ELSEVIER
Journal of Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 5 (1995) 75-80
Stabilization exercises for the aging athlete Julie DeWerd Staff Physical Therapist, Center for Spine, 5'ports and Occupational Rehabilitation, Chicago, IL 50510, USA
---------
Abstract This article describes the use of spine stabilization exercises for treating low back pain in the aging athlete. Spine stabilization exercises are appropriate for treating a variety of pathological conditions in the spine and can be effective during all phases of the rehabilitative process. The emphasis of spine stabilization exercises is on minimizing stress on the spine to gain optimal function.
Keywords: Aging athlete; Low back pain; Spine stabilization exercises
1. Introduction The aging athlete like others in the general population is subject to the musculoskeletal changes which occur with normal aging. The lumbar spine undergoes few changes until the third decade, according to Wiesel et al. In the third to fifth decades, these changes can be very pronounced with the first manifestations reflected through the intervertebral disc [1]. Adequate hydration and collagen are essential for proper intervertebral function as it is through the disc that energy is dissipated which allows the facets, muscles, ligaments and bones to assume compressive shear and tensile loads. The biochemical changes which occur in the intervertebral disc with aging are primarily loss of vascularization, loss of water content and collagen de-
generation. These changes can result in disc degeneration causing increased load on supporting structures: muscles, ligaments, facet joints and joint capsules [2]. Statistically, the incidence of the disease spondylosis and osteoarthritis (OA) is 60% in people over 45 years of age [3]. Depending on the stage of the disease, symptoms of pain and stiffness may occur which can lead to functional limitations. Symptomatic spinal stenosis occurs when very significant OA is present with large osteophytes blocking the spinal canal. The degree to which degenerative changes occur in the spine and the extent to which they are symptomatic is highly variable. One outcome of degenerative changes in the spine may be back pain from joint degeneration, foraminal stenosis, disc disease or segmental in-
1053-8127/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSDI1053-8127(94)00109-N
76
1. DeWerd /1. Back Musculoskelet. Rehabil. 5 (1995) 75-80
stability [1]. In treating the patient with low back pain, there must be a clear understanding of the biochemical and neuromuscular components which can both perpetuate and exacerbate the patient's symptoms. Once a comprehensive evaluation with an accurate diagnosis has been completed the rehabilitation phase can be initiated. An appropriate and effective method of treating these degenerative conditions would be spine stabilization exercises. Spine stabilization exercises lend themselves to a rehabilitative program for the aging athlete because the primary purpose of these exercises is to minimize stress on the spine while optimizing function [4]. Another benefit of these exercises in the rehabilitative process is the variety of diagnoses appropriate for treatment with this technique and the ability to use this technique through all phases of rehabilitation. The goals of spine stabilization exercise are to instruct the patient in their neutral spine position for improved posture and body mechanics, to increase strength and to increase endurance. The concept of neutral spine position is defined by the patient's symptoms, pathology and current musculoskeletal restrictions [5]. The components of this program are patient education, postural alignment, flexibility, strength and endurance. The principles of spine stabilization are based on spinal biomechanics. There are five principles of stabilization: 1.
2.
3. 4.
5.
Intra-abdominal pressure increases to offset loading of the lumbar spine. Thoracolumbar fascia can be engaged through muscular contraction of the abdominal, latissimus dorsi, hamstring and gluteal muscles to provide support during lifting in all postures. Hydraulic amplifier mechanism enhances thoracolumbar fascia by contracting erector spine muscles. Posterior ligamentous system makes use of the posterior ligaments during lifting, reducing compressive forces through the lumbar spine. Muscular support mechanism utilizes the small intersegmental muscles which run in
between two adjacent vertebrae and control flexion [6,7]. These principles imply that the stabilization of the lumbar spine is achieved through training and strengthening of trunk musculature to support the spine in a neutral position through co-contraction of muscular groups. The concept of intraabdominal pressure offsetting the load on the lumbar spine (principle No. 1) has been dismissed to muscular fusion as the supportive mechanism [8]. 2. Treatment progression Treatment begins with evaluation to determine deficits in posture, range of motion, strength, coordination and behavior of symptoms. The subjective portion of the evaluation gives the therapist pertinent information about the cause of symptoms and the irritability and/or severity of symptoms. The objective evaluation will show limitations in flexibility of trunk and lower extremities, segmental spinal mobility and posture. The basic information gathered from the evaluation is range of motion, strength, posture, and mobility. This information will form the guidelines for treatment and will identify positions and movements which provacate symptoms. Once this data has been secured a treatment plan can be formulated which addresses the patient's functional limitations. Stabilization exercises can be initiated early in the treatment progression as long as the limitations in range of motion, strength and coordination are taken into account. Ideally, the patient will work toward balancing all areas while gradually progressing stabilization exercises. Thus, a comprehensive treatment plan will include patient education and training for posture and body mechanics, stretching, specific strengthening and aerobic conditioning. 3. Stabilization progression The initial phase of the stabilization program is to define neutral spine position which in the most general terms is based on the available pain-free
1. DeWerd /
1.
Back Musculoskelet. Rehabil. 5 (J995) 75--80
range of motion. Neutral spine position has also been described as a position where weight bearing is achieved symmetrically through the supporting structures [5]. A working term for neutral spine position which correlates to asymptomatic range of motion is functional position or range. This will be determined individually for each patient based on the evaluation findings and is the mid-point of the pain-free range of motion. For the acute patient, the available asymptomatic range may be very limited and possibly biased toward either flexion or extension. Degenerative changes such as stenotic and facet condi-
77
tions may bias the patient toward flexion while a disc herniation may bias the functional position toward the extension range. Neutral spine position may also be variable within the same diagnosis, and it is dependent on the individual patient's signs and symptoms. During treatment, the patient biased toward extension, secondary to disc related symptoms, should gradually be able to work toward a neutral range while a patient with central spinal stenosis will always be biased toward flexion [9].
A
B
Fig. I. Beginning stabilization: (A) supine; and (B) hooklying.
B
Fig. 2. Sidelying progression: (A) knees and hips fl exed; and (B) knees and hips extended.
78
1. DeWerd /1. Back Musculoskelet. Rehabil. 5 (1995) 75-80
Stabilization training begins with instructing the patient on how to find their functional position. The functional position can be determined in any body orientation but for the initial training session supine (Fig. 1) is generally the easiest position to begin with due to increased back support. To find the functional position, the patient will rock his or her pelvis anteriorly and posteriorly through the available pain-free or pain diminished range of motion. The functional position is the mid-point of this range [10]. It is important to attempt to find the most comfortable position for
the patient to begin with. For some patients this may not be supine, at which point ,the patient should try various positions. This patient may tolerate side lying, as shown in Fig. 2, and experience decreased symptoms and greater ease in locating a functional position from which to initiate spine stabilization exercises. Once the functional position has been determined, the patient's ability to control this position is challenged by utilizing movements of the extremities, positional variations, dynamic move-
A
A
B
B
Fig. 3. Bridging progression: (A) basic bridge; (B) advanced bridge with reciprocal arm and leg lifts.
Fig. 4. Advanced progression: (A) quadruped with alternating arm lifts; and (B) Dynamic half-kneel with bilateral arm lifts.
1. DeWerd / 1. Back Musculoskelet. Rehabil. 5 (J995) 75-80
ments and resistance. The goal with progressing stabilization exercises is to move away from simple to complex, non-weight bearing to weight bearing, static to dynamic and limited range of motion to full range of motion. An example of stabilization progression from simple to complex would be bridging with the addition of reciprocal arm and leg lifts (Fig. 3). Static exercises tend to work isolated body movements ulitizing an isometric muscular contraction. The goal with dynamic exercises is to have the patient maintain a neutral position while they progress toward increasingly more difficult activities. Finally a progression for stabilization exercises is from nonweight bearing to weight bearing and functional tasks. Stabilization exercises can be categorized as
A
B
Fig. 5. Progression on Ball : A , Bridging. B, Prone with arm lifts.
79
beginning or advanced. Generally, the beginning stabilization exercises follow a training pattern of neuro developmental postural control: supine, sidelying, prone, quadruped, kneeling, half kneeling, and standing (Fig. 4). Initially, the patient will work on these exercises one on one with a physical therapist to insure their technique is correct and their program properly individualized to their musculoskeletal problem. It is essential for the patient to find and maintain proper alignment throughout the training session. Cues from the physical therapist for the proper spinal position may be needed. Once the patient has mastered the basic stabilization exercises, the program can be progressed to the advanced stage including more
A
B
Fig. 6. Dynamic Mobility: A, Flexion. B, Extension.
1. DeWerd /1. Back Musculoskelet. Rehabil. 5 (1995) 75-80
80
A
such as flexion to extension (Fig. 6). Also seated bouncing on the ball works aerobic conditioning while facilitating neutral alignment and rhythmic compression / distraction of the spine. These progressive exercises with the ball challenge the patient's ability to control dynamic movement (Fig. 7). 4. Conclusion
B
--------~----------~~----------~
This article has focused on one type of treatment for rehabilitation of low back pain in the aging athlete. It is important that the treatment plan is comprehensive for all the patient's deficit areas and that the patient is regularly re-evaluated to assess progress and make appropriate modifications and upgrades in the patient's exercise program. References
Fig. 7. Dynamic Mobility for Abdominals: A, Starting Position. B, Reverse abdominal curl.
dynamic actIvItIes. The addition of a large gym ball will sufficiently challenge the patient's ability to hold neutral alignment. An initial sequence on the ball could be supine with the ball under the patient's feet and the patient performing either leg lifts or bridging (Fig. 5a). Progression with the ball follows the same pattern of neuro developmental postures, and in this scenario the patient would go prone over the ball and perform either arm or leg lifts to promote increased back extension strength while maintaining proper spinal alignment (Fig. 5b). The final progression would be to advance to full body movements on the ball,
[1] Wiesel S, Bernini P, Rothman R: The aging lumbar spine. Philadelphia: W.B. Saunders Co 1982:17-32. [2] Vernon-Roberts B: The normal aging of the spine: Degeneration and Arthritis. In: Andersson G, McNeill TW, eds. Lumbar Spinal Stenosis. St. Louis: Mosby Year Book, 1992:57-75. [3] Grieve G: Pathological changes - combined regional. In: Grieve G, ed. Common vertebral joint problems, 2nd ed. Edinburgh: Churchill Livingstone, 1988:207-286. [4] Saal JA: Dynamic muscular stability in the nonoperative treatment of lumbar pain syndromes. Orthopaedic Rev 1990;8:691-700. [5] Robison R: The new back school prescription: stabilization training: Part I. Spine : State Art Rev 1991;53:341 - 355. [6] Kaul MP, Herring SA: Rehabilitation of Lumbar Spine Injuries in Sports. Phys Med Rehabil Clin North Am 1994;5(1):133-156. [7] Gracovetsky S, Farfan H: The optimal spine. Spine 1986;11:543- 573. [8] Gracovetsky S, Kary M, Levy S et al: Analysis of spinal and muscular activity during fiexion /extension and free lifts. Spine 1990; 15: 1333-1339. [9] Fast A: Low back disorders: conservative management. Arch Phys Med Rehabil 1988;69:880- 89l. [10] Martin L: Back Basics: General information for back school participants. Spine: State Art Rev 1991;53:333-340.
Journal of Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 5 (1995) 75-80
Stabilization exercises for the aging athlete Julie DeWerd Staff Physical Therapist, Center for Spine, 5'ports and Occupational Rehabilitation, Chicago, IL 50510, USA
---------
Abstract This article describes the use of spine stabilization exercises for treating low back pain in the aging athlete. Spine stabilization exercises are appropriate for treating a variety of pathological conditions in the spine and can be effective during all phases of the rehabilitative process. The emphasis of spine stabilization exercises is on minimizing stress on the spine to gain optimal function.
Keywords: Aging athlete; Low back pain; Spine stabilization exercises
1. Introduction The aging athlete like others in the general population is subject to the musculoskeletal changes which occur with normal aging. The lumbar spine undergoes few changes until the third decade, according to Wiesel et al. In the third to fifth decades, these changes can be very pronounced with the first manifestations reflected through the intervertebral disc [1]. Adequate hydration and collagen are essential for proper intervertebral function as it is through the disc that energy is dissipated which allows the facets, muscles, ligaments and bones to assume compressive shear and tensile loads. The biochemical changes which occur in the intervertebral disc with aging are primarily loss of vascularization, loss of water content and collagen de-
generation. These changes can result in disc degeneration causing increased load on supporting structures: muscles, ligaments, facet joints and joint capsules [2]. Statistically, the incidence of the disease spondylosis and osteoarthritis (OA) is 60% in people over 45 years of age [3]. Depending on the stage of the disease, symptoms of pain and stiffness may occur which can lead to functional limitations. Symptomatic spinal stenosis occurs when very significant OA is present with large osteophytes blocking the spinal canal. The degree to which degenerative changes occur in the spine and the extent to which they are symptomatic is highly variable. One outcome of degenerative changes in the spine may be back pain from joint degeneration, foraminal stenosis, disc disease or segmental in-
1053-8127/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSDI1053-8127(94)00109-N
76
1. DeWerd /1. Back Musculoskelet. Rehabil. 5 (1995) 75-80
stability [1]. In treating the patient with low back pain, there must be a clear understanding of the biochemical and neuromuscular components which can both perpetuate and exacerbate the patient's symptoms. Once a comprehensive evaluation with an accurate diagnosis has been completed the rehabilitation phase can be initiated. An appropriate and effective method of treating these degenerative conditions would be spine stabilization exercises. Spine stabilization exercises lend themselves to a rehabilitative program for the aging athlete because the primary purpose of these exercises is to minimize stress on the spine while optimizing function [4]. Another benefit of these exercises in the rehabilitative process is the variety of diagnoses appropriate for treatment with this technique and the ability to use this technique through all phases of rehabilitation. The goals of spine stabilization exercise are to instruct the patient in their neutral spine position for improved posture and body mechanics, to increase strength and to increase endurance. The concept of neutral spine position is defined by the patient's symptoms, pathology and current musculoskeletal restrictions [5]. The components of this program are patient education, postural alignment, flexibility, strength and endurance. The principles of spine stabilization are based on spinal biomechanics. There are five principles of stabilization: 1.
2.
3. 4.
5.
Intra-abdominal pressure increases to offset loading of the lumbar spine. Thoracolumbar fascia can be engaged through muscular contraction of the abdominal, latissimus dorsi, hamstring and gluteal muscles to provide support during lifting in all postures. Hydraulic amplifier mechanism enhances thoracolumbar fascia by contracting erector spine muscles. Posterior ligamentous system makes use of the posterior ligaments during lifting, reducing compressive forces through the lumbar spine. Muscular support mechanism utilizes the small intersegmental muscles which run in
between two adjacent vertebrae and control flexion [6,7]. These principles imply that the stabilization of the lumbar spine is achieved through training and strengthening of trunk musculature to support the spine in a neutral position through co-contraction of muscular groups. The concept of intraabdominal pressure offsetting the load on the lumbar spine (principle No. 1) has been dismissed to muscular fusion as the supportive mechanism [8]. 2. Treatment progression Treatment begins with evaluation to determine deficits in posture, range of motion, strength, coordination and behavior of symptoms. The subjective portion of the evaluation gives the therapist pertinent information about the cause of symptoms and the irritability and/or severity of symptoms. The objective evaluation will show limitations in flexibility of trunk and lower extremities, segmental spinal mobility and posture. The basic information gathered from the evaluation is range of motion, strength, posture, and mobility. This information will form the guidelines for treatment and will identify positions and movements which provacate symptoms. Once this data has been secured a treatment plan can be formulated which addresses the patient's functional limitations. Stabilization exercises can be initiated early in the treatment progression as long as the limitations in range of motion, strength and coordination are taken into account. Ideally, the patient will work toward balancing all areas while gradually progressing stabilization exercises. Thus, a comprehensive treatment plan will include patient education and training for posture and body mechanics, stretching, specific strengthening and aerobic conditioning. 3. Stabilization progression The initial phase of the stabilization program is to define neutral spine position which in the most general terms is based on the available pain-free
1. DeWerd /
1.
Back Musculoskelet. Rehabil. 5 (J995) 75--80
range of motion. Neutral spine position has also been described as a position where weight bearing is achieved symmetrically through the supporting structures [5]. A working term for neutral spine position which correlates to asymptomatic range of motion is functional position or range. This will be determined individually for each patient based on the evaluation findings and is the mid-point of the pain-free range of motion. For the acute patient, the available asymptomatic range may be very limited and possibly biased toward either flexion or extension. Degenerative changes such as stenotic and facet condi-
77
tions may bias the patient toward flexion while a disc herniation may bias the functional position toward the extension range. Neutral spine position may also be variable within the same diagnosis, and it is dependent on the individual patient's signs and symptoms. During treatment, the patient biased toward extension, secondary to disc related symptoms, should gradually be able to work toward a neutral range while a patient with central spinal stenosis will always be biased toward flexion [9].
A
B
Fig. I. Beginning stabilization: (A) supine; and (B) hooklying.
B
Fig. 2. Sidelying progression: (A) knees and hips fl exed; and (B) knees and hips extended.
78
1. DeWerd /1. Back Musculoskelet. Rehabil. 5 (1995) 75-80
Stabilization training begins with instructing the patient on how to find their functional position. The functional position can be determined in any body orientation but for the initial training session supine (Fig. 1) is generally the easiest position to begin with due to increased back support. To find the functional position, the patient will rock his or her pelvis anteriorly and posteriorly through the available pain-free or pain diminished range of motion. The functional position is the mid-point of this range [10]. It is important to attempt to find the most comfortable position for
the patient to begin with. For some patients this may not be supine, at which point ,the patient should try various positions. This patient may tolerate side lying, as shown in Fig. 2, and experience decreased symptoms and greater ease in locating a functional position from which to initiate spine stabilization exercises. Once the functional position has been determined, the patient's ability to control this position is challenged by utilizing movements of the extremities, positional variations, dynamic move-
A
A
B
B
Fig. 3. Bridging progression: (A) basic bridge; (B) advanced bridge with reciprocal arm and leg lifts.
Fig. 4. Advanced progression: (A) quadruped with alternating arm lifts; and (B) Dynamic half-kneel with bilateral arm lifts.
1. DeWerd / 1. Back Musculoskelet. Rehabil. 5 (J995) 75-80
ments and resistance. The goal with progressing stabilization exercises is to move away from simple to complex, non-weight bearing to weight bearing, static to dynamic and limited range of motion to full range of motion. An example of stabilization progression from simple to complex would be bridging with the addition of reciprocal arm and leg lifts (Fig. 3). Static exercises tend to work isolated body movements ulitizing an isometric muscular contraction. The goal with dynamic exercises is to have the patient maintain a neutral position while they progress toward increasingly more difficult activities. Finally a progression for stabilization exercises is from nonweight bearing to weight bearing and functional tasks. Stabilization exercises can be categorized as
A
B
Fig. 5. Progression on Ball : A , Bridging. B, Prone with arm lifts.
79
beginning or advanced. Generally, the beginning stabilization exercises follow a training pattern of neuro developmental postural control: supine, sidelying, prone, quadruped, kneeling, half kneeling, and standing (Fig. 4). Initially, the patient will work on these exercises one on one with a physical therapist to insure their technique is correct and their program properly individualized to their musculoskeletal problem. It is essential for the patient to find and maintain proper alignment throughout the training session. Cues from the physical therapist for the proper spinal position may be needed. Once the patient has mastered the basic stabilization exercises, the program can be progressed to the advanced stage including more
A
B
Fig. 6. Dynamic Mobility: A, Flexion. B, Extension.
1. DeWerd /1. Back Musculoskelet. Rehabil. 5 (1995) 75-80
80
A
such as flexion to extension (Fig. 6). Also seated bouncing on the ball works aerobic conditioning while facilitating neutral alignment and rhythmic compression / distraction of the spine. These progressive exercises with the ball challenge the patient's ability to control dynamic movement (Fig. 7). 4. Conclusion
B
--------~----------~~----------~
This article has focused on one type of treatment for rehabilitation of low back pain in the aging athlete. It is important that the treatment plan is comprehensive for all the patient's deficit areas and that the patient is regularly re-evaluated to assess progress and make appropriate modifications and upgrades in the patient's exercise program. References
Fig. 7. Dynamic Mobility for Abdominals: A, Starting Position. B, Reverse abdominal curl.
dynamic actIvItIes. The addition of a large gym ball will sufficiently challenge the patient's ability to hold neutral alignment. An initial sequence on the ball could be supine with the ball under the patient's feet and the patient performing either leg lifts or bridging (Fig. 5a). Progression with the ball follows the same pattern of neuro developmental postures, and in this scenario the patient would go prone over the ball and perform either arm or leg lifts to promote increased back extension strength while maintaining proper spinal alignment (Fig. 5b). The final progression would be to advance to full body movements on the ball,
[1] Wiesel S, Bernini P, Rothman R: The aging lumbar spine. Philadelphia: W.B. Saunders Co 1982:17-32. [2] Vernon-Roberts B: The normal aging of the spine: Degeneration and Arthritis. In: Andersson G, McNeill TW, eds. Lumbar Spinal Stenosis. St. Louis: Mosby Year Book, 1992:57-75. [3] Grieve G: Pathological changes - combined regional. In: Grieve G, ed. Common vertebral joint problems, 2nd ed. Edinburgh: Churchill Livingstone, 1988:207-286. [4] Saal JA: Dynamic muscular stability in the nonoperative treatment of lumbar pain syndromes. Orthopaedic Rev 1990;8:691-700. [5] Robison R: The new back school prescription: stabilization training: Part I. Spine : State Art Rev 1991;53:341 - 355. [6] Kaul MP, Herring SA: Rehabilitation of Lumbar Spine Injuries in Sports. Phys Med Rehabil Clin North Am 1994;5(1):133-156. [7] Gracovetsky S, Farfan H: The optimal spine. Spine 1986;11:543- 573. [8] Gracovetsky S, Kary M, Levy S et al: Analysis of spinal and muscular activity during fiexion /extension and free lifts. Spine 1990; 15: 1333-1339. [9] Fast A: Low back disorders: conservative management. Arch Phys Med Rehabil 1988;69:880- 89l. [10] Martin L: Back Basics: General information for back school participants. Spine: State Art Rev 1991;53:333-340.
