Lower Back Lumbar Segmental Instability
March 4, 2010
Someone with a lower spine that frequently moves through a larger-than-normal range of movement is more susceptible to low back pain. This tendency of moving beyond its normal range is known as lumbar segmental instability.
The normal range of the movement is defined as the neutral zone. A person with lumbar instability tends to move beyond the normal range of movement into the extreme end ranges.
What keeps the spine stable?
In order to understand what causes lumbar segmental instability, we first need to understand what keeps it stable in the first place. The human body holds the spine stable or steady through the help of three basic structures – the passive, active and neural structures.
- Passive structures in the lumbar spine are the vertebrae, the discs, then joints and ligaments. These are structures that do not move.
- Active structures are the global and local muscles. These contract or relax depending on the direction of the force required.
- And finally the neural structures; nerves that control and direct the muscles. This control is also known as motor control.
A stable lumbar spine segment coordinates global and local muscles using the motor control system to supply compressive forces along the spinal passive structures for stability. This coordination helps maintain the spine's normal curvature at a segmental level as we move about.
Active Structures
The global muscles include:
- Rectus abdominis,
- External oblique
- The thoracic part of lumbar illiocostalis (an erectae spinae muscle). ·
These three muscle groups are large torque producing muscles that provide general trunk stability and allow movement to occur.
The local muscles attach directly to the lumbar vertebrae. They are:
- Lumbar multifidus,
- Psoas major,
- Quadratus lumborum,
- Lumbar parts of lumbar illiocostalis and longissimus (more erectae spinae muscles),
- Transverse abdominus,
- The diaphragm and
- Posterior fibres of internal oblique.
- Interspinalis/ Intertransversii
The two lowest spinal segments, L4 and L5 vertebrae, are the most susceptible to segmental instability. This could be due to pathological/ degenerative changes to the passive structures that sometimes show up on x-rays. Instability can also occur if there is a loss of motor control and muscle strength/stamina within the neutral zone.
What does it feel like?
A person with lumbar segmental instability typically has a patient-history something along these lines.
- Back pain may have started after a direct injury to the area, or it may have just developed gradually.
- The pain tends to be recurrent and has more debilitating effects as time goes on.
- That person will try to do as little as possible in an episode of pain. According to a survey (O’Sullivan 1997), people most commonly describe the pain sensation as · catching, · locking, · giving way or · feeling of instability.
Classically, the most painful postures are sitting or standing for long periods of time, or being in bent over postures.
The most painful movements are
- bending forwards,
- moving unexpectedly quickly,
- standing up straight after being bent over, lifting or sneezing.
So basically….
The lumbar spine moves in an uncontrolled manner, causing pain. Because the big muscles and little muscles don’t work together properly and the body is unable to control each segment as the body moves.
How do I get rid of it!?
A physiotherapist will need to perform an assessment to find out what type of segmental instability is present (and the type of control that is lacking due to which structure – passive, active or neural). Based on the findings, an intervention will be planned.
In cases where the passive structures have degenerated, it is often possible to train the active and neural structures to compensate for the lower level of stability provided by the passive structures.
With this sort of condition, the exercises that are required are more ‘brain’ exercises than ‘muscle’ exercises. A new way of moving has to be re-learnt, and it requires a lot of concentration.
Heat or Ice? When to use which?
February 17, 2010
When should you use heat or ice therapy? The answer is – it depends. In general, heat therapy is for chronic conditions and ice is useful in acute situations.
If you recently sustained an injury or aggravated an old injury, ice should be applied for a period of 15mins each time for the first 3 days. If you feel your muscles are feeling tight and stiff, a hot pack on the muscles will help to relieve the tightness.
This spectrum of acute to chronic looks at the duration since injury. If the injury is sustained within 36 hours, it is considered to be in the acute stage. At this stage the inflammation process is ongoing. Ice will help to bring down the inflammation and swelling so that the injury can heal better. Note that applying heat to this stage will increase the blood circulation, inflammation and hence swelling.
There are 2 common scenarios that cause pain, making you reach for that heat/ice pack. One of them is the acute injury (for example a fall, twisting movement or direct blow that is immediately painful) and the other is the chronic injury (happened over a period of time or from an acute injury that failed to heal). Each scenario requires a different approach to reducing your pain and speeding up your recovery.
Acute Injuries
It might be that you have just sprained your ankle playing soccer, shut your fingers in the car door or fractured your hand. All these are examples of acute injuries and will show the following signs:
- Sharp, severe pain
- Swelling
- Redness
- Increased warmth
- Restricted joint movement
- Unable to put weight through the structure (e.g. leg, ankle, wrist etc).
Flickr: Kyle May
There are many ways of applying ice like using an ice pack; wrapping ice cubes in a wet towel or using a bag of frozen peas (sometimes that is the only thing on hand!). The cold agent should be in contact with the area for up to 20 minutes at a time and re-applied every 2-3 hours for around 3-5 days or until the swelling settles.
How does ice work?
1. Decreasing the pain
There are a few proposed theories regarding how ice decreases pain and it is possible that a combination of some of them can cause pain relief.
- Decreased nerve transmission in pain fibres
- Cold reduces the activity of free nerve endings
- Cold raises the pain threshold
- Cold causes a release in endorphins
- Cold sensations over-ride the pain sensations
2. Reducing swelling
Ice cools the surface of the skin and its underlying tissues, causing narrowing of the blood vessels. This narrowing leads to a decrease in the amount of blood delivered to the area and subsequently reduces the amount of swelling. After a few minutes, the blood vessels re-open allowing blood to return to the area. The narrowing and opening repeat in cycles.
The decrease in swelling also allows more movement in the area and lessens the loss of function associated with the injury. Pain is also reduced as pressure from the swelling lessens. Chemicals that intensify the pain are released into the bloodstream when tissues are injured, thus the narrowing of the vessels help to minimize this release and pain.
3. Decreasing metabolic rate
Ice reduces the metabolic rate and oxygen requirements of the cells. Thus, even with the decreased blood flow and oxygen delivery that comes with narrowing of the vessels, the risk of cell death will be lessened. This prevents further injury.
Sub-acute phase
A few days following an acute injury, the pain and swelling may have decreased so much that there may be no sign of the original injury. However, the tissues are still in the process of recovery and will still benefit from modifying your activities (less vigorous) as well as using both ice and heat alternatively. This means to apply ice for 10 minutes, followed immediately by 10 minutes of heat.
How does this work?
Doing this will cause massive increases in blood flow to the area as the narrowing caused by cooling is reversed when heat is applied, resulting in an influx of blood to the damaged tissues. The increased blood flow to the area provides proteins, nutrients and oxygen for better healing. It also helps remove the products of inflammation and reduce residual swelling.
An important point to note is to ensure that inflammation has stopped before applying this technique. That means that the area should not be red, and should not be warm to touch.
Chronic Injuries
Flickr: Capture Queen
In order to treat these, heat should be used to help relax tight, aching muscles and joints, increase the extensibility of ligaments and tendons and promote blood flow to the area. Heat can also be used before exercise in chronic injuries to warm the muscles and increase flexibility.
Heat can be applied to the area in the form of heat packs, a warm damp towel, hot water bottles or heat rubs. If using a heat pack or hot water bottle, ensure a suitable layer of protection is placed over the skin to prevent burns. The heat should be applied for 15-20 minutes.
How does heat work?
Heat applied on the skin increases the temperature of the skin and the underlying tissues. This in turn opens up the blood vessels like your ateries, allowing more blood to flow into the area. This increase flow helps to remove waste products from cells and deliver more nutrients, relaxing tissues. The increased temperature of the blood also warms up surrounding tissues. Heat also has an effect of increasing flexibility of the soft tissues.
Both heat and ice are cheap, easy to use and effective ways of speeding up recovery when used correctly. Besides managing your injuries with these modalities, it may be a good idea to consult a physiotherapist in helping you rehabilitate and/or prevent the same injuries from occurring.
What to do when your back hurts so much that you can’t get out of bed?
December 28, 2009
Source: Flickr erikogan
What you NEED to do
- Reduce the inflammation:
- Either take an anti-inflammatory medication (tablet or injection). GP prescription may be required.
- If it is too painful even to go see the GP,
- Apply a COLD press to the sore/painful area.
- Take an over-the-counter anti-inflammatory (e.g. Voltaren Gel / Tablet). This is a weaker form of anti-inflammatory medication than what you will get from your GP.
- Rest to let your body heal and reduce the inflammation naturally.
What NOT to do
- Apply Heat (either through a hot pack or some of heat rub) You will further aggravate the inflammation.
- Massage the sore area.
See your physiotherapist only after it doesn't feel so sore or painful the day after.
Improving Your Chances for a Successful Back Surgery
November 12, 2009
Spine-Health.com recently listed 5 ways to improve your chances in their article, “5 ways to minimise failed back surgery and continued back pain”1. One of the 5 ways was – “Be Ready to Rehabilitate”. We would like to add one more way to improve your chances – Pre-Habilitation. Read more
Idiopathic Scoliosis Video
August 27, 2009
Idiopathic scoliosis is the most common form of scoliosis. This video provides a good visualisation on how a scoliotic spine looks like. It also shows how the forward bending test will reveal scoliosis.
Read on here to know how the SpineCor programme helps in the treatment and management of scoliosis.
Core Concepts is an accredited SpineCor Physiotherapy Centre. The first private centre in Asia, outside of Europe and the Americas
Traction Therapy – No Help in Long Term
July 13, 2009
Traction Therapy
Many people may have heard stories about their friends having treatment for their spinal pains in hospitals or physiotherapy clinics where they were strapped into a contraption and having their back or neck stretched. This device is called a traction machine. To some the description may sound intimidating or even medieval, but in fact, traction is a very gentle form of treatment and is extremely effective when applied appropriately in specific conditions.
Bed Rest No Longer the Best Option for Back Pain
July 6, 2009
Low back pain is one of the most common reasons for consulting a physician. Despite little supporting scientific evidence, bed rest was considered the primary treatment for low back pain from the late 19th century. What has changed now is how back pain is understood and managed.
Spasmodic Torticollis
May 27, 2009
Spasmodic torticollis (ST) is also called cervical dystonia. Dystonia is a neurological movement disorder characterised by involuntary muscle spasms and sustained muscle contractions. Dystonia can affect just one muscle or a group of muscles or all of your muscles. In the case of ST, the muscles in the neck go into involuntary contractions. These sustained muscle contractions result in twisting, turning or tilting of the head and neck, and sometimes jerky head movements. Pain can also accompany the involuntary muscle contractions in the neck.
Sway Back No More
May 20, 2009
Do you stand or walk like a limbo rocker? If yes, you may have sway back. Apart from slouching, sway back is another common bad posture that leads to back pain. Like most posture problems, it is easily correctable by treating and preventing its contributing factors.
Is an Ergonomic Chair better than a Swiss Ball?
March 28, 2009
"Hi, I have a question. Is it better to sit on an ergonomic chair or a gym swiss ball if you have back pain? – Wee K"
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Chng Chye Tuan, B.Hsc(physio)
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