Treatment Options Nonoperative Care

Dorn Spinal Therapy

Spine Healing Therapy

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The nonoperative treatment plan begins with several basic rules.

1. Stop the inflammation.

2. Restore strength.

3. Restore flexibility.

4. Restore aerobic conditioning.

5. Return to full function.

To stop the inflammation of the spine in an injured athlete often requires rest and immobilization. We try to limit the rest and immobilization to the minimum. Bed rest produces stiffness and weakness, which causes the pain to persist. Stiffness and weakness are the antithesis of the body functions necessary for athletic performance. Every day of rest and immobilization may result in weeks of rehabilitation before the athlete is able to return to performance. As in motion treatment of lower extremity injuries, such as fracture bracing and postoperative continuous motion machines, rapid rehabilitation of lumbar injuries in athletes requires effective means of mobilizing the patient. Bed rest longer than 3 to 5 days is not of any benefit in the natural history of the disease. Rapid mobilization requires strong anti-inflammatory medications, ranging from epidural steroids, oral Medrol Dosepak (methylprednisolone), Indocin SR (indomethacin) to other nonsteroidal anti-inflammatories, and aspirin. Also used are lots of ice, transcutaneous electrical nerve stimulation units, and mobilization with casts, corsets, and braces. Corsets and braces are used for only limited periods of time, and strengthening techniques are started when the brace is applied in order to remove braces as soon as possible. Braces in themselves can cause a significant amount of stiffness and weakness. Exact timetables are difficult. It should be based on the individual patient's history and physical examination. As a general rule, our acute disk herniations are treated with 3 to 5 days of bed rest, then on to the physical therapist within 7 days, a corset for no longer than 10 to 14 days, and indomethacin, occasionally oral corticosteroids, and, less commonly, epidural injections. The therapist begins the neutral-position, isometric trunk strengthening program, and, depending on the response of the patient, this evolves into resistive strengthening, motion, and aerobic conditioning as tolerated.

Part of the key to being able to initiate early therapy is the understanding, based on the physical examination, of what makes the patient symptomatic. Nonoperative care should be the basis of any therapeutic approach to athletes with lumbar spine injuries. With the exception of cauda equina injuries, this should also be true in the athlete with a neurologic deficit. The key to effective nonoperative care is to have a well thought-out, balanced biomechanical approach. Common questions asked are whether to do extension exercises or flexion exercises or twisting exercises, what type of aerobic exercising should be done, when can someone lift weights, what role do Nautilus beautifi-cation exercises have in rehabilitation of the athlete, and also what type of nonoperative rehabilitation is best for the individual athlete's sport?

Everyone is concerned about the risk of increasing neurologic deficit and of producing a neurologic deficit through nonoperative care. So often, nonoperative care, in the face of a neurologic deficit, consists of no care. Bed rest is the usual initial stage for the athlete with a lumbar spine injury and neurologic deficit. It is thought that bed rest best protects the patient from increasing injury to the spine and therefore increasing neurologic deficit. Unfortunately, bed rest also produces profound weakness, loss of biomechanical function, and actually increases the risk of injury due to the weakness and stiffness that results. If the purpose of bed rest were to decrease inflammation, the logical substitute would be aggressive anti-inflammatory medication. If the objective of bed rest is to prevent motion, braces and casts can be substituted. If the objective of bed rest is to prevent abnormal motion that could injure the spine, it is with the understanding that certain mechanical functions have to take place. Patients get on and off bed pans; they get up to go to the bathroom; they roll over in bed. They cough, sneeze, and eventually have to walk. It seems logical that if we could design an exercise system that would prevent abnormal motion while restoring strength and flexibility in a biomechanically sound fashion, then the spine could be protected from the abnormal motion that produces injury and healing potentially could be enhanced. This enhancement takes place through normal bio-mechanical motion in the injured part through increasing strength and flexibility in the adjacent portions of the body that can absorb the stress potentially directed to the injured part and in preventing the atrophy, weakness, and stiffness caused by inactivity.

Lumbar spine injuries in athletes are a category that often demands prevention of atrophy and stiffness and restoration to maximum function as early as possible. Also, it follows that if this restoration can be achieved in athletes, it can function just as effectively in steelworkers, secretaries, weekend athletes, and housewives. The key to the program, obviously, lies in safety and effectiveness. If you could summarize an overall basis to our preferred rehabilitation program, it would lie in the concept of neutralposition isometric strengthening for the spine. This program is derived from work by Jeff Saal, MD, Arthur White, MD, and others, including Celeste Randolph, Ann Robinson, and Clive Brewster at the Kerlan Jobe Orthopedic Clinic, Inglewood, CA.

Trunk Stretching and Strengthening Program

This exercise program concentrates on trunk strength and trunk mobility, balance, coordination, and aerobic conditioning. It is a practical application of the use of trunk strengthening in back treatment, injury prevention, and improved performance in throwers.

It certainly appears that the place to begin the rehabilitation program in an injured lumbar spine, with or without neurologic deficit, should be with neutral-position isometric strengthening. The basis of the trunk stability program is to have the patient find a neutral, pain-free position, lying supine on the ground with the knees flexed and feet on the ground. This is about as atrau-matic as possible a beginning to rehabilitation, but it also forms the basis of an important concept in not only athletic function, but also activities of daily living for everyone. We retrain muscles to work to support the spine while the patient is using his or her arms and legs. It is not only theoretically ideal but is practically possible. Teaching muscle control with tight, rigid contraction of the muscles, controlling the spine through the lumbodorsal fascia, with the gluteus maximus, oblique abdominals, and latissimus dorsi, not only produces protection of the lumbar spine but also improves athletic performance. The power and strength of any throwing athlete come from his or her trunk. Lifting weight requires functioning of the lumbodorsal fascia.

Trunk strength also prevents back injuries and is an important treatment method for back pain. While treatment plans for patients with symptomatic back pain may include similar exercises, each of the treatment plans should be designed to match the examination and the symptoms. Any trunk strengthening plan puts strain on the spine and can produce back pain due to overload. Therefore, it should be conducted in a controlled, progressive manner.

The key to safe strengthening is the ability to maintain the spine in a safe, neutral position during the strengthening exercises. For upper body strengthening, the spine must be well aligned with the chest-out/chin-tucked posture. Doing isometric trunk exercises and upper body exercises emphasizing this chest-out/chin-tucked posture will strengthen the support of the cervical spine, strengthen the postural muscles necessary for maintaining proper body alignment, and prevent neck pain due to athletic activity.

For the lower body, trunk control plays a vital role in the ability to rotate and transfer torque safely. Trunk strengthening exercises such as sit-ups and spine extensions produce strength. Flexibility produces a protective range of motion but often the key is providing trunk strength and control at the proper moment during the athletic activity. For example, a baseball hitter goes from flexion through rotation to extension. If his trunk musculature does not maintain rigid control, despite these changes in the axis of alignment, he may lose power or get a back injury. Therefore, one can have strong muscles but, if they do not fire in sequence at the proper time, they will not protect the athlete from injury and certainly will not enhance performance. A key to producing a safe range of motion is to begin trunk control in the safe neutral position, establish muscle control in that position, and maintain it through the necessary range of motion to perform the athletic activity.

We begin our identification of the neutral spine position with the dead-bug exercises (Fig. 43-4). Dead-bug exercises are done supine with the knees flexed and feet on the floor. With the assistance of the trainer or therapist, the player pushes his or her lumbar spine toward the mat until he or she exerts a moderate amount of force on the examiner's hand. This is not exaggerated, back flattening extreme force, but a moderate amount of painless force on the examiner's hand. The player is then taught to maintain this same amount of force through abdominal contraction while

1. Raising one foot.

2. Raising the other foot.

3. Raising one arm.

4. Raising the other arm.

5. Raising one leg.

6. Raising the other leg.

7. Doing a leg flexion and extension with one foot.

8. Doing a leg flexion and extension with the other foot.

These same exercises can be performed with weights on the arms or legs.

The next stage for torque-transfer athletes is resistance to rotation, first supine, then sitting, then standing, in which the player maintains the neutral spine control position while resisting rotation of the upper body on the lower body. The player resists the rotational activity exerted by the therapist or trainer.

In the next stage, the player maintains trunk control while actively rotating through a short range of motion against the trainer's resistance. This is done in numerous positions to teach trunk control regardless of the position of the patient.

An additional benefit can be beach ball exercises. A 4-foot diameter ball can be used to do partial sit-ups while maintaining control of the ball, with the trunk in neutral position; the sit-ups and resistive sit-ups are done on the ball.

Figure 43-4 Begin identification of the neutral position with the dead-bug exercises. The dead-bug exercises are done supine, with the knees flexed and feet on the floor. With the assistance of the trainer or therapist, the patient pushes his or her lumbar spine toward the mat until he or she exerts a moderate amount of force on the examiner's hand. This is not exaggerated, extreme force, but a moderate amount of painless force on the examiner's hand. The patient is then taught to maintain this same amount of force through abdominal contraction while performing the exercises.

Figure 43-4 Begin identification of the neutral position with the dead-bug exercises. The dead-bug exercises are done supine, with the knees flexed and feet on the floor. With the assistance of the trainer or therapist, the patient pushes his or her lumbar spine toward the mat until he or she exerts a moderate amount of force on the examiner's hand. This is not exaggerated, extreme force, but a moderate amount of painless force on the examiner's hand. The patient is then taught to maintain this same amount of force through abdominal contraction while performing the exercises.

Lower extremity, trunk, and upper extremity strengthening must be done with concentration on maintaining the neutral trunk control position. It must be taught away from the sport, without a bat or ball, on the training table or floor. A routine is established for the player: think trunk control—neutral position—tense contractions. Trunk control is incorporated into throwing or batting. This will ultimately produce a more efficient transfer of torque from the lower to the upper extremities, that is, better bat control for a hitter and better endurance and ball control for a pitcher. An additional valuable benefit can be prevention of spinal injuries and spinal pain due to the athletic activity.

After establishing neutral position isometric control of the spine, extremity strengthening can begin. Probably the most important muscles needed to protect the spine itself are the quadriceps. The ability to return to work after a back injury has been directly related to quadriceps strength. Yet, quadriceps strengthening should not be done in the standard sitting, full knee extension position in a patient with severe lower back pain. Quadriceps strengthening should be done without irritating the lumbar spine mechanical pain. Also, the ability to move a weight from 90 degrees to zero degrees may not relate as specifically to lumbar spine function as quadriceps strength obtained through functional strengthening. Functional strengthening is done initially through wall slides, sliding down the wall, holding the position for 10 seconds, and sliding back up at varying depths. We begin this immediately postoperatively in our patients. Other activities include throwing the medicine ball in a flexed-knee position. Sports such as a Versiclimber, stationary cycle, and other techniques are used to teach quadriceps function while maintaining trunk control and during sports-related activity. Gluteal and hip extensor strengthening is important but must be done without inadvertently hyperextending the lumbar spine. Exercise bands that provide resistance to hip extension without a lot of spine extension are important as are other techniques that de-emphasize spine motion while producing isometric extensor strength. Nautilus machines can be very important in a safe, protected range of motion for extremity strengthening. The key to use of the Nautilus is good isometric trunk control in a pain-free neutral position prior to use of the machines. If you can establish trunk control first, then a safe protected range of motion is a good position for the spine. Therefore, military presses, latissimus, arm, and lower extremity leg strengthening with machines can be of benefit while protecting the spine. Spinal strength testing machines have been shown to be of benefit in predicting return to work. The ability to perform flexion extension exercises or resistance rotational exercises on a machine may not translate to functional spinal activity during athletics. We have not recommended such machines for treatment of lumbar injuries.

Stretching exercises are an important part of any rehabilitation program. The more flexible the legs, arms, and upper body are, the more likely there will be a proportional decrease in motion stress on the injured lumbar spine. If some muscle control is established first, through the strengthening program, then the spine can be held in a stable position while stretching of the extremities takes place. It is important to note that hamstring stretching too often is taken to the extent that it produces abnormal lumbar spine motion. Stretching the lower extremity past the point of pelvic motion only strains the spine and does not increase hamstring flexibility. Too often lumbar spine conditions are irritated because of excessive lumbar motion during hamstring stretching. The spine should be neutralized and held in a neutral, stable position when doing hamstring stretching exercises. Lumbar spine motion is important also, but it is not the initial stage of the rehabilitation program. Lumbar spine motion is begun with good muscle control of the spine during the motion exercises. The most common initial stage of motion is the "cat/cow" position on all fours, a position in which muscle control can be easily maintained.

The stretch exercises are a critical component of the program. Stretching increases the functional range of motion of the trunk and legs. Increasing the functional range of motion decreases the likelihood of lumbar spine injury during the strengthening program during play.

Most low back injuries occur when the player exceeds the strength of the spine and its range of motion. The stretching program provides a greater area of pain-free and injury-free function. For example, if a player who is stiff, having 10 degrees of spine extension and 20 degrees of spinal rotation, suddenly reaches for a ball producing 25 degrees of extension and 40 degrees of rotation, injury to his back can occur through tearing stiff tissue. If the mobility exercises produce a functional range of motion of 40 degrees of extension and 50 degrees of rotation, injury is less likely to occur. This is a protective range of motion.

The chief finding in our ball players with back pain is loss of spine extension, loss of rotation (usually greater in one direction), poor mechanics in rotation, and weak abdominals. Once the back pain starts, the weakness and contractions increase. However, this program is designed for performance enhancement and injury prevention, not treatment of back pain.

Aerobic Conditioning

There are numerous methods available for aerobic conditioning. Often we see athletes who prefer a specific technique such as running but have developed pain and problems directly related to running.

Cross-training is critically important in getting over aerobic exercise-induced injury. Not only does the runner with an injured back have to do the stretching and strengthening rehabilitation program, but he or she must learn cross-training for aerobic exercise. Water running, swimming, cycling, Nordic-Track, Versiclimber, and rowing machines all can produce the needed aerobic conditioning outside of the injurious sport. The benefit of swimming and water running program18 should be obvious. The total unweighting of the spine in water removes many of the compressive loads and allows good physical activity without the tremendous pounding and straining of running. The NordicTrack builds tremendous conditioning with strong use of the arms and increases cardiac output without the pounding of running. The Versiclimber and cycling have several things in common. First, the back can be positioned in a very beneficial position for back protection while still getting good aerobic conditioning. The cycling is slightly bent forward, which, of course, helps the stenotic spine. The Versiclimber is erect, which removes as much nerve root tension as possible. Both have the same potential hazard in that the pelvis should not laterally tilt during cycling or the Versiclimber. For the Versiclimber, short steps should be taken to prevent a lot of pelvic tilting with the motion, and in cycling, the legs should not become fully extended with the effect of reaching for the peddles, as this allows the pelvis to tilt down. Keep the pelvis and spine in a firm, neutral position with good isometric control during the aerobic conditioning. Running stairs or stair-walking machines produce good leg strength and good hip extensor strength. Rowing machines obviously can injure the back, but if done properly, with rigid muscle control of the spine, in a neutral, pain-free position, the benefit from the upper extremity and lower extremity exercise can produce good aerobic conditioning without spine stress. The better aerobic condition the athlete is in, the less likely he or she will sustain injury, including lumbar spine injury. Therefore, aerobic conditioning is an important part of every spine rehabilitation program.

The summary of an effective nonoperative treatment program for lumbar spine injuries follows:

1. Stop the inflammation. We prefer anti-inflammatory medications, Indocin SR being our most standard medication.

Patients should be advised of potential complications of any anti-inflammatory medications. Medrol Dosepak may be used in more difficult clinical situations, as are epidural cortisone injections.

2. Restricted activity. This may vary from 24 to 72 hours of bed rest to immediate immobilization in a lumbosacral corset and restriction of painful activities.

3. Spinal stability rehabilitation program. We began this rehabilitation program as soon as practically possible. It may vary from in bed, in the hospital, at 24 hours to the first available outpatient appointment in physical therapy.

In reference to some of the questions asked earlier

1. Do you start flexion or extension exercises?

The answer is you start neither. You start neutral isometric control exercises.

2. Do you use twisting exercises?

Twisting exercises can be the most injurious exercises in any rehabilitation program, yet torsional rotation is an important part of many sports. The answer lies in producing tight, rigid trunk control that controls the spine during rotational activities with the motion occurring predominantly in the shoulders, hips, and legs, and the athlete is able to produce a parallelism between his or her shoulders and pelvis during rotation, especially during the contact portion of the rotational sport. A twisting exercise that allows loss of muscle control of the spine during exercise can be injurious and may not be of benefit. Rotational strengthening can be important but has to be started with close observation and control. We twist many times in an average day and twisting is a part of many sports. Having a pain-free rotational range of motion is important; therefore, proper, slow active stretching in rotation is important. Part of the key is not to twist, but to teach the patient to rotate the whole body.

3. What type of aerobic conditioning should be performed? The type that holds the spine in its most advantageous position and best unweights the spine from injurious compres-sive loads

4. When can someone lift weights?

A patient can lift weights when he or she can do it safely meaning having tight, rigid trunk control. The patient can protect the spine while strengthening the extremities. A patient can lift weights when he or she can understand the role of balance, speed, and proper mechanical advantage in weight lifting. The key to functional weight lifting for the athlete is not to lift the weight at the greatest mechanical disadvantage, but to simulate positioning used in his or her sport. Isometric trunk control and position protection are done first, then resistive weight lifting.

5. What role do weight machine exercises have?

Weight machines can be a distinctly advantageous control situation for resistive weight lifting. All machines that strengthen the extremities require proper spinal control first. We have not used trunk strengthening machines such as the flexion, extension, and rotation machine in patients with back problems. Questions still linger as to their benefit. The key probably lies in proper use of the equipment and combining the equipment with a functional isometric control type system such as the trunk stability rehabilitation program.

6. What type of nonoperative rehabilitation is best for the individual athlete's sport?

It depends greatly on the sport and the demands as to rotational activity, compressive load, and tensile extremes of range of motion.

7. When can a professional athlete return to his or her sport after spinal surgery or a serious injury that has been treated nonoperatively?

The athlete can return when he or she can

• Complete level 5 of our trunk stabilization program.

• Complete a course of sport-specific exercises for his or her sport.

• Attain an appropriate level of aerobic conditioning for his or her sport.

• Practice the sport fully.

• Return slowly to the sport with some limit on the amount of time played.

• Continue to do the level 5 stabilization exercises after the return to play.

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