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OverviewandObjectives

EvaluationofLumbopelvic/Core Stability
RyanMcGuirePTDPTMSOCSCSCS UniversityofKentuckySports PhysicalTherapy

Focusisonexamination/assessment of lumbopelvic/corestability Definecoreinstability,stability Examineandassessthelocalandglobalstabilization systems Evidencebasedexamforclinicalsignsofinstability Determineifstabilizationtreatment necessary/beneficial

WhatisCoreInstability?
Previouslydescribedasligamentouslaxitythat producedexcessivemovementsinanintervertebral jointatendrange

RadiographicInstability
Age<37years Totalextension>26degrees Anyhypermobilityofthelumbarspine Lackofhypomobilityofthelumbarspine* Lumbarflexion>53degrees*

+L.R.=12.8;L.R.=.72 Fritzetal.EurSpineJ20051

ClinicalInstability:Panjabi18
NeutralzoneofZjointstability:ameasureofspinal laxityinthevicinityoftheneutralposition. Abnormalincreaseinsizeoftheneutralzoneleads topainsecondarytostrain Inabilityofthespineunderphysiologicalloadsto maintainitsnormalpatternofdisplacementtoavoid neurologicaldamageorirritation,developmentof deformity,andpain

ClinicalInstability:PanjabisModelof CoreStability
PassiveStabilizers
Ligaments,Bones,Discs Stabilizesinelasticzone andlimitsneutralzone

Motor(Neural)Control
Nervoussystem Determinesamountofspinal stabilityneededandactson mmtoproducerequired forces(ecc,conc,cocontraction)

ActiveStabilizers
Musclesandtendons Controlsmotionin/throughout andsizeofneutralzone

Goal: Maintain/recover neutral zone after trunk perterbation during activity both anticipatory and reflexively reactive

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StabilityoftheSIjoint
Closedpackposition:sacralflexionandposterior innominaterotation Maxligamentoustensionandjointcongruency Facilitatesmaximumloadbearingandloadtransfer combinationofthisandmuscularcontrolcreatesa selflockingmechanism

LocalStabilizationSystem
PelvicFloor TransversusAbdominus Multifidus
rapidatrophywithin24hrs ofpainonset/recoverynot automatic Multifidus fatinfiltrationandatrophystrongly associatedwithLBP6 Delayedfiringindeepcorewitharmmovements withh/oLBP5,14 HigherrecurrenceratesofLBPinacontrolvsstab groupat23yrf/u.4

LocalStabilizationSystem
Diaphragm Psoas InternalOblique Rotatores,MusculiInterspinalis,Intertransversarii medialesandlaterals

GlobalStabilizationSystem
Longerectorspinae RectusAbdominus ExternalOblique Longissimusthoracis

HipMusculatureContributions
Gluteusmaximus
stabpelvis/trunkthroughtensioninthoracolumbarfascia

ClinicalSignsofInstability
LumbarCPR:StabilityClassification3 1.Age<40 2.Aberrantmovementpresent 3.SLR>91average 4.(+)Proneinstabilitytest
K=.80,ICC.942, respondingtostabprogram:+LR1.7,LR.483

Gluteusmedius frontalplanestability HipErs: preciseeccentriccontrolwithgaittocontrolIRmoments AssistwithSIlockingforloadtransfer

5.FABQPA>8 6.Segmentalhypermobility 3findings=+LR18.8

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ClinicalSignsofInstability
1. 2. 3. 4. 5. 6. Lumbopelvicrhythm PatternofSB/rotationtowardparaspinalbulk PassivehipROM Activelegraise(sagittal) Activelegraise(frontal) Bentkneefallout

SubjectiveExamination
Age<40,FABQPA>8 H/ochronic,recurrentLBPwithfrequentepisodesof acuteattacks Inconsistentsymptoms C/ogivingaway,catching,lockingepisodes Manipulationprovidesshorttermreliefonly Pooroutcomeswithgeneralexercise

3/6+findingsusedascriteriaforstabtrainingwithsig improvementsinpreposttestingpainanddisability10,11

SubjectiveExamination
Increasedsymptomswith:
sustainedwbingpositions staticpositions sharppainwithquickmovements

ObjectiveExamination:Inspection
Paraspinalfullnessgreaterthen1/2inononeside painandlimitedSBtowardandincreased
rotationtowardsbulk

Decreasedsymptomswith: manipulationshortterm
NWBorexternalsupport

Reversal/Alterationoflumbopelvicrhythm Aberrantmovement
(+)Gowerssign hinging,fulcruming

ObjectiveExamination:Inspection
Singlelegsquattest(repetitive) Compressiontest
superiortoinferiorforceapplied tospinethroughshoulders lookforpointsofhinging

ObjectiveExamination:AROM
Forwardflexiontest standingflexion,PSISbestpalpatedatendrange
cranialPSISonpainfulsideindicatesfixation cranialPSISonnonpainfulsideindicateshypermobilityof involvedside K=.32.55 Winkeletal.1997

Decreasedpainwithdeepcontraction duringprovocativemovement
(ex:SLR,Fabers,quadrant)

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ObjectiveExamination:AROM
StorkTest restingstandingposition
palpatePSISonstancelegandsacralbase/L5,patient completesuninvolvedhipflexion PSISshouldmoveposteriorandslightlylaterallyonstanceleg positivetest:PSISmovingantsup. denotessacralunlockingand alteredloadtransfer
PSIS L5/Sacral Base

()StorkTestwithSacralLocking

(+)StorkTestwithUnlocking

ObjectiveExamination:AROM/PROM
PROMhipflexion
positiveifpainbefore120flexion

SLRforaverageROM:>91 Motioncontroltesting ASLR,BKFO SLSLR ProneSLR Withandwithoutcompression

ObjectiveExamination:AROM/Motion ControlTesting
ActiveSLR supine,completeactiveSLR8inchesfromtablewithout
compression assess:stabilityofpelvisanddifficulty/provocationforlifting reliability:ICC.8312 validity:IDpostpelvicpainsincepregnancysn.87,sp.9412 alteredkinematicsofdiaphragmand pelvicfloorpresentwith+test17

ObjectiveExamination:AROM/Motion ControlTesting
ActiveSLR retestaddingcompression:(+)isdecdifficulty/pain
anteriorilium:pelvicfloorandTA posteriorilium:sacralmultifidus pubicramus:hipaddand/or rectusabdominus8 thoraxtopelvis:obliques

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ObjectiveExamination:AROM/Motion ControlTesting
Bentkneefallout supinehooklying
eccentricloweringintohipabduction/ER positivetest:pelvicrotationduringfirst 50%motion ifsymptomsincreased,pelvic stab.shouldimprovepain reliability:K=.38.609,23

ObjectiveExamination:AROM/Motion ControlTesting
SidelyingSLR sidelyingpositionwithbottomlegslightlyflexed,topleg
extended testishipabductionwith10degreeshipextensionandslight ER lookforsubstitutions:flexinghipandrollingorhikingofpelvis earlyinmotion

SidelyingSLRPoorFormVideoClip

ObjectiveExamination:AROM/Motion ControlTesting
ProneSLR proneposition,liftleg810inchesofftable
assessneutralspineandfiringpattern:TA,ipsilateralglut/HS, contralateralmultifidusf/bipsilateral,contralateralESf/b ipsilateral 16,20 k=.72.76foragreementondeviationinfrontal,transverse, sagittalplane15 gluteusmaximustimetocontractreducedwithcompression22

ObjectiveExamination: AROM/MotionControlTesting

ProneSLRBadFormVideoClip

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ProneSLRGoodFormVideoClip

ObjectiveExamination:PROM
Lumbar andSIPAglides reliability:21
IDofosseousstructuresK=.53 motionassessmentK=.17 painassessmentK=.42 determininghypomobilityK=.717 determininghypermobility K=.297

ObjectiveExamination:PROM
Lumbar andSIPAglides validity:pooragreementK=.04withMRI7
segmentalfindingspredictiveofradiographicinstabilityand responsetostabilizationtreatments? findingsofhypermobility:failurerateswere83.3%with manipulationtreatmentand22.25%withstabilization treatment1

ObjectiveExamination:PROM
ProneInstabilityTest pronewithhipsoveredgeofplinth,feetonfloor.
2parts:PAglide,repeatPAglidewithfeetofffloor positiveifsecondtestlesspainful reliability:K=.80,ICC=.942 validity:likelihoodofptrespondingtostab.program (+)LR=1.7,LR.483

ObjectiveExamination:PROM
ProneInstabilityTestPartIandII

ObjectiveExamination:PROM
SIprovocationtestingcluster immediatepain=inflammation,systemiccondition,
hypermobility24 delayedpain=stiffness,upto2minhold24

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ObjectiveExamination:MotorControl andMMT
Assessthelocalsystem
forvolitionalactivationandendurance ifvolitionalcontrolnotedthencheckforreflexiveco contraction

ObjectiveExamination:MotorControl andMMT
PelvicFloor ptinhooklyingpalpateforactivationwithulnaraspectof
hand cueforkegels,stoppingflowofurine

ObjectiveExamination:MotorControl andMMT
TransversusAbdominus ptinprone,stabilizersetto70mmHg
inferioredgeofstabilizeratlevelofASISs drawinginwithrelaxednormalbreathing stoptestifinabilitytohold x10secfor10repsatagiven level goal64mmHg(range6860mmHg)

ObjectiveExamination:MotorControl andMMT
Multifidus samepositionasTAtest,palpateinthegutterjustadjacentto
spinousprocess(checkdifferentlevels) cuesinclude:swelling,attempttoextendthebackwithout moving,coneconcept iftheycannotactivatetryunilateralisometricHSactivation nearfullextensionengage

ObjectiveExamination:MotorControl andMMT
ChecktheReflex ifvolitionalcontractionnoted,checkpelvicfloorTAandTA
multifidusreflexiveactivation

ObjectiveExamination:MotorControl andMMT
Assesstheglobalsystem***athletes trunkendurancetesting(McGill)
situpsustained,BieringSorensten,sidebridge, comparetonormsandratios

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ObjectiveExamination:MotorControl andMMT
Hipadductor/abductorMMT
normaltestingmethod disproportionateweaknessofadductorstoabductors indicativeofhypermobility(irritation/displacement)ofpubic symphysis8,19

References
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GluteusmaximusandhipERMMT

References
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References
18.Panjabi,M.M.Thestabilizingsystemofthespine.PartII.Neutralzoneandinstabilityhypothesis.Journalof spinaldisorders&techniques.1992;5(4):390397. 19.Rst,CecileCM,etal.Pelvicpainduringpregnancy:adescriptivestudyofsignsandsymptomsof870 patientsinprimarycare.Spine. 2004;29(22):25672572. 20.Sharmann,S.A.DiagnosisandTreatmentofMovementImpairmentSyndromesMosbyInc.(2002). 21.Stochkendahl,MetteJensen,etal.Manualexaminationofthespine:asystematiccriticalliteraturereview ofreproducibility.Journalofmanipulativeandphysiologicaltherapeutics. 2006;29(6):475. 22.Takasaki,Hiroshi,etal.Theinfluenceofincreasingsacroiliacjointforceclosureonthehipandlumbarspine extensormusclefiringpattern.ManualTherapy. 2009;14(5):484489. 23.VanDillen,LindaR.,etal.Reliabilityofphysicalexaminationitemsusedforclassificationofpatientswith lowbackpain.PhysicalTherapy. 1998;78(9):979988. 24.WinkelD,MatthijsO,PhelpsV.DiagnosisandTreatmentoftheSpine.Gaithersburg,Pa:AspenPublishers; 1997.