AQUATIC THERAPY IN THE MANAGEMENT OF LOW BACK DYSFUNCTION

Rehabilitation of any athlete with a low back injury provides a major challenge to the rehabilitation specialist. In fact, the incidence of low back pain dysfunction has reached epidemic proportions in the United States. Approximately 80% of the general population will suffer back pain at some time in their life and one-half will have recurrences. In recent years recreational and organized sporting activity participation among all age groups has increased requiring that the sports medicine professional be prepared to treat a wide variety of lumbar spine injuries and conditions.

One-half of the males and one-quarter of the females between the ages of 14 to 17 participate in some type of organized, competitive team sport12. This does not include participation in recreational and physical education activities. This population will frequently present with soft tissue and/or posterior element injuries of the low back secondary to repetitive flexion, extension and torsional stresses placed on the back during participation that predispose the lumbar spine to injury9. The athletic activities that are most frequently associated with injuries to the low back include: gymnastics, weightlifting, football, dance, rowing, wrestling9, powerlifting and bowling.

In the adult population, the mechanism of injury is frequently secondary to cumulative trauma related to repetitive rotational and forward bending motions. These persistent flexion and torsional loads have been observed to predispose an individual to a progressive injury cascade that may lead to degenerative disc changes in the lumbar spine3.

 Spinal Dysfunction

Spinal dysfunction can be described as an abnormality of spinal mobility. This can be either an increase or decrease from the expected normal, ranging from ankylosis to instability. The result is an altered pattern of motion which alters proprioception from the involved segments. Any type of dysfunction at one level of the spine will not only affect that segment; but also the segments adjacent to it as well as influencing the sensory, motor and autonomic functions distal to the lesion. It is this combined effect of numerous levels and structures that serves to alter joint position sense and results in an inability to control body movements during functional activities.

Low back injuries including such conditions as osteoarthritis, instability, sprains and strains are not only diseases but also dysfunctions of the lumbar spine. These dysfunctions manifest as either an increase or a decrease of motion from the normal, or by the presence of an aberrant movement pattern and lack of neuromuscular control.

In general, when the dysfunction manifests in limited motion the treatment program includes an exercise program of stretching for the involved musculature, gentle joint mobilization and muscular strengthening activities. When the dysfunction manifests in increased motion, laxity or instability, the treatment of choice involves stabilization, postural exercises and normalization of any limitations in neighboring joints which may be contributing to the compensation.

The motion segment of the spine is the area where all movement takes place. All the tissues that can be affected by this motion include the vertebra, disc, nerves, spinal cord, vessels, facet joints, muscles and ligaments. This mobile segment can grossly be divided into an anterior and a posterior section of elements. The anterior section incudes the articulation of two vertebra, above and below, with the intervertebral disc along with the anterior ligamentous structures. Posteriorly the motion segment is composed of the facet joints, neural arch and posterior ligaments and musculature.

Injuries to the anterior portion of the motion segment most commonly result in disc pathology resulting from repetitive flexion and rotational trauma. This type of injury mechanism produces small tears in the annulus of the disc which can progress to frank herniations over time due to the cumulative effects of the forces. Individuals with discogenic dysfunction most commonly present with:

1.) spasm, a positive straight leg raise test

2.) radiating pain from the low back to the lower extremities

3.) a lateral shift

4.) positive neurologic signs including the possibility of a loss in sensation, proprioception or strength

5.) gait deviations Posterior element dysfunctions in the lumbar spine are produced from repetitive hyperextension and torsional loads to the spinal segments.

These types of injuries can range from muscular strains to acute facet dysfunction and even to fatigue fractures of the neural arch (i.e., spondylolysis)9. The lumbar facet joints are exposed to greater articular cartilage loading pressures with extension and rotational movements which can cause facet synovitis, and may lead to facet joint arthropathy13. This type of injury is fairly common with football linemen; but also has a 22% incidence among gymnasts and a 21% incidence among male high school and college athletes as well5,6. Athletes with this type of posterior element dysfunction typically present with:

1.) localized pain

2.) muscle spasm

3.) negative neurologic signs

4.) a mechanical stress point with active trunk range of motion.

Additionally, these individuals may demonstrate a lateral shift and gait deviations depending on the severity and mechanical nature of their dysfunction.

Rehabilitation of Low Back Dysfunction

Basic Concepts of Rehabilitation

As with any rehabilitation program, effective management of lumbar dysfunction is based on several basic concepts which must be followed throughout the rehabilitation process to ensure proper progression. They include:

1) The cause of the problem must be identified and treated. Treatment should not be directed solely toward the elimination of symptoms, but must address the cause of the symptoms. Proper identification of the problem or dysfunction is based on a complete evaluation of the athlete with a low back injury.

2) The effects of immobilization must be minimized. Treatment should be initiated as soon as possible. When rest is utilized following a lumbar spine injury, it must not be total bed rest; but rest from aggravating activities only. Because immobility decreases joint extensibility, articular cartilage nutrition, muscular strength, flexibility, and bone density, an appropriate acute treatment program must be initiated as soon as possible following any injury2.

3) Healing tissue must never be overstressed. A proper program of activities and exercises with constant assessment and continual adjustment ensures that each injury is progressed appropriately without aggravating the athlete's symptoms or slowing the healing process.

4) The athlete must be advanced as quickly as possible. This ensures continued participation, motivation and enhances the success of returning an individual as quickly as possible to their pre-injury activity level.

5) The program must be adaptable from individual to individual to meet their specific needs and goals as well as those of their activity, sport, and position.

6) A team approach with effective communication is the key to success. This approach emphasizes education of the athlete concerning the activities and position that may predispose them to re-injury and the activities required to minimize this risk.

 Treatment Goals

The primary goal of spine rehabilitation should be the restoration of optimal function for each injured individual. Six specific goals combine to form the comprehensive treatment goal. These goals include:

1) full range of motion of the spine and affected lower extremity structures

2) normalization of lower extremity flexibility

3) functional spinal stability

4) normalized lower extremity strength

5) the prevention of further injury and recurrence

6) return of the athlete to sporting activity.

 Exercise Philosophy

Individuals seem to recover faster following an injury with exercise. In fact, an outcome study performed n 1989 demonstrated that an important aspect of treating patients with a herniated intervertebral disc, non-operatively, was the performance of a neutral spine stabilizing exercise program11. Stabilization is the use of a "muscular fusion" technique to brace the spine and protect the motion segments against cumulative trauma. A "muscular fusion: is the use of an isometric muscular contraction of the abdominals, spinal extensors and latissimus dorsi to prevent or minimize spinal motion during functional activities. The abdominal musculature is the most important muscle group in the performance of these activities. The abdominal musculature has the unique ability to flex the spine by its action on the superficial portion of the dorsolumbar fascia, and extend the spine by its action upon the deep portion of the fascia forming the alar ligament.

Performance of an abdominal brace in conjunction with a contraction of the latissimus dorsi, forms a muscular corset to protect the lumbar spine10. This type of stabilization or "fusion" technique uses improvements in body mechanics to facilitate efficient movement patterns in functional activities. The stabilization exercise concept can be utilized through a vast range of activities and progressions allowing the maintenance of a neutral or stable spine in all activities from simple single-plane exercises to complex multi-plane athletic activities.

 Basic Concepts of Aquatic Rehabilitation

The popularity of aquatic therapy following an athletic injury has increased significantly. The use of aquatic therapy in the rehabilitation of low back injuries can serve to facilitate the attainment of all the previously outlined treatment goals; because aquatic exercise activities can generally be used earlier in the rehabilitation process before other conventional methods of exercise are safe. This will allow the athlete to maintain or even improve their present level of fitness while still minimizing the stress placed on the healing tissues, and ensuring progressive resistance in the activities performed.

A therapeutic pool can be particularly beneficial for patients following back surgery or while treating individuals non-operatively for a disc or posterior element related pathology. Pool activities can be used to: decrease pain and spasm, increase range of motion/flexibility, increase upper, lower extremity strength, increase cardiovascular endurance, and facilitate an increase in functional progression.

Additionally, the buoyancy of the water can provide a positive treatment effect for individuals who are sensitive to axial loading of the lumbar spine. For example, if a person is in the water to the level of the xiphisternum, they will be bearing only about one-third of their full body weight through their feet which significantly decreases the compressive forces on the lumbar spine4.

 Treatment Activities

The rehabilitation process following a low back injury can be divided into two distinct phases; the pain control phase and the training phase. Because the pool can promote early movement while controlling aggravating forces, it is an excellent medium to begin activities in the pain control phase. Exercise activities in the pain control phase emphasize the performance of stabilization exercises to provide proprioceptive input between the lumbar spine and limb positioning. By combining this proprioceptive exercise input with the decreased axial pressures ont he disc and posterior elements of the spine, the therapeutic pool appears to be the appropriate medium to perfect and advance these stabilizing exercises.

For other exercises, Click Here

 Acute Treatment Activities For Posterior Element Dysfunction

Initial interventions are aimed at promoting relaxation through the use of a buoyant vest in deep water to minimize the weight bearing stresses and acclimate the individual to the pool. Pool walking activities are then initiated to help normalize any gait deviations as well as to increase lower extremity strength and range of motion. It is important to always instruct and remind the athlete to perform an abdominal brace while pool walking, which will prevent an extension moment about the lumbar spine which may increase their symptoms. Four-way hip resistance activities for flexion/extension and abduction/adduction are included with a neutral spine for lower extremity strengthening.

Neutral spine vertical sculling is also utilized for upper extremity and abdominal strengthening. These activities can be progressed to the performance of bilateral deep well tucks which will serve to increase abdominal and lower extremity strength as well as providing a gaping of the posterior elements of the spine to aid in symptom reduction. These activities can be progressed from a flexed knee position to an extended knee position to increase the difficulty and the muscular activity required to perform the activity.

Additionally, deep well cycling with an abdominal brace is useful for increasing cardiovascular and lower extremity endurance, as well as abdominal strengthening in these posterior element conditions. Also, lower extremity flexibility exercises for the hamstrings and gastroc/soleus complex can be safely performed in the pool to facilitate the improved flexibility. Acute Treatment Activities for Disc Pathologies In the therapeutic pool, treatment is again initiated by promoting relaxation. Individuals suffering from disc pathology begin relaxation activities with deep well traction activities. This is accomplished by suspending the athlete in deep water with a flotation device and placing a weight belt around their waist or cuff weights on their ankles. The use of traction has become a questionable form of treatment for patients with disc pathology. Numerous studies have shown that traction can subjectively reduce discogenic symptoms; however, no research has shown that traction can actually facilitate nuclear migration7.

Deep well traction is followed by a trial of standing extension activity in the pool. If a decrease in radiating symptoms occurs, the athlete can progress to a program of activities designed to promote extension including standing active extension and prone kickboard activities.

As previously discussed, the performance of stabilization exercises is a vital part of the treatment program in this population of athletes.

In the water these can be initiated with pool walking utilizing a neutral spine, bar sitting with a neutral spine and side stroke deep well scissor kicks with an abdominal contraction.

Following the successful reduction of radiating symptoms, a similar treatment plan to the one previously outlined for posterior element dysfunctions can be incorporated to increase the difficulty and resistance for these individuals.

 Training Phase

Unfortunately, in many settings treatment for the individual with a low back injury is topped at the end of the pain control phase. The purpose of the training phase is to obtain musculoligamentous control of all lumbar spine forces to eliminate repetitive injury to the intervertebra discs, facet joints and related structures. An individual who does not progress beyond the pain control phase continued to be at risk for further re-injury. An aquatic therapy exercise program used in the acute pain control phase can frequently allow the athlete to progress to this training phase at a faster rate1.

Activities that can be performed at this stage in the rehabilitation process are only limited by creativity. During this phase, activities need to be designed to allow an individual to progress to unrestricted, symptom free, sport specific activities. Aquatic therapy at this portion of the rehabilitation process should be aimed at normalizing both lower extremity and trunk strength, power and endurance; as well as advancing functional activities. As strength and endurance re improved, spinal stabilization is adequate, and functional activities have been mastered, the aquatic portion of the treatment phase should be diminished. At this point, dry land functional stable spine activities should be increased to progress toward return to unrestricted activity. A specific discussion of the activities in this portion of the training phase are beyond the scope of this paper.

 Summary

Aquatic exercise activities can play an essential role in the management, progression and successful rehabilitation of lumbar spine injuries.

They can serve to decrease the weight bearing compressive forces, initiate activities earlier during rehabilitation and provide an environment for effective proprioceptive input training to maximize the progression of stabilization exercise activities. All these are aimed at returning the athlete to unrestricted functional activities as soon as possible. Additionally, aquatic therapy serves to keep the athlete motivated during rehabilitation. By allowing the athlete to run, jump, and perform sports related activities in the water, psychological and motivational benefits are achieved which serve to enhance the athlete's successful return to sporting activities.

 REFERENCES

1. Cheatle M.D., Esterhai J.L. : Pelvic traction as treatment for acute back pain: efficacious, benign, or deleterious. Spine, 16(12): 1379-1381, 1991.

2. Dehne K., Kriz F. K. : Rationale of immediate immobilization and restoration of joint function. J. Bone Joint Surg., 49A: 1235, 1967.

3. Farfan H.F. : Effects of torsion on the intervetebral joints. Can J. Surg., 12: 336-341, 1969.

4. Harrison R., Bulstrode S.: Percentage weight-bearing during partial immersion in the hydrotherapy Pool. Physiotherapy Practice, 60-63, 1987.

5. Hoshina H.: Spondylolysis in athletics. Phys. Sports. Med., 8(9): 75-79, 1980.

6. Jackson D.W.: Low back pain in young athletes. Evaluation of stress reaction and discogenic problems. Am. J. Sports Med., 7: 364-366, 1979.

7. Levin S.: Aquatic therapy: A splashing success for arthritis and injury rehabilitation. Phys. Sports Med., 19(10): 119-126, 1991.

8. Physician and Sports Medicine: Joe Montana: Back exercises for a super bowl winner. Phys. Sports Med., 17(9): 188,1989.

9. Saal J.A.: Rehabilitation of football players with lumbar spine injury. Phys. Sports Med., 16(9): 61-67, 1988.

10. Saal J.A., Saal J.S.: Later stage management of lumbar spine problems. Phys. Med. and Rehab. Clinics of N. Am., 2(1): 205-221, 1991.

11. Saal J.A., Saal J.S.: Non-operative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine, 14(4): 431-437, 1989.

12. Shaffer T.E., Smith N.J. (Eds): Sports medicine for children and youth. Report of the tenth Ross roundtable on critical approaches to common pediatric problems. Columbus, Ohio: Ross Laboratories, 1-9, 1979.

13. Adams M.A., Hutton W.C.: The mechanical function of the lumbar apophyseal joints. Spine, 8: 327-330,1983.

Adapted from Sports Medicine Update 7(2): 10-15, 1992, by Daniel Hughes, M.S., P.T.

Back To: Patient_Education