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A Case of Low Back Pain. Tina Gaston, ATC Steadman Hawkins Sports Symposium June 7, 2013. History. 14 year old male, right handed Football player: back up QB, WR, Safety Tae Kwon Do from 6 to 12 years old Church basketball. Presentation.

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A Case of Low Back Pain


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    1. A Case of Low Back Pain Tina Gaston, ATC Steadman Hawkins Sports Symposium June 7, 2013

    2. History • 14 year old male, right handed • Football player: back up QB, WR, Safety • Tae Kwon Do from 6 to 12 years old • Church basketball

    3. Presentation Low back pain intermittent through out TKD for 6 years Increase in low back pain after sprinting during spring football conditioning and throwing football no complaints of radiating symptoms

    4. Observation • Pain was always reported on Left side • Muscle spasms on Left side only • Point tenderness to Left of spinous process, L4/L5 • Full range of motion of lumbar and thoracic spine • Pain with right rotation, throwing

    5. Treatment Modified throwing activity Heat, ice and electrical stimulation for pain control Core strengthening Due to long history of back pain referred to Dr. Sease within 1 month of complaint

    6. Differential Diagnosis • Strain • Disc herniation • Pars defect (spondylolysis) • UTI • Tumor

    7. Matt Baird, MD Steadman Hawkins Sports Symposium June 7, 2013 SpondylolysisDiagnosis & Management

    8. Objectives Consider the complaint of low back pain in the athlete Briefly discuss the pathophysiology and diagnosis of spondylolysis (aka pars defect) Discuss treatment, specific rehabilitation techniques/protocols and RTP guidelines

    9. Low Back Pain in Athletes • Epidemiology • 10-15% of young athletes • 27% of Football players • 50% of artistic gymnasts • 86% of rhythmic gymnasts • Incidence is quite different from the adult population

    10. Low Back Pain in Athletes • Epidemiology • Pars interarticularis injuries: 47% of young athletes (<18) with back pain vs 5% in adults • Intervertebral Disc pathology: <11% in children vs 48% in adults oocities.com

    11. Low Back Pain in the Athlete Take Home Point: TAKE IT SERIOUSLY… IT IS PROBABLY SOMETHING!!

    12. Spondylolysis in the Athlete

    13. Spondylolysis back.com • Definition • Stress fracture of the pars interarticularis • Incidence • 5% in North American Population • Age • 0% at birth, reaches 5% by age 6 • Sex • 2-3 X more common in males • Spondylolisthesis more common in females (2-4X) • Other Risk Factors • Hyperlordosis • Genetics: 6X more common in families with affected members scottlaneycansell.wordpress.com

    14. Spondylolysis • Pathophysiology • Congenital vs Acquired • repetitive extension and rotation of lumbar spine • Rarely an acute injury • Most common at L5 (71-95%), followed by L4 (5-23%) • Bilateral in as high as 89%

    15. Spondylolysis triangledisc.com • Pathophysiology • What do we want to avoid? • Spondylolisthesis! • Slippage of one vertebra over another • 15% of 1st graders with spondylolysis progressed to spondylolisthesis (Frederickson, et al) scoliosisassociates.com

    16. Spondylolisthesis Stable Unstable agingspinecenter.com Grade 1: up to 25% Grade 2: 26 to 50% Grade 3: 51 to 75% Grade 4: 76 to 100% Grade 5: >100% (spondyloptosis)

    17. Spondylolysis:Diagnosis • History • Insidious onset of extension-related LBP • Radicular symptoms are occasionally reported • Pain with impact (tackling, running, jumping) bioathleticcenter.com

    18. Spondylolysis:Diagnosis • Exam • Lumbar extension elicits pain • Stork test – Masci, et al determined poor sensitivity and specificity with MRI/bone scan in 2006 • Hamstring Tightness (popliteal angle) • Acquired scoliosis • Due to pain • C-shaped • Gait disturbance • Crouched, short stride, incomplete swing phase • Hyperlordosis, spasm Pucell L, Michele L. Low back pain in young athletes. Sports Health. 2009; 1:212-222

    19. Spondylolysis:Diagnosis ep.bmjjournals.com ajs.sagepub.com • Radiographs • Lateral: slip, old pars fractures • Oblique: stress reaction of pars • “neck of scotty dog” • AP: other associated variants • Transitional vertebra, spina bifida occulta (Steiner) • Plain radiographs only identify 1/3 of defects • McTimony, 2003 • Do not let normal plain films reassure you sph.sagepub.com

    20. Our Patient

    21. Spondylolysis:Diagnosis • Advanced Imaging

    22. Spondylolysis:Diagnosis • Advanced Imaging • So what is the best test? • Established Literature: SPECT/CT • More recent literature: ? MRI • “Magnetic resonance (MR) imaging should be used as the primary investigation for adolescents with back pain and suspected stress reactions of the lumbar pars interarticularis.” • Leone et all, 2011 review article

    23. Our Patient

    24. Spondylolysis:Management kisersoandp.com • Painless rest • No contact, extension, or other painful activities • Physical Therapy • Flexion-biased core program • Bracing? • TENS unit/bone stim?

    25. Spondylolysis:Management • Return to Play • Hotly debated • Pain free, FROM, normal strength and balance • ~90% RTP by 5.5 months (Iwamoto, ‘01) • Average time out of sport: 3.9 months • Average time to full play: 5.2 months (Alvarez-Diaz, ‘11) • EXPECT AT LEAST 3 MONTHS

    26. Spondylolysis:Management • Follow up • Annual evaluation indicated through skeletal maturity for those with pars defect • Repeat imaging dependent upon symptoms and expectations • Goal is for fracture healing, but non-union does not compromise outcome or RTP

    27. Spondylolysis:Management • What if they don’t get better? • Failed >6 months of non-op care • Pars Repair vs Fusion • Candidate for pars repair if there is no slip/instability, and disc is normal • Diagnostic pars injections may be used for treatment planning

    28. SpondylolysisRehab & Return to Sport Jenn Backs PT, DPT Steadman Hawkins Sports Symposium June 7, 2013

    29. Treatment Goals Alleviate pain Address risk factors to prevent further slip & instability Pain-Free Return

    30. Return to Sport Initial Injury

    31. Phase 3 Phase 4 Phase 1 Phase 2 Return to Sport Initial Injury

    32. Risk Factors • Biomechanical Factors •  Lumbar Lordosis •  Thoracic kyphosis •  Flexibility • Iliopsoas • Thoracolumbar Extensors • Abdominal weakness (McCleary 2007)

    33. Comprehensive Rehab Program Should Include…

    34. Phase 1 – Isolated Training Week 0-2 Minimize pain Isolated muscle activation Improve Flexibility Improve Postural deficits

    35. Minimize Pain REST ICE AND TENS • Cessation of aggravating activities • Shortest time that healing is evident on serial imaging studies = 3 mos (Standaert 2007) AVOID LUMBAR EXTENSION

    36. Improve Flexibility/ROM

    37. Improve Flexibility/ROM Hip Flexors Thoracolumbar Extensors Quadriceps

    38. Muscle Activation Isolated Muscle Activation Transverse Abdominis Multifidus

    39. Muscle Activation Transversus Abdominis Stabilization of lumbar spine via attachment to thoracolumbar fascia (Hides 2006) Increase in intra-abdominal pressure (Hodges 1996)

    40. Training the TrA • Abdominal “Drawing-in” tension in anterior abdominal and posterior thoracolumbar fascia (Hides 2006) • More selective of TrA activation vs. posterior pelvic tilt (Hodges 1996)

    41. Muscle Activation Multifidus Compressive force and segmental motion control (Garet 2013)

    42. Postural Re-Education • Significant  IO and MT activity in poor sitting and standing posture •  TrA activation in erect postures vs. slumped sitting or sway back standing (Reeve 2009)

    43. Progression to Phase 2 Pain ≤ 4/10 10 second TrA & MT activation Good spinal stability with extremity movements Oswestry < 30%

    44. Phase 2 – Integrated Training Week 3-8 Minimize pain Flexibility & ROM Muscle Endurance Integrate local muscle system with global muscle system Balance/dynamic activities

    45. Phase 2 Activities • Initiate gentle lumbar ROM as tolerated • Avoid Hyperextension • Cardio endurance • Stationary Bike • Elliptical • Treadmill walking

    46. Integrate Global with Local Core Function = Provide stable base for extremity movement Lumbar Spine = Fulcrum for extremity movements

    47. Integrate Global with Local Core Function = Provide stable base for extremity movement Lumbar Spine = Fulcrum for extremity movements

    48. LE Strength + Core Activation Unstable Surfaces Add Resistance

    49. Progression to Phase 3 Pain ≤ 2/10 Improving Core Stability Full LE flexibility LE strength = 4/5 Lumbar ROM WNL, no aberrant motion Oswestry <20%

    50. Phase 3 – Dynamic Functional Training Week 9-12 Improve endurance/strength Core control during dynamic functional movement patterns Protected functional activities