ABSTRACT Conservative non-surgical management of a herniated lumbar intervertebral disc (HLD) in athletes is a complex task due to the dramatic forces imparted on the spine during sport participation. The demands placed upon the athlete during rehabilitation and return to sport are unique not only from a sport specific perspective, but also regarding return to the sport strength and conditioning programs utilized for sport preparation. Many prescriptions fail to address postural and motor control faults specific to athletic development, which may prevent full return to sport after suffering a HLD or predispose the athlete to future exacerbations of a HLD. Strength exercises involving squatting, deadlifting, and Olympic power lifts are large components of the typical athlete’s conditioning program, therefore some progressions are provided to address potential underlying problems in the athlete’s technique that may have contributed to their HLD in the first place. The purpose of this clinical commentary is to propose a framework for rehabilitation that is built around the phases of healing of the disc. Phase I: Non-Rotational/Non-Flexion Phase (Acute Inflammatory Phase), Phase II: Counter rotation/Flexion Phase (Repair Phase), Phase III: Rotational Phase/Power development (Remodeling Phase), and Phase IV: Full return to sport. This clinical commentary provides a theoretical basis for these phases based on available literature as well as reviewing many popular current practice trends in the management of an HLD. The authors recognize the limits of any general exercise rehabilitation recommendation with regard to return to sport, as well as any general strength and conditioning program. It is vital that an individual assessment and prescription is made for every athlete which reviews and addresses movement in all planes of motion under all necessary extrinsic and intrinsic demands to that athlete. Key Words: Athletes, herniated lumbar disc, rehabilitation Level of Evidence: 5
INTRODUCTION Conservative non-surgical management of a herniated lumbar intervertebral disc (HLD) in an athlete is a complex task due to the dramatic forces imparted on the spine during sport participation.1 The role of exercise prescription and manual interventions in the treatment of an HLD has evolved based on increased understanding of the injury and biomechanical healing properties of the intervertebral disc. To the best knowledge of the authors, no suggestion for phased HLD rehabilitation protocol for use with athletes has previously been published. The demands placed upon the athlete during rehabilitation and return to sport are unique not only from a sport specific perspective, but also regarding return to the sport strength and conditioning programs utilized for sport preparation. Traditionally, exercise prescription from a rehabilitation point of view may miss the opportunity to address readiness for both return to the strength and conditioning program, and the sport itself. Many prescriptions fail to address postural and motor control faults specific to athletic development, which in turn may prevent full return to sport after suffering a HLD or predispose the athlete for future exacerbations of a HLD.
The purpose of this clinical commentary is to propose a framework for rehabilitation that is built around the phases of healing of the disc. Within this framework the authors will propose and review some common, as well as relatively uncommon exercises, which fit within each of the phases of healing. These exercises selections are based on their ability to be integrated and progressed into the high level demands of many athletes’ sports as well as their strength and conditioning programs. Strength exercises involving heavy squatting, deadlifting, and Olympic power lifts are large components of the typical athlete’s conditioning program, therefore the authors will provide some suggested progressions to address potential underlying problems in the athlete’s technique that may have contributed to their HLD in the first place. By no means is the intent of this framework intended to be a “cookbook”. No textbook or commentary will ever substitute for clinical reasoning. With this taken into consideration, we ultimately leave exercise selection, progression, and regression in the hands of the individual clinician,
based on clinical experience and athlete response. The authors want to recognize the limits of any general exercise rehabilitation recommendation with regard to return to sport, as well as any strength and conditioning program. The exercises suggested in this protocol are, at best, suited for the return to strength and conditioning phase that occurs prior to return to sport. It is vital that an individual assessment and prescription is made for every athlete which reviews and addresses movement in all planes of motion under all necessary extrinsic and intrinsic demands to that athlete. This careful assessment may identify and help address potential problems in movements, which may have contributed, to their injury. Although not well described in the published literature, the authors have found clinical value in the assessment processes developed by the Gray Institute for Functional Applied Science.2 This clinical commentary is divided into two parts. The first presents an overview of and rationale for the phasing of the protocol. The second part is an extended appendix describing individual exercises that could be utilized within each phase and the evidence that was used in determining their selection.
ANATOMY Examination procedures and therapeutic interventions for pathologies of the lumbar spine are incredibly diverse; however, scientific foundations in anatomy and biomechanics should guide these procedures. Fundamental to the understanding of intervention for a multitude of low back pathologies is the understanding of the anatomy of the intervertebral disc and vertebral endplates of the lumbar vertebral bodies. Although a thorough discussion of anatomy and biomechanics of the lumbar spine is beyond the intent of this clinical commentary, a short refresher is important. Lumbar spine anatomy has been described comprehensively by a number of authors.3-5 Thorough descriptions and depictions of anatomical relationships that exist in the lumbar spine can be accessed in textbooks such as Gray’s Anatomy,6 and the authors defer those detailed anatomical descriptions to other sources. Instead, the intent of the current review is to describe relevant anatomy from a clinical perspective. It is important that the reader be able to apply fundamental anatomic and biomechanical information to the selection of any intervention for the lumbar spine. A brief overview of the intervertebral disc and body articulations will be presented in order to provide a basis for the premise of healing of the HLD.
