152 Dance Anatomy and Kinesiology
Second, there is increased evidence of the ability of
the disc to heal, albeit with greater scar tissue and
sometimes over as long a time as 12 to 18 months.
It appears that disc collagen has a slow turnover, so
repair is very slow (Adams and Hutton, 1982). And
even some dancers who initially have very debilitating
symptoms are able to return to professional dance
at a later time. Lastly, it is important to realize that
some conditions may mimic disc herniation, such as
the piriformis syndrome discussed in chapter 4.Rehabilitation of Low Back Injuries
Treatment approaches vary and will depend on many
factors including the type of injury, severity of symp-
toms, age of the dancer, and preferred approach of
the medical professional. Studies suggest that low
back pain will improve in 70% of patients in three
weeks and 90% in two months regardless of the type
of treatment utilized (White III and Panjabi, 1978).
However, in dancers, time is of the essence, and suf-
ficient rehabilitation to prevent further occurrences
is vital for professional survival. Hence, working with
a skilled physical therapist knowledgeable in the
demands of dance is highly recommended.
Initial treatment often involves relative rest, anti-
inflammatory medications, modalities, and thera-
peutic exercise (Weiker, 1982). Note that the term
“relative rest” is used, as there has been a shift away
from prescribing total bed rest for low back pain
(except in the early days with more severe injuries)
so that undesired substantial losses in muscle mass,
strength, flexibility, and bone density are avoided
(Saal, 1988a, 1988b). One study showed about 50%
reduction from normal in the size of the sacrospinalis
in patients who had been confined to bed for longer
than three weeks (Imamura et al., 1983). Modalities
such as ice, heat, ultrasound, electrical stimulation,
or massage may sometimes be prescribed in an effort
to reduce muscle spasm and pain. In some types of
injuries, joint mobilization techniques may be uti-
lized to restore normal movement between segments
of the spine (Caillet, 1996; Saal, 1988a). Mild activity
such as aquatic exercise or walking is also sometimes
useful for diminishing pain and muscle spasm and
restoring normal physiologic function.
In terms of therapeutic exercise, the controversies
and protocols are beyond the scope of this book, but
a brief overview of some common principles follows.
Many types of low back injury including mechanical
low back pain, facet syndrome, spondylolysis and
spondylolisthesis, and some types of lumbosacral
strains initially emphasize flexion exercises and may
be aggravated by adding extension exercises (Dreznerand Herring, 2001). Flexion tends to stretch the tho-
racolumbar fascia, reduce lumbar lordosis, and lessen
anterior shear forces, which can provide relief in cases
of mechanical low back pain or spondylolisthesis. Flex-
ion also increases the separation of the pedicles in the
lumbar region and decreases compression forces in
the facet joints, potentially reducing symptoms when
these structures are sources of pain (spondylolysis
and facet syndrome). Furthermore, flexion causes a
marked increase in the capacity of the spinal canal
(Liyang et al., 1989), as well as an increase in the
intervertebral foramen width of about 30% (Soder-
berg, 1986), which can provide relief when pres-
sure to the nerve root is involved. Flexion exercises
generally include gentle abdominal strengthening
exercises kept in a low range to limit intervertebral
disc pressure (e.g., pelvic tilts and small curl-ups), as
well as gentle stretches for the spinal extensors (e.g.,
double knee to chest stretch performed in a supine
position) and hamstrings in pain-free ranges. Other
anti-lordotic procedures include bracing, placing
one foot on a step when standing for extended time,
keeping the knees at or slightly higher than hip height
when sitting, using the abdominals to help maintain a
neutral spinal alignment, avoidance of sleeping on the
stomach (sleeping on the side with a pillow between
the knees is often recommended for many types of
back injury), and avoidance of wearing high-heeled
shoes. In terms of dance, when return is permitted,
overhead lifting, jumping, and hyperextension are
often initially avoided.
Unlike the injuries just discussed, acute disc
herniations often respond in an opposite manner
and are often aggravated by flexion and given relief
with extension exercises (Harvey and Tanner, 1991;
Saal, 1988a). Intradiscal pressure increases with
spinal flexion, and so curl-up type exercises are often
avoided and isometric abdominal or stabilization
exercises substituted during initial stages of treat-
ment. Passive hyperextension (such as the prone
press-up, table 3.7C) often provides reduction in
pain or centralization of pain, and McKenzie exten-
sion exercises (McKenzie, 1981) gradually progress
from passive to active extension exercises. However,
it is important to realize that active hyperextension
exercises also cause elevation in disc pressure and
should be performed with medical guidance and
in a pain-free range. Lying on the back with the
legs elevated by pillows or resting on the seat of
the chair (figure 3.50) is also often recommended
for temporary relief of disc-related back pain (and
many other forms of back pain as well). The supine
position reduces pressure in the disc, while flexion
of the hips and knees reduces potential tension due