Lumbar Spine Rehabilitation and Spinal Stabilization

Presentation

Low back pain is the leading reason for physiotherapy consultation and the top cause of functional disability worldwide according to the WHO. Approximately 80% of the population will experience at least one episode of low back pain during their lifetime. While most acute episodes resolve spontaneously within 4 to 6 weeks, 10 to 15% of patients develop chronic low back pain (lasting more than 3 months), with major impact on quality of life, work activity and psychological well-being.

Lumbar spine rehabilitation has evolved considerably over recent decades, shifting from a rest and protection approach (biomedical model) to an active approach centered on movement, functional restoration and biopsychosocial pain management. International guidelines (NICE, ACP) all recommend therapeutic exercise as first-line treatment for chronic low back pain.

Fundamental Principles

• Active segmental stabilization: deep spinal muscles (lumbar multifidus, transversus abdominis) provide intersegmental stability. Their dysfunction is consistently found in chronic low back pain patients. Rehabilitation aims to restore their automatic motor control
• Panjabi model: spinal stability relies on three interdependent subsystems: passive (vertebrae, discs, ligaments), active (muscles) and neural (neuromuscular control)
• Biopsychosocial approach: chronic low back pain integrates psychological components (catastrophizing, kinesiophobia, depression) and social factors (deconditioning, prolonged sick leave)
• Effort reconditioning: global physical deconditioning is a major perpetuating factor of chronic low back pain
• Therapeutic education: modifying erroneous beliefs, reassurance, pain neuroscience education, promoting self-management and movement

Main Indications

• Chronic non-specific low back pain (most common — 85% of low back pain)
• Recurrent acute low back pain (secondary prevention)
• Low back pain with radiculopathy (sciatica, cruralgia) in non-deficit phase
• Degenerative disc disease (protrusion, conservatively treated herniated disc)
• Isthmic or degenerative spondylolisthesis (grade I-II, conservative treatment)
• Lumbar spinal stenosis (conservative or post-surgical)
• Post-lumbar spine surgery (discectomy, laminectomy, fusion, disc prosthesis)
• Multidisciplinary functional restoration program

Rehabilitation Phases

Phase 1 — Motor control and local stabilization (weeks 1-4): Isolated transversus abdominis and lumbar multifidus contraction training, biofeedback, exercises in supine, quadruped and sitting, breathing coordination work.

Phase 2 — Dynamic integration and global strengthening (weeks 4-8): Segmental motor control integration in increasingly complex movements, McGill's "Big Three" (curl-up, side plank, bird-dog), eccentric spinal extensor work, progressive loading, cardiovascular reconditioning.

Phase 3 — Functional reconditioning and reintegration (weeks 8-12+): Exercise program adapted to professional and sports demands, manual handling and ergonomics training, progressive resistance strengthening, home exercise program, ongoing patient education.

Contraindications

• Cauda equina syndrome (absolute surgical emergency)
• Unstable or non-consolidated vertebral fracture
• Acute vertebral infection (spondylodiscitis)
• Vertebral tumor with fracture risk
• Progressive motor neurological deficit (urgent surgical evaluation needed)
• Unstable high-grade spondylolisthesis (grade III-IV)
• Severe acute hyperalgesic phase (adapt intensity, do not stop movement completely)