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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

Pelvic Floor Level 2A - Grand Rapids, MI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Mary Free Bed Rehabilitation Hospital

Pelvic Floor Level 1- Kansas City, MO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Centerpoint Medical Center

Oncology of the Pelvic Floor Level 1 - Grand Junction, CO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Urological Associates of Western Colorado

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Virginia Hospital Center

Pelvic Floor Level 2B - East Greenwich, RI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: New England Institute of Technology

Pilates for the Pelvic Floor - Livingston, NJ (Rescheduled)

Apr 18, 2020 - Apr 19, 2020
Location: Ambulatory Care Center- RWJ Barnabas Health

Genital Lymphedema

Apr 24, 2020

Pelvic Floor Level 1- Canton, OH (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Aultman Hospital

Pelvic Floor Level 1 - Rochester, NY (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Unity Health System

Pediatric Functional Gastrointestinal Disorders - Ann Arbor, MI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Michigan Medicine

Lumbar Nerve Manual Assessment and Treatment - Madison, WI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: University of Wisconsin Hospital

Pelvic Floor Level 2A - Winfield, IL (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Northwestern Medicine

Low Pressure Fitness for Pelvic Floor Care - Trenton, NJ (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Robert Wood Johnson Medical Associates

Athletes & Pelvic Rehabilitation - Minneapolis, MN (Rescheduled)

Apr 25, 2020 - Apr 26, 2020
Location: Viverant

Sacral Nerve Manual Assessment and Treatment - Fairlawn, NJ (Rescheduled)

May 1, 2020 - May 3, 2020
Location: Bella Physical Therapy

Pelvic Floor Level 1 - Fayetteville, AR

May 1, 2020 - May 3, 2020
Location: Washington Regional Medical Center

Pelvic Floor Level 1 - Boise, ID

May 1, 2020 - May 3, 2020
Location: St Luke's Rehab Hospital

Pediatric Incontinence - Duluth, MN

May 1, 2020 - May 3, 2020
Location: Polinsky Medical Rehabilitation Center

Yoga for Pelvic Pain - Online Course

May 2, 2020 - May 3, 2020

Pregnancy Rehabilitation - Corvallis, OR

May 2, 2020 - May 3, 2020
Location: Albany Sport & Spine Physical Therapy

Coccydynia and Painful Sitting - Boston, MA

May 2, 2020 - May 3, 2020
Location: Marathon Physical Therapy

Pelvic Floor Level 1 - Bay Shore, NY (SOLD OUT)

May 11, 2020 - May 13, 2020
Location: Touro College: Bayshore

Pelvic Floor Level 2A - Crown Point, IN

May 15, 2020 - May 17, 2020
Location: Franciscan Health System

Mobilization of Visceral Fascia: The Urinary System - Medford, OR

May 15, 2020 - May 17, 2020
Location: Asante Rogue Valley Medical Center