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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
New Techniques
• Local Muscle Stabilization programs
• Pilates, Yoga programs
• Functional Movement Screenings
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