Greg Keith
Greg Keith 3/30/04
Therapeutic Exercise
Herniated Disc: Theory on Rehabilitation
Lower back pain is one of the most common complaints of society. The lower back is thought to be one of the most challenging body parts for athletic trainers and physical therapists to rehabilitate. An estimated 80% of the population suffers from at least one episode of lower back pain in their lifetime, and in approximately 50% of the cases, the problem reoccurs within the next 3 years (Shiple, 51). Back problems in athletes are usually caused by congenital, mechanical, and traumatic factors (Simpson et al, 57). Due to excessive forces transmitted through the trunk and lower extremities, mechanical failure of soft tissues and body structures can occur (Hall, 7). One of the most common injuries with the lower back is a disc herniation. An athlete who complains of low back pain that radiates into the lower extremities may have a herniated disc (Simpson et al, 57). There have been several methods and protocols presented on the rehabilitation of herniated discs. Some have been quite similar, and yet others are complete opposites. However, the debate still remains on which method and or protocol is the most effective.
The anatomy and biomechanics of any body part play an integral part in the rehabilitation process. Athletic trainers and physical therapists need to understand what is happening with the body part at given movements and through forces being applied to it. The spine and lower back are some of the most complex areas of the body. The lower back region of the vertebral column includes the lumbar, sacral, and coccygeal spine (Simpson et al, 57). The lumbar spine is composed of 5 vertebrae, which provide most of the support of the lower back. Cartilaginous and synovial joints form the articulation between each pair of vertebrae. The joint between an intervertebral disc and the superior and inferior vertebrae forms the cartilaginous joint and the facets joints represent the synovial articulations (Starkey and Ryan, 323). The intervertebral discs, which make up the cartilaginous joints in the spinal column, are found in between the cervical, thoracic, and lumbar vertebrae. Each disc has two layers; a thick outer layer, the annulus fibrosus, and a moldable inner layer, the nucleus pulposus (Starkey and Ryan, 322). The intervertebral discs serve several purposes. One purpose is to increase the total ROM of the spinal column, and the other purpose is to offer additional stability to the spine by acting as shock absorbers and resisting torsional forces (Hall, 8). The intervertebral disc withstands almost 80-90% of compressive loads while a person is standing (Heck and Sparano, 205). A disc herniation occurs when the disc is subjected to an increase in internal pressure from an external force, such as compression, torsional, or sheer forces (Hall, 8). The nucleus pulposus will begin to push outward through the annulus fibrosus causing a bulge or complete rupture, a herniation. This is usually caused by repetitive flexion motions, which put stress on the disc.
Theories on how to treat low back pathologies and disc herniations have been a debated issue for the last several decades. When treatment protocols were first put out for disc herniations, rest was the appropriate treatment. A physician would have their patient bed resting for several days until the pain subsided. This method of treatment has been dismissed thanks to studies done on bed rest and the differences between rest and exercise. In one study done, the results of two days bed rest was as equal in reducing pain as seven days of bed rest (Kuritzky, 59). Other studies have shown deficits in muscular strength and endurance compared to those with no bed rest (Shiple, 52). Bed rest has become more of a treatment that is used as sparingly as possible. It has become more for those who have severe radiculopathy, and too much pain to begin exercise. Though some show benefits with bed rest, greater outcomes have come from therapeutic activity.
Exercise and therapeutic activity have been more logical approaches to treating chronic back pain caused by herniated discs. Although this is the approach usually taken, no significant evidence has shown which type of exercise or movements are most effective. One of the major focuses in most of the research has been stabilization and strengthening. Core stabilization enables the control of posture in order to prevent stress on facet joints and the intervertebral discs (Timm, 17). In several case studies found, trunk stabilization and strengthening were the main focus of the rehabilitation program. In a case report done on a 19-year-old female runner, the program began with pelvic stabilization exercises and low-back strengthening to enhance core stability and strength (Sciasica and Uhl, 52). Core stability can be accomplished by strengthening the abdominals and lower back extensors (Nieman, 5). Previous research stressed the strengthening of solely the abdominal muscles, but more recent research has questioned that hypothesis (Fritz and Haddox, 20). Research has also shown that the stabilization of the trunk involves co-contraction of the abdominals and spinal extensors to dynamically control the movements of the lumbar spine (20). One factor that should be addressed is the importance of inner core muscles. Commonly, the erector spinae, rectus abdominis, and external obliques are worked during core strengthening programs, while the transverse abdominis and the lumbar multifidis are ignored (Peterson, 41). These inner muscles supply critical support to the lumbar spine. Putting a balance between the flexors and extensors, without putting the back into a position of aggravation, should be one of the major focuses while treating low back pathology (Shiple, 62). Areas to stress throughout exercises are trunk control, torsion control (monitoring movement in transverse plane), and technique control (Timm, 19).
Another area, in which protocols have stressed, has been the importance of neuromuscular control and proprioception. Proprioception may help prevent future episodes by providing feedback regarding excessive forces, resulting in protective reflex activation of muscles (Fritz and Haddox, 19). Normal patterns of muscle recruitment and firing between the abdominals and extensors can be altered after injury to the body part (20). Exercises should progress from simple to more challenging and eventually to more functional activities. By working on neuromuscular control and proprioceptive training, the athlete will have to be more effective in withstanding the forces encountered during sports, while avoiding excessive stress on the tissues involved (24).
The most controversial debate over the treatment of disc herniations has been which type of exercise the patient should be doing. The first idea on treatment was to have the patient, or athlete, perform flexion exercises for the back. Dr. Paul Williams published an exercise program in 1937 for patients with chronic lower back pain in response to his clinical observation that the majority of patients who experienced lower back pain had degenerative vertebrae secondary to degenerative disk disease (PT doctor). His program consisted of a series of flexion exercises that were the cornerstone of rehabilitation for all lower back pathologies. Robin McKenzie, a physical therapist, came up with a program that was predominantly extension exercises, which were going against Williams’ ideas. This came about when McKenzie’s patients reported lower back pain relief while being in an extended position (PT doctor). The goal of McKenzie exercises are to centralize the pain. If a patient has pain in their lower back, right buttock, right posterior thigh, and or right calf, then McKenzie’s goal would be to "centralize" the pain to the lower back, buttock, and posterior thigh, and then to the lower back and buttock, and finally just the lower back itself (PT doctor).
McKenzie back exercises have become the most common method for treating lower back pain that is caused by herniated discs. Studies have been done to test the validity of the McKenzie exercises. In one study, two out of three trials reported positive benefits with dynamic extension exercises (Shiple, 61). Many physicians have taken the McKenzie theory to heart and advise their patients not to do flexion exercises if a herniated disc is the cause of their pain. The basis behind not doing flexion exercises is that flexion causes the mobile nucleus pulposus to shift posteriorly and press against the annulus fibrosus at its thinnest place, which leads to a herniation of the disc (Kuritzky, 58). Flexion increases the load on the disc and unloads the facet joints (Sparano and Heck, 205). Using the McKenzie system to figure out which movements centralize their pain, the proper exercises can be given, which are normally exercises involving extension (Shiple, 65).
A final area stressed with any rehabilitation program is the aerobic and muscular conditioning. If an athlete does not train aerobically during their rehabilitation, they will not be able to return to their sport at a desired level. Muscle endurance is important to maintain stabilization and support. For aerobic training the recommendations include: walking, swimming, aquatic therapy, and possibly stationary biking (Timm, 18) Stationary biking, however, may increase the symptoms of disc pathology. In some cases these forms of training are not enough for elite athletes, such as marathon runners. In one case study, a 36-year-old female marathon runner was not being compliant with the prescribed training methods (Simpson, 57). Using a highly specialized piece of equipment called the ZUNI Incremental Weight Bearing System; the athlete was able to train on a treadmill while a harness kept her unloaded. Although highly unpractical, the athlete was able to train and see increases in speed and performance (Simpson, 59). Along with the proper type of training, exercise should progress to a minimum of 20 minutes of continuous activity at 60-80% of target heart rate at least 3 days a week (Timm, 19).
Throughout the research, trunk stabilization and strengthening has been in the rehabilitation programof any lower back pathology. More specifically, extension exercises can help reduce the pain of a herniated disc by centralizing the pain (Kuritzky, 65). Major differences in the methods of treatments have been found over the years, from bed rest to flexion exercises and now to extension exercises. With new research, more efficient protocols can be produced. Although there is a lot of research, no one method of rehabilitation of disc herniations has proved to be overly effective then the other. Where most physical therapist and athletic trainers have had success with extension exercises, others have had success with flexion and bed rest; however, more research must be done to figure out the most effective treatment. Looking into a combination of both William and McKenzie’s programs might be helpful in the treating of disc herniations. Working on the stabilization of the trunk, both the flexors and extensors, and both the external and internal muscles, would be key to relieve pain and give support to the lower back region. Many factors go into a strong rehabilitation program. Integrating strengthening, stability, neuromuscular control, cardiovascular endurance, and flexibility is the key to getting the athlete back to pre-injury status and performance level. With more research the proper rehabilitation protocol can be determine and utilized in the athletic training profession.
Reference
Fritz, J., Haddox, A. (1998). Improving Neuromuscular Control Following Trunk and Lumbar Spine Injury. Athletic Therapy Today, 3(5), 19-24.
Hall, R. (1999). Differential diagnosis of Lumbar Spine Injuries in Athletes. Athletic Therapy Today, 4(2), 7-12.
Heck, J.F., Sparano, J.M. (2000). A Classification System for the Assessment of Lumbar Pain in Athletes. Journal of Athletic Training, 35(2), 204-211.
Kuritzky, L. (1997). Low-Back Pain: Consider Extension Education. The Physicaian and Sportsmedicine, 25(1), 57-66.
Neiman, D. (2004). Your Asked For It: What is Low Back Pain. ACSM’s Health and Fitness Journal, 8(1), 4-5.
Peterson, C. (2003). Strengthening the Core from the Inside Out. Athletic Therapy Today, 8(4), 41-43.
PT doctor. (2003). Williams' Flexion Versus McKenzie Extension Exercises For Low Back Pain . Backtrainer.com. Retrieved March 21, 2004, from the World Wide Web: http://backtrainer.com/Williams-Flexion-Versus-McKensie-Extension-Exercises-For-Low-Back-Pain.html
Ryan, J., Starkey, C. (2002). Evaluation of Orthopedic and Athletic Injuries (2nd ed.) Philadelphia: F.A. Davis Company. 322-323.
Sciascia, A., Uhl, T.L. (2003, October). Rehabilitative Techniques for Treating Spondylolisthesis. NATA News, 52-56.
Shiple, B. (1997). Treating Low-Back Pain: The Exercise Knowns and Unknowns. The Physician and Sportsmedicine, 25(8) 51-68.
Simpson, S. et al. (1996). Unloaded Treadmill Training Therapy for Lumbar Disc Herniation Injury. Journal of Athletic Training, 31(1), 57-60.
Timm, K. (1999). Therapeutic Exercise Guidelines for Rehabilitating Lumbar Spine Injuries in Athletes. Athletic Therapy Today, 4(2), 17-21.
Therapeutic Exercise
Herniated Disc: Theory on Rehabilitation
Lower back pain is one of the most common complaints of society. The lower back is thought to be one of the most challenging body parts for athletic trainers and physical therapists to rehabilitate. An estimated 80% of the population suffers from at least one episode of lower back pain in their lifetime, and in approximately 50% of the cases, the problem reoccurs within the next 3 years (Shiple, 51). Back problems in athletes are usually caused by congenital, mechanical, and traumatic factors (Simpson et al, 57). Due to excessive forces transmitted through the trunk and lower extremities, mechanical failure of soft tissues and body structures can occur (Hall, 7). One of the most common injuries with the lower back is a disc herniation. An athlete who complains of low back pain that radiates into the lower extremities may have a herniated disc (Simpson et al, 57). There have been several methods and protocols presented on the rehabilitation of herniated discs. Some have been quite similar, and yet others are complete opposites. However, the debate still remains on which method and or protocol is the most effective.
The anatomy and biomechanics of any body part play an integral part in the rehabilitation process. Athletic trainers and physical therapists need to understand what is happening with the body part at given movements and through forces being applied to it. The spine and lower back are some of the most complex areas of the body. The lower back region of the vertebral column includes the lumbar, sacral, and coccygeal spine (Simpson et al, 57). The lumbar spine is composed of 5 vertebrae, which provide most of the support of the lower back. Cartilaginous and synovial joints form the articulation between each pair of vertebrae. The joint between an intervertebral disc and the superior and inferior vertebrae forms the cartilaginous joint and the facets joints represent the synovial articulations (Starkey and Ryan, 323). The intervertebral discs, which make up the cartilaginous joints in the spinal column, are found in between the cervical, thoracic, and lumbar vertebrae. Each disc has two layers; a thick outer layer, the annulus fibrosus, and a moldable inner layer, the nucleus pulposus (Starkey and Ryan, 322). The intervertebral discs serve several purposes. One purpose is to increase the total ROM of the spinal column, and the other purpose is to offer additional stability to the spine by acting as shock absorbers and resisting torsional forces (Hall, 8). The intervertebral disc withstands almost 80-90% of compressive loads while a person is standing (Heck and Sparano, 205). A disc herniation occurs when the disc is subjected to an increase in internal pressure from an external force, such as compression, torsional, or sheer forces (Hall, 8). The nucleus pulposus will begin to push outward through the annulus fibrosus causing a bulge or complete rupture, a herniation. This is usually caused by repetitive flexion motions, which put stress on the disc.
Theories on how to treat low back pathologies and disc herniations have been a debated issue for the last several decades. When treatment protocols were first put out for disc herniations, rest was the appropriate treatment. A physician would have their patient bed resting for several days until the pain subsided. This method of treatment has been dismissed thanks to studies done on bed rest and the differences between rest and exercise. In one study done, the results of two days bed rest was as equal in reducing pain as seven days of bed rest (Kuritzky, 59). Other studies have shown deficits in muscular strength and endurance compared to those with no bed rest (Shiple, 52). Bed rest has become more of a treatment that is used as sparingly as possible. It has become more for those who have severe radiculopathy, and too much pain to begin exercise. Though some show benefits with bed rest, greater outcomes have come from therapeutic activity.
Exercise and therapeutic activity have been more logical approaches to treating chronic back pain caused by herniated discs. Although this is the approach usually taken, no significant evidence has shown which type of exercise or movements are most effective. One of the major focuses in most of the research has been stabilization and strengthening. Core stabilization enables the control of posture in order to prevent stress on facet joints and the intervertebral discs (Timm, 17). In several case studies found, trunk stabilization and strengthening were the main focus of the rehabilitation program. In a case report done on a 19-year-old female runner, the program began with pelvic stabilization exercises and low-back strengthening to enhance core stability and strength (Sciasica and Uhl, 52). Core stability can be accomplished by strengthening the abdominals and lower back extensors (Nieman, 5). Previous research stressed the strengthening of solely the abdominal muscles, but more recent research has questioned that hypothesis (Fritz and Haddox, 20). Research has also shown that the stabilization of the trunk involves co-contraction of the abdominals and spinal extensors to dynamically control the movements of the lumbar spine (20). One factor that should be addressed is the importance of inner core muscles. Commonly, the erector spinae, rectus abdominis, and external obliques are worked during core strengthening programs, while the transverse abdominis and the lumbar multifidis are ignored (Peterson, 41). These inner muscles supply critical support to the lumbar spine. Putting a balance between the flexors and extensors, without putting the back into a position of aggravation, should be one of the major focuses while treating low back pathology (Shiple, 62). Areas to stress throughout exercises are trunk control, torsion control (monitoring movement in transverse plane), and technique control (Timm, 19).
Another area, in which protocols have stressed, has been the importance of neuromuscular control and proprioception. Proprioception may help prevent future episodes by providing feedback regarding excessive forces, resulting in protective reflex activation of muscles (Fritz and Haddox, 19). Normal patterns of muscle recruitment and firing between the abdominals and extensors can be altered after injury to the body part (20). Exercises should progress from simple to more challenging and eventually to more functional activities. By working on neuromuscular control and proprioceptive training, the athlete will have to be more effective in withstanding the forces encountered during sports, while avoiding excessive stress on the tissues involved (24).
The most controversial debate over the treatment of disc herniations has been which type of exercise the patient should be doing. The first idea on treatment was to have the patient, or athlete, perform flexion exercises for the back. Dr. Paul Williams published an exercise program in 1937 for patients with chronic lower back pain in response to his clinical observation that the majority of patients who experienced lower back pain had degenerative vertebrae secondary to degenerative disk disease (PT doctor). His program consisted of a series of flexion exercises that were the cornerstone of rehabilitation for all lower back pathologies. Robin McKenzie, a physical therapist, came up with a program that was predominantly extension exercises, which were going against Williams’ ideas. This came about when McKenzie’s patients reported lower back pain relief while being in an extended position (PT doctor). The goal of McKenzie exercises are to centralize the pain. If a patient has pain in their lower back, right buttock, right posterior thigh, and or right calf, then McKenzie’s goal would be to "centralize" the pain to the lower back, buttock, and posterior thigh, and then to the lower back and buttock, and finally just the lower back itself (PT doctor).
McKenzie back exercises have become the most common method for treating lower back pain that is caused by herniated discs. Studies have been done to test the validity of the McKenzie exercises. In one study, two out of three trials reported positive benefits with dynamic extension exercises (Shiple, 61). Many physicians have taken the McKenzie theory to heart and advise their patients not to do flexion exercises if a herniated disc is the cause of their pain. The basis behind not doing flexion exercises is that flexion causes the mobile nucleus pulposus to shift posteriorly and press against the annulus fibrosus at its thinnest place, which leads to a herniation of the disc (Kuritzky, 58). Flexion increases the load on the disc and unloads the facet joints (Sparano and Heck, 205). Using the McKenzie system to figure out which movements centralize their pain, the proper exercises can be given, which are normally exercises involving extension (Shiple, 65).
A final area stressed with any rehabilitation program is the aerobic and muscular conditioning. If an athlete does not train aerobically during their rehabilitation, they will not be able to return to their sport at a desired level. Muscle endurance is important to maintain stabilization and support. For aerobic training the recommendations include: walking, swimming, aquatic therapy, and possibly stationary biking (Timm, 18) Stationary biking, however, may increase the symptoms of disc pathology. In some cases these forms of training are not enough for elite athletes, such as marathon runners. In one case study, a 36-year-old female marathon runner was not being compliant with the prescribed training methods (Simpson, 57). Using a highly specialized piece of equipment called the ZUNI Incremental Weight Bearing System; the athlete was able to train on a treadmill while a harness kept her unloaded. Although highly unpractical, the athlete was able to train and see increases in speed and performance (Simpson, 59). Along with the proper type of training, exercise should progress to a minimum of 20 minutes of continuous activity at 60-80% of target heart rate at least 3 days a week (Timm, 19).
Throughout the research, trunk stabilization and strengthening has been in the rehabilitation programof any lower back pathology. More specifically, extension exercises can help reduce the pain of a herniated disc by centralizing the pain (Kuritzky, 65). Major differences in the methods of treatments have been found over the years, from bed rest to flexion exercises and now to extension exercises. With new research, more efficient protocols can be produced. Although there is a lot of research, no one method of rehabilitation of disc herniations has proved to be overly effective then the other. Where most physical therapist and athletic trainers have had success with extension exercises, others have had success with flexion and bed rest; however, more research must be done to figure out the most effective treatment. Looking into a combination of both William and McKenzie’s programs might be helpful in the treating of disc herniations. Working on the stabilization of the trunk, both the flexors and extensors, and both the external and internal muscles, would be key to relieve pain and give support to the lower back region. Many factors go into a strong rehabilitation program. Integrating strengthening, stability, neuromuscular control, cardiovascular endurance, and flexibility is the key to getting the athlete back to pre-injury status and performance level. With more research the proper rehabilitation protocol can be determine and utilized in the athletic training profession.
Reference
Fritz, J., Haddox, A. (1998). Improving Neuromuscular Control Following Trunk and Lumbar Spine Injury. Athletic Therapy Today, 3(5), 19-24.
Hall, R. (1999). Differential diagnosis of Lumbar Spine Injuries in Athletes. Athletic Therapy Today, 4(2), 7-12.
Heck, J.F., Sparano, J.M. (2000). A Classification System for the Assessment of Lumbar Pain in Athletes. Journal of Athletic Training, 35(2), 204-211.
Kuritzky, L. (1997). Low-Back Pain: Consider Extension Education. The Physicaian and Sportsmedicine, 25(1), 57-66.
Neiman, D. (2004). Your Asked For It: What is Low Back Pain. ACSM’s Health and Fitness Journal, 8(1), 4-5.
Peterson, C. (2003). Strengthening the Core from the Inside Out. Athletic Therapy Today, 8(4), 41-43.
PT doctor. (2003). Williams' Flexion Versus McKenzie Extension Exercises For Low Back Pain . Backtrainer.com. Retrieved March 21, 2004, from the World Wide Web: http://backtrainer.com/Williams-Flexion-Versus-McKensie-Extension-Exercises-For-Low-Back-Pain.html
Ryan, J., Starkey, C. (2002). Evaluation of Orthopedic and Athletic Injuries (2nd ed.) Philadelphia: F.A. Davis Company. 322-323.
Sciascia, A., Uhl, T.L. (2003, October). Rehabilitative Techniques for Treating Spondylolisthesis. NATA News, 52-56.
Shiple, B. (1997). Treating Low-Back Pain: The Exercise Knowns and Unknowns. The Physician and Sportsmedicine, 25(8) 51-68.
Simpson, S. et al. (1996). Unloaded Treadmill Training Therapy for Lumbar Disc Herniation Injury. Journal of Athletic Training, 31(1), 57-60.
Timm, K. (1999). Therapeutic Exercise Guidelines for Rehabilitating Lumbar Spine Injuries in Athletes. Athletic Therapy Today, 4(2), 17-21.
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