The following article is a true account of an acute lower back pain patient. His name has been changed to Mike for purposes of confidentiality.
When Mike first walked into the clinic he looked like the leaning Tower of Piza. He had developed acute lower back pain which had dramatically worsened over the previous three or four days.
His spine was very crooked with a marked deviation to the right hand side. The pain was localised to the lower back radiating out to both sides.
There was no obvious cause for this acute onset, although he had suffered numerous episodes of this type of pain in the past. Following a detailed assessment Mike was diagnosed as having a deranged disc. The disc is the connective tissue between each vertebra with a fluid nucleus in the centre – see figure 1- in a derangement a bulge is created toward the back of the disc placing pressure on neighbouring soft tissues which results in severe pain. This process is accompanied with severe muscle spasm as a response to protect the disc from further injury.
Figure 1. Frank Netter – Human Atlas
During flexion movements the lumbar vertbrae are compressed at the front resulting in a backward or posterior migration of the nucleus within the disc. This posterior movement creates tension on the annulus which can weaken and eventually breakdown (see figure 2). This is often caused by excessive loading in flexion in activities such as heavy lifting or sitting with poor alignment.
Figure 2. The Lumbar Spine Mechanical Diagnosis and Therapy,R.A.McKenzie
Radial fissure Annular Bulge Nuclear Protrusion
Previous episodes in Mikes history indicate a weakening of the outer rings of connective tissue that surrounds the disc (the annulus) which may predispose Mike to future problems in the same region.
Mike was initially treated with soft tissue massage and spinal mobilisations to aid in the repair and resolution of the disc bulge. Once the acute pain settled it was decided that a stability programme should commence to reduce the chance of a recurrence of the same injury – these acute onsets were beginning to become too regular for Mike’s liking.
The aim of the stability programme was to strengthen the muscles around the offending vertebral level so that once the injury had resolved the muscles would control the spinal segment to reduce the shear forces on the disc. These exercises were designed to address the instability during the various planes of movement that were effecting Mike’s lumbar spine.
We identified that getting in and out of a car was particularly uncomfortable for Mike – as this movement involves flexion and rotation we knew that emphasis had to be placed on these planes of movement to restore control in the lumbar spine.
The majority of exercises were performed on a Swiss Ball. The Swiss Ball provides an ideal environment to retrain the stability muscles in the back through all planes of movement:
- Rotational Movements in the Transverse Plane
- Side Flexion Movements in the Frontal Plane
- Flexion and Extension Movements in the Sagittal Plane
The Swiss Ball exercises were as follows
- Swiss Ball Lower Abdominal Control
- Mike was taught how to contract his transversus abdominus muscles and maintained this contraction while flexing and extending his knee to move the Swiss Ball in and out.
- This was repeated 6 times on each leg for 3 sets.
- This exercise facilitates control in the sagittal plane.
- Swiss Ball Rotations
- The lower legs are supported on the ball. The legs are rolled half way to the floor and held for 5 seconds.
- This is repeated to each side.
- This exercise facilitates control in the transverse plane.
- Swiss Ball Extensions
- Mike was instructed to maintain his balance while extending his lumbar spine upward on the Swiss Ball. Care was taken to only reach spinal neutral at the end of the upward phase – note that the head and neck also maintain a neutral spine.
- This exercise was performed for 3 sets of 12 reps.
- This exercise facilitates control in the sagittal plane.
- Swiss Ball Lateral Rolls
- This exercise can be progressed by moving further laterally on the ball ,in the early stages Mike only needed a slight lateral movement to test his stabilisers – it is vital that the pelvis and upper trunk remain parallel with the floor at the extent of each direction.
- This exercise was also performed for 3 sets of 6 reps to each side.
- This exercise facilitates control mainly in the transverse plane.
- These exercises were performed once daily in the sub acute stage of Mike’s recovery.
His symptoms were constantly monitored to detect any degree of irritation in the disc or the surrounding tissues. An exercise regime for this type of injury needs to be performed under the guidance of a qualified Physiotherapist.
Following improved stability and a reduction in his symptoms Mike was then introduced to a functional strengthening regime involving cables and free weights. (This will be covered in further articles.)
THE HAPPY ENDING
During his rehabilitation Mike had been instructed to undergo an MRI (a scan which details the soft tissues and bone) to investigate the extent of the disc damage. The results showed a significant bulge in the L5-S1 disc. Based on the scan Mike was recommended for surgery. However due to the improvement following the stability programme , Mike was able to avoid going under the surgeon’s knife.
Stability training is becoming a very effective and popular means of managing many musculo-skeletal problems. Under correct supervision these exercises have been proven to significantly reduce pain and restore function. Mike’s case is an example of the use of the Swiss Ball which in this case managed to alleviate the pressure on the offending tissues .
Mike now enjoys soccer on the weekends although I am sure he doesn’t stray far away from his Swiss Ball.