Injury Prevention: Developing the Strong Back Angie Beisner MA, ATC Athletic Trainer

1. Injury Prevention: Developing the Strong Back Angie Beisner MA, ATC Athletic Trainer The Ohio State University Picture: http://web.uaccb.edu/AcademicDivisions/MathScience/Science/BWheeler/Ess/figs/06_16Figureb-U.jpg

2. Low Back Injuries • Incidence • Sport Specific • Types of Injuries

3. Traditional Low Back Injury Prevention Flexibility Core Stabilization Exercises Postural Training

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

5. Categories of Abdominal Muscles Global Abdominal Muscles Local Abdominal Muscles

6. Global Stabilization Muscles • Rectus Abdominis • External Oblique • Iliocostalis(thoracic portion) Rectus Abdominis http://home1.gte.net/imagine/rectus%20abdominis.jpg External Oblique Iliocostalis(thoracic portion) http://www.mystomachexercises.com/wp-content/uploads/2008/04/external-oblique.jpg http://www.pro-motionphysicaltherapy.com/images/evidence/5il.jpg

7. 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)

8. Local Stabilization Muscles • Lumbar Multifidus • Transverse Abdominis • Post. Fibers of Int. Obliques Posterior fibers of Internal Obliques http://www.teachpe.com/images/muscles/internal_oblique200.jpg https/://hvelink.saintlukeshealthsystem.org/library/healthguide/en-us/images/media/medical/hw/h9991417_001.jpg

9. 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

10. Global Muscles and CLBP • Global Muscles: • Typical focus of back rehab • Substitute/Dominate local muscles in people with CLBP

11. Local Muscle Function with CLBP • Local Muscles provide: • dynamic stability • control of the spine Increased evidence showing LBP is influenced by local muscle weakness

12. 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)

13. 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

14. 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

15. Palpation Test • TrA • 2 fingers medial and distal to ASIS • Slowly draw in abdominal wall • LM • Fingers side of spinous process • “Make fingers expand”

16. 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

17. 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

18. 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

19. What was changing in our program? • Increase number of athletes using jump serve • New athletes • No changes in: • Floor • Lifting program • Practice • Equipment

20. Application with MVB • Random check of previous athlete with LBP • Symptomatic • Asymptomatic • Given instructions to begin exercise • Once achieved mastery, must incorporate into ADL

21. 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.

22. 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

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

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

25. 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

26. Combating Non-compliance with Local Muscle Strengthening • First step of rehab • Make it a challenge • Random checks

27. How does it apply to you? • Awareness • Missing Link in low back rehab programs • Extra step to break the cycle of CLBP

28. 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 ObliqusInternus 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

29. Questions

30. Thank you!