REHABILITATION OF THE SPORTING BACK

Runners can use low impact devices ie. the ‘Free Runner’ (made by Stairmaster) or the Cross Trainer (made by Life Fitness) to reduce low back pain and impact whilst maintaining sports specific fitness levels. Gyms do not universally provide the Free Runner but Cross Trainers do seem to be available in most establishments.

are almost non-existent. There is evidence that a general exercise programme can be effective in chronic low back pain (11,12). And more recently, specific programmes concentrating on deep sta- bilisers have shown promising results (8).

Psychology There is plenty in the literature on chronic low back pain that sug- gests that cognitive behavioural techniques are a fundamental part of rehabilitation when combined with an effective exercise programme (5). Athletes often need assistance with coping strategies in an enforced lay-off from competition. The distress and depression caused by this may be a contributing factor to the maintenance of low back pain.

Sclerosant injections/prolotherapy Sclerosant injections (also known as prolotherapy or glucose injections) are often a useful adjunct in treatment of chronic or relapsing low back pain in the athlete as well as in the normal population.The solution commonly used is composed of glycerol (30%) anhydrous glucose (25%), phenol (2%), methylene blue

3. Mobilise (physio, osteopathy, chiropractic) 4. Stabilise (core stability and sclerosant injection) 5. Customise (sports specific exercise programmes)

Concurrent use of these active and passive modalities is funda- mental in effective management of sports related low back pain. All practitioners should become familiar with these approaches to optimise their proficiency and effectiveness in treating the spine in sports.

Simon Petrides is a sports and musculoskeletal physician who originally trained in medicine, osteopathy and sports medicine. He is director of the Blackberry Sports and Orthopaedic Clinic in Milton Keynes and is currently advising on the first Marathon- de-Sable team to compete in ‘costume’ for ‘Save The Rhino’.

Resources ● Polestar offers courses in several aspects of Pilates-based

rehabilitation using mat work and equipment info@polestareducation.co.uk

● British Institute of Musculoskeletal Medicine offer modular training in spinal injections and low back pain treatment bimm@compuserve.com ● www.wobble-boards.com

References 1. Panjabi M. et al. Spinal stability and intersegmental muscle forces. Spine 1989;14:194-199

Figure 9 Figure 10

(0.001%) and water. This is injected with an equal volume of local anaesthetic. The solution is injected into thirteen separate sites of ligament attachment at the ligamento-periosteal junction around the L4/5 and L5/S1 segments (ilio-lumbar ligament, posterior sacroiliac ligament and interosseus ligaments), along with the sacroiliac joints. The osmotic insult produces a fibroproliferative response within the ligamento-periosteal attachment.

The ligaments injected are mainly the supraspinous, facet joint capsulo-ligamentous apparatus, the ilio-lumbar ligaments and the posterior sacroiliac ligaments. These are reached from a skin punc- ture in the interspace between L4/5 and L5/S1 (13) (Figs.9&10).

The injection is made on three separate occasions and full assess- ment is made six weeks after the last injection. It would be expected that the athlete would be following an intense sports specific dynamic stabilisation programme while the injections are taking place.

Summary It is fundamental to consider using ‘a simultaneous multi-modal’ approach in sports related low back pain rehabilitation. 1. Analyse (techniques, training, coping strategies etc) 2. Therapise (anti inflammatory and pain relieving measures)

16 SportEX

2. Hides J, Stokes M, Saide M, Jull G, Cooper D. Evidence of lumbar mul- tifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994;19:165-172

3. Hodges P, Richardson C. Inefficient muscular stabilisation of the lum- bar spine associated with low back pain: A motor control evaluation of transversus abdominis. Spine 1996;21:2640-2650

4. CSAG Report 1994. Clinical Standards Advisory Group 1994 & RCGP Guidelines

5. Nachemson & Jonsson. Neck and Back Pain. The Scientific Evidence of Causes, Diagnosis and Treatment. Lippincott-Williams & Wilkins. ISBN 07817-2760-X

6. Coomes EN. A comparison between epidural anaesthesia and best rest in sciatica. BMJ 1961;264:20-24

7. Ongley M et al. A new approach for the treatment of chronic low back pain. Lancet 1987;143

8. O’Sullivan, Twomey et al. Evaluation of specific stabilising exercise in treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22(24)2959-2967

9. Malmivaara et. al. The treatment of acute low back pain - bed rest, exercise or ordinary activity? New England Journal of Medicine 1995;332:351-355

10. Faas A et al. A randomised placebo - controlled trial of exercise ther- apy with acute lower back pain. Spine 1993;18:1388-1395

11. Frost et al. Fitness programme for patients with chronic low back pain. BMJ 1995;310: 151-154

12. Frost et al. 2 year follow up. Pain 1998;75:273-279 13. Ligament and Tendon Relaxation Treated by Prolotherapy. G. Hackett M.D. library of congress catalogue Card no.57-13257. Oak Park, Illinois,USA

14. Lieu et al; An in-situ study of sclerosing solution in rabbit medial collateral ligaments. Connective Tissue Research 1983;11:95-102

15. Klein RG et al. A randomised double-blind trial of dextrose, glycerine, phenol injection for chronic low back pain. Journal of Spinal Disorders 6(1):23

TIP