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KEYWORDS
! Spine ! Rehabilitation ! Core exercises ! Radiculopathy
The prevalence of lumbosacral radiculopathy has been reported to range from 9.9% to
25%.1 Lumbosacral radiculopathy may arise from a multitude of insults to the spinal
nerve as it exits the lumbar spine. The classic description of radiculopathy is compro-
mise of a spinal nerve with resultant pain, weakness, and/or sensory impairment in the
distribution of the affected nerve root. This condition may be from direct trauma or
from chemical irritation to the affected nerve root. Regardless of the underlying cause,
injuries to the lumbar spine have been shown to adversely affect the core musculature
and spinal stability.2 In theory, prolonged injury and pain lead to pain avoidance
patterns, which can result in core muscle atrophy, loss of spine flexibility, and altered
biomechanics of the spine. These conditions can significantly delay healing or even
predispose to secondary injuries. This article reviews current concepts regarding
core stability and rehabilitation in the setting of lumbosacral radiculopathy.
OVERVIEW
Core strengthening is widely used for both injury prevention and rehabilitation of the
lumbar spine. The muscular core has been described as a box encasing the lumbar
spine with the diaphragm on top, pelvic floor on bottom, abdominals anteriorly, and
paraspinal and gluteal muscles postreiorly.3 Core musculature is required for the spine
to move freely throughout its entire range of motion, and it also serves as a functional
center of the kinetic chain by connecting the upper and lower extremities. The muscles
of the pelvic girdle and shoulder, such as the hip abductors and scapular stabilizers,
also contribute to core stability through connections to the spine and must not be
overlooked in rehabilitation program design. Panjabi4 first described a model for spinal
stability that consists of 3 components: the bone and ligamentous structures, the
muscles surrounding the spine, and the neural input controlling the spine. The bone
and ligamentous structures are thought to offer primarily passive stiffness, whereas
the core musculature provides for stability through the full range of motion. Neural
input allows for specific muscle activation patterns in both planned and unplanned
movements. Low-back pain (LBP) has been shown to cause muscle atrophy and
altered neural control of the spine musculature.5 In theory, these effects lead to altered
spine biomechanics and thus progression of the degenerative spine cascade.6
Strengthening and activation of the core musculature are fundamental in the rehabil-
itation of spine injuries. Several studies have indicated the importance of a few
muscles (transversus abdominis [TA] and the lumbar multifidi)3,7; however, as noted
earlier, evaluation of the kinetic chain and activation of larger muscles are also impor-
tant in the restoration of normal function and should be addressed in a comprehensive
core stabilization program.
Along with the multifidi, the TA has received attention in its stabilizing role in back
pain. The TA runs in a hooplike fashion around the abdomen and attaches broadly
to the thoracolumbar fascia.2 In healthy individuals, the deep fibers of the multifidi
and the TA are the first fibers to activate when a limb is moved in response to visual
stimulus, firing independently of limb movement direction to control intervertebral
movement.11 In addition to stabilizing the core in preparation for limb movement,
the TA has also been shown to increase the stiffness of the lumbar spine and the
sacroiliac joints when activated.7 The multifidi and TA are found to atrophy in people
with LBP, and there is evidence that the TA becomes dysfunctional in the setting of
LBP.2,3 Laasonen12 studied postoperative patients with unilateral LBP and found
that paraspinals were 10% to 30% smaller on the affected side when compared
with the unaffected side. In patients with LBP and functional inactivity, biopsy results
show selective type 2 atrophy of the multifidi and structural changes in type I fibers.5,13
Antigravity postural muscles have been shown to atrophy to a greater extent than
lower extremity muscles in microgravity simulation models.14
These changes in muscle composition in healthy individuals who stopped normal
repetitive low-level activity patterns are thought to result in transformation of the
muscle toward a more fatigable type of muscle fiber.14,15 All these studies suggest
that these muscles are selectively vulnerable to atrophy and dysfunction in the setting
of back pain. However, there is some evidence that with exercise training multifidi
atrophy can be reversed.16,17
The diaphragm and pelvic floor have also been shown to affect the lumbar spine.
McGill and colleagues23 showed that ventilatory challenges may cause diaphragmatic
dysfunction and thus lead to increased compressive loads on the lumbar spine. It has
also been demonstrated that patients with sacroiliac joint pain have impaired recruit-
ment in both the diaphragm and pelvic floor.24
Discussion of the key core muscles is not complete without special attention paid to
the thoracolumbar fascia and its associated musculature. This broad multilayered
fascial sheath acts as an anchor for multiple muscles and allows for the distribution
of kinetic chain forces from the lower to the upper extremities. Caudally it blends
with the fascia of the gluteus maximus; cranially its attachments to the latissimus dorsi
emphasize the importance of broadening the scope of the rehabilitation treatment
plan to include functionally engaging tasks with the upper and lower extremities. In
addition, this fascial sheath is also crucial to recall the role of the hip musculature.
The hips transfer forces from the lower extremity to the spine during upright activities.
Poor endurance in the hip extensors (gluteus maximus) and abductors (gluteus
medius) has been noted in people with LBP.25,26 There has been a demonstrated
association of hip extensor strength and subsequent occurrence of LBP in athletes
tested in preparticipation physical examination. Asymmetries in hip extensor strength
have also been found in female athletes with LBP.2729
Spinal Flexibility
Correction of spinal inflexibilities in addition to muscular imbalances has been advo-
cated as an important component of rehabilitation of the spine. However, evidence
is limited regarding the role of spine flexibility and injuries in the setting of lumbosacral
radiculopathy. In addition, review of the literature yields conflicting reports as to the
role of spine flexibility and range of motion in the treatment of spine injuries.
Several recent studies have suggested that there is no correlation between spinal
flexibility and disability or function. Kuukkanen and Malkia30 suggested that in individ-
uals with less severe back pain, flexibility did not play a role in the individuals overall
functional ability. Similarly, a study by Sullivan and colleagues31 suggested that active
lumbar spine flexion should not be used as a treatment goal. Kujala and colleagues32
looked at a 3-year longitudinal study in which specifically targeted training showed no
increase in maximal lumbar extension in adolescent athletes. Moreover, the investiga-
tors suggested that aggressive attempts to increase lumbar flexibility could cause
unnecessary stress to structures such as the intervertebral disks or the pars
interarticularis.
In contrast, other studies have suggested that specific programs can help improve
spinal flexibility. Magnusson and colleagues33 studied a group of patients with chronic
LBP and suggested that increased trunk motion could be achieved by participation in
a 2-week full-time rehabilitation program. The investigators noted that patients initially
demonstrated a pain avoidance behavior but were able to achieve the confidence to
recover despite their pain.33 Kibler and Chandler34 observed a specific conditioning
program that effectively increased the lumbar flexibility in 51 tennis players. Kujala
and colleagues32 also looked at lumbar flexibility and associated LBP between male
and female athletes and controls. The investigators found that although no differences
were observed between male athletes and controls, the female athletes (gymnasts
and figure skaters) had increased overall and lower lumbar range of motion. In addi-
tion, decreased lumbar range of motion and decreased maximal extension were
predictive of increased LBP in women. Despite the conflicting data regarding the
effect of spinal flexibility programs on recovery, it seems reasonable to focus on
specific areas of deficits.
Core Stabilization in Lumbosacral Radiculopathy 95
Table 1
General principles for spinal rehabilitation
Phases Goals
I. Initial phase: pain control Antiinflammatory medication
Physical modalities
Peripheral or axial injections
Activity modification
II. Restorative phase: correcting flexibility Mobilization of soft tissue
and strength deficits Stretching exercises to improve trunk and
extremity flexibility
Strengthening exercises to improve cervical,
scapulothoracic, or lumbar stability
Maintenance of cardiovascular fitness
III. Integrative phase: functional Normalization of spine mechanics
adaptations Progression toward functional activities
IV. Final phase: maintenance Pain free
Preinjury range of motion and strength
a 2-point stance. For the higher-level patient, a physioball can be incorporated into the
routine (Fig. 3). In addition, it is imperative to develop core training in the 3 cardinal
planes: sagittal, frontal, and transverse (Fig. 4). Research shows that neuromuscular
control can be enhanced through combinations of joint stability (cocontraction) exer-
cises, balance training, perturbation (proprioceptive) training, polymeric (jump) exer-
cises, and sports-specific skill training. This can be achieved through a combination
of exercises that challenge proprioception via wobble boards, roller boards, and phys-
ioballs (Figs. 5 and 6).40
Deficits in any of these planes of motion can be assessed by physical examination.
The multidirectional reach test, the star-excursion balance test (multidirectional excur-
sion assessment in all cardinal planes), and the single leg squat test have all been
validated for the assessment of transverse and rotational movements.41,42 Results
from these tests help direct the core training program, focusing on an individuals
weaknesses.
Progressive resistance strengthening of the lumbar extensors may be unsafe. The
risk of lumbar injury is greatly increased (1) when the spine is fully flexed and (2)
when it undergoes excessive repetitive torsion.43 For example, both the Roman chair
and back extensor machines require loads that can be injurious to the lumbar spine.22
Traditional sit-ups and pelvic tilts also increase compression loads on the lumbar
spine and therefore may be unsafe.
Fig. 4. Triplanar exercise with weights using forward lunge and rotation. (Caution should be
taken with advancing to this exercise.)
Efficacy of Exercises
Despite widespread acceptance of a multitude of spine stabilization exercises (ie,
Williams flexion exercises), there has been limited study of the utility of these programs
in the management of lumbosacral radiculopathy. Various studies have looked at the
effect of a treatment exercise program on anatomic changes in spinal muscles. Hides
and colleagues2 assessed the recovery of lumbar multifidi muscles after treatment
with an exercise program consisting of isometric contractions of these muscles with
cocontraction of the abdominal muscles compared with medical treatment only for
individuals after a nonradicular acute lumbar spine injury. The investigators reported
Core Stabilization in Lumbosacral Radiculopathy 99
improved muscle symmetry and a more rapid and complete recovery of the multifidi
muscles in the exercise group. Sung44 studied the endurance of multifidi muscles
and functional status of patients with chronic LBP after participation in a 4-week spinal
stabilization program. The investigators noted changes in the multifidi strength in
conjunction with other spinal extensor muscles but were unable to attribute the
improvement to the multisided muscle alone.
Danneels and colleagues45 analyzed the effect of 3 different 10-week exercise
training programs on the cross-sectional area of the paravertebral muscles in
Fig. 6. Medicine ball and core stabilization exercise with proprioceptive balance.
100 Kennedy & Noh
individuals with chronic lumbar spine pain. The investigators suggested that a lumbar
stabilization program combined with dynamic resistance training was necessary to
restore the size of the paravertebral muscles. These studies suggest that anatomic
improvement of the lumbar multifidi muscles could occur through a structured lumbar
exercise program.
Other studies have attempted to assess the functional efficacy of a structured
strengthening exercise program in individuals with chronic lumbar spine pain.
However, there are few prospective, randomized studies. In a prospective study,
Kaser and colleagues46 assessed functional improvement in the spine for 3 active
exercise treatments (active physical therapy, muscle reconditioning on devices, and
low-impact aerobics) over a 3-month period for individuals with chronic lower-back
pain. The investigators concluded that significant gains in muscle performance were
observed in all 3 exercise groups as noted by a similar increase in isometric strength
in all lumbar planar movements, increased activation of the erector spinae during
extension testing, and increased endurance testing.46 Similarly, OSullivan and
colleagues47 compared a treatment group using strengthening of the deep abdominal
muscles with coactivation of the lumbar multifidi with a control group in individuals
with chronic LBP and spondylolisthesis. At 30 months, the treatment group showed
a significant improvement in pain, function, range of motion, and abdominal muscle
recruitment.47
There is a paucity of scientific data with respect to core strengthening as a means to
prevent injury. Nadler and colleagues27 prospectively studied the incidence of LBP in
college athletes over 2 seasons. The athletes had a certified strength and conditioning
coach implement a core conditioning program into their training regimens before the
second season. The male athletes showed a trend but no statistical improvements in
LBP occurrence with the implementation of core conditioning. Women showed a non-
statistically significant increase in LBP after core training was implemented. This
increase in LBP occurred despite measurable increases in hip girdle strength.
These aforementioned studies suggest that a structured strengthening program
may be efficacious in the management of spine injuries. Indeed, many of todays spinal
rehabilitation programs incorporate control and strengthening of these core muscles
of the spine.48 In the lumbar spine, the program should focus on strength training of
the deep intrinsic spinal muscles, such as the lumbar multifidi, with cocontraction of
the abdominal muscles. However, more comprehensive, randomized, prospective
studies are needed to better assess the efficacy of spinal strengthening exercises in
injury treatment and prevention.
SUMMARY
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