Back in the Game: An Immediate Functional Progression Program in Athletes With a Spondylolysis.
Condition: Low Back Pain; Spondylosis
MeSH terms: Spondylosis; Spondylolysis; Low Back Pain
Study type: Observational

Summary: 
      Half of all adolescents report experiencing low back pain (LBP), and adolescents who are
      active in sport report an even higher rate. The most common identifiable cause of LBP in the
      adolescent athlete is a stress fracture in the low back, known as a spondylolysis.
      Spondylolysis injuries have been found in up 47% of young athletes with LBP. The current
      recommendations of care for a spondylolysis consist of rest for at least 3 months, bracing,
      and physical therapy. These recommendations result in athletes being out of sport for as long
      as 46 months, and are based on low level evidence and expert opinion. In addition to the long
      period out of sport, 42% have poor long-term outcomes, and 1 in 6 athletes are no longer able
      to play at their former level specifically due to their back injury. These long periods out
      of sport and poor long-term clinical outcomes suggest current care recommendations are
      suboptimal.

      The overall objective of the proposed research is to test the feasibility of using an early
      functional progression program to reduce athletes' time out of sport and improve clinical
      outcomes. Specifically, to pilot altering the rest period in athletes with a spondylolysis
      and begin rehabilitation immediately. These young athletes will return to sport as they are
      able, after demonstrating predetermined pain free functional ability. Twelve young athletes
      with a confirmed active spondylolysis will be recruited to undergo the early function
      progression intervention. The specific aims of this study are to assess the feasibility of
      implementing the immediate functional progression protocol, refine the protocol if necessary,
      and estimate potential effectiveness of this intervention. The athletes' outcomes will be
      compared to historical controls. The investigators hypothesize that the immediate functional
      progression program can be successfully implemented and with only minor changes will be
      suitable for use in larger trials. It is estimated the immediate functional progression
      program has the potential to return athletes to sport more than a month sooner than current
      practice. Once able to demonstrate the feasibility of the early functional progression
      program, the investigators plan to progress this work into larger trials to fully assess
      effectiveness, safety and long-term outcomes.
    

Detailed description: 
      Athletes who meet the inclusion criteria and consent to participate in the pilot study will
      be referred directly to physical therapy (PT) care for 2 times per week. Athletes will
      follow-up with their co-investigating physician every 4 weeks until discharge. The immediate
      functional progression program will be performed by physical therapists trained in the
      treatment protocol. Athletes will perform phase I of the program and progress to phase II as
      able without an increase in pain and without compensations noted in function. The athlete
      will be assessed at each session to determine if they meet the criteria to begin the next
      step of functional progression program. Once the athlete has met the criteria of phase II,
      they will progress into the final phase of the functional progression program for return to
      sport activity. As these athletes progress through the third phase, and are able to meet the
      return to sport criteria, they will be released to return to sport. Athletes will not be
      released to return to sport prior to their first physician follow-up visit at 4 weeks.

      Phase I Immediate Functional Progression Program Core strengthening in neutral spine Treat
      directional preference if identified Hip strengthening Peri-scapular strengthening
      Flexibility exercises Manual Therapy as needed Modalities for pain (use sparingly)

      Phase II Immediate Functional Progression Program Core strengthening in functional range Hip
      and peri-scapular strengthening Flexibility exercises Manual Therapy (use sparingly) Phase
      III Immediate Functional Progression Program- Return to Sport Return to sport activity with
      focus on functional return to all aspect of sport.

      Signs of not responding as anticipated during the immediate functional progression program:
      Inability to meet long-term goals of care in PT including inability to return to sport due to
      low back pain within three months, an increase in pain or no significant decrease in pain
      (<2/10) at physician visits until patient reports <2/10 pain with activity.

      Sample Size A sample size of 12 will be recruited for this pilot trial. As there is a
      nonlinear relationship between confidence interval (CI) width and sample size, further
      increases in participants beyond 12 have a diminishing benefit on precision for preliminary
      studies.

      Data Analysis Descriptive statistics of the patient demographics and outcome variables will
      be reported. Inferential calculations will not be performed as this is a pilot to demonstrate
      the feasibility of implementing the proposed immediate functional progression program.

      Aim 1: Discussion of the success of implementing the immediate functional progression program
      will occur during and after care of each patient. The PI will monitor patient documentation
      to assess adherence to the research protocol in care. Adverse events will be monitored, the
      immediate functional progression program will be considered acceptably tolerated by patients
      if <3 adverse events are observed.

      Aim 2: (Potential Problems and Alternative strategies) Minor problems identified in the pilot
      study will serve to refine to the protocol for the full randomized clinical trial. Larger
      potential problems include non-adherence to the experimental treatment protocol. The risk of
      this potential problem will be reduced by training of all staff involved in the research
      process. If a problem is found in the experiment protocol that inhibits patients from
      satisfactorily progressing in their care, the co-investigators will meet and decide on a
      course of action to fix this issue. An alteration in the experimental protocol that results
      in improved care would be considered a positive outcome, as the goal of this pilot study is
      to demonstrate viability and feasibility for a larger clinical trial.

      Aim 3: Clinical outcomes including pain, function, time to return to sport and recurrence of
      symptoms will be compared against historical controls to assess for potential efficacy.
      Historical controls for quality of life are not available in this population. Time to return
      to sport will be the primary outcome of interest. A decrease in return to sport time of > 30
      days compared to the historical control time of 3.8 months without a notable worsening of
      other outcomes will indicate future research is warranted.
    

Intervention name(s): Immediate PT
Intervention type(s): Other
Intervention description(s): Athletes will perform phase I (neutral spine) of the program and progress to phase II (functional motion) as able without an increase in pain and without compensations noted in function. The athlete will be assessed at each session to determine if they meet the criteria to begin the next step of functional progression program. Once the athlete has met the criteria of phase II, they will progress into the final phase of the functional progression program for return to sport activity. As these athletes progress through the third phase, and are able to meet the return to sport criteria, they will be released to return to sport. Athletes will not be released to return to sport prior to their first physician follow-up visit at 4 weeks.
Observational model: Case-Control
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        The population of interest is young athletes with a recent spondylolysis injury.
      
Keywords: Adolescent; Athlete