What is included in the maintenance phase of physical therapy to treat pars interarticularis injuries?

Updated: Jan 22, 2019
  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD  more...
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Answer

The maintenance phase represents the final phase of the rehabilitation program for those affected by spondylolysis, spondylolisthesis, or pars interarticularis injuries. A home exercise regimen is prescribed and should be performed on a daily basis. An analysis of variables should be performed for each individual athlete so that further injuries can be prevented. Such variables include biomechanical errors, anthropomorphic features, posture, cardiovascular fitness, psychosocial factors, level of training, specific activities, medical pathology, and sports participation.

Biomechanical errors should be assessed with the specific requirements of the sport in mind. For example, movements in ballet dancing require maximal hip external rotation; therefore, a deficit may cause stretching of the abdominal muscles and thereby increase lumbar lordosis. Consequently, increased stress on the posterior elements of the spine may occur. [72, 73]

Anthropomorphic features involve looking at predictive factors that may lead to back injury. For example, hypermobility of the spine in lumbar extension in female gymnasts may be predictive of back injuries. [74, 75, 76] The posture of the athlete in the specific sport is also important to analyze, because it is well known that hyperextension of the back can cause increased stress on the posterior elements of the spine. A tight hip flexor muscle can also cause increased stress on the spine because it arises from the sides of the intervertebral discs and the adjacent ends of the vertebral bodies from T12-L4 and from the transverse processes of all the lumbar vertebrae. [77]

Intramuscular electromyography (EMG) recordings have shown that the only lumbar movement that consistently recruits the hip flexor is a deliberate increase in lumbar lordosis while an individual is standing erect. [78] Therefore, if this muscle is tight, it can promote an increase in lumbar lordosis and, hence, increased stress on the posterior elements of the spine. Another study also showed an association of LBP with tight hip flexors. [79]

Cardiovascular fitness should also be stressed in order to increase endurance and decrease fatigue. Psychosocial factors are also important to incorporate into the maintenance phase, because pain can be magnified by depression.

Medical pathology should also be evaluated, especially in female athletes who are at risk for the female athlete triad, which includes disordered eating patterns, amenorrhea, and osteoporosis. Eating disorders include anorexia nervosa and bulimia nervosa. The prevalence of eating disorders in female athletes is 5-10% higher than in female nonathletes, and some reports indicate the prevalence is as high as 15-62%. [80] The prevalence of primary amenorrhea is reported to be as high as 4-66% in female athletes, compared with 2-5% in the general population. [80]

Amenorrhea is postulated to occur as a result of poor diet and excessive exercise, which can cause hormonal changes that inhibit ovulation. Consequently, with low estrogen levels, early osteoporosis can occur; therefore, the risk for fracture is increased in this population.

Sports participation should also be examined. For instance, the athlete may be involved in more than one sport. The above variables should also be carefully analyzed for the second sport. Regardless of the sport, maintenance of proper spine positioning during play should focus on spinal stabilization and maintaining a neutral spine. The program should progress to a functional exercise regimen and then to sport-specific training. In general, the abdominal, gluteal, and back extensor muscles are the key muscles to strengthen and build endurance.


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