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© 2005, Elsevier Inc. All rights reserved.
First published 2005
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ISBN 0 323 03574 4
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Notice
Medical knowledge is constantly changing. Standard safety precautions must be followed,
but as new research and clinical experience broaden our knowledge, changes in treatment
and drug therapy may become necessary or appropriate. Readers are advised to check the
most current product information provided by the manufacturer of each drug to be
administered to verify the recommended dose, the method and duration of administration,
and contraindications. It is the responsibility of the practitioner, relying on experience and
knowledge of the patient, to determine dosages and the best treatment for each individual
patient. Neither the Publisher nor the editor assume any liability for any injury and/or
damage to persons or property arising from this publication.
The Publisher
Printed in China
Last digit is the print number : 9 8 7 6 5 4 3 2 1
iv
We were saddened to hear of the death of Dr. Scott Nadler on December 26, 2004. Our heartfelt
sympathy is extended to his family and friends. Scott was a prolific writer, astute clinician, excellent
teacher, and most of all a family man who was admired by all.
We will miss you Scott.
TAL
HMC
Commissioning Editor: Dolores Meloni

Project Development Managers: Andrea Alphonse and Henrietta Preston
Project Manager: Anne Dickie
Senior Designer: Stewart Larking
Illustration Manager: Mick Ruddy
Design Manager: Andy Chapman
Illustrator: Mandy Miller
Marketing Managers (UK/USA): Verity Kerkhoff and Laura Meiskey
List of contributors
Frederick Boop, MD James J Laskin, PT, PhD
Associate Professor of Neurosurgery Director, New Directions Wellness Center
and Pediatric Neurosurgeon and Professor of Physical Therapy
Semmes Murphey Clinic Department of Physical Therapy
Memphis, Tennessee The University of Montana
Missoula, Montana
Matthew Chalfin, MD
University of Medicine and Dentistry of Julian Lin, MD
New Jersey – Assistant Professor of Neurosurgery and
New Jersey Medical School Pediatrics
Newark, New Jersey Department of Neurosurgery
University of Illinois College of Medicine at
Robert Clendenin, MD Peoria
Director of Physical Medicine Peoria, Illinois
TN Ortho Alliance
Nashville, Tennessee John Metzler, MD
Instructor, Physical Medicine and
Frank JE Falco, MD Rehabilitation
Mid Atlantic Spine Department of Orthopaedic Surgery
Newark, Delaware Washington University School of Medicine
Thomas D Fulbright, MD St. Louis, Missouri
Clinical Assistant Professor of Surgery Scott F Nadler, DO
University of Tennessee School of Medicine Formerly Assistant Professor
Chattanooga Unit Department of Physical Medicine and
Chattanooga, Tennessee Rehabilitation
Michael Furman, MD University of Medicine and Dentistry of
Clinical Assistant Professor New Jersey –
Department of Physical Medicine and New Jersey Medical School
Rehabilitation Newark, New Jersey
Temple University School of Medicine J Keith Nichols, MD
Philadelphia, Pennsylvania Associate Director of Physical Medicine
Laurie L Glasser, MD TN Ortho Alliance
Associate Professor Nashville, Tennessee
Orthopaedic Institute of Central New Jersey Ricardo Nieves, MD
Sea Girt, New Jersey Medical Director of the Rehabilitation Medicine
David C Karli, MD Unit
Spinal Physical Medicine and Rehabilitation Spine Pain Sports Med PC
Specialist Carlsbad, New Mexico
Steadman-Hawkins Clinic
Vail, Colorado
Frank King, MD
Huntington Beach
California
vii
List of contributors
Heidi Prather, DO Bryan Williamson, MS, PT, ATC

Assistant Professor and Chief of Section Outpatient Physical Therapy Department
Physical Medicine and Rehabilitation Skaggs Community Hospital
Department of Orthopaedic Surgery Branson, Missouri
Washington University School of Medicine
St Louis, Missouri Robert E Windsor, MD
Program Director, Emory/Georgia Pain
Luke Rigolosi, MD Physicians Pain Management Training
Department of Physical Medicine and Program
Rehabilitation Georgia Pain Physicians PC
University of Medicine and Dentistry of Marietta, Georgia
New Jersey –
New Jersey Medical School Lee R Wolfer, MD, MS
Newark, New Jersey Chief, Division of Physical Medicine and
Rehabilitation
Stephen Roman, MD St. Luke’s Hospital
Trenton Orthopedic Group San Francisco, California
Mercerville, New Jersey
Jeffrey L Woodward, MD, MS
Ross Sugar, MD Private Physician
Assistant Clinical Professor Springfield Neurological and Spine Institute
Emory Department of Rehabilitation LLC
and Associate Springfield, Missouri
Georgia Pain Physicians PC
Marietta, Georgia Peter Yonclas, MD
Department of Physical Medicine and
Samuel Thampi, MD Rehabilitation
Attending Pain Management, Anesthesiology University of Medicine and Dentistry of
North Shore Pain Service New Jersey –
Valley Stream, New York New Jersey Medical School
Newark, New Jersey
Robert Tillman, PT, MOMT
Professor of Orthopedic Manual Therapy
Senior Instructor for the Ola Grimsby Institute
and President of Orthopedic Rehabilitation and
Specialty Centers
Little Rock, Arkansas
viii
Preface
The diagnosis and treatment of sports injuries has changed over the last decade. These changes have
included surgical advances in minimally invasive techniques, multidisciplinary approaches to complex
problems, improved imaging studies, and preventive strategies that encompass strength training, agility, and
nutritional concepts.The sports medicine literature is abundant with the fundamentals of individual sports
and their impact on peripheral joints and soft tissues. By comparison, this same information appears
insufficient when relating individual sports to the spine. This text was developed, in part, to address this
difference and to specifically evaluate individual sports and their effect on the spine.
Our goal for this book, in part, was to evaluate spine biomechanics that are commonly seen by the
physician, therapist, or trainer during individual sports. In most chapters, general spine movements unique
to a particular sport are analyzed and the subtle and obvious impacts observed during these movements
discussed. It is our belief that a solid understanding of these biomechanics helps the practitioner to make
informed decisions when evaluating the spine disorder in the athlete.
This text, Spine in Sports, is divided into three sections. The first section features a discussion about
general spine health and biomechanics. The second section divides major categories of spinal injuries
based on age group: mainly pediatric and senior adults. Spinal disorders unique to these populations and
how they affect sports are discussed.The final section features individual sports – biking, running, tennis,
volleyball, weightlifting, wheelchair activities, martial arts, basketball, football, and gymnastics. The
predominant stresses placed on the spine were carefully evaluated for each of these sports. Common injury
patterns, treatment options, and prevention techniques are discussed.We specifically sought out experts in
their specialties, who have both personal experience and treatment expertise with each sport discussed,
to author these chapters. In addition, various specialties and viewpoints are represented, including surgical
and nonsurgical, academic and clinical, physician and therapist.
We would like to thank each author for contributing their expertise to this text. Countless hours of
research and writing are required by each of these contributors to produce such a volume. In addition,
our thanks go out to the publisher, numerous transcriptionists, medical artists, mainly Suzanne Lennard,
and our families who tolerated us during this project. We hope this text deepens your understanding of
the spine in sports.
Ted A Lennard, MD
H Mark Crabtree, MD
ix
Dedications
Ted Lennard – to my wife, Suzanne, and daughters, Selby, Claire, Julia
and Maura
Mark Crabtree – to my wife, Tammy, and sons, Nathan, Brandon and

Ryan
x
SECTION ONE • General spine fitness and preparation for sports
CHAPTER 1 Principles of Spine Fitness

in the Athlete
David C Karli
Lee R Wolfer
INTRODUCTION
The spine is the core from which our movements originate. Athletic performance is dependent upon a
stable spine with well-coordinated neuromuscular patterns of movement. A stable spine is maintained by
three subsystems with passive, active, and neural components, as described by Panjabi1 (Fig. 1.1). The
Control
Subsystem
Neural
Passive Active
Subsystem Subsystem
Spinal Spinal
Column Muscles
Figure 1.1
The spinal stability system as outlined by Panjabi. (Adapted from Panjabi.1)
3
Principles of Spine Fitness in the Athlete
passive subsystem includes intrinsic spinal anatomy comprising vertebrae, intervertebral discs, facet articu-
lations, joints capsules, and extensive ligamentous attachments.The active subsystem includes the muscles
and tendons acting on the intrinsic elements.The neural subsystem comprises afferent sensory receptors
distributed throughout all tissues, an efferent arm, which executes motor actions, and a control center,
which integrates sensorimotor function. Coordination of these subsystems is critical to the generation of
movement.
The lumbopelvic region acts as a focal point through which our center of gravity travels. Specifically,
the center of mass during standing and with movement has been determined to lie approximately 5 cm
anterior to the second sacral vertebrae. This concept is important because movement of the body as a
whole requires transfer of force from the center of mass through the extremities. Athletic performance
requires efficient and coordinated transfer of these forces. The reason a 170 lb pitcher can generate a
90 mph fastball is due to an ability to generate power by efficient transfer of forces from ground to leg,
to lumbopelvis, to trunk, to upper extremity, and, finally, to the ball. This concept has been described as
the functional kinetic chain.
This chapter outlines a physiatric approach to the spine in
sports, wherein is contained the core principles for achieving Box 1.1 World Health Organization definitions
athletic and fitness goals. This functional model is well outlined Impairment: any loss or abnormality of body structure or of a
in the 1997 World Health Organization definitions of impair- physiological or psychological function.
ment, activity, and participation (Box 1.1).These core principles Activity: the nature and extent of functioning at the level of the
include understanding spine biomechanics, flexibility, strength, person.
conditioning, core strengthening, stabilization, and cross train- Participation: the nature and extent of a person’s involvement in
ing. We also describe the concept of functional movement life situations in relationship to impairments, activities, health
conditions, and contextual factors.
and the importance of developing more efficient movement
patterns before focusing on strength training and sports-specific
Source: from WHO International Classification of Impairments, Activities, and
skills. These core principles provide the building blocks for Participation, 1997. Geneva: World Health Organization.
enhancing athletic performance. This applies to all levels of
sports participation, from the weekend gladiator to the elite
athlete.
Box 1.2 Factors influencing injury,
Yet another important concept is prehabilitation.Training to prevent injury and enhance rehabilitation, and return to sport
performance defines prehabilitation. Most times, spine fitness is not addressed until after the
onset of back pain. Many athletes develop inefficient movement patterns due to asymme- Prior injury
tries of flexibility and strength. By identifying and correcting these inefficiencies, the Age
practitioner may help the athlete prevent injury, disability and improve performance (Box Type of injury
1.2).This chapter outlines an approach towards assessment of the musculoskeletal system in Level of competition
the athlete, through baseline health-related fitness testing, functional movement screening, Overall fitness (e.g., flexibility deficit)
and developing an exercise prescription to correct the deficits. Time of sporting season
Equipment
EPIDEMIOLOGY OF SPINAL-RELATED PAIN IN ATHLETES

Injury is a realistic complication of intense exertional activity. High-velocity bodily movements, collision
and repetitive forceful muscle contractions push the limits of tissue integrity. Athletic performance con-
tinues to improve with advances in training and nutrition. Enhanced performance places muscles,
tendons, soft tissues and bony articulations at high risk for failure.
The spine links the torso to the extremities.This link ensures a coordinated transfer of power from the
ground through the body, producing movement and performance. Due to anatomical relationships, spinal
elements are subject to tremendous stresses during athletic activity. This includes normal physiologic
curvatures, which preferentially load posterior spinal structures and intervertebral discs. Zygoapophyseal
joints, the pars interarticularis, and disc structures are tissues that most commonly demonstrate pathology
in the athlete. In particular, the lumbar segments accept the greatest stresses in the form of ground reaction
forces, which are high due to gravitational effects and body weight. Episodes of pain are typically related
4
Epidemiology of Spinal-Related Pain in Athletes
to one of two mechanisms: acute trauma or, more commonly, repetitive stress fatigue injury. Sports involv-
ing potentially high-impact axial loading of the cervical spine have resulted in rare episodes of high-
profile injuries to the spinal canal and cord.
In the general population, back pain is one of the most common complaints prompting physician visits.
The lifetime prevalence of spinal-related pain in population studies ranges from 60% to 80%.2 Recovery
from episodic acute back pain occurs in 70% of cases within 3 weeks, 90% within 3 months, and 95%
within 6 months. In 4% of the general population back pain becomes chronic. Up to 70% of patients have
recurrent episodic back pain. Treatment costs and secondary disability-related costs create an enormous
societal financial burden.
During athletic activities, the spine is subject to rapid, repetitive, sometimes high-impact loading. As
the beneficial effects of exercise continue to be recognized and marketed, an increase in the number of
people participating in higher-impact exercise and athletics has followed. This trend has included older
populations and seniors. In addition, quality and quantity of training and preparticipation preparation
varies greatly.These factors have resulted in subsequent increases in the total number of injuries, including
injuries to the spinal column.
Attempts at quantifying the incidence of spinal-related pain have been difficult. As is seen in the
general population, most episodes of back pain in athletes resolve spontaneously, without specific
treatment. This leads to underreporting of the condition, and difficulty documenting the condition
among trainers and health care practitioners. Numerous authors have estimated that approximately
10–15% of sports injuries are related to the spine.3 Authors Dreisinger and Nelson reported an incidence
between 1.1 and 30% of back pain in athletes, depending specifically on the sport involved. A study by
Tall and Devault recorded spinal injury with associated neurologic deficit in 0.6–1% of all athletic
injuries.3 Most studies comparing contact and noncontact at various levels of competition reveal a soft
tissue source that is self-limited.Those injuries with significant neurologic sequellae are usually associated
with direct axial forces, and are closely related to the mechanism of injury as opposed to a specific sport.
The lumbar spine is the most frequent site of injury in gymnastics, football, weightlifting, wrestling,
dance, rowing, swimming, amateur golf, and ballet.4 In professional golf and aerobic dance, the lumbar
spine is the second most common site of injury.4 Lumbar spine pain is also a significant source of disability
in general dance, skating, tennis, baseball, jogging, cycling, and basketball. Sport-specific epidemiologic
studies have shown that 30% of football players and 15% of basketball players have lost time from play due
to low back pain.4 Among professional men’s tennis players, 38% have missed at least one tournament
because of low back pain.4 In a 10-year review of traumatic cervical spine injuries in children, 10% were
attributed to athletics.4
Similar to recovery data from the general population, a significant majority of acute-onset back and neck
pain in the athletic population are self-limited injuries that respond well to conservative management.These
recovery patterns are influenced by factors unique to the athletic population. Discrepancies exist when
comparing athletes and nonathletes as well as adolescent versus adult athletes. Epidemiologic studies suggest
that a majority of back injuries in both athletes and nonathletes are soft tissue related. In these instances, a
specific pain generator is often unidentifiable.A significant majority of cases have an unestablished diagnosis
at the time of initial presentation.With this in mind, numerous studies have identified high-risk sports and
athletic activities that predispose athletes to these types of injuries. Recall that back injuries in upper level
or professional athletes are likely to be underreported due to fear in the athletes that they will miss
competition time or financial incentives.The general population, however, may be more likely to report even
minor spinal-related pain to gain access to workers’ compensation or disability benefits. Motivation to
recover may also be different in these two populations for similar reasons.
Adolescent athletes also face different challenges from the mature athlete. Skeletal immaturity, growth,
decreased body mass, training and nutritional deficiencies all set up a unique potential for spinal
pathology. Discrepancies between bony and soft tissue growth set up excessive tightness in the lumbosacral
fascia and hamstrings, leading to hyperlordosis and increased stress through the posterior elements.
Immature skeletal endplates can lead to tissue failure and herniation of nucleus pulposis into the vertebral
body. Pars defects are more commonly encountered in the skeletally immature athlete, especially in those
subject to repeated lumbar hyperextension.5
5
FOUNDATIONS OF SPINE FITNESS
Functional spinal biomechanics

As the axis from which the extremities originate, the spine has several critical functions: (1) support, (2)
mobility, (3) housing and protection, and (4) control. As a supporting structure, the spine creates a
framework from which gross bodily movements can occur, acting as a dynamic but stable conduit to
conduct forces throughout the body. Spinal segments act as the origin for the protective bony rib cage,
and numerous attachment points for soft tissue structures within the axial body habitus.The spine houses
and protects the spinal cord and associated neural structures, and has a critical role in maintaining postural
alignment against the effects of gravity.
Spinal anatomy has often been categorized as a series of “motion segments,” or a tandem series of
functional units, working as a whole to create a physiologic range of motion.6 Each motion segment is
composed of two adjacent vertebral bodies, and the intervertebral tissues including disc, ligament, joint,
and muscle.This unit is the smallest segment of the spine, exhibiting all of the biomechanical properties
of the entire spinal column.
Actions producing movement within this functional segment relate to multiple degrees of freedom
(three translations and three rotations). Translation occurs when applied shear forces induce parallel
movement of one vertebra on its adjacent counterpart. Rotation occurs in response to torque and involves
a spinning motion of a vertebra about a stationary axis. Loads and torque applied to motion segments
along multiple axes produce primary and coupled translations and rotations, which generate complex
spinal flexibility characteristics. Bony anatomical discrepancies and primary physiologic curvatures among
different segments of the spine create unique motion limitations specific for that functional segment.
Cervical motion segments are anatomically structured to accommodate a wide range of flexion, exten-
sion, side bending, and rotation. Thoracic segments and the bony elements of the rib cage create sig-
nificant motion limitations in multiple planes, to fulfill a role as a more static framework and protector
for the chest cavity. Lumbar segments are tailored towards weight-bearing and stabilization of forces
created by the lower extremities, allowing for flexion and extension but limiting other planes of motion.
Soft tissues associated with the spine play critical roles in support and mobility. Ligaments act as passive
restraints to spinal motion, whereas muscles are both passive and active restraints. A vertebral column
stripped of all tissues except bone, intervertebral disc and ligaments is only capable of supporting around
40 lbs of axial load before collapse. Addition of the rib cage and pelvis increases weight-bearing capacity
to around 70 lbs. Active extrinsic support from the supporting muscle tissue is required to accommodate
demands of life and exercise.
Two key muscle groups – flexors and extensors – act as spinal stabilizers and functional mobilizers of
the spine. These muscle groups are most critical in the load-bearing lumbosacral vertebral segments. In
this region, spinal flexors are differentiated into two layers.The deep, short lever arm layer includes a thick
psoas group. A second, longer lever arm group includes anterior and oblique abdominals muscles. The
longer moment arm gives these muscles a distinct mechanical advantage. In part, these outer layer muscles
provide stabilization indirectly by allowing internal visceral structures to act as a hydraulic strut when they
are contracted and intra-abdominal pressures increase.A complex of paraspinal muscles make up the spinal
extensors. Due to an extremely small lever arm, these muscles have limited actions as spinal stabilizers.
They are essential in controlling spinal flexion via eccentric activation.This allows for controlled collapse
of the spine until the ligamentous system is under full stretch, where they can take over stabilization. In the
frontal plane, movements and stabilization are controlled primarily by the quadratus lumborum muscle.
Flexibility
Introduction
Among athletes, coaches, and health professionals, average to above-average flexibility is universally
considered a critical component for achieving and maintaining optimal sports performance as well as for
6
Foundations of Spine Fitness
injury prevention. Although basic science studies have supported this assertion, clinically
Box 1.3 Benefits of flexibility there is conflicting evidence on the role of flexibility in injury prevention, rehabilitation and
sports performance.7 There is a lack of critically reviewed scientific evidence to suggest that
enhanced flexibility improves performance or reduces injury risk. Despite this, flexibility
remains an accepted and relatively standard element within fitness and athletic training, as
well as most rehabilitation protocols. In addition, within exercise-oriented cultures,
flexibility-based fitness programs such as yoga and Pilates continue to gain popularity.
According to the American College of Sports Medicine, numerous benefits are ascribed to
Source: from Luebbers.8 improved flexibility (Box 1.3).
Definition
Flexibility can be quantified as either static or dynamic.9 Static flexibility is the range of motion (ROM)
of a joint or series of joints. The individual is in a relaxed state for these measurements. An individual’s
flexibility is primarily affected by connective tissue. Quantification of resistance to movement shows
tendons contribute 10%, ligaments 47%, and fascia 41%.10 Range of motion reflects a chain of elements
from the joint (which may be arthritic or have a bony deformity), to the ligamentous joint capsule, to the
tendon, to extra- and intramuscular fascial layers, and then finally to the muscle itself.
Dynamic flexibility is defined as the ease of movement within the joint ROM.7 Dynamic flexibility is
affected both by the static flexibility of a given muscle and by the strength of the corresponding antagonist
muscle. For example, a football place kicker must have the hip extensor flexibility to achieve the necessary
range for adequate force generation and then have adequate hip flexor and knee extensor strength to
follow through with the kick.
Clinically speaking, there are generally accepted static ranges of motion for given joints.9 However,
there is a spectrum of norms if one considers the difference between adequate flexibility for activities of
daily living in a sedentary individual versus the ideal range needed for a professional ballet dancer to
achieve optimal flexibility for mastery of technique and injury prevention.11 Optimal flexibility depends on
multiple factors, including the specific joint and individual factors, sports-specific demands, and so forth.11
Each sport has a specific pattern of muscle use that must be taken into account for prehabilitation,
sports performance, risk of injury, and rehabilitation for return to sport. Demands for flexibility also vary
considerably across sports. Certain obvious comparisons contrast the optimal range of flexibility needed
in ballet, gymnastics, or figure skating versus running, skiing, or football. Injuries can occur from either
too much (hyper) or too little (hypo) flexibility, depending on the stress placed on the muscles and joints.
Muscles strains, as opposed to joint sprains, are associated with a relative lack of flexibility. A lack of
hamstring flexibility is associated with low back pain. Joint sprains are more common with excessive
flexibility: e.g., pitchers may gain flexibility but lose stability and thereby develop anterior glenohumeral
joint laxity and chronic subluxation. In gymnasts there is a well-described increased risk of spondylolis-
thesis due to repetitive hyperextension movements.
Factors affecting flexibility

Many factors have been explored in the literature as having effects on flexibility. Extensive literature exists
on factors affecting flexibility; however, only selected factors will be addressed in this chapter. Flexibility
is influenced by both intrinsic and extrinsic factors: age, gender, genetic predisposition, temperature,
neurophysiologic and biomechanical properties of a given muscle, antagonist muscle strength, and so
forth.12 Factors such as neurophysiologic and biomechanical properties may be modifiable with training
and activity.
Age. Generally, it is believed that age is inversely correlated with flexibility.The young are thought to be
the most flexible, whereas the elderly are thought to be the least flexible. With careful review of the
literature, however, it is evident that there is not a simple linear decline of flexibility with aging. One of
the largest studies performed evaluated ability to touch toes in over 4500 youth, from kindergarten to
12th grade.13 The patterns of flexibility found by these authors have been borne out over time. Overall,
studies reveal that young children (ages 5–8) are the most flexible; subsequently, however, flexibility then
decreases until puberty. Micheli14 documented decreased flexibility during growth spurts when bone
7
growth outpaces muscle elongation. Clinically, this relationship is associated with overuse injuries among
active youth and Osgood–Schlatter’s disease. During adolescence, flexibility increases. After adolescence,
flexibility remains level for a short time and then begins to decrease. Barnekow-Bergkvist15 followed
males and females from age 16 to 34 and showed decreased absolute flexibility in both genders. It is
important to note that many of these studies may be confounded by not adjusting age for maturation
stage. In a study of high school boys, Pratt16 demonstrated that the maturational age by Tanner staging is
correlated with flexibility as opposed to chronological age.
In older individuals, flexibility decreases are affected by intrinsic changes to the collagen, which include
increased collagen fiber diameter, crystalline content, and intra- and intermolecular cross-links. These
changes make the tissues less compliant and mobile.10,17 Older individuals also have significantly less water
content in their tissues. In older individuals, extrinsic factors such as sedentary lifestyle, effects of disease,
and deconditioning also contribute to decreased flexibility. Fortunately, numerous studies have shown that
older individuals can maintain or improve their flexibility through a regular stretching program.18,19
Gender. Factors contributing to differences in flexibility by gender have been better substantiated by the
research literature and specific anatomic and physiologic differences. For example, the pelvic bones of
women are broad and shallow, allowing greater hip and pelvic ROM, as opposed to men whose bones
are narrow and heavy.10 Secondly, the hormonal changes associated with pregnancy are thought to
increase joint laxity and general flexibility.A female’s lower center of gravity may also allow greater trunk
flexion.20
Extrinsic gender-biased and sex-role dominant psychosocial factors encourage females to pursue
traditionally “feminine” activities such as dance and gymnastics and discourage them in pursuing more
“masculine” activities such as weightlifting, football, baseball, and so forth. The opposite social pressures
are exerted on males. Such social forces shape a person’s vocational and avocational decisions and therefore
influence body type and exercise habits. These psychosocially instigated influences are potential con-
founding factors in any gender-based flexibility research study.
Genetic predisposition. There are a number of hereditary disorders, such as Marfan’s syndrome and
Ehlers–Danlos syndrome, with defective collagen biosynthesis. Affected individuals with these syndromes
are pathologically flexible. Homocystinuria can cause joint hypermobility. In the less-severe category,
there are also individuals who exhibit genetic hyperlaxity which may or may not predispose them to
injury.
Temperature. Muscle and connective tissues change their physical properties with elevated or reduced
temperatures. Overall, elevated temperature facilitates greater range of motion. Many factors are involved,
including reduced viscosity, increased collagen extensibility, and neural facilitation of stretching. Heat
facilitates stretching by diminishing the muscle spindle reflex and increased firing of Golgi tendon
organs.21 Heat can be used therapeutically to decrease muscle spasm.
Clinically speaking, warm-up (by passive or active means), is recommended to enhance performance
and prevent injury.Warm-up is universally recommended before beginning flexibility exercises. Box 1.4
lists the benefits ascribed to warming up.
Muscle physiology
Besides actin and myosin, myofibrils contain a third, recently rediscovered, filament called titin. Titin is
thought to give myofibrils elasticity because of its intrinsic properties and position in the sarcomere.Titin
has a high proline content and is organized into random coils instead of more rigid alpha-helices.22 The
elastic titin filaments connect the thick filaments to the Z-line of the sarcomere.10 The titin filaments are
positioned to maintain resting tension in the myofibrils. Various muscle types contain differing
proportions of titin. For example, slow-twitch muscle fibers contain less titin than fast-twitch muscle
fibers and are less flexible.12 Titin is also found in different isoforms.10 The elasticity of a muscle cell may
be dependent on the type and amount of titin.
8
Muscle biomechanics. When discussing joint flexibility we

Box 1.4 Benefits associated with warming up refer to the flexibility of the connective tissue that comprises
Increased body temperature tendons, ligaments, fascial layers, joint capsules, and muscle.
Increased blood flow through active muscles by reducing vascular Connective tissue is made of collagenous fibers in a protein–
bed resistance polysaccharide ground substance with both elastic and plastic
Increased heart rate to prepare the cardiovascular system for work properties.11 With stretching there is lengthening due to both
Increased metabolic rate properties; however, when the stretching force is removed, the
Increases in the Bohr effect (facilitates exchange of oxygen from elastic elements return to their resting length and the plastic
hemoglobin) elements stay elongated. Plastic deformation causes lasting
Increased speed at which nerve impulses travel, thereby facilitating changes in the length of connective tissues, which is enhanced
body movement by elevated temperature and the application of low force loads
Increased efficiency of reciprocal innervation (thus allowing for long periods of time. These physiologic properties of
opposing muscles to contract and relax more efficiently)
connective tissue form the basis for the recommendation to
Increased physical working capacity
warm-up the body before stretching and to use static stretching
Decreased viscosity (or resistance) of connective tissue and
techniques. However, static stretching may not actually
muscle
significantly increase the length of the muscle; instead, it may be
Decreased muscular tension (improved muscle relaxation)
that regular stretching decreases the excitability of the stretch
Enhanced connective tissue and muscular extensibility
reflex and increases stretch tolerance.10
Enhanced psychological performance
Source: adapted from Alter.10

Neurologic factors. Muscle flexibility is a dynamic process
mediated by input from three major sensory receptors: the
muscle spindles, Golgi tendon organs, and articular (joint) mechanoreceptors. Muscle spindles are
composed of small muscle fibers encased within a fusiform (spindle-shaped) capsule or sheath of
connective tissue.The ends of the muscle spindles are attached to the extrafusal fibers such that when the
muscle is stretched so is the spindle.There are two types of muscle spindles, primary and secondary, which
react to change in rate of elongation and to change in absolute length, respectively.The spindle reflex is
activated during muscle elongation and prevents over-stretching by causing the extrafusal fibers to
contract and shorten the muscle. Conversely, the spinal reflex, mediated by the Golgi tendon organ,
promotes muscle elongation.12
The Golgi tendon organ (GTO) is located at the aponeuroses or muscle–tendon junctions.As opposed
to muscle spindles, which are found parallel to the myofibrils, the GTO is in line with the force vectors
from muscle to bone and therefore in series with the muscle.The GTO is a mechanoreceptor innervated
by a single fast-conducting Group Ib afferent nerve fiber.23 The function of GTOs, on a simplistic level,
is autogenic inhibition. GTOs are thought to serve a protective function against muscle contraction forces
that would cause damage at the musculotendinous junction. Past a certain threshold stimulus, the GTOs
shut down the agonist and synergistic muscles and facilitate the antagonist muscles. Of course, this
mechanism is often overridden in athletes because of higher center influence to optimize performance.
The third major sensory receptor subtype is the joint receptor, located in all the synovial joints of the
body.The receptors are classified as types I–IV, based on various morphologic and behavioral attributes of
the nerve endings. Mechanoreceptors sense stretch pressure and distension on joints.
Ergonomic factors. Researchers found that prolonged sitting in school leads to decreased hamstring
flexibility.24 Such ergonomic factors may confound age-related changes in flexibility, in that it is actually
the sedentary lifestyle that results in decreased flexibility rather than actual age-related changes in the
muscle. Pheasant25,26 evaluated the ergonomics of sitting and describes a hypothesis for the loss of
hamstring flexibility. In the classic, slouched sitting position, the hamstring muscles are relatively slack
because the pelvic is rotated backwards behind the pubic symphysis.With upright posture, balancing on
the ischial tuberosities, the hamstrings are taut. Pheasant hypothesizes that with prolonged poor seated
posture, the hamstrings adapt and shorten.
9
Flexibility and strength training

The standard conception is that increased strength training leads to decreased flexibility.There is often an
anecdotal bias in this observation: persons engaged in resistance training may not perform regular flexi-
bility exercises and may focus only on “mirror muscles,” which can create muscular asymmetries in strength
and flexibility. In fact, with proper weightlifting, flexibility can be improved with resistance training.
To enhance flexibility using resistance training, the muscle is trained utilizing its full ROM and
accentuating the negative work or eccentric phase of the lifting technique.10 In an eccentric contraction,
the muscle elongates as it contracts; in concentric contraction, the muscle shortens as it contracts. During
an eccentric contraction, there are fewer muscle fibers contracting, thus placing a greater stress and
therefore greater stretch per fiber.10 This is why focusing on eccentric contractions during weight lifting
causes such sore muscles.
Flexibility and breathing

Only a rare few publications in the literature on flexibility address breathing and flexibility and try to
answer the question of whether or not proper breathing can facilitate stretching. Proper breathing is the
core part of hatha yoga. Many different breathing techniques are used in the mainstream to elicit the
relaxation response and as a part of meditation. Breathing exercises are also a core part of the armamen-
tarium for managing chronic pain. Lewitt27 describes the term synkinesis in sports medicine, which refers
to a movement being linked with expiration or inspiration. Few studies have looked at the effects of
breathing on flexibility. According to Alter,10 a correct breathing pattern can be coupled with movements
that facilitate flexibility. For example, with forward trunk flexion, expiration decreases the size of the
thoracic cavity, moves the diaphragm upwards, reduces tension on the erecter spinae, intercostals, and
abdominal muscles, and ultimately increases flexion. Controlled breathing also can elicit a relaxation
response which can decrease the excitability of the myotactic stretch reflex. Overall, there appears to be
no negative consequence of coordinating breathing with stretching. Athletes can be instructed to inhale
in extension poses and exhale for forward flexion and lateral bending postures.
Flexibility and injury

The prevailing beliefs among healthcare professionals and athletes is that better flexibility means lower risk
of musculoskeletal injury. In particular, being flexible is thought to protect against muscle strains and
overuse injuries. The biomechanical explanation is that the more compliant (less stiff) a muscle is, the
more it can be stretched (greater strain) and thereby less chance of strain injury.7 According to Gleim and
McHugh,7 who extensively reviewed the epidemiology of sports injury, there is “no strong evidence
proving that flexibility stretching is associated with rates of strains, sprains or overuse injuries that can be
applied across all sports or levels of competition.” Gleim and McHugh7 state that sports injury is a
“multifactorial problem” difficult to study without very large studies. This is not to say that a flexibility
benefit does not exist: studies to date have not been able to definitively bear this out. Basic science research
in the animal model has shown that active warm-up with isometric contractions increases elasticity and
raises the force and length at which the muscle will fail.28 A fatigued muscle was found to be more
susceptible to strain injury.29 Smith et al30 studied adolescent figure skaters and revealed an association
between anterior knee pain and tight hamstrings and rectus femoris muscles. Interestingly, in the case of
elite runners, the less flexible runners were more economical and thus more efficient than their more
flexible counterparts (r = 0.53–0.65). The authors speculated that increased stiffness perhaps meant less
need for postural muscles or more stored energy from the elastic recoil of the stiff muscles.31 As can be
seen from the preceding paragraph, much research needs to be done to elucidate the links between
flexibility and injury.
Stretching techniques
Various stretching techniques are recommended (Box 1.5). Usually, simple static stretching is recom-
mended for most patients.The more complicated techniques require greater patient education and often
are more effective when performed with a partner. Blanke11 describes the common techniques. Static
stretching involves moving slowly to the point of moderate discomfort (not pain) of a joint ROM and
10
then holding the position for 10 seconds to 1 minute. The goal

Box 1.5 ACSM guidelines for stretching (1998) with moving slowly is to avoid eliciting the stretch reflex which
Focus: major muscle groups would inhibit elongation. Next, an athlete can use static
Warm-up first: slow 5–10 light exercise (jog or walk) stretching with contraction of the antagonist (reciprocal
Frequency: 3–7 days per week inhibition). This technique adds isometric contraction of the
Repetitions: 3–5 times antagonist muscle, which further reduces the stretch reflex (i.e.,
Type: slow, sustained static stretches (PNF, AIS recommended when stretching the hamstrings, one would isometrically
when educated by trained professionals) contract the quadriceps for 5–30 seconds). Static stretching can
Duration: hold between 10 and 30 seconds also be performed with contraction of the agonist
Don’t strain: the goal is to feel a slight pull, not pain. Muscles will (proprioceptive neuromuscular facilitation, PNF). In PNF, the
adapt to progressive slight overload over time. joint is moved to the end of its ROM and then the agonist
Cool-down after exercise bout: recent studies advocate light muscle is contracted (varying strength contraction force) for
preparatory stretching and a more intense post-workout stretch 5–30 seconds.The goal is to contract the muscle being stretched.
afterwards. One theory is that stretching after working out allows These stretching maneuvers can then be combined for even
quicker removal of energetic wastes and decreases delayed-onset
greater effect. In this method, the athlete performs static
muscle soreness.
stretching with contraction of the agonist followed by
contraction of the antagonist (PNF). First, the muscle being
stretched is contracted; then the agonist is relaxed and the antagonist muscle is contracted for 5–30
seconds. Purportedly, this method has an additive effect on stretching the muscle.
Ballistic stretching is not generally recommended because of the increased risk of injury when a joint
is moved to the end of its ROM by jerking or bouncing movements. Ballistic stretching is effective but
there is an increased likelihood of muscle strain, connective tissue sprain or bone avulsion when a joint is
moved beyond its comfortable ROM. On a neurophysiologic level, slow, steady stretching is recom-
mended over ballistic stretching because it is less likely to elicit the stretch reflex. Muscles contain spindles
that are sensitive to the amount and rate of elongation of the muscle.When a muscle is stretched quickly
and intensely, especially near the end of a joint’s ROM, the muscle spindle sends a stimulus to the spinal
cord that causes the muscle being stretched to contract.This is a protective reflex against stressing a muscle
and joint beyond its comfortable ROM.
Flexibility prescriptions
In summary, it is critical to include a warm-up and a cool-down period when designing a flexibility
program. The cool-down period is thought to help with clearing the waste products from metabolism.
Next, consider the appropriate stretching technique for the individual, e.g., static stretching versus PNF.
As a rule, apply low loads over longer duration as opposed to high loads over short times to decrease the
risk of injury. Trainers can identify the key stretches for particular sports: e.g., shoulder flexibility in
swimmers. Finally, for dynamic flexibility, be sure to strengthen the antagonist muscles. The ACSM put
forth guidelines for stretching in 1998.
Strength
Strength training remains a standard element of any core exercise program. As a working definition,
strength represents the ability of skeletal muscle to develop force for the purpose of providing stability and
mobility within the musculoskeletal system, so that functional movement can take place.32
Strength training principles have been developed and refined over many years.The rationale for these
principles is based on an understanding of muscle cell physiology and cellular adaptations to training and
progressive resistance loading. Force generation is dependent on the integrity of contractile and support
tissue within the muscle cell. It also relies on central and peripheral neural interactions and metabolic
support systems.
Skeletal muscle comprises two major fiber types, which differ in their histologic, biochemical, and
metabolic makeup. Type I (slow oxidative) fibers are densely supported by a circulatory network that
continually feeds the tissue with oxygen-rich blood. Energy production in these tissues is through aerobic
11
oxidative pathways, which allow the fibers to work most efficiently in repetitive, low-impact, sustained
contractions. Type II fibers are subdivided in types IIa and IIb. These fibers are best used for rapid,
nonsustained, high-force contractions.Type IIa (fast oxidative glycolic) fibers use a combination of aerobic
and anaerobic pathways, acting as an intermediary between type I and type IIb (fast gycolytic) fibers,
which gain energy from anaerobic pathways – namely glycolysis.Type IIb fibers produce the highest force
of contraction, but fatigue most easily. All muscles contain a variable ratio of types I and II fibers, making
some muscles more resistant to fatigue, and others set up for power generation.A high distribution of type
I fibers is found in postural muscles in which low-intensity, sustained muscle contractions hold the body
stable and erect against gravity. Muscles with a high percentage of type II fibers produce rapid bursts of
tension over short periods of time.
Neural control over muscle contraction is created by the motor unit. Neurons from the anterior horn
of the spinal cord supply groupings of muscle fibers. Motor units are subdivided into smaller type I and
larger type II groupings.These groupings are “recruited” into activation as a higher force of contraction
is required. The normal sequence of motor unit activation recruits smaller units first, due to the lower
threshold for firing of their associated alpha motor neurons, within the anterior horn. As the functional
demand for higher force increases, larger, type II motor units are activated sequentially to fill the demand.
This has important implications in training principles, as a submaximal effort will not induce a training
effect of all type II motor units.
Muscle tissue can sustain different types of contractions, depending on the applied loads.Three distinct
types of contractions can occur:
• concentric contraction is created when force generated within the muscle exceeds the magnitude of
the applied external force, resulting in muscle shortening,
• isometric contraction occurs when the force generated within the muscle equals the force of the
applied load and there is no resulting change in muscle length,
• an eccentric contraction is created when external force exceeds force developed by the muscle, and
gross lengthening of the muscle results.
Muscle force potential is effected by a length–tension relationship, set up by specialized histology con-
tained within the sarcomere unit. An optimal muscle length exists, at which the muscle can generate its
greatest force. At this length, maximal cross-bridging occurs between actin and myosin proteins of the
sarcomere.This position occurs at some midpoint of the contraction, with less force development at more
lengthened and contracted positions.
A second performance relationship exists, defining an optimal velocity of muscle contraction. Actin
and myosin cross-linking is affected by speed of contraction.The ratchet effect created by cross-bridging,
and recycling of ATP, has an optimal frequency at which the greatest force and efficiency of the system
occurs. During concentric contractions, greater force of contraction is created with decreasing speed,
approaching maximal force at zero velocity, or a static isometric contraction. During eccentric contrac-
tions, exponential increases in force generation occur with increasing speed.This effect is felt to represent
contributions by both the contractile mechanism and the elastic properties of muscle connective tissue.
A number of intrinsic and extrinsic factors affect muscle performance and strength. Intrinsic factors
include general health parameters such as neurologic, metabolic, circulatory, and hormonal effects. The
effects of aging on muscle tissue are also well established.33 With age comes a progressive decline in muscle
force potential. This results from a combination of factors, including progressive loss of muscle mass,
mainly due to a decline in the number of motor neurons, leading to a decrease in motor unit recruitment
and frequency of action potential generation.The efficiency of neuronal inputs also becomes less efficient.
These factors all contribute to lessen the ability of aged muscle to rapidly develop maximal forces of
contraction.33
Prolonged immobilization also has adverse effects on muscle performance.This applies to bedrest and
habitual or seasonal inactivity as well as to cast immobilization with acute injury, a scenario often seen in
the athlete. In the absence of muscular contraction, physiologic changes in muscle tissue result. Reduced
neural input leads to decreased muscle size, fiber atrophy, alterations in metabolic pathways, reduction in
capillary density, and connective tissue thinning.As a result, a smaller, weaker, less-efficient and less-elastic
12
muscle is created. The rate of atrophy is rapid during the first few weeks of fixed immobilization, then
plateaus and progresses more slowly.34 Muscles immobilized in shortened positions will atrophy more than
those in neutral or elongated positions.This is a result of a net loss of sarcomeres in a short immobilized
muscle, and net gain of sarcomeres in an elongated, immobilized muscle, both adaptations to the respective
positions. The end result is a change in normal length–tension relationships discussed earlier, and
compromised performance. Both type I and type II fiber types are affected by these adaptations, with
decreased type I fiber cross-sectional area occurring earlier than that seen in type II.
Muscle tissue adaptations to strength training

Muscle tissue responses to progressive loading have been investigated extensively. A series of neuro-
muscular and histologic changes occur to increase force generation capacity.The initial trigger inducing
these anabolic changes appears to be increased neural input from descending motor neurons.This induces
the opposite effect of disuse or immobilization, a catabolic effect described previously.
In addition to hypertrophic changes in the contractile elements of muscle, animal studies show evi-
dence of expansion of the synaptic area of the neuromuscular junction in response to heavy resistance
training.35 With augmented neural input, skeletal muscle hypertrophy ensues.This comes in the form of
increased muscle fiber size and cross-sectional diameter, secondary to a remodeling of muscle histology.
Sarcomeres and myofibrils are reproduced in both type I and type II fibers, depending on the stimulus
intensity, with type I fibers being trained at lower intensity levels. In addition, metabolic changes lead to
a conversion of type IIb fibers to type IIa fibers.A final effect occurs with proliferation and strengthening
of connective tissue and supportive satellite cells.36
Systemic benefits of resistance training include increases in bone mass and bone mineral density
(BMD).This effect is directly proportional to the magnitude of applied skeletal loading.This is apparent
in studies comparing endurance athletes to athletes trained for power and explosion. Smith and Rutherford37
compared male triathletes to rowers to nonathletes, with higher BMD seen in rowers over triathletes.
Other positive effects of strength training include increases in lean body mass and a decreased percentage
of body fat. Metabolic demands within skeletal muscle under exertion rely in part on oxidative phospho-
rylation of free fatty acids, which are mobilized from adipose tissue.
Functional benefits of resistance training are evident in studies on elderly subjects, which demonstrate
improvements in balance, coordination, gait, and higher level performance in athletic and occupational
tasks. These changes are impacted by comorbidities, psychological status, and pretraining strength levels.
Although no direct studies have been definitive, similar effects can be expected on a more subtle level in
highly trained athletes, who have less general comorbidity, but may often be faced with more isolated
dysfunction, as is seen with acute or chronic injury.These principles will apply on a more localized scale
to the affected body part, which will be functioning suboptimally due to tissue damage, inflammation,
and disuse.
Principles of strength training

Strength training can be tailored to selectively train and recruit different fiber types in muscles, by control-
ling and varying the load/intensity, speed, and duration of the exercise. Using basic principles of strength
training, programs can be uniquely designed for a variety of athletic activities and athletes. These prin-
ciples apply to all skeletal muscles in the body, including those structures intimately associated with the
spinal column.
In its simplest applications, strength training involves inducing stress and microtrauma in muscle tissue
by applying moderate to maximal contractions against a gradual increase over time in the applied load.
This activity is interrupted by periods of rest with nutritional support of the muscle on an ongoing basis.
Muscle undergoes reactive neurophysiologic and histologic changes, as described previously.
Resistance can be applied to contracting muscle tissue under static or dynamic conditions. Isotonic
resistance exercise is a dynamic form of exercise with a change in muscle length through an achievable
range of motion against a constant or variable load. Derivation of the term means “same or constant
tension”; however, under real conditions, tension is variable during the movement.As the muscle shortens
13
or lengthens against a fixed load, tension changes due to the effects of fixed gravity against a changing
lever arm. Variable resistance exercise equipment has been developed to maintain a fixed load on
contracting muscle through an entire physiologic range of motion, in order to load the muscle at all
points during the contractions. Isotonic contractions can be performed concentrically, eccentrically,
or both. A concentric contraction produces muscle shortening against a load. Eccentric contraction
involves resisting muscle lengthening against an applied load. Most resistance programs involve a com-
bination of both movements.The maximal possible muscle tension force is produced during an eccentric
contraction.
Isokinetic resistance exercise is a second form of dynamic exercise, during which a rate-limiting device
controls the velocity of muscle length change to a constant speed of movement. If maximal exertion is
exhibited and maximal loading is applied, then near-maximal tension is created throughout the move-
ment. Despite this increase in consistency of applied load, some variability of resistance still exists during
the movement.This increase in consistency allows for improved safety with high-velocity power training.
Isometric resistance training is a static form of exercise, occurring when muscle tension is created
without any gross change in muscle length or motion within the affected joint. Tension and force are
created within the muscle tissue; however, no physical work is done in the absence of length change.
Strength gains have been demonstrated with isometric training; however, this will only occur at the posi-
tion at which the exercise is performed. Strength gains throughout a muscle range of motion requires
dynamic progressive resistance loading through that range. Following injury, or in response to other situa-
tions requiring immobilization, isometric training can maintain or strengthen weakened tissues during the
period of immobilization.
Identifying optimal target resistance and training intensity to ensure maximal strength gains has been
a difficult task. Basic strength programs utilize a set of consecutive muscle contractions against an applied
load, repeated over several sets of increasing intensity. DeLorme and Watkins devised a method for
developing strength programs utilizing a repetition maximum (RM).38 This is defined as the greatest load
a muscle can move through a full range of motion a specific number of times. Investigators have recom-
mended a baseline of 6 RM to 15 RM to improve strength.39 Extensive research has demonstrated that
muscle strength gains have been greatest when trained between 60 and 100% of a 1 RM.38,39 Other
methods of determination have utilized isokinetic dynamometers or myometers, which are somewhat
more accurate in determining an optimal starting point to initiate a weight training program. A second
variable in resistance training programs is the number of repetitions to promote strength gains.An optimal
number of repetitions has yet to be definitively determined. Both load and repetitions can be progressively
increased as part of training to improve strength and endurance. Many standard strength training programs
involve training with 60–80% of a 1 RM through 8–12 repetitions over 3–4 sets. Great variability exists
in defining optimal resistance and intensity with which to train.
Additional variables that can be manipulated within strength training are the duration of the program,
the velocity with which movements are performed, and the ability to overload specific muscles to be
trained by isolation. Physiologic and histologic changes of muscle in response to strength training occur
over weeks to months. A balance exists between tissue breakdown (catabolism) and tissue buildup
(anabolism). This is impacted by a number of factors, including nutritional support, rest, and stress. The
velocity of concentric muscle contraction has an inverse relationship with the tension generated by the
tissue. As velocity of contraction increases, potential force generation within the muscle decreases. The
opposite is true for eccentric contractions, which have high potential force generation with higher veloc-
ity movements, often seen in multijoint, high-resistance power training. A variety of exercise movements
exist for specific muscles. Often, different exercises selectively train a portion of a muscle, allowing greater
specificity of training to tailor to an athlete’s individual needs.
Strength training for the spine and supporting elements

Basic strength training principles apply to supporting muscles of the spine in the same way they do in
muscles within the extremities. Several critical factors impact on these principles as they pertain to the
spinal column. Earlier it was mentioned that the vertebra, intervertebral disc, zygapophyseal joints, and the
ligamentous system of the spine create physiologic limitations in spinal range of motion, limiting potential
14
resistance training movements. In addition, the deep muscles, which attach or originate from the spine,
have very short lever arms, creating a disadvantage when attempting to apply loads across these muscles.
Muscles controlling spinal movements tend to work as groups, making muscle isolation difficult to
accomplish. Multiple degrees of freedom and planes of motion of spinal segments require complex
training movements, which can be difficult to perform safely and correctly.
Typically, strength training programs targeting the spinal column focus on
three core muscle groupings.All three groupings will be briefly described, with
Box 1.6 Upper spinal extensor and shoulder girdle differentiation between cervicothoracic and thoracolumbar exercises which
strength training movements target the respective regions. Little scientific evidence exists to support
Upright Row – Trapezius/Rotator Cuff selection of one form of spinal exercise over another. It must be recognized that
Barbell/Dumbbell Shoulder Shrug – Trapezius spinal-related muscle groupings can be loaded and strengthened in more than
T Bar/Bent Over Row – Rear Deltoid/Rhomboid one fashion. Popular programs utilize mat- or floor-based techniques, exercises
Seated Cable Row – Rear Deltoid/Rhomboid using a physioball, machine-based movements, and free weight exercises.
Lateral Dumbbell Raises – Deltoids Examples of each type of approach will be discussed and presented.
Military Press – Deltoids/Trap The spinal extensor complex stems from a thick thoracolumbar fascia and
Cable Lat Pulldown – Latissimus/Rotator Cuff extends cephalad along the entire dorsal spinal column, ending in the
suboccipital region. This muscle grouping comprises several layers of long
strap-like planes of muscle. The muscle planes act in combination to produce
extension and/or rotation of spinal motion segments.These muscles also serve
a postural role in maintaining upright position of the head and torso. In the
Box 1.7 Lumbar spinal extensor and hip girdle upper back the more superficial rhomboid and trapezius muscles link the spinal
strength training movements column to the scapula. From there, the shoulder girdle musculature transmits
functional movement to the upper extremity. Similarly, in the low back the
Deadlift – Paraspinals/Gluteals
gluteals, hip girdle, and hamstring muscles act in similar fashion, transmitting
Roman Chair – Paraspinals/Gluteals
force through the lower extremities, and indirectly contributing to lumbar
Squat/Leg Press – Gluteals/Quadriceps
spinal extension. Standard strength training movements for the upper back and
Lumbar Extension Machine – Paraspinals
shoulder girdle are listed in Box 1.6. Lumbar extensor and associated hip girdle
Multiaxis Hip Girdle Machine – Hip
movements are listed in Box 1.7.
Flexion/Extension/Abduction/Adduction
The spinal flexors oppose the extensor group, and work through more
Prone Leg Curl Machine – Hamstrings
complex mechanisms. In the cervical spine the sternocleidomastoid muscles act
obliquely to produce a combination of flexion and rotation of the head and
neck. In the lower torso, multiple planes of muscles act as the key flexors of the
torso. Superficially, the midline abdominals – namely the rectus abdominis – act
as key stabilizers and flexors. Internally, the iliopsoas muscles act as flexors and
Box 1.8 Lumbar spinal flexor and accessory muscle rotators. Finally, the rectus femoris and superficial hip flexors also contribute in
strength training movements stabilizing and flexing the lower torso. Traditional lumbar flexor strength
Prone Abdominal Crunch – Upper Abdominals training movements are listed in Box 1.8.
Hanging Bent Knee/Straight Knee Leg Raise – A third group of accessory muscles serve key functions in lumbar spinal
Middle/Lower Abdominals/Hip Flexors mechanics. The quadratus lumborum muscle arises off each side of the spinal
Decline Bench Situp – Upper/Middle/Lower column and inserts onto the posterior ilium. It acts as a weak extensor and
Abdominals major muscle to induce sidebending. In addition, it contributes to postural
Sidelying Oblique Crunch – Abdominal Obliques stabilization and control. A series of muscle sheets lateral to the rectus
Rotary Torso Machine – abdominus have gained recognition as important postural stabilizers in addition
Obliques/Latissimus/Paraspinals to their role as rotators and side-benders of the lumbar spine.40 The large,
posterior latissimus dorsi muscle also plays a role in controlling sidebending of
the lower trunk (see Box 1.3).
Spinal stabilization
In addition to graded, progressive resistance strengthening techniques, recent trends in spinal rehabilitation
have emphasized the functional importance of a spinal stabilization program to augment more traditional
15
strengthening, flexibility training, and conditioning.41 These principles can be applied to augment a
general spine fitness program.They build upon the idea of a “neutral spine” position, whereby the spinal
motion segments and shoulder/pelvic positioning are restored to their natural balance and alignment.
Using the lumbar spine as an example, this ensures better distribution of force through the spinal
elements, lumbo-pelvic region, and lower extremities. This type of program conceptually minimizes
mechanical stresses acting on spinal elements. For this reason, lumbar stabilization exercises are sometimes
referred to as “core strengthening” programs.They are often the beginning elements of a spinal rehabil-
itation program, from which more dynamic, resistance and flexibility training is built.
A multitude of exercises and approaches exist to achieve these measures. Most produce a training effect
by simulating basic functional movements of the lower abdomen, lumbar spine, pelvis, hip girdle, and
gluteals. Movements involve direct isolation of specific muscles and more advanced, complex multimuscle
patterns. They typically involve manual or body weight resistance of the trunk, limited to short arcs of
motion. Exercises look to create a synergy between force coupled muscles, acting in concert to restore
more natural biomechanics and a stable base. Efficiency and comfort of more complex movements can
then be achieved by training the individual to operate from a more stable neutral spine position. A series
of examples is presented, emphasizing this type of approach. Similar to more traditional strength training
movements, stabilization programs can be divided into cervical, lumbar, spinal flexor, extensor, and
accessory muscle exercises. Examples of basic and advanced movements targeting spinal flexors, extensors,
and accessory musculature are demonstrated in Figures 1.2–1.13.
Figure 1.2
Basic abdominal
stabilization movement
targeting rectus abdominis.
A. Starting position, with
slight hyperextension.
B. Finishing position, with
maximal contraction of
abdominals at end of
movement.
A B
Figure 1.3
Basic abdominal
targeting rectus abdominis
and abdominal obliques.
A. Starting position.
B. Finishing position with
abdominals at end of
movement.
A B
16
Figure 1.4
Basic lumbar stabilization
movement targeting
abdominals, lumbar
flexors, and lumbar
extensors.
A. “Angry Cat” (starting
position), emphasizing
lumbar hyperextension.
B. “Camel” (finishing
lumbar flexion and
pelvic rotation.
A B
Figure 1.5
Lumbar stabilization
movement.
B. “Bridging” (second
neutral spine position.
C. Single leg extension
while holding bridge
and neutral spine
position. A B
17
Figure 1.6
Isometric squat using physioball
and maintaining neutral spine
position. Feet are maintained
parallel and tibio-femoral angle is
maintained at 90 degrees.
Figure 1.7
Advanced spinal stabilization
movement targeting upper and
lower spinal extensors, along
with deltoids and gluteal
accessory muscles.
18
Figure 1.8
Accessory muscle spinal
stabilization movement,
emphasizing spinal rotators,
abdominal obliques,
adductors, and hip flexors.
A. Finishing position 1.
B. Starting position.
C. Finishing position 2.
A B
Figure 1.9
Upper spinal extensor
targeting cervico-thoracic
extensors, rear deltoids,
lower traps, and
rhomboids.
B. Finishing position with
rear deltoids and A B
rhomboids at the end
of the movement.
Figure 1.10
Upper spinal extensor
stabilization movement,
emphasizing cervico-
thoracic paraspinals,
middle/rear deltoids,
rhomboids, and
latissimus dorsi muscles.
19
Figure 1.11
Roman Chair dynamic
lumbar spinal extensor
stabilization movement.
B. Finishing position,
stopping at neutral
spine, without
hyperextension.
A B
Figure 1.12
Advanced lumbar flexor
spinal stabilization
movement.
A. Starting position
maintaining neutral
spine, targeting
abdominals, gluteals,
quads, and hamstrings.
B. Second position –
A B achieved by extending
unilateral extremity,
activating hip flexors,
lower abdominals, quads,
and abdominal obliques.
Partial assist by examiner
demonstrated to
maintain neutral spine
position.
Figure 1.13
Advanced dynamic spinal
targeting multiple muscle
groups.
A. Starting position,
maintaining neutral
spine.
B. Position 2: pushup while
maintaining neutral
A B spine.
C. Position 3: lower
extremity flexion, while
maintaining neutral spine
of thoraco-lumbar
regions.
20
Assessment
Conditioning and cross training

In addition to flexibility and strength training, the benefits of aerobic conditioning as part of a compre-
hensive exercise program have been well established. A detailed analysis of the physiology behind aerobic
conditioning is beyond the scope of this chapter.As mentioned previously, training goals need to be clearly
identified to maximize gains. It must be recognized, however, that maximal gains in strength and aerobic
capacity cannot be obtained at the same time. Focused strength training requires an intense, focused
progressive resistance program. Cardiovascular conditioning requires more aerobic, high-repetition, long-
duration training. Athletes can often use periodization of training to enhance multiple aspects of their
overall fitness. Under this premise, training can take on a different focus through scheduled intervals, with
time spent on aerobic conditioning, strength, and power training. This is similar to cross training, where
athletes balance participation in their primary sport, with crossover training in types of exercise that are
atypical for the primary sport. These principles help to maintain overall fitness, allow for recovery time,
and prevent overtraining.
Fitness is a global measure of cardiovascular functioning, muscle tissue performance, and general well-
being. It is often quantified as a function of maximum oxygen consumption or maximum aerobic capacity
(VO2 max).VO2 max is defined as the maximum volume of oxygen consumed by the body per minute.This
capacity can be increased with an aerobic or endurance training program. An increase in VO2 max suggests
an increase in the efficiency of the cardiovascular system and working muscle, which has a higher capacity
to resist fatigue. These principles of peripheral adaptation apply to all skeletal muscle within the body,
including those tissues closely associated with the spine.
Basic physiologic changes that occur in response to aerobic training involve the heart and peripheral
cardiovascular system, respiratory system, and metabolism. A reduction in the resting and exercise driven
pulse rate occurs, along with a decrease in resting and overall blood pressure.An increase in blood volume
and blood hemoglobin levels occurs, as well as increased stroke volume and cardiac output. At the same
time, enzymatic and biochemical changes occur in muscle tissue to increase oxygen extraction from
circulating red blood cells.This increase in extraction leads to an increased utilization of available oxygen,
and a decreased blood flow per kg of working muscle. Respiratory changes include larger lung volumes
and greater alveolar-capillary surface area.This leads to increased ventilatory efficiency, but no change in
maximal ventilation capacity. Metabolic adaptations include increased number and size of mitochondria,
and increased muscle myoglobin concentration.With exercise, muscle glycogen is depleted at a slower rate
and blood lactate levels are lower at submaximal workloads. Finally, there is an increased capacity to
oxidize carbohydrate, or mobilize energy.
The adaptations presented involve complex physiologic mechanisms that were not reviewed. Most
athletic endeavors involve some degree of endurance and aerobic activity. The manifestations of aerobic
training augment and enhance performance, irregardless of the sport.
ASSESSMENT
Baseline health-related physical fitness testing

Introduction
As part of a thoughtful and comprehensive approach to athletic participation, baseline health-related
fitness evaluation is recommended.The American College of Sports Medicine (ACSM) describes “health-
related physical fitness” as typically including body composition, cardiorespiratory endurance, muscular
strength and endurance, and flexibility.42 The authors recognize that persons engaging in various sports
cover a spectrum of ability and level of participation. At one end of the spectrum are gymnasts who are
groomed from childhood for Olympic competition. At the other end of the spectrum is the “weekend
warrior,” recreating college grudge matches on the neighborhood basketball court.The skill and motivation
21
levels of the particular athlete as well as access to training resources will determine the depth of a health-
related fitness evaluation.
Baseline physical fitness testing, in addition to a medical evaluation, provides the foundation for
identifying athletes at risk for illness and injury, for educating the athlete about general fitness and sports-
specific injury prevention, and for achieving fitness or athletic goals. In addition to the baseline health-
related fitness evaluation, assessment parameters relevant to “spine fitness” are also discussed.
The tests presented in this chapter are based on the wealth of information reviewed by the ACSM.The
majority of tests described have proven to be valid and accurate, and are inexpensive and straightforward
to administer. The reader is referred to the ACSM publication on exercise testing for detailed testing
protocols.This chapter will briefly describe body composition determination, submaximal exercise testing
for cardiorespiratory fitness, Borg’s rating of perceived exertion (RPE), dynamic strength testing of 1-
repetition maximum (1-RM), muscular endurance testing with the push-up and curl-up tests, and, finally,
flexibility testing of the low back and hip girdle.
Body composition
A relative increase in percentage body fat versus lean body mass takes place in individuals at increased risk
for type II diabetes, hypertension, and hyperlipidemia.The gold standard methods for determining body
composition are hydrostatic (underwater) weighing and plethysmography, which measure body volume
based on water and air displacement, respectively.The next best choice for determining body composition
is to use the anthropometric method of skinfold measurement. This test requires a skilled technician.
Skinfold measurement has a high correlation coefficient when compared to hydrostatic weighing
(r = 0.70–0.90).The margin of error of skinfold measurement is ± 3.5%.
Calculation of the body mass index (BMI) and waist-hip circumference (WHR) are much less
cumbersome methods; however, they are not as accurate. The BMI is the body weight (kg) divided by
height (meters squared).The Expert Panel on the identification, evaluation, and treatment of overweight
and obesity in adults43 defined overweight as a BMI of 25.0–29.9 kg/m2; obesity is defined as a BMI
greater than or equal to 30.0 kg/m2. Research has shown that health risks due to obesity increase with a
BMI greater than 25.0 kg/m2. Due to the large standard error (± 5%), however, the ACSM does not
recommend this test for fitness assessment.44
The WHR reflects the pattern of body fat distribution, being the ratio of waist-to-hip circumference.
Increased fat distribution on the trunk, especially around the abdomen, is linked with a significantly
greater risk of hypertension, type 2 diabetes, hyperlipidemia, coronary artery disease, and premature death.
This correlation holds true in individuals with the same percentage of body fat. In the evaluation of
abdominal obesity, waist circumference can also be used alone.43 Studies have also shown that increased
waist circumference is a marker for adverse health outcomes in persons of normal weight.
Cardiorespiratory fitness
Cardiorespiratory fitness depends on the heart, lungs, and skeletal muscle systems and is defined as the
ability to perform large muscle, dynamic, moderate-to-high intensity exercise for prolonged periods.42
The better an individual’s cardiorespiratory fitness, the less likely he is to die from all causes. Individuals
with poor cardiorespiratory fitness have a significant risk of premature death.45–47 The gold standard for
measuring cardiorespiratory fitness is the maximal oxygen uptake (VO2 max). The VO2 max is the maximal
cardiac output (L/min) multiplied by the arterial–venous difference (ml O2/L). Maximal exercise testing
requires technician expertise, time, and special equipment. An acceptable alternative is submaximal
exercise testing. In these tests the heart rate response to submaximal work rates is used to predict VO2 max.
The ACSM manual describes field tests such as the Cooper 12-minute test for distance, the 1.5 mile test
for time and the Rockport one-mile fitness walking test (heart rate is measured during the last quarter
mile). The other tests are more complex and use a motor-driven treadmill, mechanically braked cycle
ergonometers, or step testing. The treadmill, cycle, and step tests should include monitoring of the
subject’s heart rate, blood pressure, and rating of perceived exertion (RPE). Borg’s RPE scale is a subjective
assessment of individual exercise tolerance. Either the Borg category scale (6–20) or the category-ratio
scale (0–10) can be used. Interestingly, on the scale a rating of “somewhat hard” to “hard” (12–16) or
22
Assessment
“moderate” to “strong” (4–5) is reliably correlated with the threshold for blood lactate accumulation and
a cardiorespiratory training effect.
Muscular fitness
Muscular fitness is a term that includes both muscular strength (maximal force a muscle can generate at
a given velocity in newtons or kilograms) and muscular endurance (ability of a muscle to make repeated
contractions or to resist muscular fatigue).48,49 The gold standard of evaluating muscular strength is to test
dynamic strength with the 1-RM, which is the heaviest weight that a subject can lift while maintaining
optimal technique. For upper body strength, either the bench press or military press are evaluated; for
lower body strength, the leg press or leg extension are used. Other tests, using cable tensiometers or
handgrip dynamometers, test static or isometric strength and allow determination of maximal voluntary
contraction. These methods only test a specific muscle group, as opposed to the 1-RM, which better
evaluates overall muscular strength.
Muscular endurance evaluates a muscle group’s ability to perform repeated contractions over a period
of time sufficient to cause muscular fatigue or maintain a specific percentage of maximal voluntary
contraction for a prolonged period of time.42 The standardized tests to evaluate are simple and inexpensive
to administer and include the curl-up (crunch) test50,51 for abdominal endurance and the push-up test for
upper body endurance.52 Another popular test is the YMCA test, which uses the bench press to measure
muscular endurance by setting a submaximal resistance and counting the number of repetitions to fatigue.
Using the YMCA test, the subject lifts at a rate of 30 lifts/min.Women use a 35 lb barbell and men use
an 80 lb barbell.The score is the total number of repetitions until the muscles fatigue.
Flexibility
Flexibility is defined as the ability to move a joint through a complete range of motion. The American
Academy of Orthopaedic Surgeons9 has established normal values for all the joints in the body. Flexibility
is affected by many intrinsic factors, including age, gender, genetic predisposition, and so forth. Extrinsic
factors are also important, including level of fitness, type of athletic participation, etc. Moreover, the level
of optimal flexibility depends on the individual’s goal, whether that be simply to perform the activities of
daily living or to become an Olympic gymnast. Flexibility can be measured through visual estimation,
tape measures, goniometers, inclinometers, and so on. In terms of standards for health-related fitness
testing, the sit-and-reach test has been used to grossly assess low-back and hip-girdle flexibility. For the
purposes of spine fitness, the components of flexibility assessment should include the neck, shoulder
girdle, trunk lateral bending, trunk forward flexion, trunk extension; hip girdle (including IR/ER and the
Ely and Thomas tests); and straight leg-raise (also assess for neural tension signs).
Functional movement screen

In addition to the more standardized approaches to fitness evaluation, a new approach is being taken to
baseline fitness testing which moves beyond the usual one-dimensional, traditional spine assessment.The
typical spine examination includes measuring gross range of motion and a neurologic examination for
sensation, strength, reflexes, and neural tension signs. Rehabilitation focuses on symptomatic-relief,
achieving optimal flexibility, strengthening, conditioning, and ergonomic correction. In the occupational
medicine literature, an important theoretical and simply practical leap was the introduction of “work
hardening” to the rehabilitation.This method takes a functional approach to rehabilitation and has been
successful in returning more injured workers to their jobs. From this research it follows that our
rehabilitation should ideally include more functional assessment and functional rehabilitation. Bronner53
notes that in rehabilitation we often neglect the most important link, the “return to functional movement
with its multiple degrees of freedom and richness of expression.” Specifically, Bronner states that “the
crucial and often missing key is to provide the necessary neuromuscular learning experiences and
feedback to achieve optimal safe motor control of the lumbopelvic area.”The lumbopelvis is recognized
by these authors as the key point of control for the optimal spine fitness. This approach to functional
23
rehabilitation is also mirrored in the focus on core rehabilitation.The lumbopelvis is referred to the “hub”
for weight-bearing and functional kinetic chain movement.54
Interestingly, a functional movement approach to rehabilitation can also be much more motivating for
the patient/athlete than traditional rehabilitation strategies and thereby elicit greater compliance with the
treatment regimens.The successful introduction of such practices as yoga and Pilates to training football
players is a perfect example of this shift in prehabilitation and rehabilitation strategies. Of course, this
strategy can only go so far, in that the athletic trainer may not be able to actually tell the football players
that they are doing “dance” exercises.
One of the most compelling assessment tools born of this paradigm shift is the Functional Movement
Screen™ created by Gray Cook, MPT.55 The FMS™ consists of seven simple tests to assess functional
movement quality. Each of the seven tests is scored on a three-point scale for a total score of 21.The tests
were developed from observing the mobility and stability milestones of human development: stepping,
reaching, striding or kicking, squatting, and lunging, as well as two additional movements that require
anterior–posterior stress (pushing) and rotatory spine stabilization.55 Also included are screening tests for
shoulder impingement and back pain. The reader is referred to the original reference for a complete
discussion of the seven tests and their significance.
This method is being adopted by athletic trainers in the NFL, NHL, and NBA. Data is limited so far,
but early results are promising. There are times in science when looking only at the parts in a relatively
static, quantitative, single-variable approach limits our understanding of the whole, dynamic, functional
person.This approach to evaluating an athlete’s fitness is appealing because it looks at a set of movement
patterns that integrate multiple elements at one time, including optimal flexibility, strength, endurance,
and core stability.This approach may be akin to mastering yoga postures or Pilates exercises, which draw
from the whole of the body’s physical (and mental) resources.
Gray Cook, MPT, challenges sports enthusiasts to look first at the quality of a movement. Instead of
the foundation being a quantitative variable such as strength, the foundations of performance are
“functional movement patterns and motor control.”55 Athletic movement is comprehensively assessed in
the following three ways: 55
1. Functional movement quality: basic fundamental movements that demonstrate full range of motion,
body control, balance, and body stability.
2. Functional performance quantity: general, nonspecific performance demonstrating gross power,
speed, endurance, and agility. This element is assessed by time or distance trials such as the 40-yard
dash or vertical leap.
3. Sports-specific skills: skills that demonstrate sports-specific movement patterns.
In this brief introduction to Gray Cook’s work, the discussion is focused on functional movement quality,
as opposed to functional performance quantity or sports-specific skills, because this is a truly novel
concept in our reinventing baseline fitness testing. The “building blocks”55 of functional movement are
mobility and stability coordinated by the neuromuscular system. In terms of the spine, we have only
recently appreciated how the core muscles such as the transversus abdominus and multifidus muscles
function to stabilize spinal segments so that an athlete can efficiently transfer power through the
lumbopelvis to the extremities in motion.
Cook recommends assessing mobility of the lumbar spine and hip/pelvic girdle using functional
movements such as performing an overhead squat with a bar or an in-line lunge. Stability is defined as a
“representation of body control through strength, coordination, balance and efficiency of movement.”55
Stability is divided into static and dynamic types, where static stability involves maintenance of posture
and balance and dynamic stability involves production and control of movement. Dynamic stability is
further broken down into five components that must function optimally: mobility and flexibility, strength,
coordination, local muscular endurance, and cardiovascular fitness.55 For example, a sweep rower who has
not optimized these building blocks may have a fast 2000 meter stationary rowing ergonometer time,
representing strength and endurance, but then is not able to transfer that level of performance to a fast
time in a boat, which requires greater coordination on the water and coordination with other rowers.
According to Cook,55 the new paradigms in optimizing athletic potential can be drawn from observing
the developmental patterns in infants.The healthy infant is born with more mobility than stability. During
the infant’s development, the core is selectively stabilized before the extremities. Specifically, the infant
24
Exercise Prescription
first learns head control, then sitting, then crawling, then cruising, then walking, and so forth.This pattern
is also observed in motor recovery after a stroke. Whether in the setting of motor recovery or motor
learning, motor control and stability proceed in a predictable pattern from head to toe and from proximal
to distal.
In translating these concepts to the pre-rehabilitation or rehabilitation of athletes, the bottom line is
that proper technique, mobility, and stability are emphasized before strengthening, conditioning, and
sports-specific skills training. Cook emphasizes that “the most common mistake in sports conditioning
today is training a movement pattern before achieving full range of motion and control of that
movement.”55 Coaches, trainers and sports medicine experts have only recently dissuaded athletes from
focusing only on the “mirror muscles” instead of the core. Unless the focus is on a foundation of mobility,
stability, and neuromuscular control first, athletes risk hard-wiring movement patterns that may place
them at greater risk for injury, as well as limiting athletic potential.
EXERCISE PRESCRIPTION
Comparisons between recreational and competitive athletes will reveal varying levels of training assistance
and supervision. Levels of commitment and lifestyle factors will also affect preparedness for athletic
participation with respect to training, nutrition, and recovery.With these factors in mind, developing and
implementing an exercise program relies on clarity of communication between the physician and multiple
potential parties: therapists, trainers, exercise physiologists, coaches, parents, and most often the athlete
directly. A fundamental objective of the exercise prescription is to implement changes in personal health
and training behavior. For the athlete, this change may lead to enhanced performance, injury prevention,
or injury rehabilitation.
Traditional exercise prescription builds upon the training principle termed specific adaptation to imposed
demand (SAID).56 This principle anticipates predictable response of human tissues to a given demand.
Tissues such as muscle that are subject to repetitive high-level training will respond
with physiologic adaptation to function more efficiently at that higher level. Under
Box 1.9 Components of an exercise this premise, workload can be varied to target a particular training goal. For example,
prescription low-resistance, high-repetition training will lead to improved endurance, whereas
high-resistance, low-repetition training will build strength.
1. Mode of exercise
Identification of a targeted training goal is important to direct the progression of a
2. Intensity
3. Frequency proposed exercise program. It also allows for a selection of exercises that will maximize
4. Duration the potential that the desired training effect will be achieved. Traditional elements of
the exercise prescription involve four basic elements (Box 1.9).
Mode of exercise
Specifics of the desired training activities should be outlined based on the goals of the program. Suggested
components of the program should be identified and differentiated. General details for strength training,
aerobic conditioning, or flexibility training should be specified. This includes the type of resistance
exercise (isometric, isotonic, plyometric, etc.), details of flexibility training, and muscle groupings or tissues
to be isolated. Free weights, variable resistance equipment, theraband, or other training equipment are
some options to the practitioner. Mode of aerobic activity (bike, treadmill, elliptical, aquatic, etc, ...) should
also be identified.
Intensity
Parameters on the intensity of both strength and aerobic training should be defined. Ranges for aerobic
training vary based on VO2 max or percent maximal heart rate.Typically, 40–85% VO2 max or 55–90% max
heart rate are the respective target ranges.22 For lower level athletes, utilization of a rate of perceived
25
exertion (RPE) scale can also be helpful. For strength training, a percentage of a one or ten repetition
maximum is often identified to focus, define, and guide training and training progression.
Frequency
Frequency of exercise defines parameters on how often exercise or elements of exercise are performed.
Typical programs suggest 3–5 days per week, depending on the intensity. Competitive athletes may have
varying training schedules, depending on time of year, and how that applies to in and off season. Preseason
workouts may be daily, sometimes multiple sessions, while in-season programs will often look to maintain
general strength and fitness, with focused sport specific work, and injury rehab if needed. Practitioners
must respect the need for scheduled rest intervals to allow for tissue recovery in response to intense training.
Duration
This parameter defines the length of individual training sessions. It is usually quantified by a proposed
number of minutes at a given intensity. For power or strength training, sessions are typically of short
duration, with target parameters defining a set number of repetitions per set, and a total number of sets
per session. For aerobic training, longer, sustained sessions, at a specified percent max heart rate is needed
to achieve an appreciable training effect. For both strength and aerobic training, exercise intensity typically
has an inverse relationship with sustainable time of effort. Variable factors include continuous versus
interrupted training, rest between sets, supersets, pyramid sets and isolation versus muscle group exercises.
To ensure a worthwhile and appropriate exercise program, practitioners must understand movement,
energy contributions, and physical requirements in a sports-specific manner. Elements of strength, power,
endurance, dexterity, and flexibility must all be considered based on their relative importance to enhance
performance in a given athletic activity. Well-balanced training cannot be underemphasized, along with
cross-training to augment more specific and focused approaches. Pre-participation warm-up and post
training rest intervals are also vital elements that should be emphasized and stressed in a well-rounded
program. Over-training occurs when sustained, intense exercise is not complemented by appropriate rest
intervals and nutritional support to allow tissue regeneration and repair.This all too common scenario can
be manifest as subtle, maladaptive symptoms of mild fatigue, poor sleep patterns, mood alterations, diffuse
myalgias, and decreased performance. If uncorrected, this syndrome can lead to physiologic changes in
hormonal, cardiovascular, and musculoskeletal systems. It can also lead to tissue breakdown and increase
the risk of acute injury.
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Further Reading
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56. Young J, Press JM: Rehabilitation of lumbar spine injuries. In: Kibler WB, Herring SA, Press JM, eds.
Functional rehabilitation of sports and musculoskeletal injuries. Gaithersburg, MD: Aspen; 1998:9–15.
FURTHER READING
Anderson B, Burke ER: Scientific, medical and practical aspects of stretching. Clin Sports Med 10(1):63–86,
1991.
Bandy WD, Irion JM, Briggler M:The effect of time and frequency of static stretching on flexibility of the
hamstring muscles. Phys Ther 77:1090–1096, 1997.
Cole AJ, Farrell JP, Stratton SA: Functional rehabilitation of cervical spine athletic injuries. In: Kibler WB,
Herring SA, Press JM, eds. Functional rehabilitation of sports and musculoskeletal injuries. Gaithersburg,
MD: Aspen Inc.; 1998:127–144.
Congeni J, McCulloch J, Swanson K: Lumbar spondylosis: a study of natural progression in athletes. Am J
Sports Med 25(2):248–253, 1997.
George SZ, Delitto A: Management of the athlete with low back pain. Clin Sports Med 21(1):105–132, 2002.
Geraci MC: Rehabilitation of hip, pelvis and thigh. In: Kibler WB, Herring SA, Press JM, eds. Functional
rehabilitation of sports and musculoskeletal injuries. Gaithersburg, MD: Aspen Inc.; 1998:216–226.
Haher TR, O’Brian M, Kauffman C, et al: Biomechanics of the spine in sports. Clin Sport Med 12(3):449-
464, 1993.
Hooker D: Back rehabilitation. In: Prentice WE, ed. Rehabilitation techniques in sports medicine, 2nd edn.
St. Louis: Mosby; 1994:277–302.
Kaul M, Herring SA: Rehabilitation of lumbar spine injuries. In: Kibler WB, Herring SA, Press JM, eds.
Functional rehabilitation of sports and musculoskeletal injuries. Gaithersburg, MD: Aspen Inc.;
1998:188–215.
Kraus D, Shapiro D:The symptomatic lumbar spine in the athlete. Clin Sports Med 8(1):59–69, 1989.
Krivickas LS: Anatomical factors associated with overuse sports injuries. Sports Med 2:132–146, 1997.
MacDougal JD,Wenger HA, Green HJ: Physiological testing of the high performance athlete, 2nd edn.
Champaign, IL: Human Kinetics Books; 1991.
Pollock ML, Gaesser GA, Butcher JD, et al:The recommended quality and quantity of exercise for developing
and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports
Exerc 30(6):975–991, 1998.
Pu CT, Nelson ME: Aging, function, and exercise. In: Frontera WR, Silver JK, eds. Essentials of PM&R.
Philadelphia: Hanley & Belfus; 2002:391–424.
Scherping SC: Cervical disc disease in the athlete. Clin Sports Med 21(1):37–47, 2002.
Schneck CD: Functional and clinical anatomy of the spine. Physical medicine and rehabilitation: state of the
art reviews. Philadelphia: Hanley & Belfus; 9(3):571–604, 1995.
Stanish W: Low back pain in athletes: an overuse syndrome. Clin Sports Med 6(2):321–344, 1987.
Sward L:The thoracolumbar spine in young elite athletes: current concepts on the effects of physical training.
Sports Med 13(5):357–364, 1992.
Trainor TJ,Wiesel SW: Epidemiology of back pain in the athlete. Clin Sports Med 21(1):93–99, 2002.
Watkins RG: Lumbar disc injury in the athlete. Clin Sports Med 21(1):147–165, 2002.
Wimberly RL, Lauerman WC: Spondylolisthesis in the athlete. Clin Sports Med 21(1):133, 2002.
Wood KB: Spinal deformity in the adolescent athlete. Clin Sports Med 21(1):77–91, 2002.
29
SECTION TWO • Age-related changes of the spine in the athlete
CHAPTER 2 Common Spinal Disorders in the

Young Athlete
Julian Lin
Frederick Boop
There is no doubt that over the past 20 years sports have played a major role in the daily life of American
youth. More than 30 million children and adolescents (<18 years old) participate in some sort of
organized sports, while many others are involved in non-organized recreational sports.1 Approximately
one-half of the boys and one-quarter of the girls between the ages of 14 and 17 in the US participate in
some sort of organized sports.2 The popularity in youth sports seen in this country is mainly due to health
reasons and popular trends.This popular trend explains why sport is a multibillion dollar industry, and why
some professional athletes attract almost cult-like followings, particularly from adolescents.With increasing
participation and involvement in sports, sport injuries have become an important entity in pediatrics.
Sports-related spinal injury in children is the third most common cause after motor vehicle accidents and
falls.3 Approximately 10–15% of all sports injuries are related to the spine.4
Sports can be organized into recreational nonsupervised or supervised categories.5 Recreational
nonsupervised sports that are frequently associated with spine injuries include diving, surfing, and
trampoline. Supervised organized sports can be divided into five different types:
1. collision sports such as football and hockey
2. contact sports such as lacrosse or basketball
3. noncontact, high-velocity sports such as skiing or gymnastics
4. noncontact, repetitive load sports such as running
5. noncontact, low-impact sports such as golf and bowling.6
In regard to sports injuries, there are several important differences between adults and young athletes
that are worth mentioning. First of all, an adolescent is in a dynamic growth process which can cause back
pain by itself.4 Developmentally, the paraspinal muscles and soft tissues do not grow at the same rate as
the bone, so some of the paraspinal soft tissues may become excessively tight and cause additional
mechanical stress on the growing spine. In the adolescent, the cartilaginous end plate of the intervertebral
disc is weaker than the nucleus pulposis; therefore, excessive compressive forces can cause the end plate
to fracture.4 Increased flexibility in young children predisposes them to spinal cord injury without radi-
ographic abnormality (SCIWORA), and increased stress on the bony structures, especially with hyper-
extension, may lead to spondylolysis, commonly seen between the ages of 6 and 10.
There are also important differences seen in athletes when compared to the nonathletic population.
By definition, athletes are participants involved at the highest levels of competition in a physically
demanding sport.7 Strict criteria apply to the adolescent who is dedicated to intense year-round training
and who competes to win.There are several physical factors that make athletes different in their response
to illness and injuries. The elite athletes have the advantage of having inherent natural talents such as
33
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sometimes employed in this sense. I shall cite one passage from
Horace, where it has the same meaning as in the before-mentioned
line from Terence.
——“Censorque moveret
Appius, ingenuo si non essem patre natus.”
He to whom I owe my birth was free,

A freeborn citizen: had he not been so,
The censor Claudius Appius would have stopt,
And driven me back.
NOTE 150.
A. III. S. III. Simo. (alone) I am not exactly, &c.

Terence uses an expression in the beginning of this scene that
has been a source of discussion among the critics. It is in the
following line,
“Atque haud scio an quæ dixit sint vera omnia.”
I have selected from a very long note on this passage, by an
eminent writer, the following extracts, which will afford, I trust, a
satisfactory elucidation of the line in question.
“Atque haud scio an quæ dixit sint vera omnia: this seems, at first
sight, to signify, I do not know if all that he has told me be truth; but,
in the elegance of the Latin expression, however, haud scio an,
means the same as fortasse (perhaps) as if he had said haud scio
an non. Thus, in the Brothers, A. IV. S. V. v. 33. Qui infelix haud scio
an illam misere non amat: which does not mean, I do not know
whether he loves her, but, on the contrary, I do not know that he
does not love her. Also, in Cicero’s Epistles, B. IX. L. 13., Istud
quidem magnum, atque haud scio an maximum; this is a great thing,
and perhaps the greatest of all, or, I do not know but it is the greatest
of all. And, also, in his Oration for Marcellus, when he said that future
ages would form a juster estimate of Cæsar’s character than could
be made by men of his own times; he says, Servis iis etiam indicibus
qui multis post sæculis de te judicabunt, et quidem haud scio, an
incorruptius quam nos. There are numberless examples of this kind
in the writings of Cicero, and I know that there are some which make
for the opposite side of the question, as in his book on “Old Age,”
speaking of a country life, he says, Atque haud scia an ulla possit
esse beatior vita. But, it is my opinion, that these passages have
been altered by some person who did not understand that mode of
expression, and that it ought to be, Atque haud scio an nulla possit
esse beatior vita.” The Author of the old Translation of Terence.
Printed 1671. Paris.
Terence frequently has this construction: the two following
sentences are of similar difficulty: they both occur in this play:
Id paves, ne ducas tu illam; tu autem, ut ducas.
Cave te esse tristem sentiat.
NOTE 151.
A. III. S. IV. Simo, Chremes.
Simo.—Chremes, I am very glad to see you.

“Jubeo Chremetem (saluere)”: the last word is not spoken,
because the speaker is interrupted by Simo. It is necessary to
observe that jubeo does not always signify to command, but
sometimes means to wish, to desire, especially when the speaker’s
wish is afterwards verbally expressed; according to what Donatus
observes on this passage, “Columus animo, jubemus verbis.”—Old
Paris Edition.
Terence has portrayed Chremes as a very amiable character; he
is mild and patient, and the most benevolent sentiments issue from
his lips. It was necessary, as Donatus observes, to represent
Chremes with this temper, for, had he been violent and headstrong,
he could not have been supposed to seek Simo, and afterwards
renew his consent, which is a very important incident, upon which
the remainder of the epitasis entirely hinges. The Chremes of Sir R.
Steele (Sealand) has all the worth of Terence’s original, but is
deficient in that polish of manners which renders the Latin character
so graceful.
NOTE 152.
The quarrels of lovers is the renewal of their love.
Amantium iræ amoris integratio est.

In this sentence I have followed the Latin grammatical
construction; and I believe it is also allowable in English, in such a
case as this, to choose at pleasure either the antecedent or the
subsequent for the nominative case. Very few sentences from
profane writers have (I imagine) been more frequently repeated than
Amantium iræ amoris integratio est, an observation which is
undeniably just. This sentence has been repeatedly imitated.
As by Seneca,
Plisth. “Redire pietas, unde summota est, solet.
Reparatque vires justus amissas amor.”
Thyestes, A. III. S. I.
Affection, though repell’d, will still return:
And faithful love, though for a moment curb’d,
Or driven away, will, with augmented strength,
Regain its empire.
And also by Ovid,
Quæ modò pugnarunt jungunt sua rostra columbæ,
Quarum blanditias verbaque murmur habet.
Ovid, Art. Am., B. 2. v. 465.
NOTE 153.
Simo.—Yet the most serious mischief, after all, can amount but to a
separation, which may the gods avert.
The Athenian laws permitted citizens to divorce their wives on
very trivial pretences; but compelled them, at the same time, to give
in a memorial to the archons, stating the grounds on which the
divorce was desired. A citizen might put away his wife, without any
particular disgrace being attached to either the husband or the wife;
and when the divorce was by mutual consent, the parties were at
liberty to contract elsewhere. He who divorced his wife, was
compelled to restore her dowry, though he was allowed to pay it by
instalments: sometimes it was paid as alimony, nine oboli each
month.
For a very flagrant offence, a wife, by the Athenian laws, might
divorce her husband: if the men divorced, they were said
ἀποπέμπειν, or ἀπολεύειν, to send away their wives: but if the
women divorced, they were said ἀπολείπειν, to quit their husbands.
(Vide Potter’s Arch. Græc., Vol. II. B. IV. C. 12.)
Terence artfully makes Simo use the word discessio instead of
divortium, or discidium, or repudium: which means the worst kind of
divorce. Discessio, among the Romans, was nearly the same as a
separation among us: by separation, I mean what our lawyers call
divorce a mensa et thoro; which does not dissolve the marriage; and
which they place in opposition to divorce a vinculo matrimonii; which
is a total divorce. In the earlier ages of the Roman Republic, the wife
had no option of divorcing her husband: but it was afterwards
allowed, as we see in Martial.
“Mense novo Jani veterem, Proculeia, maritum
Deseris, atque jubes res sibi habere suas.
Quid, rogo, quid factum est? subiti quæ causa doloris?”
B. 10. Epigr. 39.
NOTE 154ᴬ.
Why is not the bride brought? it grows late.

An Athenian bride was conveyed to her bridegroom’s house in the
evening by torchlight, attended by her friends: vide Notes 116, 117,
118, 119. Various singular customs prevailed among the Athenians
at their marriages: when the bride entered her new habitation,
quantities of sweetmeats were poured over her person: she and her
husband also ate quinces, and the priests who officiated at
marriages (vide St. Basil, Hom. 7, Hexame.) first made a repast on
grasshoppers, (τέττιγες, cicadæ,) which were in high esteem among
the Athenians, who wore golden images of this insect in their hair,
and, on that account, were called τέττιγες. Grasshoppers were
thought to have originally sprung from the earth; and, for that reason,
were chosen as the symbol of the Athenians, who pretended to the
same origin.
NOTE 154ᴮ.
I have been fearful that you would prove perfidious, like the common
herd of slaves, and deceive me in this intrigue of Pamphilus.
Ego dudum non nil veritus sum.
Donatus makes a remark on the style of this sentence, which
deserves attention, “gravis oratio ab hoc pronomine (ego) plerumque
inchoatur,” a speech which begins with the pronoun ego is generally
grave and serious: to which some commentator has added the
following remark respecting the before-mentioned passage from
Terence, “Est autem hoc principium orationis Simonis à benevolentia
per antithesin.” The remarks of Donatus and Nonnius on the style of
our author, are generally very acute and ingenious. Scaliger,
Muretus, and Trapp, may be added to the critics before mentioned.
The learned writer last named has composed a treatise in Latin “De
Dramate,” which contains many very valuable hints relative to
dramatic writing.
NOTE 155.
Simo.—Ha! what’s that you say?

There is a play upon words here, which I have endeavoured to
preserve in the English. The Latin is as follows. Davus. Occidi.
Simo. Hem! quid dixisti? Davus. Optume inquam factum. If the
requisite similarity of sound was preserved in this pun, it may be
conjectured that the Latin i was not pronounced very differently from
the i of the modern Italians. Vide Note 92.
NOTE 156.
Pam.—What trust can I put in such a rascal?
Oh! tibi ego ut credam furcifer?

The epithet furcifer (rascal) is of singular derivation; and, though it
was an appellation of great reproach in the times of Terence, yet, in
later ages of the Roman Republic, it bore a very different
signification. The name of furcifer, which was originally given to
slaves, took its rise from the Roman custom of punishing a slave
who had committed any flagrant offence, by fastening round his neck
a heavy piece of wood, in the shape of a fork, and thence called
furca; this occasioned the delinquent to be afterwards called furcifer,
(furcam ferre.) Three modes of punishment by the furca were
practised at Rome: 1. ignominious, 2. penal, 3. capital. In the first,
the criminal merely carried the furca on his shoulders for a short
period; in the second, he wore the furca, and was whipped round the
Forum; in the third, after having been tied to a large furca, somewhat
like a modern gallows, he was beaten to death. Slaves were treated
more severely by the Romans than by the Athenians, who were
celebrated for their mild and gentle behaviour to that class of
persons. The furca was afterwards employed in a very different
manner; and, from a badge of disgrace, was changed to a
serviceable implement. Caius Marius, nearly a hundred years after
Terence composed this play, introduced the use of the furca among
his soldiers. It was employed to carry baggage and other requisites;
and, in use, somewhat resembled a modern porter’s knot, hence, the
word furculum or ferculum, became an expression to signify a
burden, or any thing carried in the hand: and sometimes, also, the
various courses brought to table, as in Horace,
“Multaque de magnâ superessent fercula cœnâ,
Quæ procul extructis inerant hesterna canistris?”
B. II. Sat. 6.
NOTE 157.
Ah! how foolishly have I relied on you, who, out of a perfect calm,
have raised this storm.
Hem quo fretu siem
Qui me hodie ex tranquillissima re conjecisti in nuptias.
“My father reads this passage thus, en quo fretus sum, that is, the
rascal on whom I relied,” &c.
Madame Dacier.
If an error has been insinuated into the text in this passage, it can
scarcely be of sufficient importance to render an alteration essential:
the correction suggested by Madame Dacier, is not so decidedly
superior to the usual mode of reading the lines, as to compensate for
the inconvenience which must be occasioned by a general variation
of the text.
NOTE 158.
Pam.—What do you deserve?

This alludes to the Athenian custom of questioning supposed
criminals, either before sentence was passed, or while they were
under the torture, to the following effect: What have you deserved?
and, according to the tenor of the reply, they augmented or
diminished the punishment: vide Nonni. Miscel., B. 2. It was also
customary, at Athens, when the punishment was not fixed by the
laws, but was left to the discretion of the judges, that the condemned
person was required to state what injury he thought his adversary
had suffered from him; and the answer, when delivered upon oath,
was called διαμοσία; by which the final sentence was in some
measure regulated.
NOTE 159.
Char. (alone.) Is this credible, or to be mentioned as a truth?

“Hoccine credibile est, aut memorabile,
Tanta vecordia innata cuiquam ut siet,
Ut malis gaudeat alienis, atque ex incommodis
Alterius, sua ut comparet commoda? ah!
Idne est verum? Imo id genus est hominum pessimum
In denegando modo queis pudor est paululum:
Post ubi jam tempus est promissa perfici,
Tum coacti necessario se aperiunt et timent,
Et tamen res cogit eos denegare. Ibi
Tum impudentissima eorum oratio est:
Quis tu es? quis mihi es? cur meam tibi? heus;
Proximus sum egomet mihi.”
Terence, in the composition of these lines, has admirably
succeeded in expressing the sense by the sounds and measure of
his verse, and the very lines seem as angry (if I may be allowed to
use such an expression) as Charinus, who is to speak them, is
supposed to be. The whole speech is written with a great deal of fire
and spirit; and represents, in a very lively manner, the impatient
bursts of indignation, and the broken periods which issue from the
mouth of an enraged and disappointed person, during the first
transports of his anger. The ancients particularly studied this poetical
beauty; and many of them have reached a degree of excellence
scarcely inferior to that of the moderns. Terence has as eminently
distinguished himself by his success in this ornament to composition
as he has by his other excellencies: as familiar verse, his
compositions are extremely harmonious.
Mr. Pope has described the poetical embellishment before
mentioned in a most inimitable poem, which at once explains and
exemplifies his meaning.
“’Tis not enough no harshness gives offence,
The sound must seem an echo to the sense:
Soft is the strain when zephyr gently blows,
And the smooth stream in smoother numbers flows;
But when loud surges lash the sounding shore,
The hoarse, rough verse should like the torrent roar:
When Ajax strives some rock’s vast weight to throw,
The line too labours, and the words move slow;
Not so, when swift Camilla scours the plain,
Flies o’er th’ unbending corn, and skims along the main.”
Virgil was particularly successful in his endeavours to impart this
ornament to his composition. The following lines are reckoned by the
critics to be a beautiful specimen of his ability in this species of
verse.
“Ter sunt conati imponere Pelio Ossam

Scilicet, atque Ossæ frondosum involvere Olympum.”
Georg., B. I. V. 281.
Sternitur exanimisque tremens procumbit humi bos.

Æneis, B. 5.
NOTE 160.
Those men have characters of the very worst description, who make
a scruple to deny a favour; and are ashamed, or unwilling to give a
downright refusal at first; but who, when the time arrives. &c.
This is one of those beautiful passages which prove Terence to
have been so able a delineator of character. How faithful a picture
does he here draw of this particular species of weakness! A man is
asked a favour which he knows it is out of his power to compass,
and yet feels a repugnance to candidly avow it: he cannot bear to
witness the uneasiness of the disappointed person, and, from a kind
of false shame, he misleads him with a promise which he cannot
perform. To detect those lurking impulses which almost escape
observation, though they influence the actions: to describe with force
and elegance, and convince the mind of a feeling of which it was
before scarcely conscious, is an effort of genius worthy of a Terence.
NOTE 161.
If any one tell me, that no advantage will result from it: I answer this,
that I shall poison his joy: and even that will yield me some
satisfaction.
Ingeram mala multa: atque aliquis dicat; Nihil promoveris.
Multum; molestus certè ei fuero, atque animo morem gessero.
This sentiment has been imitated by the first of dramatists in his
Othello: he has expanded it into a greater number of lines, which are
extremely beautiful.
Iago. Call up her father,
Rouse him, make after him, poison his delight.
Proclaim him in the streets, incense her kinsmen.
And tho’ he in a fertile climate dwell,
Plague him with flies: tho’ that his joy be joy,
Yet throw such changes of vexation on’t,
As it may lose some colour.—
Shakspeare’s Othello, A. 1. S. 1.
The soliloquy of Charinus, (of which the lines I have cited in the
commencement of this Note form a part,) is one of the best written in
the plays of our author: it is exactly of the kind recommended by the
Duke of Buckingham.
“Soliloquies had need be very few,
Extremely short, and spoke in passion too.
Our lovers, talking to themselves, for want
Of others, make the pit their confidant:
Nor is the matter mended yet, if thus
They trust a friend only to tell it us.”
A soliloquy is introduced with most success, when the speaker of
it is supposed to be deliberating with himself on doubtful subjects:
but, when narration is to be introduced, it is brought forward with
more advantage in the shape of a dialogue between the speaker and
his confidant. But a skilful dramatist can often employ a preferable
method to either of those I have just named, for the disposition of
narration. Papias lays it down as an absolute rule for the composition
of soliloquies, that they must be deliberations only.
NOTE 162.
Well, take her.

Sir R. Steele, in his play, called the Conscious Lovers, does not
represent Myrtle as comporting himself in his disappointment with
the moderation observed by Charinus. He challenges Bevil: though
the duel is afterwards prevented by the patience and forbearance of
the latter, who communicates to his angry friend a letter which he
had received from Lucinda, expressive of her favourable thoughts of
Myrtle. The ingenious author of the Conscious Lovers imagined, no
doubt, that to an English audience, Charinus’s easy resignation of
his mistress to Pamphilus would appear tame and unnatural. In
nothing do the manners of the ancients and the moderns differ more
widely than in their respective behaviour in cases of private injury,
real or imagined. Among the ancient Greeks and Romans, duelling
was totally unknown. Alexander and Pyrrhus, Themistocles,
Leonidas, and Epaminondas, the Scipios and Hannibal, Cæsar and
Pompey, all men whose fame will never be surpassed, and a
countless number of the heroes of antiquity, would have scorned to
draw their swords in a private quarrel. It was reserved for Christians,
to introduce and countenance this barbarous practice; which ought
to be the shame of civilized humanity. Barbarous, however, it can
scarcely with justice be called: for those nations whose unpolished
manners caused them to be termed barbarians, were never known
to have adopted it; nor has a single instance occurred, where men,
in a state of uncultivated nature, have been known to sacrifice a
brother’s life in the mortal arbitration of a private quarrel. Duelling
was originally practised among northern nations. Those who wish to
entertain just ideas on this subject cannot do better than to consult A
Discourse on Duelling, by the Rev. Thomas Jones, A.M., Trinity
College, Cambridge.
NOTE 163.
Pam.—Why do you vex me thus?
Cur me enicas.
Eneco and enico are thought by some critics to have been exactly
similar in signification; but eneco generally means to kill, as in
Plautus angues enecavit: whereas enico signifies only to teaze, or to
torment; as in the passage in Terence before mentioned. Vide
Horace Ep., B. I. Ep. 7. L. 87.
NOTE 164.
Davus.—Hist! Glycera’s door opens.
Hem’! st, mane, crepuit a Glycerio ostium.
Literally, a noise is made on the inside of Glycera’s door. As all
the street-doors in Athens opened towards the street, it was
customary to knock loudly on the inside, before the door was thrown
open, lest, by a sudden and violent swing, the heavy barrier should
injure any of the passengers. The Greeks called this ceremony
ψοφεῖν θυραν. All the doors of the Romans opened inwards, unless
(which rarely happened) a law was passed to allow any particular
person to open his door towards the street. This was considered a
very great honour, and never conferred but as a reward for very
eminent services.
In Sparta, a law prevailed that no instrument but a kind of saw
should be employed in making the doors of the houses; this
regulation was intended to prevent luxury, and wasteful expense.
Both in Athens and Rome, the first room within the door was made
extremely large, and highly ornamented. This room was called aula
by the Romans, and, by the Greeks αὐλὴ. Here were placed the
trophies gained by the master of the house, and by his family. In later
and more luxurious ages, the doors were made of more costly
materials, sometimes they formed them of metal, either iron or brass;
sometimes also ivory was used for this purpose, or scarce and
curious kinds of wood.
NOTE 165.
Mysis. (speaking to Glycera within.) I will directly, Madam; wherever
he may be, I’ll take care to find your dear Pamphilus, and bring
him to you: only, my love, let me beg you not to make yourself so
wretched.
Sir R. Steele and Monsieur Baron have brought both Glycera and
Philumena on the stage; but, in the Latin drama, the principal female
characters (if they appear at all) are generally mutes. It is a
circumstance worthy of our attention, that (except in one instance)
Terence never brings on the stage any female character of rank and
consideration: the women who take a part in the dialogue are
generally either attendants, or professional people, as nurses,
midwives, &c. But this exclusion, (though our author has been
compelled to sacrifice to it all those embellishments which the
portraiture of the Athenian ladies must have added to his scenes,) is
in strict conformity with the manners of the Greeks. Grecian women
of rank seldom appeared in company, and closely confined
themselves within doors, occupying the most remote parts of the
house. Unmarried women were scarcely allowed to quit the rooms
they inhabited, without giving previous notice to their protectors.
Terence was instructed clearly in this point, by his great original
Menander; who expressly says, that the door of the αὐλὴ, or hall,
was a place where even a married woman ought never to be seen.
Women, among the Greeks, seldom inhabited the same apartment
with the men: their rooms were always kept as retired as possible,
usually in the loftiest part of the house. Vide Hom. Il., γʹ v. 423; their
apartments were called Gynæceum, (γυναικεῖον). Vide Terence’s
Phormio, Act 5. S. 6, where he says,
“Ubi in Gynæceum ire occipio, puer ad me accurrit Mida.”
These rooms were sometimes called ὦα, which signifies also
eggs; it is supposed that the fable of Castor, Pollux, Helen, and
Clytemnestra, being hatched from eggs, took its rise from the double
signification of the word ὦα.
NOTE 166.
Pam.—The oracles of Apollo are not more true: I wish that, if
possible, my father may not think that I throw any impediments in
the way of the marriage: if not, I will do what will be easily done,
tell him frankly that I cannot marry Chremes’ daughter.
Among the Greeks, no oracles were either so numerous or so
highly esteemed as those of Apollo. The first place among them is
assigned to the oracle at Delphi, near mount Parnassus, which
excelled the others in magnificence, and claimed the precedence in
point of antiquity. Next to this, ranks the oracle in the island of Delos,
the birthplace of Apollo and Diana. It is situated in the north part of
Mare Ægeum, or Archipelago, not far from the Isle of Andros, and
between Myconus and Rhene. The Athenians reverenced this oracle
above all others, and its answers were held to be infallible. Theseus,
the most celebrated of the Athenian heroes, instituted a solemn
procession to Delos, in honour of Apollo. A certain number of
Athenian citizens were chosen, who were called Θεωροὶ, who made
the voyage in a sacred ship; the same in which Theseus and his
companions were said to have sailed to Crete. This ship was
denominated ἀειζώοντα, on account of its great age: it was
preserved till the time of Demetrius Phalereus. No criminal was ever
put to death during the absence of the sacred ship.
NOTE 167.
Char. (to Pamphilus.) But you are constant and courageous.

P. Quis videor?
C. Miser æque atque ego.
D. Consilium quæro.
C. Fortis.
Critics have differed considerably respecting this passage. Some
think the word fortis should be understood as addressed to Davus.
I have adopted the interpretation which M. le Fevre, Madame
Dacier’s father, has given of this passage. Pamphilus, after
expressing his resolution to remain faithful to Glycera, turns to
Charinus, expecting a compliment on his behaviour. After a jest on
his friend’s having reduced himself to such a forlorn situation, by
following the advice of Davus, Charinus, by the word fortis, pays him
the compliment his handsome conduct deserved.
NOTE 168.
Pam. (to Davus.) I know what you would attempt.

Pamphilus, in this speech, alludes to his jest upon Davus in the
previous scene, where he says, “I have no doubt, that if that wise
head of yours goes to work,” &c., vide p. 67, l. 8. Pamphilus means, I
imagine, when he says, “I know what you would attempt,” I suppose
you are going to provide the two wives I was speaking of. He could
not mean that he really knew Davus’s plan: because he asks him
afterwards, page 70, line 10, what he intended to do.
NOTE 169.
Pam.—What are you going to do? tell me.

The Davus of M. Baron, instead of laying the child at Simo’s door,
makes a false report to Mysis, that Pamphilus intends to desert
Glycera, and to espouse Philumena: Mysis communicates this to her
mistress, who, in her distress, throws herself at Chremes’ feet, and
shews him the contract of her marriage with Pamphilus. This induces
Chremes to favour Glycera, and to break off the intended marriage.
NOTE 170.
Hitherto, he has been to her a source of more evil than good.

“As I never was able to make any sense of facile hic plus est
quam illic boni, I choose to give the passage a turn, though contrary
to all the readings which I have seen, which makes that proper, with
the omission of one word, which was not before intelligible. The
usual construction of the words, as they stand in all editions, is this,
—there is more ill in his sorrow, or trouble, (some read dolorem,
some laborem,) than there is good in his love: see, particularly,
Camus’s edition for the use of the Dauphin, which is not only a poor
meaning, and unworthy Terence, but inconsistent with what Mysis
had said before in the preceding scenes: I therefore choose to be
singular and intelligible, rather than to go with all the editors and
translators of our poet, and be obscure.”—Cooke.
NOTE 171.
Davus.—Take the child from me directly, and lay him down at our
door.
Accipe à me hunc ocius,
Atque ante nostram januam appone.
Some commentators read vestram januam, appone, lay him down
before your door. But Davus tells Simo, A. III. S. II., (page 51, line
13,) that Glycera intends to have a child laid at his door. It could
have answered no purpose, moreover, to have placed Glycera’s
child at her own door. We must rather suppose that Davus wished
Simo to think that Glycera had sent the infant to Pamphilus as its
father. Vide Note 174.
NOTE 172.
Davus.—You may take some of the herbs from that altar, and strew
them under him.
“Altar, Altare, Ara, a place or pile whereon to offer sacrifice to
some deity. Among the Romans, the altar was a kind of pedestal,
either square, round, or triangular; adorned with sculpture, with
basso-relievos, and inscriptions, whereon were burnt the victims
sacrificed to idols. According to Servius, those altars set apart for the
honour of the celestial gods, and gods of the higher class, were
placed on some pretty tall pile of building; and, for that reason, were
called altaria, from the word alta and ara, a high elevated altar.
Those appointed for the terrestrial gods, were laid on the surface of
the earth, and called aræ. And, on the contrary, they dug into the
earth, and opened a pit for those of the infernal gods which were
called βοθροι λακκοι, scrobiculi. But this distinction is not every-
where observed: the best authors frequently use ara as a general
word, under which are included the altars of the celestial and
infernal, as well as those of the terrestrial gods. Witness Virgil, Ecl.
5.
——En quatuor aras,
where aræ plainly includes altaria; for whatever we make of Daphnis,
Phœbus was certainly a celestial god. So Cicero, pro Quint. Aras
delubraque Hecates in Græcia vidimus. The Greeks, also,
distinguish two sorts of altars; that whereon they sacrificed to the
gods was called βωμος, and was a real altar, different from the other,
whereon they sacrificed to the heroes, which was smaller, and called
εσχαρα. Pollux makes this distinction of altars in his Onomasticon:
he adds, however, that some poets used the word εσχαρα, for the
altar whereon sacrifice was offered to the gods. The Septuagint
version does sometimes also use the word εσχαρα, for a sort of little
low altar, which may be expressed in Latin by craticula, being a
hearth, rather than an altar.”—Chambers’ Cyclopædia.
Scaliger thinks that the altar mentioned by Terence was the altar
usually placed on the stage of a theatre during representation, and
consecrated to Bacchus in tragedy, and to Apollo in comedy. It is
most probable, that one of the ἐσχάραι is alluded to by our author in
this passage. The ἐσχάραι were low altars which stood before the
doors in Athens: they were dedicated to the ancient heroes.
NOTE 173.
Davus.—That if my master should require me to swear that I did not
do it, I may take the oath with a safe conscience.
The Greeks paid very great regard to oaths. They divided them
into two classes. The first kind was the μέγας ὅρκος, or great oath,
when the swearer called the gods to witness his truth; the second
was the μικρὸς ὅρκος, when the swearer called on other creatures.
They usually, when falsely accused of any crime, took an oath to
clear themselves. This oath was sometimes administered in a very
singular manner: the oath of exculpation was written on a tablet, and
hung round the neck, and rested on the breast of the accused, who
was then compelled to wade into the sea about knee-deep: if the
oath was true, the water remained stationary; but, if false, it instantly
rose up, and covered the tablet, that so dreadful a sight as a false
oath might be concealed from the view of mankind. The Athenians
were proverbial for their sincere regard for truth. Vide Velleius
Paterculus, B. 1. C. 4., also, in B. 2. C. 23: we are told
“Adeò enim certa Atheniensum in Romanos fides fuit, ut semper
et in omni re, quicquid sincerâ fide generetur, id Romani Atticâ fieri,
prædicarent.”—Marcus Velleius Paterculus, B. 2. C. 23. L. 18.
The Athenians behaved with so much good faith and inviolable
honour in all their treaties with the Romans, that it became a custom
at Rome, when a person was affirmed to be just and honourable, to
say, he is as faithful as an Athenian.
NOTE 174.
Davus. (to himself.) The father of the bride is coming this way; I
abandon my first design.
Mysis.—I don’t understand this.
Davus’s first design was (we are to suppose) to go to Simo as
soon as Mysis had placed the child at the door, and acquaint him
that Glycera had sent him Pamphilus’s child. This would have
compelled Simo to suspend the marriage until he had ascertained
the real nature of Glycera’s claims on his son. Though Davus’s
speech is not usually read aside, we cannot suppose that Mysis
heard him say, that Chremes, the bride’s father, approached,
because, in the ninth scene of the same act, (vide p. 78, l.
preantepen,) he tells her, “that was the bride’s father,” and she
replies, “you should have given me notice then.”
NOTE 175.
Mysis. (aside to Davus.)—Are you mad to ask me such a question?
Davus.—Whom should I ask? I can see no one else here.
This certainly seems a little over-acted on the part of Davus,
considering that he knew Chremes to be so very near him. If we
conclude that Davus acted his part with the proper gestures, and
accompanied the above words with the very natural action of looking
round him, to see if any other person was visible near Simo’s door; it
appears extremely improbable that he should not have seen
Chremes, who was near enough to hear all that passed between
Davus and Mysis. Davus intended that what passed between Mysis
and himself should be overheard by Chremes, whom he knew to be
but a very few yards distant. It seems extraordinary, therefore, that
Davus should make use of an expression which compelled him to
run the risk of being obliged to recognise Chremes if he looked
round, and, if he did not, of raising a suspicion in his mind, that
Davus knew him to be there: either circumstance must effectually
have spoiled the stratagem, to deter Chremes from the match. To
solve this apparent inconsistency, we must suppose that Chremes,
wishing, for obvious reasons, to overhear what passed between
Mysis and Davus, had, at the entrance of the latter, withdrawn
himself behind a row of pillars, or into a portico, or cloister, (which
were common in the streets of Athens, and were also built upon the
Roman stage,) lest his presence, which Mysis knew of, as he had
questioned her, should be a check upon their conversation; from
which he, of course, expected to learn the truth respecting the child
at Simo’s door, as he knew that Mysis was the servant of Glycera,
and Davus the servant of Pamphilus.
NOTE 176.
Mysis.—The deuce take you, fellow, for terrifying me in this manner.
Dii te eradicent, ita me miseram territas.

Literally, May the gods root you up. An ingenious French critic
informs us, that the Romans borrowed this expression from the
Greeks, who say, “to destroy a man to the very root:” and, that the
Greeks borrowed it from the eastern nations. We have a similar
expression in English, to destroy root and branch.
NOTE 177.
Chremes. (aside.) I acted wisely in avoiding the match.

Recte ego fugio has nuptias.
The general way of reading this line is as follows:
Recte ego semper fugi has nuptias.

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CHAPTER 1 Principles of Spine Fitness

EPIDEMIOLOGY OF SPINAL-RELATED PAIN IN ATHLETES

FOUNDATIONS OF SPINE FITNESS

Functional spinal biomechanics

Factors affecting flexibility

Muscle biomechanics. When discussing joint flexibility we

Source: adapted from Alter.10

Flexibility and strength training

Flexibility and breathing

Flexibility and injury

then holding the position for 10 seconds to 1 minute. The goal

Muscle tissue adaptations to strength training

Principles of strength training

Strength training for the spine and supporting elements

Conditioning and cross training

Baseline health-related physical fitness testing

Functional movement screen

CHAPTER 2 Common Spinal Disorders in the

He to whom I owe my birth was free,

A. III. S. III. Simo. (alone) I am not exactly, &c.

A. III. S. IV. Simo, Chremes.

Simo.—Chremes, I am very glad to see you.

The quarrels of lovers is the renewal of their love.

Amantium iræ amoris integratio est.

Why is not the bride brought? it grows late.

Simo.—Ha! what’s that you say?

Pam.—What trust can I put in such a rascal?

Oh! tibi ego ut credam furcifer?

Pam.—What do you deserve?

Char. (alone.) Is this credible, or to be mentioned as a truth?

“Ter sunt conati imponere Pelio Ossam

Sternitur exanimisque tremens procumbit humi bos.

Well, take her.

Pam.—Why do you vex me thus?

Char. (to Pamphilus.) But you are constant and courageous.

Pam. (to Davus.) I know what you would attempt.

Pam.—What are you going to do? tell me.

Hitherto, he has been to her a source of more evil than good.

Mysis.—The deuce take you, fellow, for terrifying me in this manner.