Work Wounds

One of the hazards of being an athletic trainer is dealing with back pain—your own back pain, that is. In this article, a back specialist offers advice on how to treat and prevent work-related flare-ups.

By Dr. Craig Liebenson

Craig Liebenson, DC, is in private practice in Los Angeles, at L.A. Sports and Spine. He is an Adjunct Professor in the School of Chiropractic, Division of Health Sciences at Murdoch University. He is the author numerous scientific publications as well as patient education books on both the neck and low back and editor of the multidisciplinary text Rehabilitation of the Spine: A Practitioner's Manual.He can be reached through his Web site, at:

Training & Conditioning, 14.7, October 2004,

Athletic trainers spend their days, and many of their nights, trying to keep athletes healthy and in the lineup. But this work can take a toll on its practitioners. Lifting heavy water coolers, taping countless athletes, or even taking a long bus ride with a travelling team can prompt an athletic trainer's body to clamor for attention of its own. For many athletic trainers, the area of the body that suffers the most is the back.

Back pain can bring even the strongest athlete to his knees and force highly trained players to the sidelines. It can easily do the same with athletic trainers—except there is no sideline for them to go to.

The good news is that back pain rarely results from serious causes, and acute flare-ups of back pain usually improve within a few weeks. When handled properly, there is typically 80 percent improvement within two weeks of the onset of back pain. Furthermore, a simple stretching and stabilizing regimen can head off problems before they happen.

The overall gameplan for an aching back is to first soothe the back through palliative care while learning to spare the spine from excessive loads, and then to stabilize the spine through appropriate exercise. Fortunately, a neuromuscular reeducation program to rehabilitate the spine can be performed in minimal time. Taking very short stretching breaks at regular intervals throughout the day can placate an otherwise overstressed back, while a few additional minutes of therapeutic exercise will go a long way toward staving off future back pain episodes.

Pain Relief
To start, it’s important for athletic trainers to understand the effects of the three stages of healing when it comes to back problems: inflammation, repair, and remodelling. Inflammation will typically last three to seven days. The main goal during this phase is to reduce the pain through palliative care, which allows function to return and lays the groundwork for future stabilization and strengthening.

Although rest is a key part of getting through the inflammation stage, it should consist of relative rest, not complete rest. Since most problems improve quickly, it's important to maintain a positive outlook and remain active. Simply shutting down completely will do little to help the healing process. In addition, an overemphasis on passive therapies can lead to a deconditioning of the back and reinforce detrimental activity avoidance.

Palliative care can begin immediately and may be used throughout the entire treatment process whenever back pain flares up. Since 80 percent of people with back pain report 80 percent improvement within just a few weeks of treatment, palliative measures should be kept as simple as possible and be viewed as temporary.

Palliative care ranges from medication to specific therapeutic exercises. It's usually best to start with over-the-counter medications, such as anti-inflammatories; and thermal agents, beginning with cold and then moving to heat. The next step is physiotherapy modalities, such as electrical muscle stimulation, and soft-tissue manipulation, especially acupressure, active release therapy, and trigger-point therapy. The key to soft-tissue manipulation is taking a focused diagnostic approach rather than just effleurage and petrissage. You need to find the tender nodules and stretch them using direct pressure. Specific therapeutic exercise, such as McKenzie technique, can also be used for palliative care.

You will need to limit the demands on your back, however, and take care to not aggravate your injury. Braces and supports are rarely necessary, but spine-sparing strategies will help prevent further damage throughout the treatment process and are especially important during the early stages.

Once pain decreases, it's time to move to the repair stage. The idea is to let the back begin to rebuild itself, which typically takes one to four weeks, depending on the severity of the injury. Moist heat, stretching, and low-load stability exercises will speed the repair process, and more importantly prevent deconditioning.

As strength returns, remodeling begins. Normally encompassing weeks 3-12 following the onset of pain, remodeling involves preparing the back for the loads it will be expected to carry. Unless the tissues are reeducated, the problem can either persist, worsen, or relapse. Therefore, this stage involves training designed to strengthen and stabilize back muscles along with specific functional training. Once functional performance returns to a pre-injury level, healing is considered complete and maintenance programs can begin.

Stabilizing the Spine
The key to strengthening the back is spine stability. A stable back is a strong back that will be able to handle the demands an athletic trainer places on it.

Initially, low-load exercises with wide margins of stability should be performed. Such exercises are able to challenge the muscles while reducing excessive joint compression, shear, or torsion load that could lead to further injury. Usually these keep the spine aligned in a neutral lordosis.

Initial stability exercises include:

Cat-camel: While on all fours, round up and then drop the back. This is not a stretch, but a gentle, limbering maneuver designed to "floss" the spine.

Quadruped leg reach: While on all fours, brace the spine and then sweep the floor with one leg without allowing the spine to move.

Side bridge on knees: While sidelying with knees and hips flexed, hinge the hips forward as the waist is raised up until the knees and hips are in line with shoulders.

Each exercise should be performed slowly with an isometric hold lasting one to two breaths, which would typically be five or six seconds. Start with six repetitions per set before progressing to 12 reps per set. Once one set of 12 reps can be performed, progress to three sets using a reverse-pyramid approach of decreasing repetitions with each successive set. For example, the first set would include 12 reps, the next set would include eight reps, and the final set would include four reps.

These initial stabilization exercises can progress to more challenging functional movements as endurance develops. For instance, an opposite arm reach can be added to the quadruped leg reach. The side bridge on knees can be progressed to ankles and a roll over. Other, more advanced, stability exercises can be utilized to isolate the abdominal wall. These include:

Trunk curl-up: Raise from the mid-thoracic region only.

Dead-bug: While supine, bring the opposite arm and leg together in the mid-line while maintaining an abdominal brace.

Once a base level of stability has been established, you can move to more advanced functional exercises that mimic athletic training demands. This functional integrated training includes squats, lunges, tri-planer push/pull exercises, and whole-body tasks performed with a neutral spine. For instance, pushing and pulling tasks can be trained using pulleys or resistance bands. Make sure to include movements from floor to waist, floor to shoulder, and waist to shoulder.

Specific functional integrated training exercises can include:
Single-leg bridge and functional reaches: Stand on one leg and reach back with the other leg while keeping the spine upright. The reach back may be performed at different angles to isolate the gluteal muscles. The support leg knee should not move inwards of the big toe or forward of the toes.

Angle-lunge with reach: Using a star diagram perform lunges at different angles while reaching across the body with the opposite arm.

Core pull: From a squat or lunge position, pull the weight across the body while maintaining a neutral spine. Keep the shoulders level and spare the spine and shoulder by generating most of the force from the core.

Core push: From a squat or lunge position, push the weight across the body while maintaining a neutral spine. Keep the shoulders level and spare the spine and shoulder by generating most of the force from the core.

All of these exercises are ideal for the recovery phase of a back pain episode. They can also be used as a preventive strategy in a healthy, asymptomatic athletic trainer.

Sparing the Spine
Whether you are currently recovering from back pain or want to decrease your chances of developing it, the most important advice I can provide is to spare the spine. This is the key to avoiding repetitive strain on sensitive back tissues. Here are some tips for spine-sparing:

Take micro-breaks: Avoid sitting or standing for prolonged periods of time by taking micro-breaks every 20 to 30 minutes. Micro-breaks are brief 10- to 30-second movements performed after prolonged periods of end-range overload, such as stooping over an athlete to tape an ankle. An effective micro-break for athletic trainers is an arm reach overhead and brugger postural exercise.

Hinge the hip: When performing daily tasks involving trunk flexion, spare the spine by learning to hinge at the hip. This would apply to activities such as lifting a water cooler or athletic training kit.

Warm up: Prior to lifting something heavy, pre-warm the back with the arm reach overhead. When lifting you should make sure you maintain an upright lordosis, which is a squat position as opposed to a stooped position.

Lift in the afternoon: Avoidance of early morning flexion has been found to spur recovery. If unavoidable, make sure to take extra time to prepare the back with proper warmups.

Spread the load: Increasing the flexibility of related areas such as the lower-quarter kinetic chain or mid-thoracic area will increase load sharing and thus spare the spine. Good flexibility exercises include a psoas stretch for hip-extensor flexibility and a back stretch over a foam roll or a gym ball for mid-thoracic mobilization.

Brace the back: Whenever performing high-stress activities, protect the spine by performing abdominal bracing. Abdominal bracing involves agonist-antagonist co-activation of muscles around the neutral (slightly lordotic) lumbar spine. Tense the muscles of the abdominal wall and low back as if getting ready to receive a punch. Such bracing buttresses the spine with a hoop-like muscle tension that stiffens vulnerable structures during bending, lifting, or twisting tasks.

Team Approach
Although it may appear strange for athletic trainers to train and warm up in order to perform their duties, these suggestions can go a long way in helping back pain sufferers. They can also help prevent back problems in those who have yet to suffer painful symptoms.

Health-care professionals do not always make the best patients. They are often more concerned about their patients than they are about themselves. But if athletic trainers work together on proper stretching and taking micro-breaks, they can keep each other from back pain flare-ups. The key is for athletic trainers to be as pro-active with their own backs as they are with their athletes.

Avoiding Back Pain

Some quick tips:

• Limit bending, lifting, carrying, and twisting in the early morning.
• Pre-warm the back before strenuous activities.
• Actively brace the spine when lifting or carrying.
• Maintain a "neutral" spine when lifting.
• Use a therapy table of appropriate height to limit bending.
• When sitting or standing in one position, take a "micro-break" every 20 minutes.

Signs of Trouble

Although back pain rarely results from serious underlying causes, it's important to remember that it can. If palliative care and stabilization efforts don't have an effect after a week or so, consult a physician to rule out serious conditions such as a tumor, infection, or fracture. Any instances of legs giving way or pain around the anus or genitalia should also prompt an urgent visit to a physician.

In some cases, back pain can become chronic if not treated correctly. The following factors indicate a greater risk of developing a chronic problem and are a sign to consult with a physician or back specialist:

•Severe sciatica.
•Decreased trunk extensor endurance (less than 60 seconds hold time on the Sorensen static horizontal extensor test).
•Increased spine flexion mobility (greater than 60 degrees).
•Decreased hip mobility (extension or internal rotation).

Additional Readings
1. Kibler W.B., Herring S.A., Press J.M. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Aspen, 1998.

2. Lewit K. Manipulative Therapy in Rehabilitation of the Motor System. 3rd edition. Butterworths, London, 1999.

3. Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, Liebenson C (ed). Williams and Wilkins, Baltimore, 1996.

4. McGill, S.M. Low Back Disorders: Evidence Based Prevention and Rehabilitation, Human Kinetics Publishers, Champaign, Ill., 2002.

5. McGill S.M. Ultimate Back Fitness and Performance. Wabunu, 2004.

6. Richardson C., Jull G., Hides J., Hodges P. Therapeutic Exercise for Spinal Stabilization in Lower Back Pain, Churchill Livingstone, 1999.

7. Waddell G. The Back Pain Revolution, 2nd edition. 2004. Churchill Livingstone, Edinburgh.