Back Injuries — Part II

Kendo Clinic articles are intended as an educational forum only. The articles presented offer only a limited over-view of the great number of possible ailments and their variations. Articles are based on documented medical practices; use established terminology and are intended to provide the reader with the information needed to engage in consultation with medical professionals. The authors of Kendo Clinic and the editors of Kendo World stress that the information offered in these articles should under no circumstances be used for self-diagnosis or self-treatment. Persons suffering from any injuries or ailments are urged to seek the advice of licensed medical professionals at the earliest opportunity.

*****

BY ARIMA SABURO MD

TRANSLATED BY M.I. KOMOTO

 

In the last article we examined the basic anatomical and physiological aspects of the lumbopelvic region, and the general classification of ailments relating to lower back pain. In this article, we will inquire into specific scenarios of lower back pain in the kendo practitioner.

As we concluded in the previous article, back injuries and associated lower back pain can be the result of a single ailment, or a number of varied, contributory factors. Generally speaking, the circumstances that precipitate injury can affect any person; however, quite commonly, we see relationships with age, the age at which the sufferer first began kendo practice, and the amount of practice prior to the onset of pain. Therefore, when a kendo practitioner presents with lower back pain, a close examination of their medical and kendo participation history is of utmost importance.

In the general case, in kendo practitioners, low back pain is most commonly related to the following types of ailments:

1. Lumbar Disc Herniation (LDH): The evulsion of the cartilaginous disc from between the vertebrae, either externally, or into the spinal canal.

2. Lumbar Spine Lysis: Fractures occurring in the bony mass.

3. Paravertebral Muscle Fasciitis (PVM fasciitis): Inflammation of the band of tissue enveloping the muscles and muscle groups adjacent to the vertebral spine.

4. Facet Induced Low Back Pain: Pain resulting from mechanical or chemical changes occurring in the joints formed by the bony processes of the vertebral bodies.

5. Lumbar Spine Canal Stenosis (LSCS): Narrowing or constriction of the spinal canal due to congenital factors, or degeneration of bony and soft tissues. Pressure translates to neurogenic pain and dysfunction.

In junior and young kendo practitioners, cases 1, 2, and 3, are most commonly occurring; however, in adults and senior men and women, 4 and 5 are occurring more often. It is important to remember that back pain often relates to more than one source, so rather than trying to isolate a single problem, the wide range of bony masses, muscles, soft connective and joint tissues, and nerves must be examined. In clinical examination, the process is to identify one component, and then that component’s circumstances within its functional group. As well as examination by palpation of tissues to determine a component or component group’s static condition, the dynamic aspects must also be examined by manipulation of joints.

 

1. LUMBAR DISC HERNIATION (LDH)

In the case of LDH, cartilaginous discogenic material is forced out from between vertebrae either by compression, hyperflexion of the joint, or degeneration of associated tissues. In some few cases, the tissue may be evulsed to extracanalary areas, termed “external herniation,” outside of the bony mass; however it usually occurs with the disc translating into the lumbar canal. The evulsed disc tissue entering the spinal canal impinges on the cauda equina or nerve roots as they extend down the canal. The patient usually suffers from severe pain in the lower back, sometimes extending to the legs. The mechanical compression against the nerves in turn triggers a chemical response in the form of inflammation. This swelling of the tissues is in itself painful, and serves to further exacerbate the compression, increasing the level and extent of discomfort. As most of the nerve roots in the low back relate to the legs, in moderate to severe cases, the patient presents with unilateral, one leg, or bilateral, two leg, leg pain. Although not common to kendo related injury, I will mention that in the most severe cases, patients suffer from bilateral leg pain, disurination, or loss of bladder control, and interruption or loss of bowel control, collectively known as bladder-bowel-dysfunction (BBD.) In such an event, or in most extreme cases of hypesthesia, loss of sensation in the lower body, total loss of motor control, seen in the form of “drop foot” where the patient’s foot actually drops down from lack of any motor control, emergency surgery is required to relieve nerve entrapment. In 95 percent of cases; however, a conservative, non-operative approach can be taken.

kendo worldThe clinical examination for LDH consists of both palpitation and joint manipulation tests. The explanation of all assessment techniques exceeds the scope of our article; however, just to mention one of the most common and telling tests in the battery, the simple Straight-Leg-Raising Test is certainly used by every examiner.

The test consists of placing the patient in a supine position, that is, lying face-up, and raising one leg straight up to a vertical position. If the sufferer is unable to raise their leg to the full range of 90 degrees due to lower back pain and discomfort in the leg, disc herniation is suggested. The test should be performed on the contralateral, or opposite, leg to confirm that inability is not related to a tight, posterior leg muscle, i.e. hamstring. Some exceptions exist, such as herniation occurring to upper discs, around L1, or the thoracic region discs, that do not indicate positive for disc herniation; however, for the most common instances of L5 up to L1 injuries, the test has been shown to be fast and reliable. The further clinical determination is one of extent, quantifying to what degree leg(s,) neural sensitivity, and motor control are affected. The findings are then compared to graphic diagnostics generated from MRI scanning. Relating to soft tissues, MRI is generally considered the optimal choice for imaging in LDH injuries.

kendo worldAs I mentioned, ninety-five percent of cases are treated non-operatively; therefore, I will forgo the extensive explanation of the many variations of surgical procedures and explain the general case of conservative treatment for LDH. In all cases, cessation of kendo and athletic activities is necessary. In extreme cases, total rest is warranted by the sufferer’s inability to stand, or sit without great duress. For ambulatory patients, a soft corset, a type of waistband, is used to support the back and muscles of the mid-torso. Non-steroidal anti-inflammatory drugs (NSAIDs) in the form of oral medicine can be very effective in reducing the tenderness and associated pain. However, although pain is relieved somewhat, care must be taken as the disc herniation problem may still remain. Once pain subsides, and movement returns, physical therapy (PT) and rehabilitation, in the form of massage and various modalities, i.e. hot-packs, etc., and stretching programs are required for increasing healing blood-flow to the affected tissues and restoring mobility in the joint. In the long-term aspect, PT must be continued for ensuring good posture and alignment of the vertebral bodies, thereby, reducing risk of future reoccurrence.

 

2. LUMBAR SPINE LYSIS

In kendo specific terms, hyperextension of lumbar joints caused by twisting or ducking to avoid an opponent’s attack, allowing hands to rise too high upon tai-atari, or body strike, “diving-in” or ‘craning’ the head while executing techniques, and compression loads resulting from improper ashi/tai-sabaki, foot/body movement, can all contribute to disc herniation. Avoiding these types of behavior not only protects the lower back against injury, learning correct execution of techniques and proper tai-sabaki are basic to improvement in kendo. Better to be hit while learning the lessons of correct kendo, than to avoid opponents’ strikes with strange movements or tricks, fail reinforcement of proper technique, perpetuate a weak kokoro-gamae, or mental posture, while risking injury to one’s self.

Lysis takes form in the fracture or failure of the bony mass of the lumbar spine due to stress, trauma, or congenital factors. Generally speaking, lysis usually occurs during adolescence and puberty. The reason being: the bones of the young are still developing. As yet, the main vertebral body is quite thin, and the lamina, the web of bones that serve to form the neural arch and in turn the spinal canal, are also small and weak. Therefore, the bony masses of the young are very susceptible to stress fracturing due to loads translated from other parts of the body, traumatic fracturing upon direct impact, or failure due to congenital weakness. In most cases, the fracture occurs in the lowest vertebra, L5, but also occur in the upper vertebrae, L4 to L1 in diminishing order.

Examination consists of palpation of the local area, and manipulation of the joint to isolate the affected area and determine extent. If Lysis is indicated by clinical examination, diagnosis is verified with X-ray image, Computer Tomography scan (CT, also called Computer Axial Tomography, CAT,) and Magnetic Resonance Imaging (MRI.) In diagnostic imaging, the fracture(s) may appear only faintly; therefore, the examining doctor’s experience and expert knowledge regarding such injuries is crucial.

If we can identify the injury early on, the treatment course is to discontinue kendo and athletic activity, full rest, wearing of a soft corset (waist band to support the lower back,) and limitation of the activities of daily life (ADL) such as doing strenuous housework, carrying heavy book bags to and from school, etc., for three to 6 months. In the case of a first time injury, cared for in timely fashion, the bone should heal normally.

kendo worldAlthough their complaints of back pain may be dismissed as the normal “aches and pains” of athletic endeavor, even the slightest fracture to a vertebra in a youth may result in lifelong back pain. If any young kendo student comments or complains of back pain or “stiffness,” immediate cessation of activities and examination by an orthopaedic physician is warranted.

As adults, we can readily understand that restraint must be used when striking children during teaching exercises and shido-geiko, or teaching practice; however, this factor can be overlooked when pitting children of different ages together. Young people in their natural enthusiasm to be competitive and vigorous may employ heavy or percussive strikes to their younger partners. The teachers and organisers of children’s practices must give full warning and monitor the progress in any junior kendo practices where strikes are made directly to the participant’s men, or protective face mask.

 

3. PARAVERTEBRAL FACIITIS

This ailment results from overuse and/or muscle fatigue induced inflammation of the fascia, the band of tissue that surround the paravertebral muscles (PVM), the muscles adjacent to the spinal column. The severity usually ranges from sub-acute to acute in which the sufferer has difficulty standing erect, or ambulating without the aid of support. PVM faciitis usually stems from (1) Spinal Cord Reflex Mechanism, the involuntary and uncoordinated contraction of back muscles resulting in muscle fatigue, spasms, and pain. Spinal Cord Reflex Mechanism can result directly from activity, or be triggered by back pain stemming from some other ailment, such as LDH, etc. (2) Overuse resulting in microscopic muscle strains, strains that in turn induce inter-facial hyper-pressure, a kind of tug-of-war between adjacent tissues. Simply put, the muscles of the lower back become tight and stiff, with patients usually referring to pain, stiffness, loss of flexibility, and in advanced cases, inability to ambulate or conduct ADL. (3) A combination of the two, both spinal cord reflex mechanism and the microscopic muscle spasms. These two conditions commonly create a cycle, one triggering the other, resulting in a chain-reaction of sorts, recurring over and over again. The resulting stiffness and loss of flexibility may set the stage for further injury in the process of ADL. Cumulatively, a reoccurring injury may develop into a chronic condition.

PVM fasciitis is not uncommon in the adult kendo man or woman, usually arising from “over-doing it” while in poor condition, fatigue from excessive practice, or injuries resulting from improper technique and manner described earlier. It is usually only after the onset of pain that the sufferer attempts aggressive stretching and warming up, but in the case of an extant injury, further aggravation caused by vigorous stretching may result in repeating trauma to the ailing tissues.

Once injury to the bony masses, discogenic irregularities, and neurological injury are ruled out, and no other conditions are can be found, PVM fasciitis is diagnosed by the process of elimination. However, as mentioned earlier, spinal cord mechanism can be triggered by another pack ailment. In such cases, PVM fasciitis can be occurring, but the condition over-shadowed by the other causal factor. In this case, the work of the physician is indeed difficult. Whereas the initial injury must be treated, PVM fasciitis must also be considered as a by-product condition, and treated accordingly. One simple test that can be used to identify PVM fasciitis is a simple, focused tapping on the posterior shoulders of the sufferer. Tenderness of the trapezius muscles, the muscles ranging from the neck to shoulders and mid-back, indicates PVM fasciitis. These are paravertebral muscles in themselves, but also related to other muscles constituting the paravertebral group, therefore, fatigue and soreness translating from adjacent paravertebral muscles serve as an indicator of PVM fasciitis, more easily distinguished, as they are spatially separated from local injuries, such as LDH, lysis, etc..

Treatment consists of decreasing activity, ranging from cessation of kendo practice to perfect rest. If the level of duress of the patient is not too severe, and he or she desires to return to keiko soon, non-steroidal anti-inflammatory drugs (NSAIDs) in the form of oral medicine can be very effective. NSAIDs are not only a treatment for the symptoms, but are as well a therapy for the causal factors of PVM faciitis. In cases where the pain is severe, activity is restricted until movement and some ADL can be resumed.

Once movement is possible, PT is necessary to restore muscle flexibility and promote high blood circulation to the muscles and connective tissue. PT is more effective and offers better long term results in preventing reoccurrence than do NSAIDs. In the third stage, when return to keiko is possible, 30 minutes of warming up and stretching of the whole body with emphasis to the legs and lower back are necessary. Following keiko, a cooling down and gentle stretching of at least 15 to 20 minutes must be done. Following the bath, additional stretching must be done to promote long-term improvement of flexibility. Care must be taken upon arising in the morning, back muscles are stiff and flexibility is poor. During the recovery period no stretching should be performed in the morning, and asa-geiko, or morning practice must be suspended. In the long term, in order to significantly reduce tendency toward, or prevent low back pain stemming from PVM fasciitis, flexibility must be improved throughout the whole body.

Relating to kendo activity, whole body fitness, in the form of both, good muscular conditioning and flexibility is necessary to avoid PVM fasciitis. Translating to technical execution, it is better to use, good form in technique, leg-power, and good cardio-vascular (breath and blood-flow) fitness, as opposed to relying on upper body muscular power for issuing one’s waza, or techniques.

 

4. FACET INDUCED BACK PAIN

Facet induced low back pain is an ailment affecting the joints formed by the bony processes, at the point the processes of one vertebra makes contact with the process of the next upper or lower vertebra. In the young, facet related pain is usually the consequence of some trauma such as twisting or being pushed-over too far, but in adults, it is more commonly the result of degenerative changes to the joint tissues and mechanics that cause pain from load, and by-product traumas stemming from diminished mechanical integrity.

In trauma injuries, the connective tissues associated with the joint are strained or ruptured. The pain is usually quite severe and the onset sudden.

In the case of degenerative changes, the problem is almost always preceded by the degeneration of adjacent structures. The common pattern is degeneration in the discs, the decrease in size and function of the discs translating loads to the facet joints. As the facet joints are simultaneously suffering from the same cartilage degeneration as the discs, the consequence is accelerated wear and tear on the facet joints resulting in pain.

In the worst cases, the joints impinge on their own component tissues and “catch,” resulting in the sudden onset of acute pain. It is sometimes referred to as “getting a ‘crick’ in the back” and usually requires total bed rest. This is a type of trauma injury that results from degraded joint structure.

Facet induced low back pain is very difficult to identify directly, as the symptoms often resemble those of other ailments. So the clinical examination is one of isolating the afflicted area, identifying the symptoms and comparing findings with diagnostic images. In the case of facet problems, soft tissues play a key role as a causal factor for pain and dysfunction; therefore, MRI with its ability to distinguish minute differences in the condition of soft tissues, particularly cartilaginous joint tissues and disc condition, is preferable to X-ray and CT scan that serve better imaging bony masses. Upon consideration of both clinical findings, and MRI images, facet induced low back pain can be deduced by the process of elimination.

Facet induced low back pain is very closely related to paravertebral muscle fasciitis mechanically and symptomatically. Both disorders quite commonly occur in combination, therefore the examiner must include consideration of the two ailments separately, and side-by-side.

Treatment as well is nearly the same as with PVM fasciitis. In particular, in the case of facet related conditions, physical therapy is necessary for bone and muscle alignment, such as varus/valgus knee, “knock-knees” or “bowed legs” respectively, hip-tilt, and so forth, conditions that affect spine geometry, and therefore loads to the low back. As for the long-term course, ongoing therapy for flexibility and fitness of the muscles of the torso must be continued. Degenerative changes occur to us all, and are unavoidable; however, rather than saying “taking great pains,” I’ll say: taking great care to avoid pain, caused by assuming awkward positions, a tight and inflexible body resulting from neglect of fitness habits. The kendo practitioner can greatly offset the impact of degenerative changes by acquiring more and more a technical, orthodox approach to kendo rather than a mere athletic manner, and maintaining a general fitness program that includes good diet and rest.

 

5. LUMBAR SPINE CANAL STENOSIS

Stemming from both congenital tendency and overuse/degeneration of spinal structures, canal stenosis is the constriction of the spinal canal, the tunnel formed by the co-aligned openings of the vertebrae through which the main bundle of nerves pass down through the body. In the lumbopelvic region, the narrowing spinal canal impinges on the cauda equina and nerve roots causing both local pain, and in worst cases, dysfunction in the lower body.

A progressive condition, lumbar spine canal stenosis does not usually develop until 50 years old or over. Typically preceded by PVM fasciitis and facet induced low back pain, it is the final stage in spinal degeneration,

The typical symptom is Intermittent Claudication (IMC), numbness and pain, and sometimes loss of motor control in unilateral or bilateral legs. In IMC, the sufferer cannot walk continuously. For example, with activity, ambulation becomes progressively painful. After a period of seated resting, the symptoms diminish and activity can be resumed. However, upon resumption of activity, pain returns again, and further rest is required.

These symptoms are similar to those of the vascular ailment, atherosclerosis, and so, the physician must take care to differentiate the two, and factor the possibility of the two occurring simultaneously. Here again, a thorough examination of the patient’s medical history and basic vital signs are of utmost importance.

Once PVM fasciitis and facet induced lower back pain are diagnosed, the patient’s age and physical condition are considered. If difficulty in ambulation, IMC, or any BBD, is also present, the clinical deduction of canal stenosis is verified with diagnostic imaging. While in the case of the soft tissue disorders, PVM and facet induced pain, MRI had been the preferred approach, in the case of canal stenosis, an affliction of the bony masses, X-ray, and in particular, CT scan are preferred. CT allows for three-dimensional computer constructs, greatly enhancing the physician’s ability to gauge extent of the constriction of the canal aperture.

For severe cases, surgical options are available, they are however, quite extensive and often result in cessation of physical activity beyond ADL. Therefore, I will limit my description of treatment to conservative, non-operative approach, the case in which limited but continued kendo practice would be possible.

Considering the nature of the ailment, options for non-operative treatment of canal stenosis are very limited. For example, no amount of stretching or pain medication can negate the root problem of bone constricting about the nerves. Instead, the approach is to minimize the impact and severity of the symptoms. Perhaps the most effective, non-invasive approach a sufferer of canal stenosis can take is weight-control. Reduction of compressive and offset loads to the cauda equina and nerve roots serves to minimize pain and effect on motor and sensory activity. A flexion brace that limits the amount of posterior extension, or back arch, is quite useful in preventing the compression loads and impingement of nerves resulting from “pinching” of the cauda equina and nerve roots in the lumbopelvic region. Various drugs, such as the NSAIDs mention earlier, and pain medication can be prescribed by the physician to address symptoms; however, the patient must exercise care and self-restraint. This condition is chronic; therefore, the tendency toward progressive increase in amount, and reduction in the interval between consumption is of great concern. Not only does efficacy diminish as a result of the body’s increasing tolerance to the agent, but destruction of the tissues of the digestive tract, liver, and kidneys, also occurs. The result of accumulated over-exposure to those medicines. Finally, as necessary, ambulation can be assisted with cane, crutches, and so forth.

At this time, we are not able to completely stop the onset and progress of spinal canal stenosis, the cumulative affect of congenital and degenerative factors; however, the kendo man or woman can minimize the impact in their own case, by the development of proper kendo technique and manner, good diet, and sensible health habits. As complex as are all the maladies pertaining to lower back pain that we have examined, the steps we can take to ward off these problems are simple, and common sense matters.

 

CONCLUSION

After this brief overview of ailments relating to lower back pain in kendo, we can see the circumstances and sources of pain are quite varied, and complex. One-time sufferers of lower back pain should bear in mind, reduction of pain does not always mean “curing” an ailment. In the case of some conditions, the affected bone, soft tissues, and neurological pathways cannot be restored. In such cases, great care must be taken with regards to amount and type of kendo activity one engages in. Also, continuation of PT and rehabilitation must be complied with as strictly and methodically as one polishes their own Nihon Kendo Kata: step by step, and with full conviction.

One common failure in treatment of muscle and ligament injuries is inadequate rest and immobilisation. The muscles and ligaments heal in elongated fashion and result in joint instability. This joint instability renders upon the patient a higher potential for re-injury or injury to adjacent structures. Oppositely, too great a period of immobilisation can lead to the shortening of these connective tissues, and in turn a stiff, or tight joint. In either case, we find the result of a joint with somewhat diminished function. Both cases reflect on joint mechanics, in turn neural input, and as a result, affected motor output. Close observation of the progress of healing and the appropriate physical therapy and rehabilitation regimen are of great importance.

Such being the case, we can understand the importance of patient counseling at every step. If such education and instruction is not forthcoming, or if explanations are not clear in process of consultation with one’s caregiver, I advise back pain sufferers to make inquiry sufficient for the thorough understanding of the circumstances of their ailment(s) and appropriate course of action.

After all, I must emphasize that prior to becoming injured, the best medicine is prevention: disciplined, sensible kendo practice, proper care of health and fitness, warming-up and stretching before practice, and cooling-down and stretching following practice, will do much to prevent or diminish the many ailments we have studied on this topic of low back pain in the kendo practitioner.

As a tradition with roots dating from Japan’s pre-modern times, the typical manner in which kendo practice is conducted has not yet come to employ recently acquired medical know-how, or systems of fitness and health care. However, an ever accumulating base of knowledge, underscored by a legion of seasoned kendo men and women who have benefited from modern medical care for their kendo-related ailments, points to a need for an ongoing evolution of our art. In the same way that kendo has developed from hazardous unprotected practice with steel and wooden swords, I hope that our present day modern kendo will continue to develop, to employ new methods and technologies, while maintaining its most valuable, essential traditions, and goal of serving as a vehicle for one’s development as a human being, one who will contribute to society. I believe that if we proceed with healthy bodies, we can do much to realize this great endeavor.