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
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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: begins after the necessary 4-8 weeks of rest required to achieve significant pain reduction. It usually takes 1-3 weeks to master the foundational movement patterns in phase 2, depending on the individual.
Appointments • Every 7-10 days
Rehabilitation Goals • Maintain pain free (or nearly pain free) range of motion • Pain free with daily activities • Increase abdominal and core strength • Ensure normal hip and thoracic mobility • Progress flexibility and lumbar stabilization to weight-bearing postures • Improve pelvic proprioception • Maintain/ Increase flexibility in key upper/lower body muscles • Re-establish aerobic fitness
Precautions • No active or passive lumbar extension ROM
Suggested Therapeutic • Crunches Exercises • Double leg bridges • 4 point alternate arm or leg raises • Side lying hip abduction or clam shells • Side Planks • Upright rows with abdominal bracing in sitting • Sitting on Swiss ball, alternate lifting an arm or leg
Cardiovascular Exercise • Light -moderate stationary biking • Deep water jogging in pool with floatation vest
Progression Criteria • Noticeable increase in abdominal strength • Can accomplish full and pain free lumbar flexion and lateral flexion range of motion • Ability to hold bridge and side plank for 30 seconds without pain • Ability to maintain neutral spine posture during dynamic arm or leg ROM
PHASE 3 Dynamic Trunk Stabilization & Coordination can be initiated when the goals of phase 2 are met. On average, this will begin ~2-3 months from Day #0. It usually takes 2-4 weeks to achieve the goals in this phase, depending on the individual.
Appointments • Every 1-2 weeks
Rehabilitation Goals • Continue increase in abdominal strength • Maintain flexibility • Ensure normal joint mobility: hip and thoracic spine; mobilize if necessary • Resume lumbar extension in non-weightbearing postures • Progress aerobic fitness • Begin sport specific drills to prepare for return to sports participation
5 621 SCIENCE DRIVE • MADISON, WI 53711 • 4602 EASTPARK BLVD, MADISON, WI 53718 UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis
Precautions • Avoid prolonged back pain with initiation of lumbar extension AROM
Suggested Therapeutic • Sit ups with medicine ball and throw ball at end for plyometrics Exercises • Single leg bridges • Oblique trunk rotation in hook lying (progress to med ball) • Supine hamstring curls on Swiss ball • Squats emphasizing hip hinge and overhead reach • Push- ups • OK to resume upper body weight lifting with spine neutral
Cardiovascular • Moderate intensity stationary biking or elliptical machine • Shallow water jogging and jumping drills in pool (immersed to chest depth)
Progression Criteria • No increase in pain with lumbar range of motion and sport skills • Physician’s release if necessary.
Suggested • Multi-planar strength progression, including forward, lateral and diagonal lunges Therapeutic Exercise • Dynamic control exercise beginning with low velocity, single plane activities and progressing to higher velocity, multi-plane activities • Sport/work specific balance and proprioceptive drills • Hip and core strengthening • Stretching for patient specific muscle imbalances
Cardiovascular Exercise • Replicate sport or work specific energy demands
Return To Sport Criteria • Dynamic neuromuscular control with multi-plane activities, without pain
PHASE 4 Athletic Enhancement and Gradual return to activity when the goals of phase 3 are met, you can initiate this phase. It usually takes 2-4 weeks to achieve the goals depending on the individual. This phase takes into account the unique demands of the sport: progresses into impact loading through running and jumping, provide sport-specific exercises and leads to the development of a maintenance program.
Appointments • Every 1-2 weeks
Rehabilitation Goals • Maintain flexibility in key muscle groups • Maintain strength in abdominals and hip muscles • Initiate lumbar extension AROM if necessary for sport • Initiate impact loading of the spine including jogging, running, jumping/landing
Suggested Therapeutic • In stance, Diagonal #1 and #2 trunk rotation patterns with medicine ball (wood chops) Exercises • Lunges (forward, backward, side) with dumbbells or medicine ball • Body weight suspension exercises (such as TRX) • Progression to Impact Loading (see Addendum A) • Gradual exposure to sport-specific activities and drills, making sure to concentrate on spine stability
6 621 SCIENCE DRIVE • MADISON, WI 53711 • 4602 EASTPARK BLVD, MADISON, WI 53718 UWSPORTSMEDICINE.ORG Rehabilitation Guidelines for Lumbar Spondylolysis/Spondylolisthesis
Impact Loading Progression • See Addendum A
Cardiovascular • Moderate-high intensity intervals with stationary biking • Initiate Impact Loading on land (see Addendum A)
Progression Criteria • Successful completion of a comprehensive exercise program • Be able to demonstrate sport-specific skills and practice drills without pain. This depends on the sport; and may include intervals of sprinting and pivoting; jumping and landing, back hyperextension and/or twisting.
PHASE 5 Independent Exercise Program and Re-injury Prevention Program At this point you are cleared to participate in your athletics. Your physical therapist or athletic trainer will provide you with specific exercises that will aim to enhance your athletic performance and may help to prevent future injuries. Depending on the extent of your injury, you may need to continue to avoid certain weight lifting moves such and Olympic style squats and deadlifts.
Appointments • Every 1-2 months
Rehabilitation Goals • Full participation in sports • Commit to completing a 10-15 minute abdominal workout at least 3 times a week for the remainder of your athletic career. • This workout should consist of some of the most challenging exercises from your rehabilitation program and might include sit ups, single leg bridges, squats & lunges, body suspension rowing, 4 point exercises with 1-2# weights on your ankles and wrists, side planks and few stretching exercises.
Precautions • May need to continue to avoid Olympic style squats and deadlifts (power lifting)
Suggested Therapeutic • Hip sled as option to replace Olympic squats Exercises • Squats with medicine ball throw • Single leg deadlift with dumbbells
ADDENDUM A Sport-specific impact loading program (for Phases 4-5) This portion of the rehabilitation Before doing the program each Your provider may modify this is designed to allow the athlete day, the athlete should warm up routine to fit the specific athletic to gradually load the spine for a with 10-15 minutes of low impact demands of the sport. For safe return to sport following a activities such as stationary biking. example, a long distance runner, low back injury. It should be used The athlete can progress to the a basketball player and a gymnast in conjunction with a specific next level when the previous will all have different impact rehabilitation program from your level has been completed without loading requirements physical therapist or athletic pain or apprehension. The athlete trainer. The athlete should be able should rest every third day. to complete the entire program before return to sport is allowed.
7 621 SCIENCE DRIVE • MADISON, WI 53711 • 4602 EASTPARK BLVD, MADISON, WI 53718 UWSPORTSMEDICINE.ORG Copyright 2017UWHealth SportsMedicineCenter regardingamedicalcondition. questionyoumayhave or withany newtreatment seek theadviceofyourphysicianorotherqualifiedhealth providerpriortostartingany Always or advicegivenbyyourphysician orhealthcareprovider. Itisneitherintendednorimpliedtobe a substituteforprofessionaladvice. amedicalemergency. ifyou thinkyoumayhave Callyourhealth provider immediately isnotintendedtoreplace thecare fromthisinformation. thisinformation options,At UWHealth, that vary and/ortreatment Pleasebe aware that advanceddiagnostic materials mayhave ormayreceiveeducational patients REFERENCES Updated 5/17 Updated and theUWhealthSportsMedicinephysiciangroup. Marc Sherry, DPT, LAT, CSCS([email protected]), Scott Tauferner, PT, LAT ([email protected]) byJulieSherry, guidelinesweredevelopedcollaboratively These rehabilitation DPT, MS([email protected]), Jog for20minutesat½speed 3. 2. 1. Jog 15minutesat½speed Jog 10minutesat½speed Jog 10minatusualpace
621 SCIENCE DRIVE •MADISON, WI 53711 Surg Br2004:86;225-31. treatment. JBoneJoint after conservative adolescents. The radiologicaloutcome of thelumbarspineinchildrenand of defectsintheparsinterarticularis Fujii K, S, Katoh K, Sairyo etal. Union 26-30. World JOrthop2010November18;1(1): ofSpondylolysis. aftertreatment athletes Matsumoto. Returntosportsactivityby J,Iwamoto YSato, TTakeda, H and North Am. 2003Jul;34(3):461- child andadolescentathlete. OrthopClin inthe andspondylolisthesis Spondylolysis Herman MJ, PizzutilloPD, R. Cavalier Jog 30min Jog 25min Jog 20min Jog 15min Jog 12min JOGGING Rehabilitation GuidelinesforLumbarSpondylolysis/Spondylolisthesis 6 x60secondfast-pacedintervals side shuffle, retro running, skipping 30 minsportspecificdrills: Such ascarioca, 6 x45secondfast-pacedintervals side shuffle, retro running, skipping 20 minsportspecificdrills: Such ascarioca, 6 x30secondfast-pacedintervals side shuffle, retro running, skipping 10 minsportspecificdrills: Such ascarioca, pivoting every 5yards pivoting every 10 x40yards atfullspeedwithcutting/ pivoting every 5yards pivoting every 6 x40yards at¾-fullspeedwithcutting/ 10 x40yards atfullspeed 6 x40yards atfullspeed 10 x40yards at¾speed 6 x40yards at¾speed UWSPORTSMEDICINE.ORG 6. 5. 4.
Suggested Progressions 2009 Mar;29(2):146-56. studies.observational JPediatr Orthop. and youngadults: ameta-analysis of inchildren and gradeIspondylolisthesis ofspondylolysis treatment Nonoperative Klein G, MehlmanCT, McCartyM. 2002, Vol.1(5),p.293-300 Gymnasts. Currentsportsmedicinereports, BackInjuriesin ofLow Management Standaert CJ. inthe NewStrategies 67. (Phila Pa 1976). 1997Dec15;22(24):2959- orspondylolisthesis.spondylolysis Spine of back painwithradiologicdiagnosis ofchroniclow exercise inthetreatment Allison GT. ofspecificstabilizing Evaluation O’Sullivan PB, PhytyGD, Twomey LT, RUNNING ■ 4602 EASTPARK BLVD. •MADISON, WI53718 Burpees 5 x8multidirectional singlelegleaping/bounding 5 x8multidirectional jumpsquats 3 x30secmultidirectional singlefoothopping 5 x8reps verticaljumpsquats 3 x20secmultidirectional singlefoothopping 5 xreps verticaljumpsquats 6 x1minjumproping 4 x1minutejumproping 2 x1minutejumproping 5 x10reps hopinplace 5 xreps hopinplace 7. 8.
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