Baseball and Low Back Pain: “Prevention is Performance Enhancement”

Trent Nessler, PT, DPT, MPT

The Reality of Statistics

• 80% of the population suffer from one form or another of LBP– Of those, 65%-85% have a

recurrence of LBP within 2 years– What is the implication?

• LBP accounts for 14.3% of new patient visits to their MD

The Reality of Statistics• Considered the 2nd to 5th most common reason to

seek medical attention• Health care cost approaching the 100 billion dollar

mark• Number one cause of work related disability.• Now the main cause of disability of individuals

under the age of 44• LBP in Sports

– Now become the 3rd most common injury in baseball

– Spondo accounting for large percentage of• With what?

The Reality of Statistics

• Common course of treatment dependent on??– Onset of care– Radicular vs. non-radicular– Age/physical status

• According to insurance industry statistics – LBP Non-radicular – 6-10 treatments– LBP Radicular – 12-15 treatments

Objectives• Understand normal biomechanical loading

of the lumbar spine.• Appreciate biomechanical loading

variations of the lumbar spine with varying postures.

• Appreciation of posturing on biomechanical loading of the lumbar spine with weight training.

• Understand NPP (Neutral Pelvic Positioning) and the importance to loading lumbar spine.

Objectives• Appreciation for the depth of lumbar/core

anatomy as relates to lumbar stabilization.• Clinical understanding of the importance to

anatomy and carry over to training and treatment programs.

• Appreciation for the importance of proper stabilization as relates to athletic performance.

Loading of the Lumbar Spine• Education - essential component of “well

structured” stabilization program.• Loading of the Lumbar Spine:

– 80% bone-disc-bone interface– 20% facets

• Disc serves as the shock absorber, properties allow to absorb large amount of force– Nucleus pulposus– Annulus fibrosis – dries out and fissures with

age

• Refer to diagram

Loading of the Lumbar Spine

Bone – disc – bone

80%

20%

Flexion vs. Extension Loading

• Abnormal posture increases pressure to the spine.– Flexion – increased pressure to the bone-disc-bone

interface, >80% load bearing• Increases interdiscal pressures• Potential increase s/s with disc pathology

– Extension – increases pressure to the facets, > 20% load bearing

• Can increase pressure on nerve at the intervertebral foramen • In these cases, nerve root irritation or facet sydrome/spondo,

avoid extension.

• Both flexion and extension posturing results in abnormal loading of the lumbar spine.

Loading of the Lumbar Spine80%

20%Flex Ext

Loading of the Lumbar Spine: Pressure Changes with Posture• Disc pressure change w/ posture

– Lying 50% BW, standing 100% BW, sitting 150% BW, forward bending ~160% BW and sitting with flexion ~200% BW.

– Why athlete reports less pain with lying, more with standing and even more with sitting

– Weight lifting take home - importance of proper lifting technique (rows, modified dead lifts, squats)

Loading of the Lumbar Spine: Pressure Changes With Lifting• Lifting loads – lever arm from spine

– Diagram indicates 200 N load and pressures on lumbar spine with various postures.

• Drives home the importance of proper lifting technique with:– Modified deadlifts, lifting of

dumbells/plates, est.

Proper Lifting (200N Load)

200 N

Improper Lifting (200N Load)

500 N

NPP: Neutral Pelvic Positioning

• What is it: Position of the spine in which you load the spine at it’s biomechanical advantage.– Different for everyone.– Exercise in the manual: lying, sitting

and standing.– Loads the spine in the 80/20

relationship.– Requires local (transverse abdominus,

mutifidus, est.) and global (Gluts, quads, rhom, est.) muscles.

NPP: Neutral Pelvic Positioning

• Difficult to learn and even more difficult to maintain during exercise and athletic activity.– Retraining of the spinal proprioceptors, muscle

spindles, and golgi tendon organs.– Involves retraining of the spinal, LE and abdominal

muscles to maintain correct spinal position.

• NPP should be maintained with all forms of training– Examples: squats, rows, bent over rows, and core

stabilization exercises.– Should have higher carryover to athletic performance.

Anatomy of the Lumbar Spine

• Various authors indicate varying anatomical contributions to the support of the lumbar spine.

• Material here from DeRosa and Porterfield: Lumbar Spine Video Series

CORE

What is CORE Stabilization?

WHY Is It Important?

Anatomy of the “CORE”• Handout on anatomy of the lumbar spine

and clinical significance.• Drawing of the anatomical correlations:

– 1. Thoracolumbar Fascia– 2. Latissimus Dorsi– 3. Internal Obliques– 4. Gluteus Maximus– 5. Gluteus Medius– 6 & 7. LE musculature and fascia

• Decreased performance and pain result when there is an imbalance and/or asymmetrical loading in the system

Poor CORE = Low Back Pain/Injury• Treatment

– Sooner the treatment implemented, less days on DL.

• Should see results in 1-4 treatments, if not referral indicated.

• Tight hamstrings controversy– Does occur sometimes with LBP as a protective

mechanism

• Radicular pain (2 components)– Mechanical compression– Inflammation in response to discal material or

compression (can affect with treatment)• Why ice is indicated

Poor CORE = Low Back Pain/Injury• Typical presentation with baseball

players with LBP– Hyper/hypomobility of spinal segments

• Typically hand in hand

– Muscle imbalance• Dominate side over developed as opposed to

the non-dominate

– Facet syndrome/Spondo– Discal

• Treatment varies

Core Stabilization (What is it?)• Complex interaction of the neurological and

musculoskeletal systems providing coordinated, precisely sequenced muscular contractions to provide stabilization to the lumbar spine.

• Complex but not Rocket Science• 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.– Variability of practice: Must be practiced in

variety of postures to have maximal carryover.

Why Core Stabilization?• Improves postural control• Ensures appropriate muscular balance and

joint arthokinematics around the lumbopelvic-hip complex

• Expression of dynamic functional strength via proper length tension relationships

• Improves neuromuscular efficiency throughout the entire kinetic chain

• Maximal transfer of kinetic energy• May help to reduce LB injury at times when

out of NPP (can not be in 100% of time)

Why Is It Important?

Poor stability adds to:1. LBP

2. Abnormal force attenuation in LE (pathokinematics)

I. Increased risk of LE injuriesa. ACL injuries

b. Ankle injuries

c. Tendonitis

d. Hip bursitis

3. Decreased athletic performance

Decreased Performance

CORE LEs

Pulling on a stable base

Poor Stabilization = decreased power

Sport Specific Training of the CORE

Similar to that of the activity:– Same type of contraction

• Eccentric, concentric, isometric

– Same sequence and timing of contractions– Same aerobic and anaerobic demands– Same number of joints– Same base of support– Same neurological input into the system from

proprioceptors, mechanoreceptors, golgi tendon organ

Sport Specific Training of the CORE

• Integral part of training routine– Should include isolation exercises for areas of

weaknesses• See Seattle Mariners Core Stabilization Program• Tried to include exercise progression for all muscles

identified in anatomy portion of presentation

– Implemented into all aspects of strength training.

• Examples: Rows in NPP, Squats in NPP, Rows on PB, Trunk rotation on PB.

CORE Basics

• Dynamic Stretches– Lunge– Sumo

• Bilateral Side Bridge

• Side Step

• Monster Walk

• Physioball 6 pack

Dynamic Stretches• Dynamic stretches are not ballistic

stretches (bouncing)• Facilitate:

– Increased flexibility via contract –relax methodology

– Increased proprioception/balance via positioning of C of G over SL support

– Increased strength via WB exercises

• Core Basics – Research based– Extremely challenging– Will reduce potential for LBP/improve

performance

Dynamic Stretches: Lunge•Key points (holding time):

–Lunge Phase•Knee 90

•Elbow to arch of foot

•Opposite knee extended

•Stretch to:

–Stride Phase•Knees Straight

•Back heel to floor

•Hands on each side

•Stretch to:

–Step Through Phase•All way to Lunge Phase

•1 set of 10-15 reps

Dynamic Stretches: Sumo (Start)•Key Points:

–Squat Phase•Full squat•Knees behind toes•Equal weight bearing (no lateral shift)•Pulling up on toes

Dynamic Stretches: Sumo•Key Points:

–Starting in squat position–Extend knees pulling up on toes

•Hold•Stretch to hams, lumbar spine, gastroc

–Walk hands out to push-up position

Dynamic Stretches: Sumo•Key Points:

–Push up position – lumbar spine in NPP–Maintain NPP while pushing up–Toe walk up to hands–Toe walk facilitates stretch to hamstrings and lumbar spine–Back to squat position–Repeat

•1 set of 10-15 reps

Bilateral side Bridge/Plank•Side Bridge

–C/L spine in neutral–Feet together–Supporting weight on elbow (shld path)–#1 exercise for obliques–Start with 3/30 sec

•Plank–C/L spine in neutral–Feet together–Chest up–#1 exercise for multifidus–Start with 3/45 sec

Pike•Key points

–Arms OH (at side is advanced)–Knees straight–Ankle at 90 degrees–Push hips in air/drive heels towards ceiling–Trains: abdominals and transverse abdominus–2-3 sets of 15-25 reps

Side Step•Key Points:

–NPP–Knees behind toes–Feet pointing straight ahead throughout motion

•Most common compensation

–Out and together–10 one direction/10 back

•Do not turn around

–2-3 sets

Monster Walk•Key Points:

–NPP–Knees behind toes–Feet pointing straight ahead throughout motion

•Most common compensation

–Out at 45 w/ R, together, out 45 w/ L–Remain in a squat position throughout–2-3 sets of 10-15 reps

Physioball 6 pack•Quick points on Physioball

–Ball size •Too large in this case

–Ball inflation•Too full in this case

–Ball position•Positioned too low in this case

•Appropriate size and inflation essential to this exercise

Physioball 6 pack•Key Points

–Start with 6 extensions to neutral w/ arms behind head–Arms straight ahead (superman position),hold 6 seconds–Arms at 45 degrees, hold 6 seconds–Arms in abduction, hold 6 seconds

Physioball 6 pack•Key Points

–Arms at side with scapular retraction (pinching), hold 6 seconds–Repeat for 4-6 reps

•Facilitates strength of:

–Multifidus w/ UE movements–Mm attaching to TFL–Increases thoracic spinal extensor recruitment

CORE

What is CORE Stabilization?

WHY Is It Important?

Core Basics

Contact InformationTrent Nessler, PT, DPT, MPT

Area Vice President – Champion Sports Medicine/Physiotherapy Associates

Owner- A.C.L. – Accelerated Conditioning and Learning