Pain control

Pain control interventions include activity modification, medications, physical therapy modalities, and/or injections into the muscle or spinal structures. Any of these interventions may be used during the acute phase of injury where they may assist with inflammation. However, during a prolonged injury, the utility of these interventions most likely relates to assisting with pain control to facilitate rehabilitative functional recovery.

Muscular strains and ligamentous sprains usually occur as a blow to the head or body creates rotary, sidebending and flexion–extension forces to the spine. Trying to maintain the head and neck in normal alignment by strong eccentric contraction creates muscle and ligamentous tearing by overcoming their tensile strength.¹² It is during the acute pain period that the athlete may learn protective compensatory posturing, resulting in abnormal posture, thus leading to a chronic pain mechanism. The head protruded forward is commonly seen in those with poor posture secondary to habit or body habitus. A cycle of biomechanical derangements occurs, resulting in an alteration of the normal anatomy and alignments. Muscles meant to stabilize come to function as movers of the spine, leading to a further pattern of chronic myofacial pain syndrome.

In general, injury to a musculoskeletal structure such as a muscle or ligament will lead to a systematic process of degradation and repair. During the initial inflammatory phase, micro/macro tears and localized hematoma formation give way to phagocytosis and enzymatic degradation with subsequent tissue necrosis. Modalities to control the inflammatory process may play a role in limiting the extent of tissue damage during the initial stages. During the reparative phase, the body attempts to repair the injured area through collagen formation. However, the reparative process will lead to disorganized fibrous tissue without the appropriate applied stressors. Prolonged pain symptoms will inhibit the rehabilitative process by limited the amount of stress one can tolerate during the recovery process. Therefore, adequate pain control is imperative during the management of an athlete with prolonged injury. It is the basis for early mobilization and is the reason why soft tissue is not immobilized for a prolonged period, unless absolutely indicated by the injury.¹³

Unfortunately, evidence supporting the use of specific pain modalities in the athlete is lacking. In the general population, there is strong evidence that prolonged bed rest is detrimental to the functional recovery of individuals with acute low back pain without radiculo-pathy.¹⁴ It could be surmised that the principle of relative rest and the avoidance of bed rest in athletes will also facilitate earlier functional recovery. Fellander-Tsai et al.¹⁵ suggested some benefit from the use of modalities for pain relief in individuals with spondylolysis, including activity modification and electrical stimulation. However, the study had several design flaws including small sample size and selection bias. Various studies provided conflicting support as to the efficacy of interventional spinal injections.^16,17 Finally, O’Sullivan et al.¹⁸ showed a signification reduction in pain intensity and utilization of pain medication at 30-month follow-up in a treatment group that underwent a 10-week exercise treatment program compared to controls. Future, randomized, controlled studies are need to better support or refute the utilization of these various modalities in managing a specific spinal injury in athletes.

Correction of inflexibilities and strength deficits

Strength deficits

Addressing strength deficits is another primary focus of spine rehabilitation. Similar to the previous discussion of spinal flexibility, prolonged injury and pain can lead to muscle atrophy, altered spine biomechanics, and decreased athletic performance. There are a variety of spine exercise programs including spine stabilization exercises, McKenzie exercises, and Williams’ flexion exercises which are utilized to treat spine injuries based upon the etiology of the spine pain.²² However, there is limited study of the utility of these programs in the management of prolonged spine injuries in athletes. The following is a review of the various studies that have attempted to analyze the role of the spine muscles in supporting the spine, anatomical changes which occur from an exercise program, and efficacy in treating individuals with prolonged spine injuries.

In the lumbar spine, the superficial and deep truncal muscles are strengthened to assist with the control of the lumbar spine. Various studies have yielded conflicting results as to changes involving the superficial muscles of the lumbar spine. In contrast, the multifidus muscles are believed to be important in maintaining stiffness and strength of the lumbar spine.^23,24 Zhao et al. suggested that functional inactivity may contribute to selective type 2 atrophy of the multi-fidus muscles in patients with lumbar disc herniations.²⁵ Antigravity postural muscles have been shown to atrophy to a greater extent than lower extremity muscles in microgravity simulation models.²⁶ Changes in muscle composition in healthy subjects who stopped normal repetitive low-level activity patterns is thought to result in transformation of the muscle towards a more fatigable type of muscle fiber.^26,27 The implication is that muscles situated on the trunk and lower extremities are affected most by prolonged inactivity and deconditioning. Fortunately, it is believed that these changes are reversible with adequate therapy.

Various studies have looked at the anatomical changes in spinal muscles after a treatment exercise program. Hides et al. attempted to assess the recovery of lumbar multifidus muscles after treatment with an exercise program consisting of isometric contractions of these muscles with cocontraction of the abdominal muscles compared to medical treatment only for individuals following a nonradicular acute lumbar spine injury.²⁸ These authors noted a more rapid and complete recovery of the multifidus muscles as measured by an improvement in the muscle symmetry. Sung studied the endurance of multifidus muscles and functional status of chronic low back pain patients after participation in a 4-week spinal stabilization program.²⁹ Although the authors believed it was difficult to measure the isolated effect on the multifidus alone, they suggested the evidence did show a change in the multifidus strength in conjunction with other spinal extensor muscles. Finally, Danneels et al. analyzed effect of three different 10-week exercise training programs on the cross-sectional area of the paravertebral muscles in individuals with chronic lumbar spine pain.³⁰ The authors suggested that a lumbar stabilization program combined with dynamic resistance training was necessary to restore the size of the paravertebral muscles. These studies would suggest that a structured lumbar exercise program can lead to anatomical improvement in the lumbar multifidus muscles.

Other studies have attempted to define the functional efficacy of a structured strengthening exercise program in the management of individuals with chronic lumbar spine pain. Unfortunately, there are few prospective, randomized studies. O’Sullivan et al.¹⁸ compared a treatment group utilizing strengthening of the deep abdominal muscles with coactivation of the lumbar multifidus to a control group in individuals with chronic low back pain and spondylolisthesis. The treatment group showed a significant improvement at 30 months in regards to pain, function, range of motion, and abdominal muscle recruitment. Mannion et al.²⁷ performed a prospective study of three active exercise treatments (active physical therapy, muscle reconditioning on devices, and low-impact aerobics) over a 3-month period for individuals with chronic lower back pain. All three treatment exercises showed a similar increase in isometric strength in all lumbar planar movements, increase activation of the erector spinae during extension testing, and increased endurance testing as measured by the Blering-Sorensen test. The authors concluded that significant muscle performance was observed in all three exercise groups.

Though these studies were not specific to athletes, they would suggest that a structured strengthening program may be efficacious in the management of chronic spine injuries. In the lumbar spine, the program should focus on strength training of the deep intrinsic spinal muscles, such as the lumbar multifidus, with cocontraction of the abdominal muscles (Fig. 130.1). Indeed, many of today’s spinal rehabilitation programs incorporate control and strengthening of these ‘core’ muscles of the spine (Fig. 130.2). However, more comprehensive randomized, prospective studies are needed to better assess the efficacy of spinal strengthening exercises in treatment of athletes.

Fig. 130.1 Spine stabilization exercise with use of balance ball for lumbar strengthening and balance.

Fig. 130.2 Spine stabilization exercise with use of balance ball for cervical/thoracic strengthening and balance.

Maintenance of cardiovascular stamina

For the athlete, prolonged recovery can have a significant impact on cardiovascular fitness. Intuitively, maintenance of cardiovascular fitness during the recovery process will allow the athlete to return to their peak performance in a shorter period of time. Prolonged recovery or decreased cardiovascular exercising will lead to deconditioning within a few weeks. In addition, aerobic exercise may assist in the management of pain, decreasing the need for medication which might have adverse side effects. Therefore, most rehabilitation treatment programs utilize some form of aerobic exercise depending upon the etiology of the spinal injury. Such interventions have included swimming, cycling, elliptical trainers, and water running.

Despite the rationale for cardiovascular fitness during the recovery process, there are no definitive studies to suggest the effectiveness of a fitness program in athletes after a spinal injury. Wittink et al. noted in a prospective case series that patients with chronic low back pain had comparable level of aerobic fitness with those of healthy subjects.³¹ Though the authors suggested that aerobic fitness level was independent of diagnosis, duration of pain, pain intensity, or work status, they felt aerobic fitness training was a useful treatment modality. Sulco et al. studied low back pain patients who underwent a 10-week aerobic fitness training regimen. In the short term, improvements in mood profile were noticed, but not in pain levels. However, at 2.5-year follow-up, the exercise group received fewer pain medication prescriptions, was given fewer physical therapy referrals, and showed an improved work status in exercising patients.³² Future prospective studies are needed to better define the amount and efficacy of aerobic fitness training for athletes with specific diagnoses. Despite this need, maintenance of aerobic fitness should be part of a rehabilitation treatment program.

Psychosocial issues

All athletes, whether amateur or professional, may experience psychosocial issues, which may affect their recovery from a prolonged injury. For most athletes, this may pertain to the frustration of not being able to return to a specific sport in a certain period of time. For elite athletes, the issues may be more complex due to the many stakeholders including agents, trainers, and coaches. In addition, burnout can cause the athlete to regress during rehabilitation, which should put the training and medical staff on notice to look for the symptoms while following the athlete’s recovery.³³ Therefore, the physician must be aware of these issues and the patient’s goals to develop a complete treatment program.

The impact on recovery of the manifestation of the psychological issues has been studies in both athletes and nonathletes with chronic low back pain. A few studies have found a relation to psychological distress and the development chronic back pain in workers.^34,35 Sports psychology, while generally relating to a much different population, can, in some ways, draw parallels with regards to anxiety and fears of pain. If the athlete’s focus falters, a negative cycle can develop which can evolve into increased tension. It is important for the support team to help the athlete maintain high self-esteem and concentration. As noted above, burnout can occur from overtraining and erode the self-confidence and motivation of the athlete.

A stepwise approach with directed goals will help with maintaining a positive outlook for the athlete as he or she reaches for new levels of achievement during the course of rehabilitation. Fear of re-injury can be an inhibitory consequence of having low back pain. Patients often will not attempt certain activities due to a belief that it will worsen their condition. Obviously, this can be quite detrimental to progression in a therapeutic program. In patients with chronic low back pain, it has been shown that if they believe that their pain will worsen, significant disability and depression will be encountered.³⁶ For these reasons, it is sometimes important to employ a sports psychologist to facilitate rehabilitation and ensure a smooth progression to eventual return to activity, as appropriate.

Reintegration in sports-specific activity

The final steps in the rehabilitation process involve integrating the athlete back into their sports-specific activity (Fig. 130.3). Progression from the basic flexibility and strengthening exercises of the spine will depend upon the athlete’s symptoms and performance needs. Athletes should begin these sports-specific motions under the guidance of the trainer or therapist. Such supervision will allow the trainer or therapist to review any biomechanical abnormalities which might impede the recovery process. In addition, the athlete should be pain free and without surgical restriction. Any asymmetry in muscle strength would limit the athlete’s progress toward the sports-specific activity.

Fig. 130.3 Open kinetic chain resistance throwing exercise.

The progression from basic to more complex motions will depend upon the subsequent forces placed on the spine. As an example, athletes participating in tennis should simulate a basic forehand or backhand swinging motion in a plane parallel to the ground. The motion should initially begin without any contact with the tennis ball or resistance measures, such as Therabands. Contact or resistance is then added in a linear plane with progression toward reaching in multiple planes as would occur in competition. Overhead volleys and serves should be avoided until the athlete is able to perform the above motions with fluidity and without pain. The athlete is then progressed to overhead serves and volleys which will place a greater amount of stress on the spine. Again, the motions should initially occur without any ball contact. The athlete can then progress from low-speed to high-speed motions with increased power as tolerated. A final decision allowing return to full activity should occur in the context of a complete medical recovery from the injury with the hopeful prevention of any future injury.

Cervical spine

Several authors have suggested an algorithmic approach for treating injuries to the cervical spine. Wang el al.³⁷ attempted to study the effectiveness of an algorithmic approach for treating different etiologies of cervical pain. Patients were grouped according to symptoms, including radicular arm pain or neck pain, referred neck or arm pain, cervicogenic headaches, and neck pain only. Treatment approaches included range of motion, traction, postural exercise, and joint mobilization. Based on the results, the authors determined that there was a place for individualized treatment approaches using such an algorithm. Beazell et al. suggested specific exercises for the cervical region to correct dysfunctional motion and restore posture.³⁸ Exercises to facilitate proper posture include stretching of the pectoralis minor and the posterior shoulder depressors in addition to the trapezial and cervical paraspinal muscles. Other muscles that can be targeted to prevent muscle inhibition include the longus colli and lower trapezius. Maintenance of proper posture during reconditioning is emphasized to facilitate normal neuromuscular patterns that can carry over to sport-specific exercises. Scapular strengthening will help with stabilizing the shoulder in order to aid in maintaining cervical alignment. Prior to returning to sport, the athlete should be able to demonstrate appropriate cervical posture. As previously noted, criteria for return are pain-free range of motion, no abnormal neurologic signs, spinal stability, normal strength, and no provocative signs.

Torg and Ramsey-Emrhein³⁹ proposed criteria for clinicians to use to help patients understand the risks of collision activities and to help make sound recommendations regarding participation in competition. The following are brief summarizations, and the reader is directed to the references for a full discussion of the recommendations. Congenital conditions such as odontoid anomalies and atlanto-occipital fusion are complete contraindications, while Klippel-Feil anomaly depend on the type and confounding pathology. Developmental cervical stenosis without evidence of instability does ‘not predispose athletes to permanent catastrophic neurologic injury’ and should not disallow the athlete from playing. However, athletes with a loss of ‘functional reserve’ as defined by obliteration of the protective cerebrospinal fluid around the spinal cord on MRI imaging should not participate in contact or collision sports.⁴⁰ Those athletes with uncomplicated cervical cord neurapraxia or ‘stingers’ can be allowed to play without risking more serious neurologic injury.³⁹ Spear-tackler’s spine as seen in athletes with developmental stenosis, straightening of the cervical column and post-traumatic radiographic abnormalities, is an absolute contraindication. There are no contraindications for athletes with single-level stable cervical fusions. However, athletes with 2–3-level fusions present a relative contraindication and those with more levels are absolutely contraindicated.

Lumbar spine

Similar to the cervical spine, a variety of algorithms have been recommended to treat lumbar spine injuries. Despite the need for more prospective, randomized, controlled studies, most physicians will utilize a spine program which incorporates lumbar stretching and assessment of lower extremity inflexibilities. The main focus of lumbar strengthening involves control of the ‘core’ muscles of the spine, including the abdominal and lumbar multifidus muscles. Prior to returning to competition, the athlete should exhibit pain-free range of motion, normal strength, and sport-specific activities.

As an example, the treatment of lumbar spondylolysis and time to return to competition will vary depending upon the physician’s beliefs and preference. Standaert et al.⁴¹ recommended that athletes may return to competition if they are asymptomatic after 4–6 weeks with a mature corticated fracture on CT scan. If the CT scan shows an earlier-stage lesion with either a stress reaction or minimal separation with noncorticated or cystic margins, the athlete should rest for 12 weeks and no extensive physical activity beyond that associated with normal daily activities. After a gradual rehabilitation program and no symptoms, the athlete can progressively return to the sport. Cogeni recommended that athletes can return to competition if they are pain free during therapy, at rest, with lumbar hyperextension motions and specific athletic activity after 8 weeks from the diagnosis.⁴² Omey and Micheli recommend the application of a rigid brace for 6–9 months for athletes with early spondylolytic lesions before returning to sport.⁴³

Despite the variation in treatment times, the overall goal is to allow adequate healing of the pars defect, relieving pain, and optimizing function. In each case, the athlete should not be allowed to return to play until demonstration of painless range of motion and relief of hamstring spasm, if present. The goal of physical therapy is to increase spinal stability, whether implemented in a brace or without a brace. However, prolonged brace use will require reconditioning. Physical therapy exercises have varied, but focus on targeting the deep abdominal muscles and lumbar multifidi.^18,44 With time, most athletes will eventually return to competition. For a more complete discussion, the reader is referred to the earlier chapter on spondylolysis.

Running sports

Running athletes are less likely to experience back pain injuries compared to injuries involving the lower extremity. However, back pain injuries may represent approximately 2–11% of all running injuries.⁴⁵ The majority of these injuries involve lumbar strains. Less common injuries that may lead to prolonged injury include lumbar radiculopathy, lumbar spondylolysis, lumbar spondylolisthesis, and lumbar stress fractures. Fortunately, the majority of lumbar spine injuries can be managed with medical rehabilitation and rarely require surgical intervention

In general, the compressive forces and flexion–extension moments generated in the spine during running are not believed to place the spine at an increased risk for injury. However, any biomechanical abnormalities that may increase the forces on the spine may contribute to lumbar spine injuries.⁴⁵ During the running gait cycle, there appears to be coordinated movements for: (1) flexion–extension of the lumbar spine and anterior–posterior pelvic tilt, and (2) lateral bending of the lumbar spine and obliquity of the pelvis.⁴⁶ The lumbar extensor muscles appear to exhibit significant muscular activation at the time of heel strike, assisting with truncal deceleration and stabilization of the pelvis. At the same time the peak compressive forces range from 2.5–5.7 times body weight at heel strike.⁴⁷ Any lower extremity abnormality, such as excessive pronation, may increase internal tibial rotation placing increased stress on the lumbar spine.

In athletes with chronic lumbar spine injuries, the physician should assess for extrinsic and intrinsic factors which may contribute to the prolonged lumbar pain. Extrinsic factors include assessment of the athlete’s running shoes, frequency and distance of running, terrain (pavement, trails and treadmill, flat versus hills) and weekly progression of time or mileage. Most athletes experience injuries when they attempt to abruptly change one of the above extrinsic factors. Intrinsic factors relate to the anatomical alignment, inflexibilities, and strength of the athlete. The physician should assess for lumbar spine and lower extremity range of motion and alignment including any increased lumbar lordosis, anterior pelvic tilt, excessive tibial rotation, or excessive foot pronation. Areas of inflexibility common to runners include hip flexors (iliopsoas), hip abductors (iliotibial band), and lower extremity (hamstring and gastrocnemius muscles). Strength deficits may involve the lumbar paraspinal muscles (erector spinae), abdominal muscles, and pelvic stabilizers, including the gluteal muscles. Finally, maintenance of cardiovascular fitness is essential in the recovery of running athletes. Aquatic running is quite useful and alleviates some of the biomechanical forces on the lower extremity and spine.

Golf

Golfers experience one of the highest incidences of back pain for all sports. The incidence varies for amateur and professional athletes depending upon the study. The incidence in amateur athletes incidence ranges 25–46%, and in professional athletes range 30–40%.⁴⁸ In the amateur golfer, the majority of golf injuries are due to technical error or biomechanical deficiencies.⁴⁹ In professional golfers, the majority of injuries are due to overuse.⁵⁰ In both types of athletes, the most common injury involves the lumbar spine including lumbar strains, lumbar radiculopathy, and lumbar spondylolysis.

It has been suggested that poor swing mechanics may lead to an increased injury of the lumbar spine. Hosea and Gatt noted that compressive, rotatory, lateral flexion and anterior–posterior traction forces are applied to the lumbar spine during the golf swing.⁵¹ The spine may be particularly at risk during the take-away or back swing and late follow-through phases of the golf swing due to the compressive forces placed on the spine. The erector spinae and abdominal oblique muscles exhibit increased muscle activity throughout the golf swing. The erector spinae assist with stabilization, while the abdominal muscles contract for truncal flexion and rotation.^52,53 For the scapular stabilizers: (1) the trapezius is active in the trailing arm during take-way and during the leading arm during acceleration, (2) the levator scapulae and rhomboid muscles are active in the leading arm during the forward swing and acceleration phases and the trailing arm during take-away, and (3) the serratus anterior is constantly active in the leading arm and mainly during the acceleration and early follow-through phase in the trailing arm (Kao, 1995) (Fig. 130.5, 130.6).⁵⁴ In any technical error in the golf swing, spinal inflexibility or truncal strength deficits could contribute to subsequent injury.

Fig. 130.5 Scapular muscle activation in the leading arm during the phases of the golf swing.

Fig. 130.6 Scapular muscle activation in the trailing arm during the phases of the golf swing.

A comprehensive rehabilitative program will focus on all components of flexibility, strength, and endurance conditioning, as well as poor swing biomechanics. Potential areas of inflexibility include limited lumbar spine mobility in any plane, limited hip motion, tight hamstrings, and tight pectoralis muscles. Strengthening exercises should focus on the lumbar paraspinal muscles (erector spinae), abdominal muscles (rectus and oblique), latissimus dorsi, and scapular stabilizers (rhomboid, serratus anterior and trapezius). Finally, a thorough review of all phases of the golf swing is essential to improve any potential technical flaws. Specific areas of focus may include: straightening of the back posture during the swing, proper positioning of the feet to allow equal distribution of weight and appropriate weight transfer during the swing, and speed control during trunk rotation.⁴⁸

Cycling

Cervical and lumbar spine injuries are quite common in the sport of cycling. The injury will vary for amateur verses professional riders and road verses off-road cycling. In addition, traumatic injuries are more likely to lead to head injuries or spinal fractures, which are beyond the scope of this discussion. For atraumatic injuries, cervical spine injuries include cervical and trapezial muscle strains, while lumbar spine injuries are typically lumbar strains secondary to the various positions of the cyclist. The incidence of low back pain has ranged from 10% to 17% of competitive cyclists.⁵⁵ Other common injuries include radiculopathies and spondylosis in the older athlete.

The position of the road cyclist for prolonged period of times may predispose the athlete to injury. The cyclist rides with the cervical spine hyperextended and the lumbar spine hyperflexed for aero-dynamic stability. The position may be exaggerated when the cyclist utilizes the drop handlebars or aerobars. Cervical and upper back injuries are probably secondary to the increased load on the arms and shoulders while riding.⁵⁶ An electromyographic study suggested increased activity in the thoracic muscles depending upon head position and aerodynamic positioning.⁵⁷ Lumbar spine injuries are probably secondary to an increased stretch to the lumbar paraspinal muscles and increased pressure to the lumbar disc in the hyperflexed position. In addition, lumbar extensor muscle activity appears to be proportional to pedal cadence.⁵⁷

Management of cervical or lumbar spine injuries requires a thorough assessment of the bicycle for proper fit to the athlete. Factors to include in the assessment of the fit of a bicycle include the frame size, seat height, fore and aft saddle position, saddle angle, handlebar reach, handlebar height and amount of rotation in the pedals. In addition, review of how the athlete pedals and utilizes gearing to overcome resistance is imperative. Physical assessment of the cyclist may often reveal decreased cervical or lumbar spine range of motion as well as hip flexor, iliotibial band, or hamstring tightness. Strength deficits may involve cervical paraspinal, trapezial, lumbar paraspinal, gluteal, and hamstring muscles. A comprehensive program should focus on correcting the biomechanical deficits of the athlete and improper fit of the bicycle.

Rowing

Injury rates among rowers are relatively low when compared to other traumatic sports. However, a fair number of injuries involve the lumbar spine, with an incidence of 15–20% among elite and club level rowers.^58,59 Fortunately, the majority of injuries relate to muscle strains from overuse and subsequent fatigue.

Rowers must repetitively cycle though four distinct phases: the finish, recovery, catch, and drive. It has been hypothesized that alterations in flexibility or strength may lead to subsequent injury due to fatigue. A study of 20 elite rowers reveals greater mobility in the lower lumbar spine region and less in the pelvic region in rowers with no history of lower back pain. In contrast, rowers with chronic lower back pain were noted to have hypomobility in the lower spine and compensatory increased motion in the upper lumbar or pelvic regions.⁶⁰ Over the rowing time period, there was an increase in the lumbar flexion and the electromyographic activity of the lumbar muscle including the multifidus, iliocostalis lumborum. and longissimus muscles.⁶¹ In theory, this may lead to subsequent injury.

The rehabilitation of spinal injuries involves a restoration of the spinal mobility and endurance training of the core lumbar muscles. Rowers will benefit from stretching exercises focusing on the hamstring and iliopsoas muscles to increase lumbar flexion and synchronize the lumbopelvic motion.^60,61 Strengthening exercises should focus on endurance concentric and eccentric exercises of both the abdominal and lumbar extensor muscles. In addition, exercises should strengthen the gluteal muscles, which assist with developing the explosive forces during the drive phase of rowing. Maintenance of the lumbar flexibility and strength should assist with the prevention of subsequent injuries.