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Rehabilitation Techniques
ATHT 4960
During a lifetime, few individuals escape back pain. The most common cause of limited activity in persons 45 years of age and younger is low back pain (Andrews, 1998) Approximately 10% of injuries associated with sports are related to the spine. The importance of the mechanical and structural properties of the intravertebral disk are of considerable interest in the relationship of injury to sports activity. At the time of injury it is important to understand the role of modified and supervised activity in trying to avoid deconditioning (Hochschuler, 1990).
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The disk is responsible for the attachment of vertebral bodies to each other. The disks increase in size from the superior to the inferior spine. The lumbosacral disk is the exception. It is one third smaller than the L5 (Lumbar) disk and lies between the lumbar spine and the sacrum. The concave curving of the spine is known as lordosis. Because of this curvature, the lumbar disks are higher anteriorly than posteriorly (Kramer 1981).
The intervertebral disk consists of three tissues: (1) the nucleus pulposus,
(2) the annulus fibrosis, and (3) the vertebral endplates, which are essentially
hyaline cartilage. The nucleus and the annulus blur into one another and are
considered as a gradient of tissue rather than separate entities (Hochschuler,
1990). The annulus fibrosis is composed of collagen fibers and provides the
tensile strength of the disk. The nucleus pulposus is a semi-gelatinous fluid
which appears to be translucent and grayish white. It provides stiffness and
the resistance to compression. The nucleus acts as its name describes. It is
the “yolk” of the disk and the annulus fibrosis surrounds it. Each disk is
bound to the epiphyseal ring above and below each vertebral body (Humphreys,
1999).
Each vertebral segment contains a foramina, or an intervertebral foramen. The foramen is the joint space that allows the passage of nerve roots from the spinal cord. The intervertebral foramina are at the same level as the intervertebral disks. The diameter of the nerve roots increase from the superior to the inferior region of the
spine. Consequently, the intervertebral foramen of the lumbosacral region is very small. The foramen can become even smaller by positional changes of the vertebral joints (Kramer 1981).
The surrounding structures of the spine include the ligaments and paravertabral
muscles. The two main ligamentous structures that connect adjacent vertebrae
are the anterior longitudinal ligament and posterior longitudinal ligament.
Both contain fibers that intermingle with the posterior and anterior parts of
the annulus fibrosis of the adjoining disk. The anterior ligament extends the
full length of the spine and provides support to all of the intervertebral disks.
The posterior ligament also extends the full length of the spine but becomes
narrow as it moves downward, providing little protection for the lumbar disks
(Williams, 1965). The paravertabral muscles of the back are divided into two
major groups: 1) the deep muscles that only span a few vertebral disks
and 2) the long erector spinae muscles that span many vertebral segments (Ebenbicher, 2001). The anterior muscles are the rectus abdominis and internal and external obliques. Posteriorly are the erector spinae, quadratus lumborum, and levator muscles (Hochschuler, 1990).
The functional unit of the spine is known as the motion segment. Each motion
segment contains the intravertebral disk and one half of the vertebrae above
and one half of the vertebrae below the disk. These 3-joint motion segments
are largest in the lumbar spine which supports the weight of the upper body
(Kramer, 1981).
The intervertebral disk is the strongest link in the motion segment. While it is responsible for the attachment of vertebral bodies to each other, it is also provides flexibility and absorbs and distributes loads applied to the spinal column. Due to its inherent elasticity, the disk resists axial loading of the spine (Humphreys, 1999). The nucleus pulposus distributes the axial pressure over the annulus fibrosus which distributes the pressure throughout the joint. During this loading, the nucleus is pressed against the annulus. As soon as the pressure is relieved, the nucleus retains its original form and position (Kramer, 1981).
The structure of the gel-like nucleus is mostly water. It has been estimated that at birth, the water content of the nucleus is 88% and decreases there after. The water binding capacity of the nucleus has been singled out as a critical biochemical factor. Without it, the disk could not retain its ability to act as a shock absorber (Nicholas, 1995). To maintain this water capacity, the bordering tissues of the disk act as semipermeable membranes. The absorption pressure which enables water to enter the disk is osmosis. Therefore, the force subjected onto the disk, originating from body posture and weight, is referred to as hydrostatic pressure or intradiskal pressure (kp). When compressed, the disk expands in order to disperse the force being applied. The rate and force by which the expansion occurs is decided by the elasticity and fluid absorbability of the disk (Kramer, 1981). The effect of compression on a disk is the loss of water from the nucleus pulposus. This loss of water results in a loss of disk height of about 1 cm over the course of one day. When compressive forces are reduced or absent (lying down), the nucleus absorbs water from the vertebral body, restoring the height of the disk. This water-absorbing cycle is lost with age (Andrews, 1998).
Regular changes between horizontal and vertical positions and flexion and extension improve the absorbing ability of the disk. All changes in the position of the spine result in either an acceleration or slowing down of the fluid transport to and from the disk. In sitting and standing, the disk decreases in height, and in lying and stretching out, the disk increases in height (Kramer, 1981).
The spine permits the following motions of the trunk: 1) flexion and extension, 2) lateral flexion and 3) rotation. The stability of these motions relies on many factors. Factors include muscular and ligamentous strength, intervertebral disk thickness and elasticity, and orientation of articulating facets (Andrews, 1998).
The human spine is the focal point of the body’s conceptual kinetic chain, consisting of many bones, joints, and muscles. A balance in the strength, endurance, and length of these tissues must be maintained to ensure proper motion, stability, and function. Stability of the trunk is provided by anterior, lateral, and posterior musculature. (Hochschuler, 1990). The erector spinae muscles and the hip flexors are the principle extensors of the lumbosacral spine. The abdominals and the gluteus maximus muscles are the main flexors of the lumbosacral spine. Every load that is lifted from the front of the vertical column is accomplished by a powerful contraction of the erector spinae muscles. This major muscle group is also assisted by multiple muscle groups, including the gluteals and leg muscles, to sustain an erect posture. The anterior musculature, the abdominal muscles, aids in the maintenance of an ideal standing posture (Williams, 1965).
Low back pain affects 70%-80% of the
population at some point in life (Andrews, 1998). An estimated eight million
people in the
Degeneration of the intravertebral disk (diskosis) plays a major role in disk herniations (Kramer, 1981). Changes in the volume and consistency of the disk, as well as in the positions of the motion segment, can all cause diskosis. Dehydration of the disk reduces the cushioning ability of the nucleus propulsus, transmitting a greater portion of the applied load to the annulus fibrosis (Humphreys, 1999).
Axial compression is the most common form of spine
loading. When compressive forces are accompanied by shear forces, disk herniation
is inclined. During forward flexion of the lumbar spine, the shear component
of the compressive forces is increased. This shear force separates the disk
endplates from the adjacent vertebral bodies (Hochsculer, 1990). This static
or repeated shear force from flexion will result in a gradual movement of the
nucleus in the posterior direction. Because the posterior aspect of the disc
is not protected by the posterior longitude ligament, it is the weakest component.
When the disk is not given a chance to move anteriorly, greater stress is placed
on the disk posteriorly, causing microtrauma to the annulus fibrosis (Andrews,
1998). The annulus tissue begins to fissure, weakening the disk. Hypo or hypermobility
of the adjacent facet joints or asymmetrical movements can put pressure on an
isolated portion of the disk. This portion of the disk degenerates more quickly,
resulting in a herniation of the nucleus into the damaged portion of the annulus.
The outer wall of the annulus will begin to protrude and impinge upon surrounding
tissue (Robertson, 2001). As the disk collapses, there is an increased loading
of the vertebral joints and a narrowing of the 
intervertebral
foramina (Kramer, 1981). As the disk continues to collapses, it begins to bulge
out of the vertebral column. The bulge becomes a herniation when disk material
extrudes into the intervertebral foramen, causing compression of nerve roots,
followed by pain. A herniated disk can also impinge against the posterior longitudinal
ligament and cause referred pain (Robertson, 2001).
The most common levels for a herniated disk are L4-5 and L5-S1. The disk is highly disposed to injury during the transition stage from one direction of trunk rotation to the other. This stage occurs in the lumbar spine when an individual flexes and sidebends, picks up a load, and tries to come to the upright position (Andrews, 1998). Lumbar disk herniations are extremely common in athletes, and can occur during or after sports participation. Very often, a “pop” or “snap” is felt in the back, accompanied by low back pain (Nicholas, 1995). The majority of symptoms is characterized by a sharp, burning, stabbing pain, radiating down the posterior or lateral side of the leg, to below the knee. Numbness and tingling are also associated with a herniated disk (Humphreys, 1999).
Almost any type of muscle training has been shown to have a positive effect on low back injuries. The direct effects of training are increased muscle strength and endurance, improved postural responses of the trunk muscles and improved muscle coordination (Ebenbichler, 2001). In low back rehabilitation, the main focus is core stabilization.
1) Gain 30% improvement of joint ROM
2) Reduce swelling by 90% through use of cryotherapy.
3) Reduce inflammation by 90% through use of NSAIDS.
4) Reduce pain by 90% through use of cryotherapy, NSAIDS and electrical stimulation (Robertson, 2001).
- Extension in standing = 3 sets of 1 min.
- Wall sits = 3 sets of 1 min.
- Water walking forward = 3 min. at 50% velocity
1) Athlete rates pain as a 2 on a scale of 1-10
2) Athlete experiences no radiating pain
3) No heat is felt during palpation of injury
4) No swelling is present
1) Teach athlete proper sitting and standing posture
2) Restore full lumbar spine flexion and extension without pain
3) Increase abdominal strength to 4/5
4) Increase pelvic stabilization
5) Increase level of physical fitness by 50%
- Dead bug = 2 sets of 20
- Swiss ball exercises - anterior and posterior pelvic tilt = 15 reps of each
- Stationary bike = 15 min. at moderate speed
- Abdominal and oblique curl-ups on wall = 2 sets of 20 each
- Wall sits = 3 sets of 2 min.
- Modified superman = 2 min. at 70% max velocity
- Water walking backward = 5 min. at 70% max velocity
- Wall crunches = 2 sets of 10 reps at 70% max velocity
- Passive assisted hamstring stretch
- Flexion and extension in lying
- Vertical traction in deep water
Athlete is able to:
1) perform proper sitting and standing posture
2) perform full ROM of lumbar spine without pain
3) perform anterior and posterior pelvic tilts with continuous balance.
4) Ride stationary bike for 15 min. at 10 mph.
5) Athlete’s abdominal strength is 4/5
1) Continue optimal lumbar spine ROM
2) Improve pelvic stabilization to 100%
3) Improve abdominal strength to 5/5
4) Improve coordination, agility, and normal gait pattern of sport to 100%
5) Improve cardiovascular fitness to 100%
- Quadruped arm and leg = 3 sets of 12 at 90% max velocity
- Forward lunge = 5 min. at 80% max velocity
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½ sit ups = 3 sets of 20
- Stationary bike = 20 min. at 11mph
Swiss ball exercises:
– hip extension in neutral = hold for 3 min.
– bridging = 2 sets of 2 min.
– bird dog position = 3 sets of 12
- hyperextension on swiss ball = 1 min.
- single and double knees to chest = 30 sec. each
1) Wall crunch with ankle weights = continuous for 3 min. at 90% max velocity
2) Water walking backwards with ankle weights = 10 min. at 90% max velocity
- incorporate ball used in athlete’s sport if possible
3) Running in deep water = 5 min. continuous
4) Cycling in vertical and diagonal position = 5 min. continuous
· Criteria to Proceed
1) Restoration of all physical fitness components – 5/5 abdominal strength, 100% pelvic stabilization, CV fitness is 100%.
2) Athlete has restored coordination and agility necessary for complete return to sport.
3) Physician’s release
Phase 4
This phase continues indefinitely. Athlete should continue pelvic stabilization exercises and maintain core stabilization strength. Joint ROM and flexibility should be maintained through lumbar, hamstring, abdominal, and oblique stretches.
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Humphreys, Craig. Clinical evaluation and treatment options for the herniated lumbar disc. American Family Physician. 1999;59(1)(Feb):575-576.
Koury, Joanne (1996). Aquatic Therapy Programming: Guidelines for Orthopedic
Rehabilitation. W.B. Saunders, Inc,
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Robertson, Lauren (2001). www.nursingceu.com/NCEU/courses/disc/
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Management.