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Herman & Wallace Blog

The Dilemma of the Multifidus

Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC is a published researcher and practitioner who has worked in the realms of brain injury, lymphedema, and oncology. Now she's leading the charge to encourage rehabilitation practitioners to utilize ultrasound diagnostic imaging with their patients, and you can learn these techniques in her Rehabilitative Ultrasound Imaging - Women's Health and Orthopedic Topics course taking place May 1 - 3 in Dayton, OH. We've partnered with SonoSite to make the best ultrasound equipment available for participants in this course.

Most of us are treating patients who have back pain of some nature, and we know the importance of the local stabilizing muscles including the transverse abdominis, the lumbar multifidus, and the pelvic floor muscles. These muscles work together to provide tension and create a corset of stability throughout the trunk. A common goal is to rehabilitate these muscles in order to restore motor control and strength, but the muscle depth can make them difficult to assess and palpate.

I recently read a study that is looking at the development of a test to identify lumbar multifidus function. Herbert et al. found promising results when looking at this “multifidus lift test” for inter-rater reliability and concurrent validity to identify dysfunction in the multifidus. They compared the results of this test with real-time ultrasound imaging of the lumbar multifidus. Inter-rater reliability was excellent and free from errors of bias and prevalence. Concurrent validity was demonstrated through its relationship with the reference standard results at L4-L5, but not so much for L5-S1. This preliminary research supports the reliability and validity of the multifidus lift test to assess lumbar multifidus function at some spinal levels. If this test could be further validated for other spinal levels it would be very beneficial for therapists who are using a specific stabilization program to treat patients.

Until this test is further developed and validated how can therapists know for sure that their patient is truly activating their multifidus? Ultrasound imaging is the answer! Ultrasound imaging gives therapists real-time feedback for whether a patient is able to correctly activate a muscle or not. It is also a wonderful biofeedback tool for patients who are trying to rehabilitate these muscles. Getting your hands on an ultrasound machine can be tough, but therapists who work in a hospital system may have an easier time than you'd think. I have worked with many therapists to help them get access to ultrasound units through “hand me down” units from imaging or labor and delivery departments. I also have helped private practice therapists set up a working relationship with a physician who has an ultrasound in their office. Thinking outside of the box can allow clinicians to gain access to ultrasound units without having to spend a lot of money. Join me in Dayton Ohio this May to hear more about how ultrasound imaging can improve your practice and allow you to incorporate a specific stabilization program into your toolbox.

Herbert JJ, Koppenhaver SL, Teyhen DS, Walker BF, Fritz JM. The evaluation of lumbar multifidus muscle function via palpation: reliability and validity of a new clinical test. Spine J. 2015; 15(6): 1196-202.

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Cyclists and Back Pain

The following comes to us from faculty member Allison Ariail. Allison teaches several courses for the Institute, her next one being Rehabilitative Ultrasound Imaging in Baltimore, MD on June 12-14. There is still room, so sign up today!

Living in Colorado, I come across a lot of individuals who are avid runners, cyclists, or triathletes. Even with a higher level of fitness, these individuals will at times have back pain. What is going on in these physically fit, strong individuals? This is what Rostami et al.[1] set out to determine in their recent study. Using ultrasound imaging, they measured the thickness of the transversus abdominis, internal oblique, external oblique, and the cross sectional area of the multifidus while laying down as well as while mounted on a bicycle. They also measured the back strength, endurance, and flexibility of off-road cyclists with and without back pain. Fourteen professional competitive off-road cyclists with low back pain were compared to 24 control. Results showed a significantly thinner transversus abdominis, and cross sectional area of the multifidus muscle in the cyclists with back pain. There was no significant difference found in flexibility or isometric back strength between the two groups. However the cyclists with low back pain demonstrated decreased endurance in back dynamometry with 50% of their maximum isometric back strength.

The results of this study are consistent with other studies that examined less athletic individuals; thinner transverseus abdominis, and smaller multifidus muscles. This further reinforces the training of the local stabilizing muscles. What does this training method consist of? Learning to isolate each of the local stabilizing muscles; the transversus abdominis, the multifidus, and the pelvic floor muscles. Once a patient is able to isolate a contraction, challenge the muscles by holding a contraction while breathing normally, or holding the contraction while performing motor tasks such as Sahrmann’s exercises. Progress the patient so they are able to perform contractions in weight bearing positions and co-contractions of the muscles. Finally, progress the patient to maintaining co-contractions during functional activities and exercise activities. This will improve stability of the back and pelvis as well as decrease the pain experienced by the patient.

Even patients with higher levels of activity and physical fitness can benefit from a program such as this one. I have used this treatment protocol using ultrasound imaging to confirm and train the local stabilizing muscles on individuals who are both active as well as with individuals not able to participate in as much physical activity. Each and every patient has made gains, even patients who already had a higher level of activity and sports participation such as cyclists, runners, and triathletes. It is rewarding to see all patients make gains and improvements!

[1]Rostami M, Ansari M, Noormohammadpour P et al. Ultrasound assessment of trunk muscles and back flexibility, strength and endurance in off-road cyclists with and without back pain. J Back Musculoskelet Rehabil. 2014; Nov.

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Upcoming Continuing Education Courses

Pediatric Incontinence - Duluth, MN (Postponed)

Oct 23, 2020 - Oct 25, 2020
Location: Polinsky Medical Rehabilitation Center

Pediatric Incontinence and Pelvic Floor Dysfunction- Remote Course (SOLD OUT)

Oct 23, 2020 - Oct 25, 2020
Location: Replacement Remote Course

Parkinson Disease and Pelvic Rehabilitation - Remote Course

Oct 23, 2020 - Oct 24, 2020
Location: Short Form Remote Course

Pelvic Floor Level 2A - Braintree, MA Satellite Location

Oct 24, 2020 - Oct 25, 2020
Location: Peak Physical Therapy

Pelvic Floor Level 2A - New York, NY Satellite Location (SOLD OUT)

Oct 24, 2020 - Oct 25, 2020
Location: 5 Point Physical Therapy

Pregnant and Postpartum Rehabilitation Special Topics - Remote Course

Oct 24, 2020 - Oct 25, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Washington DC (POSTPONED)

Oct 24, 2020 - Oct 25, 2020
Location: George Washington University Hospital Outpatient Rehabilitation Center

Pelvic Floor Level 1 - Troy, NY Satellite Location

Oct 24, 2020 - Oct 25, 2020
Location: The Green Room Physical Therapy

Pelvic Floor Level 2A - Atlanta, GA (Postponed)

Oct 24, 2020 - Oct 25, 2020
Location: Emory Healthcare

Pelvic Floor Level 2A - Greenville, SC Satellite Location

Oct 24, 2020 - Oct 25, 2020
Location: Restore Pelvic Health and Wellness

Pelvic Floor Level 1 - Self-Hosted

Oct 24, 2020 - Oct 25, 2020
Location: Self-Hosted Course

Peripartum Advanced Topics - Somerset, NJ (Postponed)

Oct 24, 2020 - Oct 25, 2020
Location: Sports Medicine Institute

Pelvic Floor Level 2A - Remote Course

Oct 24, 2020 - Oct 25, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Washington DC Satellite Location (SOLD OUT)

Oct 24, 2020 - Oct 25, 2020
Location: George Washington University Hospital Outpatient Rehabilitation Center

Pelvic Floor Level 2A - Minnetonka, MN Satellite Course (SOLD OUT)

Oct 24, 2020 - Oct 25, 2020
Location: Viverant

Pelvic Floor Level 2A -Decatur GA Satellite Course (SOLD OUT)

Oct 24, 2020 - Oct 25, 2020
Location: Emory Healthcare

Pelvic Floor Level 2A - East Norriton, PA Satellite Course

Oct 24, 2020 - Oct 25, 2020
Location: Core 3 Physical Therapy

Pelvic Floor Level 1 - Satellite Lab Course

Oct 24, 2020 - Oct 25, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Akron, OH Satellite Location (Sold Out)

Oct 24, 2020 - Oct 25, 2020
Location: Summa Health Center

Pelvic Floor Level 2A - Self-Hosted

Oct 24, 2020 - Oct 25, 2020
Location: Self-Hosted Course

Pelvic Floor Level 2A - Athens, GA Satellite Course (Rescheduled)

Oct 24, 2020 - Oct 25, 2020
Location: Thrive Integrative Medicine

Pelvic Floor Level 2A - Tampa, FL Satellite Location

Oct 24, 2020 - Oct 25, 2020
Location: Optimal Performance and Physical Therapies

Pelvic Floor Level 2A - Monroe, LA Satellite Location

Oct 24, 2020 - Oct 25, 2020
Location: Ouachita Physical Therapy

Manual Therapy Techniques for the Pelvic Rehab Therapist - Atlanta, GA (Postponed)

Oct 24, 2020 - Oct 25, 2020
Location: Emory Healthcare

Pelvic Floor Level 1 - Goodyear, AZ Satellite Location

Oct 24, 2020 - Oct 25, 2020
Location: STI Physical Therapy & Rehab

Breastfeeding Conditions - Remote Course

Oct 24, 2020 - Oct 25, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Akron, OH (Postponed)

Oct 24, 2020 - Oct 25, 2020
Location: Summa Health Center

Manual Therapy for the Abdominal Wall - Remote Course (Postponed)

Oct 25, 2020
Location: Short Form Remote Course

Mobilization of the Myofascial Layer - Medford, OR Satellite Location

Nov 6, 2020 - Nov 8, 2020
Location: Asante Rogue Valley Medical Center