Barbell Medicine - From Bench to Bedside

Spondylolysis or spondylolisthesis are two intimidating words that are often described as representing a “broken back”. These aren’t words anyone wants to hear when experiencing back pain. Doctors and physical therapists often provide complicated and ominous-sounding explanations, such as a “fracture of the pars interarticularis”. From the start there is so much complexity in this language that the person feels they are not only injured, but have failed a vocabulary exam. This article aims to demystify these diagnoses and offer reassurance and advice for returning to training.

Terminology

Let’s begin by getting the terminology out of the way. The spine (prefix “spondy-” is Greek for spine) is made up of a series of stacked bones known as vertebrae. Each individual vertebral bone has joints that link it to the neighboring bone above and below it. The pars interarticularis describes the bony bridge between these joints. “Spondylolysis” describes a fracture (suffix “-lysis”, meaning “break”) in the pars interarticularis. “Spondylolisthesis” (suffix “-listhesis”, meaning “slip”) describes a scenario where one vertebra moves forward relative to the one below it.

The rest of this article will group the two diagnoses together using the term “Spondy”, unless otherwise noted. While it might seem logical that a fracture or movement of the spinal joints would reliably cause back pain, we have 45 year follow-up studies that find no association between spondy and risk of back pain. This should sound familiar to our regular audience: pain is complex and is not always directly related to changes in the structure of our bones and tissues. This same study found that people with spondylolisthesis had slowed progression with aging, and none progressed to a point that would be considered problematic.

Unfortunately, common advice for patients with these diagnoses is to discourage movement due to fear of an increased “slipping,” even though this is not the case. There is one caveat worth noting when discussing back pain in general:

If you experience new problems with bowel or bladder function, such as incontinence or inability to urinate/defecate, or sensory changes like numbness in the groin region you should be evaluated by a medical professional immediately.

Most people end up receiving a spondy diagnosis after a sudden onset of centralized low back pain (pain that does not go into the legs). They are often quickly sent for X-ray or MRI testing. Once the diagnosis has been made, the person is left wondering whether it is safe to move, and if they’ll ever be able to get back to their prior activities. Clinicians often advise rest or avoiding certain activities, but there is no evidence that rest speeds up healing or helps people return to their prior level of function. No one has ever become a better athlete with absolute rest; there are always ways to stay active and maintain athleticism while pain symptoms calm down.

Base Rates

Before we can confidently say that something is a problem, we need to know how common it is found in the normal population who have no pain or other symptoms. This is known as the “base rate” of a condition. Unfortunately there isn’t much data to go on for spondy. As a result, treating this diagnosis falls more in the realm of expert opinion than rigorous scientific evidence.

The typical person diagnosed with spondy is an adolescent male who participates in an extension- or rotation-based sport like baseball or gymnastics. We can find spondylolysis in 3 to 7% of adolescents with no pain or other symptoms. This increases to 11.5% in the adult population with no pain or symptoms. This helps us properly frame the assessment of a person experiencing back pain in whom we find a spondy. In other words, for approximately 3-12% of these people, the finding would have been there all along without causing issues, meaning that it is unlikely to be directly causing the new back pain symptoms. We have good evidence that there is little correlation between experiencing back pain and having a spondy.

That is not to say the finding does not matter at all, but rather raises the question of whether it is a “contributor” more than a “cause”. An athlete coming from an off-season period to a sport that involves dramatic increases in low back extension and rotation is likely to need time to adapt, and may experience symptoms in the interim. An athlete in the same sport who is progressing to the next level of skill may experience the same phenomenon. That does not mean they need to be fully removed from sport, as this may take away too much of the stress needed for adaptation.

Most episodes of low back pain are complex and multifactorial, meaning that there are lots of contributors outside of the bones, muscles, and other tissues. Recent changes in training load or intensity can contribute to symptoms in other ways. Variables like adequate sleep, stress management, and general mental health also play a role in the experience of pain. More specific to the adolescent population, factors like early sports specialization and burnout need to be addressed as well.

There is no clear correlation between evidence of healing on imaging tests like X-rays and a successful outcome. One study found time and activity modification to be a stronger predictor of a successful return to sport, with no relationship between degree of healing and outcome. Other studies have similarly found little correlation between imaging findings and symptoms in the long-term. Our efforts are much better spent adjusting programming and stressors to the athlete to facilitate return to activities they enjoy, versus waiting a finite amount of time for an arbitrary change on an X-ray image. For some athletes, this may be removing a significant portion of their programming, for others it may be removing stress in one facet while adding it in another area to adapt. The following section will make suggestions for practical modifications.

Short-term Program Adjustments

Most guidelines for managing spondy recommend “activity modification”, but this vague advice often ranges from absolute rest – which is not advised – to a series of random exercises thought to target certain muscle groups. The goal of any modifications should be to allow the athlete to train with minimal pain symptoms, while providing a sufficient stimulus to maintain their conditioning and athleticism in other ways. While an athlete may not be able to squat heavy, swing a bat, or participate in competition in the short term, there are countless other ways to stay active. Sometimes we need to open up the training program and tackle the issue from a different angle.

The “starting point” for each person will differ based on what they can tolerate. If pain started after a sudden injury and the person is experiencing a lot of pain, they may need to start with lower-level activities in order to keep moving and allow things to calm down. This can involve simple movements such as:

  • Glute bridges
  • Walking lunges
  • Side-steps, with or without bands

These are things that would typically fall in a basic “physical therapy starter pack”. These exercises are not being recommended because of commonly cited reasons like “muscles being turned off,” “not firing properly”, or “needing to fire local muscles before global,” but rather because we sometimes just need to start easy as an entry point before progressing to do more. During this time, athletes should still train the upper body as normally as possible. They may need to make other modifications such as bench pressing with the feet up on the bench or limiting low back extension during overhead presses, but the goal should be to stay as athletic as possible while the pain calms down with time.

The other component of training should involve maintaining cardiovascular fitness. This can be achieved with low-intensity steady state aerobic activity on a bicycle, walking, or even pushing/pulling a sled. The main principle in the initial phase is to limit activities that push into end-range extension of the low back. As a result, rowing may be less preferable given the positions involved, although this can be incorporated in a later stage. The time component for the amount of cardio is specific to the demands of the athlete but the goal should be to at least build to physical activity guidelines of 150 minutes of moderate level activity per week.

As the person begins tolerating more activity, training should evolve as well. Someone may tolerate a belt squat machine as a means of loading the legs. Seated leg extensions and hamstring curls are also excellent substitutions for maintaining or building leg strength as well.

The typical steps of rehabilitation proceed as follows:

  • Light and slow
  • Heavy and slow
  • Light and fast
  • Heavy and fast

Heavy and light are always relative to the athlete. A lifter with a 1-rep max strength of 700 lbs and a novice with a max of 185 lbs will have different entry points to their rehabilitation. The former may be doing rehab exercises using the other athlete’s max without breaking a sweat. We will set a cap on the intensity of effort during the rehabilitation phase using ratings of perceived exertion (RPE). This will typically be capped at 7 in early stages, which allows for a wider margin for error. For example, a training set of RPE 7 accidentally becoming an RPE 8 is better than a set at 9 becoming a 10 if the goal is to build tolerance for movement. A general rule would be for “light” weight sets to be less than RPE 6, with RPE 7 or greater falling into the “heavy” category.

Symptoms should factor in here as well. When both symptoms and effort are rated on a 1-10 scale, the sum should rarely exceed 10 in short term adjustments. This may relegate an athlete with more acute, severe symptoms to very light loads. For example, an athlete rating their pain symptoms at 4/10 might limit their intensity up to the RPE 5-6 range. An athlete with symptoms rated at 8/10 might perform easy movements in a very low RPE range with a goal of simply moving over pushing for performance gains. As symptoms subside, an athlete can begin to push into higher-effort work. It also serves as an anchor that an athlete should be relatively symptom free prior to returning to max-effort training.

If an athlete participates in sports that involve rotation like baseball or gymnastics, scaled exercises that are more specific to these activities can begin. A drill may start with bodyweight and exploring the movement (e.g., a windmill) through tolerable range of motion, progressing to adding weight, and slowly going through full range of motion. As an athlete begins tolerating more load, they can incorporate drills that emphasize speed. This may involve swinging a lighter bat or basic stunts for gymnasts. For a barbell athlete it may involve back extensions or exercises on the glute-ham developer (GHD) machine with no weight, but a faster cadence.

The bottom line is that people are often instructed to wait too long, or to scale back activity too much, to the point where there is insufficient stress for healing and the athlete becomes unnecessarily deconditioned. The objective of any well-designed rehabilitation program should be to get an athlete feeling better, while also keeping them in shape as they progress towards return to sport or other desired activities. If we allow someone to return to sport due to evidence of “healing” on an X-ray, but they have not been conditioning, or even training since the time of injury, we are likely sending them back underprepared. Injury often provides an opportunity to build up components of training that have previously been lacking in the training program.

We’ll be back next week with the second and final part of this article series. In the meantime, if you are struggling with your rehabilitation process, you can reach out to the Pain and Rehab team for a consultation and assistance with returning to the activities you love.

Special thanks to Dr. Austin Baraki and Dr. Salinda Chan for their help with this article.

 

About Derek Miles

Derek Miles is a residency trained physical therapist currently working at Stanford Children’s Hospital as the Advanced Clinical Specialist in the rehabilitation department. He worked at the University of Florida prior for 10 years in sports medicine treating a variety of athletic injuries from overuse to post-operative. He is involved in the peer review process for academic journals and has spoken at national level conferences within the physical therapy profession. If not treating patients or in the gym Derek is likely either cooking some form of meat or reading books related to various random topics. He occasionally brews a pretty good American Pale Ale as well.

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