"How To Avoid Spinal Stress Fractures and Running - Part 2"

"How To Avoid Spinal Stress Fractures and Running - Part 2"

The following article is a follow up to Spinal Stress Fractures and Running - Part 1 and will explore a functional approach to preventing Spondylolysis and Spondylolisthesis. Preventing lower back injuries that could progress to more common running injuries should begin with proper and well orchestrated flexibility and strength training programs. The following should be emphasized:

* Trunk and muscular flexibility (specifically the paraspinal, hamstring and gluteal muscles)
* Improving range of motion
* Strengthening the erector spinae muscles
* Strengthening the abdominal muscles
* Learning and implementing proper neutral spine position for training and daily activities

Unfortunately, most back pain is still caused by trying to do too much, too quickly, too often. Simply reminding the athlete (or coach) to gradually increase the work load associated with progressive strength development can have tremendous preventive effects. Proper periodization principles with emphasis on recovery based training and prevention of overtraining should be the cornerstones of a triathlete’s training program.

As eluded to previously, along with proper progression and periodization principles, a sound flexibility and strength training program are crucial to preventing or recovering from spondylolysis or spondylolisthesis. If a more common running injury such as piriformis syndrome develops as a result of these lower back issues, the athlete may only treat the secondary injury rather than treating the source, thereby progressing the injury to a worse degree.

The foundation of a sound flexibility and strength program is to understand and implement neutral spine position and proper core strengthening.

Neutral Spine

Management and prevention of back pain begins by understanding the neutral spine position. Three natural curves are present in a healthy spine. The neck, or the cervical spine, curves slightly inward. The mid back, or the thoracic spine, is curved outward. The low back, or the lumbar spine, curves inward. The neutral alignment is important in helping to cushion the spine from too much stress and strain.

The natural curves of the spine are the result of the muscles, ligaments and tendons that attach to the vertebrae of the spine. Without these supporting structures, the spine would collapse. They support the spine much like guide wires support the mast of a ship. This guide wire system is made up mainly of the abdominal and back muscles. The abdominal muscles provide support by attaching to the ribs, pelvis and indirectly to the lumbar spine. The muscles of the back are arranged in layers, with each layer playing an important role in balancing the spine. By using these muscles together, it is possible to change the curves of the spine.

Controlling pelvic tilt is one way to begin helping athletes balance the spine. As certain muscles of the back and abdomen contract, the pelvis rotates. As the pelvis rotates forward, the lumbar curve increases. As the pelvis rotates backward, the curve of the low back straightens. Rotation of the pelvis is like a wheel centered at the hip joint. The muscles of the upper thighs also attach to the pelvis, and contraction of these muscles can be used to change the curve of the spine.

The abdominal muscles work alone or with the hamstring muscles to produce a backward rotation of the pelvis. This causes the slight inward curve of the low back to straighten. If these muscles cause the curve of the low back to straighten too much, this may produce an unhealthy slouching posture.

In the other direction, as the hip flexors contract and back extensors contract, the pelvis is rotated forward, thus increasing the curvature of the lower back. If this curve is increased too much, another unhealthy posture may result, termed lordosis.

A balance of strength and flexibility is the key to maintaining the neutral spine position. This balance is the basis for optimal muscle function. Like a car, an imbalance may lead to wear and tear, eventually damaging the various parts.

Muscle imbalances that affect the spine have many causes. One common cause of muscle imbalance is weak abdominal muscles. As the abdominal muscles sag, the hip flexors become tight, causing an increase in the curve of the low back. This leads to the swayback posture mentioned above. Another common problem results from tight hamstrings. As the hamstring muscles become tight, the pelvis is rotated backwards. This produces an abnormal slouching posture.

Stability/Core Training

The aim of core stability training is to effectively recruit the trunk musculature and then learn to control the position of the lumbar spine during dynamic movements. The deep muscles of the trunk include the transverse abdominis (TA), multifidus (MF), internal oblique (IO), paraspinal and pelvic floor. The co-contraction of these muscles produce forces via the "theracolumbar fascia" (TLF) and the "intra-abdominal pressure" (IAP) mechanism, which stabilize the lumbar spine, and the paraspinal and MF muscles act directly to resist the forces acting on the lumbar spine.

It is not simply the recruitment of these deep-trunk muscles but how they are recruited that is important. The co-contraction of the TA and MF muscles occurs prior to any movement of the limbs, suggesting that these muscles anticipate dynamic movements, which may act on the lumbar spine and stabilize the area before any movements.

Prior to core specific training, it is important to emphasize flexibility drills first since flexibility is crucial to successful lumbar stabilization training because flexibility allows the muscles to assume the neutral position easily. The following exercises should be recommended:

Stretching should be performed three to four times daily. Each stretch should be held for approximately 30 seconds.









Training the Core Musculature

As with any type of strength and conditioning training, the training protocol for improving the function of the deep-trunk muscles must be specific to the task required. This specificity of training must take into account the type of contraction, the muscle fiber type and the anatomical position required. By definition, the deep-trunk muscles act as "stabilizers" and are not involved in producing movements but instead involve isometric contractions. These muscles do not need to be very strong, but they must be correctly coordinated and capable of working continuously. In addition, these stabilizer muscles should act by holding the lumbar spine in the neutral position, which is the correct alignment of the pelvis that allows for the natural 'S' curve of the spine.

Core training begins with learning to co-contract the TA and MF muscles effectively as this has been identified as key to the lumbar-support mechanism. To perform the TA and MF co-contraction, the "abdominal hollowing" technique with the spine in the neutral position must be performed. The following should be taught to the athlete to properly perform this exercise:

* Start by lying on the back with knees bent.
* The lumbar spine should not be arched up nor flattened against the floor but aligned normally with a small gap between the floor and the back.
* Breathe in deeply and relax the stomach muscles.
* Breathe out and draw the lower abdomen inward as if the belly button is going back towards the floor. This can be described as zipping up a tight pair of pants.
* Hold the contraction for 10 seconds, making sure to breathe in and out as the tension is held in the lower stomach area.
* Repeat 5-10 times.

Instruct the athlete to:

* Not let the whole stomach tense up or the upper abdominals bulge outward since this recruits the rectus abdominis not the TA and MF muscles.
* Not brace the TA muscle too hard since it is muscular endurance not maximal strength that is the focus.
* Not tilt the pelvis nor flatten the back.

The Next Step

After having learned to effectively recruit the TA and MF muscles correctly in various positions, the athlete can progress to simple core exercises. Some of these basic exercises that the triathlete can perform are listed below. These exercises may also involve the oblique muscles, other lumbar muscles and gluteal muscles to assist the TA and MF in maintaining the lumbar spine in a stable neutral position.

Pelvic Tilt

Lying on the back with the knees bent and the feet flat on the floor, tighten the stomach muscles and push the lower back into the floor. Hold for 5 seconds and relax. Repeat 10 times.

Dead Bug

Tighten the stomach muscles and press the lower back into the floor. Lift one leg several inches off the floor and hold for 5 seconds and lower it. Lift the other leg off the floor, hold for 5 seconds and lower it. Alternate legs, doing 5 repetitions with each leg.

Prone Hip Rotation

Lie on the stomach on the floor. Bend the knees so the thighs stay on the floor and the lower legs are perpendicular to the floor. Keep the knees on the floor and shoulder width apart. Cross the legs over each other as far as possible. Keeping the knees on the floor, uncross the lower legs and move them as far apart as possible. Hold for 2 seconds. Repeat 10 to 20 times.

Remembering that the ultimate goal of core training is to ensure that the deep trunk muscles are working correctly to control the lumbar spine during dynamic movements such as running is important. Once the athlete has achieved proficiency of the simple core exercises, the athlete can progress to achieving stability during more functional movements with the following two exercises:

Lunge

* Stand with feet hip width apart in front of a mirror.
* Place the lumbar spine in neutral with the back tall, shoulders back and head up.
* Lunge forward and bend the knee only halfway down.
* Ensure that the front knee is in line with the toes and the back has remained upright with the lumbar spine in neutral and your hips level.
* Push back up, initiating the movement by pushing down into the floor with the front foot.
* The force from the legs should bring the athlete back up quickly and easily to their starting position.
* The back should have remained completely still and the hips level as the athlete performed the push back.

Many athletes do not initiate the up movement correctly as they pull their heads and shoulders back first. This extends the lumbar spine, losing the neutral position. Others have problems keeping their pelvis level while performing the lunge. The athlete must learn to use their deep trunk and gluteal muscles to hold their lumbar spine in neutral and pelvis level as they perform the movement up and down. The movement should only come from the leg muscles.

Press Up

* Start from the knees, even if this means it is easy for the upper body.
* Hands should be slightly wider than the shoulders, and the head must be in front of the hands.
* Lift the hips so that there is a straight line from the knees through the pelvis and lower back, through the shoulders and all the way to the head.
* Ensure that the lumbar spine is in neutral with the help of a training partner or mirror.
* To maintain a neutral spine and a straight back during the exercise, the trunk muscles must provide active support.
* Slowly lower down, bending the arms to the floor. Keep the head still with the neck straight relative to the back.
* Push up, initiating the movement by pressing down into the floor with the hands.

These two exercises enable the athlete to learn core stability while performing dynamic movements. By reducing the resistance, the focus is on the trunk stabilizers and achieving perfect technique rather than working the major muscle groups. The rationale behind core strengthening can be defined as the ability of the core muscles to work in an efficient and coordinated fashion to maintain correct alignment of the spine and pelvis while the limbs are moving. It is this kinetic chain as a whole that must be trained, strengthened and stretched to elicit positive outcomes.

By identifying the root cause of potential running injuries as they relate to the lower back, it is possible to rehabilitate triathletes in a proper, periodized fashion so that loss of training time is reduced and performance is not negatively impacted. However, a proper flexibility and strengthening program emphasizing the core musculature should be implemented year round to prevent any such injuries from developing in the first place.

References:

1. Stinson JT. Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med 1993; 3: 517-28
2. Engelhardt M, Reuter I, Freiwald J, Bohme T, Halbsguth A. Spondylolysis and spondylolisthesis and sports. Orthopade 1997; 9: 755-59
3. Rossi F. Spondylolysis, Spondylolisthesis and Sports. J Sports Med Phys Fitness 1978; 4: 317-40
4. Hoshina H. Spondylolysis in athletes. Physician and Sportsmedicine 1980; 9: 75-9
5. Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995; 149: 15-18
6. Takaaki I, Miyake R, Katoh S, Morita T, Murase M. Pathogenesis of sports-related spondylolisthesis in adolescents. Radiographic and Magnetic Resonance Imaging study. Am J Sports Med 1996; 1: 94-8
7. Libson E, Bloom RA, Dinari G. Symptomatic and asymptomatic spondylolysis and spondylolisthesis in young athletes. Int Orthop 1982; 6: 259-61
8. Congeni J, Mc Culloch J, Swanson K. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med 1997; 2:248-53
9. Goldstein JD, Berger PE, Windler GE, Jackson DW. Spine injuries in gymnasts and swimmers. An epidemiologic investigation. Am J Sports Med 1991; 5: 463-8
10. Bergmann TF, Hyde TE, Yochum TR. Active or Inactive Spondylolysis and/or Spondylolisthesis: What's the Real Cause of Back Pain? Journal of the Neuromusculoskeletal System. 2002:10:70-78.
11. Soler T, Calderon C. The prevalence of spondylolysis in the Spanish athlete. Am J Sports Med. 2000:28(1)57-62.
12. Rossi F, Dragoni S. The prevalence of spondylolysis and spondylolisthesis in symptomatic elite athletes: radiographic findings. Radiography. 2000:28(1):57-62.
13. The Bonati Institute. www.bonati.com
14. The Luklinski Back Pain Clinic. www.back-pain.co.uk
15. American Academy of Orthopedic Surgeons. www.aaos.org
16. Gatorade Sports Science Institute. Low back pain in athletes, RT# 19 Volume 6 (1995), Number 1. www.gssiweb.com
17. Spondylosis. The Athletic Advisor. www.athleticadvisor.com
18. Piriformis Syndrome. www.emedicine.com
19. Sports Injury Bulletin. www.sportsinjurybulletin.com
20. Core Stability Training. Peak Performance Online. www.pponline.co.uk
21. Core Stability. Sports Coach. www.brianmac.demon.co.uk
22. A Patient’s Guild to Rehabilitation for the Lower Back. University of Maryland Medical Center. www.umm.edu.
23. Nicholas Institute of Sports Medicine and Athletic Trauma. www.nismat.org
24. Spondylosis profile and diagnosis. Spine Health. www.spine-health.com.
25. University Sports Medicine Department of Orthopaedics State University of New York at Buffalo. www.ubsportsmed.buffalo.edu
26. Back Stretching. The Athletic Advisor. www.athleticadvisor.com
27. Back Strengthening. The Athletic Advisor. www.athleticadvisor.com
28. Bob Seebohar

Forwarded By, Natalie Pyles

Fitness & Nutritional Expert, Author, & Speaker

Call Me For Your FREE Consultation Today! 1-800-681-9894 or e-mail fitnesselementsassociates@yahoo.com

"How To Avoid Spinal Stress Fractures and Running - Part 1"

"How To Avoid Spinal Stress Fractures and Running - Part 1"

Linking Piriformis Syndrome with Low Back Injury

Approximately 80 percent of the population suffers from low back pain at some point in life. Some people are at higher risk for chronic and acute back injuries due to their lifestyles. Athletes are at greater risk of sustaining a lower back injury due to increased physical activity. Strenuous, repetitive and long-term activity, which is common in triathletes, puts a strain on the back that can cause injury to even the finest and most fit athletes. Though the entire spine is used when playing sports, it is estimated that five to 10 percent of all athletic injuries are related to the lumbar spine. Many cases of low back pain in athletes can be traced to a specific event or trauma, while others are brought about by repetitive minor injuries that result in microtraumas.

It is these microtraumas that are problematic for the triathlete. There are many injuries that are associated with running, but anatomical imbalances caused by genetics and/or the repetitive stress and impact forces associated with running can actually cause some of the running injuries that are common in triathletes.

Some triathletes experience low back pain due to running, and while this certainly may be due to muscular fatigue, more times than not it can be associated with a more chronic problem due to anatomical alterations of the spine. This can cause improper hip rotation, possible leg length discrepancy and muscular imbalances, which could lead to overstretching and/or overuse of specific gluteal muscles that are common to running injuries, specifically the piriformis muscle. One of the causes of piriformis syndrome (described later) is spinal stenosis, which happens to be a result of the conditions highlighted below. Thus, it appears that one of the most common running injuries, piriformis syndrome, could actually be linked to a lower back injury that surfaces as a result of genetic predisposition or chronic sport participation. This article will focus on two related lower back conditions, known as spondylolysis and spondylolisthesis, and how specific functional training can improve these conditions in order to lessen the impact or avoid contracting piriformis syndrome.

Spondylolysis

The most common X-ray identified cause of low back pain is a stress fracture in one of the vertebrae that make up the spinal column, known as spondylolysis. It usually affects the fifth lumbar vertebra in the lower back and is more prevalent in Caucasian males. Research has shown that more than 50 percent of these fractures are actually genetic abnormalities.

To date, there is no definitive cause of spondylolysis. Most physicians agree that the bone defect appears in children most likely due to a genetically weak pars interarticularis teamed with repeated stress to the spine from various physical activities during the major growth years. It is thought that spondylolysis appears in younger and older adults as the result of excessive stress to the spine.

Spondylolysis does not always produce noticeable symptoms. When it does, chronic low back pain is the most common symptom. The pain can stem from mechanical (structural) or compressive (pressure on nerves) pain. The following chart describes the prevalence of spondylolysis in different types of endurance sports.

Sport


# of Athletes Polled


Spondylolysis


% with Spondylolysis
Modern Pentathlon and Triathlon 54 11 20.37
Cycling 95 13 13.68
Water Polo and Swimming 307 34 11.07


Spondylolisthesis

If the stress fracture weakens the bone so much that it is unable to maintain its proper position, the vertebra can start to shift out of place, termed spondylolisthesis. This condition occurs when the weakness caused by the spondylolysis causes one vertebra to slip forward over the one below it, resulting in stenosis of the spinal canal. Most cases of spondylolysis in athletes do not lead to vertebral slippage. However, if slippage does occur, it may continue and would need immediate attention.

Many cases are non-symptomatic and do not cause any nerve problems. However, sometimes the slipped vertebra can press into the space belonging to the spinal canal. The neural pressure can lead to low back, buttock and leg pain as well as numbness in the foot. One way to detect spondylolisthesis is to look for physical signs and symptoms including the following:

* Short torso (body)
* Flat buttocks
* Rib cage appears low
* Iliac crests (hip bones) are high
* Altered gait because of tight hamstrings (a key concern in triathletes)
* Hips don't fully extend back
* Tight hamstrings
* Lower back pain or stiffness
* Localized tenderness of the spine just above the pelvis

There are five main causes of displacement and four levels of displacement. The latter is important to understand because it will dictate what type of treatment the athlete should pursue:

* Level 1: 25 percent slippage, which is not regarded as serious and where mild symptoms are not too troublesome. This is characterized when athletes do not like to stand or sit upright for long and are adverse to lifting objects.
* Level 2: 50 percent slippage, which causes a lot of pain and stiffness that is commonly associated with a herniated disc.
* Level 3: 75 percent slippage, which is visually identified by a deformity in the spine.
* Level 4: 100 percent complete displacement, which is very dangerous as this could cause paralysis through total obstruction of the spinal canal.

Prevalence

Spondylolysis develops most commonly in adolescents, typically in 10 to 15 year olds. The majority of adolescents with spondylolysis do not have symptoms or their symptoms are mild and often overlooked. There is a chance that the deformity with continued stress can lead to the slippage of spondylolisthesis and recurrent low back pain.

It is suspected that spondylolysis occurs in young athletes who are involved in sports that require repeated hyperextension of the lower back. Spondylolysis occurs most frequently in young athletes involved in throwing, gymnastics, rowing, boxing, diving, wrestling, weightlifting, modern pentathlon, triathlon and track and field.

Interestingly, females appear to be more prone to progressive displacement and may need surgical intervention more often than males. Degenerative spondylolisthesis occurs more commonly in females with a 5:1 female-to-male ratio. The incidence increases after age 40.

Older athletes can also develop spondylolisthesis because of degeneration in the disc and the facet joints, which can allow slippage even without a fracture. While it is not known exactly what causes this condition, it is theorized that it probably involves overloading the back part of the facet joints, which can eventually lead to stress fractures.

Risk Factors

There may be a hereditary aspect to spondylolysis as described previously. An individual may be born with thin vertebral bone and therefore be vulnerable to this condition. Significant periods of rapid growth may encourage slippage. In addition, athletes who participate in sports where the lower back is hyperextended at times or during contact sports also may be susceptible. The problem in triathletes lies not only in the terrain (hard versus soft) run on but also the technique of the athlete in the running position. Because some triathletes tend to not focus on maintaining neutral spine (described later), this could cause an excessive hyperextension in the lower back. This combined with the pounding of concrete or asphalt creates an inviting environment for spondylolysis and spondylolisthesis.

As described later, a sound stretching and strengthening program combined with proper running technique that is focused on achieving and maintaining neutral spine is crucial to the prevention of lower back injuries that may be masked by more common running injuries such as piriformis syndrome.

Symptoms

Generally, the athlete will have pain across the low back that may radiate down to the buttocks and may feel more like a muscle strain. The paraspinal muscles will be in spasm, giving a flat appearance to the normally curved lower back. This is mechanical pain. Mechanical pain is due to the actual injury, bony fracture and the related muscle spasms.

Compressive pain can be characterized as radiating. Any pain due to spinal nerve compression will present itself as pain that radiates down the leg. It may also present itself as numbness or heaviness in the leg.

Spondylolisthesis can cause spasms that stiffen the back and tighten the hamstring muscles, resulting in changes to posture and gait. This alteration of gait could significantly affect the triathlete’s ability to run efficiently and economically. In addition, tight hamstrings could be perceived as a separate injury of their own when, in fact, the true causal factor is related to the lower back.

Treatment Options

Initial treatment for spondylolysis is always conservative. The athlete should be encouraged to take a break from training until symptoms go away. Anti-inflammatory medications such as Ibuprofen may help reduce back pain. In most cases, training can be resumed gradually. Stretching and strengthening exercises for the back and abnormal muscles can help prevent future recurrences of pain.

Although mobilization can be done for all levels of displacement, manipulation is never recommended for this condition and must never be conducted. Any level of displacement up to level 4 can be successfully treated non-surgically. Depending on the athlete, anything from grade 2 may require surgical fusion to stabilize the joint. In all cases where non-surgical treatment is possible, the condition is treated symptomatically depending on the spinal areas affected, keeping in mind that the lower or supporting vertebra is always stiffer as a result of the displacement.

In conjunction with treatment, a specific set of exercises (described later) should be prescribed to strengthen the muscles of the trunk. The athlete should never raise his/her legs because this action causes the spine to become elongated. Swimming is beneficial, and running on a soft surface should be emphasized. Surgery may only be needed if slippage continues or if the back pain does not respond to conservative treatment.

Because of the high correlation between spondylolysis and spondylolisthesis with the ever popular triathlete injury, piriformis syndrome, it is important to understand this syndrome and how it relates to and may often be linked to lower back problems.

Piriformis Syndrome

Piriformis syndrome is characterized by pain and instability. The location of the pain is often imprecise, but it is often present in the hip, coccyx, buttock, groin or distal part of the leg. The function of the piriformis muscle is to externally rotate and abduct the thigh. Dysfunction of the piriformis muscle can cause signs and symptoms of pain in the sciatic nerve distribution, that is, in the gluteal area, posterior thigh, posterior leg and lateral aspect of the foot.

Although no general consensus about the etiology and pathophysiology of piriformis syndrome exists, many health professionals attribute this syndrome to a specific mechanism involving the sciatic nerve. Athletes with piriformis syndrome may have the following symptoms:

* Chronic pain in the buttocks
* Pain may radiate to the lower leg and worsen with walking or squatting
* Pain may imitate lower back pain
* Pain when getting up from bed
* Pain exacerbated by hip adduction and internal rotation
* Intolerance to sitting

Possible causes of piriformis syndrome include trauma to the buttocks or gluteal region, anatomical variations of the sciatic nerve and spinal stenosis (described earlier as a product of spondylolisthesis). While piriformis syndrome can arguably be contracted on its own from other causes, the spinal stenosis factor found in spondylolysis and spondylolisthesis can certainly be a causative factor in piriformis syndrome and should always be ruled out during examination.

Part 2 of this series will explore a functional approach to preventing spondylolysis and spondylolisthesis and other lower back injuries that could progress to more common running injuries.

References:

1. Stinson JT. Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med 1993; 3: 517-28
2. Engelhardt M, Reuter I, Freiwald J, Bohme T, Halbsguth A. Spondylolysis and spondylolisthesis and sports. Orthopade 1997; 9: 755-59
3. Rossi F. Spondylolysis, Spondylolisthesis and Sports. J Sports Med Phys Fitness 1978; 4: 317-40
4. Hoshina H. Spondylolysis in athletes. Physician and Sportsmedicine 1980; 9: 75-9
5. Micheli LJ, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995; 149: 15-18
6. Takaaki I, Miyake R, Katoh S, Morita T, Murase M. Pathogenesis of sports-related spondylolisthesis in adolescents. Radiographic and Magnetic Resonance Imaging study. Am J Sports Med 1996; 1: 94-8
7. Libson E, Bloom RA, Dinari G. Symptomatic and asymptomatic spondylolysis and spondylolisthesis in young athletes. Int Orthop 1982; 6: 259-61
8. Congeni J, Mc Culloch J, Swanson K. Lumbar spondylolysis. A study of natural progression in athletes. Am J Sports Med 1997; 2:248-53
9. Goldstein JD, Berger PE, Windler GE, Jackson DW. Spine injuries in gymnasts and swimmers. An epidemiologic investigation. Am J Sports Med 1991; 5: 463-8
10. Bergmann TF, Hyde TE, Yochum TR. Active or Inactive Spondylolysis and/or Spondylolisthesis: What's the Real Cause of Back Pain? Journal of the Neuromusculoskeletal System. 2002:10:70-78.
11. Soler T, Calderon C. The prevalence of spondylolysis in the Spanish athlete. Am J Sports Med. 2000:28(1)57-62.
12. Rossi F, Dragoni S. The prevalence of spondylolysis and spondylolisthesis in symptomatic elite athletes: radiographic findings. Radiography. 2000:28(1):57-62.
13. The Bonati Institute. www.bonati.com
14. The Luklinski Back Pain Clinic. www.back-pain.co.uk
15. American Academy of Orthopedic Surgeons. www.aaos.org
16. Gatorade Sports Science Institute. Low back pain in athletes, RT# 19 Volume 6 (1995), Number 1. www.gssiweb.com
17. Spondylosis. The Athletic Advisor. www.athleticadvisor.com
18. Piriformis Syndrome. www.emedicine.com
19. Sports Injury Bulletin. www.sportsinjurybulletin.com
20. Core Stability Training. Peak Performance Online. www.pponline.co.uk
21. Core Stability. Sports Coach. www.brianmac.demon.co.uk
22. A Patient’s Guild to Rehabilitation for the Lower Back. University of Maryland Medical Center. www.umm.edu.
23. Nicholas Institute of Sports Medicine and Athletic Trauma. www.nismat.org
24. Spondylosis profile and diagnosis. Spine Health. www.spine-health.com
25. University Sports Medicine Department of Orthopaedics State University of New York at Buffalo. www.ubsportsmed.buffalo.edu
26. Back Stretching. The Athletic Advisor. www.athleticadvisor.com
27. Back Strengthening. The Athletic Advisor. www.athleticadvisor.com
28. Bob Seeborhar

Forwarded By, Natalie Pyles

Fitness & Nutritional Expert, Author, & Speaker


Call Me For Your FREE Consultation Today! 1-800-681-9894 or e-mail fitnesselementsassociates@yahoo.com