Lumbopelvic Motor Control, Instability and

pain

Increasing prevalence of Low back pain and neck pain. Important problem. One of the main conditions treated by
PT
The reason of this increase is linked to this scheme. We change the way we function and the way we overload our
back is different.
- One of the reason why it is not good is linked with the posture and the facts we are keeping this posture
statically for a long period.

I. Lumbopelvic stability

Capacity to hold our low back in the right position.

Feedforward control of lumbopelvic stability

- Activity of the trunk muscles occurs in advance of the muscle
responsible for movement of the limbs.
- CNS predicts the effect that this movement will have on the body
and plans a sequence of muscle activity to overcome this
perturbation.

- Predictable movement
- CNS uses:
o Feedforward non direction specific activity of the intrinsic local muscles (Local stabilizers) to control
intervertebral motion,
o Tuned direction specific responses oppose the direction of reactive forces of the superficial global
muscles (Global stabilizers) to control spinal orientation

Postural responses use movement rather than simply making the

spine rigid. The placement of markers to measure trunk motion
and the angles that are measured are shown in (a) and (b),
respectively (c).
The onset of arm movement is shown with a solid vertical line. The
data indicates that when the arm is flexed rapidly at the shoulder
(downward motion in (c)), the spine moves in the opposite
direction initially and this spinal motion starts before the onset of
movement.

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PS: AP (Anteroposterior); C (Cervical); COM (Center of Mass); COP
(Center of Pressure); H-L (hip-lumbar angle (angle between the
thigh and lumbar spine); L (Lumbar); Sh (shoulder); T (thoracis)
Feedback control of lumbopelvic stability :
- When the spine is perturbed unpredictably, the nervous system must respond rapidly
- Reflex responses activate the paraspinal muscles in masse, with no differentiation between local and
global muscles (to protect ourselves)

The outcome of feedforward processes may be moulded by later feedback mediated processes.

Stabilizer muscles (local) Mobilizer muscles / global stabilizer

Multifidus Longissimus
Intertransverse Iliocostalis
Quadratus lumborum
Interspinales
(Lateral fibers)
Pelvic floor Rectus abdominis
Diaphragm Internal oblique
Transversus abdominis External oblique
Quadratus lumborum
(medial fibers)
Longissimus Iliocostalis
(Lumbar short fibers)
PS: this is only a theoretical list; in some cases, they can be on both sides.

II. Abdominal muscles in lumbopelvic stability

1. GENERALITIES

Provide stability of the lumbar spine by:

- Control of the intra-abdominal pressure: the abdominal cavity has for a floor, roof and walls, muscles.
- Control of the segmentary movements: to hold each segment individually close or stable compared to
one another. Avoiding any gliding compared to the neutral zone.

The stability is possible thanks to:

- Muscles
- Capsule, ligaments, fascia, facets, disks.

The main muscles involved in the lumbopelvic stability are:

- Diaphragm
- Transversus abdominis
- Pelvic floor

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Those muscles control the abdominal cavity with:
- The diaphragm = roof
- The transversus abdominis = the walls
- The pelvic floor = the floor
 They contract and activate to try to limit external pressure as much
as possible, avoid the change of pressure as much as possible.

The feedforward activity is to hold the walls to try to prevent the change of intra-abdominal pressure.
2. DETAILS OF THE MUSCLES
a. Transversus abdominis

- Intervertebral Stability
o Intra-abdominal pressure
o Thoracolumbar fascial tension: This muscle inserts on the spine through this fascia.
When the transversus activates, the fascia which was relaxed, becomes tensed. It
holds the vertebra as stable as possible. It is the same for every vertebra long the
whole spine.
 Activate feedforward to hold the spine.
 Its onset is before the deltoid one.
- Sacroiliac joint stability
o Also a role to stabilize that join or at least related with muscles that hold that
joint.
o Involved in some pathologies of that joint.

Try the draw-in maneuver (to activate the transversus) and other were ask to be relaxed 
look at the laxity of the SI joint.
- If we activate the transversus  less laxity.
o So the draw in maneuver is making the SI joint more stable so it has a role in
SI joint laxity recorded during
it. ret, draw-in exercise and
brace exercise. A lower
threshold unit represents a
 Summarizes all the main mechanisms in which the transversus is involved
stiffer SI joint.
- The draw-in and the brace
result in a reduction of the
joint laxity, but the draw-in
Control of the intra-segmental motion via lateral tension in
test with independent TrA
the thoracolumbar fascia. contraction is more effective.
Motion of the vertebra is associated with changes in the
length of the fascia (a). This motion can be restricted by
preventing lengthening of the fascia.
As the tensile stress in the fascia is increased, the amount
of rotation and translation can be limited.

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 b. Diaphragm and pelvic floor

- Stabilizer feedforward contraction

- Control of Intra-abdominal pressure

- Pelvic floor contraction is associated with transversus activity.

o Able to palpate. When we activate the pelvic floor, we can feel it in the
abdominal region.
o When it is hard to do the draw in exercise, we can work on the pelvic floor instead to stabilize the
intra-abdominal pressure and stabilize.
III. Para-spinal muscles in lumbopelvic stability
1. GENERALITIES

Roles:
- Control of the segmental movement: control of the neutral zone
o Hold every segment in the neutral zone
- Control of the lordosis
o They are low back extension so linked with the stability because
control the posture of the extensors.
- Tensioning of the thoracolumbar fascia: the activation influences the
tension of the fascia.
 The stabilizers are related within them.

The muscles involved are:

- Intertransverse
- Interspinales
- Multifidus
- Longissimus (deep fibers)
- Iliocostalis (deep fibers)

2. MUSCLES INVOLVED
a. Multifidus

Not ask about the specific anatomy.

We can see how many fibers it has, only above the

lumbopelvic region.
- The smaller the shorter and the thicker  the
better to provide local stability.
- It activates independently of the direction 
local stabilizer.

Local stabilizers

b. Longissimus and iliocostalis.

Have long and strong fibers + part of the muscles which are short and deep (more relevant to provide stability)

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 c. Intertransverse / Inter-spinalis

The ones added are rotators

 All can contract to hold every segment stable as much as possible.

Local stabilizers

IV. Lumbopelvic instability

Definition: Dysfunction in one or more of the stabilizing subsystems leading to an increase in the size of the
neutral zone
- Key word: Lumbopelvic instability.

This instability can be caused by any dysfunction of the following subsystems:

- Passive subsystem:
- Active subsystem: sensorimotor control
o The local stabilizers, the sensorimotor control, is not working properly.

Clinical instability is defined as the clinical signs and symptoms created by dysfunction of one or more of the
stabilizing subsystems of the spine.

Notes:
- Signs are what the PT will see / assess
- Symptoms are from the patients pov
- Clinical: diagnosis provided by the clinic (signs and symptoms collected during the examination).
o We may have other types of instability that can be diagnosed through an image, objectively, such as:

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  Ligament torn  major instability on the spine
 A major instability is an instability that is not a clinical one but that is diagnosed medically,
objectively, thanks to the imagery.

Clear relevance in prescribing exercises about the instability.

Main population touch by the pain in the SI joint: after child birth or during pregnancy, it is common to have
conditions over the pelvis. One of the most common is SI pain.
- Inflammation, pain over the SI joint. Every problem in this region can be related ot instability. To much
motion, joint out of the neutral zone for too long.
o The muscles become overloaded.

1. LUMBOPELVIC INSTABILITY DIAGNOSIS

There have been some researches about the lumbopelvic instability and the factors, internal or external, that play
on it.

There are objective factors, some signs, we can perform through osteo tests.
- Some are more or less reliable
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 o Prone instability test: we take one vertebra and we try to passively mobilize it (grade 3) and look for
the end-feel, which may be painful. If it is painful, maybe the vertebra is going out of its neutral zone
when reaching the end-feel and tense the ligaments, capsule etc. So maybe the ligaments, capsule
are inflamed because of the tension. If we try again with all of the muscles contracted, no pain
anymore -> mobilizing the vertebra till the end feel.
 Painful but when I push with the muscles contracted -> nothing.
 Positive when pain passively and no pain actively.
o Aberrant motion: Any aberrant motions that are present during flexion – extension ROM, including
instability catch, painful arc of motion, thigh climbing, reversal of lumbopelvic rhythm.

2. SUBJECTIVE FACTORS

Subjective = symptoms, what the patient feels

- Reports feelings of ‘‘giving way’’ or back ‘‘giving out’’. Self-manipulator who feels the need to frequently
crack or pop the back
- Frequent bouts or episodes of symptoms
- History of painful catching or locking during twisting or bending of the spine
- Pain during transitional activities (e.g. sit to stand)
Greater pain returning to erect position from flexion
- Pain increased with sudden, trivial, or mild movement
- Long term, chronic condition

3. OBJECTIVE FACTORS

Objective = signs, what we are seeing

- Poor lumbopelvic control, including segmental hinging or pivoting with movement, poor proprioceptive
function.
o Sudden change of position
- Poor coordination/neuromuscular control, including juddering or shaking
o A patient with a poor lumbopelvic control, has a poor coordination and therefore, will have shaking.
- Decreased strength and endurance of local muscles at level of segmental instability
o The local and global stabilizers have weakness.
- Aberrant movement, including changing lateral shift.
- Pain with sustained positions and postures.
- Gower’s sign: walks up thighs when returning from flexion

4. CLINICAL PREDICTION RULE – EXERCISE AND CLINICAL INSTABILITY

Best evidence for Identifying Patients Likely to Respond to Stabilization Exercises

Clinical Prediction Rule for Success with Stabilization - Positive prone instability test
Exercises: - Presence of aberrant movements
- 67% chance of significant improvement with 3 - Average straight leg raise greater than 91°
of 4 criteria. - Age less than 40 years
Clinical prediction Rule for Some Improvement with - Positive prone instability test
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 - Presence of aberrant movements
Stabilization Exercises. - Evidence of hypermobility, with lumbar spring
- 97% chance of some / significant improvement testing
with 3 of 4 criteria. - Fear Avoidance Beliefs physical activity subscale
score less than or equal to 9

Not know by heart but interesting

- Global idea is the fact, in case the patient fulfilled some factors explained before, we know exercise will
be useful, and specifically stabilizations exercises.
- Exercise prescription is one of the most effective intervention for patient with LBP of any type  has
been proven.
V. Low back pain (chronic)

In case of high chronic LBP, you can have

- Stabilizer muscles morphology changes
o Atrophy: associated with weakness or lack of activation
o Fatty infiltration: common when pathologies on the muscles and no training  higher amount of fat
in the muscles.
o Fiber transformation from type I to type IIC: opposite transformation to the one they would need.
Normally stabilizer muscles should have a lot of type I but here, they finish with more fibers type II.
 This justify the need of training those muscles, which causes hypertrophy, transformation from type II
to type I.

- Those muscles have an altered sensorimotor control:

o Impaired activity of local (and global) stabilizers
o Augmented activity of global mobilizers: increase tone of the muscles, tenderness, sensible, trigger
point, contractures.
 Even when we rest, the muscles are contracted  increase tone, …
 Multimodal treatment: manual therapy (Comfortable massage, compression, …) + prescribed
exercises + specific mobilizations of the muscles

Cause or result of Low Back Pain?

This is not clear yet:
- In some patients, they have a lack of stability  a problem of stability provoke pain (because sedentary,
hyperlaxed, …)
- In case we have LBP for other reasons (linked to traumatism or chronic disorders), we may have problem
of stability.

Possible mechanisms by which pain can affect motor

control.
Multiple mechanisms have been proposed.
- It is unlikely that the simple inhibitory
pathways(left) can mediate the complex changes
in motor control of the trunk muscles.
- The most likely candidates are changes in motor
planning via direct influence of pain on the motor
centers, fear avoidance or changes in the sensory
system.

Onset of activity of the trunk muscles with movement of

the arm in each direction for individuals with and without
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LBP.
- The vertical dashed line indicates the onset of the
deltoid activity.
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