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
Good afternoon. My name is Airelle Hunter. I am a physical therapist at the university of Delaware and I am here today to discuss…

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

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 Stress Reaction
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
Multifidus muscles are segmental extensors responsible for stabilization of lumbar motion segments
Fritz et al 2000
We all know that the erector spinae musculature are the largest contributors to extensor force in the lumbar spine and Fritz et all in 2000 showed that the multifidus muscles help with the segmental extension that is responsible for stabilization of the lumbar motion segments.

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
This leads into similar findings by Cady et al in 1979 and Chaffin in 1974 which showed that lack of muscle strength in the low back had correlation with low back pain.

33. Performing Arts and Low Back Pain
Lumbar extensor strength is needed to achieve many positions and to successfully land jumps and leaps
As we start to discuss performing artists such as figure skaters and dancers, we realize that lumbar extensor strength is greatly needed to achieve many positions and to successfully complete the high level of jumps and leaps that they need to land as well as to sustain the many postures it takes to be competitive.

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
WE are going to discuss two cases today with the first one being that of a young 13 year old female dancer who dances in point, ballet, and modern dance. She came to see us last year, complaining of low back pain with extension activities that came on with an arabesque scale about 4 weeks previous to her initial evaluation. At this time she was not resting and was continuing to dance at 100% due to numerous upcoming shows and recitals.

35. Case #1 Evaluation (-) SI testing
Cibulka et al
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
On initial evaluation: Read slide
So at this time her pain and symptoms were pointing towards a closing restriction on the right.

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
She also showed significant muscle spasms in her right paraspinals and quadratus. Not only was back pain one of her symptoms but she also complained of hip, lateral thigh and buttock pain that came on with prolonged dancing. Her straight leg test for any neural tension signs was negative.

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
She was treated on the first day for the right closing restriction. A manipulation was performed in right side lying with left rotation which produced an audible pop. Retesting in right max closing was much less painful at the L5/S1 area. Grade II and III mobilizations were also performed to try and decrease pain and inflammation as well as TENS and ice were applied after treatment.

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
At treatment 2 which was one week after her initial evaluation, she felt 60% improved and showed no signs of a ROM restriction. Treatment at this time consisted of the same Grade II/III mobilizations and continued soft tissue techniques to the spasming areas. She was allowed at this time to return to activity as long as it was pain free. She had kept all of her ROM gained in her previous treatment and just now needed to be calmed down since most likely the arabesque and repeated extension caused a dysfunction in her facet joint. At this point we’re seeing immediate responses, she is still dancing, we think we’re golden.

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
Her third treatment was one week and 3 days after her initial evaluation. She danced full out the night before and came to the clinic reporting 4x more pain than at her previous visit and thought she had regressed back to the same pain as at her initial evaluation. Upon reassessment of her lumbar spine, she was still without ROM restrictions. Treatment was the same as the previous visit being predominately pain control and she was given a Home Tens unit for pain relief.

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
After the irritable third treatment, she did continue to show signs of improvement during the next three visits with soft tissue and joint mobilizations. She was continuing to dance full out but at the 7th treatment which was 3 weeks after the initial evaluation, she was complaining of pain that was longer lasting and waking her up at night. She was also getting leg symptoms and night pain as well as the pain was shifting from the right to the left sides of her back. With such variable symptoms as these, and increasing leg symptoms, we were beginning to think that the original diagnosis was too simplistic. Our next hypothesis with no improvement and no motion restrictions is a stress fracture. We then spoke with her primary care physician about our concerns and asked for a bone scan since this would be the best way to determine acuteness or chronicity if it was a stress fracture. Her PCP refused saying it was too much radiation and ordered a 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
Her MRI results were positive for a bilateral pars fracture at L5. When we asked the MD if chronic or acute, she reported chronic but we really didn’t have a bone scan to show us those results. At this time the PCP agreed to send the patient to a sports medicine spine specialist. We held on PT for almost a month while the patient had further testing and follow up by the specialist and she continued to use the TENS unit at home and was given a CASH brace as a reminder to stay out of extension.
Spieth & Bhattacharjee
Marshfield Clinic, Dep. Of Radiology

42. Test Results Bone Scan: Ordered TLSO Reinstate PT
(+) 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
The spine specialist ordered a bone scan which revealed a bilateral L5 stress fracture at the pedicle/posterior arch with bone marrow edema at the pedicle on the L>R. This was consistent with a L5 spondylolysis bilaterally. The physician ordered a thoracic lumbar sacral orthosis and reinstated PT. The time frame is now a month and a half after the initial evaluation.

43. Treatment Isometric Abdominal Squeezes in brace
Practice Ballet in brace in the open position
Increase core strengthening
3x/week for 6wks
When she returned to PT, we implemented a treatment program consisting of a progressive core strengthening program that started with abdominal isometrics and progressed through a stabilization program. At this time, she was allowed to practice ballet in her brace in the open position as long as she was pain free. She mostly completed barre work but no pointe.

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
With the recent changes we now hypothesize that since the patient has been diagnosed with a stress fracture and has been placed in the TLSO brace, core strengthening with correct technique may be difficult. We also thought that implementation of NMES to her lumbar paraspinals would assist with more rapid return of strength in conjunction with a core stabilization program which I believe Lee will talk more about in the next segment.

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
We didn’t think that abdominal exercises while braced would be enough to help keep her strong so that she could return to dancing as soon as she was released so we discussed the need to preventing loss of or gaining strength without increasing stress to the compromised structure. We therefore considered the benefit of electrical stimulation for strengthening.
We were concerned about the force that L5 would receive with the high intensity electrical stimulation so we consulted with the physician and we all agreed to let pain be the guide and if her LBP was recreated, we would first turn it down and if no improvement, we would discontinue the treatment for that visit.

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
In 1995, Dr. Snyder-Mackler et al looked assessing the effectiveness of common regimens of electrical stimulation as an adjunct to ongoing intensive rehabilitation in the early postoperative phase after reconstruction of the anterior cruciate ligament
She concluded that the use of high intensity NMES combined with volitional exercise is more successful than exercise alone.

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
Therefore, we believed theoretically that the application…
There has been some limited evidence by Kahanovitz and McQuain et al, suggesting that NMES can work in the lumbar spine, however these studies had some limitations. Mainly, the intensity of electrical stimulation was set to the maximal level that was considered comfortably tolerable, and the stimulation units were portable battery powered stimulators that the patients were trained to set for themselves.
Once again, our hope was to minimize the morbidity of the immobilizer and be able to get her back on the ice quickly.
Therefore, our plan, was to attempt to follow the protocols utilized in the quadriceps literature.

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
Once we were set to start NMES, we followed the parameters we use for quadriceps strengthening, which are:

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
The patient is positioned prone over 2 pillows with the pelvis strapped isometrically with a belt and the patient is in a posterior pelvic tilt so that once the NMES started, there is no contraction that leads to end ranges of flexion or extension

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
We do not have the ability to assess Maximal Volitional Isometric Contraction and then grade the stimulation to a minimum of 50% as we do in the quads, therefore, we look for a visible and tolerable contraction by the patient which is hopefully tetanic in nature. There is a single channel place of each side of the spine.
Around 2.5 months into this treatment progression, the spine specialist ordered a follow up CT scan to assess the healing of the L5 pars fracture.

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)
The CT scan showed a minimal degree of spondylolisthesis of 1-2 mm in the chronic stage of the spectrum of this disease. Her physician at this time was not concerned of more slippage therefore, she was allowed to start swimming brace free and dance more while in the brace but still without hip or back extension. Keeping her braced for 2 months was a conservative measure but the doctor felt it was necessary since CT showed acute marrow edema and she wanted to return to a very advanced level of dancing. At 3.5 months, she was prescribed a soft brace and was allowed to dance into extension. One month later she was cleared to dance at 100%. Although held out of dancing for almost 5 months, she returned to dance at 100% in 1-2 weeks after being released back to sport.

52. Outcome Full dancing in all classes at 6 months
No pain with any activity
Oswestry: 0%
Fairbanks, et al, 1980
At 6 months, she was discharged from physical therapy and was dancing in all of her classes. Speaking with her now, 10 months after injury, she reports no pain with any activity including any type of dance. Her oswestry is 0% and she even reached her goal of being accepted to the 6 week Boston Ballet summer company program, which she was unable to do the year before because of injury.
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
In our second case, we had a figure skater who was referred to our clinic by the Athletic Trainer at The University of Delaware Ice Arena.
She was a 12 year old female, who complained of persistent low back pain for 2 weeks after falling on the ice. At this time she was in the midst of her competition season and she was doing incredibly well as you can see, she was ranked in the top 10 in the nation. In conjunction with her physician, it was agreed to manage her pain with anything possible until her season ended in 3months. Not competing, was not an option. Upon completion of the season, the physician would initiate further diagnostic testing.
Treatment during this time period included mobilization, manipulation, lumbar stabilization, TENS, ice, and various soft tissue release techniques.

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
Once her season ended, the physician ordered a MRI and bone scan. The bone scan was positive for a stress reaction at the bilateral pars interarticularis of L5.
Upon completion of the dx tests, she returned to our clinic, and was given the Oswestry Low Back Disability Questionnaire which revealed 18% dysfunction with ADL’s.
Her pain upon completion of the Nationals Competition was excessive compared to her response after other competitions that season. Her pain significantly decreased by 50% with just 2 weeks of rest, however, she was still at a higher level than she had been for the past 3 months.

55. Case #2 Evaluation Lumbar ROM Hip ER 60° R and 66° L
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
On physical exam, her ROM during gross screening was normal to excessive in all directions. However, more in-depth assessment demonstrated that all her motion was occurring above L3. She had : read slide
We also decided to look at the movement of joints above and below which showed asymmetrical hip ROM and weak hip internal and external rotation.

56. 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

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
To resolve her back pain we hypothesized that interventions aimed at decreasing stress in the L5 region would allow the inflammatory process to settle down.
This was in agreement with the physician, who chose to place her in a TLSO brace and rest off the ice for one month.
Our strategy included resolving the restrictions in hip Rom and lumbar mobility as well as increasing the strength of her 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?
Training
Volitional vs. Electrical
Previous attempts to increase strength volitionally caused her pain and she demonstrated no improvement. Therefore, we considered the benefit of electrical stimulation for strengthening.

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
Our treatment intervention included NMES to her paraspinals with MD approval and a volitional core stabilization program.
This young lady attempted 11 treatments of NMES but we had to stop on three occasions due to pain, which all happed to be at the end of a week, which we attributed to being fatigued since she had already had two other treatments that week and was sitting in class all day. And in respect to the last case, this patient was highly more irritable coming into PT having knowingly skated at more than 100% for some time with the diagnosis.
One of the things you will notice is that this picture shows extension of the lumbar spine while the stimulation is on. The stimulation is actually lifting her chest off the table. The patient in this picture happens to be the patient this case is about, and she barely weighed 70 pounds. This amount of extension is just in the beginning of her available arc of motion. We made a conscious decision not to strap her chest down, due to our lack of knowledge of the forces that would be generated through the lumbar spine. She was not getting pain in this position.
In most patients we have used this on, the trunk is too heavy to rise off the table.

60. Exercises Lumbar Stabilization Progression Level I- V Maintenance
Schneider et.al
Level I- V
Maintenance
When adding the stabilization exercises, we followed an exercise progression by Schneider, Schmitt and Manal. It is program with five different levels of stabilization exercises and after reaching the highest criteria, you can continue with the maintenance phase. Our patient started with level I and progressed to level three before discharge.

61. Case #2 - Outcome Return to Skating Oswestry 0% at 11 treatments
stroking and spins
9 treatments
single jumps
falling without pain
Oswestry 0% at 11 treatments
After 7 treatments she returned to stroking and spins and after 9 sessions, she returned to single jumps and falling without pain. Her Oswestry pain questionnaire was 0% after 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’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)
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 bridging
Prone quadruped arm and leg lifts
Side planks
Prone 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)
given brace for skating
New physician
Hold on brace
MRI and Bone Scan negative
Progressive 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 only
2- 40 minute sessions with only tightness in low back
Next day minutes sessions pain-free
17th Treatment
40 minutes ice dance
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 axle
few 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
WE know that par interariculars fractures exist in athletes who perform hyperextension activities but Muschik et al shows that there is no relation between their sports activity and progression of the disease process. We also don’t know if these patients potentially had the stress fracture before radiographic testing with that this could be an acute exacerbation of a chronic problem since many of them do not show healing.
So what do we do for a high level athlete while they have to be immobilized and are not allowed to participate in their sport?
This case series shows how we can assist in the maintenance of strength training which would have otherwise been lost with immobilization techniques. We have successfully optimized their strength through this time frame with NMES to the paraspinals, and an intensive core stabilization program in order to minimize what they may loose with inactivity.
These techniques have allowed them to return to sport at a faster rate once they are finally cleared to go back.

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
fusion
stress 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
Thank you for listening. I also want to the thank my colleagues at the University of Delaware for their support and as you can see, I just want to put a little plug in there for our local figure skater, Kimmie Meissner. May she have the best of luck in the Olympics.
Kimmie Meissner, U of D