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

Passive System in Stress Fracture

Pars

Scotty neck FxPars Fracture

Need Oblique view

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

CT for Pars Follow up

L4 Pars Fx ____

Plain Radiograph vs CT

L4 Pars Fx

L4 Pars Fx

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

Plain Radiographs

L4 SpondylolisthesisL4 Spondylolisthesis

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

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 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

Thank You!

Kimmie Meissner, U of DKimmie Meissner, U of D