of the Athlete’s Spine

Fig. 3.1

Watkins’ lumbar rehabilitation program

../images/468535_1_En_3_Chapter/468535_1_En_3_Fig2_HTML.png — Fig. 3.2

Dead bug exercise . (a) Level 1 of the exercise. The spine is kept in a neutral tucked position, and feet are marched in place with one foot constantly on the floor. The goal is to perform this movement consistently without pain for 2 min. (b) Levels 2–5 of the exercise. Here the spine is kept in a neutral tucked position, and the opposite foot/arm is extended in an alternating pattern. The goal for level 2 completion is to perform the exercise for 3 min. Likewise, the goals for levels 3, 4, and 5 are to complete the exercise for 7, 10, and 15 min, respectively. Weights may be added to the hands to increase the difficulty. (Instructional photo by Watkins Spine Inc.)

By focusing on a neutral spine technique, the rehabilitation program can be started 2–4 weeks after a single-level lumbar laminotomy or discectomy, 4–6 weeks after a multilevel laminotomy or laminectomy, 6–8 weeks after an artificial disc replacement, and 6–12 weeks after a fusion. Restoring normal mobility in the ankles, knees, and hips, while maintaining a neutral spine, will help reduce mechanical stress from the bony and muscular structures in the lumbar spine. This in turn will help reduce pain and improve function as quickly as possible [7].

Specifically, the program allows the athlete to progress through seven different exercises rated one through five in difficulty (Fig. 3.1). The entire program starts with finding a neutral pain-free position for the spine and strictly holding it in that position while performing the exercises. The entire program can be performed with relatively simple exercise equipment: exercise balls, hand weights, and pulleys.

The key to the rehabilitation program is to learn the proper technique. Proper technique is simply maintaining the neutral spine position. This is accomplished using the pelvic tilt maneuver . By properly tilting the pelvis using the abdominal and gluteal muscles, the patient places the lumbar spine in a neutral position. Once the patient learns the neutral position, they are taught to maintain this position while performing all levels of the rehabilitation program.

A proper pelvic tilt has three components. First and foremost, the abdominal muscles must fire correctly. Most patients will tend to fire the abdominals using the “draw-in” maneuver (DIM). It has been shown that the DIM is a very poor technique used to establish abdominal control. With the DIM, the patient is elevating the rib cage away from the pelvis and stretching the rectus abdominis rather than causing a contraction. The transverse abdominis and oblique muscles do very little. A correct technique to engage the entire abdominal muscle group is called the abdominal bracing technique (ABT) . Using the ABT creates a pushing out maneuver that draws the pelvis up toward the rib cage using the rectus abdominis, the transverse abdominis, as well as the internal and external oblique groups [8]. The second component and the third component occur together. The gluteal muscles fire and pelvis tips in a posterior direction. By performing the pelvis tilt correctly, the lumbar spine will be held in a neutral position.

Once the patient demonstrates the ability to perform and hold a proper tilt, the exercises can begin. No movement of the spine is allowed. By doing this not only will one avoid exacerbations in the early post-injury and postoperative period but develop proper timing through proprioceptive feedback of the core muscles. The goals during both the stretching and strengthening phases are as follows: stability through the spine, slow and deliberate execution with all levels of exercise, and building of endurance. Feedback insuring no motion of the spine is critical. At first feedback is tactile and eventually becomes internal as patient advances to higher levels. It is not a matter of brute strength; it is a matter of doing the technique properly.

The therapist’s objective is to teach the patient how to do the exercises correctly. Regardless of how advanced the exercise, strict spine stability must be maintained. Often one category will advance faster than another category. Patients may be doing the level 3 in dead bug exercises, yet only level 2 in prone exercises. The therapist will advance the patient quicker in some exercises as long as they are able to perform the specific exercise correctly without pain. Key to the program is strictly maintaining the neutral position with all exercises. The exercises challenge the patient in different planes of motion : anterior and posterior sagittal plane, right and left frontal plane, and right and left transverse plane. If a patient has difficulty with a certain exercise category, determine what plane of motion is the suspect. This will help direct the stabilization progression. Core strengthening is neurological retraining as much as it is physiological strengthening [8, 9]. Precise application will enhance results.

Ball exercises provide a platform that requires a higher level of coordination and proprioceptive control to maintain strict stability [10]. Initially the therapist may need to provide tactile feedback to achieve this. The leg press begins with just a simple balancing exercise, rolling on the ball, and maintaining control of the ball throughout the motions (Fig. 3.3). Prone exercises of superman’s, swimming, and shoulder abduction challenge abdominals and gluteals to prevent hyperextension. Prayer exercises and push-ups demand upper abdominal control to maintain stability. Always start slowly to insure a stable spine position.