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Non-Operative Management of Lumbar
Stress Fractures in Dancers and Figure
Skaters
Tara Jo Manal, PT, MPT, OCS, SCSUniversity of Delaware
Department of Physical Therapy
Purpose
To discuss alternative ways of successful non-operative management of figure skaters and dancers with stress fractures
Clinical Instability
Loss of the ability of the spine under Loss of the ability of the spine under physiologic loads to maintain its pattern of physiologic loads to maintain its pattern of displacement so that there is no initial or displacement so that there is no initial or additional neurological deficit, no major additional neurological deficit, no major deformity, and no incapacitating paindeformity, and no incapacitating pain
» White and PanjabiWhite and Panjabi
Clinical Instability
Anatomic ConsiderationsAnatomic Considerations Biomechanical FactorsBiomechanical Factors Clinical ConsiderationsClinical Considerations Treatment ConsiderationsTreatment Considerations Recommended Evaluation systemRecommended Evaluation system Recommenced managementRecommenced management
• Recorded cases of patient post-polio with cervical Recorded cases of patient post-polio with cervical paralysis and no instability if bones and ligaments paralysis and no instability if bones and ligaments remain intact remain intact
Stabilization of the Spine
Passive systemPassive system
Active systemActive system
Neural controlNeural control
Diagnostic Imaging
Bone ScanBone Scan
Injection of Injection of RadionuclideRadionuclide
Analyze blood flow to Analyze blood flow to tissue (Activity)tissue (Activity)
Poor ResolutionPoor Resolution
SPECT Scan for Pars Dx
Single Photon Single Photon Emission Computed Emission Computed TomographyTomography
Like bone scan but Like bone scan but provides 3-D imageprovides 3-D image
Spondylolisthesis
Spondylolisthesis – Spondylolisthesis – an anterior movement an anterior movement of the vertebral body of the vertebral body and can cause and can cause compression of the compression of the cauda equina which cauda equina which rests posteriorlyrests posteriorly
Spondylolithesis Grading
Grade 1: 25%Grade 1: 25%Grade 2: 25% to 49%Grade 2: 25% to 49%Grade 3: 50% to 74%Grade 3: 50% to 74%Grade 4: 75% to 99%Grade 4: 75% to 99%Grade 5: 100%* Grade 5: 100%*
Spondylolisthesis
5 Types5 Types Dysplastic- Congenital abnormalities of Dysplastic- Congenital abnormalities of
arch of L5arch of L5• Rare and likely to progressRare and likely to progress• More often with neurologic compromiseMore often with neurologic compromise• Surgery- Laminectomy and fusionSurgery- Laminectomy and fusion
Spondylolisthesis
Isthmic- Pars interarticularisIsthmic- Pars interarticularis• Most common in children and adolescentsMost common in children and adolescents• Lytic type- fatigue fractures of pars (stress Lytic type- fatigue fractures of pars (stress
fracture, has familial link)fracture, has familial link)• Elongated intact parsElongated intact pars• Acute fractureAcute fracture
• Pain, tight hamstrings and neurologic Pain, tight hamstrings and neurologic changes are due to spinal instabilitychanges are due to spinal instability
Spondylolisthesis
Isthmic-TreatmentIsthmic-Treatment ObservationObservation
• Low incidence of progressionLow incidence of progression• Grade 2 or less- non-op managementGrade 2 or less- non-op management• Progressive neurologic deficit may need surgeryProgressive neurologic deficit may need surgery• Grade 3- 8% relief non opGrade 3- 8% relief non op
Stress ReactionStress Reaction• Brace or immobilize for symptom controlBrace or immobilize for symptom control• Until symptoms resolveUntil symptoms resolve
Spondylolisthesis
Degenerative- Long standing instabilityDegenerative- Long standing instability• Most common cause of adult spondyloMost common cause of adult spondylo
Traumatic- Other Fracture (ie articular Traumatic- Other Fracture (ie articular process)process)
Pathologic Type- Bone diseasePathologic Type- Bone disease
Treatment
Typically nonoperative (esp. children)Typically nonoperative (esp. children) Rest from aggravating symptomsRest from aggravating symptoms ImmobilizationImmobilization
SurgicalSurgical• Failure of conservative managementFailure of conservative management• Progression of the subluxationProgression of the subluxation• Spondylo Spondylo >50% in skeletally immature>50% in skeletally immature• Can see continued slip after posterior lateral fusionCan see continued slip after posterior lateral fusion
Old Spondylolysis
Can create pseudo joint and fill with scar Can create pseudo joint and fill with scar tissuetissue
Can be going through active Can be going through active fracture/repair and active fracture againfracture/repair and active fracture again
Active System- Muscular Control of the Spine
Extensors – MultifidiExtensors – Multifidi
Span only a few jointsSpan only a few joints Produce extensor torque/resistanceProduce extensor torque/resistance Only small amounts of rotation or SBOnly small amounts of rotation or SB Contribute to correction or supportContribute to correction or support
Muscular Control of the Spine
Abdominal MusclesAbdominal Muscles RectusRectus
• Major trunk flexorMajor trunk flexor• Active with sit-up and curl-upsActive with sit-up and curl-ups• Little to no evidence to support upper/lower Little to no evidence to support upper/lower
differentiationdifferentiation
Muscular Control of the Spine
Abdominal Wall- Ext/Int ObliqueAbdominal Wall- Ext/Int Oblique
Torso Rotation and Lateral flexionTorso Rotation and Lateral flexion
Muscular Control of the Spine
Abdominal Wall-Transverse abdominisAbdominal Wall-Transverse abdominis
Beltlike support and generation of intra-Beltlike support and generation of intra-abdominal pressureabdominal pressure
Delayed onset during ballistic movements Delayed onset during ballistic movements in patient’s with LBPin patient’s with LBP
Muscular Control of the Spine
PsoasPsoas Primarily hip flexorPrimarily hip flexor Compressive force to spine during Compressive force to spine during
contractioncontraction Questionable contribution to spine stabilityQuestionable contribution to spine stability
• If so, under high hip flexor forcesIf so, under high hip flexor forces
Muscular Control of the Spine
Quadratus LumborumQuadratus Lumborum
Highly involved with spine stabilizationHighly involved with spine stabilization Active in flexion, extension and SBActive in flexion, extension and SB During Lifting, increased oblique activity During Lifting, increased oblique activity
followed increases in QLfollowed increases in QL
Muscular Control of the Spine
Deep Rotators-Deep Rotators-• Function primarily as force transducersFunction primarily as force transducers• Position SensorsPosition Sensors• Electrically silent with large rotations (involving Abs)Electrically silent with large rotations (involving Abs)
Extensor GroupExtensor Group• Generate large extensor momentsGenerate large extensor moments• Generate posterior shearGenerate posterior shear• Affect one or two segmentsAffect one or two segments
Co-activation of the Muscular Spine
90N force (20lbs) 90N force (20lbs) creates buckling creates buckling without muscular without muscular forcesforces
Co-contraction Co-contraction increases support increases support against bucklingagainst buckling
Muscular Stability
Continuous contractionContinuous contraction ~10% MVIC of abdominals~10% MVIC of abdominals No single muscle is critical oneNo single muscle is critical one
Lumbar Extensor Musculature
Erector spinae Erector spinae musculature are musculature are responsible for extensor responsible for extensor forceforce
Multifidus muscles are are segmental extensors segmental extensors responsible for responsible for stabilization of lumbar stabilization of lumbar motion segmentsmotion segments
Fritz Fritz et al 2000 al 2000
Muscle Strength and Low Back Pain
In firefighters, muscle In firefighters, muscle strength of the strength of the low back back was a good indicator for was a good indicator for the development of low the development of low back painback pain
Cady et al 1979Cady et al 1979
In manual material In manual material workers there was a workers there was a positive correlation positive correlation between strength and between strength and frequency of low back painfrequency of low back pain
Chaffin 1974Chaffin 1974
Performing Arts and Low Back Pain
Lumbar extensor strength is needed to achieve many positions and to successfully land jumps and leaps
Case #1
13 y/o female dancer Low back pain for 4 weeks that came on
with an Arabesque Pain onset: whenever dancing especially
with extension activities No pain at rest X-rays: none
Case #1 Evaluation
(-) SI testing• Cibulka et al. 1988
Forward Flexion: ↑’d pain thru mid range
↓’d Right Sidebending vs. Left
↓’d Left Rotation vs. Right Right Max Closing: (+)
Pain on the Right Right L5-S1: Hypomobile
and Painful
Case #1 Evaluation
Palpation: (+) muscle spasm and pain• Right Paraspinals L2-L5• Right Quadratus
Also has hip pain and right lateral thigh and buttock pain with prolonged dancing
(-) SLR
Case #1 Early Treatment
Manipulation: Left Rotation in Sidelying: ↓’d pain at L5/S1 with Right Max Closing
Grade II/III Mobilizations to L5-S1
TENS to Right L5/S1
Case #1: Treatment #2
60% improvement 1 week later
No ROM restriction pattern noted
Grade II/III joint mobilizations and Soft Tissue Techniques to Quadratus and Paraspinals
Progress to pain free activity only
Case #1: Treatment #3
1 week and 3 days from Evaluation
Danced full out the night before: Pain 4x worse and as bad as the IE
No ROM Restriction Pattern noted
Grade II/III joint Mobilizations for Pain and Soft Tissue Techniques and given TENS unit
3 Weeks after IE Some improvement noted over the next 3
Treatments By the 7th treatment, still dancing full out but
pain is lasting longer periods of time with night pain and increasing leg symptoms
Pain also is moving from the right to left With variable symptoms including legs
concern about current diagnosis Spoke with PCP: Requested Bone Scan but
MD ordered X-ray and MRI
Test Results
MRI: (+) for Bilateral Pars Fracture @ L5
Unable to determine if chronic or acute without Bone Scan
Referral to Sports Med Spine Specialist: Hold on PT
Continue Home TENS Unit
CASH Brace: reminder to stay out of extension
Spieth & BhattacharjeeSpieth & BhattacharjeeMarshfield Clinic, Dep. Of Marshfield Clinic, Dep. Of RadiologyRadiology
Test Results
Bone Scan: • (+) Bilateral L5 Stress
Fracture at Pedicle/Post. Arch with Bone Marrow Edema at Pedicle L>R. This is consistent with L5 Spondylolysis Bilaterally
Ordered TLSO
Reinstate PT
Treatment
Isometric Abdominal Squeezes in brace
Practice Ballet in brace in the open position
Increase core strengthening
3x/week for 6wks
Hypothesis
Now that patient is in a TLSO brace, strength gains will be slow as well as brace and fracture will make correct exercise performance difficult
Electrical stimulation used to assist patient in rapid strengthening and be a successful adjunct to her strengthening program
Intervention for Strength
Problem: • How to increase or prevent loss of strength in the
Paraspinals (while immobilized), without increasing stress to the L5 region?
Concern: how much force will L5 receive with High Intensity Electrical Stimulation?
Consultation with the Physician
Decision: Let pain be the guide• If her LBP complaint is recreated, discontinue use
or decrease intensity
Electrical Stimulation for Strength
Snyder-Mackler et al., 1995• Conclusion: For
Quadriceps Weakness, High-Level E-stim with Volitional Exercise is more successful than Exercise alone
» Fitzgerald et. al., 2003
Electrical Stimulation for LB Strengthening
The application of this same type of Electrical Stimulation to the LB may help increase strength and recovery of Low Back Musculature following injury
• Kahanovitz et al., 1987• McQuain et al., 1993
Parameters of Electrical Stimulation
2500 Hz Variable wave form
• triangle, sine, square
75 bursts/second 2 second ramp 12 seconds on time 50 second rest time 10-15 contractions
Patient Positioning: Isometric
Prone over pillows Pelvis strapped to the
table in Posterior Pelvic Tilt
Assess movement to active lumbar extension and tighten as necessary
Current Intensity
In quadriceps 50% maximal volitional isometric contraction
Look for visible contraction
Maximal tolerable contraction by the patient
A single channel is placed on the right and left side of the spine
Progression
CT scan : low grade spondylolisthesis, chronic stage
MD does not expect more slippage Allowed to swim without brace: (~2 months) Allowed to dance while in TLSO with no back or
hip extension Soft brace prescription and allowed to dance into
extension: (~3.5 months) Dancing with no brace: (~4.5 months)
Outcome
Full dancing in all classes at 6 months
No pain with any activity
Oswestry: 0%• Fairbanks, et al, 1980Fairbanks, et al, 1980
Photo by: Tessa DevelopePhoto by: Tessa Develope
Case #2
12 year old Figure Skater History of back pain which began after a
fall 2 weeks earlier For 3 months, treatment centered around
pain management in order to complete the season• Ended season as Junior National Finalist
• Ranked in top 10 in the Nation
Case #2 Evaluation
Bone Scan positive for stress reaction bilateral pars interarticularis of L5
Oswestry - 18%
Pain level after Nationals 8-9/10• 2 weeks later 4/10
Case #2 Evaluation
Lumbar ROM• Decreased L Sidebending
below L3• Decreased R Rotation
below L3• Extension Apex at L3/L4
No Extension below L4
Closing Restriction Below L3Closing Restriction Below L3
Hip ER 60° R and 66° L Bilateral Hip IR and ER
4/5
Case #2- Hypothesis
This patient will benefit from intervention This patient will benefit from intervention aimed at decreasing stress in L5 areaaimed at decreasing stress in L5 area
This will include:This will include:• Increasing hip ROM and strengthIncreasing hip ROM and strength• Increasing joint mobility in low lumbar spineIncreasing joint mobility in low lumbar spine• Increasing strength in paraspinal musculatureIncreasing strength in paraspinal musculature
Case #2 Hypothesis
Medical Strategy: TLSO brace and rest off the ice for 1 month
Physical Therapy Strategy:• Increase Hip ROM and
strength• Increasing joint mobility in
lower lumbar spine• Increasing strength in
paraspinal musculature
Intervention for Strength
Problem: Problem: • How to increase or prevent loss of strength in How to increase or prevent loss of strength in
the paraspinals (while immobilized), without the paraspinals (while immobilized), without increasing stress to the L5 region?increasing stress to the L5 region?
TrainingTraining• Volitional vs. ElectricalVolitional vs. Electrical
Case #2 - Intervention
High Intensity Electrical stimulation• 11 Attempts• 3 aborts due to
pain • All at the end of
the week Volitional stabilization
exercises
Case #2 - Outcome
Return to Skating• 7 treatments
• stroking and spins
• 9 treatments• single jumps• falling without pain
Oswestry 0% at 11 treatments
CASE #3
14 y/o female ice skater14 y/o female ice skater Low back pain for 3-4 weeks Low back pain for 3-4 weeks Pain onset during 80 minute lessonPain onset during 80 minute lesson Pain level of 8-9/10 during skatingPain level of 8-9/10 during skating Pain level of 7/10 in AMPain level of 7/10 in AM Pain exacerbated with twisting and Pain exacerbated with twisting and
bendingbending
Case #3 - Early Intervention
1 week rest from skating (symptoms 1 week rest from skating (symptoms reduced)reduced)
Return of pain intensity after 2-3 days of Return of pain intensity after 2-3 days of skatingskating
2 week rest from skating2 week rest from skating• No pain with ADL’sNo pain with ADL’s
Case #3- PT Evaluation
Limitation in lumbar L sidebendingLimitation in lumbar L sidebending Limitation in lumbar R rotationLimitation in lumbar R rotation Recreation of pain with maximal stress of Recreation of pain with maximal stress of
left lumbar spineleft lumbar spine• Opening (flexion and right side-bending)Opening (flexion and right side-bending)• Closing (extension and left rotation)Closing (extension and left rotation)
Decreased muscle mass of L lumbar Decreased muscle mass of L lumbar paraspinalsparaspinals
Case #3- Evaluation
Extension strategy for Extension strategy for return from right return from right sidebendingsidebending
Hypermobile joint play Hypermobile joint play L1, L2 and L5L1, L2 and L5
Hypomobile joint play Hypomobile joint play L3-L4L3-L4
Painful unilateral joint Painful unilateral joint play left L2-L5play left L2-L5
Case # 3 - Hypothesis
An injury occurred in practice irritating the An injury occurred in practice irritating the Left lumbar facets L2/L3 and L4/ L5Left lumbar facets L2/L3 and L4/ L5
These joints are painful in end ranges These joints are painful in end ranges Muscular imbalance of the paraspinals Muscular imbalance of the paraspinals
and stiffness of the L3/L4 segment only and stiffness of the L3/L4 segment only contribute to increased stresses at the contribute to increased stresses at the irritated siteirritated site
Case #3- Treatment Plan
Joint Mobilizations to hypomobile jointsJoint Mobilizations to hypomobile joints Electrical Stimulation for paraspinal Electrical Stimulation for paraspinal
muscle muscle Spinal stabilization exercises (pelvic Spinal stabilization exercises (pelvic
neutral)neutral)• Pelvic Tilts, supine bridgingPelvic Tilts, supine bridging• Prone quadruped arm and leg liftsProne quadruped arm and leg lifts• Side planks Side planks • Prone back extensionProne back extension
Case #3- Progress
After 4 treatments- Pain-free with ADL’s After 4 treatments- Pain-free with ADL’s not currently skatingnot currently skating
Complaints of muscle fatigue following Complaints of muscle fatigue following treatmentstreatments
Case #3- Return to Skating
After 6 treatments- Return to skating with After 6 treatments- Return to skating with pain onset 5-6/10 after 15 minutespain onset 5-6/10 after 15 minutes
Next AM pain improved and skated 40 Next AM pain improved and skated 40 minutes with increasing painminutes with increasing pain
4 weeks off skating for continued 4 weeks off skating for continued strengthening and diagnostic testingstrengthening and diagnostic testing
Case # 3 - Diagnostic Testing
Diagnosis of Diagnosis of spondyloislthesisspondyloislthesis• x-ray (minimal)x-ray (minimal)• given brace for skatinggiven brace for skating
New physicianNew physician• Hold on braceHold on brace• MRI and Bone Scan MRI and Bone Scan
negativenegative• Progressive return to Progressive return to
skatingskating
Case #3 - Strengthening Progression
One legged bridgingOne legged bridging Prone extension on a Prone extension on a
ballball 10# medicine ball 10# medicine ball
catches with rotationcatches with rotation
Case #3- Skating Progression
Return to skating at 16th treatmentReturn to skating at 16th treatment• Stroking and spins onlyStroking and spins only• 2- 40 minute sessions with only tightness in 2- 40 minute sessions with only tightness in
low backlow back
Next day- 2- 40 minutes sessions pain-Next day- 2- 40 minutes sessions pain-freefree
17th Treatment17th Treatment• 40 minutes ice dance40 minutes ice dance• 20 minutes freestyle (stopped when pain 20 minutes freestyle (stopped when pain
began)began)
Case #3- Skating Progression
Progressing with choreography and spinsProgressing with choreography and spins After 19th treatment- began jumpingAfter 19th treatment- began jumping Progressed jumps over next 4 treatmentsProgressed jumps over next 4 treatments
• double axledouble axle• few triplesfew triples
Returned to full program and practice at Returned to full program and practice at discharge of 24 treatmentdischarge of 24 treatment
Transfer exercise to training roomTransfer exercise to training room
Case #3- Oswestry Scores
At eval with ADL’s 8% At eval with ADL’s 8% At eval with skating At eval with skating
activity 17%activity 17% At discharge with At discharge with
ADL’s 0% with ADL’s 0% with skating activity 11%skating activity 11%
Follow up 2 months Follow up 2 months later 0% with skatinglater 0% with skating
Discussion
Assist in the maintenance of strength trainingAssist in the maintenance of strength training
Successfully optimized their strength through Successfully optimized their strength through with NMES to the paraspinals, and an intensive with NMES to the paraspinals, and an intensive core stabilization program core stabilization program
Minimize what they may loose with inactivityMinimize what they may loose with inactivity
Return to sport at a faster rate Return to sport at a faster rate » Muschik et al, 1996Muschik et al, 1996
Discussion
Electrical stimulation has been Electrical stimulation has been successfully added to programs of lumbar successfully added to programs of lumbar stabilization with figure skatersstabilization with figure skaters
There were no negative effects to the high There were no negative effects to the high intensity stimulation treatmentsintensity stimulation treatments• fusionfusion• stress responsestress response
Discussion
Electrical stimulation may show promise in Electrical stimulation may show promise in assisting patients in recovering following assisting patients in recovering following lumbar injury especially when returning to lumbar injury especially when returning to demanding activitiesdemanding activities
Electrical stimulation may be beneficial for Electrical stimulation may be beneficial for patients who are unable to perform other patients who are unable to perform other exercise programs due to painexercise programs due to pain
Further Research
Research must be done to determine the Research must be done to determine the effectiveness of the addition of electrical effectiveness of the addition of electrical stimulation to a rehabilitation program for stimulation to a rehabilitation program for low back painlow back pain
Work aimed at determining the forces Work aimed at determining the forces generated in the lumbar spine during generated in the lumbar spine during these contractions will help therapists these contractions will help therapists determine who can best benefit from this determine who can best benefit from this interventionintervention