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Baseball and Low Back Pain

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Lecture on the anatomy and biomechanics of lumbar spine and how to strengthen to improve performance and prevent injury.

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Baseball and Low Back Pain

  1. 1. Baseball and Low Back Pain: “ Prevention is Performance Enhancement” Trent Nessler, PT, DPT, MPT
  2. 2. The Reality of Statistics <ul><li>80% of the population suffer from one form or another of LBP </li></ul><ul><ul><li>Of those, 65%-85% have a recurrence of LBP within 2 years </li></ul></ul><ul><ul><li>What is the implication? </li></ul></ul><ul><li>LBP accounts for 14.3% of new patient visits to their MD </li></ul>
  3. 3. The Reality of Statistics <ul><li>Considered the 2 nd to 5 th most common reason to seek medical attention </li></ul><ul><li>Health care cost approaching the 100 billion dollar mark </li></ul><ul><li>Number one cause of work related disability. </li></ul><ul><li>Now the main cause of disability of individuals under the age of 44 </li></ul><ul><li>LBP in Sports </li></ul><ul><ul><li>Now become the 3 rd most common injury in baseball </li></ul></ul><ul><ul><li>Spondo accounting for large percentage of </li></ul></ul><ul><ul><ul><li>With what? </li></ul></ul></ul>
  4. 4. The Reality of Statistics <ul><li>Common course of treatment dependent on?? </li></ul><ul><ul><li>Onset of care </li></ul></ul><ul><ul><li>Radicular vs. non-radicular </li></ul></ul><ul><ul><li>Age/physical status </li></ul></ul><ul><li>According to insurance industry statistics </li></ul><ul><ul><li>LBP Non-radicular – 6-10 treatments </li></ul></ul><ul><ul><li>LBP Radicular – 12-15 treatments </li></ul></ul>
  5. 5. Objectives <ul><li>Understand normal biomechanical loading of the lumbar spine. </li></ul><ul><li>Appreciate biomechanical loading variations of the lumbar spine with varying postures. </li></ul><ul><li>Appreciation of posturing on biomechanical loading of the lumbar spine with weight training. </li></ul><ul><li>Understand NPP (Neutral Pelvic Positioning) and the importance to loading lumbar spine. </li></ul>
  6. 6. Objectives <ul><li>Appreciation for the depth of lumbar/core anatomy as relates to lumbar stabilization. </li></ul><ul><li>Clinical understanding of the importance to anatomy and carry over to training and treatment programs. </li></ul><ul><li>Appreciation for the importance of proper stabilization as relates to athletic performance. </li></ul>
  7. 7. Loading of the Lumbar Spine <ul><li>Education - essential component of “well structured” stabilization program. </li></ul><ul><li>Loading of the Lumbar Spine: </li></ul><ul><ul><li>80% bone-disc-bone interface </li></ul></ul><ul><ul><li>20% facets </li></ul></ul><ul><li>Disc serves as the shock absorber, properties allow to absorb large amount of force </li></ul><ul><ul><li>Nucleus pulposus </li></ul></ul><ul><ul><li>Annulus fibrosis – dries out and fissures with age </li></ul></ul><ul><li>Refer to diagram </li></ul>
  8. 8. Loading of the Lumbar Spine Bone – disc – bone 80% 20%
  9. 9. Flexion vs. Extension Loading <ul><li>Abnormal posture increases pressure to the spine. </li></ul><ul><ul><li>Flexion – increased pressure to the bone-disc-bone interface, >80% load bearing </li></ul></ul><ul><ul><ul><li>Increases interdiscal pressures </li></ul></ul></ul><ul><ul><ul><li>Potential increase s/s with disc pathology </li></ul></ul></ul><ul><ul><li>Extension – increases pressure to the facets, > 20% load bearing </li></ul></ul><ul><ul><ul><li>Can increase pressure on nerve at the intervertebral foramen </li></ul></ul></ul><ul><ul><ul><li>In these cases, nerve root irritation or facet sydrome/spondo, avoid extension. </li></ul></ul></ul><ul><li>Both flexion and extension posturing results in abnormal loading of the lumbar spine. </li></ul>
  10. 10. Loading of the Lumbar Spine 80% 20% Flex Ext
  11. 11. Loading of the Lumbar Spine: Pressure Changes with Posture <ul><li>Disc pressure change w/ posture </li></ul><ul><ul><li>Lying 50% BW, standing 100% BW, sitting 150% BW, forward bending ~160% BW and sitting with flexion ~200% BW. </li></ul></ul><ul><ul><li>Why athlete reports less pain with lying, more with standing and even more with sitting </li></ul></ul><ul><ul><li>Weight lifting take home - importance of proper lifting technique (rows, modified dead lifts, squats) </li></ul></ul>
  12. 12. Loading of the Lumbar Spine: Pressure Changes With Lifting <ul><li>Lifting loads – lever arm from spine </li></ul><ul><ul><li>Diagram indicates 200 N load and pressures on lumbar spine with various postures. </li></ul></ul><ul><li>Drives home the importance of proper lifting technique with: </li></ul><ul><ul><li>Modified deadlifts, lifting of dumbells/plates, est. </li></ul></ul>
  13. 13. Proper Lifting (200N Load) 200 N
  14. 14. Improper Lifting (200N Load) 500 N
  15. 15. NPP: Neutral Pelvic Positioning <ul><li>What is it: Position of the spine in which you load the spine at it’s biomechanical advantage. </li></ul><ul><ul><li>Different for everyone. </li></ul></ul><ul><ul><li>Exercise in the manual: lying, sitting and standing. </li></ul></ul><ul><ul><li>Loads the spine in the 80/20 relationship. </li></ul></ul><ul><ul><li>Requires local (transverse abdominus, mutifidus, est.) and global (Gluts, quads, rhom, est.) muscles. </li></ul></ul>
  16. 16. NPP: Neutral Pelvic Positioning <ul><li>Difficult to learn and even more difficult to maintain during exercise and athletic activity. </li></ul><ul><ul><li>Retraining of the spinal proprioceptors, muscle spindles, and golgi tendon organs. </li></ul></ul><ul><ul><li>Involves retraining of the spinal, LE and abdominal muscles to maintain correct spinal position. </li></ul></ul><ul><li>NPP should be maintained with all forms of training </li></ul><ul><ul><li>Examples: squats, rows, bent over rows, and core stabilization exercises. </li></ul></ul><ul><ul><li>Should have higher carryover to athletic performance. </li></ul></ul>
  17. 17. Anatomy of the Lumbar Spine <ul><li>Various authors indicate varying anatomical contributions to the support of the lumbar spine. </li></ul><ul><li>Material here from DeRosa and Porterfield: Lumbar Spine Video Series </li></ul>
  18. 18. <ul><li>CORE </li></ul><ul><li>What is CORE Stabilization? </li></ul><ul><li>WHY Is It Important? </li></ul>
  19. 19. Anatomy of the “CORE” <ul><li>Handout on anatomy of the lumbar spine and clinical significance. </li></ul><ul><li>Drawing of the anatomical correlations: </li></ul><ul><ul><li>1. Thoracolumbar Fascia </li></ul></ul><ul><ul><li>2. Latissimus Dorsi </li></ul></ul><ul><ul><li>3. Internal Obliques </li></ul></ul><ul><ul><li>4. Gluteus Maximus </li></ul></ul><ul><ul><li>5. Gluteus Medius </li></ul></ul><ul><ul><li>6 & 7. LE musculature and fascia </li></ul></ul><ul><li>Decreased performance and pain result when there is an imbalance and/or asymmetrical loading in the system </li></ul>
  20. 20. Poor CORE = Low Back Pain/Injury <ul><li>Treatment </li></ul><ul><ul><li>Sooner the treatment implemented, less days on DL. </li></ul></ul><ul><li>Should see results in 1-4 treatments, if not referral indicated. </li></ul><ul><li>Tight hamstrings controversy </li></ul><ul><ul><li>Does occur sometimes with LBP as a protective mechanism </li></ul></ul><ul><li>Radicular pain (2 components) </li></ul><ul><ul><li>Mechanical compression </li></ul></ul><ul><ul><li>Inflammation in response to discal material or compression (can affect with treatment) </li></ul></ul><ul><ul><ul><li>Why ice is indicated </li></ul></ul></ul>
  21. 21. Poor CORE = Low Back Pain/Injury <ul><li>Typical presentation with baseball players with LBP </li></ul><ul><ul><li>Hyper/hypomobility of spinal segments </li></ul></ul><ul><ul><ul><li>Typically hand in hand </li></ul></ul></ul><ul><ul><li>Muscle imbalance </li></ul></ul><ul><ul><ul><li>Dominate side over developed as opposed to the non-dominate </li></ul></ul></ul><ul><ul><li>Facet syndrome/Spondo </li></ul></ul><ul><ul><li>Discal </li></ul></ul><ul><li>Treatment varies </li></ul>
  22. 22. Core Stabilization (What is it?) <ul><li>Complex interaction of the neurological and musculoskeletal systems providing coordinated, precisely sequenced muscular contractions to provide stabilization to the lumbar spine. </li></ul><ul><li>Complex but not Rocket Science </li></ul><ul><li>Due to involvement of higher centers (primary motor cortex), training and effect will take a “higher understanding” of all components as well as a tremendous amount of practice. </li></ul><ul><ul><li>Variability of practice: Must be practiced in variety of postures to have maximal carryover. </li></ul></ul>
  23. 23. Why Core Stabilization? <ul><li>Improves postural control </li></ul><ul><li>Ensures appropriate muscular balance and joint arthokinematics around the lumbopelvic-hip complex </li></ul><ul><li>Expression of dynamic functional strength via proper length tension relationships </li></ul><ul><li>Improves neuromuscular efficiency throughout the entire kinetic chain </li></ul><ul><li>Maximal transfer of kinetic energy </li></ul><ul><li>May help to reduce LB injury at times when out of NPP (can not be in 100% of time) </li></ul>
  24. 24. Why Is It Important? <ul><li>Poor stability adds to: </li></ul><ul><ul><li>LBP </li></ul></ul><ul><ul><li>Abnormal force attenuation in LE (pathokinematics) </li></ul></ul><ul><ul><ul><li>Increased risk of LE injuries </li></ul></ul></ul><ul><ul><ul><ul><li>ACL injuries </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ankle injuries </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tendonitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hip bursitis </li></ul></ul></ul></ul><ul><ul><li>Decreased athletic performance </li></ul></ul>
  25. 25. Decreased Performance CORE LEs Pulling on a stable base Poor Stabilization = decreased power
  26. 26. Sport Specific Training of the CORE <ul><li>Similar to that of the activity: </li></ul><ul><ul><li>Same type of contraction </li></ul></ul><ul><ul><ul><li>Eccentric, concentric, isometric </li></ul></ul></ul><ul><ul><li>Same sequence and timing of contractions </li></ul></ul><ul><ul><li>Same aerobic and anaerobic demands </li></ul></ul><ul><ul><li>Same number of joints </li></ul></ul><ul><ul><li>Same base of support </li></ul></ul><ul><ul><li>Same neurological input into the system from proprioceptors, mechanoreceptors, golgi tendon organ </li></ul></ul>
  27. 27. Sport Specific Training of the CORE <ul><li>Integral part of training routine </li></ul><ul><ul><li>Should include isolation exercises for areas of weaknesses </li></ul></ul><ul><ul><ul><li>See Seattle Mariners Core Stabilization Program </li></ul></ul></ul><ul><ul><ul><li>Tried to include exercise progression for all muscles identified in anatomy portion of presentation </li></ul></ul></ul><ul><ul><li>Implemented into all aspects of strength training. </li></ul></ul><ul><ul><ul><li>Examples: Rows in NPP, Squats in NPP, Rows on PB, Trunk rotation on PB. </li></ul></ul></ul>
  28. 28. CORE Basics <ul><li>Dynamic Stretches </li></ul><ul><ul><li>Lunge </li></ul></ul><ul><ul><li>Sumo </li></ul></ul><ul><li>Bilateral Side Bridge </li></ul><ul><li>Side Step </li></ul><ul><li>Monster Walk </li></ul><ul><li>Physioball 6 pack </li></ul>
  29. 29. Dynamic Stretches <ul><li>Dynamic stretches are not ballistic stretches (bouncing) </li></ul><ul><li>Facilitate: </li></ul><ul><ul><li>Increased flexibility via contract –relax methodology </li></ul></ul><ul><ul><li>Increased proprioception/balance via positioning of C of G over SL support </li></ul></ul><ul><ul><li>Increased strength via WB exercises </li></ul></ul><ul><li>Core Basics </li></ul><ul><ul><li>Research based </li></ul></ul><ul><ul><li>Extremely challenging </li></ul></ul><ul><ul><li>Will reduce potential for LBP/improve performance </li></ul></ul>
  30. 30. Dynamic Stretches: Lunge <ul><li>Key points (holding time): </li></ul><ul><ul><li>Lunge Phase </li></ul></ul><ul><ul><ul><li>Knee 90 </li></ul></ul></ul><ul><ul><ul><li>Elbow to arch of foot </li></ul></ul></ul><ul><ul><ul><li>Opposite knee extended </li></ul></ul></ul><ul><ul><ul><li>Stretch to: </li></ul></ul></ul><ul><ul><li>Stride Phase </li></ul></ul><ul><ul><ul><li>Knees Straight </li></ul></ul></ul><ul><ul><ul><li>Back heel to floor </li></ul></ul></ul><ul><ul><ul><li>Hands on each side </li></ul></ul></ul><ul><ul><ul><li>Stretch to: </li></ul></ul></ul><ul><ul><li>Step Through Phase </li></ul></ul><ul><ul><ul><li>All way to Lunge Phase </li></ul></ul></ul><ul><li>1 set of 10-15 reps </li></ul>
  31. 31. Dynamic Stretches: Sumo (Start) <ul><li>Key Points: </li></ul><ul><ul><li>Squat Phase </li></ul></ul><ul><ul><ul><li>Full squat </li></ul></ul></ul><ul><ul><ul><li>Knees behind toes </li></ul></ul></ul><ul><ul><ul><li>Equal weight bearing (no lateral shift) </li></ul></ul></ul><ul><ul><ul><li>Pulling up on toes </li></ul></ul></ul>
  32. 32. Dynamic Stretches: Sumo <ul><li>Key Points: </li></ul><ul><ul><li>Starting in squat position </li></ul></ul><ul><ul><li>Extend knees pulling up on toes </li></ul></ul><ul><ul><ul><li>Hold </li></ul></ul></ul><ul><ul><ul><li>Stretch to hams, lumbar spine, gastroc </li></ul></ul></ul><ul><ul><li>Walk hands out to push-up position </li></ul></ul>
  33. 33. Dynamic Stretches: Sumo <ul><li>Key Points: </li></ul><ul><ul><li>Push up position – lumbar spine in NPP </li></ul></ul><ul><ul><li>Maintain NPP while pushing up </li></ul></ul><ul><ul><li>Toe walk up to hands </li></ul></ul><ul><ul><li>Toe walk facilitates stretch to hamstrings and lumbar spine </li></ul></ul><ul><ul><li>Back to squat position </li></ul></ul><ul><ul><li>Repeat </li></ul></ul><ul><li>1 set of 10-15 reps </li></ul>
  34. 34. Bilateral side Bridge/Plank <ul><li>Side Bridge </li></ul><ul><ul><li>C/L spine in neutral </li></ul></ul><ul><ul><li>Feet together </li></ul></ul><ul><ul><li>Supporting weight on elbow (shld path) </li></ul></ul><ul><ul><li>#1 exercise for obliques </li></ul></ul><ul><ul><li>Start with 3/30 sec </li></ul></ul><ul><li>Plank </li></ul><ul><ul><li>C/L spine in neutral </li></ul></ul><ul><ul><li>Feet together </li></ul></ul><ul><ul><li>Chest up </li></ul></ul><ul><ul><li>#1 exercise for multifidus </li></ul></ul><ul><ul><li>Start with 3/45 sec </li></ul></ul>
  35. 35. Pike <ul><li>Key points </li></ul><ul><ul><li>Arms OH (at side is advanced) </li></ul></ul><ul><ul><li>Knees straight </li></ul></ul><ul><ul><li>Ankle at 90 degrees </li></ul></ul><ul><ul><li>Push hips in air/drive heels towards ceiling </li></ul></ul><ul><ul><li>Trains: abdominals and transverse abdominus </li></ul></ul><ul><ul><li>2-3 sets of 15-25 reps </li></ul></ul>
  36. 36. Side Step <ul><li>Key Points: </li></ul><ul><ul><li>NPP </li></ul></ul><ul><ul><li>Knees behind toes </li></ul></ul><ul><ul><li>Feet pointing straight ahead throughout motion </li></ul></ul><ul><ul><ul><li>Most common compensation </li></ul></ul></ul><ul><ul><li>Out and together </li></ul></ul><ul><ul><li>10 one direction/10 back </li></ul></ul><ul><ul><ul><li>Do not turn around </li></ul></ul></ul><ul><ul><li>2-3 sets </li></ul></ul>
  37. 37. Monster Walk <ul><li>Key Points: </li></ul><ul><ul><li>NPP </li></ul></ul><ul><ul><li>Knees behind toes </li></ul></ul><ul><ul><li>Feet pointing straight ahead throughout motion </li></ul></ul><ul><ul><ul><li>Most common compensation </li></ul></ul></ul><ul><ul><li>Out at 45 w/ R, together, out 45 w/ L </li></ul></ul><ul><ul><li>Remain in a squat position throughout </li></ul></ul><ul><ul><li>2-3 sets of 10-15 reps </li></ul></ul>
  38. 38. Physioball 6 pack <ul><li>Quick points on Physioball </li></ul><ul><ul><li>Ball size </li></ul></ul><ul><ul><ul><li>Too large in this case </li></ul></ul></ul><ul><ul><li>Ball inflation </li></ul></ul><ul><ul><ul><li>Too full in this case </li></ul></ul></ul><ul><ul><li>Ball position </li></ul></ul><ul><ul><ul><li>Positioned too low in this case </li></ul></ul></ul><ul><li>Appropriate size and inflation essential to this exercise </li></ul>
  39. 39. Physioball 6 pack <ul><li>Key Points </li></ul><ul><ul><li>Start with 6 extensions to neutral w/ arms behind head </li></ul></ul><ul><ul><li>Arms straight ahead (superman position),hold 6 seconds </li></ul></ul><ul><ul><li>Arms at 45 degrees, hold 6 seconds </li></ul></ul><ul><ul><li>Arms in abduction, hold 6 seconds </li></ul></ul>
  40. 40. Physioball 6 pack <ul><li>Key Points </li></ul><ul><ul><li>Arms at side with scapular retraction (pinching), hold 6 seconds </li></ul></ul><ul><ul><li>Repeat for 4-6 reps </li></ul></ul><ul><li>Facilitates strength of: </li></ul><ul><ul><li>Multifidus w/ UE movements </li></ul></ul><ul><ul><li>Mm attaching to TFL </li></ul></ul><ul><ul><li>Increases thoracic spinal extensor recruitment </li></ul></ul>
  41. 41. <ul><li>CORE </li></ul><ul><li>What is CORE Stabilization? </li></ul><ul><li>WHY Is It Important? </li></ul><ul><li>Core Basics </li></ul>
  42. 42. Contact Information <ul><li>Trent Nessler, PT, DPT, MPT </li></ul><ul><ul><li>Area Vice President – Champion Sports Medicine/Physiotherapy Associates </li></ul></ul><ul><ul><li>Owner- A.C.L. – Accelerated Conditioning and Learning </li></ul></ul>

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