Spinal Conditioning for Athletes With Lumbar …scottsevinsky.com/pt/reference/spine/lumbar/scj_spinal... · Spinal Conditioning for Athletes With Lumbar Spondylolysis and Spondylolisthesis

Spinal Conditioningfor Athletes With LumbarSpondylolysisand SpondylolisthesisErin Nau, ATC,1 William J. Hanney, PT, DPT, ATC, CSCS,1 and Morey J. Kolber, PT, PhD, CSCS21University of Central Florida, Orlando, Florida; 2Nova Southeastern University,Fort Lauderdale, Florida

S U M M A R Y

LOW BACK PAIN IS A COMMON

CONDITION IN ATHLETIC

POPULATIONS. PARTICIPATION IN

ATHLETICS HAS BEEN LINKED TO

SPECIFIC ANATOMICAL CHANGES

TO THE LUMBER SPINE

(SPONDYLOLYSIS AND

SPONDYLOLISTHESIS). PRACTICAL

GUIDELINES FOR STRENGTH AND

CONDITIONING PROFESSIONALS

SHOULD RECOGNIZE THE

BIOMECHANICAL STRESSES

ASSOCIATED WITH ATHLETIC

PARTICIPATION IN THIS

POPULATION. PROGRAM

MODIFICATIONS CAN BE MADE IN

ATHLETES WITH SPONDYLOLITIC

DISORDERS. CONDITIONING

ROUTINES SHOULD EMPHASIZE

SPINAL STABILIZATION AND

SPORT-SPECIFIC FLEXIBILITY. THIS

ARTICLE MAKES RECOMMENDA-

TIONS FOR ATHLETES WITH

SPONDYLOLITIC DISORDERS THAT

SHOULD ALLOW PARTICIPATION IN

LUMBAR CONDITIONING WHILE

PROTECTING THE BACK FROM

UNDUE STRESS.

INTRODUCTION

Low back pain (LBP) is a preva-lent condition in the athleticpopulation (10,19). Among

athletes, LBP accounts for up to 40%of documented injuries (2,9,25). Al-though LBP is not the most frequentdisorder encountered among the ath-letic population, it is one of the mostchallenging to treat, perhaps as a resultof training demands. Although theetiology of LBP is multifactorial, epi-demiological data have suggested thatathletes are more prone to degenera-tive and spondylolytic related injurieswhen compared with the generalpopulation (2,5,8,10,13,16,26). Thepurpose of this article is to presenta brief overview of spondylolitic dis-orders and to provide a comprehensivespinal-conditioning program designedto achieve the dual benefit of improvedspinal conditioning while protectingthe spondylolitic region from unduestress.

Spondylolitic disorders among athletestypically comprise the diagnosis ofeither a spondylolysis or a spondylolis-thesis. The term spondylolisthesiscomes from the derivative of spondy-lo, which means vertebrae, and lis-thesis which means forward slippage(34). Therefore, a spondylolisthesis isessentially a forward slippage of onevertebra on another (Figure 1) (10,34).Spondylolisthesis often are attributedto degenerative changes and/or a de-fect at the vertebrae (3,35). A spondy-lolysis occurs when there is a fracture,found in a region of the vertebrae called

the pars interarticularis (Figure 2) (25).A spondylolysis disorder does notimply a forward slippage of the verte-bra (33). Spondylolysis defects may beunilateral or bilateral and may progressto a spondylolisthesis over time (13).Researchers have indicated that ath-letes with a unilateral spondylolysismay be at risk for developing a fractureof the contralateral pars interarticularis(27). For the purpose of clarity, we willrefer to spondylolysis and spondylolis-thesis conditions collectively as spon-dylolitic disorders. Where necessary,a distinction will be made.

EPIDEMIOLOGY ANDPRECIPITATING FACTORS

As stated previously, athletes are moreprone to degenerative and spondylo-lytic-related injuries when comparedwith the general population (2,5,8,10,13,16,26). Spondylolitic disorders areprimary causes of back pain amonggymnasts, divers, weightlifters, wres-tlers, and football players, with a re-ported prevalence of up to 40% (2,15).Within individual sports, the great-est incidence is found in gymnasts,weightlifters, rowing, and those whoparticipate in throwing sports (14).

KEY WORDS :

low back pain; spondylosis; spondylol-ysis; spondylolisthesis; athletic injury

National Strength and Conditioning Association Strength and Conditioning Journal | www.nsca-lift.org 43

An explanation for gymnasts having ahigh incidence lies in the demandsplaced on his or her spine while inpositions that load the pars interarticu-laris. It has been estimated the spine of a

gymnast is loaded approximately 4times the amount in that of the generalfemale population (15,23). Conse-quently, the incidence of spondyloliticdisorders has been approximated at

11% among female competitive gym-nasts (15,23). Gender also plays a role,as spondylolitic disorders are 4 timesmore common in women than men(7). Age may also be a factor to con-sider as vertebral slippage is shown tooccur more drastically during an ado-lescent growth spurt, and if the athletewas asymptomatic to begin with, theproblem potential becomes all themore accentuated (29). It has beensuggested, although not universallyagreed upon, that in the skeletallyimmature athlete, spondylolitic disor-ders should be considered until diag-nostic testing suggests otherwise (33).

DIAGNOSIS

Athletes with spondylolitic disordersmay present with a wide range of signsand symptoms, making clinical diag-nosis elusive. Although a detailed dis-cussion of the diagnostic signs andsymptoms is beyond the scope of thisarticle, a brief overview is necessary.The athletes history leading to injuryis often inclusive of repetitive loadinginto extension, flexion, twisting, or acombination of movements (4). Plainfilm radiographs possess the diagnosticutility to identify spondylolytic disor-ders using standard views; however,more sensitive imaging modalities,such as a technetium bone scan, maybe required in certain cases (25). Incases of a spondylolisthesis, radio-graphs are able to provide informationon the severity of the slip. A slip ofless than 50% is considered mild andoften managed conservatively, whereasslips of greater than 50% are oftenreferred for a surgical consult (25).Ultimately, the diagnosis of a spondy-lolytic disorder will be made bya physician who has interpreted theradiological and clinical presentation.Moreover, individuals diagnosed withspondylolytic disorders must be clearedby their physician prior to the initiationof any exercise programs.

ANATOMY

Although our intent is not to providean exhaustive discussion of the lumbaranatomy, a brief review is necessary

Figure 1. Spondylolisthesis. ( Primal Pictures Ltd.)

Figure 2. Spondylolysis. ( Primal Pictures Ltd.)

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Spinal Conditioning for Lumbar Spondylolysisand Spondylolisthesis

to establish a clear understanding ofthe information presented. The lum-bar spine consists of 5 vertebrae, andbetween each lies a disk providingcushion between the vertebrae whenloaded. The joints of the lumbar spineare referred to as facet joints (Figure 3).A facet is a small smooth area ona bone that creates an articulationbetween neighboring vertebrae (34).Each vertebra contains 2 superior and2 inferior articular facets providinga connection to the adjoining vertebraabove and below (25). Between thesuperior and inferior facet lies a small,very thin area of primarily corticalbone called the pars interarticulariswhich is illustrated in Figures 1 and 2(34). The pars interarticularis is theweakest area in this unit, and in youngpeople it is particularly thin and injurysusceptible (5). Because of its fragilenature, the pars interarticularis issometimes not capable of withstandingexcessive or repetitive forces; thus,it fractures (25). Defects or fracturesleading to spondylolitic disorders willinvariably originate at the pars inter-articularis. Although this disruptioncan occur at any vertebral level, it

most commonly occurs at the L5 seg-ment (30,33). A fracture of the parsinterarticularis (spondylolysis) may, inresponse to stress progress to a spon-dylolisthesis without causative modifi-cations and appropriate interventions.

PATHOGENESIS

Although the etiology of LBP ismultifactorial and the precise cause ofspondylolitic disorders is unknown, themechanisms precipitating these disor-ders among the athletic population aredescribed in literature (6,13). It hasbeen suggested that repetitive hyper-extension movements (extension of thelumbar spine beyond the anatomicallimits) place stress through the parsinterarticularis and over time may leadto a spondylolysis (9). This notion maylie in the association between thefrequently extended and loaded posi-tion for which gymnasts, dancers,divers, football lineman and weight-lifters assume and their increasedprevalence of spondylolitic conditions.It has been purported that accumula-tive extension at the end-range ofmobility, combined with the powerand force of jumps, landings, and

dismounts, can cause microtrauma tothe pars-interarticularis area, leading tospondylolitic disorders. Although theextended position has been establishedas both a precipitating and provocatingfactor for spondylolitic disorders (1,16,17,28), one must exercise caution whenasserting that extension should abso-lutely be avoided in the presence ofa forward slippage. Researchers havepresented conflicting findings regard-ing the effect of extension on someindividuals with spondylolitic disorders(12,17,31). In particular, extension hasshown to be efficacious in someindividuals with spondylolitic disorders(31). Nevertheless, one should exercisecaution with lumbar extension in theathletic population as it is a factorthat places stress on the pars inter-articularis and may lead to worseningof the condition.

Finally, spondylolitic disorders result-ing from a defect or fracture of the parsinterarticularis frequently present withspinal instability (24), thus interven-tions designed to increase spinal sta-bility may be efficacious (26). Studieshave reported that hypermobility (ex-cessive) and/or instability occurs at thespine levels afflicted with a spondylo-litic disorder (20,24). It is therefore thegoal of treatment to directly strengthenthe muscles that insert on the affectedvertebrae in order to increase stability.As a result spinal stabilization toachieve core stability is a key com-ponent in the training of these indi-viduals. Researchers have establishedthat exercise training of the stabilizingmuscles of the trunk reduces pain anddisability in those with spondyloliticdisorders (26). Despite compellingresearch spinal stabilization exercisesare often a neglected portion of strengthand conditioning regimens (26,32).

SPINAL CONDITIONING

In our experience, athletes often focuson the large muscles groups responsi-ble for performance and tend to neglectthe muscles responsible for spinalstabilization. It is essential that athleteswith spondylolitic disorders work bothto strengthen the stabilizing muscula-ture and spend necessary time onFigure 3. Facet joints of the lumbar spine. ( Primal Pictures Ltd.)

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specific flexibility exercises in additionto performance training. After medicalclearance to begin activity, a compre-hensive spinal conditioning that con-siders evidence-based interventionswill serve a key role in both preventionand progression of the disorder. More-over, addressing more common im-pairments in flexibility and strength ofthe stabilizing musculature will posi-tively affect performance that may beotherwise affected as a result of suchimpairments. As with any exerciseprogram the strength and conditioningor rehabilitation professional mustmonitor the individuals exercise toler-ance to avoid an exacerbation ofsymptoms.

FLEXIBILITY

Flexibility is an important componentof spinal conditioning programs. Asecondary finding of hamstring andparaspinal muscle tightness may befound among the spondylolitic popu-lation perhaps in an effort to providestabilization (8). A direct association,however, between tightness of theparaspinals and hamstrings has notbeen established. It should also benoted that not all athletes will presentwith traditional hamstring and para-spinal tightness as the length of themuscle is relative to the athlete, and therequirements of the sport. Some sports,such as gymnastics and dance, willrequire a great deal of flexibilitytherefore the athletes sport and pre-vious flexibility level must be consid-ered, or the hamstring spasm may beoverlooked, and perceived as normal.

Flexibility of the hip flexor, hamstring,rectus femoris, and tensor fascia latamusculature has been recognized as anintegral component of the spinalconditioning program in those withspondylolitic disorders (7,9,22). It hasbeen postulated in the literature thattightness of the rectus femoris mayincrease the lumbar lordosis due todirect effects on pelvic alignment (21).Rectus femoris tightness may alterpelvic positioning thus increasingstrain on the already unstable verte-brae. With proper flexibility exercisesthese muscles can maintain their

necessary flexibility for athletic partic-ipation and minimize undue stress onthe spine from aberrant tightness. Thefollowing flexibility exercises are rec-ommended as part of a comprehensivefitness routine in the athlete with aspondylolitic disorder. Static stretchingis advocated for a duration of 30 sec-onds for 3 repetitions.

FLEXIBILITY EXERCISES

Hip flexor stretch.Hip flexor stretch-ing is illustrated in Figure 4. The hipflexor stretch requires the athlete toassume a kneeling lunge position withthe extremity to be stretched extendedback. Rotate the pelvis backward byisometrically contracting the glutealmuscles in order to maintain a neutralspinal position. It is very important tomaintain this neutral pelvic position inorder to eliminate hyperextension ofthe spine. Once in position, furtherbend the front leg until a stretch is feltin the hip flexors (front of thigh) of theback leg.

Supine hamstring stretch. The su-pine hamstring stretch (Figure 5) re-quires the athlete to begin in a supineposition with a towel wrapped aroundone foot and the ends in both hands.While keeping the leg straight, theathlete uses the towel to gently pull the

leg toward the upper body untila stretch is felt in the hamstrings. Ifthe athlete reports LBP, the non-stretched leg may be bent to reducepressure on the spine.

Rectus femoris stretch. The rectusfemoris stretch (Figure 6) requires theathlete to assume a prone position(lying flat on the stomach) with oneknee bent and a pillow under theirwaist to maintain a neutral spine.While maintaining a neutral spine,the athlete is instructed to grab theankle of the bent knee with one handand pull toward the gluteal area untila stretch is felt. As flexibility increasesa rolled towel can be placed under thedistal thigh to create an increasedstretch. Athletes reporting discomfortduring this procedure may simplytighten their gluteal muscles to reduceloading of the spine and increase theefficiency of the stretch by posteriorlyrotating the pelvis (21).

Iliotibial band stretch. The iliotibialband or tensor fasciae latae stretch(Figure 7) requires the athlete to standwith one hand placed along a wall/-chair for support and place the leg tobe stretched closest to the wall/chair.The athlete is then instructed toexternally rotate the stretching leg

Figure 4. Hip flexor stretch.



and position it behind the opposite legand, once in position, bend the frontleg into a slight lunge position and shiftthe back hip toward the wall. Thismove will require a slight side bendaway from the wall.

DYNAMIC STABILIZATION

Several muscles play a roll in dynamicspinal movements and stabilization.Among these are the transversus ab-dominis (TrA), paraspinals, internal andexternal obliques, rectus abdominus,and the multifidus (32). Strengtheningof these muscles will provide support toa pre-existing spondylolitic disorder bylifting the spine and maintaining neutralpelvic alignment thus transferring theforce and thereby decreasing theamount of load to the area (32).Furthermore, the intrinsic muscles suchas the TrA and multifidus have localstabilization function necessary to pre-vent excessive movement at regions ofinstability or hypermobility.

The TrA and lumbar multifidus havea particular function in aiding withsegmental motion, and providing spi-nal stabilization (32). These 2 groups ofmuscles work together by co-contract-ing to provide a balancing effect to thespine (26). The TrA is the first muscleactivated in any trunk movement, so itbecomes an important stabilizationmechanism (11). Studies show thatactivation of both the TrA and multi-fidus is delayed in those with low backpain (11,26).

The multifidus is the deepest spinalmuscle, and because of its directinsertion to each vertebra, it is of theutmost importance to the spondyloliticpatient (6). Of the back extensor mus-cles, the lumbar multifidus can providethe greatest control to the vertebralsegment, and can potentially functionto stiffen, or bind the lumbar spine(18,26). This muscle may atrophy overtime without direct efforts to facilitateits function after an episode of low back

pain. Electromyography studies ofvertebral irregularities such as that ofa spondylolisthesis with spinal insta-bility indicated abnormal and de-creased activity of the multifidusdirectly at the unstable segment (18).When functioning properly, this mus-cle will pull the vertebra backwardsand has the ability to stabilize thespondylolisthesis directly (18). Further-more, research has shown that aftercompleting an exercise program whichspecifically strengthens the multifidusparticipants with spondylolytic disor-ders will demonstrate a significantdecrease in pain and disability (18).The following stabilization exercisesare recommended as part of a compre-hensive fitness routine in the athletewith a spondylolitic disorder. Theseexercises may be performed daily duringthe initial stages of the disorder toimprove neural activation such asrate coding and motor unit recruitment.Once in the advanced stage may beperformed 23 times a weeks as neces-sary to increase muscular performance.

DYNAMIC STABILIZATIONEXERCISES

Abdominal bracing. Abdominalbracing (Figure 8) requires the athleteto begin in a supine position, with legsbent. The athlete should attempt todraw the stomach up toward thesternum, and back toward the floor,holding the position for 3 seconds, andthen returning to start position. Thismotion is referred to as an abdominaldraw. This exercise comprises a verysmall movement that may requirea great deal of concentration toappropriately target that TrA muscu-lature. Beginning with 1 set of 1015repetitions and progressing toward 3sets of 1015 repetitions is recommen-ded. This abdominal bracing techniquewill be carried over to all advancingexercises, and the athlete should not beprogressed to further exercises until theform of this exercise is mastered.

Supine alternate shoulder flexionwith resistance. Supine alternateshoulder flexion with resistance (Figure

Figure 5. Hamstring stretch.

Figure 6. Rectus femoris stretch.


9) requires the athlete to begin ina supine position with one leg bentand a resistance band wrapped aroundthe sole of the opposite foot. Theathlete alternates lifting one armabove the head at a time whilemaintaining the abdominal draw po-sition. His or her back should be flatand the TrA should be contractedthroughout the entire set. The athleteshould begin with 1 set of 1015repetitions using a low tension re-sistance band and progress to 3 setsusing a higher tension band. Addi-tional repetitions should not be addeduntil the athlete is capable of main-taining the flat back position theentire time.

Long sit back extension with re-sistance. Long sit back extension withresistance (Figure 10) requires theathlete to begin in a long sittingposition, with a resistance band wrap-ped around the soles of both feet, andthe ends held in each hand. Whilemaintaining a straight neutral back, andan abdominal draw, the athlete shouldslowly extend his or her trunk at thehips and return to the start position.The individual should be monitoredclosely to avoid extension of their spinebeyond the neutral position. Theathletes elbows should be along thetorso and maintained throughout theexercise. The athlete should begin with1015 repetitions and progress to 3 setsof 1520.

Quadruped stabilization with re-sisted hip extension. Quadrupedstabilization with resisted hip extension(Figure 11) requires the athlete to beginin a quadruped position with a resis-tance band wrapped around the sole ofone foot, and grasping the ends in eachhand. The athlete is instructed to bendand straighten the leg while contract-ing the lumbar and abdominal muscles.The end position is held for 23seconds before bending the leg again.The athlete should maintain a straightback position and level hips for theentire duration of the exercise. He orshe should begin with 10 repetitions on

Figure 7. Tensor fasciae latae/iliotibial band stretch.

Figure 8. Abdominal bracing.

Figure 9. Supine alternate shoulder flexion with elastic band resistance.



each leg using a low tension resistanceband and progress to 3 sets of 15repetitions on each leg is advised.

Standing lunge extension with re-sistance. Standing lunge extensionwith resistance (Figure 12) requires theathlete to begin in a deep standing lungeposition with a resistance band under thefront foot and the ends held in each handat the level of the chest. The athlete isfirst asked to simultaneously draw in andcontract the abdominals to stabilize thespine in a neutral position. The trunk isthen slowly extended backward to theneutral position and then returned to theoriginal start position. The extensionmotion is relative as it occurs froma flexed to neutral position. At no pointduring the exercise should the athletes

back hyperextend in the patient witha confirmed spondylolysis. He or sheshould begin with one set of 10 15repetitions and progress to 3 sets of 1520 repetitions.

Stability ball leg lifts. Stability ballleg lifts (Figure 13) require the athleteto begin in a bridge position with thestability ball centered on the upperback and head, and feet planted on theground. With an abdominal draw, anda straight-neutral back position main-tained, the athlete should extend theknee to the level of trunk whileremaining centered on the ball. He orshe should then hold the lifted legposition for 3 seconds and repeat withthe opposite leg. The focus should beupward in order to maintain a neutral

cervical spine. He or she should beginwith one set of 1015 repetitions oneach leg and progress to 3 sets.

Stability ball pikes. Stability ballpikes (Figure 14) require the athleteto begin in a supine position, with theirarms extended over the head anda stability ball held tightly betweenthe lower legs. The stability ball is thenlifted to meet the arms (creating a Vposition), transferred to the arms, andthe body is returned to start position.The movement is then repeated trans-ferring the ball back to the feet andreturned to the original starting posi-tion. The exercise can be made easierby bending the legs and holding theball at knee level. The abdominal drawshould be maintained throughout theexercise, and a straight back main-tained. He or she should begin withone set of 10 repetitions and progressto 3 sets of 1520 repetitions.

Stability ball back bridge. Thestability ball back bridge exercise(Figure 15) requires the athlete tobegin in a supine position, with theirarms flat on the floor and feet andlower legs positioned on top of thestability ball. While maintaining anabdominal draw, the athlete lifts thestomach to the level of the legs(creating a straight body position),holds for 3 seconds, and returns tothe start position. It is important tomake sure the start and end position ofeach lift is performed while maintain-ing the abdominal draw and a neutralspine. Beginning with one set of 1015repetitions, and progressing to 3 sets of1520 is advised. The difficulty levelmay be increased by crossing the armsover the chest or performing a singleleg version.

SPORT-SPECIFIC CONSIDERATIONS

Athletic demands on the spine varydepending upon the sport, position,and level of competition. Each sportmay have unique biomechanics thatcan affect the efficacy of a spinalconditioning program and future pre-vention efforts. Certain sports such as

Figure 10. Long sit back extension with resistance.

Figure 11. Quadruped stabilization with resisted hip extension.


gymnastics, dance, cheerleading andweight-lifting will require activity mod-ifications due to their particularly highdemands on the spine.

Athletic movements that require load-ing of the spine while in the hyper-extended position can be detrimentalto the spine, particularly in patientsdiagnosed with a spondylolysis. In gym-nastics, for example, this movementoccurs frequently during performance

of such skills as that of back walkovers,back handsprings, giants on unevenbars, or improper dismount landings.All of the skills, whether performedcorrectly or not, can place the athleteinto a forceful hyperextension. Thegymnast should therefore be educatedin proper, non extended dismountlanding in order to illuminate anyunnecessary vertebral strain. On cer-tain skills, such as giants on uneven

bars, a hyperextended position mayindicate improper technique. Essen-tially undue stress on the spine fromathletic positioning or movements canbe minimized by retraining the athleteto perform the skill with modifications.The spinal conditioning exercises pre-sented are designed to have broadapplicability and will serve useful for alllevels of athletic participation. Further-more, with appropriate stabilizationand flexibility the athlete may benefitfrom improved performance, particu-larly if impairments were present.

CONCLUSION

Recognizing the need for activity mod-ifications and implementation of effica-cious strength and conditioning routinesis essential for the athlete with a spon-dylolitic disorder. Studies show that thelonger symptoms are present beforeintervention takes place, the lesserchance there is for optimum recovery(1). Early intervention that respects theunderlying anatomical irregularities andpresenting impairments is therefore ofprimary importance in maintainingparticipation in athletics.

GENERAL GUIDELINES FORSPINAL CONDITIONING Athletes with a spondylolitic disor-der must receive appropriate medi-cal clearance before participation.

Athletes should begin spinal condi-tioning slowly, focusing on flexibilityexercises, and basic static stabi-lization exercises. Incorporate moreadvanced stabilization exercises ina graduated manner avoiding painand/or compromised performance.

Any exercise that increases painshould be avoided. If this situationoccurs, the exercises should bereverted back to the less advancedstage of the regimen.

The performance of quality exercisesis far more important than quantity.Many exercises will require a greatdeal of focus while learning in orderto master correct form and thisshould not be mistaken for slowprogress.

Athletes should be encouraged tohold their spines in a comfortableposition during the exercises.

Figure 12. Standing lunge extension with resistance.

Figure 13. Stability ball leg lifts.



Aberrant postures that increase painor asymmetrically load the spinemay place additional stress to thearea, and is an indication that theathlete has been progressed torapidly.

The flexibility and stabilization ex-ercises recommended in thisarticle should be continued through-out the year and not reduced to theathletes periodized model. Mainte-nance is the key to preventingworsening, progression of the slip-page, or any future spondyloliticoccurrences at neighboring vertebrallevels.j

Erin Nau is an athletictrainer and coach at HarborCity Gymnastics and a physi-cal therapy student at theUniversity of Central Florida.

William J. Hanney is aninstructor at the University ofCentral Florida in the Phys-ical Therapy Program.

Morey J. Kolber is anAssistant Professor in thePhysical Therapy Departmentat Nova SoutheasternUniversity.

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