In the first article of this series on spondy- injuries I detailed information on epidemiology, examination, prognosis, and medical management according to recent reviews. (Check out the literature review here). In this second installment of this two-part mini-series, I will breakdown the rehabilitation of spondy- injuries into three phases (early, mid-, and late phase). The following sections include discussion of these phases, explicit goals and exit criteria for each phase to guide progression.
Early Phase: Homeostasis Restoration
Early phase rehabilitation of spondylolytic injuries consists primarily of symptom management, restoration of range of motion, lower extremity mobility/stretching, and the reintroduction of non-impact locomotive mobility. The length of this phase is dependent on several factors including acuity of symptoms, time since onset, medical precautions, and the grade of injury.
Symptom management strategies in this phase include manual therapy, dry needling, and modalities. Passive modalities can be leveraged to reduce threat, increase patient buy-in, and increase tolerance for active strategies to be implemented. As symptoms diminish passive strategies can be phased out. Active strategies during this phase include asymptomatic range of motion, lower body mobility/stretching, and non-impact exercise. Current guidelines suggest avoiding extension ROM early-on, and to be careful with rotation through early phase rehabilitation. Prescribed exercises should address limitations identified on examination as well as maintain conditioning in areas adjacent to the lumbar spine. Therapists must also consider the athlete’s sport in early phase rehabilitation exercise. For instance, a therapist includes a basic shoulder care routine in the early phase rehabilitation of a pitcher with a spondy- type injury.
Early phase rehabilitation is also a great time to introduce multi-directional locomotive activities that are non-impact in nature. Examples of this include ambulation, marching, dynamic mobility, and balance/proprioceptive drills. These interventions help to provide context to table-based hip and core exercises, increasing confidence in basic patterns of movement, and provide the basis for progressions to impact activities in mid- to late phase rehabilitation.
Exit criteria for early phase rehabilitation of spondylolytic injuries include pain-free and within functional limits lumbar range of motion and low symptoms with general ADLs.
Figure 1: Early Phase Framework
Mid-Phase: Athletic Foundation and Baseline Conditioning
The primary goals of mid-phase rehabilitation of spondylolytic injuries includes reintroducing impact, exposing the athlete to higher intensity anti-extension/rotation core strength, and preparing the athlete for later stages of rehabilitation utilizing sport specific strength and conditioning as tolerated.
A key component of mid-phase rehabilitation is reintroducing impact. Appropriate progression in this area facilitates increased confidence, reduced fear avoidance behaviors, and increased athlete buy-in through athletic patterns of movement. Additionally, when sequenced effectively these activities can double as an aerobic dynamic warm up for conditioning purposes and a platform to increase movement variability. An example of an impact progression looks like this:
Given the injury mechanism(s) associated with spondylolytic injuries, initiating higher intensity anti-extension/rotation core and full body training is key. This requires special consideration for sport specific biomechanics in order to determine which targeted patterns of movement and muscle groups will provide the most carryover.
Returning to prior level of performance and a level comparable to the athlete’s peers is key to a successful return to sport. As part of mid-phase rehabilitation of spondylolytic injuries, therapists should initiate a progressive strength and conditioning program specific to the athlete’s sport. This builds the foundation for late phase rehabilitation and return to sport progression. Initiating the program at this phase provides ample time to create a “chronic workload” that affords the athlete increased resistance to injury/re-injury upon returning to sport.
Developing an athlete’s ability to effectively create and absorb force is a common theme throughout this phase of rehabilitation. This is accomplished through effective implementation of the above interventions. Key components of this characteristic include proprioception, motor planning, myotendinous stiffness, and increased capacity in isolated and compound movements. Graded plyometrics and medicine ball drills are helpful in driving these adaptations. Mastering of these components assists athletes in consistently recreating effective strategies of movement during both singular maximal efforts and repeated higher intensity efforts in their sport.
Exit criteria I use for this phase of rehabilitation include front and side plank endurance, double-limb lowering test, lower or upper body strength capacity testing, Y-Balance Test, and hop testing. I utilize this battery of tests as I feel it provides a good overall picture of preparedness for late-stage rehabilitation. This battery includes a measure of abdominal muscle strength and endurance, measures of strength/endurance capacity of the upper/lower quarter, the ability to load the lower body in multiple planes in a controlled manner, and some measure of lower body plyometric performance and impact tolerance. This battery of tests should be tweaked however you see fit to match the demands of the specific sport for the athlete in question.
Figure 2: Mid-Phase Framework:
Late Phase: Athletic Realization
Late phase rehabilitation of spondylolytic injuries is characterized by the introduction of sport specific drills, individual training, progressive building of volume and intensity, and maximization of sport specific conditioning. Considerations in this phase include the level of competition to which the athlete will return, what season they will be entering (pre-season, mid-season, post-season, offseason), frequency of training outside therapy, and more.
Interventions during this phase serve as a complimentary role to sport specific and individual training outside of therapy. Often clinicians must perform additional needs analysis and have a thorough understanding of the athlete’s training regimen to best optimize their interventions. Understanding what athletes are doing and how often outside of therapy helps to determine the intensity of activities to be performed within sessions. The season the athlete will be re-entering also determines in-session intensity. Peak conditioning levels won’t need to be achieved if an athlete is being discharged at the beginning of offseason, for instance. Peak conditioning levels should be stressed if an athlete is re-entering in-season to post-season, however.
Effective communication is key in this phase to ensure all parties are informed and in agreement. As part of this process, the athlete is introduced to an explicitly outlined return to sport progression agreed upon by the rehabilitation team, medical team, and the athlete. Exit criteria and completion of the rehabilitation course is characterized by a successful completion of the return to sport progression.
Figure 3: Late Phase Framework:
Conclusion:
Current research suggests good long-term outcomes for spondy- injuries when managed effectively. Early identification, effective communication, respect for tissue healing timelines, and logical progressions individualized for the specific patient assist this process. I hope you find the above discussion and criterion-based rehabilitation framework helpful.
Citations:
[1] Strand, S. L., Hjelm, J., Shoepe, T. C., & Fajardo, M. A. (2014). Norms for an Isometric Muscle Endurance Test. Journal of Human Kinetics, 40(1), 93–102. doi: 10.2478/hukin-2014- 0011
[2] Krause, D. A., Youdas, J. W., Hollman, J. H., & Smith, J. (2005). Abdominal Muscle Performance as Measured by the Double Leg-Lowering Test. Archives of Physical Medicine and Rehabilitation, 86(7), 1345–1348. doi: 10.1016/j.apmr.2004.12.020
