[Physio Explained] Spondylolysis management: what does the latest evidence tell us? with Mitchell Selhorst

0:05If you're an athlete and you participate in sport on a routine basis, you have a higher likelihood of having a spongy. What we do know is that males, boys, are about two to four times more likely to have this bone stress injury in their back than females. And it occurs more frequently in overhead athletes. So our baseball players, track and field, the field part of the athletes, and cricket players sometimes as well having to increase risk. Welcome back to the Physio Explain podcast from Physio Network, where we break down the research, ideas, and clinical concepts shaping modern physiotherapy practice.

0:47In today's episode, we're exploring a condition that many clinicians working with young athletes will encounter lumbar spondylolitis. Joining me is Mitchell Sellhorst, a physical therapist and clinical researcher at nationwide children's hospital in the sports and orthopedic physical therapy department. Mitchell is a board-certified orthopedic clinical specialist and certified orthopedic manual therapist and completed his master's in physical therapy at the Ohio State University and his PhD at Nova Southeastern University, and currently serves as the Director of Research for Nationwide Children's Sports and Orthopedic Physical Therapy Department.

1:27His research really focuses around the treatment of overuse injuries in youth athletes, particularly active spondylolysis. In this episode, we discussed Mitchell's recent multi-centre randomised trial, and we unpack just how common spondylolysis is in youth athletes, and why the traditional approach of prolonged rest and bracing often leads to suboptimal long-term outcomes, and how his research challenges that model by showing that immediate physiotherapy can be both safe and more effective for recovery and return to sport.

2:00If you work with young athletes, back pain, or interested in how emerging evidence is reshaping rehabilitation strategies, this conversation is one you will not want to miss. I'm James Armstrong and this is Physio Explained. Mitchell, welcome to the Physio Explained podcast. It's great to have you on. Looking forward to having a chat today. It's great to be here. Thanks, James. Brilliant. So obviously, this is our we're chatting off the back of a recent paper that you were lead author for that was published in the BMJ.

2:35But we're gonna just get started into a bit more overview of what we're chatting to on today. So we're talking about spondylolysis today. So let's start with how common this is and maybe actually just a brief definition for the listeners, bring us all up to speed and then look at how common this is in youth athletes. Yeah, of course. So spondylolysis is a bone stress injury that's gonna commonly happen in the lumbar vertebrae of our adolescents. So extremely common in our adolescent athletes.

3:09It occurs and relatively frequently, like four to ten percent in our general population. But our adolescent athletes, we're gonna get up to 30% of them with low back pain, will have this bone stress injury in their back. And it is a fracture or bone stress injury of the parts interarticularis on that posterior element, typically at L5, but it does go up L4, L3, just less common. And then with the name, most people struggle sane spundolysis. So we usually just abbreviate it down to spondies and get on that same page there.

3:45I can't help but feel you're you're uh helping me out there a little bit, Mitchell, because uh we did have about five minutes off air with me practicing to say this, which is quite embarrassing as a physiotherapist myself, but I think it's great to hear you say that. Yeah, I think it's a little bit, a little bit of everybody. You touch on it in your schooling, but then some people dive deep into it, and some of them it is way way back a couple years back when they they learned about it, and it's a little touch point is nice.

4:13Yeah, it's brilliant. So it's so you're talking about it's quite common in youth athletes. Do we see it in more in different sports? Is are there certain sports where we would tend to maybe see this more regularly? So I would say yes and no. There's a I call it a misconception where from research that began probably 30 to 40 years ago, where they looked at gymnasts and they found a high rate of spundulysis there. So gymnasts are frequently tied to having a high rate of spondy.

4:50But looking at larger trials, we've done one with over a thousand, a couple other groups have as well. And if you're an athlete and you participate in sport on a routine basis, you have a higher likelihood of having a spondy. What we do know is that males, boys, are about two to four times more likely to have this bone stress injury in their back than females. And it occurs more frequently in overhead athletes. So our baseball players, track and field, the field part of the athletes, and cricket players sometimes as well have the increased risk.

5:25So some of those extension-based sports teams. But looking at other sports who just play a lot, we we find it in marching band as well. So really if they're an athlete participant in a lot of sport, it it should definitely be on your differential diagnosis for teens. And does it link in with sort of maturation in our adolescence? Yes, it it definitely does. So it really peaks right around that 13 to 16 year range, and we're gonna see it the most.

5:53And then it tapers down in adulthood. So it's definitely related to growth, but you can see it in adults as well, and you can see it in much younger children. So you keep keeping keeping a lookout and and and uh listening to this. And I suppose listeners often we we talk about the standard care we often think about when we see this, is it's quite often uh a rest, uh a delo, an off-stop stress, bone stress injury. Is that kind of currently still quite often thought of as the best approach to this and and maybe even bracing if you've seen that at all?

6:30Yeah. The standard care does vary a lot, but the that thought process that you mentioned of trying to delo that that bone stress injury to allow it to heal is still prevalent. So either bracing to try to stabilize that spine to allow it to heal, or rest to allow it to heal is still pretty common. There's a relatively recent study done by it's called Prism, but pediatric research in sports medicine, where they looked at the practice patterns of the physicians, and more than half of them were still prescribing some form of rest from everything.

7:09And in terms of that rest, when we look at that approach, do we see bone healing? Yeah, so we do not see bone healing. And if you if you look at the numbers, you're gonna have different rates of bony healing depending on the type of lesion. So with our spundalysis, we have progressions of the bone stress injury where it can start off with a reaction, and that has a high rate of full healing. Then we'll progress into a full lysis or stress fracture, and it'll be unilateral.

7:44So one side for the PARS is fractured, and that's relatively high. Um, usually between 70 to 90 percent, depending on the research study, we'll find bony healing through there. And then if we get a bilateral fracture, then we're gonna see it drop dramatically. The last systematic review I saw on this was about 18 to 20 percent of bilateral fractures do heal. And then there's another realm of this where it's called a chronic or a cold spongy, where there's no active signs of healing on imaging.

8:21So you may find this on X-ray. These are the ones you commonly would see with radiographs, but on MRI or a spec, you don't see any edema or increased uptake. And those have no potential for healing. They're just not going to heal. But the nice thing is, is what they're finding and what we're finding with research is patients do quite well, even if their stress fracture doesn't completely heal. And there's little, maybe a mild correlation between healing and clinical outcomes.

8:54So if they're doing well and if they're feeling well, we don't really care so much that their stress fracture hasn't fully healed. Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarize the latest and most clinically relevant research for instant application in your clinic. So you can save time and effort keeping up to date. Click the link in the show notes to try Physio Network's research reviews for free today.

9:23So I suppose that begs the question and leads really nicely on to the multi-center randomized trial that you lead the author on in terms of looking at when physical therapy comes into play. So I suppose we can now go into the paper a little bit in terms of what is it telling us and what what did your your research find, Mitchell? Well, what we found is there really wasn't any benefit of resting before starting physical therapy. To be clear here, we're still resting from sport.

9:54We're pulling them out of their sport, but a lot of people and a lot of physicians will rest from everything. So you're not doing much more than your basic ADLs, and that's all you're allowed to do. So with our study, we did immediate physical therapy, get them started right away in a very, I wouldn't say regimented, but a controlled manner that we progress them back to activity. And what we found is there really was no benefit of resting. We could get you back to full activity quicker if you start the physical therapy sooner.

10:30And there wasn't really an adverse reaction. So we actually didn't see any difference in bone healing. And we were able to kind of save that lumbar perispinal muscle, the multifidus, reduce the amount of atrophy we saw between groups. And then the one I'm most excited to look into further is the long-term outcomes in this patient population was the chronic back pain that these patients run into a couple years down the road is pretty high. But when we looked at our two groups, the rest group had a recurrence rate of back pain coming back of just under 30%.

11:06So just not quite one in three. And our immediate group was actually only 3%. So still a relatively small study, but it's definitely a promising finding that we need to look more into. A good question now would be it may be a little bit of a difficult one to answer because obviously it does need to be patient specific, but in general terms, what might that physical therapy look like immediately? So we're we we've we're turning maybe towards less of that complete rest.

11:34What would you advise physical therapists who are listening to this thinking, okay, right, well, actually this is slightly new. I wouldn't normally, I would normally leave this patient alone for a little while while they rest. Okay, now I've been told maybe I do need to start some physical therapy. What could that might that look like? Yeah, so in the paper, we have the program that we used, and it's called the Immediate Functional Progression Program, which just sounds like a bunch of words jammed together, but it actually tells you exactly what you need to do.

12:04We want to get them started in physical therapy immediately. The exercises should be functional, so they should be individualized to what that athlete needs because a wrestler is gonna need completely different demands than a figure skater. Then it's a progression. So we start off small, neutral spine, working those muscles in a pain-free range, and then we're gonna gradually and safely progress them back to everything they need for their sport. Yeah, that's great.

12:30And and it is really good in the paper, which is which is great. I think a lot of physiotherapists, physical therapists love a little bit of a recipe. I think that's often what we we like. And this does exactly that. It gives you a really nice phase one, phase two, phase three, hence then return sport, but also really nice criteria to meet before beginning each phase, um, which anyone sort of used to. ACL rehab and the Melbourne guide. It's nice to have some kind of criteria rather than just a time, yeah.

13:00Which is nice. Yeah. So the criteria to move forward, we didn't want to base it on time because people heal differently and some some struggle a little bit and they need a little bit more time, and some are doing quite well and don't need to be held back. So once they meet that criteria, they can move forward in the program. Any listeners who read the article and look at the program maybe might question some of the things that we chose to use as our criteria.

13:28You know, I guess I'm okay with that. But the very first one is good core control as judged by the physical therapist. So that's very subjective, but I'm leaving it to the expert who's working with that patient. So if I would say, you know, a double leg lowered test or a side plank for a certain amount of time, we know from research that doesn't tie to how they perform in their sport. So our physical therapists are well trained, they have their own background and they're looking at that patient.

13:59So we are a little vague because we don't have great information to give us specific, say, functional tests. So we leave it up to them to make the best choice. And I think that's that's really important. And if you agree, especially this population, this age group, where our interventions do need to be more imaginative, perhaps, to get that buy-in, to get adherence. This gives flexibility, excuse the pun, to to look at sports-specific things that mean something to the individual.

14:28Yeah, I like to think of this as a program and kind of like guide rails to keep you from going way off course rather than a protocol that you have to follow exactly because sometimes you will have a little small 12-year-old and you can have a massive 17-year-old. And it's really hard. Maybe I'm just not imaginative enough. It's really hard to come up with things that apply to both groups. So we we leave it up to the experts working with that patient.

14:57Yeah, and I think that's that's exactly how it should be. And we see that in pretty much all walks of what we do. A question for you, Mitchell, about this is a little bit kind of slightly off the paper a bit, but did you find or have you found from experience that the education element with bringing in physical therapy earlier is even more important because of the to to alleviate any fear or a misunderstanding of what's going on? We don't have any research specifically looking at that.

15:28We definitely assess the psychosocial elements. However, that we we're not quite sure how that plays a role, but it's definitely a part of our care and is definitely a part of what we do because a lot of our patients, particularly early on, when we started this line of research about 10 years ago, would come in and tell us that their bracket back is broken. They'll never be able to do that again. That's the messaging that they would receive that they have a broken back, and it becomes very fearful.

15:56So, just right off the bat, being able to relate to the patient that yes, you have a bone stress injury, but your back isn't broken and you have an amazing potential to heal up, and you'll be back doing everything you want to do. So that's a key aspect that we like to touch on early and just reframe that in their mind. And then the other aspect, and we see this with other conditions commonly, like ACL, but these are young athletes that a lot of times that's sport or their sports are their identity.

16:28They're an athlete, they're a soccer player, and they're sat out of their sport for a while. So we can see and have to keep an eye out for social isolation or depression, anxiety because of being removed from their social sphere and their sense of self. So physical therapy can be a nice outlet where they can see themselves getting back to becoming, you know, the athlete that they perceive themselves to be. So those are the key things that I see with education being a critical role.

16:57And I suppose having the physical therapy intervention early and immediate, that gives you that time as well with the individual to have those conversations and address any concerns and other psychosocial elements that might be coming into play rather than leaving them to say, right, okay, just offload, come back to me in six weeks. That gives a big time for lots of things to swell around in the mind. I definitely agree. And it's just the way healthcare works.

17:25The physician has such little time with the patient, and they can go over that you have this spundalolysis, they can tell them in as much detail as they like about the bone stress injury, but they can't, they don't have enough time. They're on to their next patient to address all the concerns. Whereas we as physical therapists, we get that one-on-one time where it's always surprising what comes into their head that we can address and answer and make sure they stay kind of on that forward-moving path.

17:54Absolutely. Rachel, it's it's been really interesting. I think this the paper not only addresses some people's maybe long-term beliefs on how they might manage this condition and and hopefully, and I think it does, give a really good insight into how to move forward with an evidence-based approach and as we said there, some guidelines, some guide rails, as you called it, yeah, on how you might approach that, but at the same time with some really great flexibility in being able to be individual and people centered towards the care and how you might deliver that intervention.

18:26Brilliant, Mitchell. Thank you very much, and we'll no doubt speak to you soon. Take care.