Transcript Non-Operative Management of Lumbar Stress Fractures in Dancers and Figure

Non-Operative
Management of Lumbar
Stress Fractures in
Dancers and Figure
Skaters
Tara Jo Manal, PT, MPT, OCS, SCS
University 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
physiologic loads to maintain its pattern of
displacement so that there is no initial or
additional neurological deficit, no major
deformity, and no incapacitating pain
» White and Panjabi
Clinical Instability
 Anatomic Considerations
 Biomechanical Factors
 Clinical Considerations
 Treatment Considerations
 Recommended Evaluation system
 Recommenced management
• Recorded cases of patient post-polio with cervical
paralysis and no instability if bones and ligaments
remain intact
Stabilization of the Spine
 Passive system
 Active system
 Neural control
Passive System in Stress
Fracture
Pars
Scotty neck Fx
Pars Fracture
Need Oblique view
Diagnostic Imaging
 Bone Scan
 Injection of
Radionuclide
 Analyze blood flow to
tissue (Activity)
 Poor Resolution
SPECT Scan for Pars Dx
 Single Photon
Emission Computed
Tomography
 Like bone scan but
provides 3-D image
CT for Pars Follow up
L4 Pars Fx ____
Plain Radiograph vs CT
 L4 Pars Fx
 L4 Pars Fx
Spondylolisthesis
 Spondylolisthesis –
an anterior movement
of the vertebral body
and can cause
compression of the
cauda equina which
rests posteriorly
Plain Radiographs
 L4 Spondylolisthesis
Spondylolithesis Grading
 Grade 1: 25%
Grade 2: 25% to 49%
Grade 3: 50% to 74%
Grade 4: 75% to 99%
Grade 5: 100%*
Spondylolisthesis
 5 Types
 Dysplastic- Congenital abnormalities of
arch of L5
• Rare and likely to progress
• More often with neurologic compromise
• Surgery- Laminectomy and fusion
Spondylolisthesis
 Isthmic- Pars interarticularis
• Most common in children and adolescents
• Lytic type- fatigue fractures of pars (stress
fracture, has familial link)
• Elongated intact pars
• Acute fracture
• Pain, tight hamstrings and neurologic
changes are due to spinal instability
Spondylolisthesis
 Isthmic-Treatment
 Observation
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Low incidence of progression
Grade 2 or less- non-op management
Progressive neurologic deficit may need surgery
Grade 3- 8% relief non op
 Stress Reaction
• Brace or immobilize for symptom control
• Until symptoms resolve
Spondylolisthesis
 Degenerative- Long standing instability
• Most common cause of adult spondylo
 Traumatic- Other Fracture (ie articular
process)
 Pathologic Type- Bone disease
Treatment
 Typically nonoperative (esp. children)
 Rest from aggravating symptoms
 Immobilization
 Surgical
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Failure of conservative management
Progression of the subluxation
Spondylo >50% in skeletally immature
Can see continued slip after posterior lateral fusion
Old Spondylolysis
 Can create pseudo joint and fill with scar
tissue
 Can be going through active
fracture/repair and active fracture again
Active System- Muscular
Control of the Spine
 Extensors – Multifidi
 Span only a few joints
 Produce extensor torque/resistance
 Only small amounts of rotation or SB
 Contribute to correction or support
Muscular Control of the
Spine
 Abdominal Muscles
 Rectus
• Major trunk flexor
• Active with sit-up and curl-ups
• Little to no evidence to support upper/lower
differentiation
Muscular Control of the
Spine
 Abdominal Wall- Ext/Int Oblique
 Torso Rotation and Lateral flexion
Muscular Control of the
Spine
 Abdominal Wall-Transverse abdominis
 Beltlike support and generation of intraabdominal pressure
 Delayed onset during ballistic movements
in patient’s with LBP
Muscular Control of the
Spine
 Psoas
 Primarily hip flexor
 Compressive force to spine during
contraction
 Questionable contribution to spine stability
• If so, under high hip flexor forces
Muscular Control of the
Spine
 Quadratus Lumborum
 Highly involved with spine stabilization
 Active in flexion, extension and SB
 During Lifting, increased oblique activity
followed increases in QL
Muscular Control of the
Spine
 Deep Rotators• Function primarily as force transducers
• Position Sensors
• Electrically silent with large rotations (involving Abs)
 Extensor Group
• Generate large extensor moments
• Generate posterior shear
• Affect one or two segments
Co-activation of the
Muscular Spine
 90N force (20lbs)

creates buckling
without muscular
forces
Co-contraction
increases support
against buckling
Muscular Stability
 Continuous contraction
 ~10% MVIC of abdominals
 No single muscle is critical one
Lumbar Extensor
Musculature

Erector spinae
musculature are
responsible for extensor
force

Multifidus muscles are
segmental extensors
responsible for
stabilization of lumbar
motion segments
Fritz et al 2000
Muscle Strength and Low
Back Pain
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In firefighters, muscle
strength of the low back
was a good indicator for
the development of low
back pain
Cady et al 1979
In manual material
workers there was a
positive correlation
between strength and
frequency of low back
pain
Chaffin 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
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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
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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
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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
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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 & Bhattacharjee
Marshfield Clinic, Dep. Of Radiology
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
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Ordered TLSO

Reinstate PT
Treatment
 Isometric
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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?
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Concern: how much force will L5 receive with High
Intensity Electrical Stimulation?

Consultation with the Physician
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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
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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
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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, 1980
Photo 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 L3
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Hip ER 60° R and 66° L
Bilateral Hip IR and ER
4/5
Case #2- Hypothesis
 This patient will benefit from intervention
aimed at decreasing stress in L5 area
 This will include:
• Increasing hip ROM and strength
• Increasing joint mobility in low lumbar spine
• Increasing 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:
• How to increase or prevent loss of strength in
the paraspinals (while immobilized), without
increasing stress to the L5 region?
 Training
• Volitional 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
Exercises
 Lumbar Stabilization
Progression
• Schneider et.al
 Level I- V
 Maintenance
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 skater
 Low back pain for 3-4 weeks
 Pain onset during 80 minute lesson
 Pain level of 8-9/10 during skating
 Pain level of 7/10 in AM
 Pain exacerbated with twisting and
bending
Case #3 - Early
Intervention
 1 week rest from skating (symptoms
reduced)
 Return of pain intensity after 2-3 days of
skating
 2 week rest from skating
• No pain with ADL’s
Case #3- PT Evaluation
 Limitation in lumbar L sidebending
 Limitation in lumbar R rotation
 Recreation of pain with maximal stress of
left lumbar spine
• Opening (flexion and right side-bending)
• Closing (extension and left rotation)
 Decreased muscle mass of
paraspinals
L lumbar
Case #3- Evaluation
 Extension strategy for
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return from right
sidebending
Hypermobile joint play
L1, L2 and L5
Hypomobile joint play
L3-L4
Painful unilateral joint
play left L2-L5
Case # 3 - Hypothesis

An injury occurred in practice irritating the
Left lumbar facets L2/L3 and L4/ L5
 These joints are painful in end ranges
 Muscular imbalance of the paraspinals
and stiffness of the L3/L4 segment only
contribute to increased stresses at the
irritated site
Case #3- Treatment Plan
 Joint Mobilizations to hypomobile joints
 Electrical Stimulation for paraspinal
muscle
 Spinal stabilization exercises (pelvic
neutral)
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•
•
•
Pelvic Tilts, supine bridging
Prone quadruped arm and leg lifts
Side planks
Prone back extension
Case #3- Progress
 After 4 treatments- Pain-free with ADL’s
not currently skating
 Complaints of muscle fatigue following
treatments
Case #3- Return to
Skating
 After 6 treatments- Return to skating with
pain onset 5-6/10 after 15 minutes
 Next AM pain improved and skated 40
minutes with increasing pain
 4 weeks off skating for continued
strengthening and diagnostic testing
Case # 3 - Diagnostic
Testing
 Diagnosis of
spondyloislthesis
• x-ray (minimal)
• given brace for skating
 New physician
• Hold on brace
• MRI and Bone Scan
negative
• Progressive return to
skating
Case #3 - Strengthening
Progression
 One legged bridging
 Prone extension on a

ball
10# medicine ball
catches with rotation
Case #3- Skating
Progression
 Return to skating at 16th treatment
• Stroking and spins only
• 2- 40 minute sessions with only tightness in
low back
 Next day- 2- 40 minutes sessions painfree
 17th Treatment
• 40 minutes ice dance
• 20 minutes freestyle (stopped when pain
began)
Case #3- Skating
Progression
 Progressing with choreography and spins
 After 19th treatment- began jumping
 Progressed jumps over next 4 treatments
• double axle
• few triples
 Returned to full program and practice at
discharge of 24 treatment
 Transfer exercise to training room
Case #3- Oswestry
Scores
 At eval with ADL’s 8%
 At eval with skating


activity 17%
At discharge with
ADL’s 0% with
skating activity 11%
Follow up 2 months
later 0% with skating
Discussion
 Assist in the maintenance of strength training
 Successfully optimized their strength through
with NMES to the paraspinals, and an intensive
core stabilization program
 Minimize what they may loose with inactivity
 Return to sport at a faster rate
» Muschik et al, 1996
Discussion
 Electrical stimulation has been
successfully added to programs of lumbar
stabilization with figure skaters
 There were no negative effects to the high
intensity stimulation treatments
• fusion
• stress response
Discussion
 Electrical stimulation may show promise in
assisting patients in recovering following
lumbar injury especially when returning to
demanding activities
 Electrical stimulation may be beneficial for
patients who are unable to perform other
exercise programs due to pain
Further Research
 Research must be done to determine the
effectiveness of the addition of electrical
stimulation to a rehabilitation program for
low back pain
 Work aimed at determining the forces
generated in the lumbar spine during
these contractions will help therapists
determine who can best benefit from this
intervention
Thank You!
Kimmie Meissner, U of D