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

1. 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

2. Purpose • To discuss alternative ways of successful non-operative management of figure skaters and dancers with stress fractures

3. 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

4. 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

5. Stabilization of the Spine • Passive system • Active system • Neural control

6. Passive System in Stress Fracture

8. Pars Scotty neck Fx Pars Fracture Need Oblique view

9. Diagnostic Imaging • Bone Scan • Injection of Radionuclide • Analyze blood flow to tissue (Activity) • Poor Resolution

10. SPECT Scan for Pars Dx • Single Photon Emission Computed Tomography • Like bone scan but provides 3-D image

11. CT for Pars Follow up L4 Pars Fx ____

12. Plain Radiograph vs CT  L4 Pars Fx  L4 Pars Fx

13. Spondylolisthesis • Spondylolisthesis – an anterior movement of the vertebral body and can cause compression of the cauda equina which rests posteriorly

14. Plain Radiographs • L4 Spondylolisthesis

15. Spondylolithesis Grading • Grade 1: 25%Grade 2: 25% to 49%Grade 3: 50% to 74%Grade 4: 75% to 99%Grade 5: 100%*

16. Spondylolisthesis • 5 Types • Dysplastic- Congenital abnormalities of arch of L5 • Rare and likely to progress • More often with neurologic compromise • Surgery- Laminectomy and fusion

17. 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

18. Spondylolisthesis • Isthmic-Treatment • Observation • 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

19. Spondylolisthesis • Degenerative- Long standing instability • Most common cause of adult spondylo • Traumatic- Other Fracture (ie articular process) • Pathologic Type- Bone disease

20. Treatment • Typically nonoperative (esp. children) • Rest from aggravating symptoms • Immobilization • Surgical • Failure of conservative management • Progression of the subluxation • Spondylo >50% in skeletally immature • Can see continued slip after posterior lateral fusion

21. Old Spondylolysis • Can create pseudo joint and fill with scar tissue • Can be going through active fracture/repair and active fracture again

22. 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

23. 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

24. Muscular Control of the Spine • Abdominal Wall- Ext/Int Oblique • Torso Rotation and Lateral flexion

25. Muscular Control of the Spine • Abdominal Wall-Transverse abdominis • Beltlike support and generation of intra-abdominal pressure • Delayed onset during ballistic movements in patient’s with LBP

26. 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

27. 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

28. 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

29. Co-activation of the Muscular Spine • 90N force (20lbs) creates buckling without muscular forces • Co-contraction increases support against buckling

30. Muscular Stability • Continuous contraction • ~10% MVIC of abdominals • No single muscle is critical one

31. Lumbar Extensor Musculature • Erector spinae musculature are responsible for extensor force • Multifidusmuscles are segmental extensors responsible for stabilization of lumbar motion segments Fritz et al 2000

32. Muscle Strength and Low Back Pain • 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

33. Performing Arts and Low Back Pain • Lumbar extensor strength is needed to achieve many positions and to successfully land jumps and leaps

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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 & Bhattacharjee Marshfield Clinic, Dep. Of Radiology

42. 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

43. Treatment • Isometric Abdominal Squeezes in brace • Practice Ballet in brace in the open position • Increase core strengthening • 3x/week for 6wks

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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