This post was written by H&W instructor Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Rehabilitative Ultrasound course in Seatlte in May.
In the past decades, evidence has been established showing the importance of the local stabilizing muscles, including the transverse abdominis, the lumbar multifidus, and the pelvic floor muscles on the stability of the pelvic ring and lumbar spine. Many therapists have embraced this knowledge and incorporate a specific stabilization program into their plan of care for patients with dysfunction in the lumbar spine or pelvic ring. This plan of care can be more time consuming for the therapist since we are no longer simply prescribing strengthening exercises to the patient, but instead are using neuromuscular re-education to retrain recruitment patterns and improve motor control. For many patients, learning to activate these muscles can be very difficult and frustrating. This is where biofeedback comes in. For years, women’s health therapists have been using biofeedback to retrain the pelvic floor muscles. Biofeedback is the process of bringing unconscious physiological processes to consciousness and gaining control over it. These same principles can be used in retraining the lumbar multifidus and the transverse abdominis, in addition to the pelvic floor. Currently, biofeedback methods used in treating low back pain include rehabilitative ultrasound imaging (RUSI) and the pressure cuff. My preferred method is using RUSI. This tool not only provides biofeedback for the patient but allows for real-time assessment of the muscle activation. Thus, providing the clinician valuable feedback on timing of recruitment and strategy used by the patient that would not be assessed with palpation alone.
Giggins et al recently released a literature review that covered different forms of biofeedback used in rehabilitation. Interestingly, there is little evidence to support the use of pressure cuff. Some of the research reported found significant increases in gluteus medius and internal oblique activity. In 2013, Grooms et al also determined that correlation and likelihood coefficients indicate that the pressure cuff is likely of minimal value to detect transverse abdominis activation. I personally have had patients referred to me from other therapists to confirm whether or not they were activating their transverse abdominis. In previous treatments, the patients had been using the pressure cuff and palpation by the therapist as confirmation of proper activation. What I found was consistently the patients were not achieving good contractions in their transverse abdominis muscles. Most of these patients were able to learn in one or two sessions how to properly contract their transverse abdominis, and were later able to progress to performing a co-contraction of all the local stabilizers during motor tasks.
Hides et al published a study that demonstrated a specific stabilization rehabilitation program using RUSI was successful in decreasing pain, increasing muscle cross sectional area, and improving motor control in elite cricket players that had previously experienced low back pain. This is a great example of how neuromuscular re-education using RUSI works for the patient when the therapist is using it as both an assessment tool, as well as a biofeedback tool.
So far the limiting drawback of RUSI is the cost of the ultrasound unit. However, companies are constantly coming out with more affordable units making this useful tool more available for clinics. If you are interested in learning more about using US imaging as both an assessment and biofeedback tool join me in Seattle this May for a course that addresses the use of Rehabilitative Ultrasound Imaging in conjunction with a specific stabilization program.
References:
Giggins, Persson, Caulfield. Biofeedback in Rehabilitation. Journal of Neuroengineering and Rehabilitation.2013; 10:60.
http://www.biomedcentral.com/content/pdf/1743-0003-10-60.pdf
Grooms, Grindstaff, Croy et al. Clinimetric Analysis of Pressure Biofeedback and Transversus Abdominis Function in Individuals With Stabilization Classification Low Back Pain. JOSPT.2013; 43(3):184-193
http://www.jospt.org/doi/abs/10.2519/jospt.2013.4397
Hides, Stanton, Wilson et al. Retraining motor control of abdominal muscles among elite cricketers with low back pain. Scand J Med Sci Sports.2010; 20: 834-842.