Introduction
- Gregg Ziemke, PT, MS, MHA, OCS
- Stewart M. Kerr, MD
- Leslie C. Hair, PT, DSc, OCS, FAAOMPT
- Charles E. Rainey, PT, DSc, DPT, OCS, SCS, CSCS, FAAOMPT
- Stewart M. Kerr, MD
Epidemiology
Age
- •
One study reported that children comprise as many as 47% of those who report to a clinic with back pain.
- •
More common in adolescent athletes, with rates listed from 8% to 15%.
- •
Age range is from ages 6 to 16, with an increasing incidence that levels off at age 16. Most report it most common during the “school-age years.” A child’s spine is fully developed at ages 8 to 10 years.
- •
There is a 2.6% to 4% incidence of spondylolysis in a pediatric population; 5.3% in a population of children with osteogenisis imperfecta (OI).
- •
Most often in children between 5 and 10 years old.
- •
Computed tomography is currently considered the most accurate imaging modality for identifying spondylolysis, and it often reveals the presence of nondisplaced spondylolysis.
- •
Of 855 patients undergoing abdominal computed tomography in Korea, 9% had spondylolysis, males affected more than females.
- •
The prevalence of a defect in the pars interarticularis is approximately 5% in the general population in the United States.
Gender
- •
More common in males; some reports indicating a male to female ratio as high as 3 : 1. In the general population is found to be 3% to 6%.
Sport
- •
Gymnastics, dance, soccer, football, wrestling, crew, weightlifting, and baseball (batting and weight of bat)
Position
- •
Football linemen, volleyball servers
Pathophysiology
Intrinsic Factors
- •
Spondylolysis is an osseous (bone) defect of the pars interarticularis.
- •
The cause of spondylolysis is not clearly defined. Most specialists believe it is caused by a genetic weakness of the pars interarticularis or results from chronic low-grade trauma, or, less often, acute trauma ( Figure 20-1 ).
FIGURE 20-1
Spondylolysis.
(From Nau E, Hanney WJ, Kolber MJ: Spinal conditioning for athletes with lumbar spondylolysis and spondylolisthesis. Strength Conditioning J 30:43-52, 2008.)
- •
Some list that the developmental process that goes on in the pars predisposes it to stress fracture. Repetitive loading causes fatigue fractures, or a traumatic event may cause a traumatic fracture.
- •
Increased lumbar lordosis may be a predisposing factor to spondylolysis. One study determined college football players with increased lumbar lordosis were not at increased risk for shortening their career.
- •
This lesion is most often seen in the adolescent lumbar spine. Adolescents involved in sports have a higher prevalence of spondylolysis than those who are not involved in sports.
- •
The sports with the highest prevalence of spondylolysis are gymnastics and dance. A common mechanism of injury in these sports is lumbar hyperextension (see Figure 20-23 A to D later in this chapter).
- •
This condition is often asymptomatic.
- •
The neural arch is found to increase in strength as we get older. Full ossification is not complete until age 25.
- •
There may be less cortical bone in the neural arch in general in the adolescent age group, especially in those who have had a fracture.
- •
Consider the biomechanics of lower lumbar spine; the position of facets is more horizontal, causing forces on the neural arch.
- •
Most common in forced lumbar extension activity accompanied by lumbar rotation, along with continued flexion to extension.
- •
May be a relationship between hamstring tightness and amount of lumbar lordosis; spinal active range of motion (AROM).
- •
Relationship between pars defect and spina bifida occulta.
- •
May be higher in children with osteogenisis imperfecta.
- •
May be related to endocrine abnormality.
- •
Multifidi muscle attaches to the mammillary process and helps to stabilize the vertebral joints. It spans from the sacrum to the cervical spine, endowing stability to each segmental level. The mammillary process is not fully developed until age 25.
- •
Spondylolisthesis is a forward slippage of one vertebra on another ( Figure 20-2 ), often a result of degenerative changes and/or a vertebral defect.
FIGURE 20-2
Spondylolisthesis.
(From Nau E, Hanney WJ, Kolber MJ: Spinal conditioning for athletes with lumbar spondylolysis and spondylolisthesis. Strength Conditioning J 30:43-52, 2008.)
- •
Not everyone who has spondylolysis will develop spondylolisthesis; if it does develop, it usually occurs in the 5th lumbar vertebra (85% to 95%) but can involve the 4th vertebra (5% to 15%).
- •
Initial treatment is always nonsurgical unless traumatic and compromise of the spinal cord is a concern.
Extrinsic Factors
- •
Cleated sports: traumatic or chronic force
- •
Baseball: size of bat
- •
Gymnastics: landing surface
- •
Football: field conditions
- •
Wrestling: surface
Traumatic Factors
- •
Some disagreement, but most seem to agree that spondylolysis is a fatigue/overuse fracture resulting from repetitive motion.
- •
Most common in forced lumbar extension activity accompanied with lumbar rotation, e.g., gymnastics, dancing and cheerleading.
- •
Also in football linemen from two- and three-point stance; weightlifting during squatting and supine leg press.
- •
Volleyball serving
- •
Wrestling holds
Classic Pathological Findings
- •
Fracture at pars
- •
No spondylolisthesis
Clinical Presentation
History
- •
Pain increases with increased activity; little pain at rest
- •
Difficult or painful lumbar extension
- •
May or may not have radiating pain
Physical Examination
Abnormal Findings
- •
Positive stork test ( Figure 20-3 )
FIGURE 20-3
To assess localized spondylolysis pain, a single-leg hyperextension stork test is performed. The patient stands on one leg and hyperextends and rotates the spine. Reproduction of the patient’s pain complaint indicates a diagnosis of spondylolysis until proved otherwise.
- •
Increased lumbar lordosis
- •
Positive stork test ( Figure 20-3 )
- •
Positive stork test ( Figure 20-3 )
- •
Tender to palpation at level of pars fracture
- •
Positive neurological findings generally not found
Pertinent Normal Findings
- •
Labs
- •
Normal neurological exam
Imaging
- •
Scotty dog on plain radiograph ( Figure 20-4 A ). Fracture is demonstrated by a black collar on the Scotty dog ( Figure 20-4 B )
FIGURE 20-4
Spondylolysis. A and B, Normal and interrupted pars interarticularis. Oblique radiograph ( A ) and corresponding line drawing ( B ) show an intact pars interarticularis at L5 and a pars defect with a collar around the Scottie dog’s neck at L4 (arrow in part B). P , pedicle (the Scottie dog’s eye); T , transverse process (nose); S , superior articulating facet (ear); I , inferior articulating facet (front leg); L , lamina (body); IC, contralateral inferior articulating facet (rear leg); SC , contralateral superior articulating facet (tail). C, Oblique sagittal computed tomography (CT) reconstruction in a normal patient. Note the intact pars interarticularis ( arrows ). D, Sagittal CT reformat shows a pars defect in L5 ( arrow ). E, Radionuclide bone scan of bilateral L5 pars defects. Coronal single-photon emission CT (SPECT) image obtained through the posterior elements shows increased tracer bilaterally at L5 (arrowheads). A CT scan (not shown) was needed to confirm bilateral defects because a unilateral defect with adaptive hypertrophy on the contralateral side could have similar bone scan findings. F, Axial CT image of unilateral spondylolysis. Note the spondylolysis on the right ( arrow ). Also note the sclerosis of the contralateral pars interarticularis ( asterisk ). This nonspecific finding may indicate that left-sided adaptive changes caused increased stress because of the right-sided pars defect or an impending left pars stress fracture.
(From Manaster B. Musculoskeletal Imaging: The Requisites. 3rd ed. Philadelphia: Elsevier; 2002.)
- •
Computerized Tomography (CT) in a normal spine, intact pars interarticularis ( Figure 20-4 C ). CT shows a pars defect ( Figure 20-4 D ).
- •
Bone scan stress reaction at pars interarticularis ( Figure 20-4 E , F )
Differential Diagnosis
- •
Generalized muscular low back pain; duration may help (3 weeks)
- •
Imaging is key, may need to use algorithm of: plain radiographs/CT/single photon emission tomography (SPECT)/magnetic resonance imaging (MRI).
- •
Significant neurologic findings
Treatment
Nonoperative Management
- •
Education
- •
Core stability
- •
Aqua/pool therapy
- •
Bracing (varied opinions here)
- •
Soft tissue mobilization/manipulation
- •
Strengthen specific muscle groups (abdominal core, lower extremities); lengthen others (hip flexors)
Guidelines for Choosing Between Nonoperative Treatments
- •
Primary complaint (pain, AROM)
- •
Lesion (spondylolysis with no spondylolisthesis)
- •
Unilateral versus bilateral pars defect
- •
Radiculopathy versus none
- •
Availability of pool/soft tissue management
- •
Type of sport
Surgical Indications
- •
Abnormal neurologic signs
- •
Severe and/or progressive neurologic deficits
- •
Failure of conservative care
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Neurologic signs
- •
Failed treatment over course of one year
- •
Patients’ desires, schedule, and time frame
Aspects of Clinical Decision Making When Surgery is Indicated
- •
Failed course of conservative care (6 to 12 months)
- •
Severe and/or progressive neurologic deficits
- •
Patient’s desires
Evidence
Multiple-Choice Questions
- QUESTION 1.
Spondylolysis is most common in males, with a male/female ratio of:
- A.
2 : 1
- B.
3 : 1
- C.
5 : 1
- D.
10 : 1
- A.
- QUESTION 2.
Spondylolysis occurs most frequently at which spinal level?
- A.
L2
- B.
L3
- C.
L4
- D.
L5
- A.
- QUESTION 3.
What lumbar motion is predominately painful with a spondylolysis?
- A.
Flexion
- B.
Extension
- C.
Rotation
- D.
Sidebending
- A.
- QUESTION 4.
A spondylolysis is a fracture demonstrated on a radiograph by what on the Scotty dog?
- A.
Ears
- B.
Front legs
- C.
Rear legs
- D.
Collar
- A.
- QUESTION 5.
What imaging modality is considered the most accurate for identifying spondylolysis?
- A.
Radiograph (X-ray)
- B.
Magnetic resonance imaging (MRI)
- C.
Computed tomography (CT)
- D.
Bone scan
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Epidemiology )
- QUESTION 2.
Correct answer: D (see Pathophysiology )
- QUESTION 3.
Correct answer: B (see Clinical Presentation )
- QUESTION 4.
Correct answer: D (see Clinical Presentation )
- QUESTION 5.
Correct answer: C (see Epidemiology )
Nonoperative Rehabilitation of Spondylolysis
- Gregg Ziemke, PT, MS, MHA, OCS
- Leslie C. Hair, PT, DSc, OCS, FAAOMPT
- Charles E. Rainey, PT, DSc, DPT, OCS, SCS, CSCS, FAAOMPT
- Stewart M. Kerr, MD
- Leslie C. Hair, PT, DSc, OCS, FAAOMPT
- •
Decrease pain with chosen activity; most important is rest until pain is subsiding
- •
Increase level of function (without pain) in chosen activity
- •
Return to sport
Phase I (0 to 3 months)
Goals
- •
Protect the healing segment.
- •
Minimize the effect of spinal immobilization.
- •
No signs or symptoms of instability.
- •
Rest; avoid sports.
| PHASE I (0 to 3 months) | PHASE II (3 to 6 months) | PHASE III (6 to 9 months) | PHASE IV (9 to 12 months) |
|---|---|---|---|
|
|
|
|
Protection
- •
For nonoperative care, use of spinal bracing as well as the type of bracing is controversial. Our recommendation is soft bracing (corset) or hard bracing (thoracolumbar sacral orthosis) for at least 3 months.
- •
After 3 months, pain should be the guide.
Management of Pain and Swelling
- •
Electrotherapy (TENS) may be used if there is pain, spasm, and muscle guarding
- •
Oral NSAIDs and analgesic pain medication as needed.
- •
Cryotherapy as needed
Techniques for Progressive Increase in Range of Motion
- •
Begins immediately after evaluation by a physician.
- •
This phase should include evaluation, discussion, and planning. Active physical therapy care will begin once pain is subsiding.
Manual Therapy Techniques
- •
With the patient in a brace, begin gentle mobilization of extremities and hips to maintain AROM of those structures if needed.
- •
No manual therapy for lumbar and thoracic spine.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Letting pain be the guide, limit flexibility training to accessory structures of the upper and lower extremities, specifically the shoulders and hips.
- •
The intent of treatment at this phase is maintenance of accessory structures.
Other Therapeutic Exercises
- •
Generalized aerobic conditioning may begin if pain-free.
- •
Continue bracing at all times or as instructed by physician.
- •
If patient is allowed to remove brace, it is advisable to recommend wearing the brace for exercise for a 3-month period.
- •
Nonexercise brace wear will coincide with pain level with activity and radiographic evidence of healing.
- •
Low-level core stability exercises, such as double/single leg bridges, active straight leg raises, and quadruped diagonals (i.e. bird dogs).
- •
Education; back school
Activation of Primary Muscles Involved
- •
Avoid all high level muscle activation of spinal musculature for at least 3 months.
Sensorimotor Exercises
- •
These activities are advisable only in the brace and only if they do not cause pain.
Open and Closed Kinetic Chain Exercises
- •
Avoid open chain activities.
- •
Closed chain activities to include walking on level surface (no treadmill walking), low-level stationary bike.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Maintain upper extremity (UE) and lower extremity (LE) muscle strength, power, and endurance.
Sport-Specific Exercises
- •
Maintain low-level aerobic fitness.
Milestones for Progression to the Next Phase
- •
No pain at rest
- •
Very little to no pain with increased activity
- •
Outcome measures
- •
Patient reported outcome tools should be implemented at the end of each phase. These tools will assist with the decision to advance to the next phase.
- •
These outcome measures can also be used more often (monthly) if desired. Tools that have been used in the literature for spinal rehabilitation include the Fear Avoidance Behavior Questionnaire (FABQ) and (modified) Oswestry Disability Questionnaire.
- •
Phase II (3 to 6 months)
Goals
- •
Protect healing segment.
- •
Minimize effect of spinal immobilization.
- •
Discontinue brace.
- •
Increase spinal AROM.
- •
Begin with minimal repetitions to assess tolerance for exercise and progress dosage of sets and repetitions as tolerated.
Protection
- •
Brace wear can be discontinued after 3 months; earlier if cleared by physician. Continue brace with exercise.
Management of Pain and Swelling
- •
Electrotherapy (TENS) may be used if there is pain, spasm and muscle guarding.
- •
Oral NSAIDs and analgesic pain medications as needed.
- •
Cryotherapy as needed.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Precautions: Initially limit AROM only to spinal flexion and extension without rotation. No manual therapy should be applied to healing segment.
- •
Slowly increase spinal AROM with AP mobilization techniques grades I to II in flexion and extension, with goal of ensuring quality planar motion without rotation in hypomobile segments.
- •
If no pain with flexion and extension after 1 week of care, begin spinal side-bending and rotation, letting pain be the guide. Mobilization for these motions should also be grades I to II in hypomobile segments.
- •
Limit increase in motion to 30°/week.
- •
Grades I to IV segmental mobilization of cervical and thoracic spine may improve overall available spinal AROM and also assist in pain management.
- •
Initiate spinal mobilization for sacrum/pelvis as indicated by evaluation.
Soft Tissue Techniques
- •
Begin instrument assisted soft tissue mobilization (IASTM), such as Graston, ASTYM, or other manual soft tissue mobilizations and techniques.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue as in Phase I; ensure upper extremity and lower extremity AROM are within normal limits.
- •
Patients may perform supine upper extremity and lower extremity AROM activities/mat activities to include straight leg raise (SLR) and shoulder AROM in spinal flexion/extension plane.
- •
Cervical spine AROM activities in all planes are encouraged.
- •
Check for purity of spinal motion and regard compensatory motion as pain and or segmental blocking. Avoidance or lack of motion at individual segments may prevent increase in overall motion and be the cause of pain.
Other Therapeutic Exercises
- •
Begin gentle mat activities to include pelvic tilts.
- •
Lower and upper extremity exercise without resistance may also be added during this phase.
- •
Lower extremity exercises during this phase may include higher level stationary cycling (slowly add resistance) and treadmill walking.
Activation of Primary Muscles Involved
- •
Stability plank and four-point unilateral leg and arm lifts, no pain.
- •
Patients are reminded to avoid high level spine activities, (i.e., plyometric activity, sport-specific activities in this phase.)
- •
Sensorimotor Exercises
Begin active replication exercises, such as yoga and movement patterns for motor control.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Overall strengthening exercise may be initiated to include therapeutic ball exercises.
Neuromuscular Dynamic Stability Exercises
- •
Lower extremity balance activities such as single leg standing, BOSU ball, star excursion
Functional Exercises
- •
Begin Phase I spinal core stability exercises, which include:
- •
Upper body rolling patterns
- •
Lower body rolling patterns
- •
Dying bug: patient lying on back with lifting alternate arm and legs while maintaining core stability
- •
Quadruped diagonals (i.e., bird dogs)
- •
Double/single leg bridges
- •
Active straight leg raise
- •
The introduction of Phase II activities/exercises coincides with limiting the use of the spinal brace until it is ultimately eliminated.
- •
A concerted phased approach to maximize effective rehabilitation must be used. The slow introduction of spine specific exercises is key in that the patient has been immobilized for up to 3 months.
- •
Techniques to increase spinal AROM include stretching and skilled manual therapy techniques. These are important tools to assist with proper spinal rhythm and restoring proper joint arthrokinematics.
- •
Often, patients are fearful of moving; this is to be expected. However, proper movement patterns play a large role in pain management.
Sport-Specific Exercises
- •
Patients may begin low level sport-specific exercises.
- •
If a training program is being used, a careful review should be initiated to decide which activities are appropriate at this time.
- •
Activities should not include maximum weightlifting.
Milestones for Progression to the Next Phase
- •
Spinal AROM is improving with no pain
- •
Able to walk aerobically without pain to patient tolerance for aerobic conditioning
- •
Begin walk to run program
- •
Begin with 5 minutes of walking and 1 minute of running and continue until reaching a duration of 30 minutes (5 cycles).
- •
Repeat twice with a day of rest in between workouts.
- •
Progress by reducing walking to 4 minutes and increasing running to 2 minutes.
- •
Repeat protocol above until running continuously for 30 minutes.
- •
If any symptoms occur, digress to previous stage until symptoms resolve.
- •
Phase III (6 to 9 months)
Goals
- •
Protect healing segment
- •
Maximize spinal mobility/full spinal mobility
- •
No signs or symptoms of instability (determined reassessment by a qualified healthcare provider)
- •
Functional spinal movement mechanics (quality of movement determined by reassessment by a qualified healthcare provider)
- •
Increased quality of life and function
- •
Begin with minimal repetitions to assess tolerance for exercise and progress dosage of sets and repetitions as tolerated
- •
Sensorimotor/proprioceptive activities are performed for 30 to 60 seconds daily. Repeat 2 to 3 times per week or as needed.
Protection
- •
Patient is out of the brace
Management of Pain and Swelling
- •
Oral NSAIDS and analgesic pain medicine should be on the decline or discontinued. May be used as needed.
- •
Cryotherapy is used posttherapy treatment for postexercise inflammation and soreness
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
AROM precautions: None.
- •
Joint mobilizations: If adhesions are noted in lower spine, joint mobilizations may begin to be more aggressive, no thrust activities. Use oscillatory techniques grades II to IV. Care must be taken when assessing structures.
- •
Continued evaluation of all joint structures for maintenance and increasing level of function.
Soft Tissue Techniques
- •
We recommend continuing IASTM treatments over the course of this phase.
- •
Soft tissue techniques can include Graston, ASTYM, manual soft tissue mobilization or deep tissue massage.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue to maintain flexibility of upper extremity and lower extremity structures special attention to hip flexors and hamstrings
- •
Increase spinal AROM
Other Therapeutic Exercises
- •
Lower body strengthening is progressed and may include closed kinetic chain exercises (i.e., lunges, tubing resistance hip flex/extension/abduction, wall sits, body weight squats) and open chain resistance exercises.
- •
Treadmill walking and stationary biking with increased resistance.
- •
Add upper body ergometer (UBE) within pain free ranges without resistance. Performing the UBE in a standing position, if possible, provides an integrated conditioning exercise involving the trunk and hip girdle musculature.
Activation of Primary Muscles Involved
- •
Plank exercise with timed activities
- •
Four-point leg and arm exercises to progress to alternating arm/leg activities, again paying attention to quality versus quantity of motion.
- •
Stability ball: all activities on mat can advance to stability ball
- •
Wall squats
- •
Upper extremity and lower extremity strengthening with light resistance may begin.
Sensorimotor/Proprioceptive Exercises
- •
The Bodyblade is an effective tool to incorporate at this phase.
- •
Balance Master, proprioceptive neuromuscular facilitation (PNF) patterns (tall/half kneeling chops and lifts).
- •
Increase functional movement exercises.
- •
In addition, purity of motion will flow into sport-specific activities to restore successful movement patterns common to the athlete’s sport of choice. This may be as simple as discussing these activities with your athlete.
- •
Successful movement patterns as this level will prepare the patient for more difficult functional patterns to be performed later as the treatment progresses. PNF patterns may be a way to integrate higher levels of sensory motor activities.
A key component to successful spinal rehabilitation is patient education for proper positioning during exercise; constant cueing is essential to maintain the purity of the designed activity.
Open and Closed Kinetic Chain Exercises
- •
Pool or aqua therapy is an effective method to get open chain activity and maximize training.
- •
Closed chain activities can include seated medicine ball flexion/extension and rotation progressing to standing medicine ball training.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progress to all muscle groups as tolerated first in sitting, then in standing.
- •
Progress to lower extremity strength training exercises.
- •
Progress to elliptical and stair stepper for cardiovascular conditioning.
Neuromuscular Dynamic Stability Exercises
- •
Progress manual rhythmic stabilization drills for spine and advance to varying degrees of spinal motion as pain and ability allows.
- •
Performing these exercises in sitting first then standing will increase core recruitment.
Sport-Specific Exercises
- •
Can begin more sports specific training here. All should be performed without pain.
Milestones for Progression to the Next Phase
- •
No pain with activities
- •
Increased endurance
- •
Early participation in chosen sport activity/no competition
Phase IV (9 to 12 months)
Goals
- •
Full function; ready to return to sport
- •
Continue sports-specific training
- •
No signs or symptoms of instability
- •
Begin with minimal repetitions to assess tolerance for exercise and progress dosage of sets and repetitions as tolerated.
Management of Pain and Swelling
- •
Should be off all medication at this phase.
- •
Postexercise cryotherapy if needed.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Should not need any hands-on treatment except for short-term care because patient has an acute condition that will respond to manual therapy/manipulation.
Soft Tissue Techniques
- •
Should not need any hands-on treatment except for short-term care.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue to maintain flexibility of all structures.
- •
At this phase, stretching is an important part of a sport-specific workout.
Other Therapeutic Exercises
- •
Continue and increase difficulty of Phase III exercises.
Activation of Primary Muscles Involved
- •
Continue with Phase III exercises.
Sensorimotor/Proprioceptive Exercises
- •
Continue Bodyblade
- •
Balance Master
- •
Side thrusts high speed crossover training
- •
Increase functional movement exercises
A continuous increase in difficulty should be part of the treatment plan. At some point, it is more of a personal training session than a therapy session. When that becomes the case, the patient should be considered for a home self-paced program.
Open and Closed Kinetic Chain Exercises
- •
Continue with pool or aqua therapy
- •
Continue with high level closed chain activities.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Continue with increasing intensity
Neuromuscular Dynamic Stability Exercises
- •
Progress Phase III exercises
Plyometrics
- •
Continue progression of Phase III exercises
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Sport specific training with team/coach
- •
No contact/competition until cleared by physician
Tips and Guidelines for Transitioning to Performance Enhancement
Once fundamental movement patterns are reestablished with no compensation observed with bodyweight, the athlete can progress to performance enhancement, as evaluated by a qualified rehabilitation heath care provider.
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
See Beyond Basic Rehabilitation: Return to Gymnastics after Surgical Repair of Spondylolysis later in this book.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
The rehabilitation specialist should be able to analyze the demands on the spinal complex and create a sufficient series of tests and exercises to ensure readiness for return to preinjury levels of activity.
- •
Meets the demand/need for the chosen sport without symptoms.
After Return to Sport
- •
Continuing fitness or rehabilitation exercises including total body strengthening and fitness exercises.
- •
Exercises and other techniques for prevention of recurrent injury.
Evidence
Multiple-Choice Questions
- QUESTION 1.
The goals of Phase I rehabilitation include all but:
- A.
Protect healing segment.
- B.
Minimize effect of spinal immobilization
- C.
No signs or symptoms of instability
- D.
Return to sports
- A.
- QUESTION 2.
What are appropriate interventions for Phase III rehabilitation?
- A.
Manual therapy
- B.
Stretching exercises
- C.
Begin return to sport activity
- D.
All the above
- A.
- QUESTION 3.
What is the appropriate phase to discontinue full-time brace wear?
- A.
Phase I
- B.
Phase II
- C.
Phase III
- D.
Phase IV
- A.
- QUESTION 4.
During which phase is the slow introduction of spine-specific exercise key?
- A.
Phase I
- B.
Phase II
- C.
Phase III
- D.
Phase IV
- A.
- QUESTION 5.
What is not a criterion for progression of the patient to the next phase?
- A.
Increased AROM without pain
- B.
Able to perform sport-specific motion without pain
- C.
Able to tolerate improved activity without pain
- D.
Contact sports without physician clearance
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Phase I )
- QUESTION 2.
Correct answer: D (see Phase III )
- QUESTION 3.
Correct answer: B (see Phase II )
- QUESTION 4.
Correct answer: B (see Phase II , Clinical Pearl)
- QUESTION 5.
Postoperative Rehabilitation after Repair of Spondylolysis
- Charles E. Rainey, PT, DSc, DPT, OCS, SCS, CSCS, FAAOMPT
- Stewart M. Kerr, MD
- Gregg Ziemke, PT, MS, MHA, OCS
- Leslie C. Hair, PT, DSc, OCS, FAAOMPT
- Stewart M. Kerr, MD
Indications for Surgical Treatment
- •
Severe, refractory lumbosacral pain that has not responded in 6 to 9 months to nonoperative management.
- •
Imaging (i.e., SPECT and/or MRI) should also be active/positive at the pars defect. The SPECT study is used most commonly and typically is most helpful for localizing a pars defect.
Brief Summary of Surgical Treatment
Major Surgical Steps
- •
Exposure of defect
- •
Debridement of sclerotic/fibrous healing response to healthy bleeding bone at the pars
- •
Use of iliac crest autograft
- •
Consideration for stabilization/instrumentation for increased bone fusion
- •
Postoperative lumbosacral bracing
- •
The single lag screw fixation (Buck) approach has been widely studied in both athletes and nonathletes. Published outcomes have shown that >90% of patients return to their preoperative sports performance.
Factors That May Affect Rehabilitation
Anesthetic
- •
A general anesthetic is required for any surgical repair.
Presurgical
- •
Flexion and extension radiographs (A-P and lateral) are taken to observe the degree of vertebrate slippage or abnormal motion ( Figure 20-5 A , B )
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