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Spinal Conditioning for Athletes with Lumbar Spondylolysis and Spondylolisthesis Erin Nau, ATC,1 William J

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Spinal Conditioning for Athletes with Lumbar Spondylolysis and Spondylolisthesis Erin Nau, ATC,1 William J Spinal Conditioning for Athletes With Lumbar Spondylolysis and Spondylolisthesis Erin Nau, ATC,1 William J. Hanney, PT, DPT, ATC, CSCS,1 and Morey J. Kolber, PT, PhD, CSCS2 1University of Central Florida, Orlando, Florida; 2Nova Southeastern University, Fort Lauderdale, Florida SUMMARY athletes, LBP accounts for up to 40% the pars interarticularis (Figure 2) (25). of documented injuries (2,9,25). Al- A spondylolysis disorder does not LOW BACK PAIN IS A COMMON though LBP is not the most frequent imply a forward slippage of the verte- CONDITION IN ATHLETIC disorder encountered among the ath- bra (33). Spondylolysis defects may be POPULATIONS. PARTICIPATION IN letic population, it is one of the most unilateral or bilateral and may progress ATHLETICS HAS BEEN LINKED TO challenging to treat, perhaps as a result to a spondylolisthesis over time (13). SPECIFIC ANATOMICAL CHANGES of training demands. Although the Researchers have indicated that ath- TO THE LUMBER SPINE etiology of LBP is multifactorial, epi- letes with a unilateral spondylolysis (SPONDYLOLYSIS AND demiological data have suggested that may be at risk for developing a fracture SPONDYLOLISTHESIS). PRACTICAL athletes are more prone to degenera- of the contralateral pars interarticularis GUIDELINES FOR STRENGTH AND tive and spondylolytic related injuries (27). For the purpose of clarity, we will CONDITIONING PROFESSIONALS when compared with the general refer to spondylolysis and spondylolis- SHOULD RECOGNIZE THE population (2,5,8,10,13,16,26). The thesis conditions collectively as spon- BIOMECHANICAL STRESSES purpose of this article is to present dylolitic disorders. Where necessary, ASSOCIATED WITH ATHLETIC a brief overview of spondylolitic dis- a distinction will be made. PARTICIPATION IN THIS orders and to provide a comprehensive POPULATION. PROGRAM spinal-conditioning program designed EPIDEMIOLOGY AND MODIFICATIONS CAN BE MADE IN to achieve the dual benefit of improved PRECIPITATING FACTORS ATHLETES WITH SPONDYLOLITIC spinal conditioning while protecting As stated previously, athletes are more the spondylolitic region from undue DISORDERS. CONDITIONING prone to degenerative and spondylo- ROUTINES SHOULD EMPHASIZE stress. lytic-related injuries when compared SPINAL STABILIZATION AND Spondylolitic disorders among athletes with the general population (2,5,8,10, SPORT-SPECIFIC FLEXIBILITY. THIS typically comprise the diagnosis of 13,16,26). Spondylolitic disorders are ARTICLE MAKES RECOMMENDA- either a spondylolysis or a spondylolis- primary causes of back pain among TIONS FOR ATHLETES WITH thesis. The term spondylolisthesis gymnasts, divers, weightlifters, wres- SPONDYLOLITIC DISORDERS THAT comes from the derivative of ‘‘spondy- tlers, and football players, with a re- SHOULD ALLOW PARTICIPATION IN lo,’’ which means vertebrae, and ‘‘lis- ported prevalence of up to 40% (2,15). LUMBAR CONDITIONING WHILE thesis’’ which means forward slippage Within individual sports, the great- PROTECTING THE BACK FROM (34). Therefore, a spondylolisthesis is est incidence is found in gymnasts, UNDUE STRESS. essentially a forward slippage of one weightlifters, rowing, and those who vertebra on another (Figure 1) (10,34). participate in throwing sports (14). Spondylolisthesis often are attributed INTRODUCTION to degenerative changes and/or a de- ow back pain (LBP) is a preva- fect at the vertebrae (3,35). A spondy- KEY WORDS: lent condition in the athletic lolysis occurs when there is a fracture, low back pain; spondylosis; spondylol- L population (10,19). Among found in a region of the vertebrae called ysis; spondylolisthesis; athletic injury Ó National Strength and Conditioning Association Strength and Conditioning Journal | www.nsca-lift.org 43 Spinal Conditioning for Lumbar Spondylolysis and Spondylolisthesis 11% among female competitive gym- nasts (15,23). Gender also plays a role, as spondylolitic disorders are 4 times more common in women than men (7). Age may also be a factor to con- sider as vertebral slippage is shown to occur more drastically during an ado- lescent growth spurt, and if the athlete was asymptomatic to begin with, the problem potential becomes all the more accentuated (29). It has been suggested, although not universally agreed upon, that in the skeletally immature athlete, spondylolitic disor- ders should be considered until diag- nostic testing suggests otherwise (33). DIAGNOSIS Athletes with spondylolitic disorders may present with a wide range of signs Figure 1. Spondylolisthesis. (Ó Primal Pictures Ltd.) and symptoms, making clinical diag- nosis elusive. Although a detailed dis- cussion of the diagnostic signs and symptoms is beyond the scope of this An explanation for gymnasts having a gymnast is loaded approximately 4 article, a brief overview is necessary. high incidence lies in the demands times the amount in that of the general The athlete’s history leading to injury placed on his or her spine while in female population (15,23). Conse- is often inclusive of repetitive loading positions that load the pars interarticu- quently, the incidence of spondylolitic into extension, flexion, twisting, or a laris. It has been estimated the spine of a disorders has been approximated at combination of movements (4). Plain film radiographs possess the diagnostic utility to identify spondylolytic disor- ders using standard views; however, more sensitive imaging modalities, such as a technetium bone scan, may be required in certain cases (25). In cases of a spondylolisthesis, radio- graphs are able to provide information on the severity of the ‘‘slip.’’ A slip of less than 50% is considered mild and often managed conservatively, whereas slips of greater than 50% are often referred for a surgical consult (25). Ultimately, the diagnosis of a spondy- lolytic disorder will be made by a physician who has interpreted the radiological and clinical presentation. Moreover, individuals diagnosed with spondylolytic disorders must be cleared by their physician prior to the initiation of any exercise programs. ANATOMY Although our intent is not to provide an exhaustive discussion of the lumbar Figure 2. Spondylolysis. (Ó Primal Pictures Ltd.) anatomy, a brief review is necessary 44 VOLUME 30 | NUMBER 2 | APRIL 2008 to establish a clear understanding of most commonly occurs at the L5 seg- dismounts, can cause microtrauma to the information presented. The lum- ment (30,33). A fracture of the pars the pars-interarticularis area, leading to bar spine consists of 5 vertebrae, and interarticularis (spondylolysis) may, in spondylolitic disorders. Although the between each lies a disk providing response to stress progress to a spon- extended position has been established cushion between the vertebrae when dylolisthesis without causative modifi- as both a precipitating and provocating loaded. The joints of the lumbar spine cations and appropriate interventions. factor for spondylolitic disorders (1,16, are referred to as facet joints (Figure 3). 17,28), one must exercise caution when A facet is a small smooth area on PATHOGENESIS asserting that extension should abso- a bone that creates an articulation Although the etiology of LBP is lutely be avoided in the presence of between neighboring vertebrae (34). multifactorial and the precise cause of a forward slippage. Researchers have Each vertebra contains 2 superior and spondylolitic disorders is unknown, the presented conflicting findings regard- 2 inferior articular facets providing mechanisms precipitating these disor- ing the effect of extension on some a connection to the adjoining vertebra ders among the athletic population are individuals with spondylolitic disorders above and below (25). Between the described in literature (6,13). It has (12,17,31). In particular, extension has superior and inferior facet lies a small, been suggested that repetitive hyper- shown to be efficacious in some very thin area of primarily cortical extension movements (extension of the individuals with spondylolitic disorders bone called the pars interarticularis lumbar spine beyond the anatomical (31). Nevertheless, one should exercise which is illustrated in Figures 1 and 2 limits) place stress through the pars caution with lumbar extension in the (34). The pars interarticularis is the interarticularis and over time may lead athletic population as it is a factor weakest area in this unit, and in young to a spondylolysis (9). This notion may that places stress on the pars inter- people it is particularly thin and injury lie in the association between the articularis and may lead to worsening susceptible (5). Because of its fragile frequently extended and loaded posi- of the condition. nature, the pars interarticularis is tion for which gymnasts, dancers, Finally, spondylolitic disorders result- sometimes not capable of withstanding divers, football lineman and weight- ing from a defect or fracture of the pars excessive or repetitive forces; thus, lifters assume and their increased interarticularis frequently present with it fractures (25). Defects or fractures prevalence of spondylolitic conditions. spinal instability (24), thus interven- leading to spondylolitic disorders will It has been purported that accumula- tions designed to increase spinal sta- invariably originate at the pars inter- tive extension at the end-range of bility may be efficacious (26). Studies articularis. Although this disruption mobility, combined with the power have reported that hypermobility (ex- can occur at any vertebral level, it and force of jumps, landings, and cessive) and/or instability
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