A Clinical Palpation Test to Check the Activation of the Deep Stabilizing Muscles of the Lumbar Spine.pdf

 International SportMed Journal,  2000, Volume 1, Issue 4 © Human Kinetics Publishers, Inc.

A Clinical Palpation Test to Check the Activation of the Deep Stabilizing Muscles of the Lumbar Spine  Julie Hides, Quentin Scott, Gwendolen Jull, and Carolyn Richardson Segmental stabilization training (SST) is an exercise approach that has been developed to target muscles associated with the control of stabilit y of the spinal segments. The basis of t he concept is to teach patients t o co-contract the transversus abdominis and multifidus muscles independently of the global muscles, with the aim of decreasing low back pain, disabilit y, and recurrence. A clinical palpation test can be used to monitor  co-contraction of the deep muscles during SST.  Key Words: stabilization, multifidus muscle, transversus abdominis muscle, low back pain, rehabilitation, therapeutic exercise

Introduction Recent years have witnessed an increasing emphasis on more specific exercises for the spinal muscles. Segmental Stabilization Training (SST) was developed to target the muscles associated with the control of stability of the spinal 1 segments, with the aim of developing more effective and efficient exercise programs for low back pain (LBP). SST targets the local, stabilizing muscles of the lumbo-pelvic region,2 including the transversus abdominis (TrA) and  4,5 the lumbar multifidus (LM). Research indicates that these muscles have motor control deficits  and/or undergo 6,7 inhibition  in LBP pati ents. The global muscle system encompasses the larger, superficial muscles of the trunk, which control trunk movement (e.g., external oblique and erector spinae muscles). These muscles may even be more 1 active in the LBP population. The concept, which has become the basis of SST, is the ability to co-contract TrA and LM independently of the 1 global muscles.  The active co-contraction of the deep muscles is performed slowly at a low l evel of muscle activity and has been described as “forming a deep muscle corset.” Clinical assessment is an essential element for the accuracy and efficiency of the exercises. Three types of clinical assessment assessment have been developed to monitor the cocontraction of TrA and LM and any increased contribution of the global muscles. These include the prone test with the Stabilizer (Chattanooga),1 a newly developed test using real-time ultrasound 8,9 and the clinical palpation test.

The Clinical Palpation Test Clinicians and clients can use a simple palpation test to monitor the co-contraction of TrA and LM while the “corset action” is being performed (Figures 1a and 1b). To palpate TrA, place the tips of two fingers (or proximal pads of  the thumb) just medial and distal to the anterior superior iliac spines (Figures 2 and 3). To recognize first a poor  muscle pattern, ask the client to cough and feel a bulging under the fingers. This occurs with increased global muscle activation and accompanying increase in intr a-abdominal pressure. For the correct action, the client is instructed to slowly and gently draw in the abdominal wall. The l ower abdomen should draw in (Figure1b) and a gentle deep tension should be felt under the fingers equally on each side. A change to a feeling of pushing out under one or both sides indicates increased activation of the global muscles rather than the independent contraction of the TrA. Clients can use palpation for self checks during exercises. These palpation tests also aid the clinician in interpretation of the prone test using the Stabiliser (Figure 4).

For palpation of the isometric contraction of LM in the co-contraction, place the index finger and thumb on each side of the lumbar spinous processes. Tests are performed separately at each level. Use gentle deep palpation, as it is the deep parts of LM, which are important (Figures 5–7). Ask the client to “slowly gently swell underneath my fingers,” and feel the gentle expansion under the fingers, equal on each side as the isometric contraction occurs. This should   be achievable without spinal movement and minimal global muscle activation.

Conclusion The simple palpation test can be used by athletes to self monitor the co-contraction of the deep muscles during SST. Up until now, no formal studies had been done on the palpation t est, but there is one presently in progress.

References 1. Richardson CA, Jull GA, Hodges PW, Hides JA. Therapeutic Exercise for Spinal Segmental Stabilization in Low  Back Pain. Edinburgh: Churchill Livingstone; 1999. 2. Bergmark A. Stabilit y of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand. 1989;230(suppl.):20-24. 3. Hodges PW, Richardson CA. Inefficient muscular stabilisation of the l umbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine. 1996;21:2640-2650. 4. Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated  with movement of the lower limbs. J Spinal Disorders. 1998;11:46-56. 5. Hodges PW, Richardson CA. Altered trunk muscle recruitment in people with low back pain with upper limb movements at different speeds.  Arch Phys Med Rehabil. 1999;80:1005-1012. 6. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994;19:165-172. 7. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine.1996;21:2763-2769. 8. Hides JA, Richardson CA, Jull GA, Davies SE. Ultrasound imaging in rehabilitation. Aust J Physiother  1995;41(3):187-193. 9. Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound imaging for feedback in rehabilitation.  Manual Ther. 1998;3(3):125-131.

Appendix: Figures

Figure 1(a) — Relaxed abdominal wall in standing.

Figure 1(b) — Observation of  posterior displacement or drawing in of the anterior abdominal wall while “corset action” exercise is performed.

Figure 3 — Palpation of the TrA using pads of therapists thumbs during the “corset action” exercise.

Figure 2 — Client self-palpating the TrA during the “corset action” exercise. The tips of two fingers are placed just medial and distal to the anterior superior iliac spines.

Figure 4 — Prone test using the Stabiliser. Palpation of  the anterior abdominal wall is performed to detect correct contraction of the TrA and to monitor for bulging of the abdominal wall (incorrect performance). The hand and forearm can be used to detect spinal movement during the test (incorrect performance).

Figure 5 — Palpation of the isometric contraction of LM in the co-contraction, using the index finger and thumb on each side of the lumbar spinous process. The other hand can be used to palpate the TrA anteriorly.

Figure 7 — Palpation of the co-contraction of TrA and LM in the sidelying position.

Figure 6 — Hand position for palpation of the isometric contraction of LM. Each segment is palpated individually.

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