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The lumbar spine: understanding the science behind both movement and dysfunction By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

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Introduction The spine is a complex structure, comprised of nerves, connective tissue, bones, discs, muscles and other essential integrative components. Whether it getting out of a chair or car, lifting or carrying items, some 29 muscles around the pelvic girdle and lumbar spine, provide stability. In this article, we will review the anatomy of the spine, common injuries to the lumbar spine, functional assessments and training strategies to work with clients with previous injuries.
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     The lumbar spine: understanding the science behind both movement and dysfunction By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS Introduction  The spine is a complex structure, comprised of nerves, connective tissue, bones, discs, muscles and other essential integrative components. Whether it getting out of a chair or car, lifting or carrying items, some 29 muscles around the pelvic girdle and lumbar spine, provide stability. In this article, we will review the anatomy of the spine, common injuries to the lumbar spine, functional assessments and training strategies to work with clients with previous injuries. Figure 1. Sit to stand Figure 2. Lifting items Basic Anatomy of the Spine  The spine is divided into three primary layers(internal, middle and outer). a. Internal layer: Consists of the vertebrae of the spine, the spinal discs, and ligaments and series of small muscles that connect, one vertebrae to another. The discs and ligaments perform two important functions:  they stabilize the spinal column, and they provide the brain with information about the exact position of every joint and vertebrae in the spine. Figure 3. Internal layers of spine   # b. Middle layer : There are four important  muscles within the middle layer, which provide stability for the lower back. Two of these muscles comprise the back, while the other two are abdominal muscles. The muscles of the back are called the multifidus and the quadratus lumborum . The stabilizers that come from the abdominal region are called the internal oblique  as well as the transverse abdominus . Figure 4. Multifidi Figure 5. Quadratus lumborum   c. Outer layer:  This layer is the thickest. Composed of large, thick muscles, which aid in assist in transitional movements, creating and sustaining muscle contraction. The outer layer is known as erector spinae. Figure 6. Erector spinae muscles   Biomechanics of movement  When we look at how the spine bends, flexes and rotates, there are several structures that directly produce these movements and are also affected.   $ Flexion and extension of lumbar spine During lumbar flexion,  the veterbrae and the intervertebral foramen in the back(posterior) separate, creating tension and stress on the posterior annulus and posterior longitudinal ligament.  This forces the nucleus populous backward. Making the disc vulnerable to bulge or herniate. During extension, the opposite motion occurs. During side bending  or lateral flexion, there is opening on the contralateral side and narrowing on the ipsilateral(same) side. Figure 7. Source: Hamill and Knutzen  As the trunk rotates, there is tension developed in the outer annulus where the annular fibers become taught(tight). While the other half of the annular fibers slacken. At the joint, the side rotated towards approximates while the other side opens(gaps). Figure 8. Trunk rotation   Source: Hamill and Kathleen Knutzen   Common injuries and causes of lumbar spine  There are different types of injuries the ankle can sustain. The most common are lumbar osteoarthritis(DDD), disc injuries, and spinal stenosis. In this next section, we will review each condition providing a deeper understanding of each. a. Lumbar osteoarthritis(DDD) Mechanism of injury/pathophysiology:  Is termed the wear and tear arthritis because it is thought that the articular cartilage breaks down because of an imbalance between mechanical stress and the ability of the joint to handle the given loads. The following are factors that can influence the development of DDD; excessive weight, repeated repetitive stressors, and muscle imbalances.   % Sign and symptoms: patients will typically describe as   a deep   ache in the morning that eases or decreases as the day progresses. During evening, the lower back stiffens once again. Figure 9. Lumbar degenerative changes b. Spinal stenosis Pathophysiology:  A narrowing within the vertebral canal coupled with hypertrophy of the spinal lamina and ligamentum flavum or facets as the result of age related degenerative process commonly seen in older individuals(Geenvay & Atlas 2010). Risk Factors: Poor posture, excessive weight, muscle imbalance between flexors and extensors. Sign and symptoms: Results in vascular compromise, bilateral pain in lower extremities particularly in back, buttocks, thighs, calves and feet. Pain is increased with spinal extension and walking. Pain decreases with spinal flexion(bending). Figure 10. Spinal stenosis Medical treatment: Conservative therapies initially and if unsuccessful, decompression laminectomies may be required. In a long term study by Atlas, S et al (2005), 148 patients,  Who either had surgery or underwent conservative care(physical therapy), were followed for 8-10 years. Results:  Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgical.  
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