Combining the treatment-based classification method & movement reeducation for a dancer with low back pain
Posted on 10th January 2014 by Elizabeth Corwin
Iâ€™ve been dancing my entire life. I dance because it brings me joy, challenges me and provides me with a perfect form of self-expression. These satisfactions are common with all dancers, but many dancers also share a long history of injuries. Since I was teenager I have had to sit out many classes and rehearsals due to a variety of injuries, most often low back pain (LBP). I recently found this article when looking up treatments for dancers with LBP.
The Use of Stabilization Exercises and Movement Reeducation to Manage Pain and Improve Function in a Dancer with Focal Degenerative Joint Disease of the Spine. By Marshall Hagins in the Journal of Dance Medicine and Science. From in November 2011.
Why are dancers unique?
Hagins explains in this article that dancers use extreme ranges of motion in the spine and that they repeat these motions hundreds of times within a day. It is often believed in dance literature that even just small technical flaws performed by the dancer can lead to increased stresses that over time will cause pain and possible injury. I think that since dancers spend hours upon hours dancing, that it is important as a physical therapist to address their technical flaws in the rehabilitation process in order to hopefully ensure long-term benefits. However, the dance literature is still relatively young and has yet, to my knowledge, had a chance to establish studies examining technique retraining. This study builds the foundation for that development by presenting the treatment of a single dancer with focal degenerative joint disease (DJD) of the spine.
A description of the case and the treatment:
First a little about the patient:
The patient was a 37-year old female who had been dancing professionally for 12 years with the same modern dance company. Her pain was located at and just above and below the T12-L1 spinal segment and she reported that it had been increasing in intensity over the last five years. She had seen other providers, including physical therapists before. She claimed she has mostly received soft tissue massage and ultrasound with some relief. She also reported that specific dance movements brought on the pain and that time away from dance provided her with a decrease in her symptoms. She had recently had radiographs, which showed DJD at T12-L1.
When she began seeing Hagins for therapy her visual analog scale (VAS) was 3/10 at rest and 7/10 with dance function. Her Oswetery score was 74%, which indicated moderate to severe disability. Her Fear Avoidance Belief Questionnaire (FABQ) work subscale was 21, which indicated moderate fear avoidance related to her work.
The physical exam:
Hagins did a thorough exam overall. In short, he found that compared to other dancers he had treated, this dancer was limited in spinal extension, bilateral sidebending and rotation. However, Hagins didnâ€™t objectively measure the dancerâ€™s ROM and only subjectively compared it based on his clinical experience. He noted a â€œjerkâ€ at the T12-L1 spinal segment with flexion, whereas the rest of the motion was smooth, and that the spine hinged at the T12-L1 segment with sidebending. He found increased passive accessory intervertebral movement of T12-L1 and decreased motion of T11-T12, L1-L2 and L2-L3. The patient also demonstrated weak abdominals.
Hagins placed this patient in the Treatment-Based Classification (TBC) methodâ€™s â€œstabilizationâ€ classification because she had 3 out of 4 of the clinical prediction rules for that classification. Those three were: she was younger than 40, her straight leg raise was above 91 degrees, and she had aberrant movement with lumbar flexion. Hagins reports that he did not check for the 4th rule during the exam due to an oversight.
The treatment of the dancer included a hot pack, soft tissue mobilization, rotary and posterior-to-anterior glides at T11-T12, L1-2 and L2-3 and lumbar stabilization as supported by the TBC method of treating LBP. In addition to this, Hagins provided the dancer with reeducation of both posture and dance movement. He states that he had to continue to encourage the dancer, which I think is an important thing to note because other research I have read states that dancers often are hesitant to heed the advice of health care providers.
For the most part, I think the treatment is reproducible and well done. However, there is one element that stands out to me: Hagins asked the dancer to limit her dance activity. He reports she took 6 weeks off from rehearsals and then left on tour. I am not sure how that is possible and suspect that the dancer might have continued to attend rehearsals during that time.
After treatment the dancer reported 1-2/10 pain on the VAS, an Oswestry score of 26% and FABQ of 16.
I think this provides some good foundational, low-level evidence for the use of the TBC method in addition to customized movement reeducation for the treatment of LBP in a dancer. However, there is no way to know which elements of this treatment were the ones that really made a change. Future studies could look at elements like rest (time away from dance), movement reeducation and the TBC method. I also think establishing normative values for dancersâ€™ range of motion and strength would be beneficial to clinicians, especially ones who do not have clinical experience with dancers to reference.
Take home message:
This patient had seen other therapists and reported little success from the treatments and clearly didnâ€™t experience a lasting effect from them. Of course we do not know what the previous therapists did. This author used the current best evidence for the treatment of LBP in combination with customized movement reeducation for the dancer. At the 5-month follow up the dancer had maintained her gains from therapy. I believe more research needs to be done in this field, but with my current knowledge I would make similar decisions as this author if I were treating a similar patient.
Hagins M. The Use of Stabilization Exercises and Movement Reeducation to Manage Pain and Improve Function in a Dancer with Focal Degenerative Joint Disease of the Spine. Journal of Dance Medicine and Science. 2011:15(3);136-142.