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Δρ. ΜαλλιαρόπουλοςΙατρός - Αθλητίατρος MD, Msc & Dipl in SEM QMUL, Phd, F.FSEM (UK)

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Guidelines for low back pain management in athletes

Guidelines for low back pain management in athletes

Dalius Barkauskas

Chief doctor Lithuanian olympic team

Causes of low back painGeneral illnesses

•        Referred pain from internal organs

•        Pathological conditions of the spine and nervous system

•        Muscular pathology

•        Other structural faults

•        Psichogenic causes

•        Somatic dysfunction

Levels of injury and dysfunction

Local

•        Muscle-fascia, TrP, FFS, GTO

•        Tendons

•        Ligaments

•        Capsule

•        Cartilage

Central

•        Body weight distribution

•        Movement paterns

•        Nerve dysfunction

Reflexive

“Parasitic” muscle function

Mainfeatures of locomotor system
(as a rule in chronic lesions)

•        Often sight of lesion not where the pain is

•        No objective signs

•        No direct correlation between the morphological and functional changes

Mechanical dysfunction always leads to muscular weakness

All the structural problems always have metabolic component involved (“slow” and “quick” responders)

Diagnosis of acute low back pain:

•        When diagnosing look for bony signs, articular signs, dural

            signs, root signs (mobility, conduction)

•        Undertake diagnostic triage at the first assessment to

            exclude red flag conditions and radicular syndrome (beware of S4)

•        Be aware of psychosocial factors, and review them in detail if there is no improvement

•        Diagnostic imaging tests (including X-rays, CT and MRI) are not routinely indicated for non-specific low back pain

Red flags

•        Symptoms from 2 nerve roots in neck area

•        More than 2 nerve roots in lumbar spine

•        Lumbago, incontinency, paraesthesia

•        Upper lumbar pain syndrome

•        Lateral deviation with lumbar spine in extension

•        Full articular pattern in patient younger than 45

•        Spinal cord compression clinical signs

Treatment strategy

•        soft” story-traction

•        “hard” story-manipulation

Predisposing factors

•        Poor sitting posture

•        Loss of lumbar extension

•        Frequency of flexion

Parts of functional examination

•        Posture sitting and standing

•        Simple movement

•        Neurological screening

•        Muscle tests

•        Examination of short muscles, fasciae

•        Examination of hipermobility, motion palpation

•        Gait

Why functional evaluation?

•        Nervous control is based largely on reflex action

•         localized painful stimulation will act in the segment to which structure belongs (HZ in the skin, muscle spasm, periosteal points, movement restriction of the spinal segment and (perhaps) some dysfunction of a visceral organ)

•        Painful afferents causes both somatic and autonomic responses (pain is also a stress factor)

•        Disturbance of function appears much earlier than morphological changes

•        We need precise information about where, how and why apply one or other method

•        We need the feedback info from the body

Main morphological findings

•        Spondiloarthrosis

•        Spondilosis

•        Osteochondrosis

•        Spondilolysis

•        Spondilolisthesis

•        Disc herniation

Scientific data

            Gresham&Miller post mortem study

•        L3/L4/L5 in age group of 35-45 years degenerative changes in 75 %., cases

•        Above  45 years old L4 degenerative changes in 75 % of cases and L5 100 % of cases

            MRI

•        30 proc.,false positive result, 13 proc., false negativeresult

            Deyo, 1992

•        20 proc., middle age americans haveasymptomatic disc herniation

The main contributing sports injury factors

Main

•        Poor training techniques

•        Specialization at an early age

•        Poor initial health status of participating individuals

Additional

•        Inadequate functional evaluation

•        Lack of proper general/basic conditioning

•        Static overload and rythm of modern lifestyle

Treatment techniques

Two basic techniques have turned out to be most effective for local stabilisers activation:

•        Sensomotory stimulation according to Janda,

•         Reflex locomotor patterns according to Vojta.

•        Treatment of the m. diafragma

Treatment of muscular disbalance

•        Activation of a muscle containing the trigger point leads to worsening of the inner imbalance in the muscle and increase the pathologic proprioceptive outputs. The persistence of a blockage in a critical segment (e.g. sacroiliac joint, joints of the foot etc.) is the cause of  uncorrect proprioceptive information, influences the activity of some muscles in a less or more known pattern. The sum of pathological proprioception will lead to changes in the software in the spinal cord segment and is the source of pathological information for the central nervous system circuits.

•         the preliminary phase must comprise the analysis of peripheral changes in muscles and joints. Relaxation of trigger points, stretching of shortened muscles, strenghtening of weakened muscles, mobilization of  joint blockages are the sine-qua-non parts of a rational treatment. Another inevitable part of any good treatment of a chronic low back pain patient are the myofascial release techniques. Any shortening of fascias will lead to inefficacy of our procedures.

•        PNF techniques

Conclusion

•        K. Lewit said that functional pathology of the motor system is routinely overlooked. Main reason for the treatment failure- insufficient functional evaluation

•        Poor motor control by synergist substitution, slow reaction time of muscles, inadequate agonist-antagonist co-activation goes together with decreased joint stability.

•        Treatment of muscular imbalance is of paramount importance. Special attention to movement pattern changes. If movement pattern is faulty-rule of thumb to initiate rehabilitation is stretch before strengthening.

•        Modification of the conditioning exercises by individual needs

•        Use imaging for differencial diagnosis purposes only

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