Role of Lumbar Stabilization Exercise and Spinal Manipulation

in Low back pain

Dr PICHET YIEMSIRI

Lumbar Stabilization Exercise

Static stability Dynamic stability

Stable of the back

Spinal stability

The stabilizing system of the Spine

Panjabi MM

J Spinal Disord 19925(4)390ndash6

Control

SubsystemNervous

Passive

SubsystemLigamentampBone

Active

SubsystemMuscle

Exercises in low back pain management

bull Exercise is one of the few clearly effective

treatments for chronic pain (evidence-based)

bull It improves body function activity and overall health

bull Systematic review located a limited number of

head-to-head comparisons of various exercise

program

Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain

bull Conclusions

Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP

Lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP

The Core Concept

29 pairs of muscle

A cylinder of deep muscles surround the spine providing stability

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Lumbar Stabilization Exercise

Static stability Dynamic stability

Stable of the back

Spinal stability

The stabilizing system of the Spine

Panjabi MM

J Spinal Disord 19925(4)390ndash6

Control

SubsystemNervous

Passive

SubsystemLigamentampBone

Active

SubsystemMuscle

Exercises in low back pain management

bull Exercise is one of the few clearly effective

treatments for chronic pain (evidence-based)

bull It improves body function activity and overall health

bull Systematic review located a limited number of

head-to-head comparisons of various exercise

program

Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain

bull Conclusions

Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP

Lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP

The Core Concept

29 pairs of muscle

A cylinder of deep muscles surround the spine providing stability

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Static stability Dynamic stability

Stable of the back

Spinal stability

The stabilizing system of the Spine

Panjabi MM

J Spinal Disord 19925(4)390ndash6

Control

SubsystemNervous

Passive

SubsystemLigamentampBone

Active

SubsystemMuscle

Exercises in low back pain management

bull Exercise is one of the few clearly effective

treatments for chronic pain (evidence-based)

bull It improves body function activity and overall health

bull Systematic review located a limited number of

head-to-head comparisons of various exercise

program

Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain

bull Conclusions

Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP

Lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP

The Core Concept

29 pairs of muscle

A cylinder of deep muscles surround the spine providing stability

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

The stabilizing system of the Spine

Panjabi MM

J Spinal Disord 19925(4)390ndash6

Control

SubsystemNervous

Passive

SubsystemLigamentampBone

Active

SubsystemMuscle

Exercises in low back pain management

bull Exercise is one of the few clearly effective

treatments for chronic pain (evidence-based)

bull It improves body function activity and overall health

bull Systematic review located a limited number of

head-to-head comparisons of various exercise

program

Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain

bull Conclusions

Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP

Lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP

The Core Concept

29 pairs of muscle

A cylinder of deep muscles surround the spine providing stability

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Exercises in low back pain management

bull Exercise is one of the few clearly effective

treatments for chronic pain (evidence-based)

bull It improves body function activity and overall health

bull Systematic review located a limited number of

head-to-head comparisons of various exercise

program

Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain

bull Conclusions

Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP

Lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP

The Core Concept

29 pairs of muscle

A cylinder of deep muscles surround the spine providing stability

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients With Chronic Low Back Pain

bull Conclusions

Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP

Lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP

The Core Concept

29 pairs of muscle

A cylinder of deep muscles surround the spine providing stability

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

The Core Concept

29 pairs of muscle

A cylinder of deep muscles surround the spine providing stability

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

The Core Concept

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Core Muscles

Global muscle system (fast-twitch) Superficial layer long with large level arms produce large amount of torque and gross movements transfer and balance load between thoracic spine and pelvis

Key global muscles Erector spinae external oblique rectus

abdominis and quadratus lumborum

Local muscle system (slow-twitch) Deep shorter controlling inter-segmental motion and responding to changes in posture and extrinsic loads maintain force control within the spinal structures

Key local muscles Transversus abdominis multifidi internal

oblique deep transversospinals and pelvic floor

Bergmark A Stability of the lumbar spine A study in mechanical engineering

Acta Orthop Scand Suppl 19892301ndash54

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Normal Co-Contraction

bull Healthy patients

ndash Transversus Abd amp Multifiduscontract 30 ms before shoulder movement and

110 ms before legs movement

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Gluteal amnesiabull Major motor deficit

bull Loss of gluteal strength and size

bull Erector spinae hamstring dominance when lifting and rising from a chair

McGill S Low Lack Disorders Evidence-Based Prevention and Rehabilitation 2nd Edition

Champaign Human Kinetics 2007110-112

Good gluteal for GOOD BACK

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Primary Core Stabilizer

MultifidusTransverse Abdominis (TrA)

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Transverse Abdominis

bull Origin inner surface of cartilages of lower 6 ribs interdigitation with diaphragm thoracolumbar fascia anterior frac34 of internal lip of iliac crest and lateral 13 of inguinal ligament

bull Insertion linea alba (broad aponeurosis) pubic crest and pecten pubis

bull Nerve Innervation T7-T12 L1 (iIiohypogastric and ilioinguinal)

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Multifidus

bull OriginSacral region posterior surface of sacrum medial surface of posterior iliac spine amp postero-sacroiliac ligaments Lumbar thoracic amp cervical regions transverse processes of L5-C4bull InsertionSpanning two to four

vertebrae inserting onto spinousprocess of one of vertebra above from last lumbar to axis (second cervical vertebra

bull Nerve Innervation Spinal

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Functions of TrA amp Multifidus

bull Deep Multifidus and TrAprovide intersegmental spinal stability

bull Deep fibers of Multifiduscontrol intervertebral motion

bull Superficial fibers of Multifiduscontrol spine orientation

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

A Core exercise program

bull Individualize for patient

bull Done in stage with gradual progression

bull Correct any existing muscle imbalances

bull Adequate muscle length and flexibility

bull Muscular endurance is more important than absolute muscle strength for proper lumbar stabilization

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

bull Isometric contract relax exercise

A Core exercise program

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

A Core exercise program

bull Flexibility section

Quadriceps Stretch

Adductor StretchHamstring Stretch

Dynamic Hamstring Stretch

Sidelying ITBand Stretch

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

A Core exercise program

Clamshell exercise

ndash isolate gluteus medius

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

A Core exercise program

bull Start on all fours

bull Cat- Inhale as you arch the back up and hollow out abdominals while head remains tucked

bull Camel- Exhale and lower abdominal and reach chin towards ceiling Tuck chin and sit back into Prayer position

bull Repeat 5 to 10 times

Beginning Cat - Camel

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

A Core exercise program

Re-education in upright positionsRichardson 1999

Isometric contraction activate the abdominal wall musculature

Contraction in 30 maximal voluntary contraction

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

A Core exercise program

bull Functions to increase intra-abdominal pressure by inwardly displacing the abdominal wall

bull Increases cross sectional area of TrAtighten like a corset and most likely improves stability of lumbo-pelvic region

bull Patient starts in hook-lying position and assumes a neutral spine position amp attempts to maintain it while drawing in and hollowing the abdominal muscles

bull Subtle posterior pelvic tilt amp flattening of lumbar spine

Drawing-In Manuever

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

A Core exercise program

bull Occurs by setting the abdominals and actively flaring out laterally around the waist

bull It has been shown to activate the oblique abdominal muscles

Abdominal Bracing

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Posterior Pelvic Tilt

bull Activated more in Rectus Abdominis

bull Awareness of the movement of the pelvis and lumbar spine

bull Activated the patient to find neutral spine position

A Core exercise program

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

bull High Bridging

Start

End

A Core exercise program

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

PROGRESSING A CORE STRENGTHENING PROGRAM

bull lsquolsquoBig 3rsquorsquo

ndash Curl-up

ndash Side Plank (side bridge )

ndash Bird dog (quadruped position with alternate armleg raises)

McGill S Low Back Disorders Evidence-Based Prevention and Rehabilitation

Champaign IL Human Kinetics 2002

Stage 2

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

bull Curl up

A Core exercise program

(A) (B)

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

bull Side-Plank

Advanced side plank

A Core exercise program

alignment of the ribcage and pelvis so that the spine is in a neutral posture

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

bull Bird-dogA Core exercise program

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

bull Bird-dog advance

A Core exercise program

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

bull Superman

A Core exercise program

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Focus on Endurancebull Repetitions not durations

bull Isometric holds in ldquoBIG 3rdquo (7-8 Secoxygenconsumption)

bull ldquoDo as much as you can while you are as

fresh as you can berdquo

ndash maintaining sufficient oxygen levels

Stage 3

A Core exercise program

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Take home massage

bull Exercise

ndash Relieve pain symptoms

ndash Restore function

ndash Prevent recurrence (by local muscle)

Donrsquot forget ldquoaerobics exerciserdquo

Buthellip

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull Definitions bull A passive movement that

tends to nudge the components of a joint or group of joints beyond their usual physiological range

Thrust High velocity low amplitude therapeutic movement within or at end range of motion

Nonthrust Those manipulations that do not involve thrust

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull Goals of treatment Relieve and prevent

physical disability Treatment on loss of

mobility and pain Discontinue use of

manipulation when mobility is restored and symptoms are resolved

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull Lumbar Spine ldquoGappingrdquo Manipulation

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull Gapping L4-L5 Lumbar Spine Flexion (Opening) Manipulation

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull Side lying Lumbar Rotation with locking Manipulation

bull To manipulate a specific lumbar segment (L1-L2 through L5-S1) into rotation

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain

Assendelft WJ Morton SC Yu EI Suttorp MJ Shekelle PG Spinal manipulative therapy for low back pain A meta-analysis of effectiveness relative to other therapies Ann Intern Med 2003 Jun 3138(11)871-81

39 RCTs were identified

Conclusion

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull In patients with chronic spinal pain manipulation if not contraindicated results in greater short-term improvement than acupuncture or medication

bull The data do not strongly support the use of only manipulation only acupuncture or only NSAIDS for the treatment of chronic spinal pain

Giles LG Muller R Chronic spinal pain a randomized clinical trial comparing medication acupuncture and spinal manipulation Spine 2003 Jul 1528(14)1490-502discussion 1502-3

Conclusion

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull CONCLUSIONS

the use of SMT andor MOB as a viable option for the treatment of both low back pain and NP

there have been few high-quality trials distinguishing between acute and chronic patients and most are limited to shorter-term follow-up

future trials should examine well-defined subgroups of patients further address the value of SMT and MOB for acute patients establish optimal number of treatment visits and consider the cost-effectiveness of care

Bronfort GHaas M Evans RLBouter LM Efficacy of spinal manipulation and mobilization for low back pain and neck pain a systematic review and best evidence synthesis Spine J 2004 May-Jun4(3)335-56

43 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

CONCLUSIONS

bull High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain

bull Determining cost-effectiveness of care has high priority

bull Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT and data related to recovery

Cochrane Database Syst Rev 2011 Feb 16(2)CD008112 doi 10100214651858CD008112pub2Spinal manipulative therapy for chronic low-back painRubinstein SM1 van Middelkoop M Assendelft WJ de Boer MR van Tulder MW

Included 26 RCTs

Spinal Manipulation

bull Complications Rare buthellip

cauda equina syndrome spinal epidural hematoma disc herniation fracture and dislocation

Take home massage

Thank you

Thank you