Lumbar Spondylolysis and Spondylolisthesis Protocol

Transcription

1 Lumbar Spndyllysis and Spndyllisthesis Prtcl Hx: Spndyllysis rest and prtect Initial Evaluatin Is it Acute traumatic vs repetitive stress spndyllysis due t hyperextensin? Can be unilateral r bilateral ccurring L5 vertebrae between 85-95% f the time; L4 5-15% f the time. Mst are unable t identify any particular traumatic incident Twice as cmmn in male verse females Genetic predispsitin- seen within families (1 st degree relatives) Is Spndyllisthesis present? Evaluate Phase 2 static stability +1-4 weeks Review HEP Pain management Neutral spine with daily activities Cre bracing techniques If patient wasn t braced initially are they a candidate fr bracing? If rest and activity mdificatin wasn t successful fr pain management Re-assess neur system Better /wrse/same? Jint mbility Abve and belw site (hip and thracic spine) Sft tissue restrictins lcally r reginally due t ptential cmpensatin Range f mtin Full UE and LE range f mtin w/ neutral spine Is it frm spndyllysis r degenerative spndyllisthesis? Degenerative slippage seen at L4 Rarely seen under age 40 Prgressin f spndyllisthesis after age f 20 is much less cmmn cmpared t prgressin during childhd and adlescence. Degree f anterlisthesis present may be f minimal clinical imprtance, degree f LBP experienced has gd crrelatin with the degree f instability Prminent instability with minimal anterlisthesis is mre prblematic then stable segments with prminent anterlisthesis. Imaging Xrays, flexin/extensin, blique CT/MRI Instability with segment? Pain: Chief Cmplaint LBP seen in 47% f adlescents wh have spndylsis and 5% adults. Lcatin: Lw back pain with radiculpathy (leg pain); pain dwn ne r bth legs especially with extensin psitins; Gluteals and psterir aspect thighs Spndylsis: Asymptmatic in majrity f peple. Active and inactive lesins: can be incidental finding Back pain in child/adlescence raise suspicin newly develped r impending spndyllysis

2 Especially athletes 15-47% f the ppulatin in sprting activities that invlve hyperextensin and rtatin such as gymnastics, diving, wrestling, dancing, thrwing sprts, sccer and baseball. Adults: lk fr cncurrent instability with spndyllysis Lw back pain usually wrse with extensin; mst cmmn symptm Aggravated with lifting r walking Relieved with sitting Psture: Child/adlescents: visual inspectin may reveal hyperlrdsis Adult: Fcal kyphsis at lumbsacral junctin with exaggerated lumbar lrdsis Palpatin: Paraspinals muscle spasm Tender t palpatin spinus prcess Flexibility: Cntracture/tight hamstrings Tight hip flexrs Gait: Flexed hips and knees Stiff legged, shrt stride, pelvic waddle ROM: Limited/restricted active and passive mtin Neur: mre seen in spndyllisthesis Lumbar radiculpathy (irritatin, stretching, cmpressin f the nerve rt framen): leg Numbness, tingling, weakness. Assess dermatmes, mytmes, reflexes Central canal stensis neurgenic claudicatin cauda equina (higher grades spndyllisthesis) bwel and bladder changes neural tensin Special tests: Step ff defrmity (high grade spndyllisthesis) Limited SLR Pain with ne legged standing lumbar extensin test HEP Lg rlling HEP Aviding hyperextensin

3 Abdminal bracing Activity mdificatins/restrictins: aviding hyperextensin and rtatin Rest 8-12 weeks acute spndyllysis Lifting techniques If in sprts n sprts Phase 1: rest and/r prtect; first ~8-12 weeks fr acute spndyllysis/spndyllisthesis, week 0 degenerative spndyllisthesis General exercise light statinary biking, TM walking with incline, Nustep Strengthening deep abdminal muscles and back muscles (transverse abdminis and multifidi) abdminal bracing (multiple psitins)- be sure nt ver recruit w/ superficial abdminal muscles Stretching in neutral psitins (supine 90/90 active knee extensin hamstring stretch, pirifrmis stretch, sidelying quad/hip flexr stretch) avid hip flexr based strengthening Pain cntrl Nsaids Bracing Analgesics Injectins-after 4-6 weeks if ther cnservative measures fail Usually nt needed fr mst peple, n clinical significant differences seen with wearing Can be used t decrease lumbar lrdsis and manage pain if 2-4 weeks f rest/activity mdificatin alne dn t reduce pain. Wrn 23 hurs/day fr 6 mnths Mdalities Lw intensity pulsed ultrasund (LIPUS) Early studies thus far have been prmising fr increasing healing times frames especially with prgressive stage fractures. Heat/ice TENS Stretching hip flexrs/hamstring (keep hip mbility intact) Dry needling pain relief Thracic manipulatin fr pain relief Gentle STM t paraspinals/ther tender areas based n palpatin Segmental tractin fr pain relief Gals Gd lifting mechanics Phase 2: static stabilizatin weeks +1-4 general exercise: light t mderate statinary biking; deep water jgging with flats bridges, sidelying hip abd, clamshells, side plank, UE/LE mvements with abdminal bracing start supine/sitting and prgress t standing exercises (hip abd, hip extensin, marching, pull dwns, rws) Prgressin criteria: pain free static exercises, pain free lumbar flexin r lateral flexin, maintain neutral spine with LE/UE mvements. Cntinue stretching PRN STM any muscular restrictins/pain Jint mbilizatin grd 1-2 fr pain alleviatin thracic spine; manipulatin fr glbal pain mdulatin and neurmuscaular facilitatin Dry needling pain relief Gals

4 Independent with pain management strategies pain free daily activities Independent with HEP (general exercise, cre bracing, neutral spine, gradually increase flexibility upper and lwer extremities) Understanding imprtance f activity restrictin/mdificatins- aviding hyperextensin Maintain pain free (nearly) range, pain free daily activities, increase cre strength, nrmal hip and thracic mbility, prgress flexibility and lumbar stabilizatin t WB pstures, imprve prpriceptin. * Exercises within each categry are t prvide the clinician with examples based n evidence based research, but are nt all inclusive

5 Evaluate Phase 3: dynamic stabilizatin; +4-6 Is patient prgressing as expected? ROM spine Prgressing twards full range, n restrictins Jint mbility Prgressing twards nrmal mbility glbally Sft tissue Decreased prtective tne, restre nrmal tensin Neur screening WNL If persistent neur- referral ut? Is Nnunin/instability present? Evaluate Phase 4: crdinatin, athletic develpment; +6-8 ROM: spine/ue/le shuld be WNL Jint mbility- WNL Sft tissue- n restrictins Neur - WNL Prgressin criteria: pain free with all mtins Phase 5: return t sprt +3-6 mnths Precautins: may need t be cautius with returning t Olympic lifting (pwer lifting) Precautins: avid prlnged pain with initiatin lumbar extensin AROM Prgressin criteria: n increase in pain with lumbar range f mtin. Pain management with increased lumbar range f mtin Imprtance f gd mechanics with high level activities General exercise: md intensity statinary biking r elliptical machine, shallw water (chest deep water) Suggested exercises: single leg brides, plank, squats/hip hinge, upper bdy lifting w/ spine neutral, lunges, blique rtatins starting in HL/supine, OH reaching. Jint mbilizatins/manipulatin pain relief, mbility, neurmuscular facilitatin Dry needling pain/neurmuscular facilitatin STM Stretching PRN Gals nrmal jint mbility in thracic spine and hip, resume lumbar extensin NWB, maintain flexibility, and cntinue increasing strength and crdinatin. Phase 4: Suggested exercises: chpping/lifting patterns (diagnals), bdy weight suspensin exercises TRX, prgressin impact lading (sprt specific), gradual expsure t sprt specific activities/drills Phase 5: Suggested exercises: squats with medicine ball thrw/rtatins, single leg DL with weight, frnt squat, lunges with twist, hip sleds, plymetrics, abdminal wrkuts, sprts specific exercises. Jint mbilizatin grade 3-4 mbility Dry needling STM Stretching PRN Gals Phase 4: maintain strength and flexibility, lumbar extensin in WB, impact lading Phase 5 Gals: full participatin in sprts * Exercises within each categry are t prvide the clinician with examples based n evidence based research, but are nt all inclusive

6 Special Cnsideratins Cnservative management: depends n the grade, high success fr early and prgressive spndylsis, and impact n daily life Can take 3-6 mnths t heal majrity f unilateral fractures and 50% bilateral Surgery Symptms persistent > 6mnths neurlgical cmplicatins (persistent ) Segmental Instability Prgressin slippage grade III r higher References Crawfrd III, C. H., Ledni, C. G., Bess, R. S., Buchwski, J. M., Burtn, D. C., Hu, S. S.,... & Sanders, J. O. (2015). Current evidence regarding the etilgy, prevalence, natural histry, and prgnsis f pediatric lumbar spndyllysis: a reprt frm the sclisis research sciety evidence-based medicine cmmittee. Spine defrmity, 3(1), Ebraheim, N., Elgafy, H., Gagnet, P., Andrews, K., & Kern, K. (2018). Spndyllysis and Spndyllisthesis: a review f the literature. Jurnal f rthpaedics. Grødahl, L. H. J., Fawcett, L., Nazareth, M., Smith, R., Spencer, S., Heneghan, N., & Rushtn, A. (2016). Diagnstic utility f patient histry and physical examinatin data t detect spndyllysis and spndyllisthesis in athletes with lw back pain: a systematic review. Manual therapy, 24, Haun, D. W., & Kettner, N. W. (2005). Spndyllysis and spndyllisthesis: a narrative review f etilgy, diagnsis, and cnservative management. Jurnal f chirpractic medicine, 4(4), Mai, H. T., & Hsu, W. K. (2015). Management f sprts-related lumbar cnditins. Operative Techniques in Orthpaedics, 25(3), Matalitakis, G. I., & Tsiriks, A. I. (2017). Spndyllysis and spndyllisthesis in children and adlescents: current cncepts and treatment. Orthpaedics and Trauma, 31(6), McNeely, M. L., Trrance, G., & Magee, D. J. (2003). A systematic review f physitherapy fr spndyllysis and spndyllisthesis. Manual therapy, 8(2), Metkar, U., Shepard, N., Ch, W., & Sharan, A. (2014, December). Cnservative management f spndyllysis and spndyllisthesis. In Seminars in Spine Surgery (Vl. 26, N. 4, pp ). WB Saunders. Vilas, P., & Lucas, G. (2016). L5S1 spndyllisthesis in children and adlescents. Orthpaedics & Traumatlgy: Surgery & Research, 102(1), S141-S147. Wang, Y. X. J., Kaplar, Z., Deng, M., & Leung, J. C. (2017). Lumbar degenerative spndyllisthesis epidemilgy: A systematic review with a fcus n gender-specific and age-specific prevalence. Jurnal f rthpaedic translatin, 11,