Bridging The

Gap between Rehab and Performance: Building A System of

Communication for Clients with Lower Back Pain

Michael Ashton
PT, DPT, ATC, CSCS, CES, XPS, CIDN,
COMT, FAAOMPT

Objectives
Explain the importance of communication between
rehab specialists and fitness professionals
Identify potential barriers to optimal communication
between the rehab specialist and fitness professional
Employ strategies to eliminate communication barriers
between the rehab specialist and fitness professional
Explain lower back pain, symptoms, and popular
mechanisms of injury as it relates to Activities of Daily
Living and performance training on a basic level
Show an example of a simple system that bridges the
gap through open communication, transparency in
documentation and decision-making processes

Importance of Communication
Communication can be defined as the process of
understanding and sharing meaning
central to your self-concept
Help you to understand others
Influences how you learn
Communication represents you and your
employer
Interviews
business and/or company in spoken and written form

Importance of Communication,
Desired by business and industry

Desired in Sports Performance Enhancement

Groups

Importance of Communication between sports

medicine and performance teams

The lack of integration and communication

between coaches, team doctors, athletic
trainers, strength-and-conditioning coaches,
nutritionists, physical therapists, massage
therapists, psychologists, and other support
personnel may result in
Greater potential for fatigue and overtraining
Increased need for recovery time
Increases in injury rates

Results from an internal audit of an athletic

department and staff evaluations at D1 Program
Athletes received conflicting messages from staff
members.
Athletic trainers and strength coaches were not always in
sync in terms of the way they explained causes of injuries.

They would often call the same exercise by two or

three different names, which created confusion for the
athletes
There was little communication between athletic
trainers and strength coaches, which led to some
inefficient practices.
an athlete might perform an exercise as part of their rehab
with the athletic trainer, then also perform the very same
exercise during a workout with the strength coach

Obstacles: The system

Traditionally, collegiate sports medicine and
strength and conditioning departments
operate as separate units under the
supervision of the athletic department
lack of standardization of services for studentathletes, especially related to injury and injury
prevention

Obstacles: Rehab Specialist

EGO (Everybody Got One)
Difficulty trusting individuals who lack high
levels of specific knowledge or experience
related to injuries
Fear
Territorial over shared territory of interest

Obstacles to Communication: You

EGO
Difficulty trusting individuals who lack high
levels of sport-specific knowledge or
experience
Fear
increased time and resource commitment for
the process.

How to Bridge the Gap

Form a relationship with a PT, ATC, medical provider in order to gain their
trust
Observe/invite them to observe you
Lunch
Expand your knowledge base
Certifications=similar terminology
Cscs, ces, pes, fms/sfma, etc

Communicate
Get an understanding of their knowledge level on performance training.
Based on that info, educated him to whatever level they need to feel safe
having athletes/clients transition over to you.
Inquire about questions, concerns, and goals and take them into
consideration. If there are things discussed that can be immediately corrected
make the correction

Know your objective. Make it clear and concise

Make sure your plan, needs and expectations are transparent

Getting Beyond the Plateau: Bridging the Gap Between

Rehabilitation and Community-Based Exercise
PROBLEM
Communities and neighborhoods across the world lack receptivity in
promoting physical activity environments that support the needs of people
with disabilities [1,2]. This situation is particularly problematic after a person
acquires a disability, completes rehabilitation, and is advised by his or her
physician or therapist to start a physical activity program.

Obstacles
facilities are notoriously inaccessible
the professionals who work in them lack training in working with persons
with a disability/injury
many people do not have the resources to pay for the membership [1-4].

The end result

Rehabilitation specialists have limited options in advising their patients on
where to exercise and the patients often return home to a life with limited or
no employment, reduced ability to complete various household chores, and
less access to sports, recreation, and fitness [5].

Getting Beyond the Plateau: Bridging the Gap Between

Rehabilitation and Community-Based Exercise

the rehabilitation process usually results

in a short-term gain in health and function
necessary for performing activities of daily
living and stabilizing health.
after a few weeks of gradual improvement
post-rehab, the individual plateaus for a
short period and then reaches an
inflection point where his or her health
can either decline or improve.
At approximately 12 wks post-rehab,
health function begins to decline
At 8 months function falls below the
minimum level of function threshold,
increasing the risk of multiple chronic
health conditions associated with
sedentary behavior (eg, obesity, falls,
cardiovascular disease) [12].

How To Bridge the Gap

Increasing your knowledge about pain,

symptoms, and popular mechanisms of injury
as it relates to Activities of Daily Living (ADLs)
and performance training which is why you
are here today.

Lower Back Pain

Lifetime prevalence of
LBP is 65% - 80%
80%-90% episodes
resolve within 6-weeks
irrespective of
treatment
Chance of recurrence
within 12 months 35%79%.

Causes of LBP
Cartilage
Facet
Vertebral endplate

Bone

Vertebrae
Spinous Process
Lamina/Pedicle
Transverse Process

Facet syndromes

Tears of the capsule

Capsulitis
Meniscoid entrapments
Osteoarthritis

Dura mater
Epidural plexus

Thoracolumbar fascia
Fat herniation

Nerve
Disc
Nucleus
annulus

Musculotendinous
Ligamentous
SI Joint
Primary source of LBP in up to 30%
of population

Causes of LBP
Vasculature
Abdominal aortic
aneurysm
Endocarditis
Myocarditis
Peripheral vascular
Post-operative bleeding
from anterior spine
surgery

Metabolic
Kidney disorders
Small intestine
Obstruction (neoplasm)
Irritable bowel syndrome
Crohns Disease

Colon
Diverticular disease
Pancreatic disease
Appendicitis

Tissue Mechanism of injuries

End plates -forced lumbar flexion and
compression, anteroposterior shear loading
Vertebrae- compressive loads
Disc annulus- repeated flexion with moderate
compression, anteroposterior shearing loads
Disc nucleus- compression
Neural arch (posterior bony elements)- repeated
stess-strain reversals with cyclic full flexion
and/or extension, excessive shear forces
Ligaments- falls, stretch

LBP Symptomology
Symptom
representation is
confusing
Brains interpretation
Medial branch of the
posterior primary rami
Recurrent nerve or
sinuvertebral nerve

LBP Symptomology
Common symptoms
Pain in the lumbar spine
Back and/or leg muscle
tightness and spasms
Pain in the SI Joint
Radiating pain and or
weakness into the
thighs, legs and feet
Numbness and tingling
in the thighs, legs and
feet

LBP Symptomology
Sciatica
A symptom, not a
diagnosis
leg pain, tingling,
numbness or weakness
that originates in the
lower back and travels
through the buttock and
down the large sciatic
nerve in the back of the
leg.

LBP Symptomology
Symptoms requiring Immediate
Medical Attention
Saddle anesthesia (buttock
and medial and posterior
thighs)
Fecal incontinence
Urinary retention
Bilateral Sciatica and Motor
weakness of the legs
Unable to heel or toe walk
Unrelieved Night Pain
Unexplained weight loss

LBP: Anatomy

Muscles
Different from limbs
Limb muscles=create motion
Trunk muscles= stop or control motion
Agonist/antagonist relationship not as black and white
Function is optimized when power is generated at the hips
and transmitted through a stiffened spine
Back muscles tend to be predominately slow twitch
Chronic lower backhigher proportion of fast twitch
fibers than normaldecreased endurance (Mannion et al,
1997)

Muscles,

Posterior muscles
Rotatores and intertransversarii
Proprioceptive and kinesthetic properties
Up to 70% tonic
Longissimus and iliocostalis
Thoracic portion: 75% slow twitch
Lumbar portion: 57-62% Type I, 20-22% IIA, 18-22% IIB, Total oxidativeL 77-87%.
Mulitifidus
Provide extensor torque together with small amounts of twisting and sidebending
torque
Provide the ability for corrections at specific joints that may be the foci of stress
Mixed but Predominantly slow twitch in nature (parkkola)
Abdominal region
All abdominal muscles have 55-58% Type I, 15-23% IIA, 21-23% IIB. Total oxidative: 70%
81%.

LBP: Disc Pathology

Disc Degeneration causes
Genetic

Mechanical
Vascular
chemical

LBP: Disc Pathology

Herniation
nomenclature is
confusing
Protrusion/extrusion
Herniation/bulge
Prolapse/sequestration

LBP: Disc Pathology

Jensen et al.
98 asymptomatic subjects given MRI
52% Bulging disc
27% protrusion of the disc
1% extrusion of the disc

38% multilevel
Bulges increased with the age

Borenstein et al. 1994

Similar study of asymptomatic patients with positive MRI
Patients followed for 7 years
NONE DEVELOPED LOW BACK PAIN

Public Enemy #1: Poor Posture and Sitting

Intradiscal Pressures in Various

Everyday Positions and Activities

Affects of Poor Posture

Cyclical loading of passive tissue (ligaments, capsule) desensitizes the
mechanoreceptors leading to loss of stiffening of the lumbar spine from
muscle contraction (Solomonow et. Al 1999)
Twenty minutes of sustained static flexion exposes the spine to decreased
muscular stabilizing forces, muscle spasm and impaired tension-relaxation
status of viscoelastic structures. Demonstrated with EMG muscle activity
was five percent of its initial value within three to four minutes (Jackson et
al. 2001)
The recovery pattern of reflexive muscular activity after continuous
passive, cyclical loading of tissue requires at least 15 to 20 minutes rest
after a 50 minute episode of cyclic loading to produce most of the possible
recovery of reflex muscular activity. Full recovery was not expected until
after two hours of rest

Common Causes in the Gym

Insufficient
Extensor moment
Flexion
Flexion with
rotation
Hyperextension

The National Institute of Occupational Safety and Health has established the
action limit for lower back compression force is not to exceed 3300N.
Repetitive loading above this is level is linked with higher injury rates.
Exercise
Straight Leg Sit-up
Bent leg Sit-up
Curl up feet anchored
Curl up feet free
Quarter sit-up
Straight leg raise
Bent leg raise
Cross knee curl up
Hanging straight leg
Hanging Bent leg
Isometric Side bridge

Compression (N)
3506
3350
2009
1991
2395
2525
1767
2964
2805
3313
2585

Med.Sci.Sports.EX, Axler and McGill, 29 (6); 804-811, 1997

Poor Lifting Mechanics

Critical point (McGill and Kippers)

At a certain point during forward
flexion (90%) where the activity
of the back muscles cease and
the back is supported by the
fascial and ligamentous structure
Any back muscle activity at this
time would be disadvantageous.
General Rule
During stooping, if the
fingertips are below the
knee you are close to the
critical point

Lumbar Spine Range of Motion

Level

Flexion

T12-L1
L1-2

L2-3
L3-4
L4-5
L5-S1

10
12
13
9

Flex/ext
combo
12

Extensio Lateral
n
bend
8
5
6
3
6
1
8
2
6
5
3

Axial
twist
2
2
2
2
2
5

All data are from White and Panjabi (1978), except flexion and extension lumbar
data, which are form Pearcy, Portek, and Shepherd (1984) and Pearcy and Tibrewal
(1984)

During injury
Chowleski and McGill 1992
Scenario: A group of power lifters lifted very heavy weight while their lumbar
vertebrae motion patterns were quantified using video fluoroscopy. One power
lifter complained of pain.
Examination of video fluoroscopy records showed that one of the lumbar joints
reached the full flexion calibrated angle while all other joints maintained their
static position (2 to 3 degrees short of full flexion). The spine buckled and caused
injury
Appeared to be due to an inappropriate sequencing of muscle forces
Was critical point reached?
Fatigue?
Prior Injury?

Lower Back Pain: Multifidus

The lumbar multifidus experiences a number of
morphological and neurophysiological changes following low
back injury. One of these changes is a segmental atrophy
which develops at the level of pathology, on the symptomatic
side and as quickly as 24 hours after the injury.Further, these
changes have been shown to persist beyond the resolution of
symptoms,5 and for at least five years after surgical
intervention for intervertebral disc herniation. There is
evidence that such findings are indicative of a neurologically
mediated process rather than a simple disuse or weakness
phenomenon.

Traditional Strengthening Exercise

Approach Ineffective for Injury
It is critical that both researchers and clinicians {and
fitness specialists} appreciate that a significant body
of research now shows that the atrophy seen in
the multifidus muscle in people with low back
dysfunction is representative of a form of impaired
motor control, not simple disuse weakness. As such,
traditional strengthening exercises will often fail to
correct this fault, just as daily physical activities fail to
maintain a normal segmental CSA at the pathological
level

Affects of the Vicious Pain Cycle

Tissue trauma/Pain and Guarding

Receptor damage
Decreased muscle recruitment
Tonic muscle atrophy
Reduced antigravity
Motion around non-physiological axis
Trauma/acute locking
Pain/guarding

The Major Keys

The So What

IF THERE IS PAIN, REFER OUT

Reduce peak and cumulative spine compressive loads
Reduce repeated spine motion to full flexion
Reduce repeated full flexion to full range extension
Reduce the length of time sitting
Posture and Form is KEY

How To Bridge the Gap

How We Bridge the Gap

System in Place
Common terminology
Information in one place

HOW WE BRIDGE THE GAP: System

TO REHAB

TO TRAIN

FMS

PAIN (0S)

YES

NO PAIN (1, ASSYM)

NO PAIN (2S, 3S/ NO ASSYM)

NO

CLINICAL EXAM

PHYSICAL THERAPY/ATHLETIC TRAINING

FUNCTIONAL EXAM/PERFORMANCE TESTS

MODIFED TRAINING/
CORRECTIVE SOLUTIONS

FULL TRAINING/
CORRECTIVE SOLUTIONS

Common Terminology

Information In One Place

Example
Client hurt the lower back while lifting a couch
over the weekend
Pain when
bending forward to 45 degrees
End range rotation
Squatting at 90 degrees
Heel drop

Summary
Communicate

Educate
Formulate
Activate

References
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