Monday, January 27, 2020

Transverse Abdominis and Low Back Pain


I remember being a second year physiotherapy student in the early 90's when we had a special tutorial on how to assess and strengthen the Transverse Abdominis (TA). While in crook lying, you move your leg (bent knee fall out), leg straightening etc and had to maintain the TA contraction.

This was just before a young Paul Hodges and his supervisor Carolyn Richardson (both very famous physiotherapists) published his article on the TA. His research compared the timing of TA and Multifidus in people with low back pain (LBP). for 18 months or more against healthy subjects with no LBP.

Using fine wire and surface EMG, the participants had to move their leg or shoulder and their timing of TA and Multifidus muscles measured. Those with LBP had delayed activation of their TA/ Multifidus.

Hodges suggested that the TA was the likely to be the main cause of LBP as it is the most important and deepest muscle in the abdomen. It looks and works like a corset to stabilise the back.

This article made the allied healthcare/ fitness industry conclude that the TA was a trunk stabilising muscle that was very important to strengthen for those with LBP. Patients who had LBP had weaknesses in their TA which led to instability in the spine.

Because of Hodges' research, many other research on LBP went in that direction. However, out of the seven systematic reviews found, six of them now showed no increase in benefit in such TA based exercises over general exercises. Further research is probably not going to significantly alter this.

As I wrote last week, this early work by Hodges, Richardson and Gwen Jull was quickly adopted by the fitness industry (though Joseph Pilates never intended this). The Allied Health/ Physiotherapy community started assessing the TA via palpation, ultrasound etc and coming up with various rehabilitation exercises for it as well. There are various continuing education courses teaching this approach still.

Although research says this may help, it is no better than general graded exercise and we know that LBP is associated with obesity and mental health (Maher et al, 2016).

There is even research advising those who have been trained to brace/ hollow their 'core' should be discouraged from doing this as this may create abnormal movement patterns creating more stress on the spine (Lederman et al, 2010).
Brace or hollow your core?
So rather than getting our patients to feel for a deep muscle (like the TA and Multifidus) in a low load movement, it would make more sense for us to get patients to do an exercise/ activity they enjoy that gives them similar benefits.


References

Hodges PA and Richardson CA (1998). Delayed Postural Contraction Of Transversus Abdominis In Low Back Pain Associated With Movement Of The Lower Limb. J Sp Disorders. 11(1): 46-56.

May S and Johnson R (2006). Stabilisation Exercises For Low Back Pain: A Systematic Review. Physiotherapy. 94(3): 179-189. DOI: 10.1016/j.physio.2007.08.010

Maher CG, Underwood M et al (2016). Non-specific Low Back Pain. The Lancet. 389(10070): 736-747. DOI: 10.1016/S0140-6736(16)30970-9

Lederman E (2010). The Myth Of Core Stability. J of Bodywork, Mvt Ther. 14(1); 84-98. DOI: 10.1016/jbmt.2009.08.001

Saragitto B, Maher CG et al (2016). Motor Control Exercise For Nonspecific Low Back Pain. A Cochrane Review. Spine 41(16): 1288-1295. DOI: 10.1097/BRS.0000000000001645

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