Injury Prevention:Developing the Strong Back

Angie Beisner MA, ATCAthletic Trainer

The Ohio State University

Picture: http://web.uaccb.edu/AcademicDivisions/MathScience/Science/BWheeler/Ess/figs/06_16Figureb-U.jpg

Low Back Injuries• Incidence

• Sport Specific

• Types of Injuries

Traditional Low Back Injury Prevention

Flexibility

Core Stabilization Exercises

Postural Training

New Techniques

• Local Muscle Stabilization programs

• Pilates, Yoga programs

• Functional Movement Screenings

Categories of Abdominal Muscles

Global Abdominal Muscles

Local Abdominal Muscles

Global Stabilization Muscles

http://home1.gte.net/imagine/rectus%20abdominis.jpg

• Rectus Abdominis

• External Oblique

• Iliocostalis (thoracic portion)

http://www.mystomachexercises.com/wp-content/uploads/2008/04/external-oblique.jpg

Iliocostalis (thoracic portion)

Rectus Abdominis

http://www.pro-motionphysicaltherapy.com/images/evidence/5il.jpg

External Oblique

Global Muscle Groups

• Large Muscles

• Act on the Spine (no attachment)

• Provide Trunk Stabilization (no influence on the

spine)

• Global Stabilization Muscles include: Rectus Abdominis External Oblique Iliocostalis (thoracic portion)

Local Stabilization Muscles

https/://hvelink.saintlukeshealthsystem.org/library/healthguide/en-us/images/media/medical/hw/h9991417_001.jpg

• Lumbar Multifidus

• Transverse Abdominis

• Post. Fibers of Int. Obliques

http://www.teachpe.com/images/muscles/internal_oblique200.jpg

Posterior fibers of Internal Obliques

Local Muscle System

• Direct attachment to lumbar vertebrae

• Control lumbar segments

• Dynamic stability of the spine

• Intra-abdominal pressure

• Local Stabilization Muscles include: Lumbar Multifidus Transverse Abdominis Posterior Fibers of Internal Oblique

Global Muscles and CLBP

• Global Muscles:

Typical focus of back rehab Substitute/Dominate local

muscles in people with CLBP

Local Muscle Function with CLBP

Local Muscles provide:• dynamic stability

• control of the spine

Increased evidence showing LBP is influenced by local muscle weakness

Chronic Low Back Pain

Lumbar spine problems

Studies have shown specific exercises directed at local muscles are effective in reducing pain

• This is due to the dysfunction in parts of lumbar spine in people with chronic/symptomatic back problems

(i.e. spondys)

Lumbar Spine Injuries

Training Local Stabilization Muscles May compensate for forces on the spine during ADL

Leads to increased stability=decreased pain/disability

http://www.lower-back-pain-answers.com/images/Pelvic-tilt-arching-elbows.jpg

Suggestion for rehab exercise

Train for a contraction of deep abdominal muscles/LM • Must be specific• Minimal activation of global muscles• Patient must be compliant

Goal:• Teach contraction of LM and TrA independent of Global

Muscle Firing

Palpation Test TrA

• 2 fingers medial and distal to ASIS

• Slowly draw in abdominal wall

LM• Fingers side of spinous

process • “Make fingers expand”

Possible Findings in Patients with LBP

Sides may have unequal firing

May be unable to maintain for 10s

May need to incorporate tactile stimulation

May have weak contraction

Mastery• Once achieved, add to

standing/dynamic tasks

• Add Global exercises (core program) to rehab

• Perform exercise throughout the day

• Continued compliance is needed to reinforce motor programming

A look at one team’s injury prevalence

1999-2000 • 1 spondylolisthesis • 1 spondylosis

2000-2001• 1 spondylosis

2001-2002• 2 spondylosis• 1 lamina fracture

2002-2003• 0 back injuries

2003-2004• 1 spondylosis

(freshman)

2004-2007

What was changing in our program?

Increase number of athletes using jump serve

New athletes

No changes in:• Floor• Lifting program• Practice• Equipment

Application with MVB

Random check of previous athlete with LBP• Symptomatic• Asymptomatic

Given instructions to begin exercise• Once achieved mastery, must incorporate into ADL

Results

• Two things were implemented as prevention techniques with this team:

• Local muscle screening• Addition of Pilates focused exercises

• While a formal study was not initiated, results were noticed.

Pilates Exercises

Potential Benefits:

• Focus is on “local” muscle group such as transverse abdominis, multifidus, and pelvic floor muscles

• Emphasizes proper technique

• Aid for postural control

Research

Pilates intervention has shown:

• Pain relief and improved weight distribution in those with LBP daFonseca J, Magini M, and de Freitas T. Laboratory gait analysis in patients with low

back pain before and after a pilates intervention. Journal of Sport Rehabilitation. 2009; 18:269-282

• Increase Transverse Abdominis firing Endleman I, and Critchley D. Transverse Abdominis and Obliqus Internus Activity

during pilates exercises: measurement with ultrasound scanning. Arch Phy Med Rehabilitation 2008; 89:2205-2212.

Keys to Pilates intervention

Proper technique• Muscle thickness (firing) is only increased if

performed correctly

Reformer based exercises vs. mat based• Exercises used were mat 100s, leg circles

Endleman I, and Critchley D. Transverse Abdominis and Obliqus Internus Activity during pilates exercises: measurement with ultrasound scanning. Arch Phy Med Rehabilitation. 2008; 89:2205-2212

Functional Movement Screens

New area of injury prevention focus

Limited research to show effectiveness with low back pain prevention• Some research support effective tool for LBP

prevention in certain rigorous occupations (i.e. fire fighters)

Theory:• Program focus on flexibility, muscle balance may

have a link to decrease LBP

Combating Non-compliance with Local Muscle Strengthening

First step of rehab

Make it a challenge

Random checks

How does it apply to you?

Awareness

Missing Link in low back rehab programs

Extra step to break the cycle of CLBP

References daFonseca J, Magini M, and de Freitas T. Laboratory gait analysis in patients with low back pain before and after a

pilates intervention. Journal of Sport Rehabilitation. 2009; 18:269-282 Endleman I, and Critchley D. Transverse Abdominis and Obliqus Internus Activity during pilates exercises:

measurement with ultrasound scanning. Arch Phy Med Rehabilitation. 2008; 89:2205-2212 Gladwell V, Head S, Hagger M, and Beneke R. Does a Program of Pilates Improve Chronic Non-Specific Low Back

Pain. Journal of Sports Rehabilitation. 2006; 15:338-350 McCook D, Vicenzino B, and Hodges P, Activity of deep abdominal muscles increases during submaximal flexion

and extension efforts but antagonist co-contraction remains unchanged. Journal of Electromyography and Kinesiology. 2009; 19:754-762

Wallwork T, Stanton W, Freke M, and Hides J. The effects of chronic low back pain on size and contraction of the lumbar multifidus muscle. Manual Therapy. 2009; 14:496-500

Hall L, Tsao H, MacDonald D, Coppieters M, and Hodges P. Immediate Effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of Electromyography and Kinesiology. 2009; 19:763-773

Peate W, Bates G, Lunda K, Francis S, and Bellamy K. Core Strength: A new model for injury prevention and prediction. Journal of Occupational Medicine and Toxicology. 2007; 2:3 1-9

Hicks G, Fritz J, Delitto A, and McGill S. Preliminary Development of a Clinical Prediction Rule for Determining Which patients with low back pain will respond to a stabilization exercise program. Arch Phy Med Rehabilitation. 2005; 86:1753-1761

Sapsford R, Hodges P, Richardson C, Cooper D, Markwell S, and Jull G. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurology and Urodynamics. 2001; 20:31-42

O’Sullivan P, Phyty G, Twomey L, and Allison G. Evaluation of Specific Stabilizing Exercises in the Treatment of chronic low back pain with radiologic diagnosis of spondylolysis and spondylolisthesis. Spine. 1997; 24:2959-2967

Hodges P. Changes in motor planning of feed forward postural responses of the trunk muscles in low back pain. Exp Brain Research. 2001; 141:261-266

Hodges P, Cressswell, A and Thorstenson A. Preparatory trunk motion accompanies rapid upper limb movement. Exp Brain Research. 1999; 124: 69-79

Hides J, Scott Q, Jull G, and Richardson C. A clinical palpation test to check the activation of the deep stabilizing muscles of the lumbar spine. International SportsMed Journal. 2000; 1:4

Hides J, Jull G, and Richardson C. Long term effects of specific stabilizing exercises for first episode low back pain. Spine. 2001; 11:E243-E248

Questions

Thank you!