Physiotherapy with (second) 10 of 20 lateral abdominal basic exercises for low back pain (ep.2)

Side abdominal exercise
(Ref: https://excelfitindia.com/)

    The lateral abdominal muscles including transversus abdominis (TrA), internal oblique (IO), and external oblique (EO). All of the trunk muscles are considered to be important for the restoration of normal function and progression involves strategies for re-education of the whole muscle system.

Refer to the recent topic which talks about lateral abdominal and spine movement that indicated multi - muscle in one movement. Torso rotation is associated between the same IO side and opposite EO side. Torso side bending acts by the same side of IO and EO and TrA. Torso forward bending such as sit up is moved by EO anterior fibers, TrA, and rectus abdominis. Abdominal flattening is developed by TrA and EO. 

Side bending exercise
(Ref: http://www.jasestuart.com/)

The second basic 10 of 20 therapeutic strengthening exercises to activate lateral abdominal muscle for low back pain (Remark: If you feel severe pain and any numbness or significant weakness, I would like to recommend you to stop exercising and observe the symptoms. And consult your physiotherapist or doctors.)

 

Each exercise needs 10 - 15 reps with 3 sets for 3 - 5 days a week. (Remark: Keep breathing during exercise for more efficiency because the diaphragm is a member of core stabilizer muscles.)

Exercise #11: Heel tap

Exercise #12: Quadrup spider

Exercise #13: Spider

Exercise #14: Lower torso rotate

Exercise #15: Upper torso rotate (Russian twist)

Exercise #16: Basic crunch

Exercise #17: Lateral crunch

Exercise #18: Rotation crunch

Exercise #19: Cross crunch

Exercise #20: Easy starfish crunch

 

A contemporary approach for LBP involves recruitment of TrA which contributes to lumbo-sacral stability by its role in intra-abdominal pressure, creating tension of thoraco-lumbar fascia, and compression of sacroiliac joints. It produces little force for trunk flexion, extension and lateral flexion. Despite its involvement in rotation of the trunk, it has only a small lever arm to produce rotational movement. 

These exercise approaches need minimal activity about 2% - 3% of maximum voluntary contraction of the superficial abdominal muscles in the early stages of rehabilitation. To stimulate TrA activity based on evidence based practice  contributes to spinal control and dysfunction of this muscle occurs in people with LBP.

Intra - abdominal pressure support low back spine
(Ref: https://www.performancehealthcarepdx.com/)

The recruitment of TrA is emphasized initially as abdominal hollowing (AH) maneuver or abdominal bracing has been presented as an activity which exercises the TrA muscle in an isolated fashion. It recruits OE with less activity of upper TrA, lower OI and RA. The technique involves inward movement of the lower abdominal wall without movement of the spine or pelvis.

  In order to control the contraction of TrA during this maneuver, palpation of its tendon medial to anterior superior iliac spine, and also Pressure Biofeedback (PBF) have been used. The efficacy of this method has been established in randomized control trials with acute and chronic LBP patients.

Surface anatomy of core stabilizer muscle palpation at
her index and middle finger where are above iliac crest.
(Ref: https://depositphotos.com/)

The 'curl-up' exercise in supine used to strengthen the abdominals, especially rectus abdominis, is a good example of this type of strengthening exercise. Producing a force or torque which can be used for specific movements is only one aspect of muscle function. It is similar to McGill that uses it to strengthen the EO majorly.   

The pelvic tilting is likely to produce greater activity of middle OI relative to upper TrA and RA.  

One musculature mechanism which involves stability is the production of tension in the lumbar dorsal fascia. Upper fascicles of TrA that attach to the rib cage are horizontal, and middle and lower fascicles that fuse with the thoracolumbar fascia and the iliac crest are inferomedial. Fibers of upper TrA are also active with the opposite direction of trunk rotation to lower and middle fibers, and activity of lower and upper fibers of OI vary during posterior pelvic tilting.

Left to right: TrA - IO - EO - Thoracolumbar fascia
(Ref: https://www.crossroadsphysiotherapy.com/)

            The lumbar dorsal fascia is a noncontractile structure which provides considerable support to the lumbar area. Its contribution to stability is increased through the influence of muscle attachments.  Tension in the fascia can be increased by contraction of the internal obliques and transverse abdominals which attach to the middle layer of the fascia. Tension is also increased between the middle and posterior layers of the fascia by the contraction of the paraspinal muscles. Although the lumbar dorsal fascia provides local protection fur the lumbar spine, it appears that increasing intra-abdominal pressure(IAP) could provide a more general mechanism for protection of the whole spine.

Ideal posture (Left) & Lower cross syndrome (Right)
(Ref: https://evergreenclinic.ca/)

Many muscles worked in synergistic groups and appeared to be specifically involved in mechanisms designed to stabilize, protect the lumbar spine and control neutral posture. For example, weakness of OE causes sway back posture which is thoracic behind the pelvic. Or Hyper lumbar lordosis posture because of TrA weakness. 

You can watch more VIDEO on https://yimphysionearme.blogspot.com/2022/09/physiotherapy-with-9-of-18-basic.html and https://yimphysionearme.blogspot.com/2022/09/the-second-physiotherapy-with-9-of-18.html 

 

 

 

Reference: 

https://core.ac.uk/download/pdf/227985494.pdf 

 

https://www.researchgate.net/publication/23480146_Altered_response_of_the_anterolateral_abdominal_muscles_to_simulated_weight-bearing_in_subjects_with_low_back_pain

 

https://www.sciencedirect.com/science/article/pii/S0004951414605146

 

http://www.pnfchi.com/fotos/literatura/1233770497.pdf

 

https://d-nb.info/1114223050/34

 

Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.

1993.  

physiotherapy with 14 abdominal muscles stretching for back pain

 

(Ref: https://thefitnessmaverick.com/ab-crunches/)

            The abdominal muscles include the rectus abdominis, external oblique abdominis, internal oblique abdominis, and transversus abdominis. These muscles play a role in trunk motion, posture, labor, vomiting, dejection, and respiration. Activity of the abdominal muscles is not generally observed during respiration at rest; however, these are activated during exercise and expiratory effort.

Abdominal muscles family anatomy
(Ref: https://basicmedicalkey.com/)

            Abdominal muscle shortness can deviate body posture. The deviated body posture

of the torso is able to be mixed between forward bending and side bending and rotation. I

will demonstrate the basic torso posture deviation in each direction.

(1) Bilateral shortness of anterior fibers of external and internal oblique muscles

causes the thorax to be depressed anteriorly contributing to flexion of the vertebral column.

In standing, this will be seen as a tendency toward kyphosis and depressed chest that is

increased forward flexion of thoracic spine. So, we can see the  increased forward flexion of

thoracic spine or kyphosis in a kyphosis - lordosis posture that due to the lateral portions of

the internal oblique are shortened, and the lateral portions of the external oblique are

elongated. These same findings occur in a sway - back posture with anterior deviation of

the pelvis and posterior deviation of the thorax.

Kyphosis - lordosis posture
(Ref: https://www.pinterest.com/)

Sway back posture
(Ref: http://www.oregonexercisetherapy.com/)

(2) Cross - sectional shortness of external oblique on one side and internal oblique

on the other causes rotation and lateral deviation of the vertebral column. Shortness

of left external oblique and right internal oblique, as seen in advanced cases of right

thoracic, left lumbar scoliosis, causes rotation of the thorax forward on the left.

Torsion scoliosis
(Ref: https://www.physio-pedia.com/Scoliosis)

(3) Unilateral shortness of lateral fibers of external oblique and internal oblique on

the same side causes approximating of the iliac crest and thorax laterally resulting

in C - curve convex toward the opposite side. Shortness of the lateral fibers of the

right internal and external obliques may be seen in a left C - curve.

C - curve scoliosis
(Ref: https://www.mitchmedical.us/muscles/info-wcb.html)

            (4) Rectus abdominis muscle which connects between chest and pelvis has been

mentioned about elongated and weakness of anterior abdominal muscles on pelvic anterior

tilt and normal thoracic spine curve in military - type posture. On the other hand, there is

potential to be shortness or strength of anterior abdominal muscles that happen in

flat - back posture, does pelvis posterior tilt and no significant thoracic spine curve changes.

I cannot conclude that anterior abdominal muscles affect thoracic and pelvis posture.

 

Flat back posture including pelvis posterior tilt
(Ref: http://www.oregonexercisetherapy.com/)

Military - type posture
(Ref: https://quizlet.com/) 

            In my physiotherapy experience in patients with low back pain, I have seen abnormal

spinal curves e.g. hyperlordosis, hypolordosis, and scoliosis. I have given massage and

stretching as a part of all treatment in postural changes. 

For example, some patients with low back pain and posterior pelvic tile demonstrated hypolordotic lumbar curve. I found a spasm of QL muscle that cannot be improved by
massage and stretching. Additionally, I found weakness in the lower back and groin
muscles. So, I gave massages and stretches anterolateral abdominal wall muscle,
and strengthening for the lower back and hip flexor muscles group.  

        14 stretche poses to improve flexibility of abdominal wall muscles. The principle

to stretch this muscle is the same as the others: stretch to the point where “tightness with

pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5

reputations following demonstrated VIDEO. 

Exercise #1: Basic Cobra stretch: During stretching needs to keep pelvic on the floor.

Exercise #2: Modified Cobra stretch: During stretching needs to keep pelvic on the floor.

Exercise #3: Basic Cobra with lateral bending stretch: During stretching needs to keep

pelvic on the floor.

Exercise #4: Modified Cobra with lateral bending stretch: During stretching needs to keep

pelvic on the floor.

Exercise #5: Basic cat stretch: Do pelvic anterior tilt and drop spine toward floor.

Exercise #6: Modified Camel stretch: Keep torso backward bending that not mean lean backward. You can apply pillow or yoga block or foam roller if you are not flexible enough.

Exercise #7: Modified Gate - Latch stretch: Do anterior pelvic tilt and torso backward bending before bend to side way and maintain all motion until finish.

Exercise #8: Seat anterior pelvic tilt stretch: Do anterior pelvic tilt and torso backward bending for stretching.

Exercise #9: Seat lateral bending stretch: Do anterior pelvic tilt and torso backward bending before bend to side way and maintain all motion until finish.

Exercise #10: Seat torso rotation stretch.

Exercise #11: Stand torso backward bending stretch: Do anterior pelvic tilt and torso backward bending for stretching.

Exercise #12: Stand torso backward bending with lateral bending stretch: Do anterior pelvic tilt and torso backward bending before bend to side way and maintain all motion until finish.

Exercise #13: Stand torso backward bending with rotate stretch: Do anterior pelvic tilt and torso backward bending before rotate torso and maintain all motion until finish.

Exercise #14: Stand hip circle.

Each abdominal muscle member is separated into layers. Rectus abdominis muscles
which we know as six pack and external oblique muscles which are outward to eleven
line, are the outermost layer that we can see by visual. If the external oblique muscles
and its aponeurosis were removed by dissections, we would see the internal oblique
muscles that we cannot see by visual because the external obliques muscles cover it
fully. The transversus abdominis muscles are the innermost of the anterolateral
abdominal wall. We cannot see muscle shape by visual but we can see its function
by abdominal draw - in maneuver. 

Layer of anterolateral abdominal muscles
(Ref: https://musculoskeletalkey.com/)

(1) Rectus abdominis

Origin: pubic crest and symphysis.

Insertion: costal cartilages of 5th, 6th, and 7th ribs, and xiphoid process of sternum.

Direction of fibers: vertical

Action:flexes the vertebral column by approximating the thorax and pelvis anteriorly. With

the pelvis flexed, the thorax will move toward the pelvis; with the thorax fixed, the pelvis

will move toward the thorax.

Weakness: a weakness of this muscle results in a decrease in the ability to flex the

vertebral column. In the supine position, the ability to tilt the pelvis posteriorly or to

approximate the thorax toward the pelvis is decreased, making it difficult to raise the head

and upper trunk. In order for anterior neck flexors to raise the head from a supine position,

it is essential that anterior abdominal muscles, particularly the rectus abdominis, fix the

thorax. With marked weakness of abdominal muscles an individual may not be able to

raise the head even though neck flexors are strong. In the erect position, weakness of this

muscle permits an anterior pelvic tilt and a lordotic posture (increase anterior convexity of

the lumbar spine).

Rectus abdominis muscle
(Ref: https://www.yoganatomy.com/)

(2) External oblique, anterior fibers

Origin: external surface of rib five through eight interdigitating with serratus anterior.

Insertion: into a board, flat aponeurosis, terminating in the lines alba, a tendinous raphe

which extends from the xiphoid.

Direction of fibers: the fibers extend obliquely downward and medialward with the

uppermost fibers more medialward.

Action: acting bilaterally, the anterior fibers flex the vertebral column approximating the

thorax and pelvis anteriorly, support and compress the abdominal viscera, depress the

thorax, and assist in respiration. Acting unilaterally with the anterior fibers of the internal

oblique on the opposite side, the anterior fibers of the external oblique rotate the vertebral

column, bringing the thorax forward (when the pelvis is fixed), or the pelvis backward

(when the pelvis is fixed). For example, with the pelvis fixed, the right external oblique

rotates the thorax counterclockwise, and the left external oblique rotates the thorax

clockwise.

External abdominal oblique
(Ref: https://learnmuscles.com/)

(3) External oblique, lateral fibers

Origin: external surface of ninth rib, interdigitating with serratus anterior; and external
surfaces of 10th, 11th and 12th ribs, interdigitating with latissimus dorsi.
Insertion: as the inguinal ligament, into anterior superior spine and pubic tubercle, and into
the external lip of anterior one half of iliac crest.
Direction of fibers: fibers extend obliquely downward and medialward, more downward than the anterior fibers.
Action: acting bilaterally, the lateral fibers of the external oblique flex the vertebral column,

with major influence on the lumbar spine, tilting the pelvis posteriorly. Acting unilaterally

with the lateral fibers of the internal oblique on the same side, these fibers of the external

oblique laterally flex the vertebral column, approximating the thorax and iliac crest. These

external oblique fibers also act with the internal oblique on the opposite side to rotate the

vertebral column. The external oblique, in its action on the thorax, is comparable to the

sternocleidomastoid in its action on the head.

Surface anatomy of external abdominal oblique
(Ref: https://biologydictionary.net/)

(4) Internal oblique, lower anterior fibers

Origin: lateral two thirds of inguinal ligament, and shirt attachment on iliac crest near anterior

superior spine.

Insertion: with transversus abdominis into crest of pubis, medial part of pectineal line, and into linea

alba by means of an aponeurosis.

Direction of fibers: fibers extend transversely across lower abdominal.

Action: the lower anterior fibers compress and support the lower abdominal viscera in conjunction

with the transversus abdominis.

(5) Internal oblique, upper anterior fibers

Origin: anterior one thirds of intermediate line of iliac crest.

Insertion: linea alba by means of aponeurosis.

Direction of fibers: fibers extend obliquely medialward and upward.

Action: acting bilaterally, the upper anterior fibers the vertebral column, approximating the

thorax and pelvis anteriorly, support and compress the abdominal viscera, depress the

thorax, and assist in respiration. Acting unilaterally, in conjunction with the anterior fibers

of the external oblique on the opposite side, the upper anterior fibers of the internal oblique

rotate the vertebral column, bringing the thorax backward (when the pelvis is fixed), or

the pelvis forward (when the thorax is fixed). For example, the right internal oblique rotates

the thorax clockwise, and the left internal oblique rotates the thorax counterclockwise on

a fixed pelvis.

Internal abdominal oblique muscle
(Ref: https://learnmuscles.com/)

(6) Internal oblique, lateral fibers

Origin: middle one thirds of intermediate line of iliac crest, and thoracolumbar fascia.

Insertion: inferior borders of 10th, 11th, and 12th ribs and linea alba by means of

aponeurosis.

Direction of fibers: fibers extend obliquely upward and medialward, more upward than the anterior fibers.

Action: acting bilaterally, the lateral fibers flex the vertebral column, approximating the

thorax and pelvis anteriorly, and depress the thorax. Acting unilaterally with the lateral

fibers of the external oblique on the same side, these fibers of the internal oblique laterally

flex the vertebral column, approximating the thorax and pelvis. These fibers also act with

the external oblique on the opposite side to rotate the vertebral column. 

(7) Transversus abdominis (TrA)

Origin: inner surfaces of cartilages of lower six ribs, interdigitating with the diaphragm;

thoracolumbar fascia; anterior three fourths of internal lip of iliac crest; and lateral one third

of inguinal ligament.

Insertion: linea alba by means of a board aponeurosis, pubic crest and pecten pubis.

Direction of fibers: transverse 

Action: acts like a girdle to flatten the abdominal wall and compress the abdominal viscera;

the upper portion helps to decrease the infrasternal angle of the ribs as in expiration. This

muscle has no action in lateral trunk flexion except that it acts to compress the viscera and

stabilize the linea alba, thereby permitting better action by anterior trunk muscles.

Weakness: permits a bulging of the anterior abdominal wall, thereby indirectly tending to

affect an increase in lordosis. During flexion in the supine position, and hyperextension of

the trunk in the prone position, there tends to be a bulging laterally if the transversus

abdominis is weak.

Transversus abdominis muscle
(Ref: https://learnmuscles.com/)

        Transversus abdominis has been of particular interest to many physiotherapists as

a core stability muscle due to its anatomy. The influence of lumbar stability on poor posture

versus upright posture has also been studied. It has been reported that there is a significant

decrease in activity of the internal oblique and multifidus muscles in poor sitting and

standing postures. 

The present study was an investigation into the changes in TrA thickness in commonly

adopted poor postures (sway-back standing and slouched sitting) compared to equivalent

neutral spine postures. The results show a significant thickening of TrA in both lumbo-pelvic

neutral erect standing and sitting postures compared to sway-back standing and slouched

sitting. TrA thickness has been shown to be correlated with muscular activity. Therefore,

the observed increase in thickness of TrA in erect standing compared to the sway-backed

position suggests that there is more TrA activity in erect standing. This increase in activity

may help to stabilize the spine. 

For healthy abdominal muscles, we need to maintain good standing and sitting

posture, stretching, and strengthening. 

Reference: 

https://www.researchgate.net/publication/24428336_Effects_of_posture_on_the_thickness_

of_transversus_abdominis_in_pain-free_subjects 

Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.

1993.