Presentation is loading. Please wait.

Presentation is loading. Please wait.

Non-Operative Management of Lumbar Stress Fractures in Dancers and Figure Skaters Tara Jo Manal, PT, MPT, OCS, SCS University of Delaware Department of.

Similar presentations


Presentation on theme: "Non-Operative Management of Lumbar Stress Fractures in Dancers and Figure Skaters Tara Jo Manal, PT, MPT, OCS, SCS University of Delaware Department of."— Presentation transcript:

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 intactRecorded 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

7

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

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 progressRare and likely to progress More often with neurologic compromiseMore often with neurologic compromise Surgery- Laminectomy and fusionSurgery- Laminectomy and fusion

17 Spondylolisthesis  Isthmic- Pars interarticularis Most common in children and adolescentsMost common in children and adolescents Lytic type- fatigue fractures of pars (stress fracture, has familial link)Lytic type- fatigue fractures of pars (stress fracture, has familial link) Elongated intact parsElongated intact pars Acute fractureAcute fracture Pain, tight hamstrings and neurologic changes are due to spinal instabilityPain, tight hamstrings and neurologic changes are due to spinal instability

18 Spondylolisthesis  Isthmic-Treatment  Observation 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 Reaction Brace or immobilize for symptom controlBrace or immobilize for symptom control Until symptoms resolveUntil symptoms resolve

19 Spondylolisthesis  Degenerative- Long standing instability Most common cause of adult spondyloMost 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 managementFailure of conservative management Progression of the subluxationProgression of the subluxation Spondylo >50% in skeletally immatureSpondylo >50% in skeletally immature Can see continued slip after posterior lateral fusionCan 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 flexorMajor trunk flexor Active with sit-up and curl-upsActive with sit-up and curl-ups Little to no evidence to support upper/lower differentiationLittle 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 forcesIf 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 transducersFunction primarily as force transducers Position SensorsPosition Sensors Electrically silent with large rotations (involving Abs)Electrically silent with large rotations (involving Abs)  Extensor Group Generate large extensor momentsGenerate large extensor moments Generate posterior shearGenerate posterior shear Affect one or two segmentsAffect 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  are segmental extensors responsible for stabilization of lumbar motion segments  Multifidus muscles are segmental extensors responsible for stabilization of lumbar motion segments Fritz al 2000 Fritz et al 2000

32 Muscle Strength and Low Back Pain  In firefighters, muscle strength of the back was a good indicator for the development of 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 Cady et al 1979  In manual material workers there was a positive correlation between strength and frequency of low back pain Chaffin 1974 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 7 th 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 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

51 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)

52 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 Develope

53 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

54 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

55 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   Hip ER 60° R and 66° L   Bilateral Hip IR and ER 4/5

56 Case #2- Hypothesis  This patient will benefit from intervention aimed at decreasing stress in L5 area  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

57 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

58 Intervention for Strength  Problem: How to increase or prevent loss of strength in the paraspinals (while immobilized), without increasing stress to the L5 region?How to increase or prevent loss of strength in the paraspinals (while immobilized), without increasing stress to the L5 region?  Training Volitional vs. ElectricalVolitional vs. Electrical

59 Case #2 - Intervention   High Intensity Electrical stimulation 11 Attempts 3 aborts due to pain All at the end of the week   Volitional stabilization exercises

60 Exercises   Lumbar Stabilization Progression Schneider et.al   Level I- V   Maintenance

61 Case #2 - Outcome   Return to Skating 7 treatments stroking and spins 9 treatments single jumps falling without pain   Oswestry 0% at 11 treatments

62 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

63 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’sNo pain with ADL’s

64 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)Opening (flexion and right side-bending) Closing (extension and left rotation)Closing (extension and left rotation)  Decreased muscle mass of L lumbar paraspinals

65 Case #3- Evaluation  Extension strategy for return from right sidebending  Hypermobile joint play L1, L2 and L5  Hypomobile joint play L3-L4  Painful unilateral joint play left L2-L5

66 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

67 Case #3- Treatment Plan  Joint Mobilizations to hypomobile joints  Electrical Stimulation for paraspinal muscle  Spinal stabilization exercises (pelvic neutral) Pelvic Tilts, supine bridgingPelvic Tilts, supine bridging Prone quadruped arm and leg liftsProne quadruped arm and leg lifts Side planksSide planks Prone back extensionProne back extension

68 Case #3- Progress  After 4 treatments- Pain-free with ADL’s not currently skating  Complaints of muscle fatigue following treatments

69 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

70 Case # 3 - Diagnostic Testing  Diagnosis of spondyloislthesis x-ray (minimal)x-ray (minimal) given brace for skatinggiven brace for skating  New physician Hold on braceHold on brace MRI and Bone Scan negativeMRI and Bone Scan negative Progressive return to skatingProgressive return to skating

71 Case #3 - Strengthening Progression  One legged bridging  Prone extension on a ball  10# medicine ball catches with rotation

72 Case #3- Skating Progression  Return to skating at 16th treatment Stroking and spins onlyStroking and spins only 2- 40 minute sessions with only tightness in low back2- 40 minute sessions with only tightness in low back  Next day- 2- 40 minutes sessions pain- free  17th Treatment 40 minutes ice dance40 minutes ice dance 20 minutes freestyle (stopped when pain began)20 minutes freestyle (stopped when pain began)

73 Case #3- Skating Progression  Progressing with choreography and spins  After 19th treatment- began jumping  Progressed jumps over next 4 treatments double axledouble axle few triplesfew triples  Returned to full program and practice at discharge of 24 treatment  Transfer exercise to training room

74 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

75 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

76 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 fusionfusion stress responsestress response

77 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

78 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

79 Thank You! Kimmie Meissner, U of D Kimmie Meissner, U of D


Download ppt "Non-Operative Management of Lumbar Stress Fractures in Dancers and Figure Skaters Tara Jo Manal, PT, MPT, OCS, SCS University of Delaware Department of."

Similar presentations


Ads by Google