In the past many physical therapists have mistakenly believed that strength is the key to lumbar spine stability. We now know that motor control coordination is actually the key to stability. F. Kermode (who performs research on the deep stabilizing muscles using real-time ultrasound imaging at a physiotherapy clinic in Western Australia) reports that typical back exercise programs, like gym-based rehabilitation program, pool therapy, and Pilates are too advanced for low back pain patients prior to retaining the tonic holding capacity and isolated co-contraction of local muscles, including segmental lumbar multifidus and transversus abdominis.

Evidence (from peer-viewed medical journals, not the anecdotal kind that most PTs embrace here in the USA) suggests that TrA is dysfunctional in all back pain subjects independent of the type or nature of pathology, while subjects who have never had significant back pain do not have this dysfunction (Hodges and Richardson 1996). The dysfunction is related to motor control deficits not strength. Evidence has shown motor control dysfunction in TrA does not return to normal without specific exercise.

Motor control deficits of TrA may include: 1. Failure of a separate low load strategy for TrA control by CNS, 2. Increased recruitment threshold for TrA, 3. Recruitment of TrA becomes dependent upon direction of loading force (similar to global muscles), 4. Onset of TrA recruitment is delayed during limb or trunk movement (as seen during EMG testing studies) when compared to healthy individuals (TrA usually contracts prior to the prime mover of a limb), and 5. Phasic activation of TrA (just thickens the muscle) instead of a tonic TrA contraction that pulls laterally on the medial abdominal fascia to produce a corseting action.

Specific back exercises that focus on deep stabilizing muscles have proven to reverse motor control deficits that occur after back injury or degenerative change. The most significant finding thus far is that patients who receive physical therapy, but do not retrain their deep stabilizing muscles are 12.4 times more likely to have recurrence of back pain within 3 years.

In order to retrain transversus abdominis (TrA), patients are initially instructed to isolate and maintain a tonic contraction separate from the global muscles (e.g., abdominal obliques, rectus abdominis, and erector spinae). This is artificial since TrA contracts along with the global muscles during normal functional activities. But, it is necessary to train this isolated tonic contraction because the central nervous system controls TrA independently of the global muscles in individuals who have never experience back pain. But in dysfunction, this independent control is lost. Therefore, we must reprogram this separate motor control strategy for optimal lumbopelvic stabilization.

Abdominal ‘hollowing’ is a non-functional task that is used to isolate & retrain the mechanical action of TrA pulling on the fascial corset which produces stiffness between individual segments of lumbar spine and pelvis.

This protocol of isolation, training tonic holding ability, training co-contraction of the local muscles, and then integration with global muscles and into functional activities is an effective means of retraining the coordinated function of the local system (Hides et al 1996, 2001, O’Sulivan et al 1997, Richardson et al 1999).” (Diane Lee, The Pelvic Girdle, 2004)

Prognosis and Expected Treatment Times
Acute, first-episode low back pain. The prognosis is good for patients who receive training after first-episode lower back pain. In fact, people who receive no retraining of deep stabilizing muscles are 12.4 times more likely to have recurrence of back pain within 3 years. Those without previous history of lower back pain who present with acute lower back pain needed only 4 weeks of training for a 70% chance of no recurrence.

Chronic, recurrent low back pain. Another study was performed on people with chronic lower back pain (onset of LBP was at least 3 months prior to the study) with a radiologic diagnosis of Wikipedia reference-linkspondylolisthesis or spondylolysis. They received 10 weeks of training with statistically significant positive results. Specific back exercise training resulted in a decrease in pain intensity and disability. (The control group had no significant change.)

More info at: www.Back-Exercises.com