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Journal of Back and Musculoskeletal Rehabilitation 16 (2002) 105115 IOS Press

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The role of therapeutic exercise in treating instability-related lumbar spine pain: A systematic review
Joshua Cleland a, , Connie Schulteb and Chris Durallc
a

The Physical Therapy Center of Milford, Milford, NH, USA HealthSouth, Kansas City, MO, USA c Physical Therapy Department, Creighton University, Omaha, NE, USA
b

Abstract. Study design: A systematic review of clinical trials. Objective: To determine the effectiveness of therapeutic exercise in the treatment of instability-related lumbar spine pain. Background: Segmental instability of the lumbar spine contributes to the overwhelming incidence of back pain and disability. The extensive range of exercises proposed to treat segmental instability is indicative of the lack of agreement as to the most efcacious management approach. Methods: A search of MEDLINE (1966- April 2002), the Cumulative Index of Nursing and Allied Health Literature (CINAHL) (1982- April 2002) databases was performed. The searches were restricted to articles that used human subjects and were published in English. Key words utilized for searches included, lumbar stability, segmental instability of the lumbar spine, spinal stability, low back exercises, and treatment of lumbar instability. The aforementioned key words were combined with clinical trial in an attempt to locate studies that were primary sources and included original data. Results: The clinical trials analyzed varied considerably in the type of therapeutic exercise evaluated. However, it has been demonstrated that therapeutic exercise can be benecial in reducing pain and improving function in patients presenting with instability-related lumbar spine pain. Conclusion: Although the reviewed clinical trials have demonstrated the effectiveness of therapeutic exercise in ameliorating pain and disability, the variations in methodologies of the studies reviewed makes it difcult to speculate which specic exercises would be the most benecial. Keywords: Segmental instability, lumbar stabilization, therapeutic exercise

1. Introduction It has been estimated that 80% of the population will suffer low back pain at some point during their lives [36]. While the cause of low back pain is often multi-factorial, many authors have suggested that instability of the lumbar vertebral segments can result in pain [11,12,25,38,39,42,43]. Instability of the vertebral segments, or excessive vertebral motion beyond
Address for correspondence: Joshua Cleland, PO Box 611, Wilton, NH 03086, USA. E-mail: jcleland@mcttelecom.com.

normal physiological limits, may damage neural tissue, ligaments/joint capsules, annular bers, and/or vertebral end plates [40,41, 47]. Stability of the spine is predicated on the integrity of both static and dynamic elements. The static skeletal structures (i.e. ligaments, discs, vertebrae) alone are incapable of providing sufcient spinal stabilization during most activities [5,9]. Indeed the static skeletal structures would buckle under their own weight without sufcient muscular tension [6]. Stabilization of the lumbar spine is thought to occur as a result of two mechanisms; antagonistic spinal muscle co-activation

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Fig. 1. Complex interaction of stiffening structures along the spine and torso. Reprinted from McGill SM and Cholewicki J, Biomechanical basis for stability: an explanation to enhance clinical utility, Journal of Orthopaedic & Sports Physical Therapy, 2001, 31(2), 96100, with permission of the Orthopaedic and Sports Sections of the American Physical Therapy Association.

and increased intra-abdominal pressure [5,8,13,14,18, 51]. Muscle activation is required to increase the stiffness and stability of the lumbar spine in both of these mechanisms. In the former mechanism, spinal stabilization is achieved through the complex interaction of agonist/antagonist spinal muscles (Fig. 1). For example, co-activation of the trunk exor and extensor muscles would logically stiffen the spine in the sagittal plane (i.e. reduce the amplitude of spinal exion and extension movement). In the latter mechanism, spinal stabilization is achieved via increased hydrostatic pressure within the abdominal cavity. During contraction of the deep muscles of the abdominal cavity (diaphragm, transverses abdominus, obliques, pelvic oor muscles), the intra-abdominal pressure increases, potentially helping to constrain spinal movement in all directions by increasing the force per unit area (i.e. pressure) on the spinal segments [7,8,13,14]. Since both mechanisms rely on muscle activation, it becomes clear that therapeutic exercise is a reasonable intervention in cases of instability-related low back pain. However there is a prerequisite need to determine how inadequate recruitment and/or force-production of these individual muscles or muscle groups can be accurately and reliably identied and quantied. In this

review, we have attempted to explain the theoretical underpinnings and experimental research relative to both mechanisms. We hope to impress upon the reader that despite the common use of exercise in the treatment of instability-related low back pain, there is no consensus on which exercises are most efcacious. There is evidence suggesting that therapeutic exercise is effective in the treatment of (non-specic) back pain [15, 24]. Unfortunately the data from many of these studies cannot be extrapolated to make inferences about the efcacy of various treatments for instability-related low back pain in the interest of formulating evidence-based practice recommendations. In an attempt to develop sensible treatment recommendations for instability-related low back pain, we systematically reviewed outcomes data from the few studies that have been conducted and examined the anatomical and biomechanical evidence related to spinal stability. This information was used to examine the validity of the antagonistic spinal muscle co-activation model and the increased intra-abdominal pressure model. It was our hope that this information could be used to formulate a list of evidence-based exercises to improve the recruitment and tension-generating capacity of the spinal stabilizing muscles while imparting minimal compressive or shear forces to the pas-

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sive vertebral elements. That is to say, we hoped to formulate a list of exercises that would seem sensible to employ in the treatment of instability-related low back pain. Details of the literature search process and the results of our systematic review are included in the paragraphs that follow. A thorough understanding of dynamic spinal stability is essential to ensure that clinicians apply both anatomical and biomechanical principles when developing therapeutic exercise regimens for a patient population.

2.3. Data abstraction All articles were abstracted for study design, testing method, population, and results by the rst author (J.C.) and conrmed by the second author (C.S.).

3. Results Eighty-three abstracts from our search strategy were reviewed for assessment of inclusion criteria. Of the 83 articles that were reviewed, 34 of these articles were omitted because they investigated the effects of therapeutic exercise on non-specic acute or chronic low back pain. Eighteen more were eliminated from this review because they investigated the effects of therapeutic exercises on a diagnosis other than lumbar instability. A further 14 articles were eliminated because they were investigating post surgical effects of therapeutic exercise. Ten more were omitted because they investigated the effects of therapeutic exercise on non-symptomatic individuals. The remaining 7 articles fullled the inclusion criteria [28,34,35,37,39,48,49]. Four of the 7 investigations were randomized control trials [34,37,39,49], two were prospective [28,35] and the remaining article was a retrospective study [48]. The selected articles, study design, study population, testing methods, length of follow-up and results are summarized in the Evidence Table (Table 1).

2. Methods 2.1. Search strategy A search of MEDLINE (1966- April 2002), the Cumulative Index of Nursing and Allied Health Literature (CINAHL) (1982- April 2002) databases was performed. The searches were restricted to articles that used human subjects and were published in English. Key words utilized for searches included, lumbar stability, segmental instability of the lumbar spine, spinal stability, low back exercises, and treatment of lumbar instability. The aforementioned key words were combined with clinical trial in an attempt to locate studies that were primary sources and included original data. Subsequently the abstracts were briey reviewed to determine if the article contained the results of original research or the results of a clinical review. All reference lists from the articles and critical reviews obtained from the search were hand-searched for other relevant publications [29]. 2.2. Inclusion criteria and assessment of study quality To be included, each study had to contain original data collection relative to lumbar spinal stability/stabilization. Each study was assessed for: Study design Participant population characteristics (segmental lumbar instability) Method of segmental instability diagnosis Randomization Blinding of the assessor and/or participant Number of subjects in the study Test characteristics-validity (sensitivity, specicity), and predictive value Reproducibility-inter- and intra-rater reliability

4. Discussion Based upon the evidence from the systematically selected and reviewed articles it is speculated that therapeutic exercise can be benecial in reducing pain and improving function and motor control in individuals presenting with lumbar instability. However, no studies directly investigated the effects of the intra-abdominal pressure mechanisms of lumbar spine stabilization to the muscle co-activation mechanisms. Therefore, there is insufcient evidence to conclude with absolute certainty which theoretical mechanism of lumbar stabilization would be most benecial in the management of patients with segmental lumbar instability. Perhaps a combination of the two mechanisms could best serve to maximize functional stability. Consequently it is essential that ongoing scientic scrutiny of both theoretical mechanisms continue. However, based upon the ndings of our review, the evidence demonstrates that a number of therapeutic exercises may be bene-

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J. Cleland et al. / The role of therapeutic exercise in treating instability-related lumbar spine pain Table 1 Selected clinical trials examining the effectiveness of therapeutic exercise in the treatment of lumbar segmental instability

Study Study design Subjects Methods of diagnosis Treatment

Moller and OSullivan et al. Hedlund 2000 1998 Prospective Randomized prospective study 9 111 Radiographs and clinical assessment 2.54 weeks of stretching, coordination exercise, and abdominal and extensor strengthening Radiographs

OSullivan et al. 1997 Randomized control trial 44 Radiographs and clinical presentation 10 weeks of specic training of deep abdominals and multidi (n = 22) vs. treatment by general practitioner (n = 22)

Nelson et al. Lindgren et al. Soratt et al. Sinaki et al. 1995 1993 1992 1989 Randomized con- Retrospective Randomized Prospective trol trial control trial 42 48 56 19 Radiographs and clinical presentation 10 weeks of strengthening of the deep abdominals and multidi (n = 21) vs. general exercise including walking and swimming (n=21) Radiographs Radiographs Not stated

Posterolateral fusion (n = 77) vs. back and abdominal strengthening (n = 34)

Group receiving exion exercises (n = 29) vs. group receiving extension exercises (n = 19)

Length of follow-up Results

47 months No change in radiographic ndings, signicant improvement in EMG nding of multidus

2 years Fusion group demonstrated a signicant reduction in the Disability rating index and pain. Exercise group demonstrated no reduction in disability and only minor reduction in pain.

30 months Specic exercise group demonstrated a signicant reduction in pain and improvement in function p < 0.0001

10 weeks Exercise group demonstrated a signicant increase (p < 0.05) in the ratio of activation of internal obliques relative to rectus abdominus. Control group showed no signicant changes.

3 years 19% of patient in exion group still exhibited moderate to severe pain and 24% were still unable to work. 67% of the patients in the extension group demonstrated severe pain and 61% were still unable to work.

Group receiving exion exercises and exion bracing vs. group receiving extension exercises and extension bracing vs. control group 1 month Visual analog scale signicantly improved in the extension group when compared to the exion group.

Mechanical extension and abdominal exercises

1 year 75% of patients reported excellent or good response dened as substantial improvement in pain relief.

cial in ameliorating the movement dysfunction associated with lumbar segmental instability. A summary of each theoretical mechanism is outlined in the following paragraphs. Specic muscles that contribute to each mechanism will be separately listed with evidence based therapeutic exercises approaches. 4.1. Intra-abdominal pressure mechanism of lumbar spine stabilization Since the abdominal cavity has a nite volume, the intra-abdominal pressure (force/area) will increase if the abdominal cavity volume is reduced. For example, diaphragmatic contraction during inhalation exerts an inferior force on the abdominal contents and reduces the abdominal volume. Likewise, contraction of the muscles in the pelvic oor of the abdominal cavity (levator ani, coccygeus, etc.), imparts a superior force on the abdominal contents, reducing the abdominal cavity volume. The abdominal cavity volume is

also reduced (and therefore intra-abdominal pressure increased) when a constrictive corset is worn. Some of the abdominal muscles (e.g. transversus abdominus) act as muscular corsets by constricting the abdominal contents when they contract, and therefore are capable of increasing the intra-abdominal pressure [8,14,18]. As the intra-abdominal pressure increases, the threedimensional force per unit area exerted on the spine increases, potentially constraining spinal movement in all directions [30]. In addition, the increase in intraabdominal pressure is thought to provide a mild distractive force to the spinal segments, due to separation of the pelvic oor and diaphragm (Fig. 2) [7,8,18,32]. It is purported that this mechanism of stability is preferable in tasks that demand trunk extensor moments, such as lifting because this mechanism can increase spine stability without cocontraction of the erector spinae; reducing compressive loading of the lumbar spine [31].

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Fig. 2. Isometric horizontal side support.

4.2. Muscle co-activation mechanism of lumbar spine stabilization Numerous investigators have reported that adequate muscle stiffness (via muscle activation) is essential for lumbar spine stability. Garner-Morse et al. [12] utilized a modeling approach to demonstrate that stability of the lumbar spine is reduced by softening (10% reduction in stiffness of elastic components) of the motion segments without adequate muscle activation. Since the generation of muscle tension is dependent on both neural (e.g. recruitment) and physiological (e.g. cross sectional area) factors, stability of the spinal segments is dependent on appropriate muscle recruitment and sufcient tension-generating capacity. Failure to generate sufcient muscular tension, as a result of inappropriate muscle recruitment and/or insufcient tensiongenerating capacity may result in excessive vertebral motion and structural damage. Attenuation or degeneration of the passive stabilizing structures could conceivably occur as a consequence of insufcient muscle force production and consequently result in greater instability. Experimental evidence suggests that both the large/ long multi-segmental supercial muscles and the small/short deep inter-segmental muscles are important for spinal stability, albeit for different reasons [5,12, 19,33,4042]. The supercial muscle groups that span multiple vertebral segments (e.g. longissimus, iliocostalis, spinalis) generate large internal torques due to

their relatively large cross-sectional areas and relatively long moment arms. These muscles, therefore, appear to function as prime movers. Although the spinal muscles have been likened to guy wires [30], this comparison seems most tting for these supercial muscles. The short inter-segmental muscles (e.g. intertransversarii, rotatores, interspinalis), in contrast, seem more aptly suited for ne-tuning vertebral arthrokinematics and providing proprioceptive feedback. The inter-segmental muscles are located closer to the vertebral centers of rotation conceivably enabling them to produce subtle changes in spinal alignment [42]. It is just as likely, however, that these muscles function primarily as spinal position sensors by virtue of their rich supply of spindles [2,11]. In an effort to elucidate the muscular contribution to lumbar spine stabilization, we have included a discussion of the role of individual muscles. Understanding the contributions of these muscles to lumbar spine stabilization lays the foundation for sensible exercise prescription. 4.2.1. Transversus abdominus There has been a lot of interest lately in the contribution of the transversus abdominus to lumbar spine stabilization [19,2124]. Since the mid-portion of the transversus abdominus attaches to the middle layer of the thoracolumbar fascia, contraction of the transversus abdominus has been thought to increase spinal stability via tensioning of the thoracolumbar fascia. Some

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authors have proposed that intra-abdominal pressure will increase as a result of thoracolumbar fascial tensioning [4,10,19]. Others have suggested that an increase in thoracolumbar fascial tension will produce a mild stabilizing compressive force on the lumbar vertebrae [1,3]. Mean contraction time (i.e. endurance) of the transversus abdominus has been found to be lower during isometric holding tasks in individuals with low back pain [10].

4.2.5. Internal and external obliques Anatomically the TrA, internal and external obliques are the three muscles of the ventro-lateral abdominal wall which have the greatest potential to increase IAP [8]. Although the TrA plays a greater role than the obliques in lumbar stabilization, researchers have suggested that the internal obliques and to a lesser extent the external obliques may contribute to the production of intra-abdominal pressure and thus stability of the spine [21]. 4.2.6. Erector spinae The erector spinae muscles (logissimus thoracis pars thoracis, iliocostalis lumborum pars thoracis, longissimus thoracis pars lumborum, iliocostalis lumborum pars lumborum), theoretically contribute to stability of the lumbar spine by providing compressive forces along the spine that stabilize the spinal curvatures [1]. The longissimus and iliocostalis muscles may also reduce anterior shear forces that occur during trunk exion [31]. 4.2.7. Multidus Cholewicki and McGill [6], via mathematical modeling, determined that the inter-segmental muscles (multidus) are capable of making large contributions to spinal stability with very slight increases in muscle tension. Wilke et al. [51] concluded that the multidus is responsible for two-thirds of the stiffness of the lumbar spine. Hides et al. [17] found reductions in ipsilateral multidus cross sectional area (CSA) in patients with unilateral low back pain and speculates that this may be a direct result of reex inhibition. This loss of multidus cross-sectional area was shown to persist after remission of low back pain [16]. Isolated multidus strengthening has been shown to restore the muscle size (CSA) at the segmental level of the dysfunction. 4.2.8. Intertransversarii and interspinalis, rotatores As mentioned previously, the inter-segmental intertransversarii and interspinalis muscles are thought to provide feedback on spinal position and movements [2, 11], and potentially to produce subtle changes in spinal alignment [42]. Through the application of intersegmental muscle (rotatores, multidi, interspinalis) forces applied to cadaver functional spinal units, it was demonstrated that the neutral zone was decreased during both exion and extension loading. The intersegmental nature of the deep muscles of the back give a tremendous advantage to the neuromuscular control system for ne tuning the stability of the spine [42].

4.2.2. Pelvic oor musculature Contraction of the pelvic oor musculature results in elevation of the abdominal contents and increased intraabdominal pressure [44]. Since the pelvic oor musculature and the pelvic visceral fascia are contiguous with the thoracolumbar fascia [45], contraction of the pelvic oor musculature may also increase the tension in the thoracolumbar fascia.

4.2.3. Respiratory diaphragm As indicated earlier, the respiratory diaphragm contributes to spinal stability by assisting with intraabdominal pressurization. Hodges and colleagues [20] suggest that the increase in intra-abdominal pressure via diaphragmatic activity allows the transverses abdominus to increase tension in the thoracolumbar fascia.

4.2.4. Rectus abdominus The rectus abdominus appears to contribute very little to lumbar spine stabilization. It may serve a benecial role by helping to stabilize the lumbar spine in the sagittal plane, however its main role appears to be tourque-production during trunk exion [30,36,39,50]. Several authors have delineated between upper and lower abdominal function. Sarti and colleagues [46] reported that upper trunk exion (e.g. curl-up) resulted in preferential EMG activity in the upper bers of the rectus abdominus while lower trunk exion (e.g. posterior pelvic tilt) resulted in preferential EMG activity in the lower rectus abdominus bers. In contrast, Lehman and McGill [27] were unable to detect differences in EMG activity between the upper and lower abdominals during a curl-up, an abdominal muscle lift, a leg raise, an isometric leg raise, and an isometric curl up.

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4.2.9. Quadratus lumborum The quadratus lumborum is an important, yet often under-appreciated lateral lumbar spine stabilizer. Activity in the quadratus appears to be an important stabilizer of the lumbar spine due to its demonstrated increase in activity during heavy lifting (50100 kgs) and upright holding activities (2040 kg) [33].

4.3. Exercise recommendations for instability-related low back pain The effectiveness of any exercise program intended to improve segmental stability of the lumbar spine is predicated on appropriate muscle recruitment and timing. Therapists should seek to improve the neuromuscular control of the muscles inherent to active lumbar stabilization, rather than simply increasing the tensiongenerating capacity (i.e. cross-sectional area) of these muscles. Improving the recruitment and timing of the spinal stabilizing muscles can dramatically increase stability. For example, a 13% increase in muscle tension in the deep inter-segmental muscles could increase the stiffness of a motion segment by 300500% [6]. Several investigators have proposed that motor control patterns between synergistic spinal muscles are altered in patients with idiopathic chronic low back pain [10,16,17,26,47]. As a result the larger multisegmental muscles tend to substitute or dominate over the impaired inter-segmental muscles. In such an instance the inter-segmental muscles would lose their ability to make minute arthrokinematic adjustments and their ability to provide proprioceptive feedback. Experimental evidence to support the hypothesis of intersegmental muscle impairment is unavailable. Nonetheless, restoration or maintenance of the inter-segmental muscles capacity to detect and ne-tune spinal movement should be considered in any spinal rehabilitation exercise regimen. Although much controversy continues to exist in regards to the most effective exercise regimen, evidence obtained from the current literature suggests that exercise may be benecial to optimize the neuromuscular control and tension-generating capacity of the muscles that contribute to segmental stability of the lumbar spine. Discussion of some of the more common therapeutic exercises intended to improve lumbar spine segmental stability follows.

4.3.1. Prone unilateral hip extension Unilateral hip extension performed in prone was shown to effectively challenge the erector spinae while imposing relatively low compressive loads on the spinal segments [32]. Other exercises commonly utilized to strengthen the erector spinae group (quadruped leg extension with contralateral arm raising, simultaneously upper body and leg extension in prone, and trunk extension from a exed position with the patient cantilevered over the edge of the table) impose high compressive loads on the lumbar spine and therefore could be deleterious for patients with instability [32]. 4.3.2. Curl-ups Curl-ups with the feet unxed have been shown to impart minimal load on the spine (1,991 N) [32]. The rectus abdominus is the prime mover during this exercise, but some activity also occurs in the oblique and transversus abdominus muscles [50]. Performing curlups on a labile surface increases the neuromuscular challenge to all of the abdominal muscles, particularly the external obliques [50]. 4.3.3. Pelvic tilt The pelvic tilt maneuver has been demonstrated to increase the level of EMG activity of the upper and lower rectus abdominus, obliques and multidus [44]. However, this pelvic tilt maneuver should entail the patient obtaining a neutral (neither hyperlordotic or hypolordotic) spine posture, which will minimize the forces on the spine and thereby reduce the chance of injury [32]. 4.3.4. Isometric horizontal side support The isometric horizontal side support [11] challenges the lateral obliques and quadratus lumborum with low lumbar compressive force [32]. The exercise is performed in a side-lying position by supporting the upper body on the ipsilateral elbow or hand then lifting the pelvis off the support surface to eliminate the sidebending (Fig. 2). 4.3.5. Abdominal drawing-in maneuver Drawing the abdomen posteriorly and superiorly is purported to facilitate transversus abdominus muscle activation [38]. This drawing-in maneuver can be performed in any position without concomitant spinal movement but may be easiest to learn in supine or quadruped. Richardson and colleagues [44] recommend initially performing the exercise in quadruped since the transversus will be passively stretched and therefore its activation will be more readily perceived. The drawing-in maneuver is also thought to facilitate activation of the multidus [1].

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4.3.6. Isolated multidus contraction Like the drawing-in maneuver, recruitment of the multidus has been suggested by Richardson et al. [44]. Re-education of the multidus should begin in the prone position with the clinician palpating the multidus at each segmental level. The patient is asked to Gently swell out your muscles underneath my ngers without moving your spine or pelvis. Palpation is crucial in determining the appropriate muscle response. If a rapid and supercial contraction is felt this indicates contraction of the erector spinae.

4.4. The efcacy of therapeutic exercise in the treatment of lumbar spinal instability In clinical practice there is an ongoing need to develop treatment regimens based upon scientic evidence. It is crucial for clinicians to continually evaluate the literature and apply evolving concepts and theories into daily practice. The results of this systematic review identify the evidence to support not only the effectiveness of therapeutic exercise in the treatment of lumbar segmental instability but also specic muscles utilized to achieve dynamic stability of the lumbar spine. The results of our systematic review revealed that therapeutic exercise has been shown to be benecial in ameliorating pain and improving function [28, 35,39,48,49]. Therapeutic exercise has been shown to be effective in the treatment of chronic low back pain with concomitant spondylolysis or spondylolisthesis [28,35,37, 39,48,49]. Although Lindgren et al. [28] did not nd any radiographic improvements in 9 subjects with segmental dysfunction, following a treatment regimen focusing on strengthen of the abdominals and multidi, evidence of a signicant increase in EMG activity of the multidus was observed. A randomized control trial by OSullivan et al. [37] demonstrated that in 42 patients with chronic low back pain training of the deep abdominals (transversus abdominus, internal oblique) was possible without co-activation of the rectus abdominus utilizing the abdominal drawing in maneuver. A study by OSullivan et al. [39], evaluating an exercise approach in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis demonstrated that a specic exercise treatment approach was more effective than general conservative treatment. Patients that received specic exercises maintained reduction in pain intensity and functional disability levels at a 30-month follow up. Sinaki et al. [48] demonstrated that individuals with spondylolisthesis who performed specic trunk exion exercises (abdominal strengthening, pelvic tilt) resulted in a signicant improvement in the patients pain and ability to work. An investigation by Nelson et al. [35] revealed that in 19 patients with spondylolisthesis 75% reported an excellent or good response (substantial improvement in pain relief) after an average of 18 sessions of trunk extensor and abdominal retraining. In further support of utilizing therapeutic exercise in the treatment of lumbar instability a randomized controlled trial by Spratt et al. [49] revealed that exion exercises demonstrated a signicant improvement over both a control group and a group that performed Mckenzie extension exercises.

4.3.7. Diaphragmatic activation As the respiratory diaphragm contributes to spinal stability via increased intra-abdominal pressure, the ability to isometrically contract the diaphragm may assist with stability during extreme spinal loading [18]. This requires momentary breath holding to sustain an elevated intra-abdominal pressure and so should be reserved for instances when maximal stabilization is required. Patients with cardiovascular impairment (especially hypertension) should be cautioned not to utilize this stabilizing strategy, as it will result in a reexive rise in blood pressure.

4.3.8. Pelvic oor volitional contraction The pelvic oor muscles, like the respiratory diaphragm, assist with spine stability by increasing intraabdominal pressure. These muscles can be facilitated by voluntary contraction of the anal sphincter (levator ani), resulting in superior movement of the pelvic oor. The transverse abdominus co-activates with the pelvic oor [44] so concomitant contraction of the transversus may be palpated during contraction of the pelvic oor muscles. Since the success of dynamic spinal stabilization depends on neuromuscular control, therapeutic exercises should be performed slowly (10-second contractions) with strict attention to movement quality. Resistance should be kept to a minimum initially to avoid muscle substitution. Once recruitment of the spinal stabilizing muscles has been achieved, the muscles should be progressively challenged to sustain activation during functional movements and activities of daily living. This could be accomplished by increasing the resistive lever arm by increasing the length of the extremities [38].

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4.5. Limitations of our systematic review A diligent effort has been put forth to identify all possible studies that investigated the efcacy of therapeutic exercise on patients with lumbar instability. However, it is possible that relevant trials could have been missed. In addition any new trials that may have recently been published may also not be included in this study. The possibility for bias exists since the reviewers of the articles were not blinded to the author or institution where the study was performed. Finally we only searched for clinical trials published in English and in two databases. It is certainly plausible that high quality articles could be indexed under other databases or perhaps published in other languages.

5. Conclusion Lumbar stability is dependent on two mechanisms, intra-abdominal pressurization and muscular coactivation. Adequate muscular recruitment and timing are prerequisite for the successful stabilizing effect of both mechanisms. Muscles that appear to play a signicant role in these mechanisms are: transversus abdominus, internal and external obliques, rectus abdominus, multidus, quadratus lumborum, erector spinae, respiratory diaphragm, and the muscles of the pelvic oor. A lack of standardization of treatment approaches has resulted in the development of numerous exercise protocols purported to effectively manage lumbar spinal segmental instability. While it is not clear which exercises are most efcacious, it is clear that the focus of the exercises should be on facilitating quality and timely movements and enhancing muscular endurance. While the muscles involved in lumbar spine stabilization must have adequate tension-generating capacity, the critical component to their successful functioning as stabilizers is appropriate neuromuscular control. Adequate neuromuscular control will enable the stabilizing muscles to modulate imposed de-stabilizing external loads.

4.6. Recommendations for future research Despite the common use of therapeutic exercise in the treatment of instability-related low back pain, little evidence is available on the extent to which exercises contribute to the reduction of pain and disability. Clinical trails of various exercise regimens on symptomatic individuals could help determine the extent to which specic exercises or exercise protocols can increase segmental stiffness and functional capacity and decrease symptoms in a symptomatic population. More research is needed to elucidate exactly the extent to which intra-abdominal pressurization and muscular co-activation affect spinal stability. In addition, there is a need to determine 1) how inadequate recruitment and/or force-production in individual muscles or muscle groups can be accurately and reliably identied and quantied, and 2) how best to ameliorate identied weakness via therapeutic exercise. In addition, studies of the safety of trunk exor and extensor exercises are yet to be performed on individuals with lumbar instability. It is hypothesized that trunk exor and extensor exercises can greatly increase the shear force placed upon the lumbar spine and may further jeopardize the health of the patient. A logical follow-up to this review would be a discussion or investigation of the motor control contributions to spinal stability. Successful spinal stabilization, after all, depends on both sufcient tension-generating capacity and nervous system input to recruit the appropriate muscles at the appropriate time.

Acknowledgment This article was written to fulll coursework requirements for the Transitional Doctor of Physical Therapy Program at Creighton University.

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