Low Back Pain

Sports and Physical TherapyAssociates

It has been well documented that low back pain will afflict most adults at one time or another. The costs of treatment of low back pain (LBP) are over 40 billion dollars each year and rising.

Back injuries are a common phenomenon in sports, estimated tooccur in 10%-15% of all participants.

Back injuries have been reported in 11% of gymnasts and up to 50% ofAmerican football linemen.

A concern to sports physicians is the recurrence of these debilitating problems in 26% of males and 33% offemales.

Early intervention and appropriaterehabilitation often reduce thechronic nature and progression of injury.

LBP Treatment ProtocolExact treatment protocol through rehabilitative medicine and physical therapy has been vague and incomplete.The following information describes the role of physical therapy and athletic training in the treatment of LBP.

Physical Therapy Evaluation

After the patient is referred to rehabilitation with a definitive diagnosis from the physician, an evaluation is performed to gather further information

The diagnosis of LBP by an MD, PA or NP can tell not only what it is but also what it isn’t. The Diagnostic tests that can be performed can expose underlying pathology that clinical signs and symptoms don’t always show.

– Heck, AT and Sparano, PT

Patient HistoryA complete detailed history of the patient’s injury is taken.- How did the injury occur?- Date of the injury or length of chronicity- Description of symptoms- Do symptoms worsen at certain times or during certain movements?- Discussion of the patients profession

and hobbies.- LOOK for RED FLAGS!! Fever, Night Pain, etc

Clinical Examination

Assessment of posture typeAssessment of active motion of the spineWhich movements cause pain?Which movements give relief?Assessment of lower extremities and flexibility.Strength testing of abdominals and paraspinals through an exercise prescription.

Treatment Plan

From the referring physician’s diagnosis, patient history and clinical exam the therapist can formulate a treatment plan.

Therapeutic Exercise Prescription

Choosing the proper exercises, movements, and stretches are a crucial part of the physical therapy program.

Isolation Movements/Exercise

Purpose of these exercises –- Improve circulation- Decrease swelling- Reduce spasm- Improve motion to affected muscles, tendons and joint structures

Fiber Type

Type I fibers accounted for 63% of lumbar deep paraspinals and 74% of deep thoracic muscles.

Sirca A, Kostec V

Whats the Difference??

Type I postural or tonic muscles become tighter and shorter when weakened. This can account for an increase in spasm with less and less trauma.

Vladimir Janda

PAIN, SPASM, WEAKNESS?

Marked asymmetry of lumbar multifidus musculature was noted on same side of pain using real time ultrasound.

Stokes, Hides et al

Acute Pain vs. Chronic Pain

Acute LBP- The acute injury being

defined as the time frame in which the injured tissue is continuing to heal.

- Isolation movements should minimize pain for acute LBP.

Chronic LBP- The chronic injury being

defined as the time frame in which the injured tissue had time to heal, but still causes pain.

- Isolation movements can be more aggressive to improve motion, circulation and strength for chronic LBP.

Directional Preference

Prescribing exercises with a directional preference for pain reduction significantlyreduced symptoms. 74% of 300 patientsstudied experienced improvement.

Long, Donelson and Fung

DON’T YOU DO THIS WITH ALL OTHERINJURED STRUCTURES!!!

Prescribing Isolation Exercises

- Flexion motion related injuries treat with extension exercises.

- Extension motion related injuries treat with flexion exercises.

- Almost all lumbar injuries respond favorably to rotational exercises in the isolation stage.

Direction of Isolation Movements

Examples:- Herniated discs are usually sustained in

flexion motions- Acute spondylo fractures are usually

sustained in repetitive extension motions- Chronic lumbar stenosis conditions are

aggravated in extension positions.

Isolation Exercises/Therapeutic Movements

- Exercises are prescribed with a minimum of 15 reps per set to ensure maximal localized circulation.

- Williams flexion, McKenzie extension and spinal stabilization all could be beginnings but none is complete at the end !

Use of Modalities- Moist heat, massage, ultrasound and electrical stimulation increase circulation and decrease swelling.-Joint Mob and stretches stimulate increases in ROM

-Remember only PRE’sCreate Protein Synthesis!!!

EXERCISE

Other exercises implemented at the time of isolation exercises can provide added benefits to the patient, as long as they do not cause added pain.

Postural Awareness ExercisesPeople are experiencing prolonged stress and strain to their backs and necks, due to their work environments.Patients with chronic work related injuries can usually progress quickly, given the correct strengthening and exercise program.The McKenzie classification system of spinal pain is used by our clinics to lessen postural pain.Introducing patients to postural awareness techniques, like the Alexander technique have given our patients great results.

Flexibility Exercises

Lack of flexibility in the lower extremities leads to greater strain to the lower back.– Tight hamstrings and piriformis in sitting leads to an

exaggerated posterior tilt.– Tight hip flexors can lead to exaggerated lordosis

when standing.

Cardiovascular TrainingEndurance training 3-5 times per week can be beneficial to patient with LBP.- Walking, biking, and swimming are ideal.Exercises that are opposite the movement pattern of the injury are recommended. - Remember flexion injuries usually use extension movements for relief and vice versa.- A patient with a disc problem will benefit from walking.- A patient with a spondylo fracture will benefit from rows.

Strengthening of the Lumbar Musculature

Rehabilitation strengthening exercises are introduced once isolation therapeutic exercises are tolerated.By strengthening the injured structure of the lumbar spine along with the hips and abdominals, more stabilization will be provided to the injured area.

Goals of StrengtheningRaise the level of physical tolerance.Introduce the use of free weights by providing exercises that correlate with daily activities, hobbies or work.The uses of MEDEX lumbar program to provide a quantitative analysis of segmental strength.

Free weights vs. MachinesStrengthening tonic stabilizing muscles during dynamic exercise i.e. lunges and squats keeps a strength balance with Phasic arm, leg and Trunk Musculature. This is why in the sports specific/ return to work phase free weights are better than machines

Sports Specific Training

This would be implemented to further specialize the strengthening program.It would simulate the patterns of sports or exercise that the patient engages in regularly.

Stages Of Rehab

Acute Stage Exercises, Therapeutic Movement– 1st seven days -frequency- daily

Subacute Exercises- add aerobic– 2nd seven days- frequency- every other day

Rehabilitation Stage- strengthening, flexibility and free weights/machines– Weeks 3 and 4- frequency- 3 times per week

Sports Specific Stage– Weeks 4 on- frequency- 2-3 times per week

Injury/Exercise SummarySpondylo-– Strengthen abs– Stretch rectus

Disc– Strengthen paraspinals– Stretch abs into

extensionScheurmanns Kyphosis– Strengthen

Thoracolumbar extensors

– Stretch abs and pecs

Through a comprehensive treatment plan patients can achieve great results, while learning ways to prevent recurrent injuries to their lower backs.

All above recommendations should be done in the guidance of an experienced physical therapist or athletic trainer