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Emily Spears
Spondylolisthesis / Spondylolysis Rehabilitation
ATHT 4960
Rehabilitation Techniques
References
Andrews,J.R.; Harrelson, G.L.; Wilk,K.E.
(1998). Physical Rehabilitation of the Injured Athlete (second edition).
Arnheim, D.D. (1991). Essentials
of Athletic Training (second edition).
Fahey, T.D. (1986). Athletic
Training: Principles and Practice.
Norris, C.M. (2000). Back Stability.
Prentice, W.E. (1999). Rehabilitation Techniques in Sports Medicine (third edition). McGraw Hill Companies, INC.
Starkey, C.; Ryan, J. (1996). Evaluation
of Orthopedic and Athletic Injuries.
Winkel, D. (1996). Diagnosis
and Treatment of the Spine.
Yashon, D. (1978). Spinal Injury.
Introduction
Spondylolysis is a degeneration
of a vertebral structure, most commonly the pars interarticularis, in which
there is no slippage of the vertebral body. Spondylolisthesis is the forward
slippage of a vertebra on the one below it which may occur secondary to spondylolsis
(Starkey 1996). These conditions typically occur in sports involving repetitive
hyperextension of the back such as with football linemen, gymnasts, cheerleaders,
weight lifters, volleyball players, pole vaulters, and rowers (Starkey 1996
and Anderson 1995). These slippages occur at the lumbrosacral joint in ninety
percent of cases (
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Anatomy of Injury
Spondylolysis is a defect in the pars interarticularis, the area of the vertebral arch between the inferior and superior articular facets. Bilateral defects in the pars interarticularis, which is the weakest bony portion of the vertebral arch (Anderson 1995), result in the posterior portion of the vertebra becoming separated from the vertebral body, with the posterior fragment consisting of the laminae, inferior articular surfaces, and the spinous process. When seen on a posterior oblique X-ray view this appears as a “collared Scotty dog” deformity. Spondylolisthesis involves defects in both elements of the pars interarticularis which result in the separation of the vertebra into two uniquely identifiable structures. The fixation between the vertebra and the one below it is lost, resulting in the superior vertebra sliding anterior and possibly inferior on the one below it. X-ray views reveal a “decapitated Scotty dog” deformity. This condition may eventually cause impingement of neurological structures (Starkey 1996).
There are five types of spondylolisthesis: 1) dysplastic, which is a congenital abnormality in the upper part of the sacrum or the arch of L5; 2) isthmic, which is a lesion in the pars interarticularis; 3) degenerative, caused by long standing inter segmental instability; 4) traumatic, a bony fracture at parts other than the pars interarticularis; and 5) pathological, which is caused by a general or local bone disease (Winkel 1996).
Spondylolisthesis can be classified in the following grading system: Grade 1- 25% of body slipped, Grade II- 50% of body slipped, Grade III- 75% of body slipped, and Grade IV- 100% of body slipped (Andrews 1998)
Traumatic Spondylolisthesis
Biomechanics of Injured Structure
Strain is placed on the pars interarticularis by having the athlete stand on one leg and move into extension. Extension of the spine compresses the spinous process and the contraction of the iliopsoas tends to pull the vertebra anteriorly resulting in a shear force being placed on the pars interarticularis (Starkey 1996).
Typically athletes with spondylolsis have a long history of “something letting go” in their back. Their pain does not typically interfere with their workout performance, but is usually worse when fatigued or after sitting in a slumped posture for an extended period of time. The athlete often complains of a tired feeling in their low back (Prentice 1999).
Athletes with serious spondylolisthesis usually have a short torso, heart shaped buttocks, low rib cage, high iliac crest, vertical sacrum, and tight hamstrings. They may also have restricted hip extension (Arnheim 1991). Spondylolisthesis is also thought to predispose individuals to having spinal cord injuries (Yashon 1978).
Mechanism of Injury
Spondylolsis can affect athletes
of any age participating in any sport. Most are a stress reaction, caused by
repetitive hyperextension such as with football linemen, gymnasts, and cheerleaders,
that leads to a fracture (Starkey 1996). Some are congenital, and may be caused
by mechanical stress from axial loading of the lumbar spine during repeated
weight bearing flexion, hyperextension, and rotation (
Signs and symptoms of this condition include dull backache which is aggravated by activity, buttock pain, possibly sciatica from nerve root impingement, spasm of erector spinae muscles, hamstring spasm, limited straight leg raise, occasional increased lumbar lordosis(with low slip), transverse crease across back (with high slip),pain that restricts active back extension, and localized back pain that increases during and after activity (Reid 1992, Starkey 1996).
Mechanism in football lineman (Fahey 1986)
Rehabilitation Plan
(Norris 2000, Andrews 1998, Yashon 1978, Prentice 1999)
Phase 1-
Goals: - Maintain Level of Physical Fitness.
- Be able to get through daily activities without pain.
- Increase abdominal strength.
- Increase flexibility in hamstrings, hip flexors, and hip rotators.
Criteria to Proceed:
- Ability to go through full range of motion without pain.
Exercises:
- In hook lying position, alternate leg lifts and shoulder flexion.(10 times each leg, 2 sets)
- Perform pelvic tilts in hook lying position.(20 times)
- Bird dog exercises(15 times each leg)
- Stretching exercises for hamstrings, hip flexors, and hip rotators. (5 times each stretch, holding each for 30 seconds.
- Pool workout: jogging in pool with swim vest. (20 minutes)
- Use of low back corset may increase athletes’ comfort.
Phase 2-
Goals:
- Maintain pain free range of motion.
- Increase abdominal and core strength.
- Increase pelvic proprioception.
- Continue to increase flexibility of hamstrings, hip rotators, and hip flexors.
- Maintain Physical Fitness
Criteria to proceed:
- Noticeable increase in abdominal strength.
- Pain free range of motion.
- Ability to hold bridging exercise for 1 minute.
- Ability to maintain proper posture while sitting on Swiss ball.
Exercises:
- Half sit ups, progressing to half sit ups at various angles.(25 times)
- Bridges on Swiss ball. (try to hold for one minute, 3 times)
- Bird Dog exercises progressing to lying prone when doing them. (15- 20 times each leg)
- Sitting on Swiss ball do pelvic tilts and concentrate on maintaining good posture. Progress by taking one foot off ground.(20 tilts)
- Put feet on Swiss ball and lift butt off ground hold 15 seconds. (10 times)
- Hamstring, hip flexor, and hip rotators stretching. (5 stretches each, holding 30 seconds)
- Cardiovascular: alternate jogging in pool and stationary bike.
Phase 3-
Goals:
- Continue increase in abdominal strength.
- Continue increase in hamstring flexibility.
- Continue to maintain physical fitness.
- Begin preparing for return to participation.
- Begin sport specific activity.
Criteria to Proceed:
- 100% in range of motion, strength, and flexibility.
- Physically fit for participation in sport.
- Ability to perform skills needed in their sport.
- Physician’s release if necessary.
Exercises:
- Trunk rotation exercises with medicine ball. (25 times)
- Do sit ups with medicine ball and throw ball at end for plyometrics. (20 times)
- Perform heel bridge on Swiss ball and bring ball up with feet. Progress to doing angles. (15 times)
- Sitting on Swiss ball, using one leg for balance, play catch with ATC. Try to maintain good posture.(5 minutes)
- Sports specific activities and drills, making sure to concentrate on good spine stability.
- Stretch hamstrings, hip rotators, and hip flexors.
- For cardiovascular, begin running, progress to sprinting, running patterns needed for their sport.
Phase 4-
Goals:
- Maintain flexibility in hamstrings, hip rotators, and hip flexors.
- Maintain strength in abdominals.
Exercises:
- Stretching for hamstrings, hip rotators, and hip flexors before and after practice.
- Complete a 10-15 minute abdominal workout at least 3 times a week. Could consist of: sit ups, bird dog exercises with weight, Swiss ball bridges, or other core stabilization exercises.
Summary
This paper has been a basic overview of spondylolsis and spondylolisthesis in the athlete and a plan of rehabilitation for the condition. An athlete with spondylolisthesis, which I worked with in the past, could one day be in too much pain to do any rehabilitation and the following day would feel as if he could participate in practice. We tried everything imaginable with him, but he would still just have a bad day or two every now and then. We also found that the one thing that relieved his pain and helped him the most was doing workouts in the pool; it took the pressure off of his back while allowing him to still maintain his physical fitness level. I think that when doing rehabilitation for spondylolisthesis, like many other rehabs, it is just a trial and error process with each individual athlete and what helps them and what does not.