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Three-Step Approach to Low Back Injuries in Athletes

It probably wouldn't surprise you to know that athletes have a much greater risk of low back injury than the average person. Can you guess which sports have the highest rate of low back injury? If you guessed, women's gymnastics, you would be right. There are two others with equally high rates: men's wrestling and American football.

It's also interesting to note that athletes have a greater number of anatomic abnormalities (seen on MRIs) compared with nonathletes. But since a person's symptoms often don't match the imaging studies, clinicians examining athletes don't rely heavily on this type of diagnostic approach.

Physical therapists have developed a method of examination for patients with low back pain called treatment-based classification. This three-step approach tries to match symptoms with a treatment approach that works best for those symptoms.

The therapist starts by making sure the patient doesn't have a serious underlying pathology causing the low back pain. This process is called screening for referral. Anyone with signs of infection, inflammation, malignancy, or fractures must receive immediate medical attention before physical therapy treatment can begin.

Once the patient has been cleared, conservative (nonoperative) care under the direction of a physical therapist is next. During this second stage, the therapist evaluates the patient in order to decide which treatment approach will work best. As part of the process, the patient fills out several surveys that help identify levels of pain and disability.

The athlete is managed using treatments divided up on the basis of three stages. The goal of treatment is to reduce pain, improve function, speed up recovery, and prevent loss of practice and/or play time. Once the stage has been identified, then special tests are performed that have been found reliable in predicting which type of treatment will have the best outcomes. Let's take a look at the three stages.

Stage I is more acute during the early days following an injury. Usually, this person has difficulty standing, sitting, or walking for very long or very far. Treatment during this stage is often with advice, manual therapy, and specific exercises. The athlete's posture is modified when appropriate. Core training of the trunk and abdominal muscles help stabilize the lumbar spine.

Stage II describes the patient who can stand, sit, and walk but has trouble with basic daily skills (e.g., vacuuming, lifting, jogging, driving). Stage III means the patient can manage daily activities but isn't able to participate in sports. Stage III is more of the chronic phase where patients experience recurrence of their low back pain that can be very limiting.

Treatment approaches for these two groups are still under investigation. Though the therapist has many treatment techniques available, predicting which one (or combination of techniques) will yield the best result remains unknown. Some of the treatment intervention will address pain while others focus on flexibility, strength, posture, and aerobic capacity. Endurance and neuromuscular control are also targeted in the more advanced levels of training (stage III).

Athletes in stage III are ready for sports-specific exercises. This approach is called functional training. It moves the athlete from limited practice time back to full participation in the sport of their choice. One of the long-term goals of treatment using this approach is to prevent future episodes of repeated back injury/pain.

In summary, physical therapists are busy researching, studying, and developing an evidence-based approach to low back pain in the athlete. Rather than applying treatment willy-nilly, they carefully examine each patient using a three-step classification-based approach. Staging the athlete (stage I, II, or III) based on level of pain, disability, and function helps direct treatment. This treatment-based classification yields a rapid return to the playing field and that's the ultimate goal of every injured athlete.

Scott A. Burns, PT, DPT, OCS, FAAOMPT, et al. A Treatment-Based Classification Approach to Examination and Intervention of Lumbar Disorders. In Sports Health. July/August 2011. Vol. 3. No. 4. Pp. 362-372.


*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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