Maitland. G D (1SeS).W
M ManrpuletiOn. 5th edn,Butterwarth.London.
Nonis. C M (1993).Abdminal musde training in S p f , BribGh
.bunm/dSpatrMe&ne,27,1,1Q-27.
m.C M (I-). Awormnal
. training. Dangers and exercise
Prysiocherapyin Sjnnt, 19,5,10-14.
Spinal Stabilisation
P.-Limiting Factors to End-range Motion in the
Lumbar Spine
Chriutopher M Norria
-word.
Lumber spine. bkmechani, proprioception, mwclelength.
Summaty
Biomechani fadm which limit range of motion in the lumbar
spine are reviewed. The effects of axial compression on the
vertebral body, intervertebral disc, and zygapophysealjoints
are considered. During axiai compression blood is squeezed
from the vertebral body leaving a latent period of reduced
shock-absorbing ability. Continuous repeated loading of the
spine is themfore not recommended during exercise. lntradscal
presswevarieswithdmmntbodypositbm,and is especially
high during slumped sitting, making this an inappropriate
~ p O s i ( i 0 n d u h g e x e r d s e .Marked loss of height through
d w l compression is seen following certain weight training
exercises making these unsuitable for subjects with discai
. .TheJBhodcebsorbingpcopectiesdthediscreduce
important considerationwhen prescribing exercise
for d d e r people. Flexbn and extension movements combine
sagittal rotatbn and translation of the vertebrae, leading to
facet hpactbn at end range. Impadion is more damaging with
mOmbnhlrn from fast movements. The importence of relative
StMneas and muscle length to lumbar-pelvic rhythm is highllghled. The relevance of artxular tropism is examined. The
p r w b a w h role d the deep intersegmental musdes of the
Frnisccmklmd,end the importance otproprioceptive trainagduringrehabiutatkoofephel~~is~$ed.
Vertebral Body
Within the vertebra itself, compressive force is
Introduction
transmitted by both the cancellous bone of the
A joint is lem likely to be iqjured if it is loaded vertebral body and the cortical bone shell. Up to
within ita mid-range of motion rather than a t the age of 40 years the cancellous bone conextreme end range. At end range, pain of mech- tributes between 25% and 55% of the strength of
anical origin can occur through over-stretching the vertebra. After this age the cortical bone
of the eurrounding eoR tissues and stimulation shell carries a greater proportion of load as the
65
66
-~
peripherally, eventually causing the annular nucleus pdposus of the disc will be compressed
fibres to become fibrillated and to crack (Hirsch anteriorly while pressure is relieved over its poetenor surface. As the total volume of the dim
and schajowicz, 1952).
remains unchanged, its preesure should not
As a consequence of these age-related changes increase. The increases in pressure seen with
the disc is more susceptible to iqjury later in We. alteration of posture are therefore due not to the
This, combined with the reduction in general fit- bending motion of the bones within the vertebral
ness of an individual, and changes in movement joint itaelf, but to the soft-tissue tension created
pattern of the trunk related to the activities of to control the bending. If the pressure at the L3
daily living, greatly increases the risk of injury disc for a 70 kg standing subject is said to be
to this population. Individuals over the age of 1001, supine lying reduces this pressure to 25%.
40 years, if previously inactive, should therefore The pressure variations increase dramatically
be encouraged to exercise the trunk under the as soon as the lumbar spine is flexed and tissue
Supervieion of a physiotherapist before attending tension increases. The sitting posture increases
fitnem classes run for the general public.
intradiscal pressure to 140%, while sitting and
leaning forward with a 10 kg weight in each
Zygapophyseal Joints
hand increases pressure to 275%(Nachemson,
The superior/inferior alignment of the zygapo- 1987). The selection of an appropriate starting
phyaeal joints in the lumbar spine means that position for trunk exercise is therefore of great
during axial loading in the neutral position the importance. Superimposing spinal movements
joint surfaces will slide past each other. How- from a slumped sitting posture for example
ever, it must be noted that the orientation of the would place considerably more stress on the
zygapophyseal joints may change from those spinal discs than the same movement beginning
characteristic of the thoracic spine to those of from crook lying.
the lumbar spine, anywhere between T9 and
T12. Therefore the level at which particular During flexion, t h e posterior annulus is
movements will occur can vary considerably stretched, and the nucleus is compressed on to
between subjects. During lumbar movements, the posterior wall. The posterior portion of the
displacement of the zygapophysealjoint surfaces annulus is the thinnest part, and the combinawill c a w them to impact. Because the sacrum tion of stretch and pressure to this area may
is inclined and the body and disc of L5 is wedge result in discal bulging or herniation. Because of
shaped, during axial loading W is subjected to the alternating direction of the annular fibres,
a shearing force. This is resisted by the more during rotation movements only half of the
anterior orientation of the L5 inferior articular fibres w i l l be stretched while half relax. The disc
processes. In addition, as the lordosis increases, is therefore more easily injured during combined
the anterior longitudinal ligament and the ante- rotation and flexion movements.
rior portion of the annulus fibrosus will be As the lumbar spine flexes, the lordosis flattens
stretched giving tension to resist the bending and then reverses at its upper levels. Reversal of
force. Additional stabilisation is provided for the lordosis does not occur at M-Sl (Pearcy et al,
L5 vertebra by the iliolumbar ligament, attach- 1984). Flexion of the lumbar spine involves a
ed to the L5 transverse process. This ligament, combination of anterior sagittal rotation and
together with the zygapophyseal joint capsules, anterior translation. As sagittal rotation occurs,
w i l l stretch and resist the distraction force.
the articular facets move apart, permitting the
Once the axial compression force stops, release translation movement to occur. Translation is
of the stored elastic energy in the spinal liga- limited by impaction of the inferior facet of one
ments will re-establish the neutral lordosis. vertebra on the superior facet of the vertebra
With compression of the lordotic lumbar spine, below (fig 1).As flexion increases, or if the spine
or in cases where gross disc narrowing has is angled forward on the hip, the surface of the
occurred, the inferior articular processes may vertebral body will face more vertically, increasimpact on the lamina of the vertebra below. In ing the shearing force due to gravity. The forces
this case the lower joints (W4, W 5 ,WS1) may involved in facet impaction will therefore
bear as much as 19%of the compression force increase to limit translation of the vertebra
while the upper joints (LU2, LW3) bear only 11% and stabilise the lumbar spine. Because the
zygapophysealjoint has a curved articular facet,
(Adamsand Hutton, 1980).
the load will not be concentrated evenly across
Flexion and Extension
the whole surface, but will be focused on the
During flexion movements the anterior annulus anteromedial portion of the facets.
of the lumbar discs will be compressed while the The sagittal rotation movement of the zygapoposterior fibres are stretched. Similarly, the physeal joint causes the joint to open and is
backwards, over-stretching and possibly damaging the joint capsule (Yang and King, 1984).
With repeated movements of this type, eventual
erosion of the lamina1 periosteum may occur
(Oliver and Middleditch, 1991).At the site of
impaction, the joint capsule may catch between
the opposing bones giving another came of pain
(Adams and Hutton, 1983). Structural abnormalities can alter the axi8 or rotation of the vertebra, so considerable between-subject variation
exists (Klein and Hukins, 1983).
Lumbar-pelvic Rhythm
The combination of movements of the hip on the
pelvis, and t h e lumbar spine on t h e pelvis
increases the range of motion of thie body area.
In forward flexion in standing for example,
when the legs are atraight, movement of the
pelvis on the hip is limited to about 90'hip flexion. Any further movement, allowing the subject
to touch the ground, must occur at the lumbar
spine. In this example the body is acting as an
open kinetic chain and the pelvis and lumbar
spine are rotating in the same direction. Anterior tilt of the pelvis is accompanied by lumbar
flexion (fig 2a). In the upright posture, the foot
and shoulders are static and so spinal movement
acts in a closed kinetic chain. In this situation
movements of the pelvis and lumbar spine (lumbar-pelvic rhythm) occur in opposite directions
(fig 2b). Now, a n anteriorly tilted pelvis is
compensated by lumbar extension to maintain
the head and shoulders in a n upright orient-
0
\\
1
Fb 2 Lumbar-paMc rhythm
(a) Lumbar-peMc rhythm in open &In
tomatton occurs
in tho same direction. Anterlor pelvic tilt accompmk.
lumbar flexion
(b) Lumbarrhythm In closed kinetic chaln formath
occ11m in opposb directions. Anterior paMc tin k corn
p8M.1.dby lumbar extomion
Atxwqmnjdnghip
johtmobbn
HiAexion
Anterkr*P
PosteriOrpeMctilt Hiextension
R i hip adduction
lateral phnc tik
(pehric drop)
Lateral phnc tik
K i t hip abduction
(hip hltch)
Fornardrotation
RigMhipMR
Backwardrotation R i t hip LR
f2awmsatw
lumbar mobon
Lumbar extension
Lumbar Rexion
Right lateral R e x h
Left lateral flexion
Rotationto the left
R o t a h to ttie &ht
individual Differences in
Zygapophyseal Joint Orientation
The shape and orientation of the zygapophyseal
joints varies between individuals, and in the
same individual, between different spinal levels.
Viewed from above the joint surfaces may be
flat, slightly curved, or show a more pronounced
curvature and be C or J shaped. Curved joint
surfaces are more common in the upper lumbar
levels (Ll-2, L2-3, L3-4) but flat joint surfaces
are more often seen at the lower lumbar levels
(L4-5,L5-Sl) (Horwitz and Smith, 1940).
Where the joint surfaces are flat, the angle that
they make with the sagittal plane will determine the amount of resistance offered to both
forward displacement and rotation (fig 4). The
more the joint is oriented in the frontal plane,
the more it will resist forward displacement, but
the less able it is to resist rotation. This orientation is usually seen at the lower two lumbar levels. When the joint surfaces are aligned more
sagitally, the resistance offered to rotation is
greater, but that to forward displacement is
reduced. Where the joint surfaces are curved,
the anteromedial portion of the superior facet
(which faces backwards) will resist forward displacement.
At birth the lumbar zygapophyseal joints lie in
the frontal plane, but their orientation changes
v
(b) Frontd
*.
wlH m
d- d
bul no(
m
patients have been shown to report back pain Muscle Length
and sciatica on the side of the more obliquely set Anteroposterior tilting of the pelvis on the
joint (Fadan and Sullivan, 1967).
femoral heads w ill change the lumbar lordosis.
The lordosis itself is controlled by both intrinsic
hprioceptive Role of
and extrinsic factors (Bullock-Saxton, 1988).
LumbarTissues
Intrinsic factors include t h e shape of the
Nerve fibres from the grey rami c o m m d c a n h sacrum, intervertebral discs and lumbar verteand the sinuvertebral nerves are found at the brae (especially L5), the inclination of the
outer edge of the disc and within the anterior sacral end plate, the length of the iliolumbar
and posterior longitudinal ligaments. It has ligaments, and the obliquity of the pelvis.
been euggeeted that the encapsulated nerve end- Extrinsic factors include the muscles attached
ings found on the annular surface have may to the pelvis and lumbar spine, which will afect
have a proprioceptive function (Malineky, 1959). pelvic tilt either actively through contraction,
In addition, the cervical intertransversarii or passively through tightness. The abdominal
muscles have been shown to have a proprio- group, hip flexors, lumbar erector spinae,
ceptive role as they contain a large number gluteals, and hamstrings can all be considered
of muscle spindles (Cooper and Danial, 1963; as extrinsic limiting factors to pelvic t i l t
Abrahams, 1977),and a similar role may exist (Toppenbergand Bullock, 1986).
for the equivalent lumbar group. The deep
intersegmental muscles of the spine in general The pelvis can be thought of as a seesaw
have up to six times more muscle spindles balanced on the hip joints. Anterior (forward)
than their superficial counterparts (Bogduk tilting of the pelvis occurs when the anterior
and Twomey, 19911,so a proprioceptive role part of the pelvis drops downwards, and
seems likely for the deep muscles and other posterior (backward) tilting is the reverse action,
with the anterior pelvis moving upwards.
small museles in the body (Bastide et d,1989).
The passive stabilisation system of the spine Anterior tilting increases the lumbar lordosis
does not provide significant stability in the and is commonly a result of lengthening of the
neutral (mid-range) position as the spinal abdominal muscles and possibly tightness in the
tissues are relaxed. However, the passive com- hip flexors. The abdominal muscles have been
ponents may have a function in mid range if shown to demonstrate little activity in standing
they act as transducers measuring vertebral (Sheffield, 1962;Basmajian and Deluca, 1985),
positions and motions (Paqjabi, 1992). Similar which is normally the position in which the
systems are found in the knee ligaments increased lordosis is demonstrated. In addition,
using standard field tests no correlation has
(Barrack et aZ, 1989;Brand, 1986).
been found between abdominal strength and
hprioception provides a link between the three
pelvic tilt Walker et al, 1987). However, a posidability systems. Muscle force produced by the
tive correlation has been shown between abdomactive system is detected by receptors within the
inal muscle length and lordosis (Toppenberg and
passive tissues and this information is relayed
to the neural system. Having measured the Bullock, 1986).
muscle tension, the neural system can then
adjust this until the required stability of the
spine is achieved. Stability in this case is a
dynamic process. If one stabilising subsystem is
degraded, othera can compensate to help maintain stability. In addition there is a functional
reserve which may be called on to provide
enhanced stability in cases of high demand,
for example during heavy lifting.
71
Posterior tilting reduces the lordosis and is commonly seen in sitting, especially with the legs
straight. In this case tightness of the hamstrings
pulls the posterior aspect of the pelvis down, and
fails to allow the pelvis to tilt anteriorly and permit a neutral lordosis (Stokes and Abery, 1980).
109-119.
Brand, R A (1986).'Knee ligaments: A new view'. Joomat d
B i o m h a n i a l ngintmnng, 108.106-110.
Bullock-Saxton, J (1988).'Normal and abnormal postures In
the sagittal plane and their relationship to low back pain',
Phydotherapv Pradice. 4,-104.
Byl, N N and Sinnott. P L (1991).'Variations in balance and
body sway in middle-aged adults: Subjects with healthy
compared with subjects with low-back dysfunction', Spine, 16.
325-330.
Cappouo, A, Feli, F, Figura, F and Gazzani. F (1985).'Lumbar spine loading during half-squat exercises', Medicine and
Science in Spods and he&, 17,5,61-.
Cooper, S and Danial. P M (1963).'Musde spindles in man,
their morphology in the lumbricals and the deep muscles of
the neck', Brain, 88,563494.
Crock, H V and Yoshizawa. H (1976).7he Mood supply of the
lumbar vertebralcolumn', ClinialO&qwt3h, 115,6-21.
Farfan, H F. Cassette. J W, Robertson, G H. Wells, R V and
Kraus, H (1970).The effects of torsion on the lumbar intetvertebral joints: The role of torsion in the production of disc d e g m
eration', Joumal of Bone and Joint Sutgery, 52A. 468.
Farfan, H F, Huberdeau. A M and Dubow, H I (1972).'Lumbar
intervertebral disc degeneration. The influence of geometrical
features on the pattern of disc degeneration - A post-mortem
study', Journal of Bone andJoint Sutgery, S A , 492610.
Relbmnc88
Abrahams, V C (1977).'The physiology of neck muscles: Their
role in head movement and maintenance of posture', csnadian
Jwmai of Physiology and Pbarmawbgy. 55,332-338.
Adams, M A and Hutton, W C (1980).The effect of posture on
the role of the apophyseal joints in resisting intervertebralcompression force', Journal of Bone and Joint Sutyery (&), 62B,
358-362.
Adams, M A and Hutton, W C (1983).The mechanical function
of the lumbar apophyseal joints', Spine, 8,327-330.
Adams, M A, Hutton, W C and Stott, J R R (1980).The resistance to flexion of the lumbar intervertebral joint', Spine, 5,
245-253.
Basmajian,J V and Deluca. C J (1985).Musdes Alive, Williams
and Wilkins, Baltimore.
Barrack, R L, Skinner, H B and Buddey, S L (1989).'Proprioception in the anterior cruciate deficient knee', American J w r rial Of Sports Medidne. 17.1-6.
Bastide, 0, Zadeh, J and Lefebvre, D (1989).'Are the 'little
muscles" what we think they are?' Surgical and Radiological
Anatomy, 11,255-256.
Bemhardt, M, Whiie, A A. Panjabi, M M and McGowan, D P
(1992). 'Lumbar spine instability' in: Jayson, M I V (4)The
Lumbar Spme and Back Pain, 4th edn. Churchill Livingstone,
Edinburgh.
Bogduk, N and Twwney, L T (1987,1991).ClinicalAnatomy of
the Lumber Spine, 1st and 2nd edns. Churchill Livingstone,
Edinburgh.
iCa,38.9&113.
Markolf, K L and Monis. J M (1974).'The s m r a l
compo-
72
&w,
SheffieM, F J (1962). Electromyographic study of the abdominal muscles in walking and other movements, American Journal of physical Medicine, 41,142-147.
Spinal Stabilisation
3.-Stabilisation Mechanisms of the Lumbar Spine
Introduction
Christopher 111Norris
Key Words
Lumbar support, muscle. fascia, biomechanics.
Summary
This paper reviews the active stabilising mechanisms of the
lumbar spine. Intra-abdominal pressure is produced by contract i n of the abdominal musdes when the glottis is closed.The
posterior ligamentous system has been shown to produce
25% of the moment of the erector spinae (ES), and the ES will
themselves produce an important passive elastic tension. In
the thoracolumbar fascia (TLF) mechanism, the horizontal
pull of transversus abdominis is changed into a vertical force via
the angled deep and superficialfibres of the TLF. The hydraulic
amplifier effect is produced as the ES contract within the fascia1
envelope formed from the middle layer of the TLF. This mechanism increases the stress generated by the ES by 30%. Multifidus is especially important to active stabilisation as it has
segmentally arranged fibres whose lines of force may be
resolved into a large vertical and small horizontal component.
The ES lines of action show it to be more suitable as a prime
mover than a stabiliser, and it is the endurance of this muscle
rather than its strength which is impoltant to stabilkation. 01 the
abdominal muscles, transversus abdominis and internal oblique
act as stabilisers. while the lateral fibres of external oblique and
the rectus -minis
act as prime movers.
no 2