988). [n ti>ct, Kelsey ( 1975) disco,•ered a specific
link !)(•tween prolonged .sitting and the intidcncc of henUation. Nlore upright sitting posrurts,
and the concomirnnt J>SOas and other muscle atti\'1\tion, impose additional compressi,·c loads on
the spine. Cha nging l 1unb~u posr\lrescallSes a migration of the loacis from one tissue ro another.

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10 ro ~ • ~ ~ ro ~ ~ ~
Strtle (%>

o 10 ro ~ • ~ ~ ~ ~ oo ~

R-IO S!ra:Jo (%•

g •
i! • ,·?-"')
i ~!-=--: . ----~~~ --~
o 10 * ~ ~ • w ~
' •
' •
' '
l ·LD Slftle ("')


1 1
~ •
l• •'
;P--....... l •53
I ••<...n I
2 ./ ~... 2
1 ~ --·--/ ''\.";·...-.~.-~~--=-'"·· u 1

10 20 30 40 50 60 70 80 90 100
•• 10 ro ~ • w ~ ro ~ ~ m
IHES S!(t'J(!(%t L·LES Slrl1e(%•



6 •
• ~ . ··-" l
I .,' ••' ' i •
.. .. .. .. ' '

10 ro SQ
•• ~
•• 100 •1..-MUI..T
10 •• $!ride (%)
•• 70

•• 100

Figure 5.7 Activation profiles (EMG sign.~ Is) irom 14 to1·so muscles during three speeds of walking with normal arm swing
and normalized to RHC to RHC. TI1e muscle pairs are (RAJ rectus abdominis, (EO) external obliqL1e, (10 ) internal oblique,
(LD) latissimus dorsi, (TES) thoracic erector spinae, (LESI lumbar erector spinae, and (MULTI multifidus.

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Normal '!_nd lnj~Mechanics of the l umbar ine 87

Callaghan and McGill (200 Ib) suggested d>;Jt no single. ideal sitting posture existS; J"llther, a variable
postt~re is rttotnmended as a strategy to minimize the risk of tissue overload. For t;,ample, Srujders
and collea!,'' Ues (20011) ha,·e suggested that a "cross-legged" sitting poswre stabilizes the sacroiliac
jnim:s via p·assive tensioning of tbe iljo )umbar li!,rame.nt and piriformis muscle.

Loads from Backpack Carriage

Backpack.< t ome in vllJi ous designs that affect low back loading. Generally if roug h terrain is
anticipated, d1e load should be placed low in tbe pack to minimize the moment ariJl or distance
ro the low b•1ck. At; the load is car ried over rong h g round it ; 1 cceler.1tes and decelerates. T he
load placed doser to the low back reduces tl1e torso forces needed to move the backpack load.
On the other hand if smooth grow>d is anticipated, carl)•iog the load high in the pack, and over
che fulcrum oF[he low h 1-ck :tnd hips, req11ires smaller [Orso muscle forces- :lncl lower lnmhar
spine loads rc-,."Uit.

Backpack Carrying
Now for Lhe curious situation in which backpacks can reduce spine loads--and rhus form one
of our exercise-based therapy prescriptions. An individual who is flexion intolerant, and also has
posterio( discogenic l)<lck p<lin exacerbated by prolonged sitting, generally has difficul ty standing
up. Upon standing, a forward torso angle (antalgic poslure) remains. If this type of individual can
tolerate compression, "'e pr~cribe wearing a backpack with about 10 kg (22 Ib) plated low in the
backpack (about the level of the lumbar SJ)ine} Md going for a walk over uneven ground. Wearing
Jile backPiltk aCIS to genecale torso exten;or momen1, bringing tile 1orso into an upright posture.
This alleviates lhe spine extensors, which were previously contracted in the slanding, bul flexed,
posture . Given their larger moment arm, lhis reduces the compresSive load on the spine. The com·
pression reduclion irom the muscles shuNing down is larger than the extra co mpression irom I he
adclitionalloacl in the pack, resulting in a net reduction in total compression on the back. Walking
over un even ground provides gentle motion to the lumb.1r spine, which is therapeutic to the type
of di>,ogenic person we are describing here. Typically the palient returns saying, "Thank.~-that
was amazing: Thus, while some have blamed backpacks as a source of back troubles, they can
actually be used therapeutically.
I recall a tadio interview in which a chimpractor was claiming !hat chil<lreO> carrying backpacks
over one shoulder was a serious problem, and the interviewers phoned for my "on-air" comment.
No doubt some children will expericnco troubl<lS, but there is also a training opportunity here. If
Jhe chi! dren were to swilch shoulders frequently.. this problematic task would become clever back
training! The issue of lhe training load versus the dangerous load hinges on some subde modula-
tors. Perhaps the chiropractor wasright-have th~ children carry their backpacks on both shoulders.
Bu11he technique oi changing shoulders would have changed a perceived danger into 1raini11g for
belter health and performance.

loads on the low Back During Various Exercises

Because e.\':ercise is a cmcial element of rehabilitation for low back problems> ir is cn1cia l that
you undcrstamJ clu:: loads you arc imposing on your paticn['s back when you pn::.s:tt·ibc an exer-
cise. OtheJ·wise whm was intended tu be therapeutic ma)' becOJne an exacerbating Ji•cror for her
back troubles. J\llasteringrhe information in this section will increase your ability to raHor every
exercise[() each client's uolque needs not only :n the OU[set of trcannent, bur a[ e\'"ery stage of
ltet' progression toward bette•· low back healtll.

Loads on the Low Back During Flexion Exercises

\le11' few Studie.' (on()' Ollr 0\Vll mat we are aware of) have quantified the tissue Joa.ding 00 me
low back cissucs during various types of tor:so Bcxion exercises, although some h:.l\'"C measured

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6 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Back OiS<lr<iers

the £MG a<.'tivity ofselected UluSdes (e.g., F~nt, 1965; Halpern and Bleck, 1979;]ctte, Sidney, and Cicutri,
19X4). T his type ofinfo11narion alone can provide insight into reh•ti,•e muscle ch.,llenge, hut it is restrictive fOI'
f:,rttiding exercise prescription da1sions bec:mse
d1e resul1>1nt spine load is unknown. Tbe goal is
Gross to challenge muscle "t approp'i"te levels but in
a way that spares rhe spine. 10o many exe1-cises
are prescrihed for hack ~~fferers that exceed d1e
Curl-up tolerance of their compn>mised tissues. In fact, I
believe that many commonly prescribed flexion
exerdscs result in so much spine compression that
they will ensure the 1>erson remai ns :l patient.
For example, the traditional sir-u p imposes
approximately 3300 K (ahout 730 lb) of com-
pressiun on the spine (Axkr and Mc:Gill, 1997).
Straight~eg (Figure 5.8 iUustrntes psoas and abdominal muscle
activation levels in a variery of flexjon rasks,
while figure 5.9 illusrr-ates activation patterns
Push-up with bent-kneesit-ups, ;md figu re 5.I 0 illustrates
rrom reet activation patterns wlth ben t-knc~ curl-ups.)
Note that muscle activation levels arc cxprCS.'\etl
in nonn"Ji>,ed units (% M VC). T his means that
leg raise tbe acti,;ty is expressed as a 1:.ercenrage of what
woulcl be ohsetved during a maximal volunta ry
t'(Jiltraction (MVC), thus quantifying activity in
a physiological and fw1ttional com<:xt. Further,
the spine is ve1y flexed dul"ing the pe•·iod of this
load (McGill, 1998). T he National fJlStitute fo,·
Bent knee Occupational Safety and Health (NTOSH)(I\181)
sit·up has set the action limit for low lrdck c..--ompres.sion
at 3300 N; repetitive loading ahovc tbis level is
liJ>ked with ltigher injury rates in worl:ers, )'Ct this
raise is imposed on the spine with each re.petition of
the sir-up! T1ble 5.7 <hows the quantification of
a variety of push-or exercises.
Press·heel M.any recommend perform.iog s it-ups with
sit-up tl1e knees bc:mt, the theory being that tl>e psoas is
realigned m reduce cornpressive loading, or per·
haps the psoa~ is shortened on d1e length-ten~ion
Isometric r relationship so that the resulting forces are
hand to I knee
red need. After examining horh of these ideas, we
found the.m tO be untenable. \•Ve rocruited a group
0 10 20 30 40 50 60 70 80 of women who were smaJJ eJlough to fil into a
Percent MVC
•mgnetic resonance imaging(MRI) scanner. We
placed e-ach woman into the scaunt:r omd varied
her knee and hip angles while she was supine
0 Psoas 1 (Sant"gnida and McGill, 1995). T he psoas did
[J Psoas 2 JlOt ch11nge irs line of action, nor cou.ld it since it

Rectus abdominis is attached to each vertebral bod\• and transverse
External oblique process (as the lumbar spine increases lordosis,
0 Internal oblique the psoas follows this curve). The psnas does nor
0 Transversus abdominis change it.~ role from a flexor to an as. a
function of lordosis-this interpretation etrOI'
F:igurc. 5.8 Activalion of the pso.-ls and the alxlomioal occurred from models in which the psoas was
muscles in a variety of flexion tnsks from J group of represented as a straight-Une puller. In fdt't, the
highly trained subjects tfivc men and three women). psoas follows the lordoti(' curve as the ltnnbar

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Normal '!_nd lnj~Mechanics of the lumbar ine 89

100 .-----------------------------------------------------------,

20 " __.. /

2 3 4 5 6 7 8 9 10 11 12 13 14
Time (s)
--- Psoas 1 indwelling electrodes
---Rectus abdominis surface electrodes
- - - External oblique indwelling electrodes
- ········ lnt•ernal oblique indwelling electrodes
- - - Transversus abdominis indwelling electrodes

Figure 5.9 Activation -lime histories of the same subjects as in figure 5 .8 performing a bent-knee sit-up. Surface and
indwelling cleclrodes arc indlcaled.

spine O e~es and exteods. Further, it is true that the psoas is shortened with hip Oe:xion, but irs
activation level is higber during bent-knee sit-ups Qu ker, l'vlcGill, Kropf, and Steffen, 1998),
nor lower as has been previously thought- This is bee::~ use rhe hip tle.,;on rorque must come
from somewhere, and the shortened psoas must contract to higher levels of acth·ation given
irs compromised length. Given that tbe sit-up imposes such a large compression load on
d1e spine, regardless of the leg's being bent or straight, the issue is nor wlticb type of sit-up
shouhl be r ecomi1Jended. Rather, sit-ups shou ld not be performed at all by most people. Far
hetter wars exist ro preserve rhe abdominal muscle cha llenge while imposi ng lnwer spine
loads. Those who are tr:l ining for health never neecl to perform :1 sir-up; rhose lYaining for
performance may gtt better results by judiciously incorporating them into their routine.
~While J>art ill of this book ("Low Back Rehabilitation") offers specific preferred exercises and
challenges to specific muscles,~ few tle,icm e.'ercises will he reviewed here. First, hanging "ith
the arms from an o verhead bar and flexing the hips to raise the legs is olten thought to im~X)Se
low spine loads bec,mse the body is hanging in tension-not compression, This is faulty logic.
This hanging exercise generates well over 100 Nm of abdominal torque (Axler and McGill,
1997). ·T his produt-es almost maximal abdominal activation. which in rum imposes compres.'iive
forces on t he spine (sec table 5.7). (Note: lianging \\1th bent knees resulted in higher overage
spine loads due ro the imprecise technique employed by many subjects who allowed substantial
lumbar flexion. Further, few s.ubject~ were ahie to maintain form during che straight~leg hang.

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0 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Back OiS<lr<iers

1 00~-----------------=~------------------~---------------------,
~I<>.. . ... ~~
~ ~-..:.Y~ ~ ~~
~ ~ t ~


> 40

20 ~

3 4 5 6 1 10 11
Time (s)
- - - Psoas 1 indwelling electrodes
- - Rectus abdominis surlace electrodes
- - - E><ternal oblique indwelling electrodes
·-·-···· Internal oblique indwelling electrodes
Transversus abdominis indwelling electrodes

Figure 5 .1 0 Activation. time histories for the same group performing curl

Good form is impomtllt bur requires subsmntial athletic ability.) Similar activ:uioo levels can be
achieved ,.;,)l rhe side bridge (shown later and discussed in demil) with lower spine loads.
T his having been .stated, those who are not interested in sparing their back and are training
with perfor.mant•e ohjeetives ma)' benefit from the high psoas t hallenge, together with recrus
abdominis and oblique acti,•ity. Cleorly, cl1e curl-up primarily ta rgets cl1e rectus (both upper
and lower), and generally other exercises shc)u ld be performed to o·;>in the obliques. Some
have suggested a twisting curl · lll' ro engage the obliques, bur this resu lrs in a poor re1tio of
oblique mnstle challenge to spine compression t.'<>mpared to the side-bridge ~xerds.e (A.xler anJ
McGill, 1997)-making tbe side IJ•idb"' a preferred exercise.

Loads on the Low Back During Push-Up Exercises

!\1-an)t have reco_b"ltized that many f01ms of spine stabilization exercise enbrage the abdominal
hoop comprising rectus abdomjuis, the internal and e.xternal obliques, <Uld transvers~ abdominis
in an isomerric contraCtion (•VIcGill, 1006). F'or this •·eason, push-up exercises are sometimes
used as a t(llniO training exercise. Clinical o bservation confinns that perfonning push -upselidts
back in SOn'l c patients yet others lind push-ups relic,~ng. l.t1 our quantification of push-up
exercises, we examined styles '"nging from uadition:tl ro placing the hands on labile surfaces
(balls), staggered hand placemenr, one armed push-ups, and so on (Freeman et a I., 2006). v\lhile
pcrformiug push-ups with the hands on labile surf.tcX'S bas. soroe effect on spine lmtd, the onc.."-
'trmed and 01ore b;>llistic forms of tbe e~ercise requil'ing the hands to n1ove aJ'e •.nuch moJ'e spine

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Normal '!_nd lnj~Mechanics of the lumbar i ne 91

Table 5.7 Total Compression While dem"nding (see t:lble 5.8). Those i11tcrested
Performing Different Styles of Push-Ups in challenging rhe abdominal ohliques ;mel
"steering"' the asymmetric fo re(' from st:'.tg-
Exercise Compression (N) gered hand placemeot through the torso will
he interested in the quite modest increase in
1838 spine compression demand . Not surprisingly,
1 Arm 5848 the plyometric forms oftl!C push-ups are much
more muscularly demanding and therefore
Staggered ~lands - Right f<Jrward 2532 resuJt in higher spine load . Thi s may be a
Staggered Hand~ -lei! rorward 2337 concern for those who may be I:Ound to be
sensitive to spine comp1·ess.ion d lll'i ng provoca-
Righi H,md on Ba II 23 15 tive d iagnostic te.stin g. Spinalloacling during
n)anr fonns o f t he push-up is :substantia l.
Left Hond on Ball 2295
There is little wonder thar these exe1"ciscs are
2 Hands on I Ball 2840 problematic for some painful hacks. On the
other hand, they 1nay be very app ropriate as
Hands on 2 Sails (1 on c.1chl 28.29 an abdominal plyometric exer·cise fo1· higb-
AlternJting 6224 perfomlance individuals.

Clapping 4699 Loads on the Low Back

Fast Concentri<.. 3905 D uring Extension Exercises

Slow Ecce!llric 2222 As \\1d> the llexion exercises discmsed in rhe

Ad.lpEtXI, bype.mlssloo, irom !:.. l·(een'li'l n,A. k<lqXWtteZ, J, Gr.l}·, and ~.M. McGill,
previous paragraph, plenty of EA·1G-based
2006, "Quamlfylng moscle IW letnS and splne lo.ld Juring vJtloos fonns oi lhe
studies h~ve e,,plored extension exercises, but
pu$hvp." ~.kdidnc <tn(l .~n«' m IOpom 01nd r wrciS<·. 38(11; 5 7Q.$il only one anempred to quanrify the resulting
ti.ssue loads. Exercise prescription s wilJ not be
successful ifthespineloadingis norconstru ined for bad backs. Usil>gthe virtual spine approach,
Callaghan, Gunning, and A·lcGill (1998) attempted to rank extension exe1'Cises on. the muscle
challenge, t he resultant spine load) and their oprima.J ratio. Tbe key to p reserving a t herape utic
muscle ac..tivation level while min.UniUng the spine load is to activate onJy one side of the.: .spiJlC
musculao1re at a time. The muscle anatomy section in chapter 4 describes the functional separa-
tion of tbe thoracic and lumhar portions of the longissimus and iliocostalis. For the purposes of
this discu.ssjon, we can think of the extensors in four sections-right and left thor:l<·ic portions
:lnd t•ight a nd left lumb:\r portions. "J'he common extension msk of performing tOI'SO extension
with the leg• hracecl ;mel the cantilevered upper hody extending over the end of a bench or
Roman chair (figure 5.1111) activates all four ertcnsor groups aud typically imposes over 4000
N (about 890 lb) of compression on rhe spine. Even worse is the prescribed back
exrension rask in clin ics, in which the patienr lies prone and extends the legs and outstretched
arms; d1is again activates all four e>~Cnsor S(-ctions but imposes up to 6000 N (over 1300 II>) on
a hyperexrended spine (figure 5.1Jb). This is not justifiable fot any patient!
Several variations of exercise technique can preserve acrivarion in portions of rhe exrensors
aud f,>Ttady-spare the spioc.of high load. Forc.xamplc, knt-elingon all fuursand cxtcndiJngonc k-g at
d>e hip ge1terally activates one side of the lumbar extensors to over 20% of maximum ~nd imposes
only 20tXl N of compression (figure 5.ll t).l'erli.>mling me bird dog, in which the opposi(e :>rm is
extended at the shoulder while the leg is raised (figure 5.1 !d), adds activity to one side of the thoracic
oxtensors (generally around 30-4Q% ofmaxitnum) and com\lios the spine load to about 3000 N. In
addition, tile special rechniques sho""' for this exercise in chaprer 12 arrempt ro enhance the motor
t•ontrol system to groove For data des<-·ribing these exerc-ises, see [;lble 5.9.

Dubious Lifting Mechanisms

In the 1950s and 1960s spine biomechanists faced a paradox. The simple spiJ>e models of the
day predicted that cl1c spine would be crushed to the point of injury during certain lifting tasks,
yet when peopl.e perfon11ed those tasks, d1ey walked away uninjured. T his motivared several

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Table 5.8 Low Back Moment, Abdominal Muscle Activity,

and Lumbar Compressive Load Du ring Several Types of Abdominal Exercises
Moment (Nm) Reclus abdominis (% MVC)• External oblique Compression (N)
Straight-leg sit-up 148 121 70 3506
Bent-leg sit-up 154 103 70 3350
Curl-up, feet anchored 92 87 45 2009
Curl-up, feet free 81 67 38 1991
Quarter sit-up 114 78 42 2392
Straight-leg raise 102 57 35 2525
Bent-leg raise 82 35 24 "1767
CI'Oss-knee curl-up 112 R9 67 2964
Hanging, straight leg 107 11 2 90 280.5
Hanging, bent leg 84 78 6-1 3313
Isometric si<le bridge 72 48 50 2'85

8 b

c d

Figure 5.11 Specific extension exerc ises quantified for muscle acrivalion and the 1·esultant spine
lood (show" in table .5.9/: (•) trunk extension, (/)) pron<t leg end 1runk extension, (c) single-leg ~.x t en­
sion, and (d) single-leg and contralateral • m1 e>~ension tbird dog).

research groups to theorize about mecha nisms tharcou.ld unload compre-ssive stresse~ from che
spine.. Rl'SCan..:hers proposed thre.c major mt:chaujs-m.s: the intra-abdominal pressure mL-chanism,
the lumbodorsal fascia mechanism, and the hydraulic amplifier. Although none has su" ' ived
~<;n1tiny, clinical ve~tiges ~till remain, Nonerlwle$S, ~ome compon~nrs provided in1ighr f(1r
subse.:1uenr study and l•d tO the underst<mding that we have today. For this reason they will be
reviewed b rieOy bere.

Intra-Abdominal Pressure
Does intra-abdominal pressure (lAP) ph1y !Ill important role in the >upport of the lwnl>ar
spine, especi;~lly during su enuO\IS lifting, as has been cl;~imed for many yea1·s? Anatomical
accuracy iJJ reprcsemarlon ofthe imrolved tissues has been infl uential in this de ba te. Fu rther,
restan.:b OJl lifting rnc:cbani<:s bas formed a corner.stont' for tht' ptc..'icription o f ab-dominal
belts for indusn·ial workers and has motivated the prescription of abdomim l strengthening
programs. Many researchers have. advocated the use of IAl> as a mechanism to directly reduce

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Normal '!_nd lnj~Mecha nics of the lumbar i ne 93

Table 5.9 Mean Activation l evels (± 1 SO) of 14 EMG Channels for 1 3 Subjects
Pe rforming a Variety of Extensor-Dominant Exercises (Expressed as a Percentage of MVC)
Righll~g l~ft l~g
Elcctromyographic and and Trunk Calibration
channel* Right leg left leg left arm right arm and legs Trt~nk posture
Right RA X 3 .3 2.7 4 .0 3 .5 4.7 .l .1 1.4
so 2.4 1.9 2.0 2.0 2.2 1.8 1.0
Right EO X 8 .4 4.9 16.2 5.2 4.3 3 .7 1.0
so 4.9 1.5 6.0 2.3 2.5 1.7 0.1>
RightiO X 12.0 8.2 15.6 12.0 12.1 '12 .7 1.9
so 6 .8 2.5 8.2 4.2 10.1 10.6 "1.2
Right lD X 6.1 5.8 12.0 12 .5 '11.2 6.5 5.9
so 5 .4 3.5 9,6 6 .2 4 .3 4.0 6.5
Right TES X 5 .7 13.7 11 .5 46.8 66.1 45 .4 2 1.0
so 2 .0 7.5 6.6 29.3 18.8 '10.6 9.0
Right lES X 19.7 1'1.7 28.4 19.4 59.2 57 .8 21.3
so 9.1 4.9 10.2 1"1.0 11 .7 8 .5 4 ,6
Right MF X 2 1.9 10 .8 31.5 16.1 5 1.9 4 7 .5 16.4
so 6.3 6.0 8 .2 12.0 14.7 12 .3 5.6
l eft RA X 4.3 :u, 4.4 4.2 o.S 3 .7 2.2
so 3.4 3.6 3.8 3 .9 3.4 2.4 2.1
left EO X 5 .4 9.0 6.2 15.9 6.3 5.2 1.8
so 2 .0 3.8 2.5 6.6 3.2 .'U 1.0
l eft iO X 16.0 11.3 22.6 15.2 11.0 12.5 1.6
so 6 .6 7.0 9.2 6 .7 5 .9 6.1 1.3
l eft LD X 4.5 5.0 10.7 6.2 9.2 5 .1 6.1
so 4.3 4.5 16.2 4.4 5. 1 4 .1 6.5
left TES X 15.0 4.5 42.9 10 .5 63.6 4 1.6 21.2
so 7.5 2.0 20.5 5 .9 22.7 10.0 9.8
l elt lES X 11.3 16.8 19.5 25.5 56.8 57.0 23.3
so 6.6 4.5 7.4 7.3 14.5 14,7 8.4
l eft MF X 11 .9 22.3 16.6 33.8 57.:1 53.3 18.7
so 7.0 b.l 7.2 1>.7 11 .4 12 .0 4 ..1
.. .. . ...
r:Jot iJQm)'OS'~htt; channeL IV\ • f("l"tV!' ,,lxlomm•smuscl('l, EO .. e\:ICin<ll obh<pl.' mu!<C:IoC>, IO .. tnt~,•I obl~ f'llll~j,e.. LO .... Ia••lt).lmV"' rlon;1ml•~. 1£S ... 1howc•c
= =
ere...ror SJ)i•'·~ m,w;le, tts klml.)<)l ct~Cilll' Sf)i fl.lf! mus.c61:!, Mt- ruulti(nlu~ muscle. <Afillf'.lllon ll~hJre: Sl.lndu'&- tlul'll.: i}e):c.od flO ·, lu.nb.v pm~ ute, I 0 ktt
(12 lbJ hekJ In h ilnd> With d fi)W l\ologii'S S.IJigiU dowl'l.

lumbar spine (.'Ompression (Bearn, 1961; ' n10mson, 1988). However, some researchei'S believe that
cl1e role of LAP in reducing spinalloarl,< has been overemphasized (Grew, 19\lO; ](,.,g er .tl., J986).

Anatomical Consistency in Examining the Role

of Infra-Abdominal Pressure
Morris, Lucas, and Bresler ( 1961) first operationalized the mechanics of the original proposal
into a model and described it as follows, Pressuriung the abdomen by closing tl1e glottis and
bearing do"" during an exertion exens hydraulic force down on rhe peh•ic Aool' and up on rhe
d iaphrab'lll,. c reating a tensl1e effect over th e lumbar spine or at le~tst alleviating some of the
compression. 1\•Ussing in the early calculations of this hydraulic potential was the full ackuo...-1-
edgmenr ot' the necessary abdominal activity (contl';lcting the abdomina l wall im poses exu"

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compression on the spine). But t~val uation of t he rracle-off~twet:n the exn-a abdomin al musdc
compression and d1e hydraulic relief depended on the geometrical assumptions made. Some of
rhese asst1mptions 3Pf)ear ro he outside of hiological reality. In fJct, experimenta I e'~dence sug-
gests that wmehow, in rhe process of hull cling up lAP, the net compress-ive load un the spine is
increased! [{rag and coworkers (1986) observed increased low b:1ck EMG activity wit b incre<lsed
IAI' during vohontary Valsalva ""'"euvers. Nachemson and Morris (1964) and Nachemson .
Anders.wn, and Sehultz (1986) showed an increase in intradis.:al pressure during a \Talsalva
maneuver, indicating a net increase in spine compression with an incre-.ssc in 1\P, presumably
a reS\•It of :.lbdominal wall muscularure ;lc-rivity.
lu our own investigation, in which we used our virtuaJ spine model, we noted that net spine
t·ornprcssion was jncreascd from t he necessary concomit'.tnt abdonUnaJ activity to increase lAP.
f urthermore, the size of the cross-sectional Mea of the diaph 1"gm and the momeJlt arm used
ro estimare force and moment at the lower hunbar level~, pro<luced br W J, have a major effe<..·t on
conclusions reached about ilic rolcoflAP (McGill and Noonan, 1987). T he tliaphragm surfuct area
was raken as2-13 em', and theceotroidofthis area wasphced 3.8cm anteriortotllecemeroftheT l2
disc (compare rl1ese valoes";th those used in ocl1er $Oldies: 511 cm1 for rJ1e peh;c Boor, 465 em' for
the: diaphr..agm, and n:JOmcnt ann distances of up to ll .4 em, which is outside the chest in most
people). D"riog squat lilts, the ner effect of the involvemeut of rhe abdominal musculature and
L>\P seems robe co increase compression railier than alleviate joim load. (A det:liled description
and analysis of the fortes arc in McGill and i'i01man, 1987 .) T his theoretical finding agrees
with the expe,·imemal evidence of Krag and coUeab'Ues (1986), who used EMG to evaluate lbe.
effecr of rech1cing the need for the extensors to contract (they dicln't)> and ofNachemson ancl
('oUeabrues ( L986), who documented intrt--ased intradiscaJ pressure \\~th an i nt reasc in LAP.

Role of lAP During Lifting

The generation of appreciable lAP during load-handling rask:< is well documented. T he role
of lAP is not. FarfJn (1973) suggested that lAP create~ a pressurized visct..·.ral cavity to maintain
the hooplike geometry of the abdominal muscle.<. ln recent wor~ in which they measured the
distance of the abdominal muscles to rl1e spine (moment am1s), McGiii,Juker, and Axler (1996)
were unable to confirm substantial changes in abdoJninal geometry when accivatcd i:n a standing
posnlfe. However, the compression penalty of abdominal activity cannot be discounted. T he
spine appears to he well suited to increased compression loads if inui nsic sr:.1hility is
increased. An unsw.blc spine buckles uudcr extremely low compressive loads (e.g., approxi1natcly
20 N, or aoout 5 Ib) (Lucas and Bresler, 1961). 111e geometry of the spinal musculature suggests
that individual exen lareraJ and anterior.. posterior force~ on the spine that can be
thought of as b>uY v.ires on a mast to prevent bending and compressive buckli11g (Cholewit:ki
and McGill, 1996). As well, activated abdominal muscles create a rigid C)'lioder of the u-uJlk,
resulting in a stiffer stmcmre. Recently, horh Cholewicki and colleagues ( 1999} and Grenier
and coUeag11eS (in press) documented incrto:ased tOrso )-tiffness duri.n g elevated lAP even when
accounting for similar abdominal w,ill contractiou levels. It also appears that lAP can iufluencc
pelvic mechanics anti pain. Mens and colleagl1es (2006) noted higher pelvic ring forces "iili
elevated lAP, which may stabiHze some yet destabiHze others-depending on the narurc of
tissue compromise. The clinical solution for this divergence is to perform Jll'OI'<X'ati,·e testiug
co ,.e,•eal "' hether the patient's problem is helped or exacerbated. Thus, although the increased
IAP commonl~r observed dudng lifting and in people e~verie.n dng hack po1in docs not have a
djrect role in redudngspinal com.prcssion or in adding to d\c extensor moment, it does stHren
the U"Unk amd p1·evenc tiSS\Ie strain or fi1ilure ~·om buckling.

lumbodorsal Fascia
Recent smdies have attributed variou$ mechanical role< to ilie hunhoclorsal f.1sci~ ( LDJ."). In
partic11lar, some have sugg-ested that the LD I' reduces spine loads-sol>ing the paradox noted
earliec. In filet, some have recoml)lended lifting postures based oo various interpretations of the
mechanics of rl1e LDE Gracovetsky, I'arfan, and La my ( 1981) origin:JIIy &Uf,>ge<ted that lateral
furces gent: rated by internal oblique and cransversc abclominis arc transmitted to the LDF via

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Normal '!_nd lnj~Mechanics of the lumbar ine 95

tl>eir ~ttlclmlents to the lateral border. They also claiJued that the Fascia could supportsubst:Ultial
extensor moments. l'urrher, laten1l tension from abdominal wall attachments w11s hwothesized
to increase longirudina1 tension from Poissc:mjs effect, caus-ing the posterior spinous proce.o;.ses
to rno\fe together resuJth1g in lumbar extension. 'I1Us sequence of events formed an attracti"·c
propositio'" because rhe LDF has the largest moment ann of all extenso•· tissues. As a result,
any extensor forces within the LD F would impose the smallest compressive penalty to vertebral
components of the spine.
T hree independent sn•dies, however, examined the mechanical role of the lDF and collectively
que,-tioned the idea that the LDF could support substantial e.~ensor moment< (Macinmsh and
Bogduk, 1987; McGill and Norwan, 1988; Tesb, DUJm, and E'"JnS, 1987). As previously noted,
regardless of the choice ofLDF a~1iv:nio11 stnnegy, the I, I)F contribution to the ,·estor:nive
e.xrension moment was neglig ible compare<l with the mucb la rger low back reaction moment
required to support a loacl in the hands. Its function may be that of an cxtcn..wr tuuscJc retinacu-
lum (6ogduk and Macimoslt, 1984). Huld.ns, Aspden, and Hickey (1990) proposed on theoretical
grounds cl1at the LDF acrs to increase rhe force per 1m it ofcross ..secrional area thar nntsclecan
produce by up to .W%. T hey suggested d1at this intTt:asc in force is achieved b)' l:onstraining
bulging of the muscles when they shorten. This contention remains to be pi'Oven. 'lesh, Dunn,
and Evans (1987) suggested that the LDF may be imporranr for supporting lateral bending.
Furthermore, rhcrc is no que.~tion th:tt the LDF is involved in enhancing stabiJjty of the lumbar
column. l"o doubt, complete assessment of these notions will be pursued in the future.

Hydraulic Amplifier
The final Jnechanisu'l hypothesized to unload <..xnnpresshre stresses from the sp:ine was the
hydraulic amplilier. This hybrid mechanism depends on rhree notions. Virst, the elevated lAP
preserves the hoopUke b"'omerry of the abdominal wall during exerci(m. The IAP must also exerr
hydrouUc p ressure posteriorly over the spine and presumably tbrougb to the wlllcrsidc of tl>c
1, ]) E Fina»ly, as d>e extensor m\tscle mass contracrs, ir was proposed ro "bulk" upon shorrening,
again incrett~ing the hydraulic pressure under the fascia . ...fbe biomechanical attraction of rhe
pressure under the fascia is that any longitudinal forces generated in the fascia reduce tl1c need
for the und.el'lyingmuscles to contribute extenso•· forces, tbereby loweriog d1e colllpressi,•e load
on the spine. Both o f these proposal< were dismissed. Given the size of the fascb, hydraulic
pressures would have to reach levels of hundreds of mmHg. Pressures of this magnitude simply
ore not observed during recording (Cart cr al., 1985). Nloreovet·, tl1e presence or abseoce of
LAJ' makes little difference on rh e hooplike geometry of the abdominal wall (McGii.I ,J uker, and
A.~er, 1996), as this is more modulated by the posture.

lAP, LDF, and Hydraulic Amplifier: A Summary

IAP, the mechanical role of the LDF: and [he existenceof the hydraulic amplifier were proposed
to acrowlt for the paradox that people w~re able to perform lilts that the simple models sug-
gested would crush their spines. Yer, although both lAP and the LI)F appear to play some role
in liftlng. 11one of the three propo~e<l mechanisms was a tenable explanation fi)r r:he paradox of
unm 1shed spiul'S under h cav~· loading, whether t:Onsiden:d S<:parntcly or tornblncd with the
other rwo. The pt'Oblem lay in the simple models oftllfee and four decades ago. Kat only were
the rather complex mechanics nor r~presenred with the necess<~ry detail, but also the strength of
the cissm.\'i to Ucar load wa~ also quite uudcrCStiJnatcd in the early tCSt$ that ustd old cadaveric
s.1mples thm were crushed uJJdemeath an:ificioUy stiff t'\UllS of materials-te.~tiog '""chines tlm
caused failure too early.

Other Important Mechanisms

of Normal Spine Mechanics
Several other fl-aturcs of .spine mechanics influence fw1ction and ultimately undc.rpin strategies
lor injury prevention and rehabilimiOI.\. T he most importam are ptesented here.

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Biomechanics o f Diurnal Spine Changes

Most peoJ>Ie h~ve e.<perienced the ease of L~king off their socks ar night compared to putting
them on in rhe morning. T he (liurnaJ variatio n in spine length (the spine being longer after
a night':> oodrest), together with the abi~ty
to llex fo,'Wa •·d, has been well documented.
Early-Morning Exercise Reilly, T)"1ell. ;md Troup ( I 98'l) measured
1osscs in sitting height over a day of up ro
Peopl~ should not undertake spine exer-
J9 mm. ~11>C)' also noted that approximately
cises-particularly those that require 54% of this loss occurred in the first 30 min-
full spine (lcxion or bending-just after utes after rising. Over the course of a da} 1,

rising irQm bed. given the elevated tissue hydroscatic pressures cause a net outflow of
stresses that result. This would hold true tluid from the disc, resulting in narrowing
for any occupational task requiring full of the space between the vertebrae, which
spine rMge of motion. iu lUrn reduces tension in t1lc l j ~uneots.
\~l'hen a person lies down at niglu~ osmoric
pressures i n the elise nucleus exceed the hydrostatic pressure, causing t he t.Hsc to expand.
Ada ms. Dolan, and Hutton ( I987) noted that the range of lumbar flexion i11creased by ;• to
6° throughom the day. The increased flt•id content alter rising from bed caused the lumba •·
spine to he more resistant to bending~ while the musculamre did not appear to compensate by
restl1cting d>e bending rnnge. Adams and coll eagu ~s estimated that disc-bending >tresses were
increased by J()(J% and lig.unent stresses by 80% in the mol'ning compared to the evening; they
concluded that t here ls an increased risk of injury to these tissues during bending fo nvard early
in the morning. Reccndy, Snook and colleagues (1998) demonstr.lted that simply a voiding lull
lumbar flexion in lhe morning reduced back symptoms. We are heginning ro understand lhe

Spinal Memory
The function of the spine i.s mo<lulatecl by certain previoLLs activity. This occttrs because the Joad·
ing history dctmnines disc hydration (ru1d thcrefurc the sire of cl1c disc space and disc gt~>met.ry),
which in tllrn modulates ligament rest length, joint mobility, stifli>ess, and lo<1d distdbution.
C'.onsicler the following scenario: McKenzie (I979) proposed that the nucleus within the annulus
migrates anteriorly during ~piJ1al C..\':tension and posteriorly durin!$ Ac.xion. Nit•Keltzic~ program
of passive exteosioo of the lumbar spioe (which is currently popular in physical therapy) was
hased on t.he supposition t hat ::.n anterior movement of the nucleus would decrease pressure on
the posterior po rtions of d1c annul us~ which is the most problematic site of herniation. Because
of the viscous properties of the nuclear material, such ret>Ositioningof tbenudeus is not immedi-
ate alter a postural change but rather takes time. Krag ;md coworkers ( 1987) observed anrerior
movement of cl1e nudcus during lumbar cxtcm,ion, aJbdt quite m i11ute, from aJl elaborate
experiment th"-t placed radio-opaque markers in the tn1cleus of cadaveric lumbar motion
segments. '\i\'herher t his ohsenration was caused .simply by <1 redisrrihudon of rhe centroid
of t he wedge-shaped nuclear cavity moving fo rward with flexion o r was a moveJnent of the
whole nucleus •·em ains to be see11. Nonetheless, hydraulic theory would suggest lower bulging
forces on rhe posterior annulus if the nuclea r centroid moved anteriorly cloring e:\'tension. If""e fo rces were -appUed to a disc in which du~ nuclear material wa.s stil) posterior (as in
lifting immediately after a prolonged period of Hexion), a concentration of stress would OCC'Ur
on the posterior annul\l.'i.
Vlhile this sp<.'Cific area o f reseru·ch needs more development, a time constant seems to be
associated with the redistribution of nuclear material. If this 1·esult is conect. it would be unwise
to li ft an obje;:t immediately following prolonged nexion, such as sittillg or stooping (e.g.. a
stooped gardener should not stmd erect and immecli:uely lift a heavy o bject). Fu rthermore~
Adams and J Iutton (L988) suggested that prolonged full Aexion ruay c-•use the po:sterior liga-
ments 10 creep, which may allow damaging nexion postu•·es to go unchecked if lordosis is not
conrroUe-d during subsequent lift5. ln a smdy of posterio r passive tissue t.Teep duriog sitting in a
sloud1cd p<)Sturc, McGill ancl Brown ( 1992) show('d d~atovcr the 2 minutes following 20 min-

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Functional Significance of Spinal Memory

It would appear protective to avoid loading immediately after a bout of prolonged flexion. In the
occupational world this has relevance to ambulance drivers, lor example, who drive to an accident
scene wit hout the luxury of time to warm up {or reset the passive tissues) before Iilting. They would
be wise to sit with a lumbar pild to avoid lumbar flexion and the associate(! creep. The athletic
world p rovides good examples as well, such as sitting on ~1e bench before engaging in play. Those
with sensitive backs would do well to avoid sitting on ~1e lxmch with a Oexed lumbar spine while
waiting t<> perform. we recently <1uantified the 1~1SS of compliance rn the lumbar spine with bench
sitting between bouts of athletic performance (Green, Grenier, and McGill, 2002) in elite \<OIIeybqll
players. Viscosity is also a consideration in prolonged postures since "internal friction" increases with
prolonged staticp{)stures. Si«ing in this way, and the associated change> in stiffness arlCI viscosity,
are detrimental to athletes' performance a nd increase their risk of injury. We will address this issue
more completely in chapter 13.

utes of fuJJ flexion, subjects rebrained o nly ha lf of t heir intervertebral joint stiffne.~. Even a fter
30 minutes of rest~ sornc residual join t laxity remained. This finding is of particular intportancc
fo•· indi1•iduals whose work is cba racreti?.ed by cyclic honts of full end t'llnge of moci on postures
followed hy exertion. Before lifting exertions following a stooped posrure or after prolonged
sitting, a c-ase coultl be m!tdc for St'.mdinq or even consciously ext ending the spine for a short
period. Allowing t:he nuclear marerial ro "equ ilibt·;ne." or move aoteriol'ly to a position associ-
arecl with norm;:t l lordosis, may decrease fo rces on the posterior n ucleus in a ~uhsequent lifting
task. Ligm1ents 11ill reg-ain some protective stiffness during a ilion period of lumbar C.'ttcnsion.
iD conclusion, the anatomy and geometry of d!e spine are not static. Much research remains to
be done to underst.and the impo rt:mce of ci:;;.sue loading history o n subsequent biomechanics,
rehabilita t&on therapies. and injury mechanics.

Anatomical Flexible Beam and Truss:

Muscle Cocontraction and Spine Stability
The osteolig:u nenrou.s spine is SOJll(!What of an anatomical paradox.: rr is ;-) weight· bearing,
upright, flexible rod. Observationally, the ability of the joints of the lumbar spine to bend in
any direction is ac<-omplished with large amouots of muscle coactivation. Such coactivation
patterns are counterproductive r.o generating rh e torgue neceS!l."lry ro <iUpport t he ;rpplied lo:HI.
Coactivatiun is a lso counte rproductive to minimize the load penalty imposed on the spine from
muscJe contNu::rjon. Researchers have poscularecl se\' eral ideas ro explain muscular c-oactiv<lt.ion:
The abdominal muscle~ are involvecl in the generation of lAP (Davis, 1959) or in providing
support fom?S to the lumb:tr spine via the LDF (Grat•ovetsky, Farfan, and Lamy, 1981). T h"'c
ideas have uor been without opposition (see previous soctiMs).
Another explanation for musC\1Iar co:ilcrivation is tenable. A ligamen tous sp ine will fl1il under
compre>sil'e loading in a buckling mode, at about 20 N (about 5 lb) (Lucas ami Brc:sler, 1961).
In other words, a bare spine is <ulable to bear compressive load! T he spine can be likened to
a 11exible rod thar will buckle under compressive loading. However, if the rod has goy wires
connt!ctcd to it, like the righring on a ship's mast , a lthough more compression is ultim;He ly
experienced by the rod, it is able to bear much more com1>ressive load since it is stiffened
and therefore more resista nt to huckling. The coconrracting muscuiHure or the lomb;H spine
(the flexible beam) can perrorm the role of stabilizing guy wires (the truss) to each lumbar
vertebra, bl"JCing it ag•inst buckling. Ret:ent work by Crisco and Panjabi ( 1990), as wd l "'by
Cholewicki and McGill (1996), Cholewicki, J ulut·u, and McGill (1999), and C'r.~rdner-Morse,
Stokes, and L<~ihle (1995), has begtm to quantify t:he intluence of muscle architecrure and the
ncccs~ry· c.:oattivation c.>n lumbar spine stabil ity. The ardUtccturc of many rorsu mus.dcs is
especiallys uited for tbe role of smbilizatio•l (Macintosh and Bogduk, 1987; J\ilcGiiJ and Not1nan,

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Injury Mechanisms
i\·1an)' clinicians, t'nbrincers, and ergonomists believe that reducing the risk of low back in jury
involves the reduction of applied loads to the various anatom.ital components at risk of injury.
Without q\1escion, reduction oF excessive loads is benefi-
cial, but this is an overly simplistic view. Optimal tissue
health requires an envelope orJoading, not too Ul uch or Muscular Cocontraction
too Iittle. W hile some occup:>tions require lower loads to In order to invoke the antibuckling ancl
reduce the risk, in sedentaryoc<.1lpations the risk can be
stabilizing mechanism during lifting, o ne
better reduced with more loading and \'arying the nature could justify lightly cocontracting the
of the loading. ' lo decide which is best, d1e clinicia n must musculature to minimize the r otential of
h<1ve a thorough understanding of the hiomech<1 nics of spine l>uckling.
injwy, whid t comes in two pa rt~. First is a Odd review
of the injul')' mechanisms of individual tissues; second is
a description of the in jury and several injuty scenar ios. AJso needed is: an under-
standing of generic situations: for low b:ttk tissue da1nagc described in the tissue injury primer
"t the end o l' chapre1· 1.

Summary of Specific Tissue Injury Mechanisms

This section provides a 1•ery brief description of damage fi·om excessive load. All in·juries noted
are knO\'-'' O to be accelerated with repetitive loading.
• End pk1tes. Sc.:hmorl's nodes are thought to he healed end-plate fra(.: ntrt:S (Vernon-
Roberts and Pirie, 1973) and pits that fonn from localized underlying trabecular bone coUapse
(Gunning, Ca llaghan, and McGill, ZOOI) ;md are lin ked to trauma (Aggrowall et al., 1979). In
fact, Kornherg (1988) documented (1;a MRI) tramnatic Schmorl's notle fonnation in a patient
following forced lumbar fle.u on d1at resulted in an injury. Poo~le apparently are not bom with
Schmol'l~ nodes; d1ei1· presence is associated with a mo1:e act.ive lifestyle (Hardcastle, Annear.
and f oster, 1992). Under ex<:essive compressive lo01cUng of spinal units in the laOOr:uory. d1e
end plate a ppears to be the first structure to be injured (Brinckmann, Biggcmann, and llilwcg,
19Sl!; Callaghan and McGill, 2001a). Studies have te1•ealed end-plate avulsion uncfe,· excessive
anrerior-po..~terior she~r loading.
• Ve1'tebrae. Vertebral ('ancellous bone is damaged under compressive loading (Ji"yhr ic and
SchaJOer, 1994) and often accom panjes disc hernia tion ,,nd annular delaminatioJl (Gunning,
C:>lh1ghan, and McGill, 2001).
• Disc tlmntliJ~·. Scvcra1 types of darnage to the disc annulus appear to occur. Classic disc-
herniation appears to be associated with repeated Aexion motion with on I)' moderate <:ompressive
loading required (Callaghan <1nd McGill, 200 la) and with full flexion with lateral bending and
twisting (Adams and l Iutton, 1985; Gordon ct al., 1991). Yi ngling and J\IcGiU (1999a, 1999b)
documented avulsion of rhe lateral annulus under ancerio,·-poscel·inr shear loading.
• Disc mtcle-us. While Buckwalter (1995), when refell'ing ro d1e disc nucleus, stated
that "no other musculoskd etaJ soft tissue structure undergoes more dramatic alterations with
:1ge," tbe rehuionsltips among loading. disc nutrition, decreasing conce11trmioo of viable cells,
accumuh tion of degraded maoi x molecules, and fatigue failure of d1e matrix remain obscure.
However, J"cccntly Lotz <1 nd Chin (2000) documented that cell death (apoptosis) within the
nucleus increases under e.xcessive compressive load. lntel'estiJlgly, these changes are generally
nor derecmble or diagnosable in vivo.
• Nerm1111nh (po;terior bat~y ekmellts). Spondrlitic fractures arc thoug-ht to occ:-ur from
repeated scress-stn in reversals associated with cyclic full Aexion and extension (Burnett et al.,
1996; Hardc<1stle, Anne<1r, • nd Foster, 1992). Cripron and collc>a!:,'tlcs (1995) and Yingling and
McGill (1999a) also documented that excessive shear forces can fracture parts of the arch.
• Ligawenrs. Ligaments seem to avulse at lower load rates but rear in thei1·mid.,;ubst»nce at
higher load r.~res (Noyes, De.Lucas, and Ton;k, 1994). McGill (J 997) hypothe_<ized that landing

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Normal '!_nd lnj~Mechanics of the l umbar ine 99

Reducing Tissue Damage

Summa ri:dng injury pathways from in vitro testing, evidence suggests that reduCtion in specific
1issue damage could be accomplished by doing the following:
• Reducing peak (and cumulative) spine compressive loads to reduce nhe risk of end-plate
• Reducing repeated spine motion to full flexion to reduce the risk oi disc herniation (reduc-
ing Sl>ine flexion in the mornins reduces symptoms\
o Reducing rCp\!<IK><i full-range fl~xion to full-r<mgc extension to reduce the risk of pars (or
neural arch) fracture
• Reducing peak and cumulative shear forces to reduce the risk of facet and neural arch
damage and painful discs.
• Reducing slips and falls to reduce the risk to passive c;:ollagenous ~issues such as liga·
o Reducing the len&th of time sitting, partiCularly exposure to seated vibration, to reduce
the risk of disc herniation or accelerated degeneration

on the butrocks from a F.1ll will 111pture the intet-spinous complex given the docttmented forces
(McGill an d Callaghan, 1999) ami joint tolerance. Falling on the behind increases the risk for
prolonged disability (Troup, Martin, and Lloyd, ! 981), which is t'Onsistcnt with th.; prolonged
length oftume it t11kes for ligamentous tissue to regain srrucwral integrity when compao·ed with
orher tissues (Woo, Comez, and Akeson, 1985).

Injury Mechanics Involving the Lumbar Mechanism

Many rese~ rdters have established that too great a load placed on a tissue will re.<ult in injury.
~:pidemiological smdies (Hilkka et al., !990; Marraset al., 1993 ; Norman et al., 1998; Videman,
N u nninen, and T roup, 1990) have proven tbjs not ion by iden tifying peak loading measures (i.e.,
shtmr, com pression, trunk velocity, extensor moment, heavy work, etc.) as factors 'th<1t explain
rhe freqt•ency and distribution of reporting of back pain or increased risk of back injury. How-
ever, the search for djrect evidence th at link..-.; spine load vtirh occupacionaJ low bac k disorders
(LBDs) may have been hrunpcred by focusing on too na rrow a rnnge of V'Jriables. Researchers
have paid a massive arnoun( of (lttCn(iOI),. for e~;.nnple, co a sing.le Vtll"i:lhle-nam eJy, acurc, Ol'
sing le maximum e:\1lQSll r e to, lumhar comp ression. A few studies have suggested that h igher
levels of compression exposure int r"oscd the risk of LBD (e.g., Herrin ct al., 1986), although
the correla tion was low. Yet some studies show that higher rares of LBDs occur when levels of
lumbar com pression a re reasonably low.
ln conu:ast, HaJicr (1991) claimed that the incidence of injury had not declined over
d1e past 25 years, even after increased research ,md •·esot11·ces bad been dedicated to the area
over that rime fi·arne. H adler suggested that the focu.'l be turned from biomechtmical causes of
injury to developing more ''comfortable" workplaccs.llowcwr, the r~o--sccarch llcscribcd thus fur
in this te.'t has clearly documented links to mechanical variables. Clearly, LBO ca usaliry is often
e.Yrremely complex "~th :.1H sorrs of fucrors interacting . \ Ve will consider ~ome of th ose factQrs
in the following sections.

Staying Within the " Biomechanical Envelope"

Work to ondem~nd rhe risk of back inju•-y in occupa<ional contexts has had carryover for train-
ing. For e;\';un ple, many researche rs h ave establ ished that roo a load pl<~ced on a tissue will
result in injury. Epidemiological studies on workers (llilkb ct al., 1990; Marras et al., 1993;
Nom1an er al., l998; Videman et al., 1990) have p•·m·en this norion by identifying peak loading
measure.~ (i.e., shear, compression , trunk velocity, exr.enso r momenr, heavy work, e tc .) as facr.ors

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that e.,plain tbc frequency and distributioJl of reporting of back pain or increased risk of back
injury. Wh~t orher mechanical variables modu late rhe risk of LB Ds? As noted in chapter I,
they are as follows:

• Too many repetitions of force and motion or prol!lnged posmres and loads have also
been indkated as potential jnjury- or pain-causing mechanisms.
• Cumulath•e loading (i.e.) compression, $hear, or exrensor moment) has bee.n identified
as a fuccor ·in the reporting of back pain (Kumar) L990; Nonnan t: t al., 1998)
• Cumulati••e "-'POSure to uochang;ng work has been lillked to reporting of low back pain
(Holmes et al., 19'13) :md inrervenehral disc injury (Videman er al., 1990).
• Many per>Onal factors appear to affect spiuc tissue tolemnce, for example, :•ge :md gender.
In a compilation of the available lirerm~re on the tolernnce of lumbar motion units w bear
compressive load, Jager and m lleagues (I 99 I) noted that when males and females <Ue m:ltche<l
for age, females arc able to sustain only approximately two-thirds of the compressive loads of
males. Furlhen11orc, jager and colleagues' data showed that within agiven geJJdeo·, a 60-yeao·-old
was able to tolerare only about two-thirds of the load tolerated by a 20-year-old. T hese data are
helpful in dctcnnining ti1C optimal training loads.
To com plicate the picture, Holm and :--lachemson ( 1983) shC)wed that increas;ed levels of
motion arc bcnctidal in providing nutrition ro the structures of du: intervene Ural disc- while 1

much oforu·lab's research bas demonstrated that too many motion t")•cles (to full Ae8.ion) resulted
in intervertebral disc herniation. Bucbv10lter ( 1995) associated intervertelmol disc degeneration
with decreased nutrition. Meanwhile, Vidcman and collea!,'liCS (!9?0) showed too little
motion from sedenrary •Vorkresultcd in inten•errcbral disc injury. While workers who performed
heavy work were also :ot increased Jisk of developing back troubles, workers who were involved
io varit'd types of work (mjxed work) had the lowest risk of developing a iniury (Vidt>nt.1l1
ct al., !990). T his preseurs tbe idea that too little motion or load, or too much 111ocion or load,
can modulate the risk of ~pinal injury.
A ll-imple experiment can be revealing. A number of year.s a!;,'U we asked a group of athletes
to stand with a barbell on their shoulders. \~'e were measuring spin:tl microshrinkage. Then we
asked the on to roll their pelvis anteriorly and posteriorly to impart some gentle motion to the
lumbar region (see fi£,>ure 5. 12). They remained standing upright. We had to stop the experiment
due to the pain reponed by t11e first few subjects. Tr.1ining spine motion ullder load requires
caution. No specific guidelines exist for derennining training loads-<tor ean such g~oidelines
exist for e<:tch individual. T he p<>int is that these notions are acknowledged and <.'Onsidered on
an individual bash.

Stoop Versus Squat in Lifti ng Inj ury Risk

While cl1e scienti fie method c•n 11ro••e th:lt a phenomenon is possible if observe(!, failure to
observe the expected result does not eliminate the possibility. One may only conclude that the
experiment was jnsensjti,,e to the parcicuJar phenomenon. The following discussion, as with many
in this book, is an attem~u to i.ncorporate (his lirnitation ~md ten1per ir with clinical wisdom.
ln a preo.;.rious section, lifting with the torso flexing ahour the hips rather than flexi11g the spine
wos 31l:tly-a:d and described. Specifically, the lifter elected to maintain a lleurral lumbar posture
rather than allowing rhe lumbar regio11 co Rex. Here we will reexami11e the li fting exercise,
hut the lift-er flexes the spine-sufficiently m cause tbe posterior ligaments to strain. This lifting
strategy (spine Aexion) has quite dranoatic effects on shear loading of the intervertchr:J colun\Jl
and the resultant injury o·isk. The dominant direction of the pars lumborum fibers of the longis-
simus tho~cis and iliocostalis lumhorum muscles when the lumbar ~pine remained in neotral
lordosis caused tl1csc cs tO produce a posterior shear force on the superior "'crteUra. ln
cootnst, "•ith spine Aelrion, the strained interspinous lig-ament complex generates forces with
the opposire obliquity and therefore imposes an 3nrerior shear force on che superior vertebra
(see figure• 5.13 and 5. I4, n-b).
Let's ex~mine the specific forces rhat result ti·om tlexing the lumbar spine. T h e re<:.t uited
ligamen(S appear to contrihute to the anterior shear force so chat shear force levels :-lre likely to

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Normal '!_nd lnj~Mechanics of the lumbar ine 101

a b

Figure 5 .12 Standing with a bar on the shoulders and (aJ cyclically flexing and (b) extending the
lumbar spine is painful and disarming-proof that training the loaded spine through a range of
motion requires extreme caution.

Putting Knowledge Into Practice

While t:he notion that too much of any activity (whether it be sitting at a desk or loading heavy
boxes onto pallets) can be harmful is widely accepted, it is rarely taken into account in practice.
for exa mple, industrial ergonomics has not yet wholeheartedly embraced the idea that not all
jobs nec..'<l to be made less demanding, that some jobs need much more variety in the patterns of
musculoskeletal loading, or that there is no such thing as "best poSture" for sitting. It is time lor the
profession as -a whole to remember that in any job, the order and type of loading should be con-
sidered and the demand on tissues should be varied. All sc(!entary workctli should be taught, for
example, to adopt a variable posture that causes a migraJion or load from tissue to tissue, reducing
the risk or troubles.

e.xcecd LOOON (224 lb). Sucb large shear forces arc of great concern from <111 injtu-y risk view-
poinr. However, when a more neocral lordotic posrore is ndopted, che excen.so1· rnusculatul"e is
responsible for creating the extensor moment and at the same time provides ;1 f>Os.terior shear
force tlw supports the anterior shearing action of gravity on the upper body and hancUtcld load.
The joint s hear forces are reduced co about ZOON (about ~5 lb). Thus, usiog muscle co support
the moment in a more neutral posn1re, rather thao being fully flexed wid1li1,rament.'isupporting
the moment, grcady reduces shear loading (sc:,-c table 5.1 0).
QuaotiGc'lltion of the risk of inju•'Y requires a comparison of tbe applied load w the toler-
ance of the tissue. Cripton and collea!,'1Jes ( 1995) found the shear tolerAnce of the spine to be
in the neighborhood of 2000 to 2800 N in adult cadavers, for one-time loadi1tg. Recent work

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b y Yingling and McGill (1999a and 1999b) o n

pig spines has shown that load r"te is n•ot a major
modui:ltor of shear toler;mce unleSS the load is VCI) '
ballistic, such as what might occur du ring a slip and
fall. T bis example demonstrates that rite spi11e is at
m11ch greater risk of sustaining shea r i11jury (> I000
N applied to the joint} (224 lb) than compressive
injury (3000 N applied to the joint) (671 11>) simply
because the spine is !\Illy 11exed. (f'o•·a mo re compre-
hensive discussion) s<..oe 1\-icGill, l997 .) ']'he marbyj_n
of safety is much larger in the c:omprc::ssivc mode
than in the shear mode since the spine can safely
tolerate well over I0 kN in compre.<Si<>n, hut 1000
N of shc3r t:auscs injury wirb <:ydk loading. This
example also illustrates the need fo.1· clinicia•lS and
ergonomist..;; tQ consider other loading modes in
Figure 5.13 This gardener apr>ears to be adopting a addition to simple compression. In this .c.xamplt the
fully ilexed lumbar spi111e. Is this wise posture/The force real ,;sk is anterior-posterior shear load. Interest-
analysis in figure 5. 14 suggests it is not. ingly, Norman and mUeagues' 1998 sl'udy showed
joint shear to be very important as a metric for risk
of injwy of auto plant wotkers, particularly C'wnulat:ive sbe;lr (high repetitiorlS of subf•ilure
she:1r loads) over a workday.
Yet another consideration impinbres 0 11 the interpretation of injury risk. Tbe abiUty of the
spine to bear load is a fullction of tile curvature of the spine in vivo. For example, Adams and

Figure 5.14 These original computer image bitmaps from the experiment conducted around 1987
illustrate {a) the iull}' flexed spine that is associ<Jtcd w ith myoelectric silence in the exlensors
.:mel strained posterior passive tissues and high shearing forces on the lumbar spine (from both reac-
tion shear o n the upper body and interspinous ligamenl strain. (b) A more neuual spine posture
rccruill; lhc pa1·s lumborum muscle groups and align:; 1hc fibers lo support the shear force:; (sec
figure 4.27). In Ihis example, pos1urc ,, resulled in 1<JOON oi she.1r l o~cl on lhe lumbar spine while
posM e b recluced lh<> shear load lo al)()ul 200N !
Rt!plitlied ftom /<~m·,., f ofB.'utrlec:h.w;,·:., JOi.St, S.M. ,\i.tC.ill ltWited p.lpt'f: 8iOO'lech.lnic~ (Jj low b.~e.k inju•f : h'1'1plic.1tioos ()u c.u!rfflt
P•<~Chceafld tl~e cllfliC... •II)S.·417S, 1M?, wl1h J*flllh:.lon froC'u l:hevk-t ~ce>.

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Normal '!_nd lnj~Mechanics of the lumbar ine 103

Stoop Versus S uat

Much has been written on rhe sroop sryleversus rhe squar sryle of lifling. Typically, conclusions were
based on very simple analyses that measured only the low back moment The reaction momem is a
iuncrion of the si>.e and position of the load in rhc hands and the position of the center of mass of the
upper body. As the previous example demonstrated, the issue is actually much more complex-the
lumbat· spine curvature determines the sharing of ~1 e load between the muscles and Ihe passive tis-
sues, In addition, each i ndlvidual elects the w(ly in which agonists and cmtagonists are coattivated.
Thus, tbe spine kinematic motion patterns, together with the muscle activation patterns, heavily
innueoce rhe resulting spine load and the ability of the spine 10 bear load without damage. The risk
of injury is tho rt'.al issue that motivated most of these lypes of analyses, yet it 'vas not addressed
with ;ufficient detail to lead to a correct conclusion.

colleagues (1994) suggested that a 1\.dly flexed spine is wea ker than one that is moder~ tely
flexed. In a recentsrudy, Gunning, Callaghan, and McGill (2001) showed that a fully llexed
spiJ1e (usiog a controlled porctne spine model) is 20% to -10% weaker than if it were in a
neutral posture.
Motor Control Errors and Picking Up Pencils
Although clinicians often hear patientS report inju des from seemingly L>cnit:,rn tasks (such
as picking up a pencil froo1 the Ooor), this phenomenon will not be found in the scientific
literature. Bt.'Cause such an injury would not he deemed compensahle in man)' jurisdictions.
medica) personnel rarely record this type of t:\•ent. l nstead they attribute the t-ause elsewhere.
Moreover, while injury from large exertions is understandable, explaining injury that occurs
during pedonnance of sttch light t:>sks is not. The following is worth considering.
A number of years ago, using video Huoroscopy for a sagittal view Qf the lumbar spine,
we im-estig:ned the mechanics of powerl.ifters' spines while they lifted extremely heavy loads
(Cholewic~'i and McGill, 1992). The r~nge of motion of the lifters' spines was calibr~ted and
n01maJized to full flexion hy firs t asking them to Bex at the waist and support the uppe r body
against gr"vity with no load in the hands. Duri11g the liftS, although the liftc•s appeared
0\ltWardly 10 have a very !1exed Spine, in WCt the i\lmbar joints were 2° to ) 0 peJ• joint from
full tlexion (see figure,< 5. 15 and 5,16). This e>lJiains bow t bey could Ufr snch magnificent loads
(up to 210 kg, or approximately 462 Ib) without sustaining the injuriC> that arc suspected to be
linked witl> full lu.mb:u· flexion.
Jiowever during the execocion of a lift one lifter reporred dio:;comfort and pain. Extuuination
1 1

of the vide<> Ouoroscopy rec-ords showed that one of the lumbar joi11tS(spttifitall)', the L2 -L3
joint) reach ed the full-flexion calibrated angle while all other joims maintained !heir static
position (2- JO short of full Aexion). Thespine budded and caused injury (see figu re 5.17). This
is the first observation we know of rcpurtetl iu the scicntifit literature doc.wnenting propor-
tionately more rotation occurring at a single Jumbar joint; this unique occt1rreuce appears to
h:we heen due to :m in~ppropriate $e(lnencing o f muscle forces (or a rempor~1ry los.5 o f motor
eontrol wisdom). This motivated the work of m)r colleague and fonner graduate student Prof~­
sor J:~cek Cholewicki to i.nvestig:~te and continuously quantify me stability of the lumbar spi11e
throughou·r a wide variety nfloading tasks (Cholewicki and McGill, 1996). Gener:1lly speaking,
the occurrence of a motor control e rror that results in a tc.mporary reduction in activation tO
one of the intersegmental muscles (perhaps, for example, a lamina of longissimus. iliocostalis, or
m\tltifldus) may allow rotation ~~ just a single joint ro the point at which p~ssive or other tissues
could become irritated o r injured.
C holew~icki noted tllat the risk of such an event was greatest when high forces were developed
by the large muscles :>nd low forces by the sma ll intersegmemalmuscles (• possibil icy with our
powerlifrecs), or when aU muscle forces were low such as durlng a low-level e:xertion. Thus,
injury frotn quite low-in.t<,nsity bending is possible. Adams and Dolan (1995) noted tltat passive
tissttes begin to experience damage with bending moments of60 Nm. This c;ln occur simply from
a temporary loss of muscula.r support clnring bending over. This mechanism of motor control

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Table 5.10 Individual Muscle and Passive Tissue Forces During Full Flexion and in a
More Neutral lumbar Posture Demonstrating the Shift from Muscle to Passive Tissue
llle extensor moment with full lumbar flexion was 171 Nm produc ing 3 145 N of compression owcl 954 N oi anterior shear. The
mor~ nw t<>! postvre ol 170 Nrn prodvced 3490 N of compression aocJ 269 N of s!uw,
Fully nexed Neutral Fully flexed Neutral
lumbar spine lumbar spine lumbar spine lumbar spine
force (N) Force (N) force (N) Force (N)
MUSCLE MUSCLE (continu<!d)
R rectus abdominis 16 39 l multifidus 1 28 102
I rectus .abdominis 16 62 R multifidus 2 28 87
R extern ~1 l obl ique 1 10 68 l multifidus 2 28 90
L external oblique 1 10 40 R psoas (Ll) 25 61
R external obl ique 2 7 62 l psoas (ll) 25 69
I external oblique 2 7 31 R psoas (l2) 25 62
R internal o blique I 35 130 l psoas (l2) 25 69
L internal oblique I 35 102 R (>SOilS ([3) 25 &2
R internal o blique 2 29 88 l psoas (L3) 25 69
L internal oblique 2 29 11 6 R psoas (l4) 25 61
R pa 1~ fu,l1bo,·um \ll) 21 253 l psoas (L4) 25 69
L par.; lumbontm (LI ) 21 285 LIGAMENT
R pars lumbol'lun (L2) 27 281 Anterior longitudinal I) 0
L pars lumborum (l2) 27 317 PosteriQr longitud inal 86 ()

R pars lumborum tL:Il 31 327 Ligamentum flavum 21 3

L pars lumborum (L3) 31 333 R inlel'tr<'lnsvcrsc 14 (}

R pars lumborum \1.4) 32 402 l inte-rtransverse 14 0

L pars lumborum (l 4) 32 355 R articular 74 0
R itiocostalis lumborum 58 100 l a rticular 74 0
L il iocostalis lumborum 56 '137 R articul¥ 2 1()3 0
R longissirrn.a s thoracis 93 135 l tut icular 2 1()3 0
L longissimus thoracis 93 179 tntcrspin<;>us 1 3()1 0
Rquadratus lumborum 25 155 Interspinous 2 345 0
L quadratus lumborum 25 194 lnter~pinous 3 298 0
R li!tisslmus dorsi (1.5J H 101 Supraspinous 592 0
L latissimus dorsi (LS) 15 11 5 R lumbodorsal fascia 122 ()

R multifidus 1 28 60 l lurnbodorsal fascia 122 0

error resulting io temporary inappro priate neural at·tivacion explains how injury n1ight oc.(.'.ttr
during extremely low-load situations, for example, picking up a pencil from the floor following
a long cl•y at work perfom1ing a very rlem;mding job.
Sources of Motor Control Errors
One must con...;ider another issue when deaHng with che possihiliry o fbu ckli og d1ar results fro m
Spl-"Cific motor control errors. In our clinical testing we obs.t:ncd sintilarly inappropriate moror
patterns in some men who were challenged by boldjng a load in the hands while breath ing
J 0% CO, to elevate breathing. (Ch:JIIenged bre<llhing causes some of the spine-supporting
musculatu re to drop to lnappropriatd}r low levels in .some people; sec ~1cGiU, Sharratt,

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Normal '!_nd lnj~Mechanics of the lumbar ine 105

figure 5.15 A group of powerlifters lifted Figure 5.16 This fluoroscopy image o f the power-
very heavy weights while their lumbar lifter's lumbar spine shows how individual lumbar
vertebrae motion patterns were quantified. join' motion can be quantifiecl in vivo. \.Yhile
Each joint was skillfully controlled to flex recording, an injury occurred in one lifter w hen
but not full)' flex. Each joint was 2 ~ to 3° the venebra at just one joint went to its full-flexion
away from the fully flexed, calibrated angle a ngle and surpassed it by about one-half degree.
(see figu re 5 . 16).

b c

Figure 5.17 (a) The powerlifter flexed to grab the weight bar a nd (b) began to extend the spine during the lift. (c) As ~1e
weight was a few inches from the floor, a single joint (L2-L3) flexed to the full-flexion angle, and the spine buckled, ind i-
cated by the arrow.

.and, l9Q5 .) These dcJicicnt motor control mcdunjsu1s will heighten biomcchan.ic:al
>usceptibiliry to iJljury or reinjury (Cholewicki 3nd McGill, 1996). M)' lab is curren.dy involved
in a large-~cafe longin1clinal investi&"<ltion tO<lSSeS$th e poweroftbese lll<)torconaol parameters
together \vith some personal pcrfom1:wce variables and role in causing back injury over
a muJciyear petiod.

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Sacroiliac Pain - Is It From the joint?

Bogduk and oolleab"'"' {1996) proved that some low hack pain is !Tom the s.~croiliac joim itself.
The following discu!t.Sion offers other considerations. The work that man;· have reported over
recem years has demonstrnred Lhe eruaordinary 111agnirudes of for~"ts within Lhe ~orso exten-
sor musculature even during nonstrenuous tasks. ~V'hile these forces have been inre.rprered for
thc:ir mech.anical role, clinicians have expre.ssed i nt:erc..~;r in their potential to c:ausc injury. One
possibility worth considering is that the high muscular forces may damage the bonyatmchments
of the corr.esponding muscle tendons. S1•ch damage has perh:1ps been wrongfl•lly :trtributed to
altern ace mechanisms. One example follows.
Pain in the s.1croiliac region is common and often attributed to disordel's of the sacroiliac
(Sl) joint itself or the iliolumbar ligament. l<or this reason, the role of the nmsc., lan~re may
have been neglected. lt is known dut :1 large proportion of the e.xtc.nsor musculature o btains
its origin in the SI and poste•ior-suptrior iliac spine (PSIS) n.:gion (Bogduk, 1980). The area of
tendon- peJ"iosteurn attachmen{ and extensor aponeurosis is relatively sm<lll in reb1tion to the
volume of musc.:le in series with rhe tendon l'Omplex. From chis~ a h}lx•thesis evol,•ed that the
:,eerning mis1nn.tch of large mustle tissue to small attaduncnt area ror cotutoctive tis~ue places
the connective tissue at high risk of sustaining mic•·ofailure, re;;ulting in pain (.VIcGill, 1987).
Knowledge of the collective muscle fo rce-dme histodes enahles spe<.-ulacion ahout one-rime
failure loads and cumulative trauma . For example, if the forces of muscles that orib..U•atc in
che sr ··egion are tallied for the uial illllstroted in table 5.4 (pages 78-79), then the rota I force
mmsm ittecl to the Sl region during peak load would exceed 5.6 kN. Such a load would lift a
small car o ff the ground!
Tbe failure tolerance bf these connecti \~e tissues is not koown, which makes speculation
over the poremial for microfailure difficnlr. Nn rloohr the risk of damage mnsr increa~e wirh
the incrc-.lst. Jn the c.xtrcn'lcly large loads observed in the extensor rnustulaturc and with the
frequency of appUcat:ion. lndostrial tasks comparable to li lting three conc;uners j~, e•cess of
18 kg (40 Ib) per minute over an R-hour day are not wmsual, suggesting rhat the potential fiJr
cumulative trauma is Si!,'ll.ific:ant.
T mech;uucal explanario11 ma)' accoum for local tendemcss on palpation associated with
ll1311}'of the S.l syndrome cases. A.s well) muscle strain and spasm often accomp:tn}' Sf pain.
Nonetheless, treatment is often dire.cted toward tbe articular joint despite the extrt'.me diffi-
culty in diagnosing d•e joint '" the po1.maty source of pain. While reduction of spasm through
conventiomal techniques would reduce rhe susmined load on the damaged connec<i,•e 6bers,
patients should be t·ounsele<.l o n techniques to reduce internal musde loads through eftCctivc
lifting mechanics. T his is a single example, of which dtere may be stveral, iJl whicl1 knowledge
of ind.ividnal muscle force-rime histories would suggest a mechanism for injury for which a
speci6t~a nd possibly oryrical-treatment modality could be prescribed.

Bed Rest and Back Pain

While bed rest has I~ lien lrom favor as clterapy, b~ven the generally poor patient outcome, tbe
mechanism for poor ourcome is just now starring to be understoO<I. Bed rest reduces the applied
load (hydrostatic) below the disc osmotic 11re<surc, resulting in a net intlow of tluid (.McGill,"'' n
Wijkct al., 1996). McGill and Axler (l 996) documented the &o·owth in spine length o'·er the
usual 8 ho.,rs of bed I'CSt and then over continued bed rest foranotheo· 32 hoors. This is tun•sual
"'stained pressure and is suspe<.~ed to cause backache. Ob"'nov and collcab'1!es (I99 I) clocwnentcd
intrt~Jsetl nl.incral density in the vertebrae following' prolonged space tmvel (weightlessness);
this finding is notable because other bones lost mine"' I density. It indicates that the spine was
stinmlated to lay down hone in response to higher loads; in this case, the higher load was due
to the swollen discs. The analog on earth is lying in bed li">r periods longer than 8 hours-it
actually stresses the spine!

Bending and Other Spine Motion

\-Vhilc SOm!C rt.-starchcrs have produced disc }u:miations tmder <.:ontrollt.~ L'Onditions (e-.g. ~ Gordon
ct al., I991), Callaghan and McGill (200 Ia) have been able to consistently produte disc be.mia-

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Normal '!_nd lnj~Mechanics of the lumbar i ne 107

tions by mimicking cl1e spine motion 3nd load

Moderation in All Things patterns seen in workers. Specific;;llly, only 3
very modest amount of spine compression
The phrase "moderation in all things" force seems to be required (only 800- 1000 N,
appears to encapsulale a lot of spine or 1'17-220 Ib), bunhe spine specimen must
biomechanical wisdom; var)'ing load- be repeated!)' Hexed, mimicking repeated
ing through constant change in activity torso-spine flexion from continuaJ bending to
is justifi able. Obviously, overload is " fu lly flexed posrure. In these experiments,
problematic. but the previous examp l ~ we documented chc pro,b'1·essivc tracking of
shows that even lying in bed too long is disc nucleus material traveling posteriorly
problematic-it increases annulus, end- through the annulus of the disc with final
pl()te, and vertebral stress! sequeso-.uion of the nucleus materi~l. This
was noted to ott'Ur arouml 18,000 to 25,000
cycles ortle.xion with low levels of spine cotnpression (about 1000 N, or 220 lb), but it wotdd
occur with much fewer cycles of be nding with higher simultaneous compressive loads (about
5000 cycle> wicl1 3000 N, or 6i0 lb, of comprcssi"n). Most inwrcMing \1' 3.S the fut·t that the
en>eking of nuclear material beg.m [rom the inside :md slowly wotke<i radially oucwnrd, sug-
gesting that, had this been a living worker, there ma)' have been Uttle indication of cmmdat:ive
damage un.til the culminating event.

ConfusiQn Over Twisting

While ru1s·ring has heen m1med in several smdies as a risk lilcwr for low back injury, rh e literature
doC!. not makc the distinctiou between rhc kinematic variable of twisting and the kinetic variable
of generati•Jg twistit>g torque. While many epidemiological surveillance studies link a higher risk
ot'LBD wir:h twisting, rn'isring with low rwlsc moment demands results in lower muscle activiry
and lower spiJJe load (McGill , t99l). Furcl>er, passh•e tissue loading is not substantial until the
end of tlte twist range or motion (Duncan and Ahmed, 1991 ). However. developing twisting
momenr pl.:tces very large compressive loads on the spine because of the enonnous coactivation
of the spine musculature (Mc-Gill, 1991). Titis can also oc-cur when the spine is nor twisted but
in a neuu3J posture in which tltc ability to tolerate loads is higher. Either single ,.~riablc (the
kinematic :.~ct of twisting or generating the kinetic V3 J"iahle of tv..-ist torque while not twisting)
seems less dangerous than epidemiological surveys suggest. 1:.1. owever, elevated riS:k from very
ltigh tissue loading may occur when the spine is fully twisted and there is a need to generate
high ru·istillg torque (McGill, 1991 ). Several studies, then, have suggested that comp1·ession on
th e lumbar spine is not the sole risk facto r. Both laboratory tissue test.-. and field ~urveillance
sum,>est that shear loa(tingof the spine, together with large twis~~ coupled with twisting torque,
increases d1e risk of tissue injmy.

Repeated Spine Flexion and Bending

Whilemuchergonomic effort has be<.>n devoted to reducing spine loads, it is becoming clearer
that repeated spine tlexion-even in the absence oi moderate load-will lea(! to discogenic
lroubles;. Furthermore, recentevidenceshows that the direction of the bending will determine
the location of the annulus damage (Aultman et al., 2005). Ergonomic guidelines will be
more effe<:tive once factors for flexion repetition and direction are includcd.

Is Viral Invol vement Possibl e in Low Back Pain?

Resc-:u-ch has suggested that the incidence orsome musculoskeleral disorders of the upr>er extrem-
il)• is elevated following exposure co 3 viral infection. Could 1•ira l infections also be l'esponsible
for LBDs? VVhile this .scenario i.s possible in individual cases, it could only <H:<.'ounr for some.
Since animal model studies use anin'lals that arc screened for dist·asc, with only approved sptti-
mens being selected for resting, controlled mechan ica) loading wottld seem ro account for the
signifkant findings. Viral infections have heen Unked to an increased prohahWry of developing

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such diseases a> <-arpal runnel >yndrome or arthritis (i\1ody and Cassim, 1997; Phillips, I 007;
Sanui et al.., 1996}. However, Rossignol and colleagues ( 1997) fou11d that work-related factors
accounted for the majority ofche causes influencing development caq>al nmnel syndmme. ~·
research sh ould examine fie links between viral infections leading to s pinal tissue degeneration
and low back injury etiolo~'Y· They seem to be involved in some select cases.
Sciatic Symptoms
Sciatica can l:>e caused bv tension of the scial.ic nerve, or of the lumbar nerve roots, OJ' within
rhe ctmda e quina. fr als~ can l)e ca\1sed hy p inching at numerous loc.nions tllong it$ Jength o r
by irritation by rough surfaces such as. arthritic bone or extruded disc material. The symptoms
ra11gc G·oro radiating pain to sensations in the leg or foot. Back paiJJ may or may uot be prescm.
11-agic:~lly, c:~ses of foot p:1 in, ankle p<~i n, or leg pain caused hy lumbar nerve CQm promise
are often stretched for therapy in the bclief that muscle tightness rathe r than neural te nsion
is the culp.rit. This just keeps the 11erve angry. We take two appro~ch es. First, spine-sp~ting
mocions ilre adopted £O avoid end range of motion and associilted nerve tension ~1nd to reduce
possible disc huJbring. T he second approach involves nerve flossing (nen •e flossing techn ique
togetber w-ith qualitying tests for patient selection are explained in the th.ird S<'Ction of this book
on page 2 16}.
Section Summary
from tills d!!scr-iption of injury m(.-chanisms '"'ith stvcral modulating f<tctors, it is dear r:hat
multifucto<ial links exist. IJlterpretation of these links wru enhance injury prevention and reha-
bilitation efforts. In fact. effective interventions will not occur v.irhout an underscan ding of how
t he spine works and how it becomes injured.

and Physiological Changes Following Injury
While the found:1tion for good clinical practice requi,·es an undersranding of the mechanism
for injury, ;_tn understanding of the lingering consequ~nces is a lso helpful.

Tissue Damage Pathogenesis, Pain, and Performance

M1my discuss spine injury as thoogh it is a static entity, d·utt isJ by focusing on speciflc tissue
damage. However, since tissue damage causes c hanges to the joint hiomech anics, o rhe r tissues
will be affected and drawn into the clinical picture. Undemanding the links in this issue begins
with the concept of paio.
T issue damage causes pain. Some have said there is no proof t hat d1is st..u:e ment is tme s.ince
pain is a perception and oo instrume-n t C<Jn nltasure it- dir~X::d}r. T bis notion ignores the large
body of pain literature (a review of which is well outside the scope of cl>is chapter), which has
motivated :a recent propos:lliTom a diver-se group of pain specialists to classify l)ain h)' n1echa ..
niSJu-specificaUy, transient pain (which d ~s not produce long-tt!rm sequelae) and tissue injury
and nervous system injury pain, both of wbich have complex organic mechanisms (\~'oolf et
al., 1998}.
Siddall and Cousins (1997} w<mJerfully summarized the great ad,•ancc'S made in the under-
standing of tbc neurobiology of p;un-in particular, the long-rem1 changes from noxious stimu-
lation known as cenm:1l sensiti1..ation. Briefly, tissue damage directly affe<.ts che response of c.he
nociceptor to further stimulatiou; over longer periods of time, both increase the mabrnitucle of
the reS(XH\Se, sensiti\·ity to the stimulus, and size of the region served by the same affere.nts.
Some clinicians have used this as a rarionale for the prescription of analgesics ear1y in acute low
hack pain. Fun:hennore, some have based arguments on whether a certain tissue could initi-
ate ty.tin from th~ presence or absenl:.c of noei c~ptors or free nerve endings, requiring proof of
damage to t he specific tisSIJe in q11es6on. Bur (issue d3mage (along3 continuum from cell damage
ro macroscrucrural failure) changes the biomechanics of the spine. Not only may this change

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Normal '!_nd lnj~Mechanics of the lumbar ine 109

cause pain, but it appears to initiate a cascade of change that can cause disruptions to tl1e joint
and continual p<~in for years in leading to conditions such :.lS f<lCet arthrids, accelen-.ted annub1·
degener<Jt i()n, and ne-r ve root irritation, to name a few. (See Kirka1dy-\•Vi1Jis and Burton, 1992,
for all excellent review of the cascade of •vine degeneration initiated by damage.) Butler and
colleagues (1990) documemed that disc damage nearly always occtu·s before foce• arthritis is
observed. fnjury and tissue damage initiate joint instabilities, causing the lxldy to re.spond with
-arthritic ac tivity to finally stabilize. T his results iB a loss of range of motion and, no doubt, pain
(Brinckmann, 1985).

Injury Process: Motor Changes

It is conclusive that patients repo•·ting debilitating low back pain suffe.r simultaneous changes
in their motor control systems. Re<:Qf,O>izing these changes is import:lnt since they affect the
stabilizing system. Richardson aod coworkers ( l999) produced quite a comprehensi·ve .rct-it:w of
tltis literatu•·e and made a case for t<trgewlg specific muscle groups during rehabi~ tation. Spe-
cificaUy, d>cir objective is to reeducate findcy mmor conrrol pmems postinjury. T be challenge
is to t rain t h e stabiliziog system during steady-settt' activities, and aho during rapi d V()luntary
motions, aud ro withstand sudden surprise loads.
Among the wide variety of motor changes researchers have documented, they have paid
particuJar attention to the transverse abdominis and multifidus muscles. For example, during
aJttkipatory rnovemem.s such ;:\S sudden shoulder tle.xion rnovemems, the onset of transverse
abdominis has been shown to be delayed in a few subjectS with back troubles (Hodges and Rich-
ardson, 1996; Richardson et al., 1999). While the Queensland group developed a rehahilit:!cion
protocol spccificaUy intended to reeducate the JllOtor t"'ntrol system for involvement of the
transverse abdominis, there are rnany other muscles that e)Chibit motor <."'nO·ol pe1·tuJ'batio11S.
A number of laboratories have also documented chanbre.."' to the multifidus complex. Further, in
a very nice study of 108 patieuts wid1lustories of chronic LBO ranging from four months to
20 years, Silwonen '"'d coUeagues (1997) noted that 50% bad disruJ'bed joi•lt motion and that
75% of those with radiatlng pain had abnonnal £MGs co the medial spine extensor muscles.
Interestingly enough, in the maoy s-tmlics on the multifidus, E.!\1G abnormalities jn tht more
lateral longissimus seem to appear along with those in multifidus in people with b3ck troubles
(Haig er al., 1995). Jorgensen and K icolaisen (1987) associaced lower endnrance in the 'pine
extensors in gcn"ral, while Roy and collc.agucs (1995) established fimer h>ti[,'UC rateS in the mul-
tifidus in those with low back troubles. In addition, changes in to.rso agonist-antagonist activity
have been documented during gait (Arendt-Nielson et al., 1995; Vogt ec al., 2003), particularly
in the glmeals, back extensors~ aod hamstrings dw·ing waJlcing. In addition, asymmecric extensor
muscle oulput has been observed during isokinetic torso estensor efforts (Grabiner, Koh, and
Ghazawi, 1992), which alters spine !issue loading.
Further,. evidence<:ates dtat the structure of tht! muscle itself el..v e riences change foUowiog
injury or pain episodes. All:ltomical changes following low back injury inclu de as>•nmetricatrO-
phy in the mulrilidu.< (Hides, Richa>·dson, and .lull, 1\196) and fiber !)1>e changes ill multifidus
even five years after surgery (Rantancn ct al., 1993). Long-term outcome was associated
v... ith certain composition characteristks . $p.;cific~ lly, good outcorne W<1S associated with

Function, Rehabilitation, and Pain

An interesting point for troubled backs is that pain can be i>Qth a blessing and a curse.
Working thro.ugh pain (<!ssuming muscular p<~in) is often a rchabiliJation and training
necessity. But· pain from tissue damage is another story. Pain is inhibitingoi normal motor
pallerllS. Furthermore, it is well established that one does not get used to p<~in from tissue
damage; rath~r the proCL'SS of central sensitization ensures that the person bcCOll1'1()S even
more sensitive to the p<~in. For many in(lividvals, addressing pror>er mechanics to spare
the damaged tissues must precede rigorous trdining-how this is done is explained in
the final chapters of this book.

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nonnal fiber appearance, while poor outcome was associated with atrophy in the type ll fibers
and a "moth-eaten" appearance in type I fibers. Moreove1·, even after symptoms had resolved.
H ides and mUeab'""' ( 1996) dommenred a smaller multifidus and suggested in>J>aired retlexes
as a mechatusm. This theory appears tenable, given docwneutcd C\•idence of this at other joints,
particobl'iy at the knee Oayson and Dixon, 1970; Stokes and Yoong, 1984). Once ng.1in, the
rea,;<m tor the clinical emphasis on t he multifidus may well be t hat the bulk of the re,;earch has
Occn pcrfonncd on this musdc. Yet rescarcltcrs who have cxamim:d otltcr Ltlusd cs have observed
similar cha nges in unilateral atrophy-for example, in the psoas (Danga ria and Nnesh, 1998).
V\~se clinicians consider aiJ muscles, not just those that have been chosen for studF.

Specific Patterns of Muscle Inhibition Following Injury

As Stilted in the pre•·ious section, pain inhibits no,,naJ motor panerns and is associated with
sever;;el other characteristics. i\llore insight is provided here.

The Crossed-Pelvis Syndrome and Gluteal Amnesia

Dr. Vladam ir Janda (see hb''"'e 5.1 8) proposed the crossed-pelvis synclrome in wh icl> those with
a histOI)' of chronic low hack tro\Joles displayed chanmerisric patterns of what he referred to
as '"weak" and "tight'' musdt:s. Specifically he described the featurG"S of the cro.sscd-pch·i s )ytl-
drome as including a weak gluteal and abdominal wall complex with cigln hamstri.ngs and h.ip
flexors. He develoj)ed a te<:hnique to "corroct" this ahemmt pattern. While I have difficulty in
integrating- the tem1s "v..·eak" and 11tighr" from a scientific point o f vicw,Jamla's general insights
were generally true. From measw·ing groups of men with clu·onic back troubles duriog squatting
')1JeS of tas ks, ir is clear that they rry to accomplish this basic motion and motor par.tern of hip
extension emphasizing the back exten.<iol-s and the hamstrings-they appear to have forgotten
how to use the gluteal complex. Noticeable restrictions in the hip Oexors may or may not be
present, hut without question the gl\ltcals are not recruited to levels that are necessa')' co both
SJ>are tbe hack and foster better performance.) refer to this -as "gluteaJ amnesia,"'
Tt is common tOr both patients and athletes to arrive at our researc-h cllnic with c:J-uonic ba<:k
ti'Otlbles and with a crossed -pelvis overlay. -rhdirional strength app1'0a.ches to re habilitating

Figure 5.18 I worked in several clinical workshoJ>S with Dr. Janda prior 10 his death. He taught
me much clinical wisdom that we were able to evaluate and quantify.

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Normal '!_nd lnj~Mechanics of the l umbar ine 111

their backs have failed since strenb'th squat patterns were artemprcd on aberrant mo to r patterns:
Specifically, t11e gluteal complex was not able to <'Oil tribute its share to hip extension,loading up
the back :1s the erector spinae crushed the spine. Sparing the back during hip extensor training
demands healthy gluwa1s. Sped fie trainjng to reprogram gluteal intet,JTacion is descrihed and
demonStrated in part ill of this book.

Lingering Deficits Following Back Injury

In a recem study (McGill et al., 2003), we extensively tested 72 workers. Of those work-
ers. 26 !had a history of back troubles sufficient to result in lost time, 24 had some back
troubles but not severe enough to ever lose work time. ~nd the rest had never had any
back complaints. All were asymptomatic and back to work at the time oi testing. The
litany of di fferences between groups is explaoned elsewhere but incl uded several motor
control deficits. Our findings can l>e summarized as follows:
• Having a history of low back troubles was associated with a larger W<Jist girth,
a greater chronicity potential as predicted from psychosocial questi()nnaires.
and perturbed flexion-to-extension strength and endurance ratios, among other
• Tho~ who ha(l a history of llack !roubles h~d a lack of muscle enduran ce-spe-
cifically. a lack of balance of endurance among torso muscle groups. Absolute
torso strength was not related, although the ratio of flexor to extensor strength
was impor1ant.
• Those \vith a history of low back rrouble had diminished hip extension and
internal rotation, suggesting psoas involvement
• Those with a history of back tmuhles had a wid~ variety of motor control deficits
including deficits during challenged breathing (as would occur during challeng-
ing work), balancing, ha,•ing to endure surprise IO<lding. and so on. Generally,
those who were poor in one motor task were likely to he poor in ano ther.
Given that those workers who had missed work because of back troubles were mea-
sured 2 61 weeks, on average, aher their last <:lisabl ing episode, the multiple deficits
appear to remain for very lengthy periods. The bro.1d implication of this work is that
having a history of low hack troubles, even when a substantial amount of time has
elapsed, is associated with a variety of lingering deficil5 such that a mullidis.ciplinary
training. intervention approach would be required to diminish their presence. "Ibis col-
led ion of evinence strongly supports exercise prescription that promotes the p.1tterns of
muscular cocontract.ion and movement pauerns observed in fit spines and quite power-
fully documents pathoneural-mechanical changes associated with chronic lJl:O, Once
ag~in, these ch~nges ~re lasting years-not 6 to 12 weeks! The evidence presented here
collecti:vely justifies the training regimens described in 1>artlll of this book. II is critical
to address basic motion and motor patterns first, before serious back training begins in
earnest. This is the way to establish the foundation for ultimate performan~e. and to do
it so as to (lreak chronicity in those with history of back troubles.

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Myths and Realities

of Lumbar Spine Stability

tability is a popula r term in d.iscossion of the low back, but it may be widely misundeo·scood
S and inappropriately use.d . In previous chapters we estabUshed several relevant fact.s. First,
all sorts of tissue damage result in joint which in turn can lead instability. For exampJe,
hLxity, to
strained or· failed ligaments C;~use joint laxity and unstable motion under load. End-plate frac-
ttLres wirh loss: of disc height are another example of tissue damage that results in unsrahJe joint
behavior. Clearly, joint instability is a conscqut ntc of tissue damage (this is nicclr
Jyy OxJand ct al., 19 91). A fundamental tenet is that lost mer.banical imegrity ill any load-
hearing tissue will result in stiffness losses ancl an increased risk of unstable behavior. We ;~ lso
saw in chapter 5 that during an event in which instability was obsc.rvcd (the buckling spine of
t:he powcrlifter), injury resulted. So, instabilit)'('<l.n both cause and be the result of injury. J<inally,
O\'erlayi ng the tissue .. based aspects of stahility are the moror concrol <1Specrs since coordinated
contraction stiffens the jointS and ultimately dettrminL-'S joint stability.
·n ,e purpose of this cbapter is to po'Ovide a definition of stability and an undeo·smndi ng of
how it is in.creased or clecreased. T his is a critiql fonnd:nion for rhose prescribing s rabili7.ation
exerdse or rtcommcnding stratebTies to prevent injury. AttemptS ro enhance stabilit}'· and pre\t1!nt
insl':lbility "re compromised without an understanding of tlte influencing factors. 'Th quantify
those t~tc-tors1 however, we must agree on definitions. VVh<lt exacd}' rio we mean when we use
the te1ms l'pine stnbilit)•, rort susbili1)1, and stlfbiliznri.IJn a:erd.rr? O ften rhc meanings depend on the
background of the individual: To the biomcchanist the tenns pertain to a mechanical structure
that can boc'Onle unstable when a."cri tical point" is reached; :l surgeon may view abnormal joint
rnotioo patterns as unstable hut correctable through chan& ring the anatomy; .md the manual
medicine p11tCtitioncr may intetl )rct paltcrns of muscle t--oordination and posrure as i11dicativc
ofinstabilio:y and an:empt to alter one, or a Few, muscle activarion profiles. Seveml ~oups have
made contributions ro the stahilit}' issue, but only a very few haveattempred m actually quantify
stahilitv. This critical issue is addressed here.
Upon completion of this chaprer. you will understand stability atld its impomn ce in injuo)'
prevention and rehahilirntion. Fluthe nno re, you wiU understand why cerrnin approache~ are
preferable for achieving sufficient St-dbility.

Stability: A ualitative Analogy_ _ _ _ _ __

T he Following demonS<ration of stnoccurol stability illustrates key issues. Suppose" fishing rod
is placed upright and ven1cal with the bun on cl1e ground. If the rod were to have a small load
placed in its tip, perhaps a pound or two, it would soon bend and buckle. Now suppose that the
same I'O d has guy wi•·es attached atdiffel'e nt levels along its lengrh and that those ""ires are also
att;~ched t() the ground in a circular pattel'n (see figure 6.1 , tt-b). Each b'llY wire is pulled t(l the
same tension (tl1is is critical). Now if the tip of the rod is loaded as befo,·e, the rod cruosustaiJO

1 13
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Figure 6.1 (a)lh.> spine is analogous to n fishing rod placed upright with the butt on the ground.
When compressive load is applied downward to the tip, it will buckle quickly. (b } Attaching guy
wires at different levels and in cli(ferent directions ancl1 most importan t~ tensioning each guy wire to
the same tension will ensure stability even with massive compressive loads. Note that th e guy wires
need not have high tension forces but that the tensile forces must be of roughly equal magnitude.
This is the role of the musculature in ensuring sufficient spine stability.

the compressive forces successfully. If you reduce the tensiot1 in just one of the wires, the rod
will buckle at a reduced load; we could actually predict rhe node, or locus, of rhe b"ckle.
Compre~"sive loading similar tO this has been pe rformed on human lumbar spines. rvpically,
an ostcolig-•mentous lumbar ;pine from a cadaver with muscles removed (and no guy wires) will
huckle under appt·oximarely 90 N (about 20 lb) of compressive load (first noted by Lucas and
Bresler, 196 I). T his is all that a spine can withstand!
T his analom• demonstrates the critical rule of tltc nmsclcs (the guy wires) to iirst ensure
sufficient stability of the spine so th;tt it is prepared to wirhsrand loading and sustain postures
and move.m ent. Also demonsn·ated with this example is the role of t he motor conuol system.
wh.ich ensures that the tensions in the cables are proportional so as to not create a nodal point
where buckling will occut. Revisiting rhe buckling iojury that we observed nuot:nscopically in
che powerl:ifter(page 105), we would hypothesiz-e that it wa.~ caused hy a mmor conitml er ror in
whic.:h poss.ibly on<: muscle reduced its activation or. from tht< previous :maiO!,ry•, lost its stiffi-tess.
The synclu·ony of balanced sti[[,, ess produced by the motor comrol system is absolurel)'critical.
Now we can address how stability is qua ntified and modulated.

Quantitative Foundation of Stability

This SL--cdon quantifies the notion of .stability from a spine perspe<.'ti\'e. During the J 980s, Pro-
fessor Anders Bef!,'fllark of Sweden very elegantly formalized stability in a spine modd with
joinr stiffness and 40 muscles (Betgmark, 1987). In rhis classic work he was able to represent
mathem;.lticall)l the concepts of"energy wells,"' stiffness~ stability, and instability. For t he most
part, tbis seminal work went unrecognized largely bc<.:ausc the cngin.eers who w1dcrstood the
mechanics did nor have the biological oo· cl inical perspective and the cl i nici~ns were hindered
in the inte r prerarion and implications of the engineeling mechanics. This section synthe-sizes
Bcrgnhtrk~ pion(.-eriug effort as weB as its continued C\'O]ucion in the work of several others
and attempts to encapsulate d>e critical notions without mathematical complexity. lf you are

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Myths and Realities qf Lumba_r2J>ine Stabilit,L__________________________l:_:lc::5

matbematicaUy incij ned, see Bergma.r k's original

work or irs formali1.1tion by Cholewicki and NlcGill
( 1996).

Potential Energy
8 as a Function of Height
T he concept of stability begins with potential
energy, wh.ich for o ur purp<Jses here is of two
basic forms. In me first fonn, obj .x r.~ k tvc poten-

b L?=1 0
tial energy (I'E) by vin11e o f meio· lteight above a
PE = mass . gntvity . he.igb r
Critical to measuring stability are the notions
of enet'b'Y wells a.od mini mum potential energy.
c A hall in a howl is considered stable 1Jecause if a
fort'C (or a perturbacion) were applied to it, ir would
rise up the s.ide or the bowl bur then come to •·est
0 again in me position ofleast porential energyatthe
bottom of the bowl (the enerb'Y well) (sec fib'llre 6.2,
d / ~ 11- d). As noted by Bergmark, "stable ·equiijbrium
prevails when the potential energy of me system
is minimum ." The system is made mo re srahle by
deepening the bowl or by increasing the steepness
Figure 6.2 lhe continuum of stability. (a) Tite deepest of the sides of the bowl, or both (see figure 6.3).
bowl is mo>t stable, •nd (d) the hump is least stahle.l'he T hus, the notion of stabilicy the
b,111 iol the bowl seeks the energy well oo· position of mini- un perturbed energy state of a system and a study
mum potential ~n ergy (m- g · h>. Deepening the bowl or of the S)'Stem following perturbation- if the joules
incrt>asing the steep11ess of the sides increases the ability o f work done hy the perturbation are I ess than the
to survive per1urbation. This increases stability.
joules of potential energy Lnhcrcut to dtc system,
then the system will rel)l~in stable (i .e., the ball
wiJI not roJI ( lUI of me bowl). ·n,e corollary is
that tbc mc<:hanicaJ S)'stenl will bt:comc Ull)'tablc
and possibl)• collapse if the applied load exceeds a
critical v<~lue (determined by potential energy and
The previous ball analogy is a two-dimensional
ex<~mple. T his would be analogous to a hinged
skeletal joint dtat has me capacity only for ftcxion-
exrensio.n. Spinal joints can rotate in three planes
and rran.sla[e alo ng three axes, reqn.iring a ,-.;ix-
dimensiona1 bowl for eath joint. 1\tlathematks
enables us to examine a 36-dimensioual bowl
PE = m -g · h (6 lllmbar joint$ with 6 degrees of freedom each)
Slope =joint stiffness representing tbe whole lumbar spine. If me height
Width at bottom of bowl= joint laxity of the bowl were decreased in any o ne of these
36 dimensions, the ball cou ld roll out. In clinical
Figure 6.3 The stceplle<S of the sides of the bowl r,or- terms, a single muscle having an inappropriate
responds 10 the stiffness oi the passive ~issu es of 1hc joinl, force (and thusstiffness) or ~ damaged passive tissue
\·Vhich Cfcale Ihe mech :~ nica l stop to motion. l he width that has lost sriffness ca n cause lnsrabil_iry rhat is
oi the bottom of the bowl corresponds to joint laxity. for both predictable and quantifiable.
example, a positive •ctr.awer test" on the knee would be Some cU nicians have <.:onfused spi11e stabil-
repMented by a flattened bottom oi the curve in ''1>ich ity with whole-bodr balance and st"bility, which
>mall applied forces produce large unopposed motion. invohre.~J the cenrer of mass and base of soppon in

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tl1c conten of falling over; tllis is quite differeot from spine stability. Figure 6.4, nand b. iJJus-
rntes the mechanics of whole-body halance and stability. Figure 6.5, 11 and b, shows the clinical
practice of prodding patients. This approach is misb"ttided for enhancing spine stability.

e e

Figure 6.4 Another 1ypc oi S-tabilily, oflcn confused wilh spine column ~tabili ly, involves the ccntt~'l' of mass and h<l.SC of
supporl in the context oi falling over. !a) This triangle is stable because a small l"'''tun)ation 10 its top would not c~usc
it to fall. The si7.e of this st,,bility c.m be quantified, in l)art, b)• the si7.e of lhe angle theta. (b ) As the center of the mass
t~pproaches a verliC(I I Iine dr<"~w•' from the base of suppon, il smaller perturbing force wot1ld be required for it 10 fall, de-m-
Or'lstrating lhat it is stable but less so.

Figure 6.5 (.-1, b ) Misunderstanding stability, illustrated in the examples given in iigure 6.4, has led clinicians to try to
enhance spine stabilit)' by prodding patients and Jttempting to knock them off balance. This is not spine stability but
whole·body stobilily.

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Potential Energy as a Function

of Stiffness and Elastic Energy Storage
While potential e nergy hy virtue of h eight is useful for illustrating the concet>t, potent ial
energy as a function of stiffness ant] storage of clastic energy is ac:tuaUy lL'iCJ for mus·culo.skdctal
application. Elastic potential energy is calculated from
stiffness (k) and deformation (x) in the elas·rJc element,
p as shown here:

PE a Ill· k-x'
PE = 112 · k -/ VVe \\·iU usc an elastic band as an ~xamplc. Stretch-
S:PE-P ing the band with a stiffness (k) a distance x, it will store
s.,o : unstable energy (P£). The stretched band has d1e n>otential to
5>0: stable do work when stretched. In other words, the greater
d1e stiffi1ess (k), the greater the steepness of tbe sides
of the bowl (ii-om rhe previous on;~ logy), ''"" the more
stabJt> the structure. T hus, stiffness creates stability (see
figure 6.6). More specifically, symmetric stiffnes.< r;·eates
even more stahilicy. (Symmetl'y in stiffness is achieved
Figure 6.6 Increasing: the stiftn<JSs of the cables by virtually all muscles of the torso; see fit:,'llfe 6. 7, a-b.)
(muscles) increases dte stability (or deepens the If more joules of wor·k m·e performed on the spine than
bowl) and increases the ability to support larger there are jollies of porential energy due to sufli•ess, the
applied loads \PI without falling. But most impor- spine will bemme unstable (see figure 6.8).
tant, ensuring th1tthe stiffness is balanced on each Active musdc am like a stiff s~ring; ami in f.wt, the
side enables the column to survive perturbation greater rl•e acrivation of the m\rscle, r.he gr·earer this
from either side. Increasing stiifness of just one stiffn ess. Hotter and Andreassen (198 1) showed that
spring will act<rally decrease the ability to bear joint stiffi1ess increases rapidly and non linearly with
compressive load (lowering PE in one direction muscle activation such that only very modest le,•eJs of
and mode), illustratirng the need for •balanc- muscle activity create sufficiently stiff ancl ~table joim.s.
ingN stiffness. for a given posture and moment Furthermore, joints possess inherent joint stiffness as
demdnd. che passive capsules Olld ~gamems contribLrte stiffness,

Figure 6.7 (a) Spine stiffness (ar1d stability) is achieved by a com1>lex interaction of stiffening structures along the spine
and (b) those iorming the torso wall. Balancing stiffness on all sides of the spine is rnore critical to ensuring stability than
having high forces or1 a single side.

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parr..icnh1r1)' at rhe end range of motion. 1l1e mot,or

Load control system is able to c-ontrol stability of the
joint$ through coordiuatcd muscle coactivation anu
to a lesser degree hy placing joinrs in positions dlat
modulate passive sciAness contribution. However, a
faulty motor control system can lead to inappropriate
magnitudes of muscle forc-e and sri ffncss. allowing a
valJey fi)r the hall to ron our or, clinically, for a joint
to buckle o r wl(lergo shear translation. However,
we a1'e limited in our abil ity to analyze the local
srahi1ity of mechanical sy.stems -and p arricularly
wust:uloskcletal linkages, since the energy wells ~rc
not infinitely deep and the many anarontical oom-
ronent$ conn·ihute force and stiffness in syn chrony
to create .surfJC<.:S of potential energ)' in which m~my
local wells exist. 'l'hus, we locate local minima bv
examinjng t he derkath'e of the energy s:urfa<.-e. (Se~
Bcr!,'lnark, 1987; Cholcwicki and McGi U, 1996, fi)r
mathematical detaiL)
l~'e quantify spine stahiliry, then, hy fonning a
matrix in whicb the tota1 "stiffness enetl:,l)"" fi)r e:td1
degree of J1·eedom of joim motion is represented by
a number (or eigenvalue); rhe magnitude of that
number represents its L'Ontributiun tO forming t he
height of the bowl in that particular dimension.
Figure 6.8 li more joules of wo,·k are performed on Eigenva lues less rhan zero indic:He the potential
the spine thon there are joules of potential energy due
fo r htstab iliry. T he eigenvector (different from the
to stiffness, the spine will be<:ome unstable-in this
case, the instabilil)' mode is buckling.
eigenva lue) can t11en identi fy Ll1c mode in which
the instabil ity occurred, wh ile sensiti\•ity analysis
is used to reveal the possible contdhumrs to unstable behavior. Gardner-A•I orse and co l ~
leagues ( 1995) iJlitiated interesting investigations into eigenvectors by predicti11g patterns
of spine deformadon due to impai1·ed muscu la1· incersegrnental control. ' l'hei1· qoestion \vas,
"'Which muscular pmern would have prevented the instability?" Crisco and Panjabi (1992)
began investigations into the contributions of the various pas.sive tissues. Our group bas been
itwesrigaring tbe eigenvector by systematicaUy adjusting the stiffness of each muscle and assessing
stabilicy in a variety of tasks and exercises. The cono:ihucions of in clividua] musck-s to stabiliry
arc shown later in tills chaptc.r.
Acti~ating a group of muscle synergists and antagonists in the optimal way 11ow becomes
a critical issue. In clinica l terms, d1e fuJI complemenr of the stabilizing muscul:uure must
work ha rmoniously to ensure stability, generation o f the requ ired moment, and desired
joint movement. But only one muscle with inappropriate activation amplitude may produce
instahiliry, or at least unstable behavior cou ld resu lr from inappro~uiate activatio n ar lower
applied load,,

Muscles Create Force and Stiffness

When a muscle COntl'aCts i<creates bO<h force and stiffness. While stiffness is alw;,
force may stabilize o r destabilize. The ndacionship berv..-een increasing forte in a mtL'K'Ie and
the oorrespondingstiffi1ess is quite nonlinear, with large increases in stiffness occmrring quite
early as acti varion begins. Thus as a 111\lsclc becomes more active it usuall)' adds to spine
stabilityi but if the force keeps rising, little additiona l sti ffi1ess is created and the force of
the tnusdc will become large enough to actually induce buckling of tbc spioe (Brown and
McGill, 2005). This is more evidence for the wisdom of clinically enhancing spine stabil-
ity '\~tb che o bjective o f balance ln stiffness and fo rce in aJI contributing muscles rat her cl1an
focusing Olil :1 single muscle. group.

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Sufficient Stability
How mnch stabiliry is nece~sary? Obviousl)l, insufficient stiffness renders the joint UJ1Sntble, hut
roo much stiffness aod coac.:tivation jmposes m~1ssive load penalties on tbe joints a.nd prevent:6
motion. We cau define su llicietll stability as d1e musc\tlar stiffness necessat)' for stalili lity, with "
mode.~t amQunrof extra srahiliry to form a margin of safety. Interestingly, given c:he ra pid increase
in joint stiffness with modest muscle force, larg~ muscular forces are rartly require d.
Chole"'icki's work (Cholewicki and McGill, 1996; Cholewicki, Simons, and Radebold, 2000)
dem.ons(rated that, in most people wirh 3n undeviated spine, modesr le\'els of coactivarion of (he
paraspi n;~l and abdominal wall muscles will result in sufficient stabiUty of the lumbar spine. This
means that people, from patients to athletes, must be able to maintaiJt sufficicn t s~bi Uty in all
activities- with low hur conrinuous muscle (ICti v:ltion. ·rhus, mainraining a stabi licy margin
of safety when performing tasks, particularly the tasks of daily Jiving, is not compromise d
IJy insufficient su·ength but probably by insufficient endur-ance. \¥care now beginning to
unde,·stand the mechanistic pathway of those studies showing the efficacy of endurance
r:raining for the muscles that stabilize the spine. Having strong abdominal muscles does not
necessarily provide the proplrylat:tic effect that many hoped for. IIowevcr, several works
suggest that muscular endur11nce reduces the risk off\ll'ure back troubles (13iering-Sorensen,
1984). Finally, the Queensland group (e.g., Richardson et al., J 999} and severa l others (e.g.,
O'Sumv:m, 1.\\·omcy, and Allison, L997) noted t11c disturbances in the moror control sysrcm
following injury (detailed in chapter 5}. These disrurbances compromise the abilicy to maintain
sufficient stability. Jn snn1mary, setbility comes from stiffness, passive stiffness is lo~t with cissue
damage, and activt: stiffucss throughout th~t rang-e of motion is Jost with pcrturbc(L motor pat-
tel'lls follo";ng injury.

Stability Myths, Facts, and Clinical Implications

:Having explored some o f the issues of spine stability, we will now consider a few crucial ques-
tions that will bel ~· enhat1Ct' clinical decisions.
• How ·mucb 111:1/sde tJctivtJti.ou iJ· 1U.tuletl w eusu:re sufficient stnllilit;y? The amc)unt of
muscle acrivatio11 ne-eded to ensure sutlicient st•bility depends on the rosk. Generally, for most
tasks of da ily living, very modest levels of abdomina l wall coconcn>crion (activation of about
I 0% of maximal voltmtary contraction or even less) are sufficient. Again, dependj ug on the
task, coconrraction wirl1 the extensors (this will also include the quadratus} wi ll ensure stability.
However, if :1 joint has lost stiffness because ofdamage, more cocontraction is neede-d. A specific
e.xample is shown in chapter 13.
• Is trny single nmsde "'0>1 imporrnlll? Several clinical groups have suggesced focusing
on one or rwo muscles to enhance stahiliry. This would he simihlr to emphasizjng ;a single guy
"ire in the fishing rod example. Rarely would it help; rather it would be detrimenml for aclliev-
iog the balance ill stiffness needed to ensure stability throughout the d1anging task dcn•ru•ds.
In particular, clinical gmups h;we emphasized the mtlltiAdus and rransverse ahdominis. T he
Queensland group pcrfom1ed some of the ori&rinal \"·ork emphasizing these two m·usdes. This
was based on their research noting motor disturbances in these muscles in some inc.Uviduals fol-
lowing injury. In fact, they developed a rissue damage model suggesting rhar chronk• lly poo1·
motor control (and motion patterns} initiar<..os mit-rotrauma in tissues that accumulares, h!<Hiing
to S)"tJ[ltOillatic injury (Ridt;>rdson et aJ., 1999). Furrlter, according to the Queensland model,
injury leads to furdter deleterious change in motor pmerns such that chronicity can be broken
only with .speclfic techniques to reeducare the local muscle-motor t·onrrol sysrem. The inten-
tions of the Queensland group were w address the docurncntcd u 10tor deficits and atteJnpt to
reduce the risk of aberrant motot· p~tterns th:>t coo ld lead to the pathology-inducing pme,·ns
in their damage modeL In other words, their recommendations aprtear co he directed mw;trd the fuulty motor pattern:;. I IowL-vcr, many cUnk--al groups have i.nte..prctcd thi.~
approach to mean that these two muscles should be the specific tatgets when ooe is tead,ing
stabiliry maintenance over all sorts of tasks. This is prohlematic.

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Hopefully the understanding obtained from the stability explanation provided earlier will
underscore the tOily of this lmidimens:ional emphasis. In fact, the multifidus: o r any orher nl\lscle
nn be t he most import:mt stabilizer at -an instance io time. Four exercises are presented as au
e.xal)lple (see figure 6.9) in wltich the contributors co stability are shown. The importance of
indi,1dnal muscles will change and adjust with snhtle changes in relm:ive muscle activatJon. In
these examples t he adjusnnents of all the laminae in each whole musde are averaged in order
to evaluate the entire muscle~ role. Obviously, adjustments in single laminae of some muscles
".:ould resu lr in yet a different clistribucion of contributions to stability. Evalu:-lring a wide variecy
of tasks an<l exerdses is most reveali ng. The muscular a nd motor control syst<:m must satisfy
require.meJ)tS to sustain postures, create. movements, brace against sudden motion o.r unexpected
forces, bu iM pressure, and assist challenged breathing, alithe while ensuring sufficient stability.
VirtuaUy all muscles play a role in ensuring stahility1 but their importance at any JX>i nt in time is
detcnnined by the unique combination of the demands just listed. E'•ery study that has attually
quantified stability of the spine has reached the same conclllsion-<>11 muscles a1·e important,
implyjng that a dinjcal focus on one mu...;de a nd not the whole s~tem i...; detrimentaL Ln some
instances, the- pe-rformance of one Jnusdc enhances another (e.g., the rectus abdoul.i.nis assists
the obliques for stabilization). Ftn'lher, evidence has demonstrated that e.ndur31Jce in these
muscles i~ necessary ro facilitate the continuous Jow· level ~tiffening contractions re.q uired fo r
the maintenance of sufficient stability (c.B'·• \Nagncr ct al., 2005).
• Do /()Ctl/lgWbttl or inh·insiclextriusir stabilizers exiJt? From the classic dclinition and
quantification of smbility, the answer would be no. Srability resu lts from the stiffness at each
joint in a pa.r ticular degree of freedom. The relative conoibution from every musde source
is dynamicaUy changing depending on its need to eoutr-Jct for other pUJliDSE:S. The way t he
various rontributors to stiff11ess :1dd up, however, is imponam. rn sotne iosrances, removing a
muscle from me analysis has ve1y little effect on joint stability. Once ag"in, it depends on d1e
demands and constrai nts unique to the task at that instant. The point is that all t'Ontrihutors are
important for some tasks and should be recognized as poteotiaUy imporr-.uu in any prevention
or rehahilit.1 tion program. Conversely, conceiving .st<lbilizers as uimrinsic" or "extri nsic" m<l)'
oft"t:!r no benefit for clinical decision making.

8 0.80
~e 7 0.70
~c CJ Rectus abdominis
; .g 6 0.60
>"' CJ External obllques
~ ·~ CJ Internal obliques
-ll<> 5 0.50 lij Pars lumborum
"-s ".Si>

1!~ CJ lllooosLaWs lumb01um
cE 4 0.40 1!1!11 Longissimus thoracls
~&~ "':;; Quadratus lumborum
g ... 3 0.30 3l Latissimus dors1
i!·~ 2 0.20 Ttaosverso abdominis
2-g Stab~i1y indo.

0 0.00


Figure 6.9 Measuring individua l muscle inrluence on h.1mbar spine stability during periormance o( (our d ifferent "stabi l iza ~
tion" exercises demonstratt"S that all muscles are important and that their relative importance changt"S with the task. Tota l
stability is also indicated by the determinant demonstrating how stability can change between tasks. {This is a n example
from a single subject. Typically, group means indicate a d ifferent stability ranking of exercises.)
Courte,;y of N. Kavett .uld ~. \'\cGIII

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• Wb·nt m·e stabifizlll ion e.w:•·rises? Stabilitv exercises and a sr~b le core are oftt:tt discussed
in exercise fonuns. \•Vhat are stahili7.ation exer·ci.Sest The fact is r.hat any exercise can be a srahi-
lization exercise depending on how it is performed. Sufficient joint sritlness is achie,,ed throngh
the creation of specific motor patterns. To adapt a phrase popular in motor cornrol circles,
"l)ractice does not make perfect; it makes permanent." Ideally, good stabilization e•ercises that
arc performed properly groove motor and motion patterns rhat ensure stability whi le satisfying
all other demands. Thus, an exercise, repeated in a way tbat grooves motor patterns and ensures
a stable spnne. consticutes a st3bil.i?.ation ex.e•·cise {McGill, 2001). However, some stabiliz.ation
exercises are be-tter [han otherst at:,rain, ir depends on the objectives. For exan1ple, the resulrant
load on the spine is rardy considered. One key to improving bad bach is to sclct:t stabilization
exercises that impose the lowest load on the damaged spine. Chaptet· 5 pro,, ides a ran king ofsucl1
exercises. On che ocher hand, the best srabilization exercise for a high-perfnrmaot·e athlere will
invotv<: the:: grooving of a d ~rnamit and complc,.; motion pattern, all the while c.nsuringsuffiticnt
spine stability. An impon:tm requ.iremetu for many athletes is to .:nsure a stable spioe while
breathing hard, such as when playing high·intensit)' spnrn. T his will he discussed in chapter
• Cnn c/i11icinns idetJ.ti}jt tbO.\'e w!Jo are poor Sfltbi/iz.t!1•s? f'rom a qualitative m>erspective.
the ~mswcr is yes as long as the clinician is <.'Ucd into seeing and feeling compromised motion
~md rnusdeact:htatiort pattenls. From a quantitative perspective, we h;we used modeling analysis
corry co find ways to identify rhose who compromise rhei1· lumb:lr stabiJicy from specific motor
conrrol errors. -\i\'e observed such inappropriate muscle St:(jUendng in men wbo were challengetl
by hoi cling a load in the handswhil.: breathing 10% CO, to elevate breathing. On one hand, the
muscles must cooontract to ensure sufficient spine srabiliry; but on the other, challenged breath-
inS' is often characterized by a rhythmic contraction-relaxation of the abdominal 11'1111 (McGill,
Sharnttt, ~md ScguU1, 1.995). Thus, the motor s ~·s tem is presented with a <.:ouflict: Should the
torso muscles remain aL'tive isomeu·ically to maintain spine srabilit)', ot· v.111 chey rhytlunically
rela.x and contract ro assist with active. expiration (but sacrifice spine stability)? Fit motor ~JS·
rcms appear w meet the siJnultancous breathing and spine Stlpport d1allcngc; unfit ones may
not. All of these defJcient motot· control mech"nisms wil l heighten biomochanicalsusceptibility
to injlll)' or reinjury (Cholewicl:i and McGill, 1996). We are currently using this paradigm in
a longitudinal study to see. if those who IJordcrcd on instability during this t hallc ng~ will be ones who develop low back u·oubles. Some other test~ to detect t\mctional ittstabiJicy are
described in chapter J I.
b1 summary, achieving stability is not just a matter of activating a few targeted musd~, be
they the multiJidus, trans\'trse abllominis, or auy other. Sufficient stabiHty is a moving target
that continually t'hanges as 'l fw1ction of the chree-dimensionaJ torques needed to support
posntres. lr itwolves achie,;ng the stiffness needed to endure unexpected loads. p.eparing for
moving qukkly~ and ensuril1g sufficient stiffuc.o;s in any degree of freedom <)f the joint that may
be compromised From injury. Motor control fitness is essential for achieving t.he stability target
under all possible conditions for pel'formanl-e and inillry avoidance.

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Injury Prevention

n part I we went back to school lor an update on lumbar function. In p<~rt II

Ithis foundation is used to justifythe best injury prevention approaches.

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LBO Risk Assessment

wo rypes of physical l'isk factOI'S pl'edispose people developing low back tro'Ubles: those
T to
linked m the person (for example, muscle endurance or the lack of) and those linked to the
demands of perfonning a certain t:1sk (for example, applied loads). T his chapter dc$tribes how
to assess the risk of back rroubles that rest~ It from the cask demands.
Upon completion of rhis chapter, you will understand the variable..~ thar are imr11orra.nt to
indudt.· fo r risk asscssmcm and be familiar with different tool!> to assess the risk. Tiu:sc tool!.
inclt~de the NlOSH approach, the Snook l)Sycbophysical approach, the lt~mbar motion mooitor
(LJ\'L\1) approach, and the Ergow:ltd> approach.
Tissue overload causes damage and ~;u bscquto t low back trc>ubles. Assessing the risk involves
comparing applied loads .,; lh some form of load-bearing tolerance value. Chapter 5 included
example.~ of applied lo<lds, cissne load~1 <llld injury s<.<>enarios. Alchough direcr measurement of
tissue loads would be ideal, ti:Us remains impractical for large munbers of people perfonning
a wide vati.ety of occupational t"sks and activities of daily uving. Researchers have developed
various modeling appro<~ches to predict these loads, but rhey remain merhodologic•llycomplex.
For t.his reason, surrogates for tissue load that are linked with posrur e, applied load, and motion
have beell proposed. These were inu·oduced in chapter 3, "Epidemiologi<:lll Studies on Low
Back Diso,.ders (LilDs)." See "Brief Re,•iew of the Risk Factors for LBO" for a list of known
risk fuctc)rs that include.'i descriJ)tions and c ti tiques c)f several appr<">aches to assessin g them.
Four risk asso"Sment approaches are presented more or less frotn least cun1plex to most
'-omplex. T he simplest approaches use metJ·ics th;>t are the easiest and cheapest to e m~>loy
fo r injury· risk assessment. However, these a re compromised hy a lack of ac:curac:y and sped ~
fici ty and are not sensitive to iudividua l worker or person technique. The more complex
appi'Oaches involve more sophistic.ued methods and lll'e more expensive to conduct, but they
are more r·obust in their sensitivity to specific tasks and the individuaJ ways in which people
clctt to pctrforrn t hcrn.

Brief Review of the Risk Factors for LBD

Here are the risk facrors tha t have been identified fi·om epidemiological approaches:
• Static work posmres, specifically prolonged tn mk Aexion and " twisted or la<er<lll)' bent
trunk posture
• Seated working postures
• Fre(Juent torso motion, higher spi ne rotational velodty~ and spine rotational devia ..
• Frequent lifting, puslting, and pulling

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LBD Risk Assessment 125

• Vi(Jrarion e>'J'OSu re, particularly seared whole-body vihration

• Peak and cwlluJativc low back shear fo1·ce, compressive force, and extensor moment
• Incidence of slip.< and falls
T hese r·isk factors have been identified from tissue-based srudies:
• Repeated 1\dllumbar flexion
• Time of day (or time after rising fi·om bed)
• Excess-ive magnitude and repetition of compressive loadsl sbe~1r loads, and torsional
disr:~lacement and moments
• lnsufficient loading so that tissue strength is compromised
• Rapid ballistic loadiJ>g (such as that resulting d<ll;ng landing n·om a faU)
And finally, these personal variables have berm identified as risk factors:
• Increased spine mobility (range of motion)
• Lower {OI'SO muscle endurance
• Perturbed motor control pauems
• Age
• Gender
• AbdominaVtorso girth

N IOS!H Approach to Risk Assessment

For about the past 40 years hotb 6eld surveillance and laiK>ratory stmlk,; have fi>cused on the
relationship between back injury and compressive forces experienced by the lumba r spine. For
example, in 1981 the Narion;>llnsrimte for Occupational Safety and Health (/'\JOSH) published
guidelines for maximwn compressive loading of tbe lumbar spi nc (hotb an action limit of 3400
N (about 7;0 I b) and a 111aximum pennissible lintitof 6300 N !about 1400 lu]) uased on some
~arlier evidence. In 1994 Leamon questioo~d !:he \ISe of compression when he quite co.l'rectly
!>"tated that the supporting evidence for compression as a metric, or index of risk, w olS sparse.
However, siuce that time. several good data sets have shown that restricting the amom1c of low
back comp.l'ession (both peak and cumulative) is one valid appro,tch to reducing the risk of low
back injury (for example, data sets in tbe previously discussed studies by Norman et al. 11998)
and Marras et al. (19951).1n addition, l\'IOSU has also:> proposed Uft:ing guidelines to limit the
30\0unt of load lifted in !:he hands. These limits are described in !:he following sections.
The influence of NlOSH has heen fur-reaching; many groups have tc<ed these values in an
attempt to reduce tbe risk in workers.lJ>filet, the NIOSilapproach continues to uc widely used
today primarily because of i t~ ease of use.

1981 Guideline
The first lifting b'1Jide (NfOSH, 1981) was re.<u-icted to lift.; in tbe "!,'ittal plane and lifts !:hat
iovolvcd onlv slow and smooth motions. Predictions of the load lifted in the hand~ were based
on some nudimenta•'V distances to characterize the kinematics of the lift and load moment at the
low back. 1\\ro limit.~ were defined: the action limit (AL). which, if e.tceeded, rriggered action tQ
apply Cn1,:ineering and adminbtrativ(' controls, and the maxilmun permissible limit (i\1PL) for
the load lifted, above wltich the •·isk is too high and nor permissible. Weights ligh(er than the
AL are considered safe. E.xpert,<\vith hiomechanical, physiological, and psychophysical expertise
chose the magnitude of d1e!>C limits and tbc variables needed tO compute them. T he general
fonn of tl>e formula used to compute the i\L for weight io Lhe hands is as follows:

AL (kg) = 40 (HF)(VF)(DF)(FF)

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HF = horizontal F.>cto•·, or the horizontal distance (1-1) from a point bisecting the ankles to
the center of gra,•ity of rhe load ar the life origin. This was defined as ( 15/1-1).
VF =vertical factor, ur th~ h~i!:ht (V} uF the load at l.ilt urigin. This was dcfin~d as (0.004)/
OF= clist:Ulce f.Jcmr, or me verric:!l rravel rlisranc-e (D) of the load. This '"'s defined <~s. 7 + 7.5/D.
H' = J1·cquell<.y li•ctor, or the lifting rate define-d as I - F/FJJ1ax.
F =average frequency of the life, while Fmax is obtained from rabuhned dara.

The logic of tbe equation is to set a maximal load of 40 kg (ll8 Ib) and multipl)• chis value
ab'llinst vadablcs that act as cli$Cnunt factors. Thus, the maximal Uft is 40 kg (88 Ib) under opti-
mal conditions and when aU (~Stowlt variables equal unity(!}. SuboptiLnal lifting cOn(Utiuns
cause the discount mu ltipliers to d•·op to smaller valoes, reducing the "safe" load. :rheA11'L is
computed ~s three times rhe AL for a particular ~et of lifting circttmst.1nce.~:
iVIPL = 3(AL)

1993 Guideline
The revised NIOSI] equation (Waters ct al., 1993) was introduced to address those lifting tasks
than•iolared the S<JgirraiJy symmeo·ic liftingrask restriction of the eal'lier eq>mion. In addition,
the concepts of the ALand MPL were replaced with a reconunended weight limit (RWL) fur
a particular situation. U the attual luad tO be lifted exceeds the RWL, the risk uf dc"Veloping an
LBD is elevated . While the RWL equation is sintilar ro the 1981equation, two additional factors
were incorporated. These incl11de an asymmetric variable for nonsagittal lifto; and a factor for
whedtcr or: not the object has h:uullcs. Note that dtc sped lie variable weightin!fS aIso changctl
from the 1981 equation form.
RWL (kg) e 2 3(15/1 1)[1 - (0.003N- 751 )J
X [.82 + 4.5/D])(FNl)[l - (0.0032A)](C.M)

11 = horizontal location forward of the midpoint between the ankles at the origi:n of the Uft.
1f sign.ificaJlt control is required ar the destinarion, tbeo H should be measured both ar the
origin and destination of the lift.
V • vcrt:ical location at the orib>in of the ~ft.
D = ve•Tical t:ravel disr,tnce between the origin and destimllion of the lift.
FM = fr.equency multiplier is obtained from a table supplied by NIOSH.
A = angle between rite midpoint of tllC ankles and tbe midpoint between d1e hands at tbe
origin of d1e lilt.
CM • C()upling multiplier ranked -as either good, Fair, or poor. It is obtained from a r:ahle.
T he 1993 equation predict!; smaller loads that can be lifted safely, when c-ompared tcJ the
1981 equation, and is thus more conservative. Interestingly, NIOSH offered no provision fur
tbe difference in C31)acicies of men and women; the)' are treated similarly largely for political
reasons. (1 discussed this issue of discrimjnation and rhe impact on protecting vuiJ1erahle worke-rs
in chapter I.) Further, the approach ignored any individual dJffcrcnces in bodr mcch;lni<:s used
dLuiog lifting. Jn addition, some have suggested that the handle factors may not be consisteJl!
wirh th e subsequenr forces endured by the body. f'or example, while NlOSH a.sumed that
having handles on the Ufted objc'tt is better, ow· wor.k has shown that handles allow the lifter tO
apply e<>en more force, resulting in subsequently higher back loads (1-lonsa et al., 1998)! None-
[.heless, rhe equations form a mdimenrn ry appro::1ch to risk assessment that is e;~sy to conclucr.
l\•1arras anti c-oUeab'1les (1999) concluded that tbc 1981 NIOSH guide identified low-risk jobs

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LBD Risk Assessment 127

well (specificity of 91%) but <lid 1\0t predict the high-risk jobs welL ·n,e 1993 g<1ide correctly
identified 73% of the high-1isk jobs hut did not identi!Y the low- and mediun1-1isk johs welL
Overall, both NIOSH f,'llides predicted those jobs rt>sulting in LBO with odds ratios berween
3 . l and 4.6. Marras and c'Oileag<1es (1999) noted that the most powerful individual variable was
average low back moment (load in hands and the hori1.ontal distance between th e anteriorly
placed load from the spine).
More recent work by the Marras lab (Ferguson et al.. 2005) has added pcrspet'l:i,·e to the
interpretation of the NIOSH approach. ·n ,e researchers measured populations of IVOrkers with
low hack pain and 'lbre-marcbed t:onrrols and nored that Ufting from the floor is problematic
for uhmy \l.>orkcrs. in parri<.:ular those wlth back pain. This has implications for retu1n1-t0-work
programs for people with injllred backs. Further, their data have strengthened rhe growing
impressioru that shear forces on the ~pine :~:re probably more i.mportam: than compression in
dctt:nn ining injury risk. In f.1ct 74% of their high-risk tasks were categorized basc.d c:mcxccssivc
lumiY.J ,· shear. Norm:>o and colleag<1es ( 1998) mc>de simib r observations.

Snook Psychophysical Approach

The psychopb)•Sical approach tu settillg load, or work limits, is based on people's perceptions
as to whar rhey feel is a rolerahle work rc>te. The main criticism of rh is approoch ;s that mosr
people perceive physiologic:all}' re.lated discomfort and not the intemalloacUngon tissues that
actually causes dam;lgo. for example, Dul, Douwes, :u1d Smitt (1994) made :tease dut muscle
discomfort, which is ,·eadily perceived, m<1y nor he correlated with actua l tissue loads. Workers
may not be cngniz:~m of the tissue loads as they reach damab,;ng levels (McGill, I997). Fw'ther-
mo.rc, Karwowski and coiJCjig<tes (Karwowski and Pongparanasucgsa, 1989; Karwowski, 1991,
1992) noted in a se1ies of studies that the general psychophysical approach is very depend em
on such factors as the inso·uc:tions provi.ded to the experimental subjects and the color of the
object l:>eillg lilted, to na01c a couple. For example, the Snook studies (1978) advised the work-
ers to determine a wo1·k rate and load to be moved based on the instruction not to become
unduly fatigued. T he workers sele<:ted the loods rhey perceived not to be fatiguing. Yet when
Karwowski repeated the experiments but d u nged the instruction to lilt loads so that subjects
would not become injured, t.he acceptable loads changed (tbeychose smaller loads). K:>rwowski
and Pongp atanasuegsa ( 19il9), when evaluating r.he eftect of th e cnlor of the boxes being lifred,
norcJ that wouJd lift more when the boxes were white, as thc.'Y peJ·ceivcd the black
boxes as being more dense. Recent work by my colleague Mardy Frazer (unpublished) suggests
rhat females hase rh eir perception of task-limiting loads more on shoulder discom fort than on
spinal indicators. LVfales, on the other hand. ba..~c perception on low back limitations. The
psychophysical approach appears to depend on many factors that modulate l)er:ception.
T he work of Snook (Snook, 1978; Snook and Ciriello, 1991) is probably the most widely rec-
ognized in the psychophysics arc.a. T he investigators t:XperimentaJiy contro!Jcd variables such as
object sire, height of tl>e lift, a11d movement distance in lifting and pushing and pulling t.~sks for
hoth men ~nd women. They conso11cted tables compiling the acceptable loads for both men and
wome.n over a variety of tasks. On one hand tbis approach inherently incorporares the dynamics
of th~ tasks, wlule on the other band the c-on terns raised in the previous paragraph ar~ worth
considering. 1'\'oned>eless, rhe Snoobpproach remains pop11lar for its ease ofimplemenr.nion
ancl hecaus:e it is one of rhe few assessment me.thods for pushing and pulling tasks.

Lumbar Motion Monitor (LMM)

SeveraJstn dies have documented the links between spine motion and the development of LBD,
but none mOr(, thoroughly than those of Manas and c•ollcagucs (1993, 1995). T hey dcvdoped
several l)'I}CS of regression models that demonstrated that spine motion and, in panicul:tr, tbe
velocit)' of motion and the range of morion are important predictors of those johs with high
rates of disorders (in fut't; some odds ratios exceeded I0). The lwnbar motion monitor is a three-
dimensional goniometer tll:lt measures the three-dimensional kinematics of tbelumbar spine (see

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figure 7. t). Marras and collellgues showed that the

kinemittic v:1rhthles ohr-Jined from workers weilring
the LMM, when combined with simple mcasw·e-
ments of lift frequency or u1otion duty q •cle :~.nd
load moment (the load magnitude mulriplied by the
distance to the low back), provide imprcssh•e risk
predictions. Using the LM.M Oil people while they
are pe1·forming real onwsire tasks and not labora·
tor;; rnockups is relatively easy to do. ln addition,
the LMM captures the indi,•idual ways in which
people use and move their spines. See chapter 5 For
a discussion o f the mechanisms of i.njury that are
dependent on spine posture and rnotion.

Biomechanical models have heen used. ro estimate
loads in the low back tissues ami identify high-risk
Figure 7.1 Wearing d1e lumbar motion monitor to jobs forapproximatclythreedecades. Some models
record the thret....dimens.ional kinematics of the lumbar
. d . , r· I .1 k
spme unng peroormance o 1nc ustna tas s.
were imendedasasimpletoolfor hcalrhandsafery
•1 • • 1 ,.. ·
personne1to provu e an approxunate an< exo tn)trry
risk on the plant lloor. Other models were designed to be more robust in illusrr.ating illju ry
mechanisms a_nd being sensiti\'e to worker variance. Decisions as [0 which model to t•se boil
down to the purJM>se and necessary con1plexity of the model.
The better "simple" models need the "complex" moods to aSS("SS tlle many simplifying
a~sumptions that aFFect accuracy and validity of output, wh ich in ru.rn depend on the type of
application. Funher, in many workplaces, the most blaranr or overt ergonomic injut1' risks have
been addressed, and only the. 1norc subtLe risks remaiu. Ergonomists need siu'1plt. nu.xlcls but
also musr be com·ersant with the more complex models rhat ".;11 assist in rectifying the more
suhcle injury Jisks and a.s.sist ln developing more effective imenrenrion strate-gies.
1\Jthout;rh simple:: biomc..:hanimlly based models to obtJin quick estimates oflow oock COtnprC>-
sion ex.istJ risk assessment f01' most jobs reqoires mo1~e cotnplex melrics a.od analysis:tppt·oaches.
lo an eFforr to optimize biofideUry and indus erial utility, Bob Nonnan, Martly Frazer, Rich ·wells,
and l developed tl1c software patka&>'C Ergowatch. It utilizes tl1c 3D moments complltCd ar joints
while wo•·kers perform 3D postures or tasks togetl>er with the founh dimension of time and
me eftect of repetition on determining the safe load. (lt is available by t'Ont:tcting D.Gmside®
uwatcrloo.c:a). T bc package uses the detailed output of the virtual spine (described in chapter 2) as
a foundation but makes assumptions to simplily data collection and to f~ci linne o·ourine analysis.
ln this way individual worker heh~wior and spine mechanics are quantified hur simplified into
"av~rag~" muscular responses seen in workers performing similar tasks. This greatly simpli fies
data collection aJld preserves tbe benefits of better anatomical representation and more valid
predictions of low b~ck loads. Fu,-rhermore, by incorporating the injt")' d<1ta ontained From
samples of workers, Erbi'()Watch quantifies the risk of back injury during fully three-dimensional
tasks and postures. The fourth dimension is time, in tltis case a variable needed ~o take into
accotmt the repetition oF tasks "''era work shift.
\-Vitb use of the Erbrowatch, the joint coordinate data -are entered manuaJJy or the user
manipulates an on-screen mannequin il\to the work posture of in terest. The software executes
the difficult task of dctennining the three-<limensional joint moments by computing the F:ule•·
angles a11cl o-ansfonning them into momems ahout the orthopedic axe-s of each joint. ln this
way, dtc IYJitkagc is capable of calculating joint loads in any posture an.d for any t_.ombination of
lift, lower, push, or pull task It also incorpo•·ates algorithms that caprure the avernge muscular
response measured fi·mn workers co suppon three· dimensional spine moments of force rogerher
with strength data for both mcu and women. As \\o·cU, the model is sensitive ro spine p<>Sturc in
that ligam.enxand passive tiSS\oe l(ll"ces are invoked during fully flexed spinal postures. T hus, the
model mor.e accmately predicr$ low back shear forces supported by the spine (as compared to

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LBD Risk Assessment 129

reaction shear forces of otl>cr models), together with cumpression forces t.baLresult !rom
load ;md the many torso muscles contracting co support a particular set of three-dimensional
moments (see figure 7.2, tt-b} (noting t hat shear more o ften is the var iable. closest t <) tolenmce).
While the upper limit for shear has been suggested to be I 000 N (222 Ib), tl>e equiva.lcnt "action
limit" for repeated loading has been set at 500 N (II l ib) (McGill et aI., 1998, ~·om tissue-based
data; and Nonn<m et al., 19981 using industrial inju ry repo rting data) Finally, the risk is also cal-
culated from accwnulated loads during repetitive work via compru·ison of the km l-time imegrals
with epidemiologic dHta obtained Ji·om a large surveillance srudy conducted in an antomotive
assemhly plant (Nonnao et al ., 1998). (See 6gure 7.3, a-d.)
T he Ergowatch appruacb represents a oomprou1isc between )in'1plc models th at an:: easy
to implement but are nor very robust in their risk assessment and mo•·e comple.t ~pproaches.

~ 6,000



0 -50
y X y
All data, x =FIE, y = twist All data, x = FIE, y =bend
a b

Figure 7.2 Ergowatch tomputcs lumba r compressive load from an algorithm representing the averJgc response of the
many muscles, mct~su rcd from real workers, that combine to support the infinite combinations of th ree low b<tck momcot.s:
flexion.cxtension, l r~teral bend, and axial twist. Bcc.1usc only three dimensions can he graphed ar one lime, (a) shows the
su1face of lumbar compression from combit'l<llions: of flexion-extension a nd twist moments, while (b ) shows the sulfacc or
compression from flcxi on-extension a nd lateral bend.

Euler Angles and Orthopedic Moments

Estimations of three-dimensional joint moments are typically performed using three orthogonal axes (XY7.). llut
as a person mOves, 1he ortho1>e<lic axes r)f the joints (ior example, in 1he lumbar ;pine. axis 1- flexion-extension,
axis 2-laleral bend, axis 3-axial twist) also move so th~llhey no longer align with the inertial XYZ axes. The
difference between the orthopedic joint axes and the XYZ axes is described with Euler"ang lt>s. The orthopedic
moments arc then obtained from the E-vector appro~ch described by Grood and Suntay ( 1983). This involves
taking the cross-prooucl of Ihe long axis (the primary axis, usually twisl) of two adjacent segments 10 form Ihe
secondary axis (ust•ally flexion-extension). The cross-product of the primary and seconda·ry axes forms the" E-
vcctor, which in tllrn becomes the third joint Qrthopcdic axis (usually lateral bend). Moments computed about
axes XYZ can now be transfonned into joint-specific orthopedic axes. This technique ensures that 1he joint axes
convention "stay with the join ~· as the person moves within the inertial coordinate system.

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130 Low Back Disorders

Low bacl< pain reporting index

Combined 0.2'!
Paak hand load 0.51
(Task groop i.:Taa.'lt 1: Action 1}
l'<lak l4-1.5 moment 0.53
(Taskgroop t ; fas.i( 1:Acuon 1}
Poak L4·L5 compression 0.52
(Task group 1.:Task 1: Action 1}
Peak L4·L5 reacliqn sllcar 0.47
(Task groUp 1 :Task 1: Action 1}

Cumulative l4-l5 moment

Curnulati:Ye L4·LS cornprossion

a 0 .75 1.00 b

Low back pain reporting index

Combined ! 0.20 ;
Peak hand load 0.59!
(Task group t:Task t : Acbon t) '
PeaJt LA·LS moment li 0.23
(Taste guxll) 1:Task.1: AciJOn 1)
Poo.k L4~L5 compression '' 0.23
Peak L4-t.5 reac1Joo shear
(TmgrOUp t:Task. J:A.ction I)
CI,IJllulativ.e l4 ·l.5 momeflt
'i 0,21
Cumulative 1.4-LS oompress.ion 10.13
Cumutat;,.. L4·LS reaction sllear ' 0.24
c 0.00 0.25 0.75 1.00 d

Figure 7 3 Ergowatch computes the joint.spedfic, three-dimensional orthopedic rnomcnls at each joint and uses Se'V'cr.:tl
metric:s to c-alculate risk For exampl~ the low back risk includes compression a nd shear load threshold values along w ith
accumulated loads during repetitive work by compJr1ng the load-time integrals with epidemio logic data obtained from a
large surveillance study. Two examples are shown: (a, b ) a reaching lift and (c~ d) an overhead assembly t.c1sk.

£rgowatch is scill relatively easy to 11se, and it provides some degree of sensitivil)' to the way
individual workers pt:rform cornplex tasks. TttL'ies lllaJl)' rL'ik indext.>:S to quantitY tbe subsequenr
risk from a specific 1~sk performed over a work shift.

Biological Signal-Driven Model Approaches

The final approach for risk assesstnellt is to measure biological signals lrom ead1 subject in an
arrempt ro capmre che individual ways people perfonn their jobs aJ1d then use sophisticated ana-
to.-nita1, l>iomt<.:hanical, and physiologk-aJ relationships to assign forces to the various tissues.

The Ma rras Model and the Mc Gill Model

1 'he M.am1 s model (J\'Iarras and Sommerich, 199 Ia, 1991 b) measures eleca·omyograms (EMGs)
from several musdes and, using known physiological relationships: assih'lts forces to the muscles
during virtually any industrial task. As noted carljer, this approach revealed powerful evidence
linking the physical demands of specific occupational tasks "1th rhe incidence of L Bl).
T he McGill model (McGill, 1992; i\lkGill and Nonnan, J 986) uses the same philosophical
approach to assign forces to the muscles but attempts to include the highest level of :matonu-
cal accuracy possible. (rhis model was introduced in chapte1· 2.) For e~ample, it ;~ lso measures
three-dimensiona.l spine curvantre to asses.." forces m the various passive tis~mes, in cluding the
intervertebral di...;cs and the various Jigrun~nts. By assigning forces to muscles and passive tissues

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LBD Risk Assessment 131

throughoul the full range of spine motioll, it captures the differeJtt ways people perform their
johs ;md even how they cl>ange with repetitions of the same joh. The obvious liability of the
approach is its e no rmo us cOJnputational requirement..;, posq)rocessing of data, and difficulty of
eoUetting such comprchensh'e data from a wide number of workers in the field.
T he question of the validity of this type of model must be addressed along with o'ther models
based on the biological approach. Some have arbrued tha t since these models contain known
biomechanicaland physiological relationships, they contain a certain arnount of content validity.
Moreover, both the Marras model and the ..VlcGill model ha1•e been quite successful in estimating
t he various passive tissue and muscle forces that sum £ogether to produce flexion and extension,
lateral bend, and axial twisting moments. (These mmncnts have been wcU prcdi('tcd, with t he
exception of the [wisting moment.) Jn sununary, if cwisting is not a domi n.ant mom enr of force
in a partic:lllar joh, t hese mociels appear to be predicting accurate diso·ibutions of forces among
the support tissues.

EMG-Assisted Optimization
Perhaps the cuJTent pinna de of model evolution is a hybrid modeling approach known as EMG-
assistcd optimization (developed by Cholewiclci and McGill, 199i) with stability :.1nalysis and
ti>-<ue lo<1d prediction (Cholewicki and McGill, 1996). This approach exploits the asset of the
biolob>ical EMG approach to tlimibute loads among the cis.<ues based on the bioloJ:,-ical behavior
of the subject. It then uses optimization to fine-tune cl1e satisfaction ofjoint torques a bout several
low back joints. The opt.imiration rakes the "biological!)'" predicted Forces and adjusts muscle
forces the minimal amount pos.."iihle m satisfy che three~<lim en.sional moment axes at ever)' joint
over the lettgth of the lurubar spmc. Once the three~ dimensional moments have been assigned
'"'d tissue forces detennine<l, an ana lysis of spine stability is pe,-formed via comparison of the
jo>de.• of work imposed on the spine through perturbation with d>e joules of potential energy
existing in the stiffened colwnu.
T his most highly evolved of spine models provides the biomechanist or ergonomist wid>
insight into injucy mechanisms caused by instability (as witnessed by Cholewiclci and McGill,
1992) such as OCCUr> during picking up a VCI)' Ught load from tbc floor. £yen though patients
have reported back injury from iocidems such as be.nding over to tie a shoe, pre1•ious modeling
approaches were semirive only ro tissue damage and injury scenarios produced fi·om large loads
and moments. Now a biomcchanical c:.xplanation is available to the sub:requent tissue
damage, an d a mecl10d is available to detect the risk of irs bappc1ling. Alcllough the routine use of
this type of sophisticated model by ergonomists is not feasible, it is useful (for m1inecl scientists)
for analyzing individu;~l workers ;~nd idencifying those "·ho are at elevated risk of injury because
of liluh:y personal motor patterns.

Simple or Complex Models?

In sun1mat-y the com pie.'\: models provide a tool to investibrate rhe mechanism." of injury and rh e

effcG'tS of tLX'hniquc during material handlu>g on the risk of iojUI:y. The most contpkx amlmost
highly evolved models p1·ovide insight as to how injul')' occurs "'th all types or heavy :tnd light
loads. On the orher hand, the simpler models, while sacri6cing accuracy, can he a powerfi1l tool
for routine survciUar\ct of physkul dcrrtalids i11the workplace but must be wisdy iriti:rpri:ted io
each case For their lin>irations and constraims. Biomechanics and ergonornics reqoi1·e the ntll
t'Qndnuum of sophistication in models. T he ch oice of which o ne 'tO use depends on the issue
in question.

The Challenge Before Us

l.n this chapter r have st1mmari2.ed and critiqued severa I approaches fo1· their assers alld liabilities.
The choice of the most appropriate tool depencl<on the objet.'fjve at hand. Yet many ergono-
nlists and engineers believe that rninirnal tissue loading is best for all johs, motivat-
ing them to direct their interventions toward making all jobs easier. This concept is l~ulty.

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Biological tissues require repeated loading and stress to be healthy. Virtually all risk assessment
tools consider only the risk of too much toad. Risk assessment tools that survey too linle load-
ing for optimal health are just srarting to emerge. T he challenge is to develop a wise rest hreak
strategy to Fati~tate optimal tissue adaptation. More robust assessment tools will be de,·eloped
in the futu re based on the most healthv combination of work and rest. ' l' his will be achieved
through fir:st an underst.tndingof the hio.mechanicaf, physio1ogical, and psycbological parameters
of injury and human performance and then thoughtful application of this wisdom.

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Reducing the Risk

of Low Back Injury

s I h.-we S:u£,rgested in previous chapters, many of the classic insrrucrions fi·om "experts"
A about lifting (for example, bent! the knees and not the bac-k) arc in most cases no»sensc.
In 1\lct, very few occupational lifting tasks can be perl\mned this way. The resulting tra&-edy is
that clinicians or other e.xperts lose credibiliry in t he eyes of t he worker; the worker knows she
cannot do her job clJat way. She lift; objects from tl>e floor, out of parts bins, over tables, and
so forth. The «:ience shows rhat squaL~i og can have ;lO increased physiological cost and that,
depending on the cbaracreristics of the load. it m<lYnor even reduce loads. Squatting is not
always the best ~;huice of po~ition; it depends on the speci fics of the task (size, weight, and
Jensity of rhe object; pick and place location; number of repetirioo\s, ere.). Fm example,
the golfer\; lili: (see figure 8.6 later in chis chapter) ma)• he preferable for reducing spine loads
to beniling the knees ami keeping chc back srnighr for som<'OM rcpcarcclly lifting light objects
from the Oocu·.
Reducing pain and improving fun ction for parjents wirh low hack pain involve cwo <.'Ompo·

• Reo11oving the stressors that ~reate or exacerbate damage

• Enhancing activities that build healthy supportive tissues
This chapteo· addresses the issue of prevention, Sl>ecifically, reducing the overlo;oding
stres..wrs that c.1use occupational low b:.1ck disorders (LBDs). After rc\~ewing k>sso:ns ti·om the
literature aud presenting the scic.ntific i s..~ul'S1 J wiH provide two sets of guidelines:: one for work-
ers and another for management. Finally, 1 will offeo· a few notes to ellhance the effecri'•eness of
consuletnrs. The lists provided in this chapter wiU result in more successful injury prevention
programs. -I'hc practitioner or umsultant who employs them wilJ stand out from hi~ or her
Upon completion of this chapter, you will he able to formulate scientifically based guidelines
effec-tive for any ac-tivity that retluce the risk of occ-upational low back troubles. F urcher, you
will be aw•re of, and so will be able to avoid, the pitfalls that cause ergonomic approaches to
fail. Fu1;olly, you will be a more effective consulrant by harnessing tl1e real expertise-that of
the worker_

Lessons From the Literature

Why does industry cao·e about the backs of workeo·s? Competitiveness in Lhe new econom)'
re(.1uires be ing protJrable, and for m:my the only way [() enhanl'C: profit is ro m:u imize loss:
concrol. A major source of Josscs tO Nord1 American industry is worker injw·y, which results in
direct costs for compensation and indio·ecr costs of hiJ·ing and o·eplace111ent workers as
well as reduced productiviry due to lower speed and incre-ased errors. For this re:.son-w pre\•enting
injury and promotitlg du: 111pid rCtul1l to work of inju red workers have becomc a major focus

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for industry. Bet.-ause b::1cL: injury reJ)resem:s an enormous cost in both re.1l dolh1r.s and suffeling,
t.-ompanies art realiz.iug the bem:firs ofsupporring injury prevention and rehabilitation programs.
f oUowing ate a number of studies that have addressed the issues that must be exam ined if such
programs are to he successful.

Compensation Board Statistics-An Artifact?

\i'Vhen completing injury report fonTIS, clinicians are often requ<!$ted to ''name the event"" (hat
causetl tbe '"injury."' This information fonns the statistical base for compcnsarion boards, which
compile these reports ioto "injury mechanisms"-for example, tbe injw·ed worker "lilted aod
n\~S[ed." V\lhile these events may have heen the ~·culnli nati ng evenr.," they were no r the cause
of the cumulative rrauma that was, allowing the injurious e\lent to occur. Addressing the
~.~culminating event'• rather than the cause of the cumulative traurna may have Little efti<:acy.

Ergonomic Studies
If LBDs arc associated with loading, then changes in loading should change injurr and absen-
teeism rates. But surprisingly, the literature does not provide cle.1r guidance for reaching this
objective; it needs interpretacion. T he traditional ergonomic approach is to establish a criterion
that, if applied in the job design, would lead to a reduction in incidence nlte. In a review in
1996, Frank and colleagues suggested dm modified wo,·k with lower demands can be successful
in reducing du~ munber of injuries hut that other changes such as oq,raniz.:ttiooa1 parameters
1nade it difficult to conclude that physk-a l demand changes accounted for any reported differ-
ences. T is becallsc 1>e1y few sn1dies have simply altered job demands. Furthermore, Winkel
and Westgaard (1996) noted that the implementation of erb'(lnomics can lead to what they
t..-a11cd an ergonomic pirfull. That is, the new crgonomk con.sciousneS!t c.~mscs many workers to
report concerns that they did not pre1•iously reali?,e were a result of their job situations. Thus,
many newly implemented ergonomic jmervention rrograms haw: resulted iu a temporary rise
in muscu1oskelctal disorders. Tl1is ctl"e('t appears to have confounded any .study of ergonomic
eOicacy of insu fficient duration. The number of good investigations documenting me effects of
joh change, or the implemenr::1tion of ergonomic principles, is also low because such re:;earch
is very tinu:-t:onsuming and difficnlt t<) perform on-site.
Noneth eless, SCI'Cral nice >'tudies qualify by documenting only the effect of ergonomic job
redesign. For example, in a report on a series of smdies on working women in Nonvay, Aaras
(L994) noted a mllcctivcly documented reduction in sick leave due to musculoskeletal troubles
from job redesign (specifically, from 5.3% to 3. 1%) and a reduction in employee turnover from
30.1 % to7.1i%.

Rehab and Prevention Studies

Loisel and collcaf,'tli!S ( I 997) conducted a wry interesting and im[>OJtmt study in which they
used a randomized control trial design witl• four groups. One group of people with back injuries
recei,.,ed ''clinical"' inten•ention consisting of a visit ro a back pain specialist. OOck school, and
functional n .hahilitarioo therapy. Another group receh'e<l ::m occupational intervencion cons-ist-
ing of a visit to an ottupationa1 physician and tben an erbrononllst to arrive at ergonomic solu-
tions. A third group, the "full intervention group,• received both of these app1-oaches, and the
fourth ~rroup received 01 usual care.,, The b'Toup receiving full interYenrion returned ro reguJar
work 2.41 times faster than the usua l-car~ grouf>, although the sp...:ilic effect of occupational
inten·ention (ergonomics) accounted fo1· the largest proportion of this result with a rare ratio
of rentrn to regular work of 1.91.
Those paying tOr injury (government ag'Cncics and compensation boards and the in.!turanc.c
industry) could ''easonably argue from tb is c1•idence that, to ,·educe costs, care for t:he injuJ·ed
back should be removed from medica l hands (once the medics have ruled out "red tlag" condi-
tions such ;as tumors) and brivtn to c.rgouomists! Tongue-in-check aS dtis srntcmmc may be, ib
point is worth)' of deep consideration. Hopefully, the last section of d>is book wiUprovide dues

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for more e fficacious medic'al intervention. Krause, Dasinger, and Neuhauser (1998) reviewed
the literanore on the role of modified work in the return to work and rated as high quality the
Loisel srudy. as well as the srudies of Baldwin, Jolmson, and Butler ( 1996). T his latter re\iew
wncluded that modified work (involving tJ,e modification of musculoskeletal loadi ng) is effec-
tive in facilitating the return to work of disabled workers.
ln addition to worl1llace dcsib'll modifications, v.torkplace interventions mliy he nefit fro m
addressing the personal movement strategies of eath worker. In a l~sdnating study Snook and
colleagues (1998) demonsmted that of 85 p3tients randomly assigned to a group thnr con-
o·olled the amount of early·morning lumbar tlexion, the experiment1J group had a significant
reduction i.n pain intensity c.:OJopared to a t:Oiltrol group. VVhen the c-ontrol f,'f'oup ..c:ceivcd the
experimental treatment, they •·esponded with similar redllCtions. -lltis is yet another example
of how personaJ spine morjon patterns and loading posrure c~m influence whether dte person
will become injured. l11c next scttion blends notions of job design with personal movement
strategies to rednce loading and the ·~isk of I.BD.

Studies on the Connection Between Fitness

and Injury Disability
It is fruitful to di!;('USS briefly d'e role of fin1es-< in the link between injury and disability. Altl,ough
several studies have shown links between various fiu1ess factors and d'e il,cidence of LB D (e.g.,
Suni et al., IY98, who showed rhar higher VO,max scores were linked to LBDs), <hese eros.<·
SCL"tional srudi&'i cannot infer causation.
Probably the most widely deed longitudUtal study was reported by Cady and collea goes (1979),
who assessed the fime.'~ of Los Angeles firefighters and noted that those who were 111 ted "more
fit'~ had fc\tler subsequent back injuries. However, what is no t widely quo te d by those citing this
study is th:> t when the more fit did become injured, d'e injury was more severe. Perhaps the more
fit were willing to expe•1ence higher physical loads. Severa I have S\lggested chat a psychological
profile is associated with being fit (e.g., Fanner er al., 1988; Hugbes, 1984; Ross and Hayes,
1988; Young, 1979) and that tlte unfit may complain more about the more minor "ches. Along
those lines, some athletes have demonsrrated the ability ro compere despite injury. Olurnett and
coUeab'lles (1996) reported ~Ticket bowlers with pars fracntres who were still able to compete. [s
this due to their suprCJllC fitness and ~t bility to achieve spine St:lblli ty or their rnc:.ntal toughness?
Pel'l>aps it is both. T he issue remains unresoh•ed.
It is also interesting to note that personal fitness factors appear tC.l play some role in first·time
occurrence. Bic•1ng-Sorcnscn (1984) tested 449 men and -179 women for a \'1lriety of physical
characteris tics and showed that those wi[h larger amounts of spine mobility and lower ex{ensor
Dlll~>ele endw·ance (independent f:·lctors) had an jncrett.sed occwTence o f suhseq1tenr fi rst-time
back rroul>lcs. Luoto and colleagues (1995) reached similar conclusions, It would appear that
muS<:Ie endurance, and not amhropometr·ic va•·iabJes, is pmtective.

Beyond Ergonomics: Is It Time to "Modify" the Worker?

Ergonomics is o ften descnl-;e d as "fitting the task to the person." T here -are many efficacy srud-
ies now showiug that ergonomic job change is eff(..-etive to various clcgre~ but not as effective
as might be thought. ~-or example, " smdy of mechani1.ed lifting aids in a patient care mcility
showed that the ergonomic aids reduced ph)ISical demands <1nd decre.ased .staff fatigue, yet
injury rates remained unchanged (Yassi et al., 2001). \.Vhile training of the worker h:>s been
shown to be necessary with virmally any physical e•·gonomic intef\•ention (e.g., van der Molen
et al., 2005), the way the worker moves also appears to be highly important. Reducing injmy
with ergonomic approachc;S appears to have some efficacy, but any further advances wiUprob-
ably requi•·e "changing the pc•-son <0 fir the task.• wgnon (2003) obsetved "experr" lifte•·s and
conclude<! thar their lifting scrategies and personal body movemenr$ led ro their health success.
Our work for the past several years has converged on the." notion that the way the exertion is
perfom1ed determines the risk. Our quantification of martial ac·~s task~. weigluJiJtiog, strongman
competitio ns. and so on proves that technique cletem1ines d1e risk in very chillleng:ing physical

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tasks. The next section of this chapter incorponltes these llOtions within the
oonrext or reducing the risk of hack injul)'·

LBO Prevention for Workers

This set1:ion addresses a list of issues th3t arc sdcurificaJiy justifiable to reduce
lhe risk of occutn tional LBDs.

Should Workers Avoid End Range

of Spine Motion During Exertion?
Ge11e•·ally, the a11swer to whethe•· end range of motion should l>e nvoided is
yes-for several reasons. Al\aintaining a more neutrally lordotic spine will
max.imi·ze shear support, ensure a high tolcraut,"'C of the joint to withsmnd
compressive forces, elimiJlate the risk of ~g;tmentous damage since the
ligamems remain m1strained~ eliminar.e the 1isl.: of disc herniation since this
is as,.,;odated with a fu)Jy Elexcd .spine. and qualitatively emulate the .spine
postures that Olympic lifters adopt to avoid injury (see ligure 8. 1, 11-b, for
an illusrr:~rion of a tlexed ;md a neun"'l spine). Unformnarely, t!tis issue has
a become confused wlth issu(.os such :ls whether it is bl!tttr to stoop or squat.
Another source of confusion has evolved frorn the common rocotnmenda-
tion ro perform" pelvic tilt when lifting; the scientific base for this clinically
popuJilr nution is none:\iStcnt! Pe.rfo1minga pelvic tilt increaS<.>s tissue stresses
and the risk of injury!
What spine and hip posu, ·e best the risk of inj11ry? We do
know that very few limng task< in industry can be accomplished by bending
the knees a.nd not the ba<:k. l'urtltcnnorc, most workers rarely adhere to this
tt.'chnique when repetitive lifts are requ ired-a face lhar i< quire probably
due to the increased physiologic:a Icost of s:quarting <..'Om pared witb stooping
(Garg an<llle11;1l, J 979). llowcvcr, a case can be made for preserving neuttaJ
lombar spinecurnwre during lifting (specifica lly, a<•oiding end r;tnge limits
of :ipi ne motion ahoutanyofrhe three < This is a differenr_<..'fmcept from
tmnbnglc, as tlw posture of the lumbar spine can be maiutainecl independent
of thigh a11d rrunk angles.
T he litenmue is confused herween tnmk angle or indinacion and the
amount of Ac...xion in the lumbar splnc. Bending over is a('l'Omplishcd by
either hip flexion or spine flexion or ooth. lt is t:he issue of specific lumbar
spine flexion that is of imporrance here. Normal lordosis C<ln he considered
tO be the curvature of the lwnbar spine associated with the upright standing
posture. (lo be precise, tbe lw11bar spine is slightly extended from elastic
b equilibrium during mnding; see Scannell and Mc-Gill, 2003 .) lot figure 8.2,
a warehouse worker is successfully spari ng his .spine by avoic.liog e nd range of
Figure 8. 1 ( ,1) Flexirng the spine motion even though he is not bending the knees; he has accomplished
torso involves eilher hip flex- torso flexion by rotating ahom the hips. In ~gure R.3, a fire~ghrer is dem•
ion or spine flexion, or (as in onsuating a spine-sparing technique (fi!;,rure 8.3b) versus a spine-damaging
this case) both. (b) A neutral teclutique (figure 8J11) for lifting extingtusher>. C hapter 10 offers further
spine with hip flexion. occu pation-specific ex:.lmples (e.g.. l he construction workei"S demonstrating
spine-sparing postures in figure l0.3).
ln chapter 5, l cxplaint-d the load distribution among the tissues of t:hc low back. Of inter-
est here are the tlr:!matic effects on shear landing as a function of spine CUI'\•;mu·e. Recall the
following facts;
• A spine that is not fully flexecl ensures t:hat d1e pars lumborum fiher:s of the longissimus
tborac.:is and iliocostalis lumborom arc able to provide -a ~'upporting posterior shC"M forte
on •he supetior vertebra, while fu ll llexion causes the interspinous ligament complex

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m strain, iJnposing an atnet1or shear force on d'le

superior verrebr.-. . For these reasons1 avoiding fi.lll
flexion not onJy ensures a lower shear load but also
el.itninates tig.1menr damage.
• A fully flexed spine is signiticantly comp romised in
its abilityto "1thstand tomprc>Si"c load.
• Because herniation of the nucleus through d1e
annulus is caused by re(}Cated or prolo nged full
flexion, avoidance of the posrurc minim izcs the 1·jsk
of herniation (a cumulative t:rawna proble111) and
minimizes the stresses on any de,•eloping annular
Olympic lifters prm~de a convincing example of the
efficacy of avoiding lumbar flexion in lifting. They lock
their spines in a neutral posrure and emphas·ize rotation
ahout the hips (st.-e fib>"Ure 8.4), lifting enormous weights
without injury. Tile ambulance <lttendants in figure 8.5 are
also sparing their backs by locking d1e lumbar regions to
avoid flexion.
figure 8.2 This warehouse worker is not bend ..
ing the knees, yet he is sparing the spine by ~rl1us, the important issue is not whttller it is better to
electing to bend and rota1c about the hips; the smop lift or to squat lift; rather, the emphasis should be
lumb.1r spine is nol flexed. to place the load close to the hndy to reduce the reat'tion
moment (aml tbc subsequent extensor fOrces and resultant
compressive joint lo;tding) and to avoid a fully
flexed spine. Sometimes ir may be better to squat
w achieve this; in cases in_which the objttt i~ too
large to fit benveen the knees. however, it may be

Figure 8.3 (a) This firefighter, who is flexing his lumbar Figure 8.4 World-class performances in O lympic
region, is IOilding the passive tissues and increasing his weighilifting are charat~e<ized by a lumbar spine
risk of back trouble.<. (b) Avoiding full lumbar flexion locked in neutral, where the motion takes place
<1nd rot<lling about the hips sp<lrc 1hc spine. aboulthe hips and knees. Sp1ne motion would eitht'f
lead to injury, or an uncompetitive lift_

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better to stoop~ flexing at the hips bur always

avoiding full lumba1· Oe.xion to minimize pos-
relior ligamentous invoh•emenr. (For a more
compre hensive discussion, sec l\•fcGiiJ and
Kippers, 1994; M.cGill and No.,nan, 1987:
Potvin, Korman, and McGill, 1991.)
Yet another spine~spc1ring lifring posrure is
the golfer's lift. which reduces spine loads for
repeated lifting oflight objects (see figure 8.6,
n-b) (Kinney, C..allaghan, and Mc-{';ill, 1996).
The hips act as a fuknun in which one leg is
cantilevered behind with isomeo:ic muscle
contraction, fonnjng a couoterweig hr to
rOtJtC the upper body back tO upright.

What Are the Ways

Figure 8.5 These ambulance attendants Me attempting
to spare lheir backs by avoiding lumbar flexion and I ifting to Reduce
together to share the U<X>d. They have also been laugh! to the Reaction Moment?
lightly contract the stabilizing abdominal musculature,
A popuhlr instru~"tio n is ro hold tbe .load close
ro rh e torso when handling material. 1bis is biomechanically wise; a reduced !eve•· ann of che
load requi res lower internal tissue loads ncc.:c.:ssary to support cl1e- reaction moment. But phras-
ing the prit1ciple in tet·ms of holding tbe load close restricts the notion to lifting tasks. T he real
biomechanical principle is to reduce rhe reacrion momenr. When phrased rhis way, the llFinciple
is now applit-ablc to auy cask invoh~ng the exertion of cxtemaJ force.
One technique is to expaJld d1e concept used by archers-termed l"l1e "archer's bow" by some
of my Auscralian colleagues (figure 8.7). Here, one arm pushes m support the re:1crion moment
needed to support the upper body while the other am• lifts the load.
Directing the Pushing Force Vector Through the Spine
\Vhc:n one is pushing a cart h ~mdlc, directing the pushing forte vector through the lwnbar spine
reduces the t"e"ction molllent and therefore the tissue loads and spine load (see figut·e 8.8). In

a b

Figure 8.6 The golfer's lift has been documented to minimize low back motion and reduce the loads on the lumbar ti ssu~--s
by using the leg, which is cantilevered behind, as a counterweight; lhe hips act as a fulcrum to raise- the torso to upright. This
is an effective technique for repeated lifting of light objects from Hoor level. (a) Most still adhere t<> the general instruction
lo bend the knees and keep the l>ack straighl, not (b ) considering lhe spine-conserving benefits of !he golfer's lift.

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a b

Figure 8.7 (.1) The archer's bow (b) is translated to a lifting situation minimizing b.ock loading.
Opposing hand forces are shown with ..1rrows.

conrrasr, a pushing force directed through the shoulder would nor be tlirected through the low
lrJck (see fib'llre 8.9, tt-h); this fonns a transmissible vector. The large pcrpendicalar d.isnmcc &om
tllis Ioree ro tl•e spine causes a high reaction torque tl>at is balanced by muscular force; tlus imposes
a t'OITesponding compressive penalt)•on the spine. Redirecting the trJnsmissible vector rhrongh the
low back reduces this moment ann (and the moment), the muscle fort-es, an d the.: spine compres-
sive load. Other examples from everyday activities include tl1e technique used ro o pen a door;
directing the pulling force thro\•gh the low hack is sparing (see fig<.re 8. 10, n-<). Another ex-•mple
is vacuuming, which is o ften reponed by o ur parient'i to exacerbate tbeir syrnpwms. Ho lding
tl1e handle to the side creates a large moment ann for tl>c pushing and pulling forces; this heav-
ily loads the back (see figore 8.1 111). Directing the pt~sh and pll ll forces through the low back
minimiz.cs the moment arm (see figure 8.11 b) and removes the loads that ensure that patients
remain patients! These ex<m1plcs demon.srrarc how this
powerful but ra •-ely practiced tecl>nique of skilled control
of tbe trausmissihle vector spares the back.
Diverting the Force
Around the Lumbar Spine
Sti ll oth er very effective ways <c<ist to reduce rhe reaction
moment. The next examples demonstrate how workers
skillf\lll)' spare t.he low back l)y diverting fQrce arotmd
rhe h1mbar region when lifting. T he workers lifting rhe
shaft in a paper factory in figure 8.12 are minimizing the
reaction momell! by lifting the shaft with theu· tltigh (by
plantar Aexing the foot). fn this way, rhe weight of the
shaft is directed down the thigh to the Aoor, bypassing
the upper body linkage and spine. Prior to ·redesigning
rhe job, the workers had to lift the shalt with arm forces.
Figure 8.8 Pushing through the hands but direct- causing low back problems and motivating o ur im•olve-
ing the force vector to pass through the low back ment. Figure 8.13, 11 through c. illustrates how a workc.r
minimizes the low back moment (and minimizes c:m pedorm the same m :lnellver to lift a padenr. Observe
the muscular loads). cl>at the lifter is puu;ng the pariem~ peh1s onto bis thigh

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Figure 8.9 (il) l,ushing o r pulling forces that pass by the spine with a large moment .-nrm ensure a
high moment and corresponding high muscle forces and spine loads. (b) Pushing forces direc1ed
1hrough Ihe low back minimize !he momenl and spine load.

Figure 8.10 (a) Open ing a door by directing hand for.ces through the low back spares lhe spine . Many people are not
taught how to optimize Lhis principle during the performance of daily tasks. (b) Instead, they sacrifice their spine by open-
ing the door so that lhe force is lateral to the lumbar spine creating a twisting torque or (c J produce a pulling force that
passes over the low back.

and standin g along with t he patient. {Note t bat patient lift~ <.:an not 00 performed with u ujvcrsal
teclmique since all patients are different and can offer variable assistance.) Minimal forces are
o-.m smitted down the spine. Shoveling snow hy resting t he forearm o n the thigh invo lves the
~m e spin c:-spari ng prindplc (see figure 8. 14, 11-b).

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Figure 8.11 (a) Vacuuming is often repotted as prob. Figure 8.12 This task requires a worker to lift a heavr
lematic lor bad backs. The transmissible vector in this shaft while another worker slides on a core from the end.
example has a large moment arm with respect to the back A high incidence of back troubles: motivated our consult..
and requires large twisting torque forces (causing IXlin). ing recommendation to install a bar lor the fool, which is
(b ) The transmissible vector is directed through the low ptan!M flexed to raise the shaft now supported on the thigh.
back, minimizing the load and the pain and enabling The forces 110V\' transmit directly down the leg, completely
vacuuming. bypassing the arm and spine linkage.

c L __ _ _ _ _ _ _ _ _...J

Figure 8.13 (a) Lifting the patient can be perforlfled with minimal loading down the spine provided the height of the seat
is dose to the height of the lifter's d•igh when in a squat position. (b) The patienfs pelvis is pull..d and slid onto the lifter's
thigh, and (<:) then cl1e lifter stand> up, hugging the patient's pelvis and minimizing the forces up the arms and down the
spine. TI1is spine-sparing technique is reserved for patients who are able to stand.

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Figure 8.14 (a) Shoveling snow with a large moment arm for the load o n the shovel loads the
back. (b) Resting the a rm on the thigh directs the forces to the ground, bypassing the a rm and
spine linkage.

A Note on Pushing and Pulling

0\>r srudies comp~ring rhe expen techniques of ~reflghrers versus graduate sn•dents we•·e
noted in chapter 5. Specifically, for rasks "'cb as hose pulling. the fire6ghrers brac-ed tbe body
and pulled the hose with the fon.:C vector tr"JveUng through the low back to n'liuitnjze lumbar
loading (see tigut·e 8. 15). Some of our recent wo•·k documenting rhe techniques employed by
hospital workers when d1ey transfer patients hif.rhlighted once abrain this importan t technique
(McGill and K1vcic, 2005). On occasion friction-reducing dc1iccs are placed un (Lcrneath the
patients thar need robe transferred. Pushing and puJiingbythe pro1>ider are then applied 10 rhe
patient. £\'en with the frictio n· reduc:ing de\rices1
the principle of directing tbc hand forces through
the lumbar spine is a very imporrnm compoJ\ent
in minimizing spine for(,.'e$.
Reducing the Load
Finally, workers use sl111 ro reduce rhe actual load
and hand fo rtes when lili:ing lafb'<l objecrs. Some
tasks can be perfom>ed by lifting only hal f oflbe
objecrata time. lior examp le, when loading long
logs onto the hack of a truck, a worker could lift
just one end (effectively handling 011ly half of the
full weight of the log) and p lace it on rhe bed.
T he worker could then walk around to the other
e nd of the log an d lift whfle sliding the log onto
rhe bed (see fig<tre 8.16). Each lift is half ofrhe
totall(.)ad . A S<.-':(1Ueoce of unloading a refiigerator
denlonst::rntcs the same.tcdmiquc; the fuU weight
of the object is neve•· lifted (see figu•·e 8. 17, "-:!)!
Figure 8.15 Directing the pulling iorces through the low The worker lifting the mini~refrigct-:ator (shov.'fl
bad< helps to minimize :spine (orces. Spine poswre loeutraiJ in figure 8.18, a-b) tilts it up o nto an edge, rais-
and whole~body posture (to rt.~ u ce the reaction moment) ing its cen.tet· of gr;wity together with the it\ it ial
are also important variables for injury avoidance. lifting heighr. Lifting from rhis higl>er S[;)rting

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Figure 8.16 ll1is girl loads the log iniO the truck by lifting only half its weight at a lime. First she
Iifts one ~nd onto the truck. U1en sh ~ lift> the othe1· end and sli d~ th~ log onto the b.,d.

Figure 8.17 1lliS worker ~nlloads the reMgE>rator from the trailer "'ithout having to lif1 its f1..1ll weight. (aJ He "'wfllks" lhe
refrigerator on its comers to the edge of the trailer, where he balances it ov~r the lip of the bed. !bJ Next, he slides the
refrigerator down the tra iler1s 1ailg.1tc. (c) He walks the rcfrigcraror cle<1r of the 11ailer and leaves i t standing uprighl while
he retrieves the dolly. (cl, f!) He tl(lgc of the refrigerator up just enough 10 slide the dolly under il. ({} Finally,
he and t,t <:owork¢t \\~)~I the appli<1nc.e away.

position reduces the ne.cess3ry moment. The concept of minimizing rhe reaction moment is
much more robust than simply telling people to hold the load close to the body.

Should O ne Avoid Exertion Immediately

After Prolonged Flexion?
Recall that prolonged ftexion caoses both ljgamentous creep and a red isuibt1tion of the nucleus
wirhin [he:.1nnulns (see chapter 5). In this way the spine tissues have a loading memory. F'tu·rher,

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evidence from jackson and colleagues (1001) suggests that prolonged ne.~ou
modifies the e.'tensor neurologic-J I response and c->uses muscle spasming,
at least until the ligamentous creep has be.en restore{). ln this case it was 7
hours! Spine stability would be compromised during this period, and the risk
of annulus damage 1·emains temporarily high. If possible, after prolonged
stoopi ng or sltting <lt·civities, pt!ople should spend time stan<ling uplight
before attempting more strenuous e.xertions. For example, it would be very
unwise for the gardener in figure 8.19 to stand and lift a bag of peat moss or
for the shipper/receiver in figure 8.20 to rise and inunediarely begin load-
ing pallets . .I low long should one wait before perfonning an exertion? Data
from Twomey and Taylor ( 1982) derived from cadaveric Sl)ines suggest that
age delays recovery of cl>e spinal tissues. McGiUand Brown ( 1992) nored
cl1at residual laxity rcrhaincd in tl1<: passive tissues even aftc.r a half hour of
st:tnding following prolonged flexion-although the llexion was e.xcreme in
an ()(.'Cnpa tional <."'ntexr_ At leasr 50% of the joint ~riffness reouned after 2
1ninures of stamling following the session of prolonged Acxion.
As noted in chapter 5, because the mechanics of the joims are modulated
hy previous loading hL<itory~ one should never move inunedi:ueJy to a lifti11g
msk from a stooped posture or after prolonJ:,>ed sitting. Rarl>cr, one should
farsr stand, or even consciously exrend thespine, lot· a short periodi. Obviously,
people in certain occuparions such 3S eme.rgencyamb1tlance personnel cannot
follow this guideline. They arrive at an accidt·nt scene without tile luxury of
time ro warm up their backs and may have to perform nasty ~f~uch as a
ISO kg heart mack victim out of a barhrub! For these individuals, the only
srrateb'Y is to avoid a fully flexed spine posture while driving so that the spine
remains best prepared to withstand the imposed loads. "Il\is may be done with
accenl\13ted lumbar pads in che ambulance sears and with wo1·ker training.

Should Intra-Abdominal Pressure (lAP)

Be Increased During lifting?
Gcncr.1lly the answer is no: At least lAP shouJd not be im.:r~sed consciously.
Recall the discussion concluding that lAJ' does not reduce Sl>ine .loading
hur does act ro stiffen ir ab>ainst buckling. By successlldlj• completing cl>e
rchabiliracion ruining advocated in the final section ofthis book, people can
Figure 8.1 8 (a) This man lifts train their breathing and lAP to be independent of exertion. In this way
the mini-refrigerator by tilting any specific instructions reguding breathing and exertion hecome moot
it up onto an edgeJ roising poincs. In most cases lAP will rise natu rally, and no fnrthcr consdous effort
its center oi gravity together
is required.
with the initi.11 lifting height.
A linal caveat is required here. Very strenuous lifr:s~ if rl1ey must be per·
(h) lifting from this higher
funned, will require the buildup of lAP w increase torso stiffness and ensw·c
sta11ing position reduces the
necessary moment so the srabiliry(Cbolewicki,julucu, ;U\dMcGill, 1999). On tbcotber baud, we know
man can reach the sta ''ding that a substantially increased intrathoracic pressure (as occurs with lifting)
posilion wilhout damage to will compromise venous return (i\'lolmysaari 1 Ancila 1 a11d Peltonen, 1984).
his back. Further, breath ltOiding during exertion raises both systolic and diastolic blood
pressure (Haslam et al., 1988), which can be a concem for so1ne. Blackout
is not uncorum1m in strenuous lifting even though it is not clear which m<..ochanisnn is respon-
sible (i\bciDougall et al., 1985). Reitan (I 941) proposed that blackout may be due to elevated
central nervous system Auid pressu re (lAP also raises cenn':ll nervO\ISsysrem fluid pressure in
the spine and up tU the head), whereas Hamilton, Woodbury, and HaqJer (1944) proposed that
an increase in cercbrospina] fluid pressure ll'".ight actu:1Uy scn•c a protective function (i.e., the
consequen t decrease in transmural pressure across the cerebral vessels couJd acma lly decrease
the risk of vascular damage). At this point, given cl>ese issues and a lack of full understanding,
moder.ttc l AP may be warranted with the understanding of the negative side effects. Extrcrnc
lifting efforts involving conscious increases in lAP should not be performed m work.

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Are Twisting and Twisting Lifts

Particularly Dangerous?
'While several researchers have identified twisting of the trunk as a
factor in the incidence of oceupationallow hack pai11 (Frymoyer e t
al., 1983; Troup et al., 1981), the mechanisms of risk require some
e'ph111ation. The kinematic act of twisting has been confused in the
lirerarure with the L:inetic va riable of generating rv.;sting t:orque.
1\visting torque in the torso C•ln be accomplished whether cltc spine
is Pi\ is red or not.
Generally. tv.'isting ro moderate clegree~ without high rwisting
torque is not dangerous. Some have h}rpothC!Siz.ed bastd on an inertia
argument that twisting qujcldy will impose da•1gewus a.<ial torques
upon hn1l-lng the axial ro tation of the rrunkat the end rang:e of motion.
Farfan and colle.b'lltS (1970) propo>ed that twisting of the disc is the
Figure 8.19 This gardener would only way to damage the collagenous libers in the annulus leading w
be unwise to stand and immediately failure. Ther reported that distortions of the neorol arch permitted
lift a heavy object after spending a such injurious rotations. Shintzi-Adl and colleab'lles (1986) conducted
long period of time in a stooped more detailed analyses of the aMulus under twist. ll1ey supported
posture. Rather, standing for a briei Farfan:~ concencion that twisting indeed can damage the annulus at
period and even extending w ill end range hut aJso noted that twisting is not dle .sole mechanism of
prepare the disc and p<:~steri or pas.. annulus fu.ilu rc. In contrast, some research has suggested that twisting
sive tissues to reduce the risk of in vivo is not dange1"0us co the disc as the facer in compression fom1s
injury. a mechanical stop to rotation well before the elastic limir of the elise is
rcachetl; thus, the .fucct is the first struc:turc to sustain torS:ioua1 fuHurc
(Adams and Hutron, 1981 ). ln a studyol'ligament im•ol9ernent dtll'ing
twisting, Ueno and Liu ( 1987) concluded that the Ugament$ were under
only negligible strain during a ntll physiological twist. However, an
atlalysis of the L4-L5 joint by McGill and Hood.less ( 1990) suggested
that posterior lif,':Unems may become itwolved if the jointis fuUy flC'ed
prior to twisting.
Generoting twisting 10rque is a differem issue (see NgiH'e 8.2 1, n-
h). Since no muscle ha.s a primary \·ector direction desif,'11ed co create
twisting torque, all muS<.'Ies arc: activatttl in a stare of bFfC:at to<:Ontrac-
tion. T his results in a dramatic increase in comp•·essive load on the
spine when compared to an equivalent rorque abour another axis. For
e.xample, data from a combinatjon of our pret-ious studies indicate
that supporting 50 Nm in the extension a.xis imposes about 800 N of
spi nal compression. The same 50 Nm in the lareral bend axis results
in about 1400 N of lumbar compre.o;.sion, but 50 Nm in the axial twist
axis would impose over 3000 N (i\'lcGill, 199i). It appears that the
Figur• 8.20 This shipper/receiver's joint pays dea t·ly to support e\•en small axial torques when extending
w·o,·k is char<lcteri7cd by periods during the lili:ing of a load.
of sill ing iollowoxl immediately hy To conclude, the generation of axial twisting torqu e when the
lifling when a lt'uck pu lis u1> to the spine is untwisted does nor ~1ppear to he of particular concen1. Nor
loading <Jock. Again, standing an(f is the act of twisting over a moder:n e range without act.'Ompanylng
waiting ior a few rninutes prior lo twisting torque. But generating high torque whiJc: the spine is twisted
Lhe exertions will reduce th~ risk appeats to create a problematic combination and a high risk. This is
or injury. of particular concern in seveml sports and will be addressed in clu t
<-ontc.'<t in chapter I 3.

Is Lifting Smoothly and Not jerking the Load Always Best?

T he answer to this question is no. We have all heard that a lo"d should be lifted smoothly aod not
jerked. T his t•ecommeodation was most tikely made on the basis that accelerating a load upw;~rd

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Figur(! 8.211 (d) Twisting the lotso is occurring at the same time that rwisling torqu~ is required,
which is a dangerous combination. (b) Generating the twisting torque but restricting the tOo$0 twiSl
is a spine·SP·<"lring strateg)1 (a1'1d can also enhance pe·rforrnnnce).

incre-ases its effective mass Uy virtue of ~ul additional incrtiaJ force acting downwa~rd together
with rhe gravit<~rional vector. However, d>is may not nlwa~'S be the case. It is possible to lift a load
by tr:msfe.rring momenrum from an already moving segmenr. Ancier :md colle-•b'Ues (1996) showed
that when <.·omparcd to novice Jitters, CX('>crt materials hattcUcrs somctimc.s choose tedutiqucs that
make more elticient use of momeJltum uansfer. Tney do not always lift slowly and smoothly.
Troup a.nd Chapman (1969) referred ro tbe t'Qncepr of momenn1m transfer during lil'ring, as
bas Grieve (19H), who coined the tcnn kinetic lift. Later, McGill ami Nonnan (1985) docu-
mented that smaller low back moments were possible in cermiJ1cases using a skill ful transfer of
momeno.u n. For example, if a load is awkwardly placed, perhaps on a work table 75 em (30 in.)
from the worker, a slow, smood1lift would necessitate the gcncr;1tion of a lafb.TC lumbar c.xtcusor
torque for" lengdt)7 duratio11 of time-a siru,ltion that is most strenuous on tbe back. However,
che \vorkcr could lift r.his loacl with a very low lmnbar extensor moment or quire possihly no
moment ar all . Ifthe worker leaned forward and placed his hands on the load, witb bent elbows,
the elbow e.nensors aod shoulder musculature could tlu·ust upward, initiating upward motion
of rhe cnmk ro create both linear and angul:1r momentum in the upper body (note that the load
has not yet moved). As th.t worker straightens his anns, t-·oupling takes plate benveen the. load
and the large trunk mass (as d>e hands then start to "PJ>ly upward force 0 11 the load), ~r-JJ>Sferring
some, or aUI, of the hody momentum to the load and causing it to be lifted with ~ jerk.
T his mechanical solution was proven to be effective in a very early experiment in my r.s.'iearch
career. The person shown in figure 8.22, o and b, is demonstrating a task in which the load can
be lifted slowly, which would load the low back unduly, or with the kinetic lift technique, which .
ifcoJTectly pe1·formed, will spare the hack. (Obviously the markers o n the model's l)od}' were to
"ssist tbc measurement of body movement.) This highly skilled "inertial" technique
is observed quire fi·equendy througho11t induscoy and in some athletic events S\och as competi-
tive weightlifting, but it must be so·essed that sucb lifts are conducted by highly prncciced and
skiUed indi'~ duals. In roost C"..tscs, acceleration of loads to decrease low back stress in the manner
described is not suitable for the average .individual conducting the lifting chores of daily living.
The momenrum..mmsfer technique is a skillerl movement that requires practice; it is feasible
only for awkwardly placed lighter loads and cannot be justified for heavy ~ fts.
Fig\IJ'e 8.23 shows another example of skiUnol,ation of dlis priociple by " worker per-
forming rhe "~addle toss" liti:.
Another mechanical variable should be intt:gmtcd intO the ana1ysis of a dynaJnil: technique.
The tissue propenyofviscoelnstici tyenables tissues to sustain higher loads when loaded quickly
(Burstein a:nd Frankel, 1968), 1'iY.>up ( 1977) sugb"'Sted that viscoela~ticity may be used to increao;c
the margin of safcry for spin!! injury during a higher strain rate but c·:mtione.d that incorporating

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Figure 8.22 lifting .1n awkwardly placed load slowl)' and smoothly, as common wisdorn suggests,
compromises the back. Rather, accelerating the torso first and then transferring the m ornentum to
the load as. lhe arms slraightcn c.1n reduce the spine loact. Accelerating the torso and the load a1
the same lime is poor lcchnfquc that violates Ihis principle and Ccluses higher spine lnading. ll1cre
photographs i11'C from an e~ul)r cxp·erirnent in the author's research career~

Figure 8.23 This lift is termed the ·'saddle toss" by some; the load is swung with k noo contact,
minimizing muscular rorct> in the back.

rhis princip le into lifting technique should depend on the rate of increase in spinal stress, rhe
m:Jf,'llitude of peak s-tress. and its duration. T issue vist'Oelascidty means that under faster load-
ing the tissue~ do not have time to deform, even when the mag1Utude of the force is high. ln.
rhis way the critical levels of tissue deformation req\1ired to <.'<ruse danHlgc are not re<lched. B\lt
given varia bility in response to load rare among the tissues. and among individuals_., no specific
guidance p-ertaining to actual load rate can be offered here.
T he inS[l1tction to always lift a lo<1d smoorhly may not invariably resll lt in the least o·isk of
injury. LJdeed, it is p<>:c,ible to skillfully transfer momennom to an awl·wardly placed object to
position the load dose to the body quickly and minionize the extensor torque required to support
the load. In addition, tissue l'isooelasriciry can be protecri"e during higher load ra~es. Clearly;
re<lucing the extensor momenr required m support the hand load is p<lramnunr in reducing the risk
of injury; tihc best way ttl accomplish tbis is to keel' the load as dose ro the body as IJOSSiblc.

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Is There Any Way to Make Seated Work Less Demanding

on the Back?
Prolonged sia:ing is prohlematic for the back Unfom marely; this f;~cr seems to be r.1ther unknown
in tbe o<:cupacionaJ world. T bose rOCOW!ring &om back injwi cs. wbo rcrurn to modi fied work
a•·e olten given "liglu duties" tlm involve prolonged sitting. \Nhile such duties are pel'ceived as
heing easy on the back. they can he fur from that. Even though the remrning worker stares rhar
sh~ ca1mor tolerate sitting, that in fiu:tshe would be more comfortable walking and .even lifting,
she is accused of maliogeril'lg. This is the result of a miswlderstanding of sitting 01echanics.

Sitting Studies
Epidemiological evideoce presented by VidemM, Nu11ninen, and ' Ji-oup (1990) documented the
increased risk of disc herniation in those who perfonn sedentar y jobs characterized by sitting.
Known mechanical changes asrociared with the scared posture indudc the following:
• I ncn'3$C in intradiscaJ pressure when compared to standing postures (Nachl~m~n, 1966)
• 1J1c•·eases in posterior am>ulus strain (Pope er 31., 1977)
• C 1·e ep in posterior pa!5Sivc cissues (i\·f cGill and Brown, I992), which decreases anterior-
posterior stiffness and iucr<»S<'S shearing onc,.cmcnl (Schultz et al., 1979)
• Posterior migration of the mechanic" I flllcrum (Wilder et al.. 1988), which reduces the
mechanical advantage of the exrensor musculature (resulting in inc reased compressive
T hese changes t:auscd by prolonged sitting have motivated Mcupational biomechanisb
attempting to reduce the risk of injury to consider the duration or sitti11g as a risk factoI' when
designing seated work. A recently proposed guideline suggested a sirting limir of 50 minutes
Vt;th out a b reak, although tltis proposal ,.,.; u be tested :md eva)uatcd in t he furure.

Strategies to Reduce Ba<:k Troubles

During Prolonged Sitting
vVe have developed a three-point approach for reducing back
rroubles associated with prolonged sitting:
I. Use an ergonomic chair but use it properly (very few-acm~

all)' do). Nlany people thin k that they should adjust rl><:ir
chair to create the idea l sining J>Ostlll'e. "J)'Pically. they
adjust the chair so that the hips ;md knees are henr ro 90°
a11d the torso is upright (sec figure 8.24). In futt, dtis isoftdt
shown as the ideal posmre in many ergo•tomic text s. This
may be the ideal sitting posrure, bur for no longer than LO
minutes! T i!oisue Joads must be migrated fro m tiSSUI: to
tissue to minimize the dsk of any single rjssue's accumu-
lating microtr;~uma. This is accomplished by changing
posture. Thus, an e rgonomic c hair is one that facilitates
easy posture changes over a variety of joint angles (see
figure 8.2 5). Callaghan and M e(; ill (2001a) documented
the range of spine postures tim pct>r>le rypkallr adopt ro
avoid fatigue. Some have three o•· four preferred angles.
'l 'he prim:uy recommendation is to continually change rhc
Figure 8.24 ll'e "ide• I sitting posture" settings on the c hair. A1any workers continue to bdieve t hat
(9()0 a ngles a l the hi ps. knees, and there is a single best posture for sitting and reluctant
elbo'"'S} described in rnosr e(gonomic ro trv others. This is. of course. unforrunate, as the ide<~ I
guides. This is et t'OI'Ieous; the ideal sil- sitti~g posture is a variable o ne. Nlany emplo}:·ees need to
Hng post~.u·e isone thal i nvolves variable be educated :-1S to how to change their ch.ajrs and t he v:uiety
postures. of posru,·es that are possible.

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Figure 8.25 G ood posture for prolonged sitting is a variable one that m igrates the internal loads among
the various tissues. Possible short.tenn sitting posture o plions are shown.

2. Ger out of the cluir. 'I11ere simply is no suhsrjrute for gerting our of the ch:1ir. Some
gui<lelines sug!,rtSt perfonrUngexerd se brt.oak.'\ wltile seated, and some ev~n go as far as to
suggest OelciJ>g the torso in a stretch. This is both not1Sense and disastrous! A rest break
mosr consist of the opposite activicy ro reduce the imposed stresrors. £xtension relieves
pos.rerior annulus s tre.o;.S1 bur more flexion while seated increas<.>s it. The rec(nmn<!nded
break that we have developed involves standi11g from the chair and maintaining a rdaxt:d
standing postme for I0 to 20 seconds. At this stage, some may choose ro pe rform neck
roiUs and ann windmHls to relieve neck and shoulder discom fort from their desk work.
The main objective is to buy some time to allow redistribution of d1e nucleus and reduce
annular stresses. T he person then raises the arms ove1·the head (see figure S.26, "-<)and
me:n pushes the hands upward to the ceiling. By inhaling deeply, one will 6nd that the
low l>atk is fully extended. ln this """Y• the person has taken the back through gentle and
progresshre lumbar c."\'te.nsion without having been tauglulumbar posilion awareness or
eve:n understanding the concepr. Some wilJ arbTUe that in their jobs rhey cannnt snmcl and
r.akc a break; they must continue tbcir seated work. Thtse people gencrallywillneed to
be s hown the opportUJlities for standing. Fo1· exampk , they could choose to stand when

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Figure 8.26 A strategy lo thwart the accumulation of disc stresses from prolonged sitting is to (a) stand (note the forward
antalgic posture often >ObseJVed after sitting). (b) reach for the ceiling. stretch pushing !he hands upward, and (c) lhen
inh01le deeply. l11is sequ ence when performed slowly c.Juses a gentle ;and progressive extens1on of the lumb;.r region and
d ispe ls the stresses of sitting.

the phone rings and speak standing. With these simple examples, they will soon see the
opportunities tO pr.tcrice this part of good spine health.
3. Perfonn an exercise routine at some time i11 the workd;w. Nliddav would be ideal, but
fi•·s[ thing in the morning is unwise (see the previous g<;ideline). ·A good general back
routine is presented in the last section of this bc:MJic
A couple o f athletic: ex;.Jmples ma}' provide insight as well. Athletes who sit on t he hench
between plays (figure 8.2 7a) arc often iU prepared for cmmediately resuming play (Green ct al.,
1002). 'lo help w mbat this p>·oblem, they should sit in t~Ucr chairs " 1th anguJated seat pans
to reduce l umbar tlexion (figure R27/1), and stand ancl sometimes p;l ce approximarely every
20 minutes. In addition we <JuCStion the many exercises performed in a s-eatc.d position, whk h
appears to be for conveu.ience •-acl1er than related to a11y scientific rationale.

Some Short-Answer Questions

The fo iJowing questions and their answers prov-ide fu rther guida nce to reduce the dsk of occu-
p:~tioual LBD.
• Is it advisable U1 nuti11tniu rt >-ettS!mllbk level offitntS!i? As much as we wotdd all ~ke
to believe that higher le~els of fi tness arc protective for low b"ck troubles, it is argoed by some
chat the Uterarure is not strongly supportive. -:n1is is for seven1J reasons. Many d i o ical trials in
which t he intervention was designed to e nhance fitness actually chose t::xc.r<ises t h at inadver-
tently increased the risk ofspine damage. Fo1·example, many assumed that enhancing abdominal
strenf,'th was a good idea and addressed this goal by prescribing sir-up exercises. Sit-ups will
damage tl1<.: batks of most people; tltey will not increase back healt!J. Perhaps tl1is has acted as
an artifact biasing the lirerowre. Interestingly enough, Lhe most recent stud.ies that have used

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Figure 8.27 (a) Silting on the bench with a Oexed lumbar spine is problematic because it uedtes or exacerbates a posterior
disc bulge (or both), and it causes loss of the benefits obtained from wMming up the bac-k. (b) Sitting in taller chairs with
angl..d seat pans will help extend the hips and lumbar spine.

biomt:cbaltical cvid('.[]CC to develop excrt'.ises-part:icularJy st'Jbilizarion exercises- have shown

thelll to be efficacious. J.n fact, a review of ptevemive inrervention.s hy Li nton and van -Halder
(2001) suggests that weJI ...chosen exercise is che most strategy for preventing occu ..
pational ba t~k troubles. A stable spine maintained with healthy and \\<·ise motor patterns, along
with higher muscle eoduraoce, is protective.
• Should lffl< lift or perfonu. extrem e to·rso />emliug shurtly lifter· risi11g:ftwn bet/? T he
answer is no . Recall rht> biomechanics of daiJy changes in cl1e spine as discussed in cbapter 5.:T he
discs are hydrophilic and imbibe 11uid overnight. Tlus is why people are taller i11 the moming
thal1 whe11 they retire at night. T his is also why it is much more diflicolt to hend in the morn-
ing to put one's socks on compared to taking them off at nib>ilt; the bending stresses are much
lugbcr together with the risk of disc damag-e. Tltis diurnal '"Jriation in spine length and the
:~bility co fllex forw;mJ IHve been well documented. A~ previousl)• noted, Snook and colleagues
( t 998) found the strategy of restricting forward spine flexion in the morning to he very effec-tive
in reducing s~1nptoms in a group of back-troubled patients.
• Sh, uld wqrket"> at/opt a 1ifri11g stm tegy to •·ecmit the lmubotlorsal fascia zyr in volve tbe
h)'tlnmlic t1mplifier 1necbtmil'm? As nOted on page 95 in chapt(·r 5, rhtsc m..:chanisms have bct:n
>hown to be untenable proposals for sparing the back. While somes rill atteOlpt to train workers
co invoke these strategies, they have lirtlescientific .support; in many c:.1ses such sr.nuegies will
be de.trimc ntal.
• Sbc"'kl the trunk musculature he cocontrtldtll to mrbilize the >pine? i\s noted in chapter
6, the answer is generally yes. On page 97 in chapte1·5, we noted that although such c:oactivation
imposes penalty on the .spine.• it is he$t for the spine to pay this price to enhance stiffnes.s
and resistance. to buckling and to redm.:e the risk of other unstable l:K:ha\~Or. [low 11'nu.:b <.:oc.:on-
o·nction is necess:.lry? 1\s noted in chapter 6, in most tasks, stdTicient stability is eosuced wilh
very mo dest amounts o f cocontraction-so mewhere in the magnirude of 5% to l 0% of maximal
voluntarycontrat:tion for the abdonlinal wall-and other antagonists. Achieving added stiffness Ln

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the spiJlC through cocontraction will help prevent injuries that can otherwise result even during
rhe lifting of a very light object, sneezing, or tying one's shoe. Of cou1-se, where there is the
potential fo r surprise loading o r handling nc)nrif,Tid materia) or ht>avier loads, the c.·oactivation
magnitudes must increase. Damaged joint tissues also require higher levels of <.·ocontr.lction to
avoid unstable joint behavior. The necessary lc1•els of coactivation would depend specifically on
the tt~~k an.d the hlst()ry of the i.ndjvidual. T hus, lighdy cocontn1<:ting the smbilizing muscula·
turc upon exertion is a reasonable guideline; this should become automatic follow:ing stability
rrai1\ing for those who do not naturally stiffen.

LBO Prevention for Employers

Nor all prevention strategies can be implemented solely by workers. Emp1oyers, too, play a
role, which is outlined here.
• Proville prot.tctive clothing to JitdliULte tbelellst .-trenful pvstm·es. Workers sometimes
handle mare1·ial that .is too noxious o1· too hna rdous to hold close to their bodies. For example,
1 have Oeen involved in cases in whkh workers held dirty material away from the hody to keep
their shirts dean, unuccc.ssarily loading their backs. The solution was to prO \~dc protective
covern lls to spare workers' backs. Leather aprons are helpful if the material is sha1-p to foster
holding the load at,'llinst the abdomen, as for sheet metal workers, for example. K nee 1mls are
good fur prolonged work on the ground. Once the employer has provided cl1e necessary prOt<'<.'tivc
clothing. workers will figure out tbe \'llriety or working postures that can spare tbeir backs.
• SIJould abdominal bebs be pr-esn·ibed to 11111/WIJI mttl.e1-i-
IJ/$ l;amllm? Chapter 9 contains a tl\orougb disc\ission of this
• Optintize f:V11taint~ tmd packagi11g of 1'/fUJ .,,utterin/J.Q
.rpn:rework~1-s' IJncks. Often in che design oftheindliStTial process,
spadng the joint.~ of the workers is nor considered. '~'hen consid-
ering the industrial process, see if bandied materials can be uulk
conrnineri7.(!d. Can raw material be handled in smaller bundles or
in hundlt!S of different dimensions? Sometinu..os the matter is as
simple as contacting the suppliers to find alternate ways of pacb g-
ing rnaterial that foster handling in a \1/(lY thar conser· the bod)'
joiots. T he purch;asing department plays a role in reducing injury!
Bins and containers with folding sides help if parts must be picked
out of the bin.
• Encourage workers to prm:tice lifting 1111d wor·k ()r lllsk
kiuemntic ptlttenlS. Some individuals .simply do not ~:nove, bend,
and work in ways rlm spare theit spines. ln a recent stud)' (McGill et
al., 2003), we norecl rhm workers who had a previous historyofback
rroublcs were more likely to adopt motion patterns that resulted
in higher spine loads! Kinematic pane1·ns need robe pr-Jcticed and
grorwed into movemenr repertoires. (Rememher the expression
quoted earlier: "Practice does not make p~rfett; it makes perma-
nent.") Some people mus1 practice the spine-<:Onserving motions
every day-especially before attempting 3 particula1·ly stren\10\IS
task. Even hi gh~performance athletes must continually regroove
motion patt erns daily. Some worker groups have attempted to fab-
rictlte their own job~specific training :lnd J)r:.u.."tice equipment. An
example of this cype of worker professionalism is shown in figure
Figure 8.28 Nurses al a palienl C(lre 8.28, wJtkh shows 3 dUJruny sitting in a wheelchair. N urses built
facility fabricated this dummy 10 prac- the dummy from plumbing pipes 3nd use ir ro p1·acti<:e one- aod
lice 1heir l)atienl liits-•n example of two.. per~on patient lifts. This i~ pan o f the worker professionalism
worker professionalism . cthi_c note.d in the following section.

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• Opr.imi.zt wO'I·ket· rest /rre11ks. A properly designed rest break consists of Lhe opposite
activity (and consequently the opposire loading) from that required b)• the joh. Fm example,
cl1e sedentary secretary will he best serve-d by a dynamic rest break. T he welder. <Jn the other
ha11d, will be better served with r<-st and perhaps a stretch. T he following example illustrates
a violarion of this principle that caused grief. flack in the 1960s, operators in a power plant
monitored the process from a chair and had to respond to a vi,brilance buzzer on thcir desk r:hat
went off every I0 minutes (S('e figure 8.29, 11-b). At caclt buzzer interval they would stand and
walk around cl>e control panel making adjustments. "11>ere was no histo,·y of back troubles. 'l "he
room recently became obsole te and was re placed with a n updated control room. T 'he design
tc::am fo r the new control room believed that rising from the c hair every L0 minutes was too
strenuous. Consequently, the job was redesigned so d>at the operators were able to stay seated tO
perform all oreration<. T hese oper:>tors worked 12-hour shift:.<. Having the workers sit for this
period o f tiJnc {and removing the need to get o ut o f the <:hair regularly) resulted in an inl':rCasc
in low back problems. T he power plaot then hired a consulting group who recommended ,·est
hreaks thar- consisted of h:.rving rhe workers sit on an exercise bike. The workerst backs failed ro
improve lx.~-ausc the Consultants failed to unde rstand that the rest break must not exace rbate.
or replicate the forces of the job. In case, sitting on a bike was not a break from sitting on
d>e job.
• lttwJlve v.mrken in the ergonomic process. Design ceams often neglecr to consult with
the expert on a particub r job-the worker who bas done it fc1r years. Quit~ often the worker
knows of w good .solut ion, and it is simply a matter of IL.;cening and facilitating the imerven-
rion. An added benefit, psychologists claim, is that workers are more likely to comply wirh the
intervention if they perceive t hemselves to be a major parr of the solution.
• work to be t:nrillble. A..; .\ever;,~( previous cxa.tnplt;S have docwnc.ntec..ll, accuutula-
lion of tissue so·ess is thwarted by a change in posture,, or acti\lity. Human beings were
not made to perfonn repet itive wo rk tha t emphasizes only 11 few tissues. N or were human.~
designed not to be stressed. Research has established that tissues adapt and remodel .i n response
to load (e.g., bone: Carter, 1985; ligamel\t: Woo, Gomez, ;u>d Akeson, 1985; disc: l"orrer, 1992;
verrehr•e: llrinckmann, Biggemann, and Hilweg, 1989). 1bo tittle activity can be as ]Jroblematic
a> too much. Krismcr and colleagues' srudy (ZOO!) strongly reinforces the idea so frequcncly

Figure 8.29 Ia) The first control room was built in the "1960s and required the operator to stand every 10 minutes to
respond to the vigilance buzzer a nd make a n adjustment to the a nalog instrumentation. There were no reported back
troubles. (b) This room \·vas replaced with a new layout based on the designers' assumption that standing every 10 minutes
\'Vas too strenuous; the operators were a ble to sit for hours. A huge low back problem emerged .

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stated in this text that the object of good work Jesign is not to make every job easier; in fact,
some jobs s hould be nude more dem~nding for optima I hea lth. In the Krismer stu dy, smdents
who reported low back pain were distinf:,Yllished ti·om those who did not by several risk factOrs.
1\,~o of those factors- were

- watching TV or pbying t'(>mpurer g<~mes more than 2 hour$ per day (sedentary)
- regulaJ'I y going beyond personal tin>its in SIXH' activities (roo much load·ing).
Good oecupatiOilal beald> from a muS<:uloskeJeml perspective is achieved when people perfonn
a l'ariery of tasks with well-designed rest activities, along with all of the traditional components
sut·h as pro~r nutriti<)n, sleep, avo idance of smoking, and so on. Desibrn work to be \"'Jriable!
As illustrated iJ1 the p•·evious egamples and guidelines, management plays a role in reducing
back troubles in workers. It is a mistake to think that management does not need to undersea nd
the science- to justify specific injury prevention approaches. A<i we saw previously, inj.ury preven-
tion involves a tl10rough w>derst"nding of the industrial process, the way in which goods and
m~uerialsa·rc pttrchased, provision of pro(ective eqt1ipmenr. appropriate tr~lining, consider-ation
of the cosrs and benefits of intervention, and so forth. Training of both workers ;md manage--
rnent cnsw·cs tbc best results.

Injury Prevention Primer

l'h use bi()mechanics t() .it.~ fuJI po tentia] in injury prevention, workers and employers must
have a reasotMble undemanding of the concepts as we u uders~.ulCI them today. \.Vorkers must
be educated in the biomech:mically justifiable principles described earlier using exomples with
which they are familiar. Armed with the general principles, the)' c<1n tackle any job an d devise the
best joint-<.:onserving ~tnnegies. The intention is to enhance the industriaJ prOl·ess and enalJlc
workers to retire in good health. ' I'he highlights of this chapter are summarized here:
• First mul furemwt, tfeJign work t111d tttsks that fi1cilitnte VtiTiety. Perhaps the siogle
most imporrant guideliue should be this: Don't do too much of any one thing. Both too much
and roo lirde loading are detrimental.
- Tc:xl much of any single activity le:~ ds to trouble. Relief of cumulative tissue str;Jins
is accomplished with posture changes or, better yet. other tasks that ha,·e differel\t
mus,'Uloskeletal demands.
- \Nhilc d1c task~ of many jobs cannot be changed, the working routines and arm"h'C-
ment of r"sks within a job can be designed scientitica!Jy ro incorpontte this princi ple.
Sometimes it is as easy as Lxmrinually changing the sitting posture.
• During al//()(u/ing ttuks, lli/oitl a .fullyjlr-:r:ed or- bent spi11e mu/J'Ofllte the trunk tiJ·ing
the bips (prtser~Jirtg 11 neutral Clll1;t iu the spiut). Doi11g this bas the folwwing be11tjits:
- Disc herniation cannot occur.
- Ligaments tannot l>e damaged. as they arc slack.
- The :!Interiorshearing effect from ligament involvement is minimized, ;mel the posterior
supporting shear of the musculantre is maximized.
- Compressive tcscing of lmnbar motion units ha~ shown increases in tolcr:uu:c with
partial Aexion but decreased abiliry m withstand ~>)mpressive load at 1\111 tlexion.
• Du•·ing lifting, choose 11 pol"turt to tlliui'tnize the reaction torque Qu tbe low bt~ek (eitbtr
stoop or struttt o•· somewJ,.,., hr betwee11), /rut keep the extermli load close to 1-!Je body.
- A neucr;ll spine is still maintained, but sometimes the lo;ut can be brought closer to
the spine with bent knees (squat Wt) or relatively straight knees {stoor>lift). The key
is to reduce the torque that bas been shown to be a domimult risk factor.
- \..Vhe-n exerting force "ith the hands or shoulders, tr)' ro direct che line of the force
through the low back. This will reduce d1c reaction tOrque and dw spine load from
muscle conn·:1ction.

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• Com-itler the trrmsmisribk vector. Attempt to direct external forces through the low
hack, minimizing the mornent al1n 1 which cau!ies high (Orques and cn;shing forces. This
prindple shoultl be applied as people use pulling fi>rces when opening a door, vacuuming, and
performing other household chores.
• Uw: teclmi'fllt.r that miuimiu the ttctual weight of the /om/ bei11g ba11dled. Tbe log-
lilting (~xallt plc given in chapter demonstrates how one can lift: an encirt log into the back
of a truck by lifting no more than half of its weight at any point.
• Allow t ime ftrr tlu tlisc 1mclem· to "equilibrate, " ligaments to 1-egain #iffiuss~ aud tbe
stren 011 tbe mmulu:r to equfllize after prolongetl flv:icm (e.g., sitting or .rtoopiu.g ), mul tlo uot
itu'iutdilttely pe-;form )..1.,--enuous e:~trtious.
- After pro longed sitting or stfXlping, spend time standjng.
- ..[his principle can be adapted to many special jobs, but some workers do oot have the
lmul)' of being :>ble to take the time to alloll' tile disc nucleus to equilibrnte. For e.'ample,
ambulance drivers are often coUed on ro lift heavy loads immediately after significant
jX-riOd'i of driving. A strategy for them is to usc a lumbar support in their scat while
driving ro the incident so that their spines are not Aexed. T hus it can be prepared for
c:he load with minimal disc equilibr.trion (parr of the process of warm-up).
• Avuiil/ijtillg 01· spiue btlt(/ing sburtly tiftet· rising from bet!.
- Forward-bending StTes,ses on the disc and ligaments al·e higher arter rising from bed
compare-d v;ith later in the clay (at lea.o;r I or 2 hours after rising), causing di~s to
bcoomc iojmed at lower b ·cls of load and degree of bending.
- This p1inciple is problematic for some occupotionssuch <~S firefighting in which workers
are ofwn arous~d from sleep tO attend a fire. Such workers should not sit in a slouched
posture with the spine flexed when traveling to the scene but rather sit upright. In this
way the spine will be best prepared for strenuous work a wann.., 1p.
• Prestrel·s 1111d Jtllbilize the Jfriue even tl:uriug ligbt t11sks.
- r.ighrly coconttact the srnbilizing muscularure m re!llO\'e Lhe slack from lhc system
and stiffen the spine even duri ng light rask< such 3S picking up a pencil. T he exercises
&hown in chapter L2 \I.'Cre chosen tO groove these motor patttrns.
- l\1..ild cocontraction and tile increase in stability increase tbe margin of
<:~tety of marerial f:lilwe of the column under axial load.
• Avoi1l twiJt:ing mul the siuwlurne&us ge-ue·rnti011 o.fhigb twisting torques.
- -1\visting reduces the intrinsic strength of d1e disc annulus by disabling some or its
s.upporting fibers while increasing the S<Yess in the remaining fibers under load.
- Since there is no muscle designed to produce ottly axial torqu~, the coiJecti"e <lbiliry
of the muscles to resist axia l torque is limited, and they may not be 3ble to protect the
s.pine in <:ertain postures. The additional comprcsslve burden on the spine is substantial
for even a low amount of axial torque production.
- Gener~ni ng twisting torque with the spiJle Wltwisted may not be as probJemacic, no1·
is twisting lightly without subst:tntial rorque.
• Use 111/J'mentum whe., exerti11g[orce toret!JICe tbespi11e font! (rarhe,. tbtw nfw11ys li}N11g
slowly and smootbly, wbicb is an ill-founded , ..co11nnmdationfon1Ja~ty .<killed 11to rk=) .
- This is a skill that sometimes need to be dcvelopecl.
- Th is sn-.neg)' is dangerous for heavy loads and should not be used for lifting them.
- Jtis possible that a transfer o f momentum from the upper m 1nL: ro the load can start
m oving an awl..'"lvardi)T placed load without undue low back involvement.
• Avoid prolonged siNing.
- Prolonged sitting is associate<l wirh di~c herniation.
- v\lben required to sit for lotlg periods, adjust posture often, sta11d up at least eve!)' 50
mi.nures, e~tencl the spine, •1nd, if possible. walk for a few minnres.

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:::ow Back OiS<lr<lers

• O rf,' anize wo rk to break "1' bout< of !" <>longed sitting into shoner periods rhat are
better tolerated uy the spine.
• Co•uider the best brT.ak >trtttegies. Customize this principle for eli Ffe rem job clas-
sifications ~nd demancl<.
· \Norkers engag.:d iu sedentary work would Lc best S<:rved by frequent, dynamic breaks
co reduce tissue SlTess 3CCurnul3tion.
• \i\iorkers engaged in dynamic work may be berter setved \\~th longer and more re.srfnl
• Prot•ide protective clothing to fo>'ll:t·jorm· roflsf!1-vitzg posmns. Provide COI•er.alls for dirty
material htmd1ing, heavy aprons for sharp metals, knee pads for those who work ar groond le::vel,
and soon.
• P·l"ar.ticejoinf ...tonservillg ki,f'matic1uoveme111 patt.ents. Some workersneed roconsca.ndy
regrHOVe motion patterns such as locking the lumbar spine when lifting and rotating about ffie
• JWa.intain tt t•ea.sonnble leveL
• TbttJ·e guidelines may be cmnbinetlfi>r.specinlsittwtions. for e.xample, some people have
difficulty rolling over in bed when their backs are painful. Nearly all <'all be taught to manage
their p;lin ;lnd sOli 3Ccomplish this task b)' con1bining a momentum transfer \\~th the minim~1l
rwisting gu idelines (see figure 8.30, a-d).

Figure 0.30 Rolling over in bed Co-"U'l be ~a ught lO those \\~'10 ma inlain lhat it is too painful ~1n
activity. The figure illustrates rolling from the left side to the right. !a) While lying on one side, the
patient braces the torso so thai the spine does not twist i11 the steps that follow. ( b ) Then the uf)l>er
arm .r•d leg are raised together with the lower arrro and leg prying off the floor. !c) TI•is is perlormed
quickl)' enough to gt'nerate rnomenturn that will carry the patJent through the roll. (d) Th~ patient
should now 1,., resting comfortably on ~w other side.

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A Note for Consultants

Acting as 11 oonsulLa1u, I have made rnany mistakes, some of which motivated rbe foUowing
• Don't fall into rhe tr.lp of thinking that you are the expert and that you know what is hest
for clte wo,.kers (unle.o;s you have done the job for years yollrseil). Always consult the worker.
Successful job incumbems have developed personal strategies for working that assist them in
avoiding fadgue and injury. T heir insights are the restah of t housands of hour~ of l>erfom1ing
the task, and they can be very perceptive. Try to accommodate t hem.
• Do uot take the instru('tions for a spcdfit: worker verba tim from the prec-eding Inju ry
Preventioll Primer. Instead, explain the rele••ant biomechanjcal principle in langt,oge apd ter-
minology chat :~re f.uniliar to the worker.
• Do not focos only on Lhe most demaodlltg tasks. GiveJl the links among diEferent tasks
from a tissue load perspective, ym1 can often ohr::1in berter solutions by <:On.._icfe,-ing the full
complement of exposures. In a similar vein, some <-·unsultantS tend to focus o n a sing le metric
of risk (low back compression, for example) or rely on only a few simple solutions. The avcr.tge
ergonomist probably does not have the specific tr.lining necessary to achieve the best solutions
fo r low back problems. Perhaps I am biased since in recent ye-ars 1 am asked to consult only
when consultants' poorly conceived ergonomic approaches have failed. I am n.>questoo to become
involved w.hen the t-ompany faces lawsuits or other issues thar have raised che stakes. Remembe,·
chat many solutions are neicher simple nor un idimensional, regardless of your t rain ing. Use t he
Injury Prevention Primer as a checklist to evaJuate whether potential exists for better and more
comprehensive solutions.
• Do nor focus exclusively on t he muscuJoske leraJ issue. Rather, look for the o ppo rtunities
that Ue iu enhancing the industrial process. Any management board wiU rccogui:w tbt worth
of n consultant who makes the process more efficient, produces a bigher-quali ty product, or
reduces injury compens:uion cosr.s.
• Mo'Vement is taught more eflecuvely when it is considered a compkx movement skill.
Sirnply having an ''expert" (i.e., yourselQ demonstrate more effff.:th•e work techniques will usually
fail. Coaching the movement and motor patterns in an interactive session leads to performan ce
enhancement and greater safety (see McGill, 2006, for a fuU overview of this process).
• Finally, never make a re<:ommendation that is not feasible to implement, whether for
monernry or any other reasons.

Reducing the Risk in Athletes

Athletes a nd teams from a variety of sporting activities--from world-class professionals
to am~t eurs-have sought my advice as <t low back injury consultant. In many coses their
bad backs were ending 1heir careers. But as we have seen in preceding chapters, success
in dea!Lng with bad backs requires efforts to address both the cause of the troubles and
the most <1ppropriate rehabilitative therapy. In rrt3ny cases, addressing the cause mcMt
that athletes had to change 1heir technique. Without exception, they had 10 change the
way they trained. Their backs were breaking down for a reason! As loads applied to the
lx>dy read> world-class levels, technique must be impeccable. Tcchniqut>S for athletes arc
well covered in my other textboqk, Ultimate Back Fitness and Performance (2 006).

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The Question
of Back Belts

hischaprerwill focus on occupnional beltuse(see 11-r, for the typiCll l types of belts
T in
used and rested). Readers intere-sted athletic use of belts
9. 1,
are refened ro UJtimtTU Bntk Fitnes..:
l/l/{ll'cJfomm11ce (,\kG ill, 2006). After reading this chapter, you will be able to make decisions
on who should wea 1· a belt and to justify the guidelines fo r their prescription and use.

Issues of the Back Belt Question

T he average patient musr be confused when observing bnth Olympic arhletes and back-injured
people we-ar ing 01 bdominal be lts. SeVt:rnl years ago l conducted a review of t he effects o f belt
wearing (McGill, 1993) and summad...ed my finrUngs as follows:
• Those who ha\ C never had a pre\•ious back injury appear to have no addjtionc'tl prott:etivc

hen efit from wea ring a belr.

• lt would appear thar rhose who were injured while wearing a heir risk a more severe
injury rhan if bdts were not worn.
• llellS appear co gi\•e people the perception they can lift more ;md may in fact enable rhem
ro lift more.
• Belts appea r to increase intra-alx.lominal pressure and blood pres.<ure.
• Belrs appear to change the lifting styles of some people to either decrease the loads on
the spine or increase the Joads on the spine.

Figure 9.1 Several types of belts are worn and have been tested: (a ) the leather belt, (b ) the inflatable cell belt, and
(c) lhc stretch bch wilh suspenders .uc a few cx.1mples.

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The.Question of Back Belts 159

In suutlllary, given the assets and liabilities of belt weariJJg, I do not recommend tbem ror
heal(hy individuals either in routine wod.: or in exercise participation. However, the cempon1ry
prescriptio n of belts may help .some individual workers return to work.
Manufacturers of abdominal belts and lumbar supports continue to sell them to industry in
rhe absence of a regulatory requirement to conduct controlled cl inical trials similar to those
required of drug.s and other medical device,li. Many claims h<1ve been made ~s t<) how abdominal
belts could reduce injury. For example, some have suggested that belts perfonn the following

• Re~>>ind l=~>le tolift properly

• Support shear loading on the spine that results from the effect of b>Tavity acting On the
h:utdheld load and mass of the upper body when the trutlk is flexed
• Reduce compressive loading of the luml>ar spine through the hydraulic action of increased
intra-abdominal pres~'Ure assodated with belt wearing
• Act as a splint, reducing d>e ,,.nge of motion and thereby deereasiog the l'isk of inj<•r)'
• Pro,~de warmth ro the region
• Enhance propriocepLion via pressure to increase the perceptio11 of stability
• Reduce muscular fatigue
T hese ideas, among others, will be addressed in this chapter. The follo"1ngsection addresses
the scient'e regarding the occupational use ofbclrs and ooncludes with "'1dene<.~hased b'uidelines.
The 1994 National Institute for Occupational Safety and Heald> (NIOSII) report, "v\l:>rk-
place Use of Back Belts," contained critical reviews of a substailtial number of scieotilic reports
evaluating IHck belts. The repoll concluded t:hat b:tck belts do not prevent injuries among
uninjurctl '\\'Orkt:rs nor arc they protective for those who bavc not been injured. VVhiJc this is
gener:llly consistent with out position stated in 1993, my personal posiLion 011 belt prescription
i$ somewhat more moder:-1re.

Scientific Studies
In the following sections I have >'Ubdividcd the. scientific studies into cijnic:tJ trials and those
that exami·oed biomechanical,, and physiological changes from belt we.1ring.
tinaUy, l>ased on tbe evidence, l recommend ~,~tidelines for the prescription and us.e of])el" in

Clinical Trials
Many clinical trials reported in the literature were fraught with merhodological p1·oblems and
suffered fr<nn the ahsence of a matched control group, no posttrial follow-up, limited oiaJ
du.ration, a.nd lnsuffident s:unple size. As a result. I will review only a fc::w clinical trials in this
chapter, while acknowledging the e.•treme difficulty in executing such trials.
• I+Olrh mul Scbwnrrz (1990) divided ~I male warehouse wot·kers into three groups:
- A control group (11 s 27)
- A group that reeeived a balf-bour training session on lifting mechanics (11 = 27)
- A grou11 th:>t re~-eived a 1-hour rr:1ining session and wore low back orthoses while at
work for the subsequent six months (n • 27)
lnstead of using more common rypes of abdominaJ hehs, this research group used orthoses
with hard plates that were hc-dt molded to the low back region of each individual. Given the
concern chur belt '~·earing was hypothesized ro cause che abdominal muscles co weaken lhe 1

researchers me:tSttre<l rhe abdominal flexion srren~ of the workers hmb before ;Uld afrer the
clinical trial. The control group and the rraining-~nl)' group showed no changes in abdominal
tle.xor srrengtb or any change .in lost rime li·om wo,·k. T he third grou p, which receh•ed ttaining

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and wore the belts, showed J\O cbauges in abdontinal fie.,or strength or accident rate but did
show a decrease in lost time. However, the incre:1serl benefit appeared only m accrue ro rhose
workers who had a previous low hack injury. Van Poppe! and colle<l!,'U<s (1998) reached a similar
wnclusion in a study of 311 airline l!agg-•gc handlers.
• Reddell tmtl t"OIItfl{tlleS (1992) studied 642 bagg-age handlers who worked for a major
:~irl ine. They divided
the haggage handlers into four treatment grot•ps:
- A control group (11 = 248)
- A group that received only a belt (u =57)
- A group that received only a 1-hmu· back education session (11 • 122)
- A group that received both a belt and a !-hour education session (n = 57)
T he trial lasted eight months, and the bd t tL'led was a fabric wcig-htlifting belt 15 em (6 in.)
wide posteriorly and approxilllately 10 em (4 u1.) wide anteriorly. The researche:rs noted no
signifi<..·ant differences among cre:umem {,"''Oups for total lornh:;Jr injury im;ident nue, lo!it work ..
days, or wo rkerS compensation rates. .1\· ..ldtough the lack of oompliancc by a significant nwnber
of subjects in the experimeornJ group was cause for c-ottsidennioJ>, those wbo bej,'M. wearu1g
belts hut discontinued their use had" higher lost-day case injury incirlent rare. In facr, SR% of
workers belonging tO the belt-wearing groups discontinuc.d wearing belts before the end of the
eight-month trial. Furthert an increase in the number and severity oflumbar i11juries occurred
following rhe trial in those who previously wore belts.
• Miuhe/1 tmtl coiiMgues (1994) conductd! a retrospective study administered to 13 L6
workers who perfonned lifting activities in th e milital)'· While this study relied on self-reported
physical exposure ancl lnjury data over six years prior to the study. the authors <lid note that the
costs of back injurios that occurred while workers were wearu>g a belt were substantially higlter
than the costs of injuries sust<>ined while not wearing a belt.
• K1"1lu.r and mllettgue.•· (I 996), in a widely reported study, surveyed che low hack injtuy
rates of nearly 36,000 employees of the Home Depot stores in California li·o.rn 1989 to 1994.
Duri11g Lhis study period the company implelllented • mand•rory back belt use policy. IJ\jtll")'
rates were re<..-orrled. £,•en though the auffiors cl:lim thar heir wearing reduced dle incidence
of low back iujury, analysis of the data and methodology suggests that a much mure cautiou.s
interpretation may be warranted. The dam show that while belt wearing reduced the risk in
yotJJlger males and rhose older dlan 55 years~ helt wearing appeared t:o increase rhe risk of low
l>ack injwy for men working longer than four yc-•rs by 27% (ald10ugh the large confidence
intetval required an even larger increase for sta tistical significance) and in men workU>g less
rhan one year. J-lowever. of gn~atesr concern is rhe Jack of scienri fie c;om:rol to ferret onr the 0 1 1e.
belt-wearing effect: There was no comparable non-belt-wearing group~ which is critical given
that the belt-weariog poljq, was not the sole intervention at Home Depot. For example, over
the period of the su•dy, the com~>any increased the llSC of pallets and forklifts, installed mats
for cashiers, implemented postaccidt:nt drug testing, and enhanct'd w<>rker rrainhlg. In fact, a
conscious attempt was l'nade to enhance safety in the corporate culture. This was :.1 large study,
and the authors deserve credit for the massi"e data reduction and logisrics. However, despite the
tide and claims that hack be1rs reduce low hack injury, this uncontrolled study cannot a.nsv.·er
tl>e question about tl>e cffetti,·c•lcss of belts.
• f#lsse/1 mul colle11gues (2000), in response to the huge promotion of the Kr-:ms and rol-
leagues ( 1996) paper by some interest groups and d>e study~ metJ>odological concerns, replicated
Kraus ami colleague."' wnrk under the sponsorship of NlOSH. These researcbers howc\•er~ asecl

better scientific control in order to evaluate only the effect of the belts. Stu"Vcyi.ngovcr 13,873
employees at newly opened stores of a major t•er:U ier, in which 89 stores required employees to
wear heirs ancl 71 stores hacl only volunrnry use, chey clist'Overed that the belt." failed ro reduce
the incidence of back injury claims. l11is study has more powc.r than d1e Kraus: srudy.
In summary, diffin tltiC> in cxccuru>g 3 d init'31trial 3J"Cacknowledged. The Hawtbornc offctt
is a concern, as ir is difficult to p•·esent a true double-blind paradigm ro workers since those

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The.Question of Back Belts lol

wbo receive belts certainly know so. In addition. logistical constraims on durotioo, divel'sity .iu
occupations, ;md sample size are problematic. However, the dat.1 reported in the hen:er·executed
clinic-al u ials Cilnnor supJX>rt the notion of universal prescdption of belts to all workers involved
in manual handling of materbls to reduce the risk of low back injury. vVeak e'·idence suggests
that those alre1dy injured may benefit from belts (or molded orthoses) with a red11ced 1·isk of
injury r<..•c.ti!ITence. However, evidl!nce does not appear to support uninjured workers' wearing
belts to reduce the risk of ittjury; in fact, the risk of injury seems to increase during the period
foUo";ng a trial of belt wearing. Finally, some e'<idence suggests that rhe cost of a back injury
may be higher in workers who wear heirs than in workers who do not.

Biomechanical Studies
Researchers who have studied the biomechanical issues of belt we1ring have focused on spinal
forces, in tra-abdominal pres..~urc (lAP), load, and ranbrc of motion. T he most iofonnative studies
are reviewed in this section.
lAP and .Low Back Comp ressi ve Load
Biomechanical studies have exam.i ned changes in low back ki11ematics a11d posture in addition
ro issues of specific rissoe loading. Two sn1dies in particular (Hannan e[ 31., 1989, ilnd Lander1
1 lund ley~ and Simonton, 1992) suggested that wearing an abdominal bc::lt can increase thct
margin of safety during repetitive lifting. Both of these papers reported grouod reaction force
and measu,·ed lAP while suhjecrs repearedly lili:ed harbells. Both reports observed an increase
in lAP in >11bj"'-'IS who wore abdominal belts. T bese researchers assumed that lAP is a good
indicaror of spittal forces, wl1ich is highly contentious. Nonetheless, they assw11ed the bighe,-
rec;ordingl< of IAP indicated an increase in low h;~ck Sllpporr that in their view justi~ed the use
of bdts. Ncirl>er srudy measured or calculated spinall<lads.
Several studies have questioned the hypotl1esized link berweeu elev;lted lAP an.d reduction
in low b<~ck lmcl. For ex:>mple, using •n •nalytical model and d•ta collected from rhree sub-
jects Ufting various mabmimdes of loads, J\-lcGill and Nom•an (1987) notc'CI that a buildup of
lAP requir·ed additional activation of the muscularure in the abdominal waU, resulciJ1g in a net
increase in low hack compressive lo:ld and not a net reduction of load, as l'esec1rchers h::ld pre-
viously thought. In addition, Nachemson and colle•gues (1986) published some experimental
results that directly measured intradiscal pressure during the perfOrmance of\ '.1.Jsalva maneuvers,
documentl ng that an increase in IAl> iI)Creased, not decreased (he low back compressive .IO<ld.

Therefore,. the co nclusion that an increase in L-\1> due to belt wearing reduces compres..'iivc load
on the spi ne seems erroneous. In fact, such :1n increase may have no effect or may C't•Cn increase
the load oo the spine.
l AP and .Low Back Muscles
Several studies have put to rest the belief that lAP afft::ct:S low back extensor acti\~t.y. !'vfcGill
and colleagues (1990) e.x.tmined lAP and myoelectric activity in the trunk mus..·uht11re while
six male snbjects performed va1i0t1s types oflifts either wearing Ol' nor wearing an abdominal
belt (a Stretch belt with lumbar support stays, Velcro r:ahs for cinching, and suspenders for when
subjects were not lifting). Wearing the belt increased lAP by approximately 20%. Further, the
authors hypothesiZ<.>d that if belt~ were able to help support some of rhe low ba<·k extensor
moment, o ne would expect m me•1sure a recluctioo in extensor muscle activity. There was no
change in ~ctiva tion levels of the low Uac.:k extensors or in any of the abdominal n1usclcs (rectus
abdominis Ol' obliques).
In a study tbat examined the effect of hefts on muscle function, Reyna and colleagues ( 1995)
examined 22 subje<:ts for isometric low bark extensor strength ''"d found belts provided no
enhanceroem of function (although this study was only a touJ·-<lay u·ial and did note.xamioe the
effects over a longer duration).
Ciriello and Snook ( 1995) examined 13 men over a four-week period lifting 29 metric
tonnes in 4 twice a week both with and without a belt. Median frequencies of the low
back eleccromyographic signal (which is sensitive ro localmu<cle fatigue) were not modified by

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tl1c presence or ~bsence of a back belt, strengthening the notion dtat belts do not sign.ificar> tly
alleviate the loading ofh~H.:k e>.tensor muscles. Once c1gain1 t-his trial was not condtlC[ed over a
very long period of time.

Belts and Range of Motion Restriction

In L986 La otz aud Schultz. obsc.rvcd the kinematic range of lumbai motions in subjects wearing
low back orthoses. While they studied corsets and braces ratlte.o· than abdominal belts, they did
report re$tticrion.s in the range of motion, alrhough the resrrictecl motion wa."i minim::.J in the
flc:\:iOn plan e.
h> another study McGill, Seguin, and Bennett (1994) tested flexibility and stiftj>ess of the
lumbar tor.-;os of20 male and 15 female adult subjects, both while rhey wore and did nor wear a
I 0 em (4 in.) leather abdominal belt. The stiffness of the torso was si&mificantly incre'JSCd about
tl1e lateral beod ~JJd axial twist axes _.id1 wearing belts but not when subjects were n·otated into
f\.111 Aexion . T hus, rhese snadies seem to indicare char abdominal heirs help restrict the range
of motion about the lateral bend and axia I twist axes but do not have the same effect when the
torso is forced in flexion, as in an industrial Hft:ing situation.
Posmre of the lumbar spine is an imponanr issoe in injury prevention for several reasons. In
particular, Adams and 1-Iuttcm (1988) showed that the-compressive strength C)f the lmnhar .spine
decreases when people approach the end range of motion in Aexion. 1l1erefore, if belts restrict
rhe end range of motion, one wot•ld expect the risk of inj\Jiy to be correspondingly decreased.
\>Vhile the splinting and stiffening action of belts occurs about the lateral bend and axial twist
axes, about the llcxion-cxtension axis appears to be less.
A more recent data set presented by Granata, A·larras, and l)a.·is ( 1997) supports the notion
that some belt srvles are better in stiffening the tor,~ in the manner d<..oscribecl [lreviouslv-
namcly, the tallc; da~lic belts d1at Span tbc"'pelvis tOthe ri!J cage. furthermore, tlacse autl~ors
<llso documented that a •·igid orthopedic belt generally increased the lifting moment wb.ile the
elastic helt generaiJy reduced spinal loacl. Nevertheless~ the authors noted a wide variety in suh..
jcct response. (Some subjects experienced increased spinal loading with d1e clastic belt.) Even
in well-<.-ourroJieJ studies, belts appear ro modulate lifting mechanics in some positive ways in
some peop1e and in negative ways in others.

Studies of Belts, Heart Rate, and Blood Pressure

Hunter and colleagues (1989) monitored the hlood pressure and be<>rtrate of five males and one
female performing dcadJifts and one-ann bench presses and riding bicydcs while wearing and
norweaaing a IOcm (4 it>.) weight belt. Subjects were required to hold in a liftiog posture a load
of 40% of thelr m~nimum weight in the deadlift for 2 minures. The subjecr.o; were required to
l>reathe throughout the duration so tbat no Valsal"" cffet't occurred. During tbe exercise
blood pressure(up to 15 mmHg)andheaa~ nnewe•·eborhsignificanclyhigher in subjects wearing
heirs. (;ive n the rel<lrionship berween elevated S}'Smlic hlood pressnre and <ln increased risk of
stroke, Hunter :md coUeab'tles (1989) concluded that individuals who may have carcliov:asmlar
system compromise are probably ~r greater risk when uoden:aking exercise while wearing back
supt-)()rrs than when nor wearing them.
Subse~!lent work conducted in <lllr "''"' lalxm>t<lry (Rafucz and AkGill, 1996) invt!Stig.ned
tl>e blood press11re of 20 yow1g men J>Crfonning sedentary and very mild activities botl>with
and without a belt. (1' he belt was the elastic type with suspenders and Velcro rnbs for cinching
at the front.) Weaaing this type of industrial back belt sib>nificantly increased <liastolic blwd
pressure during qwet sitting and standing both with and without a handheld weight, during
a trunk rocation cask, and during a squat liliing rnsk. !·:vidence increasingly suggests that beltS
increase bl<xxl pres!-.·ure!
Over the past decade I bave been asked to deliver k-ttures and participate in academic debate
on the back belt issue. On sever~ I occ.1sions occuj>ational medicine personnel have approached
me after hearing of the effects of belts on blood pressure and lAP and have expressed suspicions
that long-tcnn belt wearing at their partkuJar worlq,Jact n1ay possiUly be linked with Inure inci-
dents of va.ricose veins in the testicles, hemorrhoids, and bemias. As of this writing, there has

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The.Question of Back Belts 163

been no scieotific and systematic iMestigation of the validity of these suggestions. Rnl1er than
wait for su·ong scientific da{ll ro either lend support to rhese ideas or dismiss d>em, it may he
prudent to simply st'Jte concern. This "~U motivate studies in the future to rrack the inddente
alid prevaknce or these pressure-related disorders to assess whether d>ey are indeed linked to
belt wea1i11g.
Addicic>na1 stndk--s have ex-amined che effe~'t of beJt wearing on other physiolc)gica1 phenom-
ena. Bobick and colleagues (2001) reported lower mean O>ygen consumption while Parker and
colleagues (2000) reported >'eductions in lnng venrilnion tidal volumes in groups with highe1·
abdomiml fat, but increased tidal V(>lumes in groups with lower fat. Collectively these data
would have Unplications regarding lower work n1tCS dw·ing bdt wearing, or modula ted lung
func6on that would impact performance, or both. Once again, thecffect ofbelr wear ing appears
ro depend Qn the characteristics of the individual worker, milking it djfficulr m justify a single,
uoil'ersall>clt-wearing- policy or guideline.

Psychophysical Studies
Some have c.xpn.:sscd com:crn that wearing Uclts fosters an increased Sc:!nse of stcurity that may
or may not be wananred. Studies based on tbe psychophysical paradigm allow workers to select
weights th:lr iliey can lift repeatedly using their mvn snbjecdve perceptions of physical exer·
tion. McCoy and colleagues ( L988) examined 12 male college students while they r<pctitivdy
lifted loads from Ooor to knuckle height at the rate of three lifts per mioute for a duration of
-15 minutes. They repeated cl1is lifting bout three times. once without a belt :md once each with
tWO tliffcn:nt typeS Of abdominal belts: a bdt with a pmnp :1nd arr bladder pOSterio rly and cl1e
elastic stretch belt pt-eviously described in rheMcGiU, Norman, and Sharratt (1990) study. After
examining the va11ous magnitudes ntloads that subjects ha<l selected to lif'r in the three condi-
tions, the rt:searchen; noted d1at wea.ring belts inc.:reased the load that subjectS were willing tO
lift by approxim:nely I9%. This evidence may lend some support to the theory that belts give
people '' fu lse sense of security.

Summary of Prescription Guidelines

My e<lrliest reporron hack belts (McGill, 1993) presented dan> and evidence rhat neirher com-
pletely suppm~ed nor condemned the wearing of abdominal belts for industrial workers. After
more labor-Jtury stucUes and field trials, my position (which has been implemented by several
governments and corpol";ltions) h:lS not changed.
Given the available literature, jr would appeaJ" d1at the universal prescription of belts (i.e.,
providing belts to all workers in an industrial operation) is not in the best interest of globally
reducing both the •·isk of inj11ry and compensation cost.<. Uninjured workers do not appear to
enjoy any additionaJ benefit from helt wearing and, in f.1cr, nuy be e.'!posing themselves to the
risk of a 100rc severe injury if they were to b<..x-omc injured. i\·lorcovcr, they may bavc to con-
front the problem uf weaning themselves from the belt. However, if some indi•·idual workers
perceive a benefit from heir wearing, they .should he allmt,.·ed to wear a heir conditionally hut
only on trial. The mandatory conditions for prescription (for which there should be no excep-
tion) 3rc ,lS follows:
• Given the toncentS regarding increased blood pressure and heart rate a11d issues of liabil-
ity, all can<Udatcs for belt wearing should be screened for cardiov,>Sallar risk by medical
• Gh~en the concern that belt wearing may pro\ride a false sense of security: belt wearers
u'lu:,;t rt'<.:eive cduc.:ation on mechanics (back school). All too oFten, bclts are being
promoted to industry as a quick fix ro the injUI'Y problem. 1'1·omorion of belts, conducted
in this way, is deoimental to the goa.l of reducing injury as it redircctc; the focu..~ from
tbc c~1u s.c of the. injwy. Education prograuls should jndudc information on how tis.,ucs
become injured, techniques m minin_ l ize musc..•Joskeletalloading1 and whtlt to do about
feelings of discomfort to avoid disabling injury.

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• Consulmnts and dinidans should not prescribe belts w1til they have conducted a full
ergonomic assessmen t of the iuctividual's job. The etgonomic approach should es"mine
and attempt to c..'Orrect (he cause of rhe mnsculoskeletal overlo:lfl :mel prO\•ide solutions
to r·educe the excessiv<.' loads. In this way, belts should only be used as a supplement for
"few individu"ls, willie a greater phuuwide emphasis should be 011 the development of
a comprehensive ergonomics program.
• Belts •hould not be considcrt'd for long-term use. The objective of any sm•ll-scale belt
program should be to wean workers from the beirs by insisting on mandatory participation
in compre hensive fimess program~ and education o n lifting med1anics, comhinecl with asse~nent. Furthermore, con.suJtants would be v.isc tO continue vigilance in
ll10JlitOLing former belt wearers for a period of time folJowiog belt wearing, given fiat
this period appears to be characterized hy an elevated risk of injury.

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Low Back
Rehabi Iitation

his part of the book presents better rehabilitation pr<>t1ices based on

Tthe evidence discussed in previous chapters.

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Building Better
Rehabilitation Programs
for Low Back Injuries

he evidence presented in this book suppons the establishment of spine stability first, folloll'ed
T (smnetwnes) by srine mobility in some back-injured patients. Although a small proportion
of patients need rnobilizing in a Iota) spinal n.:.!,ri<>n tirst most patients-from those Jooking tOr

Functional eohaocement aod pain relief to athletes seeking ped'ol'll>ance enlw>cemem-benefit

From stabilizing the spine first. In fact, once stability is established and the pain re,;olves, many
pa tients find that their mobllity r(·turns \\~th no further intervention.
Many people develop bad backs because of movement flaws. Lifti11g even extremely heavy
loads can De :u.x:ompHshed safely by 11rhletes who have perfecr form. Bur movement Aaws cause
rqlc:.ated OT prolonged loading that is abnormal for the rissuc, so it slowly becomes painful.
A helpful analogy is as t'ollo"·s: lf you were to hit your th\unb lightly, but repea~edly, with a
bam mer>it wottlcl evenmally hecome ''cry painful. In fact, soon rhe slightest touch would cau!ie T his ~ymptom magni.fil~ation occurs bec:ause the tissues arc hyp<:rsensitizcd-not bet.-'3usc
of psychosocial modulators. The tissues are continu:llly "hit with the hammer• beca11se of the
aherran( m otion and moror p:nterns. P:lrt of t he sr::~hili7.3tion appro:-1ch is ro cone:ct the aber...
rant pa tterns to literally "take the hamme r away." Then d1e tissues become less sensitized , t he
repertoire: of pain-free msks increases. and nlOtlon returns. This is why it js to _perfonn
thel'::apelltic exercise pain free. Pl'esence of pain also leads co va1·ic)us suhstiturion patterns a.s
the spine li rerally learns to "limp." T hese must be t.'Orrecred, and require paln-free motion. So,
don't worry about the concept of restoring function too soon. Tllis retards progress. Address
the painful tissues -and then wodc on function.
E''idence presented throughout. this book is unanimous: A spine does not behave like a knee
or shoulder. and approaches that work with these joints are often not effective for back therapy.
Loading throughoot the range of motion-which works well for joinrs in the exll'ernities-is
the nemesis of many b.ack.•), ;n least io the ea.rly stages of rehabilitation. During this period.
training tOr strength is usually (:Ounterproc.J uctivc. Unfortunately, the prln<.iplcs used in body-
building pervade rehabilitation "clinical wisdom." This approach hyperu:ophies musd.e ar the
C~'JX'nSC of developing functional motor and motion patterns needed for optimal health. In this
chapter several !:_,f'Cneral recommendations to maxim.izc the chance for sucC'essful rehabili tation
are discussed, followed b)' considen>lions of the sr:>ges of patiem prog•·ession and g\•idelines for
developing rhe best exercise regimen for each pariem.

Our Five-Stage Back Training Program

\~'e have developed a five-stage approach to back training that begins with nur identifying fuulry
movement patterns and ends with the paricnt:S achic\•ing uJtimatt athletic perfonnance rea(li-
ne.,g. Cons ider this rhe "large pict\U'e," as onl)' athleres and people who pe1form demanding

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tasks will complete all five srages. 1-Iowever, it is im portam to w1dermnd Lhe components and
objectives of each srage, together with their order. For example, patients may he unknowingly
following a srrenbYlhening re.gimen (stage 4) without having smx:essfully addressed perturbed
motion patterns (swge l ). Doiog so will delay their reco\'ery, or make them worse off. So when
approachi"g the program, one must fi·rst ask, Is the objecrive pain reductlon and reha bilitation
of problems or is it athletic performance? 1~lea 1 th objectives demand a focus on Jno rion and
motor patterns, .stnbility, and endurance to achieve low tissue loads and a low-risk el'wironmcnt.
Perfonntlnce reqvires moreove•·load. with an elevated risk naturn.llyocc\•rring. The tTick in rhat
case is to stay within the "lowest risk possi ble. ·~
VVhilc all five 1najor stages are listed here~ only the first three stagt'S arc appropriate for reha-
bilitation and are addressed in this book. Rigoi'O\JS strength, speed, and powe,· trni.niog is only
for those .inte-rested in enhancing these attributes. They are not needed for the average person to
have good back health. I have addressed this ruorc advouccd athletic training in detail iu Ill)' book
UltimtJJc Bnrk i'/111e.<r dllil f'r,jimnm~<·e (2006). He1.·e is a summary of all five trainiog stages:

• Stage I: Groove motion palterns, motor pattems, and corrective C.'Xercisc .

- Identi ty pertu rbed patterns and de,·elop appropriate corrective exercise.
- Address basic movement patterns through to complex-activity specific patterns.
- Address basic balance cha llenges through to complex and specilic bah~>ce environ-
• S~Jg<l 2: Builtl whole-body and joint stabi ~ty (focus on spine sra bi~ty here) .
- Build stability while sparing the joints.
- Ensure sullitiem stability conunensura.te to Lhe demands of the task.
- 'Ihmsfcr the patterns into application dul'ing d~lily activities.
• Stage 3: Increase e11durance.
- Addrey; basic enduran<;e o·aining to ensure che capacity needecl for srabilization.
- Atldress activity-specific endurance (dun1cion, inrensiry).
- Build the base fi>r eventual perfonnant'e o·aining (only in tbose wid1 this goal).
• Staf.'C 4: Bw1d strength.
- Sp;;lre the joints while 1uaximizing neuromuscular con'lparonent challenge.
• Stage ; : Develop speed, power, agility.
- Develop \lltinme pel'fo,,nance with the foundation l:.>id in smges I through 4.
- Focus on optimizing elastic enerbY)' srorage Uld recovery.
- Employ rhe techniques of soper~tiffi><:ss.
If you master the first three stages, whicb are diS<:ussed in this chapter, you will understand how
to get bad hacks w respond ;md how to develop lx:tter rehabilirntion pmgrams.

Finding the Best Approach

Given the 'i.\ride variet-y of low back patients, one cannot expect to be succes!-;fuJin )ow hack reha-
bilitation by o·eating everyone with tbc same cookbook pmgram. -nc following strato&~cs will
help g11ide clinical decisions to individualize-and thus optimi7.e-the rehabilitation program.
• Trtc:iu. for hea./tb t'ersus pe1fonutr.nce. ll1e norion th<'t athletes axe healthy is gene.rally a
myth, at least from a musculoskeletal point of view. Training for supe1ior athletic performance
demands subst;mrial overload of the muscles and tissues of the joints. An elevated 1isk of injury
is associated with athletic &raining and performance. UnfQrrunately, many patients observe the
routines l>y athletes to enhance porlilnlwnce ami wrongly eondudc that copying them will
help their own backs. 1raining for health requires quire a different philosophy; it emphasizes
muscle endurance, motor conrro1 perfection, and the mainten;,lnce of sufficient 5pine sr-JhiJiry

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in all expected task~. \.vruJe strength is not a targeted goal. strength gains do result. Ifa p;ttient
wkh back p:tin states that her ohjective is ro play tennis nr golf, then she has the wrong short-
term objective. First and foremost the objecdve is to eliminate pain . T hen rhe ohjecriv~ may
shift toward a performance objective such as participation in a specific sportit>g activity.
• l11teg;rnte prevemion a11d rebnbilitntion appm11cbes. The best Lherapy rigorously fol-
lowed will not produce rest~rs if <he c;mse of the back troubles is not addressed. Part II provided
guitlcHnes for rc.dudng the risk of back troubles: RCJno,~ng the source that exacerbates tissue
overload cannot be overstressed. Linton and van T11lder (2001) demonstr:ued the efficacy of
exercise for prevention; exercise satisfies rhe ohjective for horh beuer prevention a:ncl rehahili·
ration outCome. First, reach patients what is causing their rroubles: then work wlth them to
elimimte the cause.
• Estt~blisb 11 slow, C011tinmms{)Vtf11U!'nt iu jum:ti011 nrul p11i11 7-eductifm. The rctum
of function and reduction of p~in, particuhtrly fo,· che chronic b<1d back, is" slow ]}rocess. The
typical pattern of recovery is akin ro the stock market pricing histot)'· Daily, anti even weekJy,
('rice fluL'tu.ations evcntuaUy result in higher prices. Patients have good days ami bad days. A·lany
cimes lawyers have hired privne investigators co makeclan.destine videosof bnck-ti'O~bl ed people
performing tasks that appear int·on.sistent. I am hired to prmride comment. Some of people
arc true malingerers and get caught. Others arc simply having a good day on the day thC)' arc
videotaped.. l see all sorts of JllOI•emenr ~1athology COJtsistent wid> their ch,·o,lic history, and chey
are exoner-ated.
• Htrve the pmimt keep a jQUrnal of daily octittities. Documenting daily back pain and
stiffness is essential in identifying the linkv.~rh mechanical scenarios that exacerbace the troubles.
Two criti c~] components should be recorded in a daily journal: how the back feels and what tasks
:md activiries were performed. When p:n-ients encounter repeated setbacks, they should cry to
identify a common C;lsk or activity that preceded the trouble. Likewise, even when is
slow, patients will be encouraged ro sec some progress nonetheless. VVithout referring ro the
dial')', p<ltients sometimes do no( reali1.-e rhe}' are improving.
• En$tn-e tiJe "posit.hJe slope" in progress. Chapte1·s 12 and 1.1 introduce d1e "big three"
exercises im different forms. We designed rh ese exercises to sr>•re the spine of large loads and to
groove stabilizing motor patterns. U~c the d1rL"C to establish a positive slope in patient improvc-
mem. On,-e the slope is established, )'Oll may choose w add new e.'ercises one ar ~ time. The
patienr may tolerate some e.xercises well and others not so we11. If the improvement slope Is
lost after adding a new activicy·, remove it, go back tu the big thr~, and reestablish the posi-
tive slope. 1f d1e 1:r.1tiem requil'es advanced objectives for atbleti.c perfOI1ll<U>ce, perhaps spine
mobi liry, you may add exercises to achieve s11ch objectives alie•· eStablishing ~he po.sir:ive slope.
How long should each st.age be? 'There is oo singlt! answer fi)r all hackc;. Some wilJ progres.s
quickly, while others will require great patience. 'I11is is tbc job of the cUnici;n-to derermillC
the ini tial challenge, co gauge progress and enhance rhe cl1allenge accordingly, <Jnd to keep the
patient motivated. even chuing periods of no apparent pro.brress. T he great diuidans blend keen
clinical skills and experience with scientifically founded gujdcliues and knowled&-e.
• Detenuim: whether tbe patie-utiY willing to 1/ltlke 11 cbtJnge. Ob\~ous ly, the. patient must
change the cunent patterns that caused him co become a back patient. This will require moti-
vation1 which is not always easy to establish. Others ha\•e listed the impnrnmce of :anrl sreps in
dcvcioping- a thange in motivation aod attitude (e.g., Ranney, 1997). Brit i:ly, ~uth a prOb'I"<Jm bcbrin~
widt the sen ing of goals-for e."'mple, returning to a specific job or part\ll:ing i11 a leisure activity.
The employer's role in enhancing motivati(m is co ensure that modified work is available together
with cl1c opportw1iry for graduated rt'I1U11 t<1 th1ry. Employers can also play a role in morivm:ion by
fOstering a wlture in which worker success eqwtes to company success, which in tum helps tbe
\•lorker. T he -recond step in a motivation program is to foml\lhte a realistic plan for re<lching
the goal established in the. first step. It is l>eyond the mandate of tlus book to develop the com-
ponents of m-a intaining and cnho1nci.og motivational oppon:unjtit.--s al ~ch stage of recover)'·
• Dete.nniuewhetber the ptttieutn.eetls initUtlmobiliZIItiuu. \·V1Uic evt·ryone shuuJd: incor-
porate spine scabiliz;~cion exercises into daily acti>icy, there is a small gl'oup who will benefit from
some dlr~cted soft- tissue work. This may include manipulation, rrigger point [heirapy Active 1

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Release Thentpy, the use of foam rollers, ;u>d so on. These techniques are not the focus of this
hook. A word of c~ution is requ ired here. Too many make the mist:lke of IT)~ng to mobili1.e a
painful spine reb.;on th<tt already has mobility. N one theless there is good evidence rhat t hose
wicl1 docwucnted hypomobiHty may benefit frorn sou1e initialmanipuJatiOJl or mobilization
wid> a nnnsition into stabilization training (Fritz at al., 200)).
• Con.,~Uier· otber J'Oft tisl~ue tretu:ments. Patients often present with local musdC!spasms anJ
"odd-feeling" l oc~l muscle texture as perceived by a good mat~ual medicine clinician. Further,
these spasms and local neurot'Omparnnent di~orrlcrs are associated with larger dysfunctions of
the agonist and synergist musdes in"olvcd in a movemen t. In many cases these dysfum:tions
deJa)' re<:overy or prevent complete recovery. Cti•tici.ans use a >-nriety of soft tissue l.l'eatments to
remove spa~m and release dte tissue.~ r.har can impede arraining more nonnal muscular and joint
function. Documenting them is beyond t he SlX>pc o f this book. The reader is simply alerted ro
their potential significa.nce and role in rehabilitation.
• Avoid >piue fXYU>e~: Spine power is the product of ••elociry and force (powe1· = force x
velocity). Thl~ means that the spine is bending quickly and there is velocity jn the muscles'
lengthening and shortening. Techniques that invoke high velocity in the spine have been shown
to lead to back troubles, as they usually indicate high power (Marras et al., 19<13; Stevenson et
al., 2001). To minimize power and maximi1..e safe ty, the forces uan~auin:ed duough the n·unk
must be low if the spine is moving. If the forces transmitted through the mmk an: high, then
the ••elocity most be low. T he powe1· must be generated ar the h i~lS and shoulders and be trans-
mitted through an isometricaJiy stahitized torso. Forrunarely, this fundamentaJ r.ener for safe()'
also helps to maximize pcrforntantc.

Stages of Patient Progression

Before we can undertake to remO\'e the ::1ct:ivities th(lt ex<~cerbate low back troubles, we n1ust
detem1ine what tlu·y.. are. This is a cmcia) part of the rehabilirarion J)rocess. Uncovering the activi-
ties that cause back t roubles begins wirh a patient inten•iew. Sontc d inidan.s perfonn provocative
testing at this time as welL ...I'he next chapter thoroughly discusses how ro inte1·view and tesc lhe
patient. Once this has been done, the re habilitation can proceed. The d htician m.-y ch cx)se to
overlap the stages im·olvcd in this process or conduct them in parallel. At all times, however, the
objective is to establish :md maintain the positive slope of continual improvement.

Stage 1 : Detect and Correct Perturbed Motion

and Motor Patterns
Some people are very "body aware" alld ;tre able to adopt a neutral spine or a Oex:ed spine ou
command. Others can be frustra tingly clueless.
Distinguish Hip Flexion From Lumbar Flexion
The initia l objective of this stage is to have the patient consciously separate hip rotation from
lumbar motion when Aexing rhe rorso. For the more diffitult cases we typically beE,rin by dem-
onstrating on ourselves lumbar flexion versus rotation about the hips. Other techniques rhatwc
h,we found particularly helpful are as follows:
• Ha.•e your patient place one hand on the rummy while placing the other over the lumbar
surfd('C. This way the p-dtient can fL):CI whether the spine is locked <Utd motion is occu.rrlng about
the hips (see figlu'e
• Sometimes patients are recepth·e to being coached while using a practice load. The
dummy constructed by nurst.os tO help t bem rehearse prope r patictnt lifting and sho"\'11 in figu re
8.28 on page 152 is an example of such a practice load.
• Otller patients respond well to photos of people cotTectly doing tasks that they will also
be atUell on to do in d1c course of their jobs o r their everyday activities:. Figure 10.2, 11 and b,
shows examples of such photos.

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Figure 10.1 For people who are not ·'bod)' aware'' and are unable to adopt a neutra I or a tlexed
spine on command~ we suggest (a) rehearsing the spin e~neutral position <:~nd hip (not lumbar) flexion
while doing knee bends be(ore (b) exertion, such as lifting this typic~ I Canadian hOu!iehold itt.'m.

b ......___ _

Figure 10.2 Sometimes patients arc receptive to t(1sk.specific illustrations showing spine and hip postures. (a) A rescue
wOI'ker is ~1 ppl ying a pulling force 10 the victim with the spine flcl<cd. Discussion vvith the patient of this flexed spine pos-
ture together wilh one that would bcuer spare the spine is very helpfuL (b) Also discussed .-we exercise postures such as
1hc neulrallumhor posture adopted by lhis p.11icn1 pc•fom1ing cable pulls.

• Before (incom:ct) and after (correct) photos, such as those in 6h'U r<: 10.3, n through d,
can be espe<.1ally helpful.
• Yet another technique is to place a srick "long the spine with rhe insrroccion ro flex the
r:orso fo rward lL~ing the hips but maintain t:onta<:t \\~tb tht! stick over the lcnbrth of the spine
(see figure I0.4, a-c). V\'hile this begin.1 in the clinic, other, more co111plcx benr~ng t:>sks can
also help g roove these panems into rhe general monon patrerns used in "'ork :mrl other d~ily
• When ~II of these attempts mil, we resort to the final tcch.oique: having tl1e pari em per-
fonn me "midnigh< movement" (rolling t:he pelvis}-this is lumbar monon. Interestingly, some

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Figure 1 O.l Workers relate to tasks with which they are familiar. These photos are helplul for con·
struction workers, especially since they can readily see the difference between the (a, c) incorrect
and (b, d) correct spine postures.

Figure 10.4 Placing a stick al(u)g the spine with the instruction to fl~x forwMd but maint.;~il'• cootacl with the stick over
the length of the spine will help patients separate hip rotation from lumbar motion when flexing the torso. Examples oi
motions that can be used are (a) sagittal plane symmetric lifts. lb) various three-dimensional cable pull exercises, and !c)
specific \VOrk tasks that are familiar lo the J>atient.

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paticms who found sex painful never associated pelvis tilting with lumbar Bexion (see figure
I0.5, 11-d). Pointing thisou• to them often facilitates their making the next leap in sp ine ]:>OSition
awareness ~md in being ahie to avoid these painful motions and posmre.s.
Once you ])egin to see that any or se'•eral oF the tecluliques just listed are helping these
ttdifficule' J>atients learn how to achieve and maintain neutral spine position dl1ring their daily
acth·ities, you may have them -atte mpt some tasks ro see if the concept of the neu.tral spine is
bcooming ingrained. One such task is to tak~ the spine stick and ask the patient to imock down
an imagina.ry spider web in ''" ove,·head comer of dle room.. If he loses dle lumbar neutral pos-
rure, point this out ro him so he can corre<.'[ it. Obviously you should contin ue spine position
awareness training wlth such a P'Jtic.ut.
Some people have a very difficult time remembering the protective neut•·al spine partern.
vVe tell these types of patients to
I. stop before an exerrion (perhaps prior to lifting a household item),
2. place the hands on d1e rummy and lumbar •-egiOJ\,
3. practice a few knee bends with the motion abm•r the hips and nO{ the lumbar spine. and
4. the" perfomJ the lift.
This practice is eflective for many people.
Teach Locking the Rib Cage Onto the Pelvis
For many individuals, learning to lock the Jib <.:age on th(' pd vis is e~cntial for iJ•jury prevention
and for perfonnance-though of cou•·se not fo•· alL We have de,•eloped a teaching progression
that is effective for most patients and that is fully •~l>lained in chapter 12 (page 22 1). T be motion
pattern sho uld be accompanied by the abdominal brace motor pi<ttcrn (sec figure 10.6). More
athlecic ve•'Sions of the progression are derailed in McGill (2006).

Distinguish Abdominal Bracing From Abdominal Hollowing

ll·1aintaiuin.g a mild conmtction of the abdominal wall can also hclp ensure sufficient spine stability.
Th is maneuver is c.1lled abdom inal boll owing ill many back care cirdes. but we prefer to avoid
chat termin olof.'Y as i[ suggests ro most people eirher pulling in or puffing out rhe abdominal

a c d

Figure 10.5 Allowing the patient to feel spine (a ) flexion and (b) extension helps them to eliminate these from the squat·
ing motion. Others :'ge-l it" by (c) adopting the sho1tstop "'ready posi1ion"' and then (d) standing up.

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a c
Figur<' 10.6 Ia, b} 11": w,1ll mil begins w ith the patient in the " plank" with hath elbows planted on the wall. f(lcus is on
spine and hip motion• .generally adjusting the spine and hip posture to shift the pelvis toward the wall in order to find the
..sweet spot'' in spine pmi~io n with minimal pai1'1 . (c) The abclomin-31muscles are braced CH'Id 1he l'ib c<lge is ... locked ... on
the pelvis. The patient pivots on the balls of the feet, pulling one elbow ofl the wall. No spine motion is permitted. l11ese
corrections are repeated until the patient Ciln control their spine and eliminate IJain.

w:lll. VVhen the contraction is perfonned correctly, no geomeu·ic change at all O<:curs in the
abdominal waJL In other words, rather tban ""hollowing or drawing in" the abdominal Wtl11, d1c
patient simply activates the muscles to make them still \•Vc call this cont:r.~ction "abdominal
hracing," or oistiffening/' whereas when we speak of abdomin:~l hollowing, we are referring ro
the pulUng in of tbe abdominal wall, discus.~ed in more derail nexr.
Some <.:Onfu~ion exists Jn the interpretation of the literature rcgdrding the issue o.f abdonUnal
hollowing and abdominal bracing. Richardson's group observed thar the hollowing (see figure
10.7tt) of the abdominaI waU recruits tbe transverse abdomi.nis. On tbe o ther hand, an isometric
abdominal brat<: (sec figure l0.7b) coartivates the transverse abdomin is \\oth the cxttrnal and
inremal obliques to ensure stability in virn,ally all modes of possible instability•· er al.,
J 9118). Note tbar in bracing, the wall is neither hollowed in nor pushed ouL Jlrad ng also sta·
biUzcs the spine in bending and twisting challenges, wbcrc•s hollowiug docs not. In this way,
abdomi11al bracing is superior to abdominal hollowing in ensuringsmbiliry. \~r,rh this background,
Rid1ardson and colleagues ( 1999) suggested that the recruim1ent of mtnsverse a bdominis is
impaired following injury. This idl'a remains controversiaJ as some ochers have either not been
able to replicate these results in people with back pain on both sides or tlte torso, or have found
Of>posire results. Nonetheless, the group develol-.ed a therapy prowam designed ro reeducate
the motor system to activate mtnS\·e,-.e abdominis in • nonnal way in low back disorder (LBD)
patients. Tllis was the basis for hollowing; however, hollowing does not ensure stability. Some
clinical practitioners may have misinterpreted Rich;n dson's work to suggest that :-1hclominal hol-
lowing should be recommended ro patie-ntS who require enhanced stahility in ordcc- to perfonn
daily activi ties. This is misguided. Abdominal bracing, which activates the tl1ree layers of the
abdominal wall (externa l oblique internal oblique, transverse abdominis) with no "dr;n
1 _ving in,"
is much more e ffective than abdomina] hollowing at enhancing spjne st<lhiliry (i\'lcGiH, 2001;
Grenier and McGill, 1007, Brown et al., in J>ress).
Two mechanisms can shed some light on this im te of hollowing ve,-sus bn~cing. First, the
supporting "guy wires" are more effective when they bave a wider base (see fibrure 10.S, n-t~,
th~tt is, when the abdomen is not hollowed. Second, the obliques rrutst be active to J.)r<wide sri ff-
ness wirh c>·isscrossing so,,ts, wh ich measurably enhances srabiliry. B1·acing enha11ces oblique
acthriry while hollowing inhibits .ir. The hun bar torso must prepare to \l.ithstand al l manner of

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Figure 10.7 (a) Hollov,ling involves the sucking in of the abdomen to activate transverse alxlomi·
nis. (b) On the other hand, the abdominal brace activates !he three la)'ers of the abdominal wall
(external oblique, internal obliqul', transverse abdominis), with no •drawing in.'



Figur~ 10,8 (,t) Hollowing the muscles reduces the size of the bJse of the guy wires, together with the incidence 3ngle
vvhere they attach to the spine. (b) This inherently reduces the ir contribution to spine stiffness in various modes, which
compromises spine stability. (c) Bracing assists in keeping a wide b.1se to the guy wires a nd recruits lhe oblique muscle to
supply cross-bracing silfUfs for stability in a ll t~xes.

possibJc loads, including ste:ady-.Statc loa din~ (which lll:ly be a comple.l COJnbinatiOil of flexion-
extension, later·a l bend, and axial twisting moments) and sudden, .,nexpected complex loads
rogetber wid1 loads dut develop from planned ballisric mocion. Stiffuess is required in every
rOt'JtiOn and translation axis to clirninate rl1e possibility of unst"Jblc behavior. T he abdo JninaJ Urate
enStll'es sufficient stability usir1g the oblique cr·oss-bracing, although high levels ofoocootraction
are rarely requireci- probahly ahour s•x. maxjmal volunr::1ry conuacrion (.!\ fVC) coconrraction

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of the abdominal wal l during daily activities and up to 10% MVC during 1·igorous activity. Tbe
pat:ienr mnsr match rhe level of conrracrion to the needed stabilily- there is no need to cntsh
rhe spine \Vitb overton traction.
A quantitative compariSOll of 1.he hoUow and the brace is clearly seen in an iJ>dividual
standing upright with loads in the hands. Simt)ly hollowing can cause the subility index to
drop to low levels or even negathre levels, which indicates the possihilicy of instability {sec
figure 10.9}, Bracing increases the positive stability i11dex value. The subject in these figures
is typical in d1at even though the hollow was <aught to target the mmsverse abdominis.
all ahdomlinaJ muscles were -activate<] when measured. Thu~ .stahili tv was created whlle
attempting ''hollowiJtg" although true bracing is superior to create lwnbar stability. 1ra true
"hollow" is accomplished wirh just the tra nsverse abdominis, as simulated in figure 10.\lb,
s<ability is low compared to that with a brace where the three layers of the abdominal wall
ace activated. SimpJy hoJiowingt:auses the stability index to drop to negative levels when the
load is placed in rhe hands, com pressing the spine . A negative value inclicates that instabiliL)'
is possible. lu conrrast, bracing maintains a rositive st-ability index value, elilninating the
possibility for buckling.

x 1o·1S Abdominal hollowing vs. abdominal bracing

~ 1.4

.s 0.8
<!> 0.6
:6 0.4
0.2 Bracing
0 50 100 0 f 150 200 250
ata rames

x10·'5 Simulated abdominal hollowing vs. abdominal bracing


>< 2
.5 1.5
.~ Brace
:s.l!! Transttion
(/) 0.5 Hollow
0 20 40 60 80 100 120 140 160 180
Oara trames
Figure 10.9 I•J An example comparing rhe hollow with lhc brace {h1gher stability) in an individual sranding upright,
arms althc sides, with loads placed in the hands. The problem for p~1 1 ients is that isol.lting transverse (llxlominis is vi11ually
impossible. fb ) A ''pcrfccf' hollow was crea1cd wilh simuliltion and shown 10 be signific::anlly inf:Crior to the brace.

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Teach Abdominal Bracing

GeneraJI)r to demonstrate abdominal brt1cing to the patient, we stiffen

ont' ofour own jointS, such as an elbow, hy s.imul.tanoously at·civ•Jting

t\)e llexors a11d extensors. T he patient then palpates the joint both
before and after we stiffen i<. Then we ask the patient to ;>ttempt to
stiffen be r own joi nt through simultaneous activation of flexors and
extensors. Once ;he can successfully stiffen various peripheral joims,
we demonstr:lte (again on ourselves, with patientpalp;~rion) the same
techniqueio the torso, achieviug abdominal bracing. F"maJiy, \\·e again
ask her to rt·.plicatc the technique in her own torso. Ot:C<'IS.ionaUy, we
use a llOI"table electromyographic (EMG) monitor so the patient can
learn through hiofeedhack what, fi>r example, 5%, 10%, nr 80% <Jf
maximum contraction feels tike (see figure l 0.1 0). vVe usc similar
devices to reach patients how to mai nt:lin rhe contraction wh ile on a
wobble board and in hmccional situations such as when picldug up a
child, ~tting on and off the toilet, and getting in and out of cars.
Given our resea I'Ch on the impoJ't~tnce ofspine positjon awareness
to spare the spine and our experience in reaching positioning, we
became intcrt-!t'tCd i.u pn)prioccptive for du; back. T he f.1tt
that ve1y little evidence was ava ilable to validate the use of proprio-
ceptive rehabilitation for the lumbar spine motivated our recent work
on spine proprioception (Preuss et al., 2005). T he purpose of this
wo•·k was to quallti fy the effects of a six-week rehabilitation program
figure 10.10 EMG biofeedback (lesigne<l ro impr<we lumhar spine position :;ense and sitting hal;~nce.
devices arc an economical w.1)' to 1\vdve subjects with a previous history of low back pain ·were cvenJy
provide feedback to the patient regard- sptit imo a ttaillillg group and a control group. Subjects in the comrol
ing the level of abdominal aclivation group rece.ived no im;e1vention~ while the subjects in the tr:lining
during ~ny type of functional lask, group received a 20-minutc rehabilitation st-'Ssion three tim(>s pu
fro"'? st~nding on a wobble board to week spine stabiJization exercises wid'l a neutral spine.
gettmg 11110 a cal. Lumbar spine repositioning error in four-point lmeelingand sitting
lr.-lance for the training group showed sibYilificant improvement over the study. T bis small bur
iL'Litial study demonsll':lted tJ1at proprioception '3ud position awareness in tJle lwnbar spint.: can
improve rhrough active rehabilitation.

Mental Imagery
The use of menUll imagery is helpful ior both spine position and musde act ivaHon awareness. Following is a
general protocol that we have adapted from the imagery literature for use with spine training.
I. Focus on feeling the surface under the feet or buttocks. Whatever body part is touching a surface, be
awttre ot the sensation.
2. PtaC1 ice sitnl>le motions such as f·ighteoiog and then relaxi ng specific muscles in d ifferent areas of the
body. Then graduale 10 ~rforming Lhe al>ctominal brace.
3. Palpate, ancl have the patient self-palp;~te, the muscle involved while he is attempting to lighten and
relax it. Sometimes a full-body mirror is helpful. The focus for the patient is on I he specific muscle(s)
4. Perform mo tions slowly, chunking them into segments and sequences; then visua" ze the tot<JI motion.
For example, beginning with a simple task such as a forward reach, visualize I he neu1ral spine, then
activating the extensors and the bracing abdominal muscles, and fl nally the motion about the hips.
5. Practice the imagery in(!ependentof physi<:<~l aCtion. Of course, the patif:nt will haw already been suc-
cessful in leamiog spine position awareness, proper muscle control, and desirable motion patterns.
Souu:e: !Qd~~yn MtGill, spo• ~ f»)'ehol~y t.'Onsuh••nl

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Build Squat Patterns

Agood back needs healthy gluteal muscle function, while fw1crion dema11ds balanced llip power
aOOm each axis. This section describes some hip moror panerns rhat inhibit spine ....sparing pat·
ten1s1 together with do<.·mnencing several o-aining progressions to address them.
The crossed-pelvis syndrome is a term given ro the conctition in which the glurea l complex
appears to be inhibited during squatting patterns; this syndrome is vel)' common in those with
a history of back troubles (toged1er v.ith some o thers as well). lnrerestingly, we still do no t know
if the crossed-pelvis syndrome existS prior tu back troubles or is a consequence of having them.
Nonetheless, the S)'ndrome is noticeable in many patients referred to ou1· research clinic. This
results in two concerns. First, those with aberrant gluteal panen1s cannot spare their hack..'i
during squatting patterns sin<:e they use the hamstrings and erector spin a<.~ to drive the extension
motion. S'-'bsequently, the erector spinae imposes unnecessary loads on the lumbar spine. In this
way, hc.. Jtby gluteal patterns are needed to sp<lfe the back. Second, it is impossible to rebuild
optimal squat pcrfonnancc, either for stn~ngth or hip extensor ~wer1 wi thout wclJ-int<:grated
hip e>tensor panerns. In fact the failure of many people to propel'iy rehabilitate is due ro neglect
of d1e ahiJi ry to sql tat and rise off the toilet. or egress .&om a C<lr, or walk up stairs, without fit-st
addressing the aberrant gluteal patterns.
Reu'llining the gluteals cannot be pe1ofomted with tt'llditional squat exercises that utilize a
machine. Perfonning a traditional squat requires little hip abduction. C:on.sequendy is
little gluteus m('dius activation) and the gluteus maxim us activation is delayed during the squat
un til lowe,· squat angles are re,tcbed. This is weU docuoJlented in McGiU (2006). In contrast to
che tr:ulitio.nal squar, a one .. leggerl squat acriv<~tes the gluteus medius immediiltely to assist in
the frontal plane hip drive necessary for spine-sparing funccion together with sooner integration
of gluteus maximus during the squat descent motion.


The following maneuvers will enable most patients to learn how to isolate and a etivate both
gluteus medius and gluteus maximus.


The first st.<~ge involves isolating gluteus medius. Once ag<1in the patient needs to "feel" the
muscle and perceive its activation. The patient lies on his or her side. The patient places the
thumb on the anterior-superior iliac spine (AS IS}and reaches with the ftngers posteriorly-the
tips will be over the gluteus medius (a). With the hips and knees nexed, the patient spreads
the knees aparl like a clam shell, with the
feet remain ing together and acting as a
hingl' (b). The patient feels with the fingers
the gluteus medius activate. This maneuver
is to simply activate Lhe gluteus medius a nd
should not be considered a strengthening
exe rcise. There is no need to offer resis-
tance at this stage (resistance is imposed
later during strength training). True isolation a
of the gluteus merlius is not possible, and
other muscles are active. In this posture, the
external hip rotators are recruited. Extending
the hips to a neutra l posture and repeating
the movement tends to activate the gluteus
medius wi th a greater integration with !he
tensor fasc ia latae.

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Lying on the back with the knees flexed and the fe@l on the floor, 1he patient place-s the fingers
on gluteus maximus to feel its activity. Have the patient image a coin placed in the gluteal
fold ~1at must not be dropped. The patient
activates gluteus maximus by "squeezing·• the
buttock~not by creati ng hip extension. The
focus is on the pelvis at this stage 10 ensure
that no pelvic tilting occurs. The lumbar spine
remains in neutral posture (a). Then, once
the activation has been masterc-!<1, the patient
begins bridging the torso off the floor. The
clinician at thisstage pi!lp;ucs the hamstrings
(b). TI1ose who are hamstring dominant and
gluteal deficient wil l immediately activate
the hamstrings just prior to the occurrence
of motion. This pattern is very dominant in
those who have Lhe aberram crossed-pelvic
syndrome, but is also seen in some sport-
specific athletes such as cyclists. TI1e patient
must repeatedly try to begin the bridging
action without hamstring activity (or at least
only mild al'tivily).
To override the hamstring-dominant ten-
dency in some patients requires coaching
and cueing from the clinician. For these
challenging cases we place our foot against
the patient>s toes and instruct the patient
to <:Ont inue with the preparatory gluteal
activation but then also very mitdl y activate
the quadriceps by very mildly attempting to
extcncl the knl>es. Ruttrcssing the !)<itient's feet
with the cl inician's foot assists this. A gentle
stroke on the quads to assist 1he patient's
b irn<lging and perception of mild knt'C exten-
sion also facilitates this pattern to enhance
gluteal dominance. Then the patient repeats
the <~ttcmpt to bridge with glutc;>.al dominance.
Once this is mastered, squat perfom1ance
will improve_
Imaging squeczing the gluteLJs maximus
muscles prior to performing the back bridge
will assist in grooving gluteal-dominant hip
extension patterns. Then the patient performs
the bridge with a focuson gluteal contraction
throughout the full range. For 1hose having
difficulty, quadricej)S stroking ca n assist with
mild knee extension 10 further reduce ham-
string contribution.

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First a word of caution: Do not stJrt this too early w ith patients who either are disabled or
have very painful backs.

When appropriate we would begin a basic squat progression with a "potty squat." Sitting on
the corner of a chair or a stool, the patient positions the feet under the body to rise o ff the chair
w ithout using any momentum shi~s. The lumbar spine is neutral and braced. This begins to
groove a good two-legged squat position. Then, with progrt>ssion to a standing position,
the arms are held out laterally .l nd moved in front of t he body as the patient squats. Of
course, em phasis i s placed on maintaining a neutral lumbar spine and abdomina l brac-
ing. The h ips follow a trajectory along a line about 45° from tho vertica l. "Squat back" is
a better instruction than "squat down." TI>e motion is predominantly at the hips, know n as
the "hip hi nge."

a b

Progressing to a single-legged S<luat involves the same arm motion to assist balance. As the
single-legged squat is performed, the free leg is held behind and the knee is touched to the
floor, or the toe is reached with an outstretched leg to a distant obje-ct behind. (~,b) Then,
the free leg is reJched out to a distant objeCt f)laced laterally duri11g the squat (c) . Variations
include working the free leg to different positions "around the clock" (see page 180). Thi s
challenges the fuil hip extensor, flexor, and abduction torque generators together wi th keen
motor control. Fuil integration w ith the pelvis and lumbar spine is achieved with emphasis on
the appropriate motor and motion patterns. Specific focus is directed toward maintaining a
neutral lum bar spine. Focus on hip motion, w i th gluteal muscles producing the hi p extension
torque, an<l a stiff torso. Caution with anterior foot placement is necessary with some patients
who are unable to maintain a neutral spine ( d).
The single-leg squat follows the same hip hinging motion. The nonsupport leg is projected
to the rear and to the side. Be cautious w ith forward projection of the foot to the iront. as it
often causes spine flexion. The abdominal muscles are braced, the lumbar spine is neutral,
and the mental focus of the patient is on hip eX!ension torque. Notice that the hips are drifted
posteriorly during the descent to place mort' cmph<•sis on the gluteals for hip extension.
unloading bo1'11 the knees a11d the back.

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Rising from a chair follows the polly squat mechanics. Faulty motion pattems
often include initiating the motion with spine flexion. Instead the spine should be
extended with 1he rib c~ge rising, and the hips flexed. The feel are drawn undemeath
the patient, the knees and feet spread. and the hips externally rotated to integrate
Ihe gluteal muscles for hip extension (SCt' figure 10.11 ).

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a c

Figure 10.11 (a, b) First lauhy motion is initiatt'(l with spine flexion. (c) TI1en the hips are extended with tht' hamstrings
and !d) the spine is extended with the back extensors.

a c

figure 10.1 2 Cor·rected patterns include spreading the feet placement then consciously hying to ''spread the noo,;• which
facilitates the gluteJl mUJscles. (a. b) Better motion is initiated with spine extension and hip fiexion, then (c) hip e>.1cnsion.

Stage 2: Establish Stability Through Exercises and Education

l'or patients to achieve stability not just duri ng rehab, hut also in all aspects of tl1cir li•·cs botb
during and after rehab, both e'ercise and education are ct·ucia l. It is essential that you pursue
both of these srrateb~es.
• Groot·e sftlbiliz ing 'moto,. patterns thrQugh st11biliz11tion exercises. Genel'aHy rhe ne~
stage shoHirl begin with stabiliz.1rion exercise. The trick is m find an appropriate starring level.

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for rhe chronic "hasl.:et cases' who arrive atour tm.iversiry d inic ha\ring faile<l rraditional d1en-1py,

we gcneraUy undtrshoot what many would <.·tmsider an appropriate loading level. The typical
progressive improvement philosophy of"work hardeniug'' with weekly jmprovemcnt g'Oals wiJ1
not work fo r rhese people; they •·equ ire more patience. They will h>ve good and b3d days, but
the gene raJ posltive slope in improvement must he established-howe\•er b'Taclual. Once we t-an
document a positive slope in improvcntettt then we c~ul increase the rehabilitatio11t chaJlenge.

Specilic exercises are discussed and illustnted in chapter 12.

• En:r:ure sttebilizing '1Jwtion patte-nzs and nwsde activation patterns during all activi·
ties. You nlust druiry the range of activities (daily living, occupational, athletic, etc.) for whk.h
the individual patient must be prepared. "!'his is obtained through interview. Vvl1ile there is no
standard fom1> we begin br documenting the patients' daily ro utine, which includes their occu-
pational dem ands and those of daily living. Previous d mptcrsoffered mru•y cxampk'$ in which
the spine is spared with an apprOJ>riate posture and muscle activurion pauem. The guidelines
m selecting exercises disctL~et-1 in r.he next section \\'' ill he lp you determine whar exercises r.o
pre.scribe for patients in this stage. In addition, we spend time rehearsing daily activities to
be sure the patient is leaming <111d utilizing spine-sparing motion 3Jld motor (muscle activation)

Stage 3: Develop Endurance

Endurance is necessary for maintaining stabilizing patterns of m.~..scJe acrivity. · l'hel·e is a progres-
sion to building endurance, and ir Sl<l rts. by huilding endurance w-it hout he<.:oming tired! Here is
what you s hould k~ep in mind as you progress patients tOward g·rcater endurance:

• 1}J1ictilly, mdut·ance is built fi-rst wiJb repetit ed

stLr ofreltltivtly sbort bolds. Holds shoul<l
l:>c no longer
An Important Reminder than 7 or 8 seconds. The duration is based on recent
evide nce fro m near infrared spectroscopy indicating
Remember, since half the baule is to rapid los.!. of available oxygen in torso nrusdes ('on-
remove the irritants, make sure to follow rracring at these levels. Short relaxn cion of the muscle
the recommendat•ions of the previous restores oxygen (J\o!cGill er al., 2000). The ench•rnnce
chapters. objcctive.s arc achitvcd by building up repe titions of
rhe exertions 1'1\tber than by increasing rh" du rt~tion of
e:1ch hold.
• ltlentify emlurnnce deficits. Motivated by the evidence for the superiority of extensor
endunmce over strength as a benchma•·k for good back hoolth. we recently documented normal
ratios of e ndurance rimes fo r the torso flexors relative to the extensors and later.JI rnuscularure
(see next cbapter). Usc these values to identitY endurance defici~-both absolute v:1lues and
values for o ne muscle group relative to anod1er.
• U\'e the 1·ners~ pyramid for endurance trllinin.g. Thi~ approach ro designing e ndur..
ance setS is founded in the Russian tr'Jdition o f mai11taiuing excellent technique and form.
The idea is to rra in endurance without becoming liJ'ed. l-O r ex;~m ple, if one were to design
sets fo r the ~ide ..bridge exercise using five repetit ions 1 rhe training session would look like
I. Five repetitions on the right side li. Rest
2. Five re pe titions on the left 7. T h.ree on rhe right
3. Rest 8. 1ltree on the left
4. Four rC(>ecitions on the right \1. Fini~heci
5. Four on the left
Good technique is facilitated as rhe repetitions are •-educed with each fatiguing set. T his is
generally done ro huild the enclur:mce- base, sioce t be objective of maintaining sufficient 0 1
levels is met so th at dte f.tiJurejs no t oxygen starvation or acidk mct'.t.bolite buildup .. Endurance
o·allling Fo,- more athletic patients is described in McGill (2006).

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Summary: Checklist for Patient Progression

As we have noted, the first three stages of our five-stage program arc focus~'(! on rehabilitation. Here
we incl~,~cle an expancled checklist for rehabi lit<Hion th;~t arl(!s some critic<~l elem~nts.
1. Identify and remove the cxacerbati ng activities.
2. Have lhe patienl record in a journal daily how the back feels as well as the tasks and aclivi-
ties performed.
3. Identify and correct perturbed motion and motor patterns using corrective exercise. Develop
spine !>OSition awareness (hips vs. lumbar motion) and the ability to maintain abdominal
bracing. Groove motion and motor palterns.
4. Begin the appropriate spine exercise and appropriate stabil ization an<;l mobilization tasks.
5. Develop muscular endurance.
6. Transfer to daily activities.
Note lhatlrai ning athleles in our program involves the same s1ages with the addition o( two
stages-tr<lining strength and power (sGoe chapter 13 and McGill, 2006).

Guidelines for Developing

the Best Exercise Regimen
The reported effectiveness oF various training and rehabilitation programs for the low back is
quite v~riai'>Je. with some claiming gre3t success while o~hers report no success or even negative
results (Fa as, 1996; Ko<.>s et al., 1991). T he discrepancy reganUng the effectiveness and safety
of exercise programs is probably due to cliniti>lllS prescribing inawropriatc exercises because
they do nor undersnmd the tisslle loading that resulrs during various tasks. Resist the urge to
enhance mohility just to adhere with the disability rating system. Thar system is for legislative
t<.mveJtiem.:e only. Ratbcr, judge your success by how well you arc able. to reduce patients' pain
and •·esro•·e cheir ability w complete tasks. Also, there must be a reason to perfo,,, an exercise,
and to perfom1 it in a specific way. Tbe ne'~ charter \\~II heir you identi~· deficits in patients
so that they can be addressed by a specific program. If there is no spedfic reason tO prescribe an
exercise, then don't-only wo1·k within the resu·icted capacity of th.e patient to achieve specilic

Developing a Sound Basis for Exercise Prescription

I have selected cUld evaluated the exercises in the following chapters based on tissue loading
evidence :md rhe knowledge of how injlll')' occurs to speciAc tissues (described in previous
chapters). Choosing exercises, howevt:r, still involves d1e best educatt:d bruess that is developed
tl>rough cl.iinical experience. The following example iUustr11tt!$ the need for quantita'l:ive analysis
in order ro evaluate [he safety of certain exercises.
"'ehave a11 been told to r~rfonn sir-ups and or her flexion exercises with the knees flexed-but
on what evidence? Several hypotheses have .suggested that this disables the psoas or changes the
line of action of the psoas, or both. Magnetic resonance imaging (Nl Rl)-based data {Scmtaguida
and McGil.l, 1995) demonstrated that the rsoas line of action does not change due to lumbar or
hip p<>sture(e,xceptat L5-SI) as the psoas laminae attach to cad1 vertebra and follow thcdoang-
ing orientation of the spine. However, there is no doubt that the psoas is shommed with the
flexed hip, modulating force production. But the question whether there is a reductio11 in spiJle
load with the legs bent remains. In 1995 MeGill examined 12 yow1g men using tho: laboratOI)'
teclmique descril>ed pre,•iously cond observed no majo•· d.iffe,·ence in lumlxtr load as the •·esult
of bending- the knees (aver<1ge moment of 65 Nm in both straight and bent knees; compression
of 3230 N with s1r.1ight lc@! and .\410 N with bent knees; sbcar of 260 N with straight legs

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and 3()0 N wirh bent knees). Compressive loads in e.":es.< of 300() N certainly r:1ise quesrions of
safety. This type of quantitative. analysis is necessary to demonstrate that whether ro perfo rm
sit-ups using bent koecs or strajght legs is probably not as jmpormnt as wbether to prescribe
sir-ups at a II! Thet·e are better ways to challenge the abdomimtlmusdes.

Basic Issues in Low Back Exercise Prescription

Sevcn1J cx.c:rcis:es: nrc required to train all the 1nusdes of tht~ lumbar torso, but whi(:h exercises
are best for a given individual? Making this determjnation will depend 0 11 a number ofvariables,
such as rhe inclh~dual~ fimess leve.l, training goals~ hisror)' of previous spinal injury, ~mel orher
f.:1ttors. I (owcvcr, depending on the pur (>OSC of the cxcn.:isc prOf,rram, .several prindpJcs apply.
For examp le, an individual begin.niJtg a postinju•·y ptogram would oe advised to a•·oid loading
the spine Lhroughout the range of motion, while a trained athlete may indeed ach ieve hibrher
performance levels by doing so. Another general rule of dtwnb is tO prcscn•c the nonnal low back
curve (similar ro that of upright standing) or some variation of that min imizcs pai11.
VVh.ile in t b e past man~~ cllnicians have recommended perfom1ing a }}elvic tilt when exercising,
this is not justiJied; we now know cl1at the pelvic tilt increases spine tissue loading, as the spine is
no longer i 11 sratic-ehtscic equilibt·ium. Thus, the pelvic tilt apptars to be comraindic.1red when
challenging rhe spine. Basic issues you shoulrl consider when prescribing exercises for low hack
rehab a rc discussed in the foUowing sections.

Flexibility to train for optimi7..a tion of spine Oexibility depends on the person's injury history and
exercise goal. Generally, for the injured back, spine flexibiJjcy should nor be emphasized unci I the
~tpin(1 has s.t'.tbilizcd and has undergone endurance and str engcl1 conditioning-and some may
never reach this stage! Despite the notion held by some, d1ere are few quantitative dam to sup-
port the idea that ll major emphasis on mmk flexibility will imprm'e back hea lth an d lessen rhe
risk of injury. In fJct, some exercise prob'Tilms that have included loading of the torso throughout
the range of motion (iu nexion-e.xrension, lateral bend, or axial twist) have had neg:arive results
(e.g., Nachemson, 1992), :md greater spine mobil ity has heen associated with low h"ck rrouhle
in some cases (e.g.~ Biering-Sorensen~ J9S4). Further, research has shown that spine flexibility
bas ljttle predjct:ive value for future low back trouble (e.g., Sullivan, Shaof, and Ridd le, 2000).lu
the context of crying to stretch the back and train nexibiliry, the insightl\d work of Solomonow
and mlleagues (2002) bas shown that the stretch reflex is diminished and muscle spasms can
result. T he most successful progr:uns appear to emphasize trunk stabiJizati()n through exercise
with a neuD'al spine (e.g., Hides, Jull, and Richardson, 200 I; Saal and Saal, 1989; Kot•mantakis
et al., 2005) while stressing mobility at the hips ;md knees. (Bticlger, Orkin, and Henneberg,
L992, demonstrate advantages for sitting ;md standing, while McGill and Nonnan, L992, outlitJC
advamages for lifting.) Finally, removing lumb:u flexion li·om morning actil•ities substantially
in1proves l)arients, on average (Snook etal. J9Y8). Despite this evidence, many J>ariems are still

instructed to "pttll tbeir knees" to their chest in the rnorning and pcrfonn toe touches (sec fit;,ru.rc
I0. 13, n-c). The consequences of full flexion were desct~ibed in chapters 4 and 5.
For rhes.e reasons, torso flexibility exercises should be limited to tmJoadecl flexion and exrension
for those tQnccrncd with safety. Those in terested in spccifi(' athletic al'tivitit~ may somctirnes
be an exception to thh nde. (Of course, spille Llexibility may be more desirable atthleres who
have never suffered back injury.)

In general, .Strength secn'IS to have little to do with Uack hc:tlth even though in<:rc-Jsing torso
muscle strength is a popular obje<:tive of low back rehabilitation protocols. T his is not to imply
that srrengt:h is nor importanr. Rather it ism emphasize that the way d1e spin e moves is relatively
more imJX) rtan t in tc nns of spine health. Bac.:k n1usdc strength in parti<:uJar h~\.s no t Ucen fOund
to be a sig11ili.canr p•·edictor of 6rsr-time injury. (ln the conte'~ of cnuse and effect, predicting
first-time [njury oflers special insight.) Only lroup, !\llarrin, and Lloyd (198 1) found, while
testing torso musdcs, that rcducc.d dynanllc strength was a predictor of recurring back pain.

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b c
Figure 10.13 •Silly stretches: such as ra, b) pulling the knees to the chest and (c) toe touches,
are oflen presc•·ibed to i>alients to do in the morning. These can cause instabil ity! Paradoxically,
the stretch receptor> in Ihe back are stimul•ted, providing a false sense of relief that may laS! about
20 rninut~.

However, in a prospe<:tive snulj•, Leino et al. (1987) found tlm. neither isometric nor dynamic
mmkstrengtb predicted d1c development of low hack troubles over a I0-year follow-up period.
The 13iering-Sorcnsen ( 1984) study, previously noted, found that isometric back mength did not
predict the appe.rant-e of low hack rroublein pre~>iously healthy subject.• over a one-year follow-
up. Holmstrom ;md Moritz (l 992) recorded reduced isometric mmk extensor endurance times
in male workers with LBDs compared to thos.: wiLIJOut but found no differences in isometric
tle.'\:ion o r e.«tension stre ngths. Strength tlppears to have lin le. o r a-ver")' weak, re lariQnship wir,h
low back health. Strength is for athletic performance objectives. In t'Ontrast, mu.sde endurance,
when separated from srrength, appears to be linked with better back health.
.VIost recent data h;we suggested rhat while ha1•ing a histo•y ol'low hack troubles is not related
to reduced strength, it is related to a perturbed Acxion~to-extension strenhrth ratio (NlcGill et
al., 2003). This difference in cl>e nuio appeared to be ma.iJ>Iy influenced uy g1·eatcr extensor
strength rebrive to tlexor strength in those with trO\Jbles.

Two cross-sectional smdies, those of Nit'oh>isen and Jorgensen (1985) and Ab ram-a and col-
leagues (1994), found reduced extensor endurance in worker> who reported low ba.c k troubles.
Both Bierillg-Sorensen (1984) and Luoto and coUeagucs ( 1995) suggested that while ison>erric
strength w:as not associated with rl1e onset of b;~ck troubles, poor static back endul!ance scores
are. Some have e.\1)rcssetl concern that patients v.~ th poor muscle e ndurance scores have po()r
>eo•·es frolll a lack of effort (a psychological variable) ratlwr than any physiological limitation. A
st11dy by M~1mion and colleagues (2()() I) suggested rharofrhe total variance measured in the endur-
ance scores of their back patients, 40% was ~vlaine<l by physiologic-al f•tib'lle (quantified as declines
in the EMG power speetrw11), while only 10% was explained by psychologic~! variables (quantified
as motivation and fear of pain ""iables, from a questionnai•-e). Another study ~'VIcGill et al., 2()()3)
has suggested that hm>ing a hisro11' of low hack o·oubles appears tn he associated with a <tifferent
flexiOJ l~to-txtensiun endurance ratio, with the t:..'<tensors having Jess endurance and dJl' Bt:.xo.rshaving
more endtu-.mce. ' 11>is imbalance in endttr~nce also•ppeared between the right and left side laternl
muscu1antr·e as evidenced by rJ1e asymmetry in right and left endurance bolcling rimes (e.g.,
RSB/LSB t-atio of, 93 for those wirl1 an LBO history vs. (.05 fur cl10sc witllOut). Tlte ucxt issue

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addressed the question of "+tether strength a1td endurance are related. lnterestiJlgly, tlte flexor
strength (Nm)-to-endur:mce (sec) ratio was between 3 and 3.5 for the flexors in both "nonnal"
backs and i n those with a history o f troubles, and fo r the exten.~ors o f the norma-ls. The ratio
was much larger for the extensors (5.3, p = .033) in those with a history ofLBD.
In summa1y,seventl stt,dies havesnggested that diminished trunk extenso,· endurance and not
strength is linked to low back trouhles. Re<.-ent data confi rn1 d1is no rio11 and enhance it funher
by suggesting that the balance of enduntnte between flexor and e."cnsor muscles and the bal-
ance between right and left sides of the torso appear to be I inked to a history of back troubles
severe enough to result in work loss. Note that these were losses that Hngered long afi:er th e
disabling episode. ln those with a history of disabling LBD, tJ•c average length of ti1ne since the
last work loss episode was 261 weeks (standard deviation= 27 5), while the average length of time
lost from work in that episode WilS sm•en days (stJndard deviation • 1()). The lesson for exercise
prcstriptio n is that gratluatcdt progressive exercise programs (i.e., of longer c.Juracio n and lower
effort), which empbasize endw11nce, thus seem p•·efet'llble ove1· SO'engthening exer<.Oises.
Aerobic Exercise
i\1ounting evidence supporting the role of<~erobic exercise in botb reducing the incidence of low
back injur)' (Cady ct al., 1979) and treating low back patients (Jukcr ct al., 1998) is wwpelling.
Recent investigation into loads sustained by the low bachissues during wal.king (N'urrer, 1988)
confirms \'ery low levels of suppnrcing p<lssive tissue load coupl.ed with mild, but prolonged,
activation of the supporting musmlaturc. Callaghan, Poria, and McGill (1999) doclllnCntcu
that fast walking with the arms swinging results in lower oscill:.ning spioe loads. W hen
rolerable, -aerohic exercise particuh1rly fast walking, appears tO enhance rhe effects ofbac:k-

spcdfic exercise.

Order of Exercises Within a Session

Because the spine h~1s :l loading memO I'}~ 3 p1·ior ~crivity can rnodul;ne the bi_pmechanics of {he
~-pine in a suhset1uent activity. For e.xamp1e, if a person sat iu a slouched posrure for a period
of time sufficient to cau~ Ligmnentous and disc creep, she would bavc rcsidua!lig:anlcnt laxity
for a perio<.l of time. (\Ne have measured h>Xity of ove•· a half hour in some cases I.VlcGill and
Brown, 19Y2].) The nucleus volume appears to rerlisrribute upon adoption of a st;mc:ling posmre
(Krag ct al., 1987). This redistribution takes tunc. If d1c >pine is Ac::.,ed in one maneuver, tht:n
it p1'0bably should rentl1> to neurral or extension for the next.
\ftScosiry is another properry of biological cissues-in chis case a frictional resistance to
motion within the spine and rorso tissues. This: is: why motion exercises an· usually performed
first as l)art of a warm-up; once the viscous friction has
been reduccd suh.sequenr mo1ion cau he accomplished
Establishing Grooved Patterns 1

with I("SS stress.

We have iound that patients are best AJioaJconsideration is the tteed to continuallv groove
served when we establish 1he grooved healthy, joinr..conse1ving, and :-;rabilizing moror panems.
patterns for spine stability at the begin- Depending on t he cx~rcisc ohjtccives, we often beb>iu an
ning of the session. On the other hand. in exercise or u-ainiug session wllh some spine stabilization
a performan~-e-orienled !raining program, exercises to groove the pan:erns rhar will continue over
participanls move on to tor.;o slabilization to o cl1e.r exercises in the proc0onun. In sumnu 1-y1 u nder-
exercises at 1he end oi the session. standing spine bionlechanics can optimize t he ordering
of tasks in a training session.

Debare continues regarding training for breathing exe,·tion. Should one exhale or inhale
during a particular ph<1se of movement or exertion?
In the rare cases of very heavy lifting or lllaxi.maJ exertions (which would not 'be part of a
rehahilitar<on program), high levels of intra-abdomina l presstll'e (lAP) are produced by breath
holding using the Valsalva maneuver. T his elevated IAP, when comhined with high levels
of abdominal wall coconmction (bracing}, ensures spine stiffness and stabiljty during tl1<.'Sc
t!.<traordinary demands.

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Another u>otivation given for striving to achieve higl1er lAP is the need to reduce the trans-
mural grad ient in the cranium to lessen the risk of blackout or scrnke (McGill, SlwTatt, and
Seb'ttin, 1995). T he explanation for this risk reduction is as follows:
• BuiMing TAP isassociared with l rise in the central nervous S)'litem (CNS) tluid prt'J;sure
in the spine, which forms an open vessel to the CNS and brajn,
• Upon exe rtion, e normous elevation in blood p ressure occurs (documented in weight~
lifters to be well over 400 nun) Ig).
• TI1£s pressure in tl1e cranial vessels creates a large transmunll pressure gradicot that is
reduced if the CNS nuid pressure is likewise ebe.lted, redLJcing the load on the V11SCulat·

Altbouf,rh cibis explanation is vaJid, tbe ma·hanism shou)d be considered only for e:are.Lne weight-
liftiJ\g chall enge~not for rehabilitation exercise.
When designing rehabilitation exercise, a major objective is to esrahli~h spine srabiliMtion
patterns. A n impo rtant fearure of stable and functional backs is the ability to e<x.·omr.1ct th e
abdominal wall (abdomiMI brace) independently of any lw1g ventilation patterns. Good spine
st~lbilil.ers m;lint:.lin che critical symmetrical muscle stiffness du ring anycornbi nntion of torque
demands and hreatlung patterns (>-uch as when playing a hasketl>all g•me, for example}. Poor
stabilizers allow abdominal contraction levels to cycle
with breathing at c6 tical moments where stability is
needecl. Gr ooving muscular activation patterns so tha t
Breathe Freely
a particular direction in lung -air flow is entrained tO a Train to breathe freely while maintaining
particular parr of an exertion is not helpful. T llis would the stabilizing isometric abdominal wall
be of little c.m ynver value tn other actil~ries; in fact, it contractions.
v.rould be <.:ounterproduccivc.

Time of Day for Exercise

As pointed out in pat~ IT, tl1c intervertebral dis.:-s ru·c highly hydnned upon rising ITom bed; the
annulus is subjected to much higher stresses dllring bending under these condirjons, and the
end plates f:1il at lower co mpressive loacl'i as weJI. Thus, performing spine~bending maneuvers
at this dmc of day- is unwise. Yet many manual mcclicinc physicians continue to s uggest d'lat
patients perform their therapeutic ro\Lrjnes fi.rst thing in the morning. This appears io be due ro
convenience and ib"'orance. Because the discs generaUy lose 90% of the Huid thar they will lose
over the course of a day within cltc first hour after risin~ fi·om bed, we sughrcst si1nply avoiding
this period for exercise (that is, bending e.><ercise) for eid>er l'ehabilitatioo or performance train-
in g. \;vhile the-r e hasn't been ~ sntcl}' o n t he e nh ancements obtained during exercise routines as
a function of citnc. of day, Snook and toUCa!,'UCs (1998) did prove that the conscious avoidance
of lo rward spine ~ exion in tile mornjng impJ'o,,ed their patients' back trO\tbles.

Notes for Rehabili tation Exercise Prescription

Exercise profli!ssionals face the challenge of designing exercise programs that consi<ler a wide variety
of objectives. Consfdet these guidP,Iines:
• While some experts believe that exercise sessions should be performed at least three times
per week. low back exercises appear to be most beneficial when performed daily (e.g.,
Mayer el al., 1985).
• The no pain- no gain axiom (loes not apply when exercising the low back, particularly when
appliL'Cl lo weight training. Scientific and clinical wisdom would suggesl the opposile is 1rue.
• Research has shown that general exercise programs lhat combine card iovascular compo-
nents (such as v.'<Jiking) are more cff~ctive in both rt~habilitation and inj ury prevention (e.g.,
NuHer, 1988).

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• Diurn~l vari~tion in the fluid level of the intervertebr~l discs (discs are more hydratE!(! early in the
morning after rising from bed) changes the stresses on the disc throughout the day. People should not·
perform full-range spine motion under load ior 1 to 2 hours after rising from bed (e.g., Adams and
Dolan, 19,95).
• Low back exercises performed for health maintenance need not emphasize strength with high-lo.1d,
low-repetrtion tasks. Rather, more repetitions of less demanding exercises will .enhance endurance
and strength. There is no doubt that back injury can occur during seemingly low-level demands (such
as picking up a pencil) ~nd th~t injury from motor contro l error can occur. While the Chilnce of motor
control errors t, result in inappropriate muscle forces appears to increase with fatigue. evidence also
indicates that passive tissue loadi ng changes with fatiguing li~ing (e.g., Potvin and Norman. 1992).
Given that endurance has more protective value than strength (Luoto ct at., 1995), strength gains should
not be overemphasized at the expenseoi endurance.
• No set of exercises is ideal for all individuals. An appropriate exercise regimen should mnsider an
individual 's training objectives, be they rehabifitatioo, reducing the risk of injury, optimizing general
health and fitness, or maximizing athletic performance. While science cannot evaluate the optimal
exercises for each situation, the combination oi science and clinical experience will result in enhanced
low b.1ck he;~lth.
• Both patients and cl inicians should be patient and stick with the program. Increased iunction and
reduction in pain may not occur for three months (e.g., Manniche et al., 1988).

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Evaluating the Patient

irtually any manual medicine rexrbookdesc,·ibes the typic.1l rests for determining the range
V of motion (RONI). But of whar real importance isd1is information to d1e cHnician? These
numi:Jcrs ..-c more for the lcg:d determination of dis.1bility as defined by the American Medi-
cal Association than for aiding in the clinical decisio11 process. Son1e e1Toneously thinktbatall
patientS sh ould have ~'nom1al to otveragen RONl vahtes even though they probah ly were not
~'average" prior tO becoming- a patient. The tests discussed in this cltaptcr offer more useful
indicato,·s or >'arhology to assist you in n1aku1g treatment decisions.
Of t he St:\'eral de ficir.s in low back variables ideotified in earlier c hapters, many :ue t he direct
rtsuJt of injury. They iJKiudc aberrant lumhar motion patti'ms, pcrrurbcd motOr patterns of
muscle recrujunetn, atld aberrant joint motion v..·ich concomitant pajn <Uld loss of muscle endur-
ance. Unfommat.ely, testing for these deficits is not easy. The challenge is ro find t:he tests that can
btost identify the deficits and that arc reasonably safe and do not require cxpcn..;ivc or speciaJiz.ed
equipment. The tests that come closest to rneeti11g these criteria are described in this chapter,
along wirh guidelines for rests designed ro q11antify patient deficits. T he results 1vill form the
re habilitation objectives for th e patient, wgcther with dues for designing exercise. The chapter
also discusses how patients can help to define tbeir own rebabilimtion targets.

The Most Crucial Element in Evaluation

Before discussing any specific rests o r re.chniques, however, ir is vital t hat youtmder.stancl d1e
central dement in all diagnoses: your brain! [f your own observation and reasoning skills arc
11ot well developed, the best tests and d1e 11\0St advanced technology will be of little use to you
as the foll(>wing rext will .<how.
Geoff Maidand, the well-knOIIll Australian physical thera~ist, promoted the "hypoth<sis"
fonnulation approach to diagnosis-which is very similar to our own. Just as 3 detective must
pi~Ge tog~ther ~videnGe, a <;linidan nwst consider evidence li·om all .<<.mrce~, A~ e~ch piece i~
cousidcred, the hypothesis :is either srrCnJ,rthenccl or wt.-akem:d. However. unJike the situation
with a crime, tbe eKpert clinician is able to obtain a defUiitc history. even tl1ough 3 patient may
!)resent conflicting signs and disguised ch:u:>cteristics. This comple.xiry means no more th:m
that the patient has a complex presentation. Such patients may he fanhe r down t he deg-enerative
cascade of tissoe and nervous system change, or they may have some biological processes under
way rhat complicate the search. Biomechanical knowledge is critical for success in hypothesis
fonnarion. Usually, the overused tissues are the o nes involved in sympto m creation. The solution
often lies in changitlg the biomechauic~ to alleviate loa<ling of the painful tissues.
A keen "clinical eye" is a fcarnre of :1ll great clinici:ms. r oli:en tell the stOI)' of when l was
invired to a renowned spine center a nd part o f my course was to t·omlucr three examinations
u1 Ji-ont of the tenter's l 8 c~nkians. The clinicians included orthopods, neurologists, physical

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therapists, and so on. We went ro the

Interpreting Patient Presentation waiting room and were introduc(-d to
Form <> working hypothesis and continu<>lly the fifst pacienL The patient rose from
re~ssess 1he hyi)Othe$i$, doing the follow·
the chair and w<1lked to rhe large train·
ing: ing room that served as our exam room.
Tbertl asked the clinicians ro turn awov
1. Obrerve everything, stJrt ing with the from the patient and f.tce rhewall. I asked
person's sitling posture. rising from them to tell me alxmt the patient-and
the waiting room chair, standing. and not one of them cotdd answer. I said to
walking. them that thev all roiled.
2. !Elic it and record the history: Link 1 then described all that 1 had observed,
fnjury mechanisms .1nd p.iin mecha- beginning with the seated posture of tbe
nisms. p;uient, which was a fttii-Aexion, slumped
posture (tbis usually suggests flexion
J. ll'erlorm provocative tests: What loads,
intolcram:e). Rising from t hl! chair was
postureS and motions cxilccrbate;
initiated with more llexion and
what relieves? less hip extension. Then the bip~ rose,
4 . Perform functional screens and tests: i.ndit."ating typical hamstring dominance
Ate there perturbed postural. motion, fo,· hip extension and gluteal de6ciency in
and mo1or panerns? generating the hip exte nsor torque. The
spine extended last with spine c..xtensor
muscle accivation. This strengthened the working diagnostic hJ1lOthesis that wa; fanning in
m y head. The classic antalgic walking posnue was s.hown with <111ns swinging be n ding at Lhe
elbows insr.:ad of the shoulders. Then l observed the dassic standing posture with the weight
sbi(ted predominamly onro one leg.
Alter pointing our these feanu·es 1 'tared that my working diagnostic hyporhes;s was a disc
bulgt on the right po~lctior-lateral side of L4-L5. Further testing showed t his to be t'Orrett.
The other two patients included a stenotic individua l and one with a highly unstable spine
lumha r •'hi nge~ wirh overstiffness in the rhorac;ic region. Afrer oonducring the same qu~litttive
observations o n these two~ the din..icians undcr~tood what I meant when I said th:!lt their eyes.
and hattds were their best "scalll\ers." lnterestittgly, a few older clinicians stated that they had
forgotten their observacional skills beC<luse of access to high-tech medical imaging-- this was a
poignant reminder to rehone their observational and <lS.."it:ssment slci lls.

First Clinician- Patient Meeting

Each patient has limited capacity fOI' physical work. Cve•·y aspecr of therapeutic eJ<ercise must
be ju.nified; ochern·ise capacity is wasted. The objective is to deten11ine the capacity, determine
what is tolcra blc, dctcnncnc the deficits, and design the best therapy to roctify the short·
contings. HJ.a,~Jtg a road 1nap to follow will allow you to converge Otlthe f.·mest and most etliciem
journey to optimal hack health. FinaUy you should proceecl only alter you have screened yollr
patient for ::~11 "red flag" condition s. The following cheddist wiU help determine appropriate
rehabilitation exercise.
I. ltfemify tb< rehllbifjtntiou objective.< (specific health or perfomwuce objectives). The
spt.ocific rehabilitation ob.iective determines rhe act.-eprahle benefit r:n:io. A ]>erformance
objective carries higher risk. Since the p1inciples of bodybuilding and arhJecic training art: so
perv,tsive, you need to be sure th;tt all patients understaJ\d the difference between a thletk per-
fonnance o bjectives ancl rhose for J)3in reduction and improved daily function. Genemlly, direct
aU effo rt'i toward pain e limination prior to an ); trairUng for perfonnance (such as strenbTth or
spine motion).
2. Cons-itl~r patient age and genrrfll condition. Younger parient"i rend to have m ore disco~
genic trOubles (from cl1C teens tO the fifth decade), whilcarcl1ritic spines tend to Jx.-gin developing
after 45 yeat-s aud srenoric conditions after that. Note how patients walk ;~od sit. A•·e they i.n
notice;.lhly poor conclition, either emaciated with little muscle mass or heavy ancl loose with fat

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rather thau muscle? It is also asswned that patients have bt.'en medically screened a11d cleared
for <.-a ,·diovascubr concerns, or any red nag <:onditions such as n unoi"S.
3. ui<mtif.r occupllli"" aud lifr•tyle detaiLf. Generally, you should he1,>in by documenting
patients' daily routim:.s: when and how they rise from and retire to bed, mea] routines, ami C.X('t-
cise a11d rec1·eational habits. Then direct specific focus toward areas of concern. Fo•· example, if
the patient reports watching 'IV fur 2 hours in the evening, ask for details on tbe type of chair,
rang:t of po~·turcs used, and so on. After gathering information about the patient's daily routines,
inquire about occupational demands. All of t.his iJJfonnation, when added ro the cliJJical pre-
sem:a tion, will help you evaluare common Jinks. Discogenic rroubles are linked wirh prolonged
sircing (particularly prolonged driving) and repeated tOrso flexion. A passive or inactive lifestyle
is also associated wid1 disc U'Oubles. Arthritic conditions, fucet troubles. and the like are u•ore
linked \\rith johs and activities that involve large r:mges of motion and higher loadiing. Former
athletes such as soccer players also fuJI into this cate&rury, aJthough long-distance runners do
not since they do not, preswnably, take tl1e spi11e to the end ROM.
4. Co11sider tbt 111tduuris·m ofiujmy. Attempts to re-create injury mechanisms arc fruitful
on ly when the real mecha nisms are understood. These were de1<1iled in chapters 4 and 5. Once
identified. the mechanisms can he linked with specific tissue damage (much of which is other-
wis.: not diagnosable). Not only will this assist in dcsi&o•u•g the therapeu tic exercise, but it will
also help in teachillg patients to avoid loading scenarios that c-otild exacerbate the damage and
syrnpmms. Note thar some of these wiU have acute onset~ while others slowly. Slow
onset may r('Sult in some patients' being- unable to identi fy the mcdtauism of injury. Neverthe-
less, n "cul<ninating event" is usually involved. CareftJ questioning about events leading up to
chat event 'Nill provide clues a~ ro the mechanisms of injury.
5. Htwt lbt Jllllietlt dcsaibt rbt ptrreivtll exacerblllors of paiu mtd sympllrtJtS. l'rompr
the patient to desCJ·ihe the tasks, posrures, and movements that exacerbate the pain. Examine
these reported tasks from a biomc-ehanical pcrspecti,·e to detcnn inc which tissues are loaded or
irritated. 'l nese tissues should be sp<>red in the e.'ercise therapy, and the e.x<>cerbaring movement.<
miui.mize<J .
6. Huve the putitmt describe the type ofpain, its lncation, wbether it is radiating, anti spe-
cific tlerouttomes anti 11I)'Otames. Description of the type of pain is sometimes helpfuJ; patit~nts
n1ay describe their pain as deepaJJd boring, scrntchy, sizzling, at a f)()int, general over t.he back
re0>ion, continnall)' cha nging, and so on. You may need ro help some people de~crihe their
pain by offering adjectives tO choose from. In chapters 4 and 5 I de.scribed the li·nk between
pa in types and specific tissues and syndromes. Keep in mind t.hat cbangi11g symptoms over
the shorr ~ime of au examination gener:·llly suggest more fibromyalgic syndromes:, which c:m
sometimt:S be resistive to exercise therapies-particularly ones that cause:: pain. The jssue here is
that pain-li·ee motion must be li:>u nd a11d repeated, slowly expanding the repertoire of pain-G·ce
7. Take tltrmntome.rattd111)1QlQtJtes int() ncrotmt. \Vith 1-adiati.ngS)'lllptoms. the derm:nomes
and myotomes can assist in understanding the involved segrnental levels and whether the pain
originates from a specific nerve root. For example, direct pressure on the root <.:ould indicate a
unilateral d isc bulge or end-plate n·acrure that would cause a loss iJl disc height together with a
loss of root onder foramen size. ln this way rhe spinal level can he linked wirh the dermatome or
myOtOJnt: but oot the acruaJ tissue damage. Further, nen•c root prl'>Ssurcc.-an occur at a specific
spinal level on the outlet nerve, COJlSistent with a dennutome or fnyomme, or on the tra,•ers-
ing nerve from above if chere is pressure on the cauda eqnina centr<llly. Thus denna1omes and
m). Otomes art! another consideration whc.n fomting- an opinion from the consistdu'y obralned
from. seve~] Lests that C(ltl include medic;ll imaging, provocative tests, and so forth.
8. Pe-rfor7u pnn.:()Cative te:.TS. You have already obsern~d the patient sir.. rise fTorn a chair,
stand, and wa lk. You have <1 working diagnostic hypothesis. Once you suspect that specific tissues
are damaged or sensitive, you t-an loacl them tOsee ifloading produces pain. This is provocative
testing. Many patients have more complt.l. presentations, with scvcr~tl tissues involved. Nonethe-
less, t:be provocative p1'0cedure still indicates which postul'es, motions, and loads cause pain and
thusshoulrl be avo.ided when designing the therapeutic e.:\!ercise. Generally~ patients' de.scriprion..~

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of the activities they find exacerbating of their pain (item ; on tltis list) will guide your deci-
sion ;.ls to which specific rissoes ro lo:.H.i and stress. For example, lumb(I J' e~tension wir.h a twist
can provo ke the facets, while the antelior shear test may he warranted for suspected insr:ahiUry
(sllOwn in tbe next few pages).
9. Peiform functiotutl sa-eens. 'TO detennine whether a patient is moving in a spine·
l'Onscrviog- and efficient way, fuuetion-al StTCCOS are used. ]n addition, fun<.:tional SLTCCns arc
used w indic;~te the suitability of a specific exercise or as a qualifying test pl'ior to esercise
pre:;crlptio n.

Some Provocation Tests

Provocative tes-ting is intended to identify tfu.• poStUres, motions~ and loa(b that cause discom-
fort or pain. They are used to guide the design of pain-free dterapeutic exercise and avoidance
strategies to l'emove the caose. T he following list compl'ises some rha( we have -designed 0 1·
quanti fied (or both). Since they may mimic the mechanism nf injury, it is up to d1e clinkian
\•,..orking wlth the patient to set the intensity so cl1at