Spine Injury Prevention

Spinal injury and back pain are a common problem facing patients seeking medical care including athletes, which can lead to significant disability, medical costs, and impaired performance for these patients. Rehabilitation including core muscle stabilization, Kinesio taping, and flexibility have been shown to help with treatment and prevention. Critical factors such as equipment, technique, and rule changes can also be an important part of spine injury prevention.

Key points

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Low back pain and spinal injury are a common pathology and disability among athletes that can be prevented.
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Core stability, flexibility, and Kinesio taping have been shown to be important adjuncts to any rehabilitation or spine injury prevention program.
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Equipment, technique, and rule changes are all important aspects of spine injury prevention in sports.

Introduction/Incidence

Spinal injury or back pain is considered to be the leading cause of disability worldwide and one of the most common symptoms for which patients seek medical care ( Table 1 ). It is thought to have a lifetime incidence ranging between 60% and 90%, with 26% of people reporting an episode of low back pain within the previous 3 months. The direct medical expenditures as well as the indirect costs through loss of work productivity and disability due to back pain are increasing, and in 2008 care related to back pain was estimated to be $86 billion. Up to 25% of all workdays missed in the United States are attributed to low back pain, and more than 75% of episodes have no clear diagnosis. Among athletes, low back pain has been shown to have a lifetime prevalence ranging between 33% and 84% with variability based on one’s sport participation. The highest prevalence of low back pain was noted in skiers, floorball players, and rowers, whereas the lowest prevalence was found in shooters, golfers, and triathletes. Although most patients will have near-complete resolution of symptoms within 30 days of onset, some will have persistent pain lasting for more than 90 days. In addition, some patients may experience resolution of symptoms but also experience episodes of recurrent pain.

Table 1

Core exercises for the spine

Exercise Type	Muscle Group	Number of Repetitions	Number of Days per Week	Number of Weeks
Strengthening Exercises
Plank	Back extensors, quadratus lumborum, erector spinae, abdominals	5–10	Daily	4–6
Side bridges ^a	Quadratus lumborum	10–20	Daily	4–6
Hip bridges	Back and hip extensors, gluteal muscles, hamstrings	10–20	Daily	4–6
Bird dog	Back extensors, erector spinae, gluteal muscles	10–20	Daily	4–6
Abdominal bracing	Abdominals	10–20	Daily	4–6
Stretching Exercises
Cat back stretch	Middle and lower back	5–10	Daily	4–6
Kneeling back extension stretch	Low back	5–10	Daily	4–6
Seated side straddle	Adductors, medial hamstrings, semitendinosus, semimembranosus	5–10	Daily	4–6
Piriformis stretch	Piriformis, external and internal rotators	5–10	Daily	4–6
Knee to chest stretch	Quadratus lumborum	5–10	Daily	4–6

a Can perform modified side bridges.

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Heat should be applied to the lower back for 15 to 20 minutes before performing the exercises.
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Pain should not be experienced during exercises. If pain does worsen or it does not improve after performing exercises for 3 to 4 weeks, discuss with your physician.
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Exercises should be performed in conjunction with a progressive cardiovascular training program that consists of aerobic exercises (ie, walking, swimming, cycling) for 30 minutes, 3 to 5 days per week. When performing aerobic exercises, the spine should be maintained in neutral position while stabilizing the abdominal muscles.

Core stability strengthening/rehabilitation

In recent years, core strengthening has become a major trend in rehabilitation and is a term used to describe the muscular control required around the lumbar spine to maintain functional stability. The “core” is described as a box with the abdominals in the front, paraspinals and gluteals in the back, the diaphragm as the root, and the pelvic floor and hip girdle musculature as the bottom. It both functional and athletic events, the core provides proximal stability for distal mobility. Trunk musculature helps to stabilize the core by compressing and stiffening the spine. In addition, intraabdominal pressures increase as core muscular contracts, further increasing spinal stiffness and subsequently enhancing core stability.

However, there remains considerable debate regarding which core muscles are the most important in optimizing spinal stability, specifically regarding the importance of transversus abdominis and multifidi musculature. ^, In patients without lumbar pathology, the transversus abdominis muscle has been shown to contract before upper extremity motion irrespective of the direction of motion. In contrast, there is a substantial delay in activation of the transversus abdominis in patients with lumbar pathology with all movements, indicating a motor control deficit that can result in inefficient spine stabilization. A lack of sufficient coordination within the core musculature can lead to decreased efficiency of movements and compensatory patterns, thus leading to strain and overuse injuries.

Although core strengthening can decrease the risk of injury by enhancing lumbar spine stability and has also been shown to decrease the risk of injury to lower extremities, ^, there is no strong relationship between core stability and performance, ^, and excessive spinal loading can also increase the risk of injury. A study in 2002 reported that no single core muscle can be identified as the most important for lumbar spine stability, and furthermore, no single muscle contributed more than 30% to the overall spinal stability. Therefore, lumbar spine stabilization exercises may be most effective when a focus is placed on relearning motor control of the entire spinal musculature under various loading conditions.

A core exercise program is typically done in stages and with gradual progression. Initially the program will begin with restoration of normal muscle length and mobility with the goal of correcting any existing muscle imbalances to allow proper joint function and movement efficiency. Following this, activation of deep core musculature is taught via lumbopelvic stability exercises with eventual progression to incorporation of a physio ball. The final step involves transitioning to standing in order to facilitate function movement exercises that promote balance and coordination of precise movements. When evaluating patients, it is important to also note that not all core exercises are appropriate for all individuals. Exercises that cause hip and trunk flexion can be problematic in those with lumbar disk pathologies due to increased intradiscal pressure and spinal compression ^, as well as those with osteoporosis due to the risk of vertebral compression fractures. As such, these patients may benefit more from exercises that maintain a neutral spine and pelvis. Individuals with facet-mediated pain and vertebral or intervertebral foraminal stenosis may not tolerate lumbar extension–based exercises and may therefore better benefit from lumbar flexion–based exercises.

One study found that certain factors can be used to assess which patients will respond favorable to core stabilization exercises:

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Younger age (<40 years)
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Greater general flexibility (hamstring length > 90°, postpartum)
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Positive prone instability test
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Presence of aberrant movement during spinal range of motion (painful arc of motion, abnormal lumbopelvic rhythm, and using arms on thighs for support)

Another study proposed certain physical modalities that can serve to predict a good response from stabilization exercises in postpartum women:

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Positive posterior pelvic pain provocation (P4) test (also referred to as “thigh thrust test”)
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Positive active straight leg raise
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Positive pain provocation (persists greater than 5 sec after palpation) with palpation of posterior superior iliac spine region (long dorsal sacroiliac ligament)
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Positive pain provocation (persists great than 5 sec after palpation) with palpation of pubic symphysis
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Positive trendelenburg gait

Multiple studies ^, have demonstrated that there is a lack of proper core musculature recruitment and core weakness in patients with chronic low back and sacroiliac pain. There is also evidence of core musculature instability in high-level athletes, which can lead to additional musculoskeletal injuries. ^, These patients have been noted to have increased difficulty with balance and compensation for unexpected truncal perturbation. They have also been noted to have overactivation of superficial global musculature but impaired control and activation of deep spinal musculature.

Although lumbar spine stabilization exercise programs have been effective in treating patients with chronic low back pain, there has been no conclusive evidence to demonstrate that stabilization programs are more effective in treating patients with chronic low back pain as compared with a generalized, less-specific exercise program. In addition, although there is some evidence that suggests core stabilization may help prevent injury in athletes, these programs have not been well studied and have not been proved to enhance athletic performance.

Flexibility has been shown to assist patient with low back pain. Stretching muscles and fascia of the back, legs, and buttock such as the hamstrings, erector muscles of the spine, and hip flexors can help increase the range of motion of the spine and assist back pain. Pilates and other flexibility exercises have been shown to decrease chronic low back pain. Decreased flexibility in the hip flexors and lumbar extensors have been shown to increase lumbar lordosis, which can increase back pain.

Strengthening exercises

Plank ( Fig. 1 ):

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Patient should lie on their stomach with the forearms on the floor and elbows directly beneath the shoulders.
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As the abdominal muscles are tightened, lift the hips off the floor.
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As the gluteal muscles are squeezed, lift the knees off the floor.
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Keep the body straight and hold for 30 seconds. If unable to maintain this position, bring the knees back to the floor and hold with just the hips elevated.
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Slowly return to start position and rest for 30 seconds, then repeat.
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Throughout the exercise, do not let the pelvis sag toward the floor and keep the abdominals tight.
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Perform 5 to 10 repetitions per day for 4 to 6 weeks.

Side bridges ( Fig. 2 A) and modified version of side bridges ( Fig. 2 B):

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Patient lies on their side on the floor. Can be modified with knees bent at 90°.
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With the elbow bent 90°, patient contracts the abdominal muscles and lifts the hips off the floor as shown while keeping the body straight.
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Hold the position for 15 seconds then slowly return to neutral and repeat on the opposite side.
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Throughout the exercise, the patient should keep the neck in alignment with the spine and avoid shrugging the shoulders to the ear.
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Perform 10 to 20 repetitions per day on each side, for 4 to 6 weeks.

Hip bridges ( Fig. 3 ):

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Patient lies on their back on the floor with arms either at the side or extended away from the body. Knees should be bend and feet flat on the floor.
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While contracting the abdominal and gluteal muscles, lift the pelvis up so that the body is in a straight line from the shoulders to knees.
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Hold this position for 10 seconds, then slowly lower the pelvis back to the floor.
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Throughout the exercise, keep the weight centered over the shoulder blades and do not tense up the neck muscles.
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Perform 10 to 20 repetitions per day for 4 to 6 weeks.