Video and Transcript: What Is Spinal Instability and How Is It Treated?

Hi! My name is Dr. Orit Hickman of Pain Science Physical Therapy.

I’d like to address a question that came up with one of my patients recently. If you’re a patient-if you’ve ever been a patient of ours, one of the things you know is that I don’t do a lot of core strengthening and core stabilization exercises. I use core strengthening or core stabilization for very, very specific diagnoses. One of the most common is back instability. And, I hate using this term because somebody quote unquote having an “unstable back”-what that means to us as clinicians is very different than what you might visualize as a patient or a layperson out in the general public. So, I want to explain that first. 

When somebody is experiencing back pain [and] has been experiencing it for a long period of time, one of the most common things that happens is that your abdominal muscles and your back muscles no longer work together in a cohesive fashion. So, when I do something like bend over to pick up something off the floor or even if I lose my balance and I have to prevent myself from falling over, my trunk muscles have to work pretty hard just to stabilize me and prevent me from going too far. If your trunk is not working, if your abdominal and your back muscles are not working together, then what happens is you might fall over. When I go to pick something up from the floor for example, there’s a very strong relationship between how the back and abdominal muscles work to help control this movement. And, when you've had pain anywhere in your body for a period of time, but specifically we’re talking about the low back, if you’ve had pain in the low back for a period of time, then your abdominal muscles and your back muscles don’t always work well together. So, that relationship or that nice, coordinated muscle control that we’re used to having when we do movement tends to go away. We see this with lots of different diagnoses, but, again, we’re talking about back pain today. 

So, I wanted to talk a little bit about this idea of instability in the lumbar spine, or the low back region. One of the ways we test this is that if we-we might do this what we call passively. So, the patient is laying on their stomach. We might push into the low back just to see how much muscle tension exists around the lumbar spine. And, if somebody’s back muscles have taken a vacation for example and they’re just not working the way they need to, what might happen is that when we go to push on those vertebrae, the-they move a little too much. And, that can happen again because the back muscles are not kicking in to stabilize that region very well. This is not something where your vertebrae are just moving willy-nilly all over the place. When you get up and you move and you walk around, as long as your muscles are not paralyzed, your trunk muscles are still kicking in to help to stabilize and help move you through space. The problem is is they can be a little bit uncoordinated, and that can cause discomfort in patients. 

The other way we’ll test if somebody has back stability is we might have them do a movement where they’re bent over the side of a table, and they’re having to stabilize and hold themselves and then lift their legs up. And we’ll monitor-we’ll monitor what the back muscles are doing with that activity. If somebody’s back muscles are stabilizing really well and coordinated and working when we need them to, then they typically don’t feel any discomfort. But, if somebody’s experiencing some spine-spinal instability, then their back muscles may not kick in at that moment. 

What that means for you is that if you go to bend over and you lift something up when you really need your back muscles and your core muscles, which are your deep abdominal muscles, to work together in a nice relationship, they may not be doing that. So, again, when we use the term instability in physical therapy, we’re not talking about vertebrae that are just moving will-nilly all over the place. 

Something to remember about the spine is that it’s very, very well supported. You have muscles. You have about nine layers of back muscles. You have four layers of abdominal muscles in the front, and they go around, and they help to control what the trunk is doing. You also have multiple layers of ligaments that connect to the vertebrae to each other. So, again, when we think about the spine, the spine is actually a very stable, structural-structural element in your body. So, we’re not at risk for just developing injury or spinal cord injury or other some sort of injury because the spine is quote unquote “unstable.” So, again, what a clinician is referring to when they are referring to instability is different than when a layperson-what you may understand about instability. 

So, the reason [why] I’m bringing up this idea of spinal instability is because it’s a diagnosis that we get in physical therapy. Sometimes, patients will come to us and say, “My spine is unstable. I’ve been told this by other clinicians and other providers within the musculoskeletal field.” And, again, we will test to see how unstable something is. And, it usually means that the muscular control around the region is not as good as we would like it to be. It’s not as well coordinated. So, in that case, we will start to teach patients how to do spinal stabilization. Again, this is not something we do with every single patient because not every single patient requires spinal stabilization exercises. 

The basic spinal stabilization is what we call a transversus abdominis contraction. One of the things to note is, again, I mentioned earlier [that] you have four abdominal muscles that sit along the front of the trunk. You also have nine layers of back muscles. But, your deepest abdominal muscle is called-or one of your deeper abdominal muscles is called your transversus abdominis muscle. And, that muscles acts a little bit like a corset. Its fibers run across the trunk. They are not-it is not a muscle group that’s involved in doing movement. It’s more a muscle group that’s involved in sucking in and holding. Again, that’s why we use the term corset. That muscle works with one of the deeper spine muscles called your multifidus or your multifidi muscles. And so, together your transversus, or your TA muscle, with your multifidus will help stabilize the spine. 

So, one of the ways, and there are a number of ways that we will teach this to patients, so please note that if you try to do this and you find that you're not successful, you might want to get with a physical therapist because everybody learns differently. So, specifically with the TA, what you’d be doing is you’d lay on your back. And, a lot of times, what patients do is they [go], “Uhhh!!” And, they want to tighten up everything. That’s not going to feel good, especially if you have back pain. So, really what you want to think about is a gentle contraction where you’re gently almost thinking about bringing your pelvic bones together or just very so slightly pulling your navel towards your spine. When you do this, you are gently pulling in that transversus. And, you can see that I’m able to talk to you while I’m describing this muscle contraction. A lot of people will-when you’re first learning how to do a muscle contraction, especially one that you haven’t been connected to in a long time, you’re going to hold your breath. That’s really common, so try not to do that. One of the ways that you can do that is you can count. So, as I am gently pulling in this muscle contraction, you can see I’m sort of flattening out this lower part of my abdomen. And, I might count, “One. Two. Three. Four, Five.” As I do this, there's no pelvis movement. There’s no rocking. There's no twisting. There’s no nothing. It’s a very, very slight contraction, which is why it really is done best with the help of a provider like a physical therapist who can make sure you’re doing this correctly. But, this is a basic muscle contraction. When somebody is having spinal instability or back pain and their muscles aren’t coordinated well, it’s one of the first things that we’ll do with patients.

So, I hope that this was helpful for you. Feel free to give me a thumbs-up if you thought it was a good video. And, I’d love any comments below. And, thanks! Have a great day!