CHAPTER 24

Rehabilitation of Injuries to the Spine

Daniel N. Hooker, PhD, PT, ATC
William E. Prentice, PhD, PT, ATC, FNATA

FUNCTIONAL ANATOMY AND BIOMECHANICS

From a biomechanical perspective, the spine is one of the most complex regions of the body with numerous bones, joints, ligaments, and muscles, all of which are collectively involved in spinal movement.32,70 The proximity to and relationship of the spinal cord, the nerve roots, and the peripheral nerves to the vertebral column adds to the complexity of this region. Injury to the cervical spine has potentially life-threatening implications, and low back pain is one of the most common ailments known to humans.

The 33 vertebrae of the spine are divided into 5 regions: cervical, thoracic, lumbar, sacral, and coccygeal. Between each of the cervical, thoracic, and lumbar vertebrae lie fibrocartilaginous intervertebral discs that act as important shock absorbers for the spine.

The design of the spine allows a high degree of flexibility forward and laterally and limited mobility backward. The movements of the vertebral column are flexion and extension, right and left lateral flexion, and rotation to the left and right. The degree of movement differs in the various regions of the vertebral column. The cervical and lumbar regions allow extension, flexion, and rotation around a central axis. Although the thoracic vertebrae have minimal movement, their combined movement between the first and twelfth thoracic vertebrae can account for 20 to 30 degrees of flexion and extension.

As the spinal vertebrae progress downward from the cervical region, they grow increasingly larger to accommodate the upright posture of the body, as well as to contribute to weightbearing. The shape of the vertebrae is irregular, but the vertebrae possess certain characteristics that are common to all. Each vertebra consists of a neural arch through which the spinal cord passes and several projecting processes that serve as attachments for muscles and ligaments. Each neural arch has 2 pedicles and 2 laminae. The pedicles are bony processes that project backward from the body of the vertebrae and connect with the laminae. The laminae are flat bony processes occurring on either side of the neural arch that project backward and inward from the pedicles. With the exception of the first and second cervical vertebrae, each vertebra has a spinous and transverse process for muscular and ligamentous attachments, and all vertebrae have multiple articular processes.

Intervertebral articulations are between vertebral bodies and vertebral arches. Articulation between the bodies is of the symphysial type. Besides motion at articulations between the bodies of the vertebrae, movement takes place at 4 articular processes that derive from the pedicles and laminae. The direction of movement of each vertebra is somewhat dependent on the direction in which the articular facets face. The sacrum articulates with the ilium to form the sacroiliac joint, which has a synovium and is lubricated by synovial fluid.⁷⁰

Ligaments

The major ligaments that join the various vertebral parts are the anterior longitudinal, the posterior longitudinal, and the supraspinous. The anterior longitudinal ligament is a wide, strong band that extends the full length of the anterior surface of the vertebral bodies. The posterior longitudinal ligament is contained within the vertebral canal and extends the full length of the posterior aspect of the bodies of the vertebrae. Ligaments connect one lamina to another. The interspinous, supraspinous, and intertransverse ligaments stabilize the transverse and spinous processes, extending between adjacent vertebrae. The sacroiliac joint is maintained by the extremely strong dorsal sacral ligaments. The sacrotuberous and the sacrospinous ligaments attach the sacrum to the ischium.⁷⁰

Muscle Actions

The muscles that extend the spine and rotate the vertebral column can be classified as either superficial or deep. The superficial muscles extend from the vertebrae to the ribs. The erector spinae is a group of superficial paired muscles that is made up of 3 columns or bands—the longissimus group, the iliocostalis group, and the spinalis group. Each of these groups is further divided into regions—the cervicis region in the neck, the thoracis region in the middle back, and the lumborum region in the low back. Generally, the erector spinae muscles extend the spine. The deep muscles attach one vertebra to another and function to extend and rotate the spine. The deep muscles include the interspinales, multifidus, rotators, thoracis, and the semispinalis cervicis.

Flexion of the cervical region is produced primarily by the sternocleidomastoid muscles and the scalene muscle group on the anterior aspect of the neck. The scalenes flex the head and stabilize the cervical spine as the sternocleidomastoids flex the neck. The upper trapezius, semispinalis capitis, splenius capitis, and splenius cervicis muscles extend the neck. Lateral flexion of the neck is accomplished by all of the muscles on one side of the vertebral column contracting unilaterally. Rotation is produced when the sternocleidomastoid, the scalenes, the semispinalis cervicis, and the upper trapezius on the side opposite to the direction of rotation contract in addition to a contraction of the splenius capitis, splenius cervicis, and longissimus capitis on the same side of the direction of rotation.

Flexion of the trunk primarily involves lengthening of the deep and superficial back muscles and contraction of the abdominal muscles (rectus abdominus, internal oblique, external oblique) and hip flexors (rectus femoris, iliopsoas, tensor fasciae latae, sartorius). Seventy-five percent of flexion occurs at the lumbosacral junction (L5-S1), whereas 15% to 70% occurs between L4 and L5. The rest of the lumbar vertebrae execute 5% to 10% of flexion.32 Extension involves lengthening of the abdominal muscles and contraction of the erector spinae and the gluteus maximus, which extends the hip. Trunk rotation is produced by the external obliques and the internal obliques. Lateral flexion is produced primarily by the quadratus lumborum muscle, along with the obliques, latissimus dorsi, iliopsoas, and the rectus abdominus on the side of the direction of movement.

Segmental spinal stabilization is produced by the deep muscles of the spine (multifidi, medial quadratus lumborum, iliocostalis lumborum, interspinales, intertransversarii) working in concert with the transversus abdominis and internal abdominal oblique (Figure 24-1). Their location is close to the center of rotation of the spinal segment, and their short muscle lengths are ideal for controlling each spinal segment. The transversus abdominis, because of its pull on the thoracolumbar fascia and its ability to create increased intra-abdominal pressure as it narrows the abdominal cavity, is a major partner in segmental spinal stabilization (Figure 24-2). This combination creates a rigid cylinder and in concert with the deep spinal muscles provides significant segmental stability to the lumbar spine and pelvis.^85,86

Spinal Cord

The spinal cord is that portion of the central nervous system that is contained within the vertebral canal of the spinal column. Thirty-one pairs of spinal nerves extend from the sides of the spinal cord, coursing downward and outward through the intervertebral foramen passing near the articular facets of the vertebrae. Any abnormal movement of these facets, such as in a dislocation or a fracture, may expose the spinal nerves to injury. Injuries that occur below the third lumbar vertebra usually result in nerve root damage but do not cause spinal cord damage.

The spinal nerve roots combine to form a network of nerves, or a plexus. There are 5 nerve plexuses: cervical, brachial, lumbar, sacral, and coccygeal.³²

THE IMPORTANCE OF EVALUATION IN TREATING BACK PAIN

In many instances, after referral for medical evaluation, the patient returns to the athletic trainer with a diagnosis of low back pain. Even though this is a correct diagnosis, it does not offer the specificity needed to help direct the treatment planning. The athletic trainer planning the treatment would be better served with a more specific diagnosis, such as spondylolysis, disc herniation, quadratus lumborum strain, piriformis syndrome, or sacroiliac ligament sprain.

Regardless of the diagnosis or the specificity of the diagnosis, the importance of a thorough evaluation of the patient’s back pain is critical to good care. The athletic trainer should become an expert on this individual patient’s back. Taking the time to perform a comprehensive evaluation will pay great rewards in the success of treatment and rehabilitation. The evaluation has 6 major purposes:

1. To clearly locate areas and tissues that might be part of the problem. The athletic trainer should use this information to direct treatments and exercises.14
   
2. To establish the baseline measurements used to assess progress and guide the treatment progression and help the athletic trainer make specific judgments on the progression of or changes in specific exercises. The improvement in these measurements also guides the return-to-activity decision and provides one measure of the success of the rehabilitation plan.⁷⁴
   
3. To provide some provocative guidance to help the patient probe the limits of his or her condition, help him or her better understand his or her problem, present limitations, and understand the management of his or her injury problem.⁵⁶
   
4. To establish confidence in the athletic trainer. This increases the placebo effect of the athletic trainer–patient interaction.¹⁰³
   
5. To decrease the anxiety of the patient. This increases the patient’s comfort, which will increase his or her compliance with the rehabilitation plan. A more positive environment is created, and the athletic trainer and patient avoid the “no one knows what is wrong with me” trap.⁵⁶
   
6. To provide information for making judgments on pads, braces, and corsets.^51,105

Table 24-1 provides a detailed scheme for evaluation of back pain.

REHABILITATION TECHNIQUES FOR THE LOW BACK

Positioning and Pain-Relieving Exercises

Most patients with back pain have some fluctuation of their symptoms in response to certain postures and activities. The athletic trainer logically treats this patient by reinforcing pain-reducing postures and motions and by starting specific exercises aimed at specific muscle groups or specific ranges of motion (ROM). A general rule to follow in making these decisions is as follows: Any movement that causes the back pain to radiate or spread over a larger area should not be included during this early phase of treatment. Movements that centralize or diminish the pain are correct movements to include at this time.¹¹⁰ Including some exercise during initial pain management generally has a positive effect on the patient. The exercise encourages him or her to be active in the rehabilitation plan and helps him or her to regain lumbar movement.⁴²

When a patient relieves pain through exercise and attention to proper postural control, he or she is much more likely to adopt these procedures into a daily routine.⁹⁵ A patient whose pain is relieved via some other passive procedure, and then is taught exercises, will not be able to readily see the connection between relief and exercise.

The types of exercises that may be included in initial pain management include the following:

• Spinal segment control, transversus abdominis, and multifidus coactivation
  
• Lateral shift corrections
  
• Extension exercises—stretching and mobilization
  
• Flexion exercises—stretching and mobilization
  
• Postural traction positions
  
• Gentle rhythmic movements in flexion, extension, rotation, and side bending
  
• Spinal manipulation

SPINAL SEGMENT CONTROL EXERCISE

In devising exercise plans to address the different clinical problems of the lumbo-pelvic-hip complex, the use of core-stabilizing exercises is a must for every problem for recovery, maintenance, and prevention of reinjury. Clinically, the core stabilization rehabilitation exercise sequence begins with relearning the muscle activation patterns necessary for segmental spinal stabilization. This beginning exercise plan is based on the work of Richardson, Jull, Hodges, and Hides.45–48,86

Table 24-1 Lumbar and Sacroiliac Joint Objective Examination

The first step in segmental spinal stabilization is to reestablish separate control of the transversus abdominis and the lumbar multifidii (Figures 24-1 and 24-2). The control and activation of these deep muscles should be separated from the control and activation of the global or superficial muscles of the core. Once patients have mastered the behavior of coactivation of the transversus abdominis and multifidii to create and maintain a corset-like control and stabilization of the spinal segments, they may then progress to using the global muscles in the core stabilization sequence and more functional activities. Segmental spinal stabilization is the basic building block of core stabilization exercises and should be an automatic behavior to be used in every subsequent exercise and activity.^{45–48,86,99}

The basic exercise that the patient must master is coactivation of the transversus abdominis and multifidii, isolating them from the global trunk muscles. This contraction should be of sufficient magnitude to create a small increase in the intra-abdominal pressure. This is a simple concept, but these muscle contractions are normally under subconscious automatic control; in patients with low back pain, the subconscious control of timing and firing patterns become disturbed and the patient loses spinal segmental control.⁴ To regain this vital skill and return the subconscious timing and firing patterns of these muscles, the patient will need individual instruction and testing to prove that he or she has mastered the conscious control of each muscle individually and in a coactivation pattern. The next step is to incorporate this coactivation pattern into functional exercise and other activities. The success of this exercise is dependent upon this muscular coactivation becoming a habitual postural control movement under both conscious and subconscious control.

A muscle contraction of 10% to 15% of the maximum voluntary contraction of the multifidus and the transversus abdominis is all that is necessary to create segmental spinal stability. Contraction levels greater than 20% of maximum voluntary contraction will cause overflow of activity to the more global muscles and negate the exercise’s intent of isolating control of the transversus abdominis and multifidii.⁶⁰ Precision of contraction and control is the intent of these exercises; the ultimate goal is a change in the patient’s behavior. As this behavior is incorporated into more daily activities and exercise, the strength and endurance of these muscle groups will also improve, and the core system will work more effectively and efficiently. A clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program includes the following criteria⁸²:

• Age less than 40 years
  
• Straight-leg raise greater than 91 degrees
  
• Aberrant movement present during lumbar ROM
  
• Positive prone instability test

Transversus Abdominis Behavior Exercise Plan

1. Test the patient’s ability to consciously contract and control the transversus abdominis in isolation from the other abdominal muscles. The athletic trainer can assess the contraction through observation and palpation. The patient is positioned in a comfortable relaxed posture: stomach-lying, supine, side-lying, or hand-knee position. The best palpation location is medial to the anterior superior iliac spine (ASIS) about 1.5 inches (Figure 24-3). The internal abdominal oblique has more vertical fibers and is closest to the ASIS, whereas the transversus fibers run horizontal from ilia to ilia. The clinician monitors the muscle with light palpation and instructs the patient to contract the muscle, feeling for the transversus drawing together across the abdomen. As the contraction increases, the internal oblique fibers and external oblique fibers will start to fire. If the patient cannot separate the firing of the transversus from the other groups and/or cannot maintain the separate contraction for 5 to 10 seconds, he or she will need individual instruction with various forms of feedback to regain control of this muscle behavior. In patients with low back pain, transversus contraction usually becomes more phasic and fires only in combination with the obliques or rectus.45
   
2. The patient is positioned in a comfortable pain-free position and instructed to breathe in and out gently, stop the breathing, and slowly, gently contract and hold the contraction of his or her transversus— and then resume normal light breathing while trying to maintain the contraction. Changes in body position (positions of choice are prone, side-lying, supine, or quadruped), verbal cues, and visual and tactile feedback will speed and enhance the learning process (Figures 24-4A and B). The use of imaging ultrasound as visual biofeedback to visualize the contractions of these muscles provides visualization of the tendon movement and can help in isolating and bringing these muscle contractions under cognitive control.⁴⁵
   
3. The lumbar multifidii contractions are taught with tactile pressure over the muscle bellies next to the spinous processes (Figure 24-5). The patient is asked to contract the muscle so that the muscle swells up directly under the finger pressure. The feeling should be a deep tension. A rapid superficial contraction or a contraction that brings in the global muscles is not acceptable, and continued trial and error with feedback is used until the desired contraction and control are achieved.^84,111
   
   
   

   

   
   

   Figure 24-3. Palpation location to feel for isolated transversus abdominis contraction.

   
   

   
   

   
   

   

   
   

   Figure 24-4. The quadruped position can be used to demonstrate and practice the isolated transversus abdominis contraction. The patient is instructed to (A) let his belly sag, then (B) slowly and gently contract his pelvic floor muscles and practice holding this position for 10 seconds.

   
   
4. As soon as cognitive control of the transversus and multifidii is achieved, more functional positions and exercises aimed at coactivation of both muscles are begun. The clinician should attempt to have the patient use the transversus and multifidii coactivation in a comfortable neutral lumbopelvic position with restoration of a normal lordotic curve so that the muscle coactivation strategies can start to be incorporated into the patient’s daily life (Figure 24-6). Repetition improves the effectiveness of this contraction, and as it is used more, the cognitive control becomes less and the subconscious pattern of segmental spinal stabilization returns to normal.²
   
   
   

   

   
   

   Figure 24-5. Palpation location to feel for isolated lumbar multifidii contractions.

   
   
5. Incorporating the coactivation contraction back into activities is the next step and is accomplished by graduating the exercises to include increases in stress and control. Supine-lying with simple leg and arm movements is a good starting point. Using a pressure biofeedback unit for this phase will help patients measure their ability to use the coactivation contraction effectively during increased exercise. The Stabilizer pressure biofeedback unit is inflated to a pressure of about 40 mm Hg. As the patient coactivates the transversus abdominis and multifidi, the pressure reading should stay the same or decrease slightly and remain at that level throughout the increased movement exercises (Figures 24-7A and B). This is an indirect measure of the segmental spinal stabilization, but gives patients an outside feedback source to keep them more focused on the exercise.¹⁰⁶
   
   
   

   

   
   

   Figure 24-6. Palpation location to feel contractions to give the patient feedback on his ability to perform a coactivation segmental spinal stabilization contraction.

   
   
6. This can be followed with trunk inclination exercises in which patients maintain a neutral lumbopelvic position and incline their trunk in different positions away from the vertical alignment and hold in positions of forward-lean to side-lean for specific time periods (Figures 24-8A and B and 24-9A and B). This is first done in the sitting position. As control, strength, and endurance increase, the positions can become more exaggerated and the holding times longer.
   
7. Return the patient to a structured progressive resistive core exercise program (see Chapter 5). The incorporation of the segmental spinal stabilization coactivation contraction as the precursor to each exercise is the goal at this point in returning the patient back to functional activity.
   
8. The athletic trainer should teach this technique both as an exercise and as a behavior. The exercises should be taught and monitored in an individual session with opportunity for feedback and correction. Patients must also use this skill in the functional things they do every day. Patients are asked to trigger this spinal segment control skill in response to daily tasks, postures, pains, and certain movements (Figures 24-10A and B). As their pain is controlled, the coactivation contraction should be incorporated into activities of daily living (ADLs).⁶³

Figure 24-7. (A) The Stabilizer pressure biofeedback unit can be used as an indirect method of measuring correct activation of the segmental spinal stabilization coactivation contraction. The stabilizer is inflated to 40 mm Hg pressure and placed under the patient’s (B) abdomen or (C) back. The patient should be instructed to contract the transversus in a way that does not make the pressure in the cuff start to rise or fall.

Figure 24-8. Trunk inclination exercise. The patient finds a comfortable neutral spine position and coactivates his transversus abdominis and lumbar multifidii to provide the segmental spinal stabilization.

Segmental spinal stabilization is complementary for all forms of treatment and different pathologies. This exercise program can be incorporated and started at the same time as other therapies. The different forms of therapy summate, and the patient improves more quickly and maintains the gains in range and strength achieved with other therapies. Spinal segment control may also decrease pain and give the patient a measure of control to use in minimizing painful stress through the injured tissues.

Lumbar Lateral Shift Corrections

An acute onset lumbar lateral shift is a common clinical observation associated with low back pain.57 Lumbar lateral shift corrections and extension exercises probably should be discussed together because the indications for use are similar, and extension exercises will immediately follow the lateral shift corrections.⁶⁷

The indications for the use of lateral shift corrections are as follows:

• Subjectively, the patient complains of unilateral pain reference in the lumbar or hip area.
  
• The typical posture is scoliotic with a hip shift and reduced lumbar lordosis.⁷⁸
  
• Walking and movements are very guarded and robotic.
  
• Forward bending is extremely limited and increases the pain.
  
• Backward bending is limited.
  
• Side bending toward the painful side is minimal to impossible.
  
• Side bending away from the painful side is usually reasonable to normal.
  
• A test correction of the hip shift either reduces the pain or causes the pain to centralize.

Figure 24-9. The patient challenges his spinal segment control by leaning away from the vertical position while holding the neutral spine position for 10 seconds.

Figure 24-10. The patient is instructed to become posture savvy by frequently using the coactivation contraction throughout his day. The coactivation thereby becomes a subconscious movement pattern the patient incorporates into all he does.

The neurological examination may or may not elicit the following positive findings:

• Straight-leg raising may be limited and painful, or it could be unaffected.
  
• Sensation may be dull, anesthetic, or unaffected.
  
• Manual muscle test may indicate unilateral weakness of specific movements, or the movements may be strong and painless.
  
• Reflexes may be diminished or unaffected.71

The patient will be assisted by the athletic trainer with the initial lateral shift correction. The patient is then instructed in the techniques of self-correction. The lateral shift correction is designed to guide the patient back to a more symmetrical posture. The athletic trainer’s pressure should be firm and steady and more guiding than forcing. The use of a mirror to provide visual feedback is recommended for both the athletic trainer–assisted and self-corrected maneuvers. The specific technique guide for athletic trainer–assisted lateral shift correction is as follows (Figure 24-11):

1. Prepare the patient by explaining the correction maneuver and the roles of the patient and the athletic trainer.
   

   a. The patient is to keep the shoulders level and avoid the urge to side bend.

   
   

   b. The patient should allow the hips to move under the trunk and should not resist the pressure from the athletic trainer but allow the hips to shift with the pressure.

   
   

   c. The patient should keep the athletic trainer informed about the behavior of the back pain.

   
   

   d. The patient should keep the feet stationary and not move after the hip shift correction until the standing extension part of the correction is completed.

   
   

   e. The patient should practice the standing extension exercise as part of this initial explanation.

   
   
2. The athletic trainer should stand on the patient’s side that is opposite his or her hip shift.¹⁰⁴ The patient’s feet should be a comfortable distance apart, and the athletic trainer should have a comfortable stride stance aligned slightly behind the patient.
   
3. Padding should be placed around the patient’s elbow, on the side next to the athletic trainer, to provide comfortable contact between the patient and the athletic trainer.
   
4. The athletic trainer should contact the patient’s elbow with the shoulder and chest, with the head aligned along the patient’s back. The athletic trainer’s arms should reach around the patient’s waist and apply pressure between the iliac crest and the greater trochanter (Figure 24-11).
   
   
   

   

   
   

   Figure 24-11. Lateral shift correction exercise. Emphasis is on pulling the hips, not on pushing the ribs.

   
   
5. The athletic trainer should gradually guide the patient’s hips toward him or her. If the pain increases, the athletic trainer should ease the pressure and maintain a more comfortable posture for 10 to 20 seconds, and then again pull gently. If the pain increases again, the athletic trainer should again lessen the pull and allow comfort, then instruct the patient to actively extend gently, pushing the back into and matching the resistance supplied by the athletic trainer. The goal for this maneuver is an overcorrection of the scoliosis, reversing its direction.¹⁰⁴
   
6. Once the corrected or overcorrected posture is achieved, the athletic trainer should maintain this posture for 1 to 2 minutes. This procedure may take 2 to 3 minutes to complete, and the first attempt may be less than a total success. Repeated efforts 3 to 4 minutes apart should be attempted during the first treatment effort before the athletic trainer stops the treatment for that episode.
   
7. The athletic trainer gradually releases pressure on the hip while the patient does a standing extension movement (Figure 24-16). The patient should complete about 6 repetitions of the standing extension movement, holding each for 15 to 20 seconds.
   
8. Once the patient moves the feet and walks even a short distance, the lateral hip shift usually will recur, but to a lesser degree. The patient then should be taught the self-correction maneuver (Figure 24-12). The patient should stand in front of a mirror and place one hand on the hip where the athletic trainer’s hands were and the other hand on the lower ribs where the athletic trainer’s shoulder was.
   
9. The patient then guides the hip under the trunk, watching the mirror to keep the shoulders level and trying to achieve a corrected or overcorrected posture. He or she should hold this posture for 30 to 45 seconds and then follow with several standing extension movements as described in step 7 (Figure 24-16).

Extension Exercises

Lumbar extension exercise resistance training has been shown to be effective in treating chronic low back pain.^26,101 The indications for the use of extension exercise are as follows:

• Subjectively, back pain is diminished with lying down and is increased with sitting. The location of the pain may be unilateral, bilateral, or central, and there may or may not be pain radiating into either or both legs.
  
• Forward bending is extremely limited and increases the pain, or the pain reference location enlarges as the patient bends forward.
  
• Backward bending can be limited, but the movement centralizes or diminishes the pain.
  
• The neurological examination is the same as outlined for lateral shift correction.

The efficacy of extension exercise is theorized to be from one or a combination of the following effects⁶⁶:

• A reduction in the neural tension
  
• A reduction of the load on the disc, which in turn decreases disc pressure
  
• Increases in the strength and endurance of the extensor muscles
  
• Proprioceptive interference with pain perception as the exercises allow self-mobilization of the spinal joints

Figure 24-13. Prone extension on elbows.

Figure 24-14. Prone extension on hands.

Hip shift posture has previously been theoretically correlated to the anatomical location of the disc bulge or nucleus pulposus herniation. Creating a centralizing movement of the nucleus pulposus has been the theoretical emphasis of hip shift correction and extension exercise. This theory has good logic, but research on this phenomenon has not been supportive.110 However, in explaining the exercises to the patient, the use of this theory may help increase the patient’s motivation and compliance with the exercise plan.

End-range hyperextension exercise should be used cautiously when the patient has facet joint degeneration or impingement of the vertebral foramen borders on neural structures. Also, spondylolysis and spondylolisthesis problems should be approached cautiously with any end-range movement exercise using either flexion or hyperextension.

Figures 24-13 through 24-20 are examples of extension exercises. These examples are not exhaustive but are representative of most of the exercises used clinically.

The order in which exercises are presented is not significant. Instead, each athletic trainer should base the starting exercises on the evaluative findings. Jackson,⁵³ in a review of back exercise, stated, “No support was found for the use of a preprogrammed flexion regimen that includes exercises of little value or potential harm and is not specific to the current needs of the patient, as determined by a thorough back evaluation.”

Flexion Exercises

The indications for the use of flexion exercises are as follows:

• Subjectively, back pain is diminished with sitting and is increased with lying down or standing. Pain is also increased with walking.
  
• Repeated or sustained forward bending eases the pain.
  
• The patient’s lordotic curve does not reverse as he or she forward bends.
  
• The end range of sustained backward bending is painful or increases the pain.
  
• Abdominal tone and strength are poor.

Figure 24-15. Alternate arm and leg extension.

Figure 24-16. Standing extension.

Figure 24-17. Supine hip extension—butt lift or bridge. (A) Double-leg support. (B) Single-leg support.

Figure 24-18. Prone single-leg hip extension. (A) Knee flexed. (B) Knee extended.

Figure 24-20. Trunk extension—prone. (A) Hands near head. (B) Arms extended—superman position.

In his approach, Saal elaborates on the thought that “No one should continue with one particular type of exercise regimen during the entire treatment program.”91 We concur with this and feel that starting with one type of exercise should not preclude rapidly adding other exercises as the patient’s pain resolves and other movements become more comfortable.

The efficacy of flexion exercise is theorized to derive from one or a combination of the following effects:

• A reduction in the articular stresses on the facet joints
  
• Stretching to the thoracolumbar fascia and musculature
  
• Opening of the intervertebral foramen
  
• Relief of the stenosis of the spinal canal
  
• Improvement of the stabilizing effect of the abdominal musculature
  
• Increasing the intra-abdominal pressure because of increased abdominal muscle strength and tone
  
• Proprioceptive interference with pain perception as the exercises allow self-mobilization of the spinal joints

Flexion exercises should be used cautiously or avoided in most cases of acute disc prolapse and when a laterally shifted posture is present. In patients recovering from disc-related back pain, flexion exercise should not be commenced immediately after a flat-lying rest interval longer than 30 minutes. The disc can become more hydrated in this amount of time, and the patient would be more susceptible to pain with postures that increase disc pressures. Other, less stressful exercises should be initiated first and flexion exercise done later in the exercise program.

Figures 24-21 through 24-31 show examples of flexion exercises. Again, these examples are not exhaustive but are representative of the exercises used clinically.

Figure 24-21. Single knee to chest. Stretch holding 15 to 20 seconds. Alternate legs.

Figure 24-22. Double knee to chest. Stretch holding 15 to 20 seconds. Mobilization can be done using a rhythmic rocking motion within a pain-free ROM.

Figure 24-23. Posterior pelvic tilt.

Figure 24-24. Partial sit-up.

Figure 24-25. Rotation partial sit-up.

Figure 24-26. Slump sit stretch position.

Figure 24-27. Flat-footed squat stretch.

Figure 24-29. Hip flexor stretch.

Figure 24-30. Knee rocking side-to-side.

Figure 24-31. Knees toward chest rock.

Joint Mobilizations

The indications for the use of joint mobilizations are as follows:

• Subjectively, the patient’s pain is centered around a specific joint area and increases with activity and decreases with rest.
  
• The accessory motion available at individual spinal segments is diminished.
  
• Passive ROM is diminished.
  
• Active ROM is diminished.
  
• There may be muscular tightness or increased fascial tension in the area of the pain.
  
• Back movements are asymmetrical when comparing right and left rotation or side bending.
  
• Forward and backward bending may steer away from the midline.

Figure 24-32. Supine hip lift—bridge-rock.

Figure 24-33. Pelvic tilt or pelvic rock (quadruped position). (A) Swayback horse. (B) Scared cat.

Figure 24-34. Kneeling (quadruped position)—dog-tail wags.

The efficacy of mobilization is theorized to be from one or a combination of the following effects:

• Tight structures can be stretched to increase the ROM.
  
• The joint involved is stimulated by the movement to more normal mechanics, and irritation is reduced because of better nutrient–waste exchange.
  
• Proprioceptive interference occurs with pain perception as the joint movement stimulates normal neural firing whose perception supersedes nociceptive perception.

Mobilization techniques are multidimensional and are easily adapted to any back pain problem. The mobilizations can be active or passive or assisted by the athletic trainer. All ranges (flexion, extension, side bending, rotation, and accessory) can be incorporated within the exercise plan. The mobilizations can be carried out according to Maitland’s grades of oscillation as discussed in Chapter 13. The magnitude of the forces applied can range from grade 1 to grade 4, depending on levels of pain. The theory, technique, and application of the athletic trainer–assisted mobilizations and manipulation are best gained through guided study with an expert practitioner.²³

Figures 24-30 through 24-39 show the various self-mobilization exercises.

Figures 13-35 to 13-45 show joint mobilizations that can be used by the athletic trainer.

Figure 24-35. Sitting or standing rotation.

Figure 24-36. Sitting or standing side bending.

Figure 24-37. Standing hip-shift side-to-side.

Spinal Joint Manipulation

The research from the mid-1990s through 2000 clarified the role of spinal mobilization and manipulation in the overall scheme of back and neck rehabilitation.62 Treatment algorithms have evolved and the role of mobilization and manipulation techniques are better understood and are taking their rightful place in rehabilitation plans. There is moderate evidence that mobilization and manipulation are effective in reducing pain and improving function for patients with chronic low back pain. While both therapies appear safe, manipulation appears to produce a greater effect than mobilization.²³ The literature supports manipulation for the short-term benefits of pain relief and quicker return to functional activities. Long-term results show no detriment to this approach compared to other specific treatment plans. The reverse, however, is true. When manipulation is not included in a population that would benefit, the pain and loss of function symptoms last longer and can worsen.¹² This makes the case for including greater use of spinal manipulation in rehabilitation plans than might have previously been used by athletic trainers.^19,20,28,30

The techniques used are shared among osteopathic, physical therapy, chiropractic, and athletic training disciplines with theoretical rationales for use, and matching certain techniques to certain evaluative findings vary between groups. The basic technique is simple and can be learned and used by any athletic trainer from the undergraduate student to the most experienced practitioner. Figures 24-39, 24-58, and 24-59 show the basic positioning for the athletic trainer and the patient. Once the positioning is set, the athletic trainer delivers a high-velocity, low-amplitude thrust mobilization to the lumbar spine or innominate that creates a sudden perturbation of the general lumbar and sacroiliac region. Although there is often an associated popping sound attributed to a cavitation of one or more of the facet joints, the success of the treatment and pain relief mechanisms are not attributed to this sound.^29,89 The pain relief effect of the manipulation is poorly understood, but the action mechanism will likely be multimodal and will include the afferent input to the central nervous system and its effect on the endogenous pain control systems.^{5,6,19,20,28,90}

The increased use of a technique adds to increased skill in performance and security with that particular technique.

A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation includes the following criteria¹³:

• Duration of current episode of symptoms less than 16 days
  
• Location of symptoms not extending distal to the knee
  
• Score on the Fear-Avoidance Beliefs Questionnaire Work Subscale less than 19 points
  
• At least one lumbar spine segment judged to be hypomobile
  
• At least one hip with more than 35 degrees of internal rotation ROM

The athletic population should have a high proportion of low back pain patients that meets this clinical prediction rule. Manipulation should definitely be included in their rehabilitation plan.

Athletic trainers are usually entry-level caregivers for patients with low back pain and are well positioned to use manipulation in the first treatments aimed at reducing back pain and increasing function.^{19,20,28–30} If the patient has only three of the above findings, the treatment results might not be as good, but including manipulation would still be worth the effort and would not be contraindicated.

The side effects and potential adverse events are frequently used as contraindication to lumbar spinal manipulation but, in fact, are unproven and in most studies the complaints are musculoskeletal in nature and consist of mild pain, stiffness, and guarding of movements. These changes are usually self-limiting and do not affect the long-term outcome of the patient. The risk for serious complications (disc herniation, cauda equina syndrome) is very low.^{9,12,13,30,90,94}

REHABILITATION TECHNIQUES FOR LUMBAR AND SACROILIAC PAIN

Low Back Pain

Pathomechanics

In most cases, low back pain does not have serious or long-lasting pathology. It is generally accepted that the soft tissues (ligament, fascia, and muscle) can be the initial pain source. The patient’s response to the injury and to the provocative stresses of evaluation is usually proportional to the time since the injury and the magnitude of the physical trauma of the injury. The soft tissues of the lumbar region should react according to the biological process of healing, and the timelines for healing should be like those for other body parts. There is little substantiation that injury to the low back should cause a pain syndrome that lasts longer than 6 to 8 weeks. Pain avoidance and fear mechanisms are issues that also play a big role in return to activity and require some inclusion in the rehabilitation plan.24,25,64

Injury Mechanism

Back pain can result from one or a combination of the following problems: muscle strain, piriformis muscle or quadratus lumborum myofascial pain or strain, myofascial trigger points, lumbar facet joint sprains, hypermobility syndromes, disc-related back problems, or sacroiliac joint dysfunction.

Rehabilitation Concerns

ACUTE VS CHRONIC LOW BACK PAIN

The low back pain that most often occurs is an acute, painful experience rarely lasting longer than 3 weeks. As with many injuries, athletic trainers often go through exercise or treatment fads in trying to rehabilitate the patient with low back pain. The latest fad might involve flexion exercise, extension exercise, joint mobilization, dynamic muscular stabilization, abdominal bracing, myofascial release, electrical stimulation protocols, and so on. To keep perspective, as athletic trainers select exercises and modalities, they should keep in mind that 90% of people with back pain get resolution of the symptoms in 6 weeks, regardless of the care administered.

There are patients who have pain persisting beyond 6 weeks. This group of patients will generally have a history of reinjury or exacerbation of previous injury. They describe a low back pain that is similar to their previous back pain experience.

These patients are experiencing an exacerbation or reinjury of previously injured tissues by continuing to apply stresses that may have created their original injury. This group of patients needs a more specific and formal treatment and rehabilitation program.²⁵

There are also people who have chronic low back pain. This is a very small percentage of the population that suffers from low back pain. The difference between the patient with an acute injury or reinjury and a person with chronic pain has been defined by Waddell.¹⁰⁷ He states, “Chronic pain becomes a completely different clinical syndrome from acute pain.”¹⁰⁷ Acute and chronic pain not only are different in time scale but are fundamentally different in kind. Acute and experimental pains bear a relatively straightforward relationship to peripheral stimulus, nociception, and tissue damage.

There may be some understandable anxiety about the meaning and consequences of the pain, but acute pain, disability, and illness behavior are generally proportionate to the physical findings. Pharmacological, physical, and even surgical treatments directed to the underlying physical disorder are generally highly effective in relieving acute pain. Chronic pain, disability, and illness behavior, in contrast, become increasingly dissociated from their original physical basis, and there may be little objective evidence of any remaining nociceptive stimulus. Instead, chronic pain and disability become increasingly associated with emotional distress, depression, failed treatment, and adoption of a sick role. Chronic pain progressively becomes a self-sustaining condition that is resistant to traditional medical management. Physical treatment directed to a supposed but unidentified and possibly nonexistent nociceptive source is not only understandably unsuccessful but may also cause additional physical damage. Failed treatment may both reinforce and aggravate pain, distress, disability, and illness behavior.¹⁰⁷

Rehabilitation Progression

A discussion of the rehabilitation progression for the patient with low back pain can be much more specific and meaningful if treatment plans are grouped into 2 stages. Stage I (acute stage) treatment consists mainly of the modality treatment and pain-relieving exercises. Stage II treatment involves treating patients with a reinjury or exacerbation of a previous problem. The treatment plan in stage II goes beyond pain relief, strengthening, stretching, and mobilization to include trunk stabilization and movement training sequences and to provide a specific, guided program to return the patient to functional activity.

STAGE I (ACUTE STAGE) TREATMENT

Modulating pain should be the initial focus of the athletic trainer. Progressing rapidly from pain management to specific rehabilitation should be a primary goal of the acute stage of the rehabilitation plan. The most common treatment for pain relief in the acute stage is to use ice for analgesia. Rest, but not total bed rest, is used to allow the injured tissues to begin the healing process without the stresses that created the injury. If the patient fits the clinical prediction rules for spinal manipulation, this should be initiated as soon as the patient can tolerate the positioning.34

Along with rest, during the initial treatment stage, the patient should be taught to increase comfort by using the appropriate body positioning techniques described previously, which may involve (1) lateral shift corrections (Figure 24-11), (2) extension exercises (Figures 24-13 through 24-20), (3) flexion exercises (Figures 24-21 through 24-31), (4) self-mobilization exercises (see Figures 13-46 and 13-47), or (5) spinal manipulation (Figures 24-39 and 24-58). Segmental spinal stabilization exercise should be initiated concurrently with these other exercises. Outside support, in the form of corsets and the use of props or pillows to enhance comfortable positions, also needs to be included in the initial pain management phase of treatment.^51,105 The patient should also be taught to avoid positions and movements that increase any sharp, painful episodes. The limits of these movements and positions that provide comfort should be the initial focus of any exercises.

The patient should be encouraged to move through this stage quickly and return to activity as soon as range, strength, and comfort will allow. The addition of a supportive corset during this stage should be based mostly on patient comfort.¹⁰⁵ We suggest using an eclectic approach to the selection of the exercises, mixing the various protocols described according to the findings of the patient’s evaluation. Rarely will a patient present with classic signs and symptoms that will dictate using one variety of exercise.

STAGE II (REINJURY STAGE) TREATMENT

In the reinjury or chronic stage of back rehabilitation, the goals of the treatment and training should again be based on a thorough evaluation of the patient. Identifying the causes of the patient’s back problem and recurrences is very important in the management of his or her rehabilitation and prevention of reinjury. A goal for this stage of care is to make the patient responsible for the management of his or her back problem. The athletic trainer should identify specific problems and corrections that will help the patient better understand the mechanisms and management of the problem.⁷⁴

Specific goals and exercises should be identified about the following:

• Which structures to stretch
  
• Which structures to strengthen
  
• Incorporating segmental spinal stabilization and abdominal bracing into the patient’s daily life and exercise routine
  
• Progression of core stabilization exercises
  
• Which movements need a motor learning approach to control faulty mechanics⁷⁴

Stretching

The clinician and the patient need to plan specific exercises to stretch restricted groups, maintain flexibility in normal muscle groups, and identify hypermobility that may be a part of the problem. In planning, instructing, and monitoring each exercise, adequate thought and good instruction must be used to ensure that the intended structures are stretched and areas of hypermobility are protected from overstretching.⁴⁹ Inadequate stabilization will lead to exercise movements that are so general that the exercise will encourage hyperflexibility at already hypermobile areas. Lack of proper stabilization during stretching may help perpetuate a structural problem that will continue to add to the patient’s back pain.

In the athletic trainer’s evaluation of the patient with back pain, the following muscle groups should be assessed for flexibility48:

• Hip flexors
  
• Hamstrings
  
• Low back extensors
  
• Lumbar rotators
  
• Lumbar lateral flexors
  
• Hip adductors
  
• Hip abductors
  
• Hip rotators

Strengthening

There are numerous techniques for strengthening the muscles of the trunk and hip. Muscles are perhaps best strengthened by using techniques of progressive overload to achieve specific adaptation to imposed demands (the SAID principle). The overload can take the form of increased weight load, increased holding time, increased repetition load, or increased stretch load to accomplish physiologic changes in muscle strength, muscle endurance, or flexibility of a body part.

The treatment plan should call for an exercise that the patient can easily accomplish successfully. Rapidly but gradually, the overload should push the patient to challenge the muscle group needing strengthening. The athletic trainer and the patient should monitor continuously for increases in the patient’s pain or recurrences of previous symptoms. If those changes occur, the exercises should be modified, delayed, or eliminated from the rehabilitation plan.

Core Stabilization

Core stabilization training, dynamic abdominal bracing, and finding the neutral position all describe a technique used to increase the stability of the trunk (see Chapter 5). This increased stability will enable the patient to maintain the spine and pelvis in the most comfortable and acceptable mechanical position that will control the forces of repetitive microtrauma and protect the structures of the back from further damage. Core muscular control is one key to giving patients the ability to stabilize their trunk and control their posture.¹⁰ Abdominal strengthening routines are rigorous, and the patient must complete them with vigor. However, in their functional activities, patients need to take advantage of their abdominal strength to stabilize the trunk and protect the back.⁵²

Richardson et al focus attention on motor control of the transversus abdominis and lumbar multifidii in various positions.^85,86 Once this control is established, different positions and movements are added. As the vigor of the exercise is progressively increased, the patient will incorporate the more global muscles in stabilizing his or her core (see Chapter 5). Then the patient moves into the functional exercise progression with the segmental spinal stabilization as the base movement in core stabilization, which is needed to perform functionally.⁸⁶ The concept of increasing trunk stability with muscle contractions that support and limit the extremes of spinal movement is important.

BASIC FUNCTIONAL TRAINING

Patients must be constantly committed to improving body mechanics and trunk control in all postures in their ADLs. The athletic trainer needs to evaluate patients’ daily patterns and give them instruction, practice, and monitoring on the best and least stressful body mechanics in as many activities as possible.

The basic program follows the developmental sequence of posture control, starting with supine and prone extremity movement while actively stabilizing the trunk. The patient is then progressed to all fours, kneeling, and standing (Figure 24-40).

Emphasis on trunk control and stability is maintained as the patient works through this exercise sequence.⁴⁸

The most critical aspect for developing motor control is repetition of exercise. However, variability in positioning, speed of movement, and changes in movement patterns must also be incorporated. The variability of the exercise will allow patients to generalize their newly learned trunk control to the constant changes necessary in their movements. The basic exercise, transversus abdominis and lumbar multifidii coactivation, is the key. Incorporating this stabilization contraction into various activities helps reinforce trunk stabilization and returns trunk control to a subconscious automatic response.

Figure 24-40. Weight shifting and stabilization exercises should progress from (A) quadruped, to (B) triped, to (C) biped.

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