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ARTICLE Table of Contents   
Year : 2003  |  Volume : 37  |  Issue : 1  |  Page : 4
Non-surgical management of segmental spinal instability


Ashwini Back Institute, Thane, India

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How to cite this article:
Kher S, Nadkarni S, Ekbote S, Joshi D. Non-surgical management of segmental spinal instability. Indian J Orthop 2003;37:4

How to cite this URL:
Kher S, Nadkarni S, Ekbote S, Joshi D. Non-surgical management of segmental spinal instability. Indian J Orthop [serial online] 2003 [cited 2019 Dec 10];37:4. Available from: http://www.ijoonline.com/text.asp?2003/37/1/4/48518
Instability does not always indicate need for surgical fusion. Many instabilities are known to stabilize themselves spontaneously, though some of them in malaligned positions. Many of them inspite of the looseness of segments, and the painful soft tissue incompetence, do not show any further progression of the hypermobility.

A large number of spinal instability patients can be satisfactorily treated by appropriate conservative therapy In fact, no patient of spinal instability, except when under threat of major neurological deterioration, should undergo surgery without a fair trial of carefully planned, individualized and meticulously executed, conservative care of the back. We, therefore, insist on well-supervised conservative care even when the patient has had treatment on similar lines. Any significant contribution from psychosocial factors must be treated with appropriate counseling, functional restoration, and work-hardening or pain programs. [1],[2] The proper non-surgical management requires responsible patient compliance.

There are many nonoperative programs. A few of the best known are McKenzie, Williams, Rolfing, and Feldenkreis. [3] Less well known are Reike, Heller, Aston and Alexander. [4],[5],[6] Each has well-defined techniques and applications, but few have rigid time frames. The conservative care must be a dynamic changing process. Unfortunately, in many medical setups it is a static unindividualised protocol which may not work in every patient.

Pain relief and/or improvement of function must be the primary aim of any conservative management program. There has been a great deal of controversy about which treatment philosophy achieves this best. [7],[8]. We feel that any active patient participation program that gives patients the responsibility and the power to manage their low-back problems and prevent further injury can be useful. The program developed at our is modified to suit demands of an average Indian patient. The program is being used for over 20 years. Over 3500 patients have been treated by this program. The relief rate has ranged from 60% to 80% depending upon the nature of instability, patients' resources and patient compliance. The mainstay of our program is balanced development and maintenance of all the muscles surrounding the lumbar spine.

The basic principles in the non-surgical management of spinal instability are as follows :

  • Avoiding specific postures : Patient must learn about and carefully avoid the specific postures causing pain and/or showing radiographic hypermobility.
  • Making postural readjustments : Many insta-bilities become less painful in certain postures. The postural changes are desirable in these patients. The classic example is that of degenerative prolisthetic tendency in a patient whose lumbo-sacral disc orientation is more vertical than horizontal. In such a patient, pelvic tilting could change the lumbo-sacral orientation and reduce the magnitude of shear stresses making it less painful and sometimes even reducing the magnitude of translatory movement. Such a therapeutic change of posture calls for a major muscular re-adaptation and development of enhanced proprioceptive mechanism. These postural adjustments cannot be achieved without continuous awareness, sufficient strength and endurance in the controlling muscles.
  • Developing and maintaining a 'good muscular corset' around the spine.
  • Narrowing down the range of movements during activities of daily life.
  • Lumbar orthotic bracing- Many would need a rigid type of lumbar brace in the early stages. The brace restricts their mobility and adaptation to new narrowed range of movements during activities of daily life is facilitated.
  • Careful supervised mobilization of adjacent painful stiff but stable segments.
  • Care of other pain producing trigger points in the soft tissues by physical therapy modalities as and when needed.


In the acute phase of low-back pain the exercise should start within a day or two to help realign the stressed spinal area and recondition the muscles required to maintain a pain-free position. If one is uncertain about selecting a specific exercise program, then a painless balanced range or neutral body mechanics program is usually quite adequate. [9],[10] Supine or reclined cycling may be substituted for greater weight-bearing exercises in early rehabilitation. [11]

Neutral spine and stabilization training begins in the initial phase of rehabilitation or the pain control phase [12] and is carried through to the patient's discharge and then throughout the rest of his or her life.

Neuromuscular training must then progress through the full range of motion to allow strength and control toward the end of the range where injury occurs. This neuromuscular coordination and control is the goal of stabilization training. Stabilization training progresses from the simplest non-weight-bearing supported positions to complex high-speed functional activities. All exercises must be performed with an emphasis on proper technique, and progression is undertaken only after a new skill has been completely mastered. Progression must be made within the constraints of the patient's pathology and ability.

Non-surgical stabilization of the lumbar spine

Active rehabilitation in the form of exercise therapy can make the musculature stronger and connective tissues more resilient. This scientific fact is regularly used in sports medicine .[23],[13],[14]

The strong and powerful connective tissues around the unstable segment can make it more stable and help the patient to remain pain-free.

Our treatment program principally involves 4 important aspects: -

  1. Patient education through a "Back School"
  2. Learning specific dynamic muscular spinal stabilization.
  3. Finding neutral (trouble free) zone for the patient.
  4. Functional movement training while using already learnt stabilization.


1) Patient education : In most back pain patients the pain production is due to the mechanical stressing of the spine either due to the normal stresses on abnormal tissues or abnormal stresses on the normal tissues. If the patient is educated about these medical facts in simple language he himself can take care of his back while continuing with his routine. This is done effectively if they are given proper classroom coaching with the help of audio-visuals. A back school education should cover basic anatomy of spinal structures, simple biomechanics, mechanism of pain production and brief information of the disease processes. Once the patient has understood all this in detail the patient complies much better with the stabilization training program and its subsequent use in daily life. [15],[16],[17]

2) Stabilization concept : The attempted stabilization by the paraspinal spasms is a spontaneous response to pain. The phenomenon of stabilization is therefore not new but 'Stabilization training' is a recent concept. The "stabilization training" encompasses many known theories and practices from various sources. These include regimes like back school [18],[19] , proprioceptive neuromuscular facilitation (PNF) [20] , orthopedic sports medicine. [2],[21],[22] manual therapy[21] , [23],[24],[25],[26] and sound exercise principles. [14],[ 27]

Though the stabilization and neutral spine program of training can be applied to a variety of conditions throughout the phases of degeneration including disc herniation, stenosis, facet syndrome, it has a special place in instability. An accurate diagnosis is important to identify indications and contraindications. [12],[23],[28],[29] There are many studies in the literature evaluating the efficacy of stabilization and neutral spine programs. [10],[18],[30],[31],[32],[33],[34]

The aim of any stabilization and reconditioning program is to restore the functional capacity by having the deconditioned patient work through the pain in a work-hardening and strengthening program. The success is measured by the ability of the patient to return to work in the original capacity, which can be upto 85%.

The program focuses on bringing about appropriate and sustained co-contraction of the relevant axial musculature specifically around the unstable and painful segment. This produces local immobilization, while allowing movements at other pain free joints of spine. This will vary from patient to patient, and also will depend upon the underlying disease process, the activity being performed and the posture assumed during the activity. [34],[35],[36],[37] The patient needs excellent strength, endurance of muscles and flexibility of the surrounding soft tissues in order to be able to do this. An athlete devoting several hours a day to this type of training can progress from poor to excellent in a few weeks. Less co-ordinated and less motivated individuals can take months to improve performance. [38],[39],[40]

3) The neutral zone : The neutral zone can be defined as a "biomechanically stable area in the range of spinal motion in which the spine is in its most pain free state". It is a zone of comfort dictated by the underlying pathology and patients' symptoms. In acute painful phase this neutral zone may be quite narrow and as pain is relieved it becomes broader. In stenosis and facetal arthropathies it will be towards slight flexion while in active disc lesion it will be near the extension posture. [34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46] Deliberately maintaining or using only neutral zone in all the day-to-day activities will keep the patient pain free and symptom less. Maintaining of the neu­tral zone will require continuous proprioceptive feedback and continuous neuro-muscular re-adjustments to minimize the local stress and reduce the risk of injury. This is made possible by promoting the muscle sensitivity to stretch by enhancing sensitivity of the muscle spindle and Golgi apparatus that are responsible for proprioception. The patient is trained to contract the right muscle at the right time in the right proportion. This is done by using the principle of Proprioceptive Neuromuscular Facilitation (PNF) used in exercise therapy. [20],[41],[47],[48].

Musculature involved in stabilization

The key muscles responsible for trunk control are the abdominal muscles. [48],[49],[50],[51],[52],[53] Some common observations in chronic spinal problems are :- 1) Abdominals are generally poor in strength and endurance, 2) The flexor / extensor strength ratio is not appropriate and 3) Rate of torque development is poor. Hence these muscles get priority over others in the reconditioning program.

The abdominal musculature through its peculiar attachment to the dorso lumbar fascia gets inserted in transverse and spinous processes. The rectii try to produce flexion while the oblique abdominals through dorso-lumbar fascia try to produce extension. This, in combination with a tightening of the posterior ligamentous system, acts as a corset to fortify the spinal elements against torque and shear forces. Use of the oblique abdominal muscles, called "dynamic abdominal bracing," is found to stabilize the spine through an increase in intra-abdominal pressure. [48],[49],[50],[51],[52] This tensing is produced by the oblique muscles through their attachment to the lumbo-dorsal fascia. In forward-bending activities, the internal oblique muscles are needed to counteract the shear forces of the extensor muscles. [12],[52]. Many patients tend to use the rectus abdominus exclusively without oblique contribution. They get additional support of latissimus dorsi from above and gluteus maximus from below. In prolisthesis multifidus contracts eccentrically to reduce local lordosis. Education in abdominal bracing, emphasizing oblique recruitment is the key to stabilization training.

When strengthening the abdominal musculature, all components like rectii and obliques should be strengthened individually. e.g. Slowly raising and lowering of both legs ensures lower abdominal isolation. Curl ups up to initial 45 degrees will ensure the upper abdominal strengthening. Raising both thighs in abduction and exercising will improve internal and external obliques.[Figure 1] shows development of different components of abdominal musculature.

To improve endurance the number of repetitions is increased whereas to improve strength resisted exercises are needed.Emphasis is placed on achieving quality and grace in movement with the kinesthetic awareness to control spinal posture automatically. The patient can develop this response only through exhaustive practice.

It is not only the spinal musculature that needs attention.The lumbar spine rests on the pelvis, that is why pelvic positioning will be the key to postural control of the lumbar spine above. For this adequate stretchibility and flexibility of lumbo-pelvic musculature like quadriceps, hamstrings, iliopsoas, hip rotators and soft tissues like lliotibial band is important. If these structures are tight then there is excessive strain on the other structures.

Before starting the stabilization training program thorough evaluation of the patient is necessary to define his current functional status, available pain free range and to identify the factors that aggravate or relieve the pain. With this information an individualistic treatment a plan can be developed with definable, realistic and reachable goals. This base-line evaluation will also help in assessing the progress and in modifying the treatment plan.

Most patients are reluctant or afraid to comply with exercise regime in the presence of pain or if it develops during the treatment. It must be emphasized to the patient that pain does not always mean damage and he must be encouraged to continue exercises. In most cases patients find relief of pain following exercise sessions. Electro-therapeutic modalities like short wave diathermy / ultra sonic waves / transcutaneous electrical nerve stimulation are useful. Exercises are advanced as strength and endurance improves and the right technique is mastered. By training on gym ball [Figure 2] which acts like an unstable base the musculature learns to accommodate rapidly and synergistically to sudden changes in loads and stresses. [35],[54],[55].

Practicing in various positions and situations prepares the patient to face the unanticipated demands in daily activities. Aerobic exercises should be an integral part of the program right from the beginning. It helps to improve the general fitness. Various studies have proved the direct beneficial relationship between good general physical fitness and reduced incidence of back pain. A frequently cited study on firefighters listed optimal cardiovascular fitness as one of the important parameters for prevention of back injuries. [56] This will help the patient gain enough confidence to discontinue the external support.

Such a goal oriented program needs to be carried out under close supervision of a therapist. Simultaneously the patient should also be given home exercise program to avoid dependence on the therapist and the clinic. Bracing for the lumbar instability

In the non-surgical management of lumbar instability spinal bracing forms an important part. No brace can totally immobilize or reduce displacements in the lumbar spine except in an indirect manner. Lumbar corsets and braces are essentially given to restrict movements of the lumbar spine while the patient is ambulant and functioning. Immobilizing any joint involves gripping of the participating bones by some external means. This external agency can achieve this if anatomically the concerned bones are accessible for direct purchase. The lumbar spine even in a thin person is inaccessible for this purpose.

Mechanism of lumbar bracing [57],[58],[59]

  1. It can be indirectly immobilized by controlling relative motion between lower thorax and the pelvis. This can be achieved through the use of semi-rigid frame type lumbo-sacral brace which should be long enough to hold the non-floating lower ribs and the pelvis. It must have rigid posterior and lateral supports and it must have good wide anterior corset to cover as large a part of abdominal wall as is possible. The total contact body brace made of lighter material like plastics would serve this purpose even better.
  2. The lumbar mobility and the loads on the lumbar spine can be controlled to some extent by transmitting the controlling forces through the abdominal tissues. The commonly used soft lumbar corsets with small metallic plate posteriorly work in this manner. There efficiency is much lower than the above-described frame braces.


Transmission of forces

In the lumbar area, the forces are transmitted through the soft tissues like skin, fat, muscles, viscera, air, water in the intestines and lower thoracic ribs at the upper end and through the pelvic bone at the lower end. All these structures have different viscoelastic properties. Stiffer the structure better are the forces transmitted. Thus the abdominal soft structures are poor transmitters of forces as opposed to the ribs and pelvis.

Increase in the intra-abdominal pressure produced by tightly gripping corset pushes the thoracic diaphragm attached to D 12 - L1 upwards and the pelvic diaphragm with surrounding pelvis downwards. This causes the distraction and elongation of the lumbar spine. This results in the reduction of the lumbar lordosis and reduces the compressive and shear forces acting on the lumbar spine.A tight lumbar corset around the abdomen converts the abdominal wall into a semi-rigid cylinder. This can transmit some of the upper loads to pelvis bypassing the lumbar spine. It can also restrict the mobility to small extent.While prescribing the brace, the clinician has to decide on the degree of immobilization desired. In our experience the soft lumbar corsets, though found convenient to use, are ineffective in controlling the lumbar spine.

The pressure of the tight fitting of the brace and lack of local skin ventilation may lead to skin irritation and can cause pain. Gradually the skin and the underlying soft tissues undergo biomechanical adaptations and the patient can then tolerate the brace better. The patient must continue using the brace, under supervision, even if it causes some discomfort and pain.Ideally the brace should not be used permanently. EMG studies have shown that prolonged use of the brace reduces abdominal muscle activity. [60] When the abdominal muscles develop adequate strength and provide a strong corset around the lumbar spine, the patient should gradually discontinue the brace.

Problems of usage of the brace

  1. The patient may develop psychological dependence on the brace. Therefore the brace must be discontinued gradually.
  2. The increase in the intra-abdominal pressure while using the brace may worsen the certain problems like hernia, varicose veins, piles, distal edema.
  3. Conversion of upper lumbar spine into a stiff segment by the brace may sometimes produce stress concentration at lumbo-sacral junction. If the instability is related to this junction primarily, it may worsen.[61]


 
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Correspondence Address:
S Kher
Ashwini Back Institute, Thane
India
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