RETURN TO ADVANCED STRENGTH TRAINING AND WEIGHTLIFTING IN AN ATHLETE POST-LUMBAR DISCECTOMY UTILIZING PAIN NEUROSCIENCE EDUCATION AND PROPER PROGRESSION: RESIDENT'S CASE REPORT

Abstract

Study design: Case Report.

Background and purpose: The use of pain neuroscience education (PNE) is indicated when there are psychosocial contributions to a person's pain experience. The scientific literature has established the efficacy of the use of PNE in a population with chronic pain but there is a paucity of evidence to support the use of PNE in athletic populations. The purpose of this case report is to describe the use of PNE and graded exposure exercises specific to an athlete returning to Olympic weightlifting.

Case description: The patient underwent an L5-S1 discectomy to resolve paresthesia in his leg, completed a bout of post-operative rehabilitation but returned 15 months after the surgery. He presented with the chief complaint of low back tightness and fear of lumbar flexion. When asked to touch his toes during the lumbar flexion range of motion examination, he demonstrated aberrant lumbar movement by hinging at the hips with a straight back due to fear that flexing would damage his lumbar spine. The patient was seen for four weeks with a focus on PNE and graded exposure to weightlifting activities.

Outcomes: The patient returned to Olympic weightlifting and decreased his Fear Avoidance Behavior Questionnaire (FABQ) score from 22 to 4 during the course of physical therapy. His Tampa Scale of Kinesiophobia (TSK) score also decreased from 55 to 31. By discharge, he was able to bend at the lumbar spine with full flexion and no longer believed the motion to cause damage.

Discussion: The case is unique because it describes the implementation of PNE in an athlete returning to weightlifting, and the scientific literature for use of PNE in this population is lacking. The identification of kinesiophobia and implementation of PNE and graded exposure exercises lead to an optimal outcome for this patient.

Level of evidence: Level 4.

Keywords: graded exposure; kinesiophobia; lumbar discectomy; movement system; pain neuroscience education; weightlifting.

© 2019 by the Sports Physical Therapy Section.

Figures

Figure 1.

The patient's body chart at the 1st physical therapy initial examination.

Figure 2.

Chronology of events.

Figure 3.

Lumbar flexion range of motion evaluation 3a) When asked to touch his toes during the lumbar flexion range of motion examination, the subject maintained a neutral spine and hinged at the hips due to fear of flexing at his low back. The severe limitation in lumbar flexion with a fear-induced hip hinge rather than a lumbar lordosis reversal gave further evidence that PNE and flexion based graded exposure exercises would be recommended. 3b) With encouragement from the physical therapist that no damage would occur to the low back with flexion, he was able to flex at lumbar spine with normal reversal of lordosis.

Figure 4.

The decision-making model used to identify fear-avoidant behavior and kinesiophobia and how to implement PNE and graded exposure on subsequent visits. Fear is assessed during treatment by identifying feared movements via subjective reports and correlating them with previously completed outcome measures. FABQ = Fear Avoidance Behavior Questionnaire. TSK = Tampa Scale of Kinesiophobia. PNE = Pain Neuroscience Education. ROM = Range Of Motion. VAS = Visual Analogue Scale.

Figure 5.

Progression of exercises prepare for graded exposure to the overhead squat. 1) Squat. 2) Kettlebell squat. 3) Double front rack kettlebell squat. 4) Barbell front squat. 5) Barbell back squat. 6) Overhead squat.

Figure 6.

Outlined is the pathway taken to allow graded exposure towards the barbell deadlift. Regardless of load variations, bringing the load closer to the floor is another way to progress towards a conventional barbell deadlift.

Figure 7.

Bracing sequence before performing a weighted barbell movement. Patient is first instructed to exhale in order to depress ribs and then slightly posteriorly rotate the pelvis in order to allow the two structures to align vertically. Patient is then instructed to activate the lower abdominals and the breathe into the active tension created.

Figure 8.

Linear Periodization Model that was used with the patient in the case. RPE is described in Figure 9. Load is defined by the weight lifted during the exercise.

Figure 9.

Resistance exercise-specific Rating of Perceived Exertion (RPE).