[headline style=”1″ align=”center” headline_tag=”h2″] Introduction to Multifidus Treatment
If you have ever dissected a human cadaver you will have immediately noticed the multifidus in the lumbar spine. This muscle basically forms the bulk and not the erector spinae. It important for stabilizing and controlling motion in all three planes. When the multifidus isn’t doing it’s job, instability and pain can occur. In this post I will disclose a clinical observation that I have made of which patients need strengthening of this muscle, how to assess it properly, and finally some traditional and non-traditional exercises to strengthen this muscle.
[headline style=”1″ align=”center” headline_tag=”h2″]Importance of Multifidus
The multifidus provides segmental stability of the back. When not working optimally it is usually due to hyper-mobility or trauma. This creates abnormal shear and motion in the lumbar spine. Hodges and et al further this claim in their research showing that the muscle atrophied after injury.
Many times as clinicians or even in the minds of our patients we need to strengthen the abdominal muscles. Although they are weak in many cases, the multifidus is probably even more important for those that have hyper-mobilities – it has attachments directly to the spine. The abdominals connect indirectly through the fascia, pelvis, and rib cage so they don’t have as strong of a pull and connection.
Clinically, I strengthen this muscle in a few populations. They are the following:
- After Trauma and Injury
- General Hyper-Mobility and Spondylolisthesis
- General Weakness of the Lower Back
The abdominals attach to the spine indirectly while the multifidus attaches directly to the spine.
There are many assessments that check the functioning of the multifidus muscle. However, I try to keep it simple and do the following test and measures in my examination listed below. I have provided some insight as to what I look for in each section.
- Structural Inspection
- Passive Joint Play
- Janda Hip Extension Test
- Functional Tests
- Scott Gray’s Low Back Strength Test ( yes, I made it up)
- Prone Instability Test (no video)
[headline style=”1″ align=”center” headline_tag=”h2″]Structural Inspection of Multifidus
[img_text_aside style=”1″ image=”https://www.scottgraypt.com/wp-content/uploads/2017/03/IMG_0499-1-768×1024.jpg” image_alignment=”left” headline=”Multifidus%20Atrophy%20″ alignment=”center”]As you can see in this patient, she lacks tone and hypertrophy of the multifidus muscle. Based on this observation, we can postulate that she may need training of this muscle.
[headline style=”1″ align=”center” headline_tag=”h2″]Passive Joint Play
Intersegmental mobility can be tested and palpated with manual techniques. When the spine moves too much you will feel this under your hand. When excessive, this discerns this patient will need strengthening of the stabilizers of the spine. The prone instability test could also be used as a test but I have not provided this information.
[headline style=”1″ align=”center” headline_tag=”h2″]Janda Hip Extension Test
In Janda’s test below, you want to feel the contralateral low back muscles and ipsilateral glute and hamstring fire. This test shows not only the contraction of multifidus but also compensatory motions during hip extension.
[headline style=”1″ align=”center” headline_tag=”h2″]Functional Tests
The Janda test is a good test but it doesn’t look at the multifidus during more compIex movement patterns. For this reason, I now look at this muscle when bending, lifting, and twisting. Below is just a sample of how I do this.
Remember, the multifidus should fire primarily with an eccentric contraction, not just concentric. Muscles control motion eccentrically to provides stability. This is just one of the many reasons why I like these tests.
The multifidus should be palpated during and eccentric contraction for muscle activity, not concentric.
-Dr. Scott Gray
[headline style=”1″ align=”center” headline_tag=”h2″]Scott Gray’s Multifidus Strength & Endurance Test
Over the past few years I have tried several lower back strength tests and I never really cared for them.
One, they were hard to get the patient into.
Two, rarely if ever was that patient going to be in that position.
Three, it tested only an isometric contraction.
Finally, it wasn’t specific to how the muscles and hips were integrated nor a functional movement pattern. Therefore, I made my own.
I have found if a patient can twist with a red Theraband about 20 repetitions before fatigue sets in they have adequate strength and endurance.
[headline style=”1″ align=”center” headline_tag=”h2″]Traditional & Non-Traditional Exercises
Now that we have laid the frame work to detecting a not so active multifidus muscle and its importance to spinal health, here are some traditional and non-traditional ways to get this muscle up to par.
I use the exercises with a more neutral spine initially and transition into the multi planar exercises. It has been my experience with patients that less is more and to start single plane then work into the other planes.
Please note that you can create your own exercise to make this muscle work as long as you understand what this muscle does. For instance, it is an extender, opposite side rotator, and side bends to the same side.
Knowing this information is crucial because if I can provide a stimulus in the opposite directions (eccentric) I can turn this muscle on and make it work. Plus, I can incorporate multiple planes at once. Cool, right?
You can create your own multifidus exercise as long as you know what motions it wants to control eccentrically
[headline style=”1″ align=”center” headline_tag=”h2″]Conclusion
The multifidus is a very important muscle in keeping the spine healthy. It forms the bulk of the musculature in the lower back and provides intersegmental stability in all three planes. By following the sample assessments and exercises that I have provided, this muscle will certainly not be neglected in your patient care.
What exercises and assessments have you found to be beneficial?
[headline style=”1″ align=”center” headline_tag=”h2″]References
Frank, Clare C., Robert Lardner, and Phil Page. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Champaign, IL: Human Kinetics, 2010. Print.
Hodges, Paul, Allison Kaigle Holm, Tommy Hansson, and Sten Holm. “Rapid Atrophy of the Lumbar Multifidus Follows Experimental Disc or Nerve Root Injury.” Spine31.25 (2006): 2926-933. Web.