Treatment of Lumbar Instability Without Surgery For AthletesSports athletes are not immune to low back pain. Bony defects such as spondylolysis and spondylolisthesis present from birth or as a result of stress fractures from overuse can be a common cause of lumbar instability. In the case of spondylolysis, the supporting bony column (called the pars interarticularis) fractures. If the fracture displaces (separates) and the vertebral body shifts forward, the condition is referred to as spondylolisthesis.
It is estimated that nearly half of all low back pain in athletes comes from spondylolysis/spondylolisthesis. And there isn't one main sport or activity where these injuries occur most often. Anyone who participates in a sport that includes extension of the spine with rotation (and especially rotation with compression or load) is at risk. For example, this condition has been reported in dancers, gymnasts, figure skaters, weight lifters, and football players.
As you might imagine, most athletes would prefer a nonoperative approach to treatment -- but preferably one that gets them back on their feet and returns them to full participation quickly. In an effort to identify the most helpful conservative (nonoperative) care for these patients, a group of physical therapists conducted this systematic review and reported their findings.
They conducted a computer-assisted search of articles published in English over a span of 46 years (from 1966 to 2012). After gathering all the acceptable articles and compiling all the information, the authors organized the data into five tables. Information in these tables included:
1) Description of each study (design, patient demographics, training type and duration)
2) Type of injury (acute versus chronic, severity) and type of surgery (decompression, fusion, fusion with or without instrumentation)
3) Comparison of outcomes for nonoperative treatments (bracing versus activity restriction)
4) Comparison of outcomes for nonoperative treatments (bracing and physical therapy versus placebo/control)
5) Results for exercise interventions (core training, back strengthening, postural exercises, general exercise)
Although the information was carefully organized, as it turned out, many of the studies collected (and reported on) different things. There wasn't enough consistency across studies to make comparisons with meaning. The authors report "limited investigation" and "lack of homogeneity" as the two main reasons there was no consensus on the role of conservative care or on outcomes of nonoperative care versus surgery for this condition.
There was one other major stumbling block in studying the effects of exercise: poor patient compliance. In other words, the patients didn't do the exercises as prescribed (or didn't do them at all)! With the limited evidence available, the best that can be said is that surgery (over conservative care) seems to be most effective for higher grades of vertebral slippage. And exercise to strengthen the core muscles (abdominals and trunk stabilizers) decreases pain and improves function.
No evidence but clear consensus (based on expert opinion or case studies suggest) suggested that bracing works better for healing the fracture when compared with restricted activity for children and teens with spondylolysis (fracture without separation). In adults, lumbar exercises helped some people recover and return to work. But there was inconsistency in the most effective type of lumbar exercises. For example, some people responded to extension exercises better than flexion exercises and vice versa.
This very carefully constructed systematic review of the results of conservative (nonoperative care) for low back pain in athletes caused by spondylolysis or spondylolisthesis faced some challenges because of limitations in how studies are conducted. The lack of consensus or evidence-based agreement on the best way to treat these patients must be addressed in future high-quality research.
Matthew Garet, PT, DPT, OCS, FAAOMPT, et al. Nonoperative Treatment in Lumbar Spondylolysis and Spondylolisthesis: A Systematic Review. In Sports Health. May/June 2013. Vol. 5. No. 3. Pp. 225-232.
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