Study Design. The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbance to the spine produced by arm movement.

Inefficient muscular stabilization of the lumbar spine associated with low back pain : A motor control evaluation of transversus abdominis

MEDICAL LITERATURE has been deluged during the past few years with books and papers on penicillin; but a book which has been produced under the general editorship of Sir Alexander Fleming himself represents a complete and authoritative summary of penicillin therapy as it stands today.' The book contains a series of independent contributions by \"experienced and eminent men who have worked with penicillin in Great Britain\". Their opinions and practical methods differ slightly, and there is some overlapping; but these are not disadvantageous, comparison and contrast lending interest to the reading. In the first or general section of the book Fleming contributes two chapters, one on the history and development of penicillin, introducing some interesting sidelights in the romance of discovery, the other on the bacteriological control of penicillin therapy. In both chapters the information is set out in meticulous detail and with a clarity and simplicity which can be enjoyed by all readers. Fleming also gives the right perspective to the place of penicillin amongst the antibiotics and lays down the principles of treatment. Both chapters are well illustrated and are the most outstanding in the book. Included in this first section also are chapters on the chemistry and manufacture of penicillin and its pharmacy, pharmacology and methods of administration. The second section of the book is entirely clinical, giving each author's view on the use of penicillin therapy in a disease or an infection of some particular region of the body. The entire range of peniCillin-sensitive conditions is considered in twenty authoritative and clearly written chapters; these contain many references and illustrations. Dental and veterinary diseases are also given fairly full consideration. The final section is a condensed resume of much of the preceding chapters and is written for. the general practttioner. This chapter is superttuous: it does not contain enough detall to be of much practical value. The book as a Whole, however, will undoubtedly be considered a classical contribution to medical literature and is strongly recommended, not only because of the general interest of its topic, but as a reference book on penicillin therapy of hitherto unequalled excellence. The typography, although conforming to war economy standards, is clear and the paper is good. There is an excellent list of references and the index is satisfactory.

Gray's Anatomy

Objective: To review 16 years of National Collegiate Athletic Association injury surveillance data for women’s lacrosse and identify potential areas for injury prevention initiatives. Background: Women’s lacrosse is a fast-paced, primarily noncontact sport. Participation in collegiate women’s lacrosse almost doubled between the 1988–1989 and 2003–2004 seasons. Lacrosse equipment consists of sticks made of wood or a synthetic material and a hard rubber ball. Until recently, mouth guards were the only required protective equipment. Main Results: Collegiate women’s lacrosse game injury rates increased over the 16-year study period. More than 60% of all severe game injuries were lower extremity sprains and strains and knee internal derangements, most frequently the result of noncontact incidents. The most common injury scenarios by injury mechanism and player activity were no contact while ball handling (16.4%) and contact from a stick while ball handling (10.5%). Contact from a stick or a ball accounted for 5.6% and 5.2% of injuries sustained during shooting activities, respectively. Approximately 22% of all game and 12% of all practice injuries involved the head and neck. Contact from a stick accounted for the majority (56.0%) of above-the-neck injuries in games; contact from the ball accounted for 20.0% of these injuries. Participants had 5 times the risk of sustaining a concussion in a game as in a practice (0.70 versus 0.15 injuries per 1000 athletic-exposures, rate ratio 4.7, 95% confidence interval 3.8, 6.5). Recommendations: To reduce the lower extremity injuries that comprise the greatest injury burden in women’s lacrosse, future researchers should evaluate proprioceptive, plyometric, and balance training interventions designed specifically for female players. Other research areas of great interest involve determining whether protective eyewear (mandated in 2004) reduces injuries to the eye, orbit, and nasal area and identifying any unintended consequences of the mandate, such as increased risk of injuries to other areas of the face or more aggressive play.

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Descriptive epidemiology of collegiate men's football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004

Study design A randomized, controlled trial, test--retest design, with a 3-, 6-, and 30-month postal questionnaire follow-up. Objective To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and a radiologic diagnosis of spondylolysis or spondylolisthesis. Summary of background data A recent focus in the physiotherapy management of patients with back pain has been the specific training of muscles surrounding the spine (deep abdominal muscles and lumbar multifidus), considered to provide dynamic stability and fine control to the lumbar spine. In no study have researchers evaluated the efficacy of this intervention in a population with chronic low back pain where the anatomic stability of the spine was compromised. Methods Forty-four patients with this condition were assigned randomly to two treatment groups. The first group underwent a 10-week specific exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects. The activation of these muscles was incorporated into previously aggravating static postures and functional tasks. The control group underwent treatment as directed by their treating practitioner. Results After intervention, the specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at a 30-month follow-up. The control group showed no significant change in these parameters after intervention or at follow-up. Summary A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.

Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis

Study Design. A clinical study was conducted on 39 patients with acute, first-episode, unilateral low back pain and unilateral, segmental inhibition of the multifidus muscle. Patients were allocated randomly to a control or treatment group. Objectives. To document the natural course of lumbar multifidus recovery and to evaluate the effectiveness of specific, localized, exercise therapy on muscle recovery. Summary of Background Data. Acute low back pain usually resolves spontaneously, but the recurrence rate is high. Inhibition of multifidus occurs with acute, first-episode, low back pain, and pathologic changes in this muscle have been linked with poor outcome and recurrence of symptoms. Methods. Patients in group 1 received medical treatment only. Patients in group 2 received medical treatment and specific, localized, exercise therapy. Outcome measures for both groups included 4 weekly assessments of pain, disability, range of motion, and size of the multifidus cross-sectional area. Independent examiners were blinded to group allocation. Patients were reassessed at a 10-week follow-up examination. Results. Multifidus muscle recovery was not spontaneous on remission of painful symptoms in patients in group 1. Muscle recovery was more rapid and more complete in patients in group 2 who received exercise therapy (P = 0.0001). Other outcome measurements were similar for the two groups at the 4-week examination. Although they resumed normal levels of activity, patients in group 1 still had decreased multifidus muscle size at the 10-week follow-up examination. Conclusions. Multifidus muscle recovery is not spontaneous on remission of painful symptoms. Lack of localized, muscle support may be one reason for the high recurrence rate of low back pain following the initial episode.

Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain.

The effect of low back pain on the size of the lumbar multifidus muscle was examined using real-time ultrasound imaging. Bilateral scans were performed in 26 patients with acute unilateral low back pain (LBP) symptoms (aged 17–46 years) and 51 normal subjects (aged 19–32 years). In all patients, mul

Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain.

Study Design. A randomized clinical trial with 1-year and 3-year telephone questionnaire follow-ups. Objective. To report a specific exercise intervention’s long-term effects on recurrence rates in acute, first-episode low back pain patients. Summary of Background Data. The pain and disability associated with an initial episode of acute low back pain (LBP) is known to resolve spontaneously in the short-term in the majority of cases. However, the recurrence rate is high, and recurrent disabling episodes remain one of the most costly problems in LBP. A deficit in the multifidus muscle has been identified in acute LBP patients, and does not resolve spontaneously on resolution of painful symptoms and resumption of normal activity. Any relation between this deficit and recurrence rate was investigated in the long-term. Methods. Thirty-nine patients with acute, first-episode LBP were medically managed and randomly allocated to either a control group or specific exercise group. Medical management included advice and use of medications. Intervention consisted of exercises aimed at rehabilitating the multifidus in cocontraction with the transversus abdominis muscle. One year and three years after treatment, telephone questionnaires were conducted with patients. Results. Questionnaire results revealed that patients from the specific exercise group experienced fewer recurrences of LBP than patients from the control group. One year after treatment, specific exercise group recurrence was 30%, and control group recurrence was 84% (P , 0.001). Two to three years after treatment, specific exercise group recurrence was 35%, and control group recurrence was 75% (P , 0.01). Conclusion. Long-term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone. [Key Words: multifidus, low back pain, rehabilitation]

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Long-term effects of specific stabilizing exercises for first-episode low back pain.

Study Design. Two abdominal muscle patterns were tested in the same group of individuals, and their effects were compared in relation to sacroiliac joint laxity. One pattern was contraction of the transversus abdominis, Independently of the other abdominals; the other was a bracing action that used all the lateral abdominal muscles. Objectives. To demonstrate the biomechanical effect of the exercise for the transversus abdominis known to be effective in low back pain. Summary of Background Data. Drawing in the abdominal wall is a specific exercise for the transversus abdominis muscle (in cocontraction with the multifidus), which is used in the treatment of back pain. Clinical effectiveness has been demonstrated to be a reduction of 3-year recurrence from 75% to 35%. To the authors' best knowledge, there is not yet in vivo proof of the biomechanical effect of this specific exercise. This study of a biomechanical model on the mechanics of the sacroiliac joint, however, predicted a significant effect of transversus abdominis muscle force. Methods. Thirteen healthy individuals who could perform the test patterns were included. Sacroiliac joint laxity values were recorded with study participants in the prone position during the two abdominal muscle patterns. The values were recorded by means of Doppler Imaging of vibrations. Simultaneous electromyographic recordings and ultrasound imaging were used to verify the two muscle patterns. Results. The range of sacroiliac joint laxity values observed in this study was comparable with levels found in earlier studies of healthy individuals. These values decreased significantly in all individuals during both muscle patterns (P < 0.001). The independent transversus abdominis contraction decreased sacroiliac joint laxity (or rather increased sacroiliac joint stiffness) to a significantly greater degree than the general abdominal exercise pat-tern (P < 0.0260). Conclusions. Contraction of the transversus abdominis significantly decreases the laxity of the sacroiliac joint. This decrease in laxity is larger than that caused by a bracing action using all the lateral abdominal muscles. These findings are in line with the authors' biomechanical model predictions and support the use of independent transversus abdominis contractions for the treatment of low back pain.

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The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain.

SECTION 1: Introduction 1. The time to move forward SECTION 2: The joint protection mechanisms Part 1 Introduction 2. Lumbo-pelvic stability: a functional model of the biomechanics and motor control Part 2 Specific joint protection of the spinal segments 3. Abdominal mechanism and support of the lumbar spine and pelvis 4. Paraspinal mechanism and support of the lumbar spine Part 3 The antigravity muscle support system 5. Stiffness of the lumbo-pelvic region for load transfer 6. The role of weightbearing and non-weightbearing muscles SECTION 3: IMPAIRMENT IN THE JOINT PROTECTION MECHANISMS: CONCEPTS 7. The deload model of injury 8. Joint injury 9. Pain models SECTION 4 IMPAIRMENT IN THE JOINT PROTECTION MECHANISMS: LOW BACK PAIN 10. Abdominal mechanism in low back pain 11. Paraspinal mechanism in low back pain 12. Impairments in the muscles controlling pelvic orientation and weightbearing SECTION 5 TREATMENT AND PREVENTION OF LOW BACK PAIN 13. Principles of the 'segmental stabilization' exercise model 14. Local segmental control 15. Closed chain segmental control 16. Open chain segmental control and progression into function

Julie A. Hides

Papers

Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain.

Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain.

Long-term effects of specific stabilizing exercises for first-episode low back pain.

The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain.

Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain