Determining the Stabilizing Role of Individual Torso Muscles During Rehabilitation Exercises Natasa Kavcic, MSc, Sylvain Grenier, PhD, and Stuart M. McGill, PhD Study Design. A systematic biomechanical analysis involving an articial perturbation applied to individual lumbar muscles in order to assess their potential stabiliz- ing role. Objectives. To identify which torso muscles stabilize the spine during different loading conditions and to iden- tify possible mechanisms of function. Summary of Background Data. Stabilization exercises are thought to train muscle patterns that ensure spine stability; however, little quantication and no consensus exists as to which muscles contribute to stability. Methods. Spine kinematics, external forces, and 14 channels of torso electromyography were recorded for seven stabilization exercises in order to capture the indi- vidual motor control strategies adopted by different peo- ple. Data were input into a detailed model of the lumbar spine to quantify spine joint forces and stability. The EMG signal for a particular muscle was replaced either unilat- erally or bilaterally by a sinusoid, and the resultant change in the stability index was quantied. Results. A direction-dependent-stabilizing role was noticed in the larger, multisegmental muscles, whereas a specic subtle efciency to generate stability was ob- served for the smaller, intersegmental spinal muscles. Conclusions. No single muscle dominated in the en- hancement of spine stability, and their individual roles were continuously changing across tasks. Clinically, if the goal is to train for stability, enhancing motor patterns that incorporate many muscles rather than targeting just a few is justiable. [Key words: lumbar spine, spine stability, modeling, muscles] Spine 2004;29:12541265 While muscles function to create torques, which support postures and facilitate movement, they are also critical for ensuring spine stability. 1 Clinically, the question of how to train lumbar spine stability requires knowledge of howthe various muscles contribute to ensuring stabil- ity. A common functional distinction used to classify the role of the different muscles is that intersegmental or local muscles are hypothesized to function primarily as stabilizers and multisegmental or global muscles are hypothesized to function primarily as moment produc- ers. 24 This distinction, formalized by Professor Anders Bergmark, 2 focused the early discussions on stability; however, debate continues over which muscles are im- portant stabilizers and how to best train the neuromus- cular control system to ensure sufcient stability. Researchers have used various techniques to investi- gate the question of which muscles stabilize the lumbar spine. Electromyographic analysis of torso muscle onset times to various perturbations has suggested that the more internal muscles, particularly the transverse abdo- minis and internal obliques, behave in an anticipatory manner, irrespective of loading condition, suggesting a proactive control of spine stability. 5,6 Others have ob- served a wasting of the multidus muscle on the side of the reported low back pain with MRI techniques, 7 sug- gesting that in order to ensure a stable spine this muscle requires specic training to return the cross-sectional area of multidus to normal levels. 4 While these studies did not quantify stability but rather relied on qualitative intuition, other approaches have attempted to quantify stability. For example, in vitro approaches have repre- sented muscle forces with wire cables acting on cadaveric lumbar spines. Through investigation of predominantly small, local muscles, several researchers have found that these muscles successfully increase the stiffness within the spinal structure, critical for stability. 810 While many believe that the local muscles are cru- cial for spine stability, others hypothesize that the global, larger muscles play a role. Panjabi et al 8 sug- gested that the role global muscles have in stabilizing the lumbar spine comes from their efcient ability to impact the stiffness of the entire spinal column, opposed to local muscles that can only act on a fewjoints. Cholewicki and McGill 11 and Cholewicki and Van Vliet 12 suggest from the results of their biomechanical analyses, that no single muscle, local or global, possesses a dominant responsi- bility for lumbar spine stability and therefore concluded that training efforts should not focus on any single muscle. Contrasting results and descriptions for the neuro- muscular control of spine stability have led to the devel- opment of various training theories. Patterns such as an- tagonist cocontraction as a method of increasing spine stiffness has been conrmed through numerous stud- ies 1316 ; however, some argue that enhancing this re- sponse for therapeutic purposes to train spine stability can lead to very high compressive load penalties. 4 Some advocate training isolated groups of muscles, primarily local, with the goal to minimize global muscle activa- tion and compressive loads. Identifying muscle impor- From the University of Waterloo, Faculty of Applied Health Sciences, Waterloo, Ontario, Canada. Acknowledgment date: May 21, 2003. First revision date: June 26, 2003. Acceptance date: August 6, 2003. Supported by the National Science and Engineering Research Council of Canada. The manuscript submitted does not contain information about medical device(s)/drug(s). Federal funds were received in support of this work. No benets in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence to Stuart M. McGill, PhD, Faculty of Applied Health Science, University of Waterloo, Waterloo, Ontario, Canada N2L 3G1; E-mail: mcgill@healthy.uwaterloo.ca 1254 tance during different loading conditions is necessary to properly critique existing clinical practices for training and restoring a healthy lumbar spine. The purpose of this study is to use a highly sophisti- cated and detailed torso model, driven with biologic sig- nals measured directly from each study participant, to compute spine loads and stability. Each muscle was sys- tematically adjusted to assess the impact on the stability of the spine, thereby quantifying their contribution at a specic instant in time. Furthermore, an attempt to iden- tify the different mechanisms as to how the various mus- cles contribute to lumbar spine stability was performed. Materials and Methods Ten male study participants performed a series of eight differ- ent exercises (Figure 1) while electromyography, three- dimensional lumbar motion, and external forces were mea- sured. These data were input into a series of biomechanical models in order to calculate a measure of lumbar joint forces and spine stability. These methods are extremely detailed and have already been published. While the interested reader can refer to the manuscripts for details, 11,17,18 the essential details are documented here. A schematic of the protocol is shown in Figure 2. All procedures were approved by the University Ofce for Research Ethics. Subjects. Ten male university students with an average age of 21 years (SD 3 years), height of 177.8 cm (SD 6.2 cm), and weight of 80.2 kg (SD 12.1 kg) volunteered to participate in this study. Subjects had no history of low back pain. Before testing, study participants height, weight, and breadth dimen- sions at the feet, ankles, knees, hips, hands, wrists, elbows, and shoulders were obtained while standing in anatomic position. Figure 1. Pictures of different stabilization exercises. A, Abdominal curl. B, Right side bridge. C, Sitting on a stool. D, Sitting on a gym ball. E, Four-point kneeling with contralateral arm and leg extension. F, Four-point kneeling with single leg extension. G, Back bridge with single leg extension. H, Back bridge. 1255 Torso Muscles and Rehabilitation Exercises
Kavcic et al Data Collection Exercises. Each study participant performed a series of eight exercises presented in random order. The exercises (shown in Figure 1) include the abdominal curl (A), right side bridge (B), sitting on a gym ball (D), four-point kneeling with a left arm and right leg extension (E), four-point kneeling with right leg extension (F), back bridging with right leg extension (G), and back bridging (H). To act as a control trial for the gym ball condition and allow for assessment of unstable support sur- faces, study participants performed trials sitting on a stool (C). Figure 2. Flow chart of the various models used in the stability analysis. 1256 Spine
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2004 The stabilization exercises were chosen for ease of analysis as well as to ensure moments to the spine in all three axes of rotation (Table 1). Each exercise was performed with a neutral lumbar spine position and controlled limb positioning. Limb and/or pelvis position was controlled through the use of an external frame with metal bars that was placed alongside body segments to act as targets. Each exercise was held isometrically for 2 seconds with an isometric contraction of the abdominal muscles (termed ab- dominal brace). 1 A brace is an isometric contraction of all the muscles of the abdominal wall without any change in the po- sition of the muscles. This is in contrast to the abdominal hollow, described by Richardson et al, 4 which is intended to focus on the recruitment of the transverse abdominis while minimizing activation of the rectus abdominis and the ob- liques. Bracing has been shown to be superior to hollowing for enhancing lumbar stability. 23 Subjects were shown the tech- nique for performing both the hollow and brace abdom- inal contraction, and the instruction was to perform the brace to the same perceived intensity as a hollow. Conse- quently, the intensity of the contraction was fairly low, however, since the intensity was chosen subjectively, the stability demand of some postures may have required that study participants brace more intensively than originally instructed. Subjects were given an unlimited number of practice trials and once comfortable with the technique of performing each exercise with an abdominal brace, three successive trials were measured. Instrumentation Electromyography. Fourteen channels of EMG were col- lected fromthe following muscles bilaterally: rectus abdominis, internal oblique, external oblique, latissimus dorsi, thoracic erector spinae (longissimus thoracis and iliocostalis at T9), lumbar erector spinae (longissimus and iliocostalis at L3), and multidus (1cmlateral to L5). We acknowledge the difculty in capturing multidus with surface electrodes 19 and therefore assign validity of the EMG signal to the landmarked location rather than to the multidus muscle itself. Ag-AgCl surface electrodes were positioned with an interelectrode distance of about 3 cm. The EMG signals were amplied and then A/D converted with a 12-bit, 16-channel A/D converter at 1,024 Hz. Each study participant was required to perform a maximal contraction of each measured muscle for normalization of each channel. For the abdominal muscles each study participant, while in a sit-up position and manually braced by a research assistant, produced a maximal isometric exor moment fol- lowed sequentially by a right and left lateral bend moment and then a right and left twist moment; little motion took place. For the extensor muscles, a resisted maximum extension in the Biering-Srensen position was performed with focus on quasi- static motion throughout neutral lordosis, which was found to create larger neural drive. The EMG signal was normalized to these maximal contractions, full wave rectied and low-pass ltered with a second-order Butterworth lter. A cutoff fre- quency of 2.5 Hz was used to mimic the frequency response of the torso muscles. 11 Three-Dimensional Kinematic Positioning of the Lumbar Spine. Lumbar spine kinematics was measured about three or- thogonal axes using a 3 Space IsoTRAK, electromagnetic tracking instrument (Polhemus Inc., Colchester, VT). This in- strument consists of a single transmitter that was strapped to the pelvis over the sacrum and a receiver strapped across the ribcage, over the T12 spinous process. Thus, the position of the ribcage relative to the sacrum was measured, isolating lumbar motion. Overall rotation of the lumbar spine was normalized relative to each study participants standing neutral spine pos- ture. In this way, individual variance in the passive tissue con- tributions as a function of maximum range of motion was represented. However, in this experiment, there was minimal contribution of the passive tissue restorative moment because of the neutral spine posture characteristic of the stabilization exercises chosen. External Force Measures. For exercises requiring an inverse dynamic load application, namely, the four-point kneeling ex- ercises, back bridging exercises, and the side bridge, external force measures were recorded using an AMTI force plate. The signals were amplied to produce a peak to peak range of 20 V (10V) and then A/Dconverted with a 12-bit A/Dconverter at 1,024 Hz. Forces and moments were measured about three axes and were used to calculate the external force center of pressure values in the x, y, and z direction. For each exercise, the study participant was instructed to position the contacting segment on the force plate around the 0, 0, 0-reference point located at the center of the force plate. Reaction forces were measured at different parts of the upper body depending on the exercise being performed (Figure 1). Force plate measures were not recorded for the abdominal curl or ball sitting and chair sitting exercises. The process of using whole body linked seg- ment dynamics and measured external forces has been ex- plained previously. 11 Kinematic Limb Positions. Kinematic marker data for each exercise were measured from a single study participant, not part of the group of 10 mentioned above. This study partici- pant had a height of 178 cmand a weight of 79 kg. The external segment kinematics were recorded for each exercise posture with a single digital video image and guided by a space frame jig. The isometric position of each exercise was used to analyze the segment kinematics in the sagittal plane. The joints digi- tized for the kinematic analysis were the metatarsal, ankle, hip, shoulder, elbow, wrist and hand bilaterally, as well as L4L5 and C7T1. The kinematic posture obtained for each exercise was controlled in the other 10 study participants with the ex- ternal jig, and the marker data were scaled to the height of each individual study participant. The joint locations about the z- axis, or in the frontal plane, were scaled to the breadth mea- Table 1. Summary of the support moments created at the L4L5 joint in order to perform the different exercises Average L4L5 moment (Nm) Bend ( 1 SD) Twist ( 1 SD) Flex ( 1 SD) Abdcurl 1.30 (1.9) 0.72 (0.99) 56.71 (7.0) Chair 0.54 (0.5) 0.10 (0.3) 1.47 (0.5) Ball 0.72 (1.0) 0.18 (0.5) 1.28 (0.5) Bridge 0.15 (3.9) 2.64 (7.6) 73.81 (32.7) Bridge leg 8.42 (5.0) 15.74 (7.6) 65.94 (33.3) Fpn_leg 4.84 (2.9) 15.62 (8.1) 6.14 (25.3) Fpn_arm/leg 0.05 (5.1) 57.05 (14.6) 32.84 (23.2) Side bridge 69.18 (21.9) 12.80 (3.9) 2.87 (3.4) Average and standard deviations are listed. In the sagittal plane, exion is negative and extension is positive. In the frontal plane, right lateral bend is positive and left lateral bend is negative. In the transverse plane, right axial twist is negative and left axial twist is positive. 1257 Torso Muscles and Rehabilitation Exercises
Kavcic et al sures taken from each study participant. Since no exercise re- quired deviations of the limbs from anatomic position in the frontal plane, breadth measures were assumed to be constant across exercises. Data Analysis Calculating a Stability Index. The analysis of stability was performed using a method documented by Cholewicki and McGill 11 and involved three cascading and interdependent models. For the interested reader, these models are described in detail by Cholewicki and McGill, 11 McGill and Norman, 17 and McGill 18 ; however, a brief description is provided here (Figure 2, ow chart showing the modeling process for the stability analysis). The rst model is an 8-segment link segment model that uses external force measures recorded from the forceplate, study participant kinematics, and anthropometrics of height and weight to calculate reaction forces and moments acting at each of the 6 lumbar intervertebral joints through a top-down, in- verse dynamics approach. The L4L5 moments calculated fromthis linked-segment model are used to ultimately drive the EMG-assisted optimization routine that determines the muscle force proles; however, this will be described in more detail later in this section. 20 The reaction forces fromthe link segment model calculations are used to determine the shear and com- pression forces at the L4L5 joint. The second model is the lumbar spine model, which con- sists of an anatomically detailed, three-dimensional ribcage, pelvis/sacrum, and ve intervening vertebrae. More than 100 laminae of muscle and the passive tissues, which are repre- sented as a lumped parameter of torsional stiffness, are mod- eled about each axis. This model uses the measured three- dimensional relative spine motion data from the 3-space IsoTRAK system and assigns the appropriate rotation to each of the lumbar vertebral segments based on ndings from White and Panjabi. 21 Muscle lengths and velocities are determined from their motions and attachment points on the dynamic skeleton of which the motion is driven from the directly measured lumbar kinematics obtained from the study participant. As well, the ori- entation of the vertebral segments along with stress/strain rela- tionships of the passive tissues was usedtocalculate the restorative moment created by the spinal ligaments and discs. The third model, termed the distribution-moment mod- el, 22 is used to calculate the muscle force and stiffness proles for each of the muscles. The model uses the normalized EMG prole of each muscle along with the calculated values of mus- cle length and velocity of contraction to calculate the active muscle force and any passive contribution from the parallel elastic components. When input to the spine model, these mus- cle forces are used to calculate a moment for each of the 18 df of the six intervertebral joints. The objective function for the EMG-assisted optimization routine is to match the moments with a minimal amount of change to the EMG driven force proles. In this way, biologic validity of using EMG is pre- served while mathematical validity is addressed with achieving balanced moments. The adjusted muscle force and stiffness proles are then used in the calculations of L4L5 compression and shear, as well as in calculating spine stability. The most recent updates to the model, specically regarding the much improved representation of the transverse abdominis, are doc- umented by Grenier and McGill. 23 The value for stability, or stability index, was obtained by calculating a level of potential energy in the spinal structure for each of the 18 df (three rotational axes at six lumbar joints) resulting from the combined potential energy existing in both the active and passive spinal structures, minus any work done from external loads. The 18 values of potential energy were formed into an 18 18 Hessian matrix and diagonalized. The determinant of this matrix represented an index of spine stability. For a more detailed description of the mathematical procedures, refer to Cholewicki and McGill 11 and for sensitivity testing and mathematical validity of the approach see Howarth et al. 24 Before inputting data into the link-segment model, certain modications were made to both the data and the model so to enable accurate calculations of spine load and stability for cer- tain exercise postures. They are noted as follows: Abdominal curl. When performing this exercise, study par- ticipants were directed to perform a curl-up such that rotation of the upper body occurred about the base of the rib cage. Consequently, the weight supported consisted of the head and neck, thorax, and arms. Calculating moments about the L4L5 joint would consider the entire torso mass and result in an overestimation of the exor moment required by the muscles. To consider the true axis of rotation, the L4L5 marker was shifted up along the long axis of the spine to accurately repre- sent a rotation of the thorax opposed to the trunk. A thorax distance of 0.4 m, which is characteristic of a 75 percentile male was used. The mass proportion assigned to the thorax was 0.216 of body mass. 25 For this exercise only, the abdomen segment was considered a rigid segment and the thorax mo- ment was then translated to the L4L5 joint, recognizing that the rectus abdominis carries equal loading along its length. Bridging with single leg extension. In this exercise, the inter- nal oblique activation prole did not accurately represent that of the psoas muscle because of the extended leg. To account for the extra force necessary to support the extended leg, the psoas force in the lifted leg was calculated as a proportion of the moment supporting the leg, which was assumed to be primarily generated from combined action of the rectus femoris, iliacus, and psoas. The moment arms and peak isometric muscle forces used to calculate the proportions for the three listed muscles were obtained fromthe literature (Table 2). 26,27 Then, for each study participant, the support moment required to maintain the posture of the lifted leg was calculated. This moment was then multiplied by a proportionality constant for psoas and divided by its moment arm. The resulting force value was input into the 18 df lumbar spine model (Figure 2) by adding it directly to the compressive force acting on the spine, consistent with the psoas line of action. 28 Table 2. Parameters used to calculate the contribution of the psoas muscle to the support moment of the extended leg for the back bridge with single leg extension Muscle Peak isometric muscle force (N)* Moment arm (cm) Relative proportion of total hip-exion moment Psoas 370 2.9 0.19 Iliacus 430 3.0 0.23 Rectus Femoris 780 4.2 0.58 * From Delp et al. 26 Moment arms are measured at the hip during the mid stance phase of gait. Arnold et al. 27 1258 Spine
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2004 Determining a Muscles Impact on Spine Stability. The contribution of each individual muscle to spine stability was evaluated in the following way. A value of external force and muscle activation for each muscle was taken at a point in time corresponding to the 1-second point of each 2-second trial. This prole was then frozen and extended for the entire duration of the 2-second trial. The activation prole for all fascicles of a single muscle of interest, or target muscle, was then replaced by a sinusoid wave that varied from0%to 100% MVC (Figure 3A), and the analysis was run with the new mus- cle prole. A sinusoid wave was originally chosen as an input because it was thought that some muscles would demonstrate more control over stability than others. Control of spine sta- bility would be reected by a strong correlation between changes in stability with changes in muscle activation. In those muscles that had little control over spine stability, the sinusoi- dal pattern would be less evident in the stability output. A sinusoid was chosen as a very specic input that could be iden- tied in the output. Through a pilot analysis, however, there appeared to be no signicant difference in how closely stability followed muscle activation across the various muscles tested; therefore, this analysis was not performed. The specic target muscles assessed were the rectus abdomi- nis, external oblique, internal oblique, pars lumborumbers of longissimus thoracis and iliocostalis lumborum, thoracic bers of iliocostalis lumborum, longissimus thoracis, quadratus lum- borum, latissimus dorsi, multidus, and transverse abdominis. This analysis was systematically repeated for each muscle, one at a time, both unilaterally and bilaterally. To isolate the effect of each target single muscle at this level of analysis, the EMG- assisted optimization routine (Figure 2), used to balance the moments, was not used. This prevented the force and stiffness proles of the other muscles from changing. In effect, this pro- Figure 3. Sinusoidal muscle acti- vation prole from 0 to 100% MVC (A) and the associated change in the stability index when manipulating each muscle EMG prole (B). RL corresponds to the muscle on both the right and left side. Rect rectus ab- dominis; Ext external oblique; Int internal oblique; Pars pars lumborum bers of longissi- mus thoracis and iliocostalis lumborum; Ilio thoracic bers of iliocostalis lumborum; Long thoracic bers of longissimus thoracis; Quad quadratus lum- borum; Lat latissimus dorsi; Mult multidus; Trans transversus abdominis. 1259 Torso Muscles and Rehabilitation Exercises
Kavcic et al cedure allowed each muscle to be rattled and the subsequent effect of this perturbation on the spine assessed. The articial sinusoidal activation prole impacted many variables within the analysis; however, the effect was only quantied in certain variables of interest: namely, muscle force, muscle stiffness, spine loads, and the stability index. The max- imum increase and decrease in these variables, resulting from the sinusoidal manipulation, were computed and compared to a nonmanipulated control trial. In an attempt to better understand the different mechanical advantages for each of the muscles to stabilize, the RMS differ- ence was calculated across each stability index curve resulting from the manipulated muscle activation prole, as well as across the corresponding muscle force curve. The RMS differ- ence was used to quantify of the magnitude of uctuation within the particular curve. The force RMS difference was then divided into the stability index RMS difference. In this sense, an efciency ratio was created to describe the coupling between the uctuations in the force of a particular muscle and the corresponding uctuations in spine stability. Results The effect of the sinusoidal EMGactivation prole on the calculated stability index is shown for each muscle in Figure 3B The stability index for each manipulated mus- cle is superimposed on the same graph. Assessing the Absolute Impact of a Single Muscle on Lumbar Spine Stability The effect of increasing each muscle activation prole to 100%MVCon increasing the stability index is shown in Figure 4A, whereas the effect from decreasing muscle activation to 0% MVC is shown in Figure 4B. A major Figure 4. A, Increase in stability index resulting from activating a muscle bilaterally to 100% MVC. B, Decrease in stability index re- sulting from turning a muscle off bilaterally to 0% MVC. Across tasks there is no consistent pat- tern in the ability of the different muscles to affect stability. How- ever, it appears as though, across the larger muscles, in- creased activation of the mo- ment antagonist enhances stabil- ity and decreased activation of the moment agonist reduces stability. 1260 Spine
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2004 nding in the analysis is that, between the different tasks, there is no consistent pattern across muscles in their abil- ity to affect stability. This is particularly evident with some of the larger muscles, such as the rectus abdominis and the lumbar and thoracic extensors. In contrast, the quadratus lumborum, latissimus dorsi, multidus, and transverse abdominis demonstrated only small changes in their relative patterns in terms of both increasing and decreasing stability. Quantication of each muscles absolute impact on the stability index shows that, compared with the rectus abdominis, obliques, and lumbar and thoracic extensors, the quadratus lumborum, latissimus dorsi, multidus, and transverse abdominis each created minimal changes. In contrast, both the internal and external obliques con- sistently demonstrated a large impact on both increasing and decreasing stability irrespective of the task condi- tion. Between the two muscles, a more dramatic effect was produced fromthe internal obliques. One important note is that in the stabilization exercises assessed, no individual muscle, either unilaterally or bilaterally, when articially reduced in activation, created an unstable situation. An interesting result is that certain muscles demon- strated a direction-dependent effect on lumbar spine sta- bility. Specically, coactivation of what would be con- sidered an antagonist, in a torque context, enhances stability. Compare the rank order of the predominant exor: rectus abdominis versus the major lumbar exten- sors, pars lumborum, iliocostalis lumborum, and longis- simus thoracis. In the abdominal curl, which is a exion dominant task (Table 1), the three extensor muscles demonstrate a greater effect on increasing the stability index compared with the rectus abdominis. However, this pattern is reversed when quantifying each muscles ability to reduce spine stability. In contrast, during the extension dominant tasks (Table 1), the rectus abdomi- nis creates a greater increase in stability over the pars lumborum and longissimus thoracis. For the iliocostalis, lumborum, this pattern is not so evident; however, care- ful examination shows that across the extension domi- nant tasks, as the required support moment increases, the relative difference between the effects of the rectus abdominis and the iliocostalis lumborum decreases. As with the abdominal curl, when the activation levels are reduced to 0% MVC, the pattern between the exors and extensors reverses. The same association observed between the exor and extensor muscle groups is observed between certain right versus left muscle groups during asymmetric tasks such as the four-point kneeling tasks and side bridge (Figure 5). It should be noted that the above results refer to group means calculated from the 10 study participants. Across the individual study participants, the pattern of muscle impact on stability was not consistent for any given task; however, the direction-dependent effect observed among the group means exists at an individual level as well. Assessment of a Potential Mechanical Stabilizing Mechanism for Each of the Different Muscles The cost of certain muscles to stabilize is demonstrated in Figure 6. These gures showthat the larger muscles, such as the rectus abdominis, obliques, and upper and lower erectors, impose larger changes in L4L5 load compared with the other muscles tested. Given this, the nal anal- ysis assesses the efciency with which each muscle can translate their respective generated force to spine stabil- ity (Figure 7). Those muscles with higher values of the efciency ratio have a greater normalized contribution to spine stability for a given change in muscle force. In contrast to the absolute impact of the various muscles to spine stability, large efciency ratios were observed in the multidus, quadratus lumborumand transverse abdomi- nis, internal and external oblique, and iliocostalis lum- borum produced. Relatively smaller values were ob- served in the rectus abdominis, pars lumborum, longissimus thoracis, and latissimus dorsi. Discussion Clearly, there is no single muscle that is superior at en- hancing spine stability. In addition, the muscle manipu- lation method described here has provided insight into the potential neuromuscular control of lumbar spine sta- bility. Results of this analysis indicate that muscles in the trunk play several roles at once and that their roles de- pend on the instantaneous demand placed on the spinal column. Generally, those muscles that were antagonist to the dominant moment of the task were most effective at increasing stability. This nding supports the direction- dependent cocontraction pattern that has been reported in the more global muscles during different tasks. 14,29,30 The greatest reductions in stability were observed when muscles that opposed the dominant destabilizing forces were inactivated. For example, in a lateral bending task such as the right side bridge, the dominant external force at the spine is the ground reaction force acting at the forearmthat forces the L4L5 joint in a left lateral bend. The right abdominal muscles are activated not only to oppose the left lateral bend moment to support the total- body posture, but at the level of a single lumbar joint, they potentially also protect against an instantaneous instability resulting from an excessive rotation in lateral bend. During an in vivo study by Cholewicki and McGill, 31 the authors observed a temporary excessive vertebral exion in a powerlifter who incurred an injury while lifting. The authors hypothesized that a motor con- trol error in a crucial back muscle may have been respon- sible for the excessive exion instability. These tempo- rary reductions may prevent those muscles, whose job during a particular task is to oppose crucial destabilizing forces and rotational instabilities, from controlling ver- tebral motion. As the destabilizing forces on the spine change through different postures, so do the muscles that are able to oppose these forces. 1261 Torso Muscles and Rehabilitation Exercises
Kavcic et al Across the various torso muscles, the mechanical ad- vantage to provide stability to the lumbar spine varies depending on the muscle. It appears as though, on aver- age, the larger, more global muscles are better able to alter spine stability than the smaller, intersegmental mus- cles. This is most likely because of the larger force- generating potential in these muscles and their ability to generate higher levels of L4L5 compression, translating to higher levels of spine stiffness. As well, their larger moment arms enhance their ability to act as guy wires. Interestingly, the increase in compressive loads on the spine that result from muscular cocontraction has been estimated to increase stability at a higher rate than the additional compression. Specically, Granata and Mar- ras 32 have estimated that stability is enhanced threefold for a given increase in compression, whereas Grenier and McGill 23 have computed the enhancement to be at least twofold. It would appear that the qualitative assumption that activating muscles that impose low compressive loads as prime stabilizers is problematic when evaluating a quantitative stability analysis. Among the more local muscles, it is interesting to observe the minor ability of the transverse abdominis to alter spine stability when manipulated through its entire force- and stiffness- generating abilities. The mechanical advantage for the smaller, interseg- mental muscles, particularly the multidus, and quadra- tus lumborum, appears to come fromtheir efcient trans- lation of generated force to spine stiffness and stability. These results can potentially be explained by a phenom- Figure 5. Increase in stability in- dex resulting from activating a muscle unilaterally to 100% MVC. A, Results are shown for two asymmetrical tasks. B, Decrease in stability index resulting from turning a muscle off bilaterally to 0% MVC. Results are shown for two asymmetrical tasks. The same pattern observed between agonist and antagonist muscles noted in Figure 4 is observed be- tween right and left muscles dur- ing asymmetrical tasks. R corre- sponds to the muscle on the right side; L corresponds to the mus- cle on the left side. 1262 Spine
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2004 enon known as the follower load, described by Pat- wardhan et al. 33,34 According to this theory, those mus- cles that insert onto the spinal segments are better able to translate their generated force along the compressive axis of the spine or tangent to the curve of the lumbar spine. It is important to note that previous work by Crisco and Panjabi 10 reported the opposite, in that the more multi- segmental muscles are more efcient at creating a critical level of lumbar spine stiffness over the intersegmental muscles. The discrepancy in ndings, however, is consis- tent with the different models used. In their study, the lumbar spine was modeled as a straight elastic column with motion restrained to the frontal plane. With such a linear model, a given level of activation in the multiseg- mental muscles would impact many joints, whereas the intersegmental muscles may only affect one or two joints, as they described. In our analysis, the spine was modeled with a natural lordotic curvature and motion existed in a total of 18 df The ability of the intersegmental muscles to follow the curvature of the spine and direct a large com- ponent of force along the compressive axis is how the efciency of these muscles dominated over the more mul- tisegmental muscles. When attempting to apply the results of this study to clinical practice, consideration of the physiologic rele- vance of this technique is necessary. In a human neuro- muscular system, muscle synergies exist, where changes in a given muscle activation level rarely occur in isolation but rather are associated with changes in that of other muscles. For example, Richardson and Jull 35 reported Figure 6. A, Increase in L4L5 compression resulting from activating a muscle bilaterally to 100% MVC. B, Decrease in L4L5 compression resulting from turning a muscle off bilaterally to 0% MVC. The larger, multisegmental muscles stabilize through their ability to generate high levels of L4L5 compression, which is associated with increased levels of spine stiffness, together with their action as guy wires enhancing the systems potential energy. 1263 Torso Muscles and Rehabilitation Exercises
Kavcic et al that activation of the multidus is linked to that of the transverse abdominis. In order to accurately assess the stabilizing role of a given muscle and represent physio- logic reality, synergistic patterns need to be considered. Since this study examined the effect of changing a single muscle, this could be considered a limitation in terms of assessing synergies. Assessing the consequence of syner- gies is much more difcult given the many roles each component muscle plays, but it is our objective to exam- ine this in the future. The benet of this analysis, how- ever, is to address the clinical misconception that at any given moment a single muscle can provide the necessary stability to the lumbar spine. One nding observed in this analysis was that no single muscle, when manipulated from 0% to 100% MVC, created an unstable spine. It does not seem reasonable then that any one muscle in isolation has the capabilities to dramatically impact spine stability, at least in the stability exercises tested here, although we have found some low challenge tasks where this is not the case. This study showed that as loads are applied to the spine there is an integration of the many different muscles in order to balance the stabil- ity and moment demands, and these patterns change as the spine loading patterns change. One feature of this technique was that it was successful at identifying the total contribution that each muscle can make to stability, relative to the other torso muscles tested. In this light, it is noticed that the smaller muscles have a stabilizing role through their efcient generation of force, however, as loads increase the need for the stronger global muscles is required. One important note is that only the contributions of the muscles force proles to stability were assessed. Other potential roles that inuence stability such as proprioceptive integration or passive-elastic link with intra-abdominal pressure were not assessed. Another benet of manipulating a muscle in isolation is that the changes created in stability can be associated with only the manipulated muscle. Allowing an optimi- zation routine to balance the muscle force moments to the external moments would have caused changes in the force proles of various muscles, and associating these changes to that observed in the stability index would be a difcult task. Many assumptions were made in this study as a result of the biomechanical modeling procedure used. Assump- tions made in the biomechanical models used in this analysis have been documented previously, 11 and while great attempts were made to achieve biodelity, this highly complex analysis could not be performed without them. Lastly, the conclusions of this work are limited to the contrived stability exercises tested. One important note is that in the abdominal curl exercise, the actual torque is generated at the level of the midthoracic spine; however, in this analysis, in order to assess the stabilizing ability of the different muscles in the lumbar spine during a exion task, the moment created at the thoracic level was translated to the lumbar spine. Given that the study participants were fully supported laying supine on the oor, the individual muscle contributions to lumbar spine stability during the type of abdominal curl per- formed here remain unknown. In terms of the practical application of the ndings in this study pertaining to prevention and rehabilitation, the clinical practice of isolated training of a specic mus- cle or group of muscles in attempts to reduce the com- pressive costs must be questioned. According to the re- sults of this study, it appears justiable to train motor patterns that involve the contribution of many of the potentially important lumbar spine stabilizers. This seems to be the case since although some of the highly regarded Figure 7. RMS of stability curve normalized to RMS of muscle force curves. One mechanism explaining how the smaller, intersegmental muscles stabilize could result from their ability to efciently translate their respective generated force to spine stability. 1264 Spine
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2004 local muscles can create stability very efciently, their abso- lute contribution is not dominating and may not be suf- cient during functional tasks. Focusing on a single muscle, or only a few, appears to be misdirected clinical effort if the goal is to ensure a stable spine. Key Points Using various assumptions and variations to a biomechanical model, assessment of the stabilizing role of different muscles was quantied for different loading scenarios. The role of each individual lumbar muscle changes as the loads placed on the spine changes. Consideration should be given to each potential stabilizer when designing exercise programs in- tended to increase spine stability. References 1. McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilita- tion. Champaign, IL: Human Kinetics, 2002:143. 2. Panjabi MM, Abumi K, Duranceau J, et al. Spinal stability and intersegmen- tal muscle forces: a biomechanical model. Spine. 1989;14:194200. 3. Bergmark A. Stability of the lumbar spine: a study in mechanical engineering. Acta Orthop Scand Suppl. 1989;60:154. 4. Richardson C, Jull G, Hodges P, et al. Therapeutic exercise for spinal seg- mental stabilization. In: Lower Back Pain. London: Harcourt Brace, 1999. 5. Hodges PW, Richardson CA. Feedforward contraction of transverse abdo- minis is not inuenced by the direction of arm movement. Exp Brain Res. 1997;114:362370. 6. Hodges PW, Richardson CA. Delayed postural contraction of transverse abdominis in low back pain associated with movement of the lower limb. J Spinal Disord. 1998;1:4656. 7. Hides JA, Stokes MJ, Saide M, et al. Evidence of lumbar multidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994;19:165172. 8. Panjabi M, Abumi K, Duranceau J, et al. Spine stability and intersegmental muscle forces: a biomechanical model. Spine. 1989;14:194200. 9. Wilke HJ, Wolf S, Claes LE, et al. Stability increase of the lumbar spine with different muscle groups: a biomechanical In vitro study. Spine. 1995;20:192 198. 10. Crisco JJ, Panjabi M, The intersegmental and multisegmental muscles of the lumbar spine: a biomechanical model comparing lateral stabilizing potential. Spine 1991;16:793799. 11. Cholewicki J, McGill S. Mechanical stability of the In vivo lumbar spine: implications for injury and chronic low back pain. Clin Biomech. 1996;11: 115. 12. Cholewicki J, VanVliet J IV. Relative contribution of trunk muscles to the stability of the lumbar spine during isometric exertions. Clin Biomech. 2002; 17:99105. 13. Cholewicki J, Simons A, Radebold A. Effects of external trunk loads on lumbar spine stability. J Biomech. 2000;33:13771385. 14. Gardner-Morse M, Stokes I. Trunk stiffness increases with steady-state ef- fort. J Biomech. 2001;34:457463. 15. Gardner-Mores M, Stokes I. The effects of abdominal muscle coactivation on lumbar spine stability. Spine. 1998;23:8692. 16. Granata K, Orishimo K. Response of trunk muscle coactivation to changes in spinal stability. J Biomech. 2001;34:11171123. 17. McGill S, Norman R. Partitioning of the L4L5 dynamic moment into disc, ligamentous and muscular components during lifting. Spine. 1986;11:666 677. 18. McGill S. A myoelectrically based dynamic three-dimensional model to pre- dict loads on lumbar spine tissues during lateral bending. J Biomech. 1992; 25:395414. 19. Stokes I, Henry S, Single R. Surface EMGelectrodes do not accurately record from lumbar multidus muscles. Clin Biomech. 2003;18:913. 20. Cholewicki J, McGill S. Relationship between muscle force and stiffness in the whole mammalian muscle: a simulation study. J Biomech Eng. 1995;117: 339342. 21. White A, Panjabi M. Clinical Biomechanics of the Spine. Philadelphia: Lip- pincott, 1978:79. 22. Ma SP, Zahalak GI. A distribution-moment model of energetics in skeletal muscle. J Biomech. 1991;24:2135. 23. Grenier S, McGill S. Lumbar spine stability fromhollowing vs. bracing: the transverse abdominis is no more important than any other muscle to ensure lumbar stability. Submitted. 24. Howarth S, Allison A, Grenier S, et al. On the implications of interpreting the stability index: a spine example. J Biomed. In press. 25. Winter DA. Biomechanics and Motor Control of Human Movement, 2nd ed. Toronto: John Wiley and Sons, 1990:5657. 26. Delp SL, Loan JP, Hoy MG, et al. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE Trans Biomed Eng 1990;37:757759. 27. Arnold A, Salinas S, Asajawa D, et al. Accuracy of muscle moment arms estimated from MRI-based musculoskeletal models of the lower extremity. Comput Aided Surg 2000;5:108119. 28. Santaguida PL, McGill SM. The psoas major muscle: a three-dimensional geometric study. J Biomech. 1995;28:339345. 29. Thomas JS, Lavender SA, Corcos DM, et al. Trunk kinematics and trunk muscle activity during a rapidly applied load. J Electromyogr Kinesiol. 1998; 8:215225. 30. McGill S. Electromyographic activity of the abdominal and low back mus- culature during generation of isometric and dynamic axial trunk torque: implications for lumbar mechanics. J Orthop Res. 1991;9:91103. 31. Cholewicki J, McGill S. Lumbar posterior ligament involvement during ex- tremely heavy lifts estimated from uoroscopic measurements. J Biomech. 1992;25:1728. 32. Granata KP, Marras WS. Cost-benet of muscle cocontraction in protecting against spinal instability. Spine. 2000;25:13981404. 33. Patwardhan AG, Harvey R, GhanayemA, et al. Afollower load increases the load-carrying capacity of the lumbar spine in compression. Spine. 1999;24: 10031009. 34. Patwardhan AG, Meade KP, Lee B. A frontal plane model of the lumbar spine subjected to a follower load: implications for the role of muscles. J Biomech Eng. 2001;123:212217. 35. Richardson C, Jull G. Muscle control-pain control: what exercises would you prescribe? Man Ther. 1995;1:210. 1265 Torso Muscles and Rehabilitation Exercises