September 2010:   Flexibility work on hip flexors, HS, Gluteals, Hip Rotators, LB   Initiated resisted rotational movements provided pt correctly

performed & maintained TrA contraction   Exercises initiated NWB then progressed to WB seated

standing   Initiated seated & standing w/isometrics progressed to CONC/

ECC work

Rotational Based Rehabilitation of a Lumbar Disc Herniation in a Collegiate Football Player: A Case Report Lazenby T, Devins K, (2011). Athletic Training Education Program Department of Exercise and Sport Sciences

Background:   19 y. o., Div III collegiate football DE injured his low back

during off-season lifting program: performing max effort squat & hang clean   Awoke next morning c/o pinching & needle-like pain in LB & R

gluteal region   Pain progressed to radicular pain shooting down R leg into foot

& great toe   Did not report or seek treatment as it was the end of spring

semester & player thought pain would go away   Pt returned home for the summer and noted intermittent

symptoms until end of June   Pain worsened; became constant & debilitating

  July 2010:   Pt received PT & Chiropractic care with no relief   Consultation with Spine Orthopedist

  X-rays (-), MRI (+) for L4-5 R posterolateral disc herniation   Microdiscectomy performed 7/31/10

Uniqueness:  Use of a rotational based exercise program provided multiple

benefits for the various tissues during the healing process. The program addresses disc (annular & nuclear), neurological, & muscular & affords a more functional rehabilitation process.

Conclusions:  Use of rotational exercises provided stimulation for annular healing as well as, early facilitation of TrA & LM musculature

References: Grimsby O. S.T.E.P. (Scientific Therapeutic Exercise Progressions). The Oloa Grimsby Institute;1998

Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Churchill Livingston; 2000

Mulligan, B. R. (2004). The Lumbar Spine. In Manual Therapy: "NAGS", "SNAGS", "MWMS" etc. (5th ed., pp. 42-53). Wellington, New Zealand: Plane View Services Ltd. (Original work published 1989)

Lumbar Spine Stabilizing Structures:

Outcome:   Little to no aggravation noted with rotational protocol   Player was ready to return to full activity in November, if not

redshirted for season   Participated in offseason conditioning program and

recreational sports without incident

Case Management:   Initial Management:

  Physician ordered no rehab beyond walking until 6wks post op

  Pt reported to campus 4wks post op   Initiated postural education, sidelying

NME’s, TrA and LM isometric contractions   Performed pain-free crunches w/TrA

contractions & NWB rotational movements (caudal to cranial direction)

  Modality Tx:   Hivamat 200, STM, light stretching, IFC

& ice per symptoms

Lumbar Multifidus

  Transversus Abdominis (TrA):   Deepest abdominal muscle  Runs from thoracolumbarfFascia (TLF), iliac crest, inguinal ligament to the aponeurosis between the pubis & linea alba

  Comprised primarily of Type I mm fibers  Function relating to stabilization:

 Increases intrabdominal pressure (IAP) & TLF tension

  Aids in increasing spinal stiffness & intersegmental control

 Lumbar Multifidus (LM):  Comprised of 5 bands

  Originating on spinous processes & laminae  Inserting on mamillary process of vertebra 2 segments caudad & L5 fibers to the sacrum

 Comprised primarily of Type I mm fibers  Function:

 Control orientation of lumbar spine  Support & control rotation &/or translation of lumbar segments

Transversus Abdominis

  Annulus Fibrosis:   Lamallae comprised of Type I collagen

 Fibers are grouped into lamellae w/layers oriented at varying angles (30°-60°)

 Imbibition & lamellae heal best with tension provided in the line of stress (rotation)

  Provides structure, tensile strength, wt distribution, & spacing for nerve roots

Lumbar Disc Anatomy:

  Nucleus Pulposus Changes   As the disc dehydrates the change in pressure leads to:

  Reduced swelling pressure of the nucleus  Decreased ability of nucleus to distribute forces evenly

circumferentially to inner lamallae; keeping them bulging outward   Inner lamellae layers sag inwards while outer layers sag

outwards delamination occurs bulging &/or herniation

Palpation of LM contraction

Supine Rotations

Seated Rotations Standing Rotations

Annular Fibrosis Lamellae Orientation

Normal Disc Dehydrated Disc

  October - November 2010:   Continued w/ flexibility work, seated NME’s   Progressed rotational movements to

incorporate flexion/extension   Increased resistance as tolerated   Initiated jogging running per symptoms

agility drills   Emphasized importance of proper mechanics &

TrA initiation with all strengthening work   Utilized Mulligan Sustained Natural Apophyseal

Glides (SNAGs) throughout as symptoms indicated   Provide a sustained superior glide to the

superior segment (articular facet) while patient moves through offending range

  Functional technique, as the segment is bearing weight

  Can be performed seated or standing   Motion must be pain-free for technique to be

successful   Instructed in core maintenance program to be

performed 3-4x/wk

Combined Flex/Rotation

SNAGs Performed in a Sitting Position