Rest Before Physical Therapy in Adolescents With Active Spondylolysis and Spondylolisthesis

Spondylolysis is as stress fracture in the pars interarticularis of the vertebral arch most
commonly occurring in the lower lumbar spine. Spondylolisthesis is the forward displacement
of a vertebra, especially the fifth lumbar vertebra, most commonly occurring after a break or
fracture. These injuries to the spine are extremely common in adolescent athletes and some
research reports that spondylolysis and spondylolisthesis account for over 40% of all
adolescent athletes' low back pain.

While these injuries are common in the adolescent population there is very little research to
guide treatment of these patients, particularly with rehabilitation. Conservative standard of
care with the treatment of spondylolysis and spondylolisthesis injuries are to rest from
sport, brace the lumbar spine, and begin physical therapy and return to sport as the patient
is able. There is some evidence to show that patients should rest for 12 weeks prior to
returning to sport, otherwise there is an increased risk of injury (El Rassi, 2013). There
currently is no research to suggest when to begin physical therapy. Physical therapy for
rehabilitation and return to sport is a part of standard of care, but recommendations for
beginning therapy vary widely and are not supported by evidence. A concern for beginning
physical therapy too soon is that the fracture will not have adequate time to heal and
re-injury can occur. While a concern for waiting too long to begin therapy is increased
muscle atrophy, high fear avoidance beliefs, and unnecessarily long avoidance of activity.

Currently, Nationwide Children Hospital physician's vary from immediate referral to physical
therapy to 3 + months of rest prior to beginning therapy. By performing a retrospective chart
review assessing time to referral to therapy and patient outcomes we can gain some guidance
for when it is safe to prescribe physical therapy rehabilitation for patients with
spondylolysis and spondylolisthesis injuries.

Currently, no research exists to guide referral for safe physical therapy rehabilitation for
patients with spondylolysis and spondylolisthesis injuries. By performing this retrospective
study we can gain information to better guide physical therapy referral time. This may also
serve as foundation for a future prospective randomized trial.

The are two primary objectives of this study: (1) Does time to referral to physical therapy
affect time to full return to activity. (2) To assess the safety of an early referral to
therapy compared with a long rest period prior to therapy. Safety will be determined by
relative risk of adverse reaction and percent of patients able to fully return to activity.

Secondary objectives include:

Assessing pain with early and later referral to therapy. Number of physician visits Number of
physical therapy visits Compliance

We will perform a chart review of all spondylolysis and spondylolisthesis patients who have
been treated by Nationwide Children's Hospital Sports Medicine physicians and physical
therapists since 12/2009 when electronic charting on these patients began. As we are unable
to track the outcomes for this study of those patients referred to outside physical therapy,
they will be excluded from the study.

The chart review will begin by running a report for all patients with a spondylolysis or
spondylolisthesis diagnosis from 2009 to 2013.

Variables that will be automatically pulled in the report will be:

Age at time of diagnosis Gender Treating physician Pain Compliance Sports Played **Any
missing variable from the report will be gathered by reviewing the patients chart.**
Variables that will be gathered from reviewing the patients chart Diagnosis Level of injury
Type of imaging Brace Results of imaging Rest before Physical Therapy Rest before cleared for
return to sport Treating physical therapist Number of physical therapy visits Number of
physician visits

Variables that will be gathered in a short follow-up survey by contacting the patients.
Patients will be contacted by phone, or mail.

Recurrence of symptoms Michelli Function Score Modified Odom's criteria Current level of
sport participation

Patients will be divided into 2 groups: Early referral to therapy and late referral to
therapy by physician. To account for the fact that patients who are referred to physical
therapy sooner may have a less severe injury we will be sub-grouping patients by physician.
Patients of a physician with a median referral rate < 10 weeks to therapy will be sub-grouped
into Early referral to therapy and patients of a physician with a median referral time >10
weeks will be sub-grouped into Late referral to therapy. To account for possible changes in
the way a particular physician treats their patients with a spondylolysis or
spondylolisthesis physician referral rate will be assessed yearly and patient grouped based
on that calendar year referral rate. For example if a doctor has a median referral rate of 12
weeks to therapy in 2009, but 9 weeks in 2010, their 2010 patients will be placed into the
late referral to therapy while there 2010 patients will be placed into the early referral
group.

Data Analysis To assess the first primary object we will assess if there is a between group
difference (early vs late referral to PT) for time to return sport. We will assess between
group differences using a t-test if the data are parametric and a Mann-Whitney U test if the
data are nonparametric.

To assess the safety of an early referral to therapy compared with a long rest period prior
to therapy. We will examine the relative risk between groups for experiencing a significant
recurrence of symptoms.

Secondary Outcomes for the following variables will be assessed by t-test (parametric) or
Mann-Whitney U (nonparametric) for continuous data and chi-square analysis for categorical
data.

Pain

- PT visits

- physician visits Michelli Function Score Compliance

Descriptive statistics will be reported for all other variables

Inclusion Criteria:

- Patient must have been treated by the Nationwide Children's sports medicine physicians
as well as Nationwide Children's sports and orthopedic physical therapists for
spondylolysis or spondylolisthesis from 2009-2013 confirmed by MRI or Bone Scan.

Exclusion Criteria:

- Diagnosis made by: X-ray, CT, suspicion