David D. Stanley PT, DPT, Cert. MDT, Cert DN, CSCS

The Rehabilitation Institute-Dawsonville

Of the Northeast Georgia Health System

Disclosures

I have no financial interests, relationships, or potential conflicts of interest relative to this presentation

Words of Wisdom

• Stay engaged with the patient, the parents and the physician throughout the rehabilitative process. Keep the patient motivated and make it functional!

Spondylolysis Classifications :

➢Dysplastic

➢ Isthmic/pars interarticularis (primary pathology)

• Lytic

• Elongated but intact pars

• Acute fracture

➢Degenerative

➢ Traumatic

➢ Pathological

➢ Postsurgical(Newman et al, 1976)

Anatomy

By Princekareem - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=18706303

By Lparis22 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=18344987

Etiology and Incidence of Spondylolysis

❑ Often an incidental finding and asymptomatic

❑ Incidence is ~7-21% adolescent athletes; 14-30% in those

symptomatic

❑ Most common cause of LBP in children (2:1 ♂ /♀ distribution)

❑ Thought to be result of fatigue fracture mainly at L5 > L4 (80% bil)

❑ Repetitive, excessive hyperextension and rotation

❑ Associated with athletic participation

❑ Hereditary predisposition? (40% correlation)

❑ 75% develop spondylolisthesis

Sports related activitiesInsert picture/text

Sports related activities

Imaging

❖ ≤50% sensitivity on plain anterior-posterior radiographic views

❖ ≥75% lesions can be viewed with plain lateral/oblique radiographs

❖ CT and SPECT are more sensitive than radiographs

❖ MRI if neurological sx are present

Imaging

Imaging

CT vs. SPECT scan

Clinical Presentation of Spondylolysis:

▪ Back pain (gradual vs. acute)

▪ Localized around L5

▪ +/- Radiation into buttock/thigh

▪ Very often FROM

▪ Extension consistently painful & exacerbates/produces sx

▪ Flexion might also worsen sx

▪Pain with/after activity

▪Rest usually relieves sx

▪TTP (spinous process)

▪Tight hamstrings

▪Postural deformity (↓ lordosis)

▪Abnormal gait pattern

Differential Diagnosis

➢ Discal

➢ Facet

➢ Postural syndrome

➢ Acute bony injury (MOI)

➢ Sprain/strain

➢ Spondylolisthesis

➢ SIJ

➢ Radiculopathy

➢ Spinal stenosis

➢ Pyelonephritis

➢ Osteomyelitis

Management

Physical therapy

• Relative rest/activity restriction

• TLSO Bracing

• Modalities

• Strengthening (core)

• Stretching (hamstrings)

• Functional progression

Lumbosacral Orthoses

• Designed to limit extension and rotation of the spine

• Meta-analysis showed no effect on outcomes

• RCT needed

• Best used with those who fail to improve

Physical Therapy Evaluation

SUBJECTIVE:

➢ Onset (quick vs. gradual)

➢ MOI

➢ Pain location

➢ Worse/Better

➢ Constant/Intermittent

➢ Numbness/tingling*

➢ Weakness*

➢ Bowel/bladder*

OBJECTIVE:

➢ROM

➢Strength

➢Flexibility

➢Neuro

➢Posture

➢Palpation

➢Special tests

Clinical Special Tests

➢ One-legged hyperextension/Stork standing test/Michelis’ test (“virtually no value”)

➢ Quadrant test (sitting or standing)

➢ Manual lumbar extension pressure

➢ Palpation of spinous process (Pain, Drop Off?)

➢ Neurological signs (rarely)

➢ Mechanical assessment

➢ Posture correction

One-Legged Hyperextension Test

Low-moderate Sn (50-73%), Low Sp (17-32%) (Algarni, et al, 2015)

Isolated TA/LM co-contraction effective for pain relief (nonfunctional).

Functional integration of core stabilization effective in reducing pain and disability. Now we’re getting somewhere…

CS is a “reductionist fantasy” and “no more effective than any other forms of physical therapy or exercise.”

Apply specific core strengthening to general and sport specific program for management of spondylolysis.

Assessment

• Prone over pressure device inflated to 70 mmHg

• Draw in abdominal wall x 10 secs

• Record length of time pt can hold 4 mmHg drop

• Monitor for improper compensation

• “Good” if duration ≥10 secs

(Selhorst, et al, 2020)

Pressure Biofeedback Unit Test of the TA

Assessment

• Prone, shoulders 120° ABd, elbows 90⁰flex

• Palpate adjacent to L4-5, L5-S1

• Pt to lift contralateral arm 5 cm

• Qualitatively assess multifidus

• Normal= “robust, obvious” contraction

• Abnormal= “little or no” palpable contraction

(Selhorst, et al, 2020)

Multifidus Lift Test

Assessment

• Patient raises both LEs until knees are off the table

• Hold the position

• Time how long patient can no longer maintain knee clearance OR reports pain

(Selhorst et al, 2020)

Prone Double Leg Raise Test

Assessment

• Supine, PT elevates fully ext LEs to point where sacrum begins to rise

• Patient to maintain contact of lower back with table while lowering LEs

• Measure when lower back loses contact w/table due to anterior pelvic tilt

(Selhorst et al, 2020)

Supine Double Leg Lowering Test

Micheli Functional Scale

➢ Oswestry and Roland-Morris more ADL related and poses limitations for adolescent athletes

➢ Designed for adolescent athletes with LBP

➢ 3 parts (Sx, ADLs, VAS)

➢ More appropriate for those struggling with higher level activities such as running, jumping and sport specific motions

➢ High internal consistency (α=0.90) and concurrent validity established w/ODI.

Phase I: Isolated Training

• Modalities PRN

• Core strengthening

• Directional preference if identified

• Hip/shoulder girdle strengthening

• Flexibility exercises

• Manual therapy (?)

• Modalities

• Reduce fear avoidance behaviors

Treatment Ideas:

• Symptom management

• HSS

• Pelvic tilt

• Crunches

• SLRs

• Dying bug

• Prone alt UE/LE lifts; bird dog

• Bridges (march, knee ext)

• Planks

• McGill 3

• Recumbent bike

Criteria to progress to Phase II

➢ “Good” TA activation (prone press. biofeedback >10”w/4 mmHg drop)

➢ “Normal” MT contraction with Prone MT Lift Test

➢ Pain free repeated lumbar flexion/extension (x10 reps)

➢ “Good” global muscle performance

➢ Micheli Functional Scale

Selhorst et al (2020)

Phase II: Integrated Training

❑ Local and global muscle systems

❑ Progressive core strengthening

❑ Progressive hip/shoulder girdle strengthening

❑ Stretching/flexibility

❑ Assess:

▪ Prone DL raise, Supine DL lower and Micheli Functional Scale

Exercise Suggestions:

• Squats Paloff Press (anti-rotational)

• Med ball chest pass

• ½ kneeling/single leg

• Unstable surface (foam pad, BOSU)

• Biceps curl/row/lat pull/OHP

• Knee ext/HS curl/leg press

• Lateral elastic band walk

• T-mill (walk/light jog)

Vary positions

Vary resistance and surface

Criteria to progress to Phase III

➢ “Good” global muscle performance

▪ Prone DL raise >30 secs

▪ Supine DL lowering <70⁰

➢ Full trunk AROM all planes

➢ “Sufficient” flexibility/ROM in the sport specific kinetic chain

➢ 0% score on parts B and C of Micheli Functional Scale

➢WFL extremity ROM and strength

➢Bring AT into picture

Phase III: Return to Sport Training

➢ Maximize sport specific strength/endurance

➢ Good mechanics and control

➢ Sport Specific training with AT

➢ Modified, one-on-one practice sessions

➢ Graded return to sports

➢ Independent training program

Exercise suggestions:

• Running/cutting

• Lunges

• Plyometrics

• Quicksteps

• Med ball/Elastic band diagonals

• Ladder

• Hurdles

• Functional exercise (Cross Fit-esque)

Discharge Criteria

➢ Normal “fluid” movement patterns with SS training and activities

➢ Compete at pre-injury performance levels pain free.

➢ Micheli Functional Scale = 0% score

References❖ Algarni AM, Schneiders AG, Cook CE, Henderick PA. Clinical Tests to diagnose lumbar spondylolysis and spondylolisthesis: A systemic review. Phys Ther

Sport 2015; 16(3):268-275.

❖ Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. Am Fam Physician 2007;76:1669-1676.

❖ Bouras T, Korovessis P. Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review. Eur J Orthop Surg Traumatol2015; 25(suppl 1):S167-S175.

❖ Carlson, CT. Spondylolysis and the athlete. American Medical Society for Sports Medicine 2007;12(4):37-39.

❖ Cassas KJ, Cassettari-Wayhs A. Childhood and Adolescent sports-related overuse injuries. American Family Physicians 2006;73(6):1014-1022.

❖ Garet M, Reiman MP, Mathers J, Sylvain J. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: A systematic review. Sports Health

2013;5(3):225-232.

❖ Ghorbanpour A, Azghani MR, Taghipour T, Salahzadeh Z, Ghaderi F, Oskouei AE. Effects of McGill stabilization exercises and conventional physiotherapy on

pain, functional disability and active back range of motion in patients with chronic non-specific low back pain. J Phys Ther Sci 2018;30:481-485.

❖ Klein G, Mehlman CT, McCarty M. Nonoperative treatment of spondylolysis and grade I spondylolisthesis in children and young adults: a meta-analysis of

observational studies. J Pediatr Orthop. 2009;29(2):590-595.

❖ O’Sullivan PB, Twomey LT, Allison, GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22(24):2959-2967.

❖ Peer, KS. Spondylolysis: A review and treatment approach. Orthopaedic Nursing 2007; 26(2):104-113.

❖ Richardson CA, Jull GA. Muscle control-pain control. What exercises would you prescribe? Manual Therapy 1995;(1):2-10.

❖ Sakai T, Tezuka F, Yamashita K, et al. Conservative treatment for bony healing in pediatric lumbar spondylolysis. Spine 2017;42(12):E716-E720.

❖ Wicker, A. FIMS Position Statement: Spondylolysis and spondylolisthesis in sports. International SportMed Journal 2008; 9(2):74-78.

❖ Wiltse LL, Newman PH, Mcnab I. Classification of Spondylolysis and spondylolisthesis. Clin Orthop Relat Res. 1976; 6(117):23-9.

Questions??

Spondylolisthesis

• Forward displacement of a vertebral body, which can occur if there are defects in both neural arches.

• Severity of slip is based on amount/degree of slip compared to S1 width:

• I 0-25%

• II 25-50%

• III 50-75%

• IV >75%

• V >100% (spondyloptosis)