Impact of post-manipulation corrective core exercises on the spinal deformation and lumbar strength in golfers: a case study (2024)

Abstract

[Purpose] This study examined spinal shape in professional golfers with chronic backpain, and analyzed the effects of a 4-week regimen of semi-weekly manipulation andcorrective core exercises on spinal shape. [Subjects] Two golfers with chronic back pain.[Methods] The pelvis and spinal vertebrae were corrected using the Thompson “drop”technique. Angle and force were adjusted to place the pelvis, lumbar spine, and thoracicvertebrae in neutral position. The technique was applied twice weekly after muscle massagein the back and pelvic areas. The golfers performed corrective, warmup stretchingexercises, followed by squats on an unstable surface using the Togu ball. They then used agym ball for repetitions of hip rotation, upper trunk extension, sit-ups, and pelvicanterior-posterior, pelvic left-right, and trunk flexion-extension exercises. The sessionended with cycling as a cool-down exercise. Each session lasted 60 minutes. [Results] Thedifference in height was measured on the left and right sides of the pelvic bone. Thepelvic tilt changed significantly in both participants after the 4-week program.[Conclusion] In golfers, core muscles are critical and are closely related to spinaldeformation. Core strengthening and spinal correction play a pivotal role in thecorrection of spinal deformation.

Key words: Chronic back pain, Manipulation, Core exercise

INTRODUCTION

Gosheger et al.¹⁾, in their study of 703golfers, reported muscle damage due to overtraining in 82.5%, and external injury in 17.4%.In elite golfers, the most frequently affected areas were, in descending order, the back,wrist, and shoulder. In amateur golfers, the order was the elbow, back, and shoulder.McHardy et al.²⁾ demonstrated that the backis the most frequently affected area in golfers due to the impact experienced when hitting aball, and due to an incorrect swing form. The subsequent disruption in balance alters bodyshape, and has a significant effect on performance. According to data on injuriesexperienced by amateur golfers³⁾, the mostcommonly involved area was the back. In a survey conducted by Pink and Jobe⁴⁾, 59% of the injuries reported during the1990 US Professional Golfers’ Association (PGA) tour were related to the back. This highback injury rate is attributed to intensive training with an incorrect swing form. It isalso associated with excessive rotation of the body to increase the shot distance, and thenumber of repeated swings⁵⁾. All sportactivities require performance of specific techniques, and players incur various types ofinjuries. In particular, golfers use muscles that are not commonly used in daily livingactivities, which leads to frequent injuries⁶⁾. With the game of golf increasing in popularity over the past20 years, the risk of associated injuries has risen as well. Playing golf can cause injuryprimarily in the back, shoulder, elbow, hand, and wrist⁷⁾. Kohn⁸⁾ reportedthat the causes of injuries experienced during golf include weakened muscles, lack offlexibility, excessive exercise, insufficient warmup, and an incorrect swing form. Allmeasures requiring use of therapists’ hands for diagnosis and therapy are referred to as“manipulation”, and the various types of orthopedic manipulation include the Cyriax,Kaltenborn, Maitland, Mennell, Paris, and Grimsby methods⁹⁾.

Chiropractic spine correction technique applies stimulation to joints at high speeds andsmall amplitudes. This technique corrects the spine by applying force to joints so that theyexceed their normal range of motion and reach the paraphysiologic space, which is the limitof elasticity¹⁰⁾. Chiropractic correctsabnormal spinal segments to change the mobility of the spine, enabling delivery of thecommands issued by the central nervous system to effector organs through the efferentnervous system, which is the functional subsystem of the peripheral nerves¹¹⁾.

Positive effects of manipulation therapy are evident immediately, or within 4–6 weeks ofthe first treatment^{12, 13)}. The therapy is deemed effective if 50% improvement inacute lumbago is made in one therapy session. Fisk¹⁴⁾ and Potter¹⁵⁾ setthe threshold rate at 93%. Dynamic trunk stabilization exercises effectively mitigate spinaldysfunction; these exercises strengthen the core muscle groups around the lumbar spine,which play an important role in dynamic stability of the spinal segments¹⁶⁾. Without sufficient muscle stability, bodymovements cause incorrect movements of the muscles¹⁷⁾. Various terms are used to describe muscle-adjusting activities fortrunk stability: lumbar stabilization, dynamic stabilization, exercise control training,neutral lumbar adjustment, muscle integration, and trunk stabilization¹⁸⁾. All stability-related muscles are attached to the spinalcord. The multifidus, transversus abdominis, and internal oblique provide stability betweenspinal segments; the larger-sized erector spinae and rectus abdominis facilitate overallmovement of the body¹⁷⁾. Gym ballexercises were introduced in the 1900s in physical rehabilitation programs for the treatmentand prevention of stroke, myelosis, and back and neck pain, as well as for posturalcorrection. Recently, these exercises have been used as a core strengthening tool byprofessional athletes, as they improve muscle strength, joint movement, and balance, andthus improve spinal flexibility and stability¹⁹⁾. Gym ball exercises improve muscle strength, endurance,flexibility, and coordination; these benefits are a result of efforts to maintain balance onan unstable ball, which leads to improved reflexes and cognition, and thereby improvedbalance^{20, 21)}. As noted previously, only a few exercise programs can help correctspinal vertebral distortion and strengthen surrounding muscles in golfers. Severaltheory-oriented and formalized rehabilitation programs have been applied in both athletesand non-athletes. Against this background, this study examined spinal shape in twoprofessional golfers with chronic back pain, and analyzed the effects of a 4-week regimen ofsemi-weekly manipulation therapy and corrective core exercises on spinal shape.

SUBJECTS AND METHODS

Two golfers were selected as study subjects. Subject A was 43 years old, 174 cm tall,weighed 78.30 kg, had a body mass index (BMI) of 25.9 (kg/m²), and a 24 yearcareer. Subject B was 46 years old, 171.40 cm tall, weighed 73.40 kg, had a BMI of 25.0(kg/m²), and a 28 year career. The first subject is a golfer who visited thisrehabilitation center. He complained of chronic pain at the right waist region and rightlower extremity for at least six months, and showed hamstring shortening, at less than 60°during straight leg raising (SLR) tests. A three-dimensional (3D) spinal imaging device,Formetric III (Germany), was used for examination (Fig.1), and the Togu and gym ball (Swiss ball, USA) were used for the exercises. TheThompson bed was used for manual therapy. The Formetric III was used to identify therelationship between the spinal shape and the pelvic state by analyzing the back surface. Toensure data reliability, the measurement was repeated three times, and the average value wasused.

Thompson Terminal Point technique effectively corrects the pelvis using drop points on adrop bed after conducting Derifield leg checks. Based on the Thompson technique, the pelvisand spinal vertebrae were corrected using the Thompson bed. This technique uses a “drop.”The angle and force were adjusted so that the pelvis, lumbar spine, and thoracic vertebraewere in a neutral position. The technique was applied twice a week, after 20 minutes ofmuscle massage in the pelvic and back areas. Using isokinetic lumbar muscle strengthmeasurement equipment (IsoMed 2000 Back system, Germany), peak torque/body weight of flexionand extension of the lumbar region were measured. Isokinetic back muscle strength wasmeasured before and after 4 weeks of treatment. For corrective exercises, the golfersperformed warmup stretching for 10 minutes, followed by three sets of 20 squats on anunstable surface using the Togu ball. The participants then used a gym ball for 30repetitions of hip rotation, upper trunk extension, and sit-ups, and pelvicanterior-posterior, pelvic left-right, and trunk flexion-extension exercises, with 30seconds of rest between the exercises. At the end of the session, they cycled for 5 minutesas a cool-down exercise. Each session of correction and exercises lasted for a total of 60minutes. Both subjects understood the purpose of this study and provided written informedconsent prior to participation, in accordance with the ethical standards of the Declarationof Helsinki.

RESULTS

This study applied a 4-week manipulation therapy and spinal exercise program in twoprofessional golfers with chronic back pain due to deformation of spinal vertebrae; theeffects of this program are shown in Table1. The difference in height was measured on the left and right sides of thepelvic bone using the posterior superior iliac spine (PSIS) as a reference point for acomparison of the pelvic tilt. The pelvic tilt changed significantly in both participantsafter the 4-week exercise program. In Subject A, an 8 mm deformity on the right sidedecreased by 6 mm after four weeks. In Subject B, a 3 mm deformity on the right sidereturned to the normal position in 3 weeks. Pelvic torsion was also evaluated by measuring aline perpendicular to the line that connected the two PSISs. In Subject A, a tilt of 5.4° inthe anterior direction decreased by 2.6° after 4 weeks. In Subject B, a tilt of 5.5° in theanterior direction returned to a normal position after 4 weeks. The trunk length increasedby 35 mm, from 594 mm to 629 mm in Subject A, and by 10 mm, from 468 mm to 478 mm in SubjectB. In both participants, the hypo-lordotic curve changed to a normal lordotic curve after 4weeks.

Table 2 shows the isokinetic back muscle strength of the golfers after the 4-weektreatment. Both A and B showed improvement in peak torque flexion at 30°/sec after 4 weeks,with increases from 2.06 to 2.51 Nm/kg and 2.08 to 2.56 Nm/kg for A and B, respectively. Aand B also showed increases in peak torque extension at 30°/sec, from 2.13 to 2.91 Nm/kg and2.28 to 3.12 Nm/kg, respectively.

DISCUSSION

Weak lumbar muscles cause back pain and are at a higher risk for injury. For this reason, acustomized exercise program is needed to strengthen lumbar muscles. Akuthota et al.²²⁾ and Mckenzie²³⁾ reported that strengthening lumbar extensors reduces backfatigue and can prevent injury, with a stronger resistance to vertical pressure on thespine. Kim et al.²⁴⁾ applied a 10-weekcore rehabilitation exercise program in golfers, and reported increases in lumbar extensorstrength. Lee et al.²⁵⁾ used small toolsfor lumbar stabilization exercises in middle-aged women and reported that the exerciseimproved lumbar extensor muscles, mitigated back pain, and prevented damage, by improvingthe stability of the trunk muscles. Other studies by Park and Ham²⁶⁾, Kim and Lee²⁷⁾, and Lee et al.²⁸⁾ showed that stabilization exercises were effective in changingsurface muscles of the trunk, cross-sectional areas of the muscles, and thickness of thedeep muscles. It was reported that the cross-sectional area and thickness of the deepmuscles increased significantly after stabilization exercises²⁹⁾.

The relationship between pelvic displacement and back pain has a neuromuscular origin andinvolves biomechanical elements. The pelvis can have a considerable impact on the sacroiliacjoint and biomechanics of leg length inequality. It is known to be an early cause of bothacute and chronic damage to the sacroiliac joint, and the joint dysfunction can lead to leglength inequality³⁰⁾.

Athletes develop an asymmetrical body posture due to long-term training of particularmovements. This deformation makes maintenance of the normal curve of the spine difficult,and causes reduced range of motion and weakened abdominal muscles, as well as back pain³¹⁾. Bradford and Winter³²⁾, and the study by Marica and Susan³³⁾, demonstrated that gym ball exercises and a correctivestretching program can be effective when they consist of exercises that extend the bodytrunk and improve flexibility of the rigid areas, as well as exercises that strengthen thetrunk muscles for better posture and stability. This study produced similar results comparedto previous studies, as it showed that core strengthening exercises lead to a betterright-left balance and increased length of the trunk in professional golfers.

A study by Gong et al.³⁴⁾ showed thatpelvic adjustment has a positive impact on functional leg length inequality and footpressure. Park et al.³⁵⁾ reported greaterstability after pelvic adjustment in an elderly population. These findings are consistentwith the findings of the present study, which showed improvement in spine deformation afterthoracic, lumbar, and pelvic manual therapy. This study showed that manual therapy and gymball exercises can be effective in improving spinal deformation in professional golfers,which is consistent with the results of previous studies. Seo and Park also reportedsignificant effects of lumbar stabilization exercise, using a Togu ball for 8 weeks, on backmuscle strength in middle-aged women.

In our opinion, golfers, fencers, and baseball players who present with a distorted posturedue to unilateral body movement can improve performance by improving balance, with manualtherapy and gym ball exercises. The core strengthening exercises were effective in treatingback pain in both participants, and such programs are important for effective rehabilitationof patients. In golfers, core muscles are critical, as they are closely related to spinaldeformation. Core strengthening and spinal correction play a pivotal role in the correctionof spinal deformation.

Acknowledgments

This research was supported by the Kyungpook National University Research Fund, 2013.

REFERENCES