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Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis

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Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis UW HEALTH SPORTS REHABILITATION Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis The lumbar spine consists of Eighty-five percent of athletes five stacked bones (vertebra). report good/excellent clinical Spondyloysis (spon-dee-low-lye- outcome by year one, regardless sis) is defined as a stress fracture of the fracture healing or not. defect of the pars and can occur (2) on the left, right or both sides of the bone. The vast majority The Role of Rehabilitation of these injuries are at the L5 Spondylolysis creates relative bone, with the L4 level being instability of the lumbar region. the second most likely to be Rehabilitation focusing on affected. specific training of muscles Spondylolysis occurs in 6-10% surrounding the lumbar spine of the general population that provide stability can be and has been found to be as very effective in reducing and high as 25-60% of the athletic Figure 1 Stress fracture defect on the vertebrae preventing pain and instability. population.(1,2) It is especially common in young athletes under in the terminal stage, the defect the age of 18, who participate shows non-union, with little in sports that involve twisting or chance of healing. Because of backward bending motions of this, terminal stage defects can the spine. This injury also runs often progress more quickly in families and is more common through rehabilitation. in some populations suggesting Not all lumbar stress fractures that there might be a hereditary heal. If the stress fracture is component. only on one side of the bone (unilateral) and is detected as Understanding the Injury soon as possible (early stage), An x-ray, MRI, CT scan or bone the likelihood of healing is scan can confirm the diagnosis ~70%.(3) If diagnosis and rest and determine how new the are delayed (progressive or injury is. The fracture line or the terminal stage) then healing bony defect can be classified rates decrease to 28%.(3) The into various stages of acuity: likelihood of healing also goes early, progressive and terminal. down if fractures are present In the early stage, bone edema bilaterally (on both the left and Figure 2: X-ray of the lumbar spine showing might be a hairline fracture spondylolysis, decrease in disc space and bony the right side). visible. In the progressive spur formation (side view ) stage, the fracture may have progressed to a wider gap and The world class health care team for the UW Badgers and proud sponsor of UW Athletics UWSPORTSMEDICINE.ORG 621 SCIENCE DRIVE • MADISON, WI 53711 ■ 4602 EASTPARK BLVD. • MADISON, WI 53718 Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis Consequences of the Injury • In addition to a calcium-rich Just like any bone fracture, stress diet, vitamin D is essential for fractures in the low back need bone health. Your provider may time to heal. This means resting test your vitamin D level and if from all sporting and impact it is low, suggest that you take a activities until there is little, to vitamin D supplement. Research no pain. This usually takes 4-8 shows that vitamin D deficiency weeks, but may take longer. likely exists in orthopaedic trauma patients living in northern In patients with a bilateral latitudes.(7) In Nebraska, over 60% stress fracture, there is a rare of adolescents with spondylolysis complication where spinal were found to have low vitamin alignment could be affected. D levels.(8) This condition is called • Rehabilitation under the spondylolisthesis (spon-dee-low- guidance of a physical therapist lis-thee-sis). If a small amount of or athletic trainer. Corrective Figure 3: X-ray of the lumbar spine showing slip occurs, research reports that spondylolisthesis (posterior and side view) exercise training is emphasized- it is still safe to participate in beginning with gentle upper competitive sports. These muscles are the deep and lower body stretching and abdominal muscles (transversus However, if too much slippage progressing to an individualized abdominis and internal oblique) occurs, the bones may begin to core strengthening routine that and the lumbar multifidus. press on nerves and orthopedic gradually builds over time. Training of these “stability” surgery may be necessary to • For most people a brace is muscles in the lumbar spine correct the condition. provides a solid foundation for not needed for this condition. the athlete to integrate them into Treatment Options Clinical outcome of patients their sport-specific movement The recommended treatment treated with a brace to patients patterns. Exercises focusing on program for spondylolysis is treated without a brace was not (6) these muscles have been shown usually a combination of the significantly different. However, to significantly decrease pain following: if 2-4 weeks of rest/activity restriction alone do not reduce and disability in people with • For early or progressive the pain, then a brace may be spondylolysis/spondylolisthesis. defects = rest/protection for the beneficial. This training effect persists for first 4 weeks, possibly longer: no many years following only 10 sports participation, no physical • On rare occasions, orthopedic weeks of practice (4). education class, reduce backpack surgery should be considered weight and avoid sleeping on when symptoms persist, there are Goals of Treatment your stomach (5) associated nerve complications 1. Pain control or there is a progressive slippage • For terminal defects = a brief 2. Healing when possible of the bone. In these cases, period of activity reduction surgery can provide additional 3. Restoration of normal function prior to starting stabilization stabilization to the area. including return to sports exercises (5) • Pain medications as needed/ recommended by your physician 2 621 SCIENCE DRIVE • MADISON, WI 53711 • 4602 EASTPARK BLVD, MADISON, WI 53718 UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis Diagnostic Stage Consider other diagnosis Early/progressive defect The process may include x-rays, If (-) result MRI, CT scan and/or bone SPECT in the pars interarticularis Terminal defect in pars interacticularis Rest Stage Rest, including no sports participation, recreational activities or physical education class. Weeks 0-8 Week 0 until nearly Consider bracing if still symptomatic after painfree with full ROM 2-4 weeks Rehabilitation Stage Exercise Phase 1-2 Foundational Range of Motion Weeks 4-12 When progressed Low-impact aerobic conditioning through acute stage Neutral spine Stabilization Exercise Phase 2-3 Recovery Range of motion Aerobic conditioning Weeks 8-16 Resistive / strength training When progressed Progressive spinal stabilization through recovery stage Assess kinetic chain and sport technique Exercise Phase 3-4 Functional Aerobic conditioning >8 weeks; when Resistive /strength training progressed through the Dynamic, multi-planar spinal stabilization When progressed recovery stage Sports specific retraining through functional stage Skill and technique refinement Return to Play Stage Exercise Phase 5 Full, painfree or nearly painfree ROM 3-6 months total time Normal strength & aerobic fitness 2-4 months total time Improved spinal awareness & mechanics Able to perform sports-related skills without pain Skill and technique refinement 3 621 SCIENCE DRIVE • MADISON, WI 53711 • 4602 EASTPARK BLVD, MADISON, WI 53718 UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis Rehabilitation Timeline: Phases of the Exercise Progression Rest/ Rehabilitation Rehabilitation Rehabilitation Return Total Time Protection Foundational Recovery Functional to Sport to Return Stage to Sport Exercise 1 2 3 4 5 Phase Rest/protection, Static Dynamic Athletic Development Core initiation, stabilization stabilization and enhancement and of maintenance Emphasis Abdominal bracing coordination gradual return exercise routine to activity Duration 4-8 weeks +1 - 4 weeks + 2 - 4 weeks + 2 - 6 weeks Return to sport 2-6 months PHASE 1 Rest & Protection, Core Initiation, Abdominal Bracing begins on the first day of complete rest (Day #0) and continues for 4-8 weeks, depending on your progress. To promote proper healing of the stress fracture(s) it is important to rest completely and for the entire length of time recommended by your health care professional. Appointments • First rehabilitation appointment should be within 1-2 weeks of diagnosis, every 1-2 weeks thereafter Rehabilitation Goals • Allow sufficient time for healing to occur, hold all sports participation, protect the area • Pain-free with daily activities • Initiate deep abdominal stabilization recruitment • Gradually increase flexibility of key upper/lower body muscles Precautions • No active or passive lumbar extension ROM • Consider bracing if still symptomatic after 2-4 weeks rest Suggested Therapeutic • Abdominal bracing in various postures (supine, prone over pillow, 4 point, kneeling, Exercises standing) • Stretching exercises for key UE/LE muscles with emphasis on neutral spine alignment and in non-weightbearing postures • Supine 90-90 active knee extension hamstring stretch • Child’s pose latissimus dorsi stretch • Supine pectoralis stretching in 90-90 shoulder position • Supine or side-lying hip flexor & quad stretching • Supine figure 4 piriformis stretching Cardiovascular • Light stationary biking 4 621 SCIENCE DRIVE • MADISON, WI 53711 • 4602 EASTPARK BLVD, MADISON, WI 53718 UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis PHASE 2 Static Stabilization:
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