What is Lumbar Stabilization?
Spinal stability refers to the spine’s ability to keep its shape and structure under normal bodily stress. It was suggested in the 1990s by Manohar Panjabi that spinal stability is maintained through the combined work of three linked systems:
1. The passive system, including the spine bones, disk joints, capsules of the facet joints, and spinal ligaments.
2. The active system, which is made up of the muscles surrounding the spine.
3. The neutral system, which is the bridge of communication between the passive and active systems.
In a healthy spine, these three systems work together so that the spine can move normally without pain. If the passive system (bones, disks, ligaments, and joints) is put under pressure, the active system (muscles) spring into action to prevent the spine from being deformed. If you were to take away the muscles, leaving just the bones, discs and ligaments, under a light load of around 20 pounds (9 kg), the spine would buckle or fold under pressure.
The neural system, which helps control everything, gets signals from both the passive and active systems. This system then tells the spinal muscles what to do in order to protect the spine from injury and to allow for the movement you want.
However, if the active system can’t maintain the structure between different parts of the passive system when the spine is under normal stress, this can result in back pain. This is often described as clinical instability, which is when the spine moves abnormally when under normal stress. If the three systems interact properly and maintain stability in a healthy state, any injury or wear and tear to the passive system means the active system (muscles) needs to work harder to make up for the decreased support from the passive system (bones, discs, ligaments, and joints).
What Causes Lumbar Stabilization?
Your spine’s flexibility can be divided into two main zones: the neutral zone and the elastic zone. Simply put, the neutral zone is where your spine moves normally and freely. Towards the end of your spine’s range of motion, the elastic zone begins, where moving the spine feels stiffer and needs more effort.
Lumbar stability, or the stability of the lower part of your spine, is the ability to keep the spine in this neutral zone during everyday activities, without causing nerve issues, significant changes in shape, or severe pain.
It is your muscles that help keep your spine stable in the neutral zone. Here, both the strength of your muscles and their ability to endure exertion for an extended period, are equally important. If your muscles are weaker or can’t endure as long, you might experience lower back pain. Surprisingly, aspects such as the curvature of your lower back, the tilt of your pelvis, and differences in leg length, don’t seem to be as critical as the strength and endurance of your muscles. There’s even evidence suggesting that weak muscles can lead to instability in your spine and cause back pain, even if there’s no structural damage.
Keeping the spine in the neutral zone helps to prevent injury. You’re more likely to get injured in the elastic zone or when bending your spine to its limits. Even powerlifters, who frequently bend their spine to lift heavy weights, keep their individual spinal bones (or segments) safe by avoiding flexing them fully and keeping them within the neutral zone.
If you’re experiencing chronic lower back pain, a standard treatment involves exercises and retraining to increase the strength and endurance of your muscles to provide better stability. These exercises also help you learn the right sequence of muscle activation. Surgery is considered in rare cases, only when such non-surgical treatments are unable to stabilize your lower back.
Risk Factors and Frequency for Lumbar Stabilization
Research spanning 165 studies in 54 countries revealed that around 18.3% of individuals experience low back pain at any given point, and around 30.8% will experience it over the course of one month. Women are commonly affected more than men. Low back pain is most common between the ages of 40 and 69. Wealthier countries have a higher prevalence (30.3%) compared to middle-income (21.4%) and low-income countries (18.2%). The prevalence of low back pain is similar in both urban and rural areas.
Low back pain is the main reason for years spent living with disability in both developed and undeveloped countries. Research that included data from 28 countries demonstrated that even children are affected by low back pain, with an increased prevalence as they age. 27.4% of 11-year-olds experience low back pain, and this percentage rises to 46.7% among 15-year-olds.
It is important to note that low back pain has a significant economic impact due to the cost of treatment and the productivity lost due to the condition. However, measuring the precise cost of back pain is challenging. In the United States in 1996, two different studies estimated the indirect cost of back pain at $18.5 billion and $28.2 billion respectively. By 2005, these costs had risen to $102 billion.
Signs and Symptoms of Lumbar Stabilization
When diagnosing a patient for possible back pain or spinal issues, doctors rely on a thorough history and an examination. During the history portion, doctors document the details of the pain through a method called SOCRATES, which stands for Sight, Onset, Characteristics, Radiation, Associated factors, Timing, Exacerbating factors, and Severity. They also look for certain red flags which may indicate a more serious condition. Red flags include things like:
- Pain starting after the age of 50 or under 20
- Pain that doesn’t improve with rest
- Pain that wakes you up at night
- History of cancer
- Unexplained weight loss
- Fever
- Trauma
- Drug abuse
- Use of steroids or immuno-suppressants
- Numbness in the pelvic area
- Bladder problems
- Problems with walking
The examination part of the assessment includes checking gait, range of motion, looking for tenderness, neurological examinations, and performing special tests like straight leg raising. These examinations help identify severe disorders and radiculopathy and myelopathy, but they can often miss weaknesses in the stabilizing systems of the spine. Physicians should also include other tests to evaluate the endurance and stability of the patient’s spinal muscles, these tests may include:
- Aberrant movement on flexion-extension test
- Passive lumbar extension test
- Prone instability test
- Sorensen test
- Prone isometric chest raise
- Prone double straight leg raise
- Supine static chest raise
- Supine double straight leg raise
- Flexor endurance test
- Prone Plank/Bridge test
- Supine Bridge test
- Side Plank/Bridge test
These tests evaluate different aspects of spine health, including endurance, strength, stability, and flexibility. All professionals involved in diagnosing and treating spinal disorders should understand and be able to perform these tests.
Testing for Lumbar Stabilization
Segmental instability can be seen in certain x-rays known as dynamic radiographs. Experts like White and Punjabi believe that certain measurements on these x-rays can indicate this instability. As an example, the following measures may suggest segmental instability: a shift, or ‘sagittal plane translation’, of over 4.5 mm, or more than 15% of the width of the vertebral body, or a rotation in the sagittal plane over 15 degrees at specific points in your spine (L1/L2, L2/L3, or L3/L4) or over 20 degrees at L4/L5, or more than 25 degrees at L5/S1.
Ultrasounds can reveal that the multifidus muscle, an important muscle in your back, may become smaller in patients dealing with lower back pain. Similarly, a CT scan (computed tomography) can draw a connection between fatty changes in the multifidus muscle and the presence of low back pain. An MRI (magnetic resonance imaging) can also show the curious link between low back pain and a decrease in the multifidus muscle’s size.
Treatment Options for Lumbar Stabilization
Physical exercises have turned out to be an important way of treating and preventing back pain. It seems that if our back muscles are weak, this can lead to back pain, even if there isn’t any other damage or wear and tear present. It was found in a study involving teenagers aged 14 to 16 with hardly any spine wear and tear, that those with weak lower back muscles were more likely to suffer back pain.
So, how can this be tackled? There are several types of exercises that can help reduce back pain such as stretching, strengthening, endurance and aerobic fitness exercises, walking, yoga, pilates and motor control exercises. Each of these activities can ease back pain, but current research does not show that one type is superior to the others.
This article focuses on motor control exercises which aim to regain stability and control of the spine, things that people with low back pain might have lost.
To understand this, it helps to know a bit about our back muscles. We have certain muscles called paraspinal muscles which control the stiffness and movements between our vertebrae (the bones making up our spine). Among these muscles, the deeper, smaller ones are activated first when we move an arm or a leg. This is because our limbs can only move properly if our torso is stable. Therefore, the coordination of our spinal and abdominal muscles is required before we move our limbs. If these deep muscles fail to function properly, the larger muscles jump in to assist. However, this can lead to issues in the control of our muscles and result in increased pressure on parts of our spine, which in turn can cause pain.
So, motor control exercises are all about teaching those deep muscles to react first before the larger muscles kick in. This is done through a Motor control exercise (MCE) program, which consists of three stages.
In the first stage, these deep back muscles are activated by a technique known as an abdominal drawing-in maneuver (ADIM), which is done while maintaining normal breathing. The aim of this stage is to perform this movement in four different positions (sitting, standing, lying down on the back and on all fours), in sets of 30 repetitions.
The goal should be met within the first two weeks, at which point the second stage begins. The second stage is about pushing further by placing more weight on the trunk of the body while performing the ADIM. This could involve a range of exercises, like heel slides while lying down or planks. This stage should carry on from the second to the fourth week.
From the fifth week, the patient can move on to the third stage, which involves performing everyday movements like sitting up, standing or squatting. These exercises are further detailed with images in sources such as Rabin et al.
Research suggests that rehabilitation can improve the ability of patients with low back pain to respond to sudden balance issues. It also helps increase the size of the essential back muscles which in turn reduces the chances of recurring and long-term back pain. However, evidence for the effectiveness of MCE in reducing chronic low back pain compared with minimal intervention varies from very low to moderate.
What else can Lumbar Stabilization be?
: Doctors may consider a variety of conditions when trying to understand the cause of severe back pain. These could include:
- Aortic aneurysm, which is a bulge in a major blood vessel called the aorta
- Epidural abscess, an accumulation of pus around the spine
- Spondylodiscitis, inflammation of the spine
- Compression fracture, a break in one of the bones of the spine
- Spondyloarthropathy, diseases involving the joints of the spine
- Certain types of cancer
- Disc prolapse causing radiculopathy, a slipped disc causing pain to radiate along the nerve
- Spinal canal stenosis, narrowing of the spinal canal
- Cauda equina syndrome, a serious condition where the nerves at the base of the spine are compressed.
The doctors use your medical history, physical examinations, and tests to help identify the cause of the back pain.
Non-specific low back pain is a term used when doctors can’t find a specific cause for the pain. This is actually quite common, with more than 90% of people going to their doctors with back pain not finding a clear cause. Other causes, including bone fractures, spinal stenosis, inner organ diseases, cancer and infections, are less prevalent.
What to expect with Lumbar Stabilization
Most people with lower back pain get better quickly. However, for some, the pain can become chronic and continue for a long time. A systematic review, which included almost 5000 patients from 24 different studies, showed that patients with acute (or short-term) pain improved significantly. The pain was initially rated at 52 on a scale of 0 to 100 and declined to 23 after six weeks, 12 after 26 weeks, and just 6 after 52 weeks.
However, the groups of patients who dealt with persistent pain only saw their pain levels drop to 23 after 52 weeks. Factors that were linked to a poorer outlook included older age, poor overall health, mental or emotional distress, poor relationships, physically demanding work, poor functional disability at the start, sciatica (pain affecting the back, hip, and outer side of the leg), and ongoing legal or compensation cases.
Possible Complications When Diagnosed with Lumbar Stabilization
The fact that chronic conditions don’t seem to get better, even with medical intervention can be quite concerning. Despite a significant increase in spending on treatments such as epidural steroid injections (rising by 629%), opioids (rising by 423%), MRI scans (rising by 307%), and spinal fusion surgery (rising by 220%), the outcomes for patients don’t seem to improve.
It’s important to note that,
- Overprescribing opioid painkillers can lead to death.
- Surgery is often suggested for chronic lower back pain. However, evidence has shown that surgery isn’t better than non-surgical treatments for this kind of pain.
Preventing Lumbar Stabilization
It’s important for patients to know that most of the time, low back pain isn’t harmful and usually goes away on its own. Being overly fearful and avoiding activities can actually be harmful, so there’s no need to stay in bed and avoid all activity. It’s crucial to keep moving instead, because staying still for too long can lead to weaker muscles.
Healthcare professionals can have a significant impact on patients. They should use their interactions with patients to help improve their attitudes and beliefs about their condition, and encourage them not to be fearful or inactive. It’s all about finding a balance that helps you manage your pain while still staying active and healthy.
