Jan 29, 2015Stretched Back
Whether it’s due to being stretched out of position or repetitive motion, back pain known as lumbar hypermobility syndrome can be debilitating. A specialist in treating this injury shares his exercise prescription.
By Dr. John Winslow
John Winslow, DPT, OCS, MTC, ATC, CSCS, is the Director of Physical Therapy and Sports Medicine at Cayuga Medical Center in Ithaca, N.Y., where he treats athletes from local high schools, Cornell University, and Ithaca College. He is also an adjunct professor at Ithaca College, and can be reached at: [email protected]
Of all the neuromuscular complaints athletic trainers deal with, the one that is often most perplexing is back pain. When an athlete says, “My back is killing me,” it can mean many different things. And with the medical knowledge on how to treat these injuries still evolving, assessing and treating back pain requires a deft touch.
In the majority of cases, diagnosing low back pain is difficult because of the inability to identify the injury’s structural pathology. One major problem is that diagnostic images of the spine can often provide information that is misleading. For example, it has been reported that one third of asymptomatic individuals show some degree of disk herniation on MRI.
Many researchers have suggested that rather than attempting to make an initial patho-structural diagnosis, clinicians sort patients with similar low back pain symptoms into subgroups that dictate what type of treatment they receive. Patients with lumbar hypermobility (LH) would be identified as one of these subgroups, and many athletes with back pain would find themselves in it.
LH is defined by a loss of stiffness between spinal motion segments. With the condition, normally tolerated external loads result in deformity and pain or place neurological structures at risk. Common causes of LH include repetitive strain, trauma, or congenital ligamentous laxity. Athletes are susceptible to LH due to the repetitive nature of their sports and their workout routines. Those who participate in sports that require extreme ranges of motion, such as wrestling and gymnastics, are most prone to developing the condition.
An athlete with LH will typically describe an insidious onset of low back pain. Initially, they are often relatively asymptomatic during activity. However, over time the pain becomes progressively worse and interferes with their sport participation. Prior treatments, such as medication, modalities, massage, joint manipulation, or non-specific exercise, have not provided any significant relief.
The athlete is usually able to be very specific about describing the pain and can point to the area where they are experiencing the most discomfort. They will describe having pain during prolonged sitting or standing and have difficulty sleeping at night. They get temporary relief by changing positions, walking, or self manipulating (cracking their back). In many cases there is a history of trauma and/or previous low back pain.
When examined, the athlete will demonstrate some form of aberrant motion, have segmental hypermobility, a positive prone instability test, and no neurological abnormalities. If the LH is chronic, plain film x-rays frequently show some osteophyte formation.
The diagnosis of LH has traditionally been made based on lateral flexion and extension radiographs. Parameters for defining LH were established by radiographic studies that measured the magnitude of translatory movement normally available at each spinal motion segment during flexion and extension of the spine. However, use of these criteria for diagnosing LH has proven unsatisfactory. An article in Spine found that 42 percent of asymptomatic subjects had at least one segment exceeding the threshold for hypermobility. In addition, lateral flexion-extension radiographs are performed at end-range only, while many patients with LH often complain of symptoms while performing mid-range movements.
A group of researchers recently identified reliable clinical examination measures to diagnose symptomatic LH, and then went on to develop clinical prediction rules for determining which patients with low back pain will respond to a stabilization exercise program. Their formula says: If a patient is younger than 41 years old, has a straight-leg raise test of greater than 91 degrees, demonstrates aberrant motion, has a positive prone instability test, and exhibits lumbar hypermobility as determined by segmental mobility testing, they are likely to respond to a stabilization exercise program.
To test aberrant motion, have the athlete do a forward bend. If he or she demonstrates any of the following symptoms, aberrant motion is present:
Painful arc in flexion: Symptoms are felt at a specific point or through a portion of the range of motion.
Painful arc on return: Symptoms occur during the return from a flexed position.
Gower sign: Also referred to as “thigh climbing,” the athlete pushes on the thighs with hands for assistance during the return from a flexed position.
Instability catch: The athlete has a sudden acceleration, deceleration, or deviation of trunk movement during forward or backward bending.
Reversal of lumbopelvic rhythm: On returning from the flexed position, the athlete bends their knees and shifts forward before returning to the erect position.
To test prone instability, have the athlete lie prone on an exam table, with feet on floor. If pain is present with posterior/anterior provocation testing, but disappears when the athlete raises their legs, then muscle activity must be effectively stabilizing the segment, thus indicating the presence of hypermobility.
To test segmental mobility, have the athlete lie prone as you apply anterior-posterior force with the lateral border of your hand (thenar eminence). Mobility is measured as hypermobile or not hypermobile in relation to segments above and below the level being tested.
Athletes are more likely to develop LH if they have generalized ligamentous laxity. This can be identified by using the Beighton Ligamentous Laxity Scale, which consists of nine separate tests. Four tests are each assessed separately on the right and left side, with a final forward bend test. One point is given for each test movement the athlete can execute. The scoring range is zero through nine with higher scores indicating a greater level of laxity.
1. Passive hyperextension of the elbow to greater than 10 degrees. 2. Passive hyperextension of the fifth finger to greater than 90 degrees. 3. Passive abduction of the thumb to contact the forearm. 4. Passive hyperextension of the knee greater than 10 degrees. 5. The athlete must bend forward and place both hands flat on the floor without flexing the knees.
Athletes with chronic LH may show varying levels of osteophyte formation on the vertebral bodies, facet joints, or uncinate processes. These osteophytes are most likely a result of spinal ligaments pulling excessively at the bone during aberrant motion. The excessive stress stimulates osteoblasts (bone building cells) to lay down new bone. Osteophytes may or may not cause symptoms depending on their size and location.
The pain associated with LH can be reduced through a lumbar stabilization program. The goal is to strengthen the neuromuscular control system to restrain aberrant motion and increase spinal stiffness.
In the textbook, Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain, published in 1999, the authors specifically identify the Transverses Abdominus (TA) and the Lumbar Multifidus (LM) as important muscles for providing spinal stability. In their research, the authors used electromyography and ultrasound to evaluate the integrity of the trunk muscles in patients with low back pain. They concluded that even after resolution of acute symptoms, patients demonstrate a side-to-side difference in the size of the LM. The atrophy of the LM may be one reason for LH and a high reoccurrence rate of low back pain.
A good analogy is a knee injury or post surgical knee that results in quad atrophy and eventually leads to abnormal patellofemoral tracking and pain. After a back injury, regardless of what type (muscle strain, facet injury, or disk herniation), it’s essential to restore muscle size and strength to prevent future mechanical dysfunction. There is substantial evidence to support the relationship between atrophy of the LM and poor functional outcomes after back surgery. The TA and pelvic floor muscles have been found to function jointly with the LM in stabilizing the lumbar spine.
Other authors have suggested that besides the deep intrinsic trunk muscles, a full compliment of muscles is necessary to ensure stability. These muscles include the Rectus Abdominus (RA), Internal and External Oblique Abdominals (IO, EO), Erector Spinae (ES) and the Quadratus Lumborum (QL). A lumbar stabilization program should include exercises that challenge the intrinsic muscles as well as the global muscles of the trunk and lower extremities.
Previous outcome studies that have evaluated the effectiveness of lumbar stabilization exercises in reducing low back pain in specific populations support this current research. One randomized controlled study compared lumbar stabilization exercises to usual care by a general practitioner for patients with spondylolysis or spondylolisthesis. At the three-year follow up, there was a statistically significant reduction in pain and disability for the exercise group. Other studies have demonstrated similar results.
Spondylolysis and spondylolisthesis are conditions commonly seen in athletes and can be difficult to manage. Based on the research and my work with athletes, I believe that spondylolysis may be caused by lumbar hypermobility and one of the reasons why this patient population responds to lumbar stabilization exercises.
AT THE CORE
There are literally hundreds of exercises that can be used to strengthen the deep intrinsic trunk muscles, also called core muscles. They include those performed on a mat, with a stability ball, with a medicine ball, or using cable column machines or stretch chords.
To start, athletes must be taught how to use their core muscles properly in everyday activities. Early in the rehabilitation process, they should be taught proper sitting, standing, and sleeping postures as well as proper body mechanics for lifting and carrying. They should also be given a home exercise program to be performed daily that complements their supervised program in the training room or clinic. The success of treating LH is dependent on the athlete understanding the condition and having complete commitment to an aggressive strengthening program.
When teaching athletes to perform core-strengthening exercises it is essential to first show them how to “set” the TA. Contracting the TA prior to performing core exercises assists in recruiting the deep lumbar intrinsic muscles, including the LM. The TA should be contracted prior to and while performing each exercise.
Athletes should be initially taught how to contract the TA while supine in a hook lying (knees bent) position. They should be shown where to palpate the TA–just medial to the anterior superior iliac spines (ASIS)–then instructed to: “Raise your belly button up and in to the arch of your rib cage towards your spine.” This verbal cue was shown to be most effective in producing a TA contraction during ultrasound imaging exams.
Some clinicians make the mistake of having patients attempt to flatten their backs (posterior pelvic tilt) when performing core exercises. But the greatest EMG activity of the TA occurs with the pelvis in a neutral position (midway between an anterior and posterior pelvic tilt).
During the initial rehab session, it’s best to simply instruct the athlete on how to correctly perform a TA contraction. At the next session, when the athlete masters activating and holding the TA contraction, they can progress with active exercises.
I divide up core exercises into three levels of difficulty (see “Three Levels” on below). Each athlete starts at the lowest level, and as they gain neuromuscular control, they progress to more challenging activities. Eventually, sport-specific exercises such as kicking a soccer ball, shooting a basketball, and swinging a baseball bat can be introduced. These are all performed with a neutral pelvis and a TA isometric contraction. Core activities that include balance, agility, proprioception, and kinesthetics are also essential for athletes preparing to return to play and should be gradually incorporated into the program.
Relief of symptoms can be expected after approximately four to six weeks, although more chronic cases may require a longer rehab time. Athletes may return to play when they are able to perform sport-specific activities or functional movements without pain or discomfort. It is important for athletes with lumbar hypermobility to continue their core-strengthening exercises to prevent future pain and disability.
References for this article can be found here.
Sidebar: THREE LEVELS
The following are beginning, intermediate, and advanced core-strengthening exercises for rehabbing lumbar hypermobility.
Supine Hook Lying Transversus Abdominis (TA) Isometrics: Lie supine on a mat with legs bent. Place your middle and index fingers of each hand just medial to the ASIS. Raise your belly button up and in to the arch of your rib cage toward your spine. Hold the contraction for 15 seconds. Breathe normally (do not hold your breath). Repeat 10 times.
Supine Alternating Arm and Leg Raises: Lie supine on a mat with legs bent. Contract the TA. Raise opposite arm and leg. Repeat 10 times on each side.
Side-Lying Leg Raises: Lie on one side with bottom leg bent for support. Contract the TA. Raise the top leg 10 times and repeat on opposite side.
Standing One-Arm Rows: Cable or stretch cord is at waist height. Contract the TA. Pull arm back, bending the elbow. Repeat 10 times on each side.
Standing One-Arm Pull Downs: Cable or stretch cord is over head. Contract the TA. Pull arm down to the hip, keeping the elbow straight. Repeat 10 times on each side.
Stability Ball Quadruped Alternating Arm and Leg Raise: Lie over the stability ball. Contract the TA. Raise opposite arm and legs. Repeat 10 times on each side.
Front Planks: Lie on stomach with forearms flat on the ground. Contract the TA. Rise up on toes and forearms keeping spine straight. Hold the position for 30 seconds. Repeat two times.
Resisted Walking: Cable or stretch cord is at waist height. Hold handle in front of body. Contract the TA. Side step out and back 10 times. Turn around and repeat 10 times.
Stability Ball Bridge with Alternating Leg Raises: Lie on a mat with feet up on the ball and hands flat on the mat. Contract the TA. Bridge up and hold. Raise one leg at a time off the ball, alternating sides. Repeat 10 times.
Punches: Cable or stretch cord is at chest height. Hold handle with one hand and step forward with the opposite leg. Contract the TA. Punch forward and slowly return to the starting position. Repeat 10 times on each side.
Medicine Ball Lunges: Hold medicine ball out in front of body. Lunge forward with one leg and return to starting position. Repeat 10 times on each side.
Stability Ball Roll Outs: Kneel in front of the ball. Place hands low on the front of the ball. Roll forward, allow feet to lift off the ground, rock on the knees, and return to the starting position. Repeat 15 times. (Roll left or right to incorporate the obliques.)
Side Planks: Lie on your side with forearm flat. Contract the TA. Rise up until your spine is straight. Hold the position for 30 seconds. Do the same on opposite side. Repeat two times on each side.
Quadruped Alternating Arm and Leg Raises: Get on your hands and knees. Contract the TA. Raise opposite arm and leg. Repeat 10 times on each side.
Stability Ball Supine Alternating Arm and Leg Raises: Sit on the ball and roll onto your back, with head and shoulders supported on the ball. Contract the TA. Raise opposite arm and leg at same time. Repeat 10 times on each side.
Stability Ball Walkouts: Lie flat on the ball. Contract the TA. Propel yourself forward and walk out on your hands, keeping spine straight. Add a push-up at the end and walk back. Repeat 10 times.
Sitting Medicine Ball Twists: Sit on the floor. Bend knees and raise feet just off the floor. Touch the medicine ball on one side and then carry it over to touch on the opposite side. Continue back and forth 15 times on each side.
PNF Diagonals (D1): Cable or stretch cord is over head. Hold handle with both hands. Contract the TA. Pull handle down from shoulder to opposite hip keeping elbows straight. Repeat 10 times on each side.
PNF Diagonals (D2): Cable or stretch cord is low. Hold handle with both hands. Contract the TA. Pull handle up across body from hip to shoulder keeping elbows straight. Repeat 10 times on each side.