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Lumbar Spondylolysis In Female Gymnasts Health And Social Care Essay

Gymnastics was started (introduced) by Greek and Egyptians to prepare men for warfare. Although now it is more of sport and a recreational activity predominated by young women .Among the registered gymnasts 70% are women. (5)Gymnastics has under gone many positive change in the recent times.(young gymnast equipment).Today, the coaching techniques and equipments used, have significantly enhanced the performance of gymnast as well as increased the complexity of the game and difficulty level of the maneuvers performed. Although there were measures taken to improve injury prevention, the risk of injury is multiplied due to complexity and demands of competition. Now a day’s children start training as early as from 5 to 6 years of age to compete at elite and competitive level. Gymnast require many hours of daily training, which is about 20-40 hours a week in case of elite level. Gymnasts have to practice every single move several times to gain perfection and the repetitive stress can make the lumbar vertebrae vulnerable to injury (11).

The sport demands lumbar flexibility and also puts a substantial amount of stress on the musculoskeletal structures during training as

Well as competition .low back complains are higher in gymnasts as compared to other athletes who require rotational, flexion extension and high impact activities of the spine. Muscle strain and stress fracture (Spondylolysis) are among the common causes of low back pain in gymnasts. Occurence of Spondylolysis is 15 -20%in gymnasts as compared to 8% in general population. Along with physical stress women’s body have certain psychological, nutritional and hormonal factors which predispose to cause Spondylolysis

Epidemiology

Occurrence of Spondylolysis is 15 -20%in gymnasts as compared to 8% in general population.Rosi6 found that among 1430 radiographs of young athletes 15% of athletes have Spondylolysis in which gymnasts have a higher rate. Jackson et al examined radiographs of 100 young female gymnasts and observed 11% among them had Spondylolysis on the other hand Roche and Rowe examined 4200 cadaveric spines and observed that rate of Spondylolysis is 2.3 % for Caucasian females. Comparing both above mentioned studies it is clear that the rate of Spondylolysis is five times higher in young female gymnasts as compared to the general Caucasian females. (22)

Classification on Spondylolysis

(Nance and Hickey, 1999; standaert et al., 2000)Spondylolysis is classified in five types namely Isthmic, dysplastic degenerative, pathogenic and traumatic. Dysplastic Spondylolysis occurs due to congenital abnormalities, like attenuated pars. Isthmic Spondylolysis is an injury of pars interarticularis as a consequence of stress fracture. Degenerative Spondylolysis is caused due to degeneration of intervertebral discs that can lead to segmental instability and alteration of articular processes. Traumatic Spondylolysis includes fractures on any part of the neural arch except pars, and lastly pathological Spondylolysis that is caused by disease of the bone and their complications (23)

Mechanism of injury: Isthmic Spondylolysis is thought to be one of the most common cause of low back pain in athletes (15) .It occurs as a aftermath of excessive mechanical stress to the portion of neural arch called as pars interarticular which lies between superior and inferior articulating process (Hodge1991Rodts, 2002). (23) This Condition is often related with the hyper mobility of the lower back, classically due to excessive hyperextension forces. (23). extension of back in split leaps, stag leaps and arches are some of the maneuvers that can predispose to cause stress fracture of the pars interarticularis(11) .Mechanical load on a posterior arch of the vertebra, whilst flexion extension, rise from L1 to L5.Pars interarticularis of L5 is thus bearing the highest mechanical stress during such movements. The position of the L5 vertebrae is such that it resists both shear and axial forces. Intervertebral disc, ligamentous and osseous structures are static stabilizers .these static stabilizers along with the neuromuscular system contribute to the dynamic stability during loading and movement of the spine. Posterior bony aspect of vertebrae and intervertebral disc withstand the shear forces. Pars interarticularis is the weakest part of the posterior bony aspect of the spine and it links body of vertebrae and posterior aspect (12).

Spondylolysis may not be caused due to single traumatic episode, most of the episodes are induced by repetitive load and fatigue, even though single incidence of trauma can complete the under developing fracture (whiltse et al)(22).where as Farhan et al suggested that single incidence of trauma can cause a primary micro fracture in pars interarticularis and later the progression of fracture occurs due to the repetitive overloading .(22)

Predisposing factors:-

Nutritional; deficiency, menstrual abnormality, low bone mineral density, psychological stress are some of the factors contributing to Spondylolysis. There is in congruency in the evidence found for the predisposing factors. According to…….. et al, in spite of higher rate of eating disorders among the athletes the evidence of Osteopenia or osteoporosis is not a significant element in the occurrence of spinal injury. He also explains that, there is an increase noted in the bone mineral density of the lower skeleton of elite gymnasts suffering from menstrual dysfunction. (15)

Whereas et al explains Nutrition deficiencies, menstural abnormalities and osteoporosis are the components of female triad that contribute for increasing susceptibility to injuries

Nutrition deficiencies

In order to enhance the performance, gymnasts need to maintain lean body structure which provokes disordered eating. Eating disorders include true eating disorders like anorexia nervosa or bulimia nervosa and pathological disorders like excessive caloric limit and infrequent vomiting. 74% of the female gymnasts have been reported of practicing pathogenic weight control (purging, laxatives and diuretic abuse, fasting, excessive exercise, diet pills or severe caloric restriction).6% to 7% of the female gymnasts are reported to have true eating disorder like anorexia nervosa as compared to overall population where it exists only in 1% of population.(24)nutrition deficiencies along with rigorous exercise have a profound(change the word) effect on menarche and beginning of menstrual abnormalities.

Psychological stress

Menstrual abnormalities:

eating disorders along with excessive training and psychological stress can lead abnormalities in the menses(24).menstrual abnormalities include primary amenorrhea( absence of menses till sixteen years of age), secondary amenorrhea(absence af menstruation for three or more months in menarcheal women) or oligomenorrhoea(when menstrual cycle continues for more than thirty six days)(18). Abnormal menses leads to low circulating estrogen levels in the blood (hypoestrogenemia). This has an adverse affect on bone mineralization causing reduced bone calcium deposition. Consequently resulting in weak osteoporotic bones which can give rise to stress fracture (18,24)

Bone mass density:-a major element of bone mass density in later age depends on the quantity of bone a person gains in first two decades of life (29).a greater than normal bone density is required to tolerate enormous stress of training. Normally menstruating gymnast with higher density are at lower risk of stress fracture as compared to amenorrhea gymnasts with normal bone density. Even though there are studies which demonstrate increase in BMD in female gymnasts at a particular site, the rate of stress fracture is way higher in females 30% than that in males21%.(24)

.

Psychological stress: can be an element that contributes in the occurrence of Spondylolysis, a desperate need to be successful as well as fear of losing,

can lead to anxiety, stress and depressed mood

Management:

Treatment: various therapeutic interventions, diagnostic criteria and outcome measures are used to study treatment of Spondylolysis. It is difficult to explain the ideal treatment plan for Spondylolysis due to lack of unanimity on these issues and insufficient clinical trials on its management and diagnosis. The practical advantage of plain radiography in old studies for follow up and diagnosis has been limited by the development in the imaging technology. (22) Specific activity restriction , rigid brace, no bracing , soft corset, pelvic tilts, strengthening exercise for abdominals , spine stabilizing exercises, hamstring stretching and electrical stimulation (5& 19 of stimulation thing)are some of the varying treatment program described by numerous authors.

Although conservative treatment is reported to be effective, only 25 to 40 percent show bony healing in reality. Study suggests various types of braces as well as no bracing, both helps in healing the lesions of pars interarticularis. Though bony healing of lesion in the pars may seem advantageous, it is not mandatory for excellent clinical outcome that bony healing be achieved.(55 of22)67 patients suffering from Spondylolysis and low grade spondylolisthesis were assessed for clinical outcome and healing of bones. Anti Lordotic Modified Boston Brace was being used for about six months, 23 hours in a day. Further six months of weaning of the brace, Physiotherapy and activities (non symptomatic) with the brace were permitted .twenty five of the patients were subjected to scintigraph and rest of them underwent a plain radiograph, during the diagnosis as well as follow up. Bony healing had started as early as 4 months in 12 of the patients.78 percent could return to their activity without braces demonstrating good to excellent result. Another resembling study done by Blanda et al in which 82 athletes with the incidence of Spondylolysis and/or spondylolisthesis. Diagnostic tools included scintigraph and plain radiograph where as follow up modality included only plain radiographs. Physiotherapy, activity restriction and bracing was included in the treatment, lordotic curve was maintained dissimilar to the antilordotic curve in the study of Steiner and Micheli, until there no pain with spinal extension and daily activity the braces were worn for two to six months full time. Also there was a similarity between the result of both the studies , but unfortunately for 15 patients the conservative treatment failed and they have to undergo surgery . The author suggests that restricted size , controls and dependency on plain radiography are the reasons for limitations of the study furthermore author suggests that the effect of above two treatments are unclear , moreover the effectiveness and position of the brace during night or resting time is not discussed. Also there are studies that suggest electrical stimulation can be effective in the bone healing if conservative treatment fails, according to study of pettine et al, electrical bone growth stimulator shows positive effects on bone healing. Activities were restricted and thoracolumbar sacral orthosis was worn for daily activity at starting of treatment .Later externally applied bone growth stimulator was included in the treatment, and instruction was given to the patient to use it daily during sleep. Complete healing was shown by the computed tomography scan after continuation of the treatment for a year (40). All the three theories mentioned above showed positive results in a year’s time, so it is unclear whether bracing and activity restriction alone or a combination of bracing, activity restriction and electrical stimulation improved the healing process or is it the body’s natural healing mechanism, also ultrasound therapy and cryotherapy

Can be included in the treatment as to reduce pain and promote healing by improving the circulation.ice can be helpful in reducing the pain in a localized area by interrupting the pain gait mechanism during an episode of inflammation or an acute inflammation. Moreover ice can help in reducing the swelling and thus release the structures compressed under swelling. Further, blood flow can be improved by the use of therapeutic ultrasonography along with isometrics of the muscles surrounding the spine, once the pain reduction is achieved. The increased blood flow leads to an increase in production of neovascular, collagen and myofibroblast .Also it improves the supply of required components for the healing lesion and removes localized waste.(Houglum,2005 from 23)

Rehabilitation:

There is a considerable chance of healing of the bones in the athletes with acute or progressive stage pars lesion. Only necessary activities of daily living were allowed along with this rest in the initial time that involves no sports related activities. The minimum time taken for the bony healing in the pars appears to be three months if the athlete shows signs of early relief of symptoms then rest is continued for three months, and if the symptoms persist for more than 2 to 4 weeks of rest, considerable activity restriction is achieved by bracing. Early neutral spine stabilization low impact aerobic exercise is started if the athlete recovers fully and if full range of motion of lumbar spine is achieved after three months. With a focus on sports specific rehabilitation a dynamic core stabilization program is started. The probability of bony reunion is minimal, in case the lesion is at the final stage. Once the full range of motion is achieved at the lumbar spine, after a period of rest, the rehabilitation program is initiated.

Two distinct groups help in the stabilization of the lumbar spine. Erector spinae, quadrates lumborum, external oblique and rectus abdominis provides an overall stability while Multifidus provides inter segmental stability while transverse abdominis and internal oblique assist with local stability. In a study by (48of 15) patients with low back pain were assessed for activation of abdominal muscles, against the control group. It was noted that before an upper extremity movement there is contraction of transverse abdominis in control grup. Whereas in patients with low back ache, upper extremity movement usually precede transverse abdominal activation. Similarly in a study on Multifidus, it was noted that there was early fatigue, cross sectional area was reduced and pattern of activation was reduced.

Precautionary Measures: thorough detailed supervision of the activities and surroundings of the gymnast may be kept in consideration.

Training: in order to reduce the risk of injury, as in most sporting activities, a conditioning plan is suggested to prepare the gymnast for the competition (2). Flexibility, speed, strength agility, endurance and power are required in combination to perform at the competitive level, various competitive events range from few to 90 seconds. Competitive gymnastic training is sub grouped into complete competitive, pre competitive, specific preparatory and general preparatory. According to a five year cohort study of Sands et al… there are less incidence of gymnastic injuries in any other training period in college going female gymnasts than in those who begin their training after imposed break, competition and customary performance .Moreover, he suggest that shock of greater work demand after a period of enforced break , increased level of exertion due to prolong series of skills, can lead to higher incidence of gymnastic injuries during preparation period(2).however according to Daly et al… incidence of injury are higher at the competition level than at an unorganized level .Higher speed and intensity is required at competition level as compared to the preparation and term play, which leads to an increase in the incidence of injury(37RF). Hence it remains unclear whether the rate of occurrence of injury in the sport of gymnastics is higher during preparation period or in competition phase.

Prevention of injury at preparatory phase and competition:

Training for the attainment of the skill may be in such a way that even if there is a slightest hint of the injury a precautionary measure should be taken in order to avoid the injury. Caine et al recommends that instead of bearing the load of intensive training in a step wise pattern, progressive cyclical manner should be preferred. A recommended criteria of exercise may be practiced prior to and after in the preparation as well competition phase. According to the evidence the muscles will be unable to adapt the stress of the upcoming sporting session in case of an inadequate warm up. Furthermore there is study done by Linder and caine… for three years on competitive female gymnasts that shows that initial first hour of training is critical to cause strain and that can be due to inadequate warm up. Since there are no official studies that proves relationship between injury prevention and warm up(2) .the effect of warm up training on prevention of injury remains unclear, however further research is needed to establish relation between warm-up training and injury prevention.

(2)According to study which explains the consequences of stretching prior to participation on the performance that shows reduction in ability to produce a higher force. Also according to (38) gymnasts need a high range of motion in joints. A pre-participatory drill is required in order to attain the required range for the performance (38)

Cool down session is said to be the common practice performed after competition and practice, unfortunately there are no studies that can suggest the relationship between the injury prevention in the gymnastics and cool down session, also according to the study of Borsa and Lephart, cool down session can result in early recovery, retain and enhance flexibility and decrease the chances of soreness in muscles (2)

Coaches generally, keep in mind the competence level and repetition of drills and routine of gymnasts from other countries, based on which they pressurize the gymnasts to increase the intensity of their exercise. Also it is said that injuries to the gymnasts can occur due to unrequired increment in the repetitions. Combination of skill practicing of gymnast with development of fitness can be an important aspect in training the gymnast to encounter the load of greater intensity of the exercise. although finest level gymnasts suggests that load of greater intensity training can be tolerated but coaches hardly considers the level of fitness of the gymnast .composition of body, flexibility ,strength and talent recognisation were used as a criteria for fitness assessment, but according to the consistent increase in the competition level gymnastic coaches and researchers are always run short of time ,this is due to the fact that in past requirement of fitness criterion for performing skill was not as high as today or in future, so frequently the gymnasts deceit and practice the skill over and over to get skilled for the movement and attain fitness .and overtraining can cause fatigue and injury .in order to avoid excessive fatigue and injury the attainment of proper fitness level is important to learn the skill, also with the help of a physiologist who can help developing the program for the proper fitness level and biomechanist who can explain loading on the body (ebsco)

Also education of the coach can play an important role, but there are no studies that suggest the relation of gymnastic injuries and education of coaches (2)

Another study that recommends that light days should be there in the weekly sessions and hourly breaks for the daily session (2)

According to kirkendall supportive tasks like (momentary support, passing support during movement and supportive hold) account for up to 30 percent of the movement performed by female gymnasts. A successful execution of these tasks requires high degree of strength and power (2). Also there is evidence that shows that reduced strength and endurance can be associated with increased injury incidence.(39)

. Colby and Fricker26 recommended a back program for protection, stretching and strengthening of the lumbar spine. After practicing the program along with the warm up for at least 3 times a week for about a year, the injury rates in women gymnasts were found to be decreased.(2) another aspect that can lead to the occurrence of gymnastic injury is poor posture, it can result in improper distribution of body weight and forces both during dynamic as well as static phase of movements and can produce excessive load on the skeletal system. A common complaint of pain in the lumbar region of the female gymnasts is usually caused due to activities requiring hyperextension at lumbar region. There is a study that shows movements like back handspring, back and front walkovers can cause greater hyperextension at lumbar region when the maximum load is carried by feet and hand. Forces over the lumbosacral region can be decreased by maintaining a correct approach; however, gymnasts already suffering from spinal pathologies may try to avoid movements with excessive hypertension in relation with increased mechanical loading. Inappropriate use of equipments can lead to numerous injuries in gymnastics (2). A considerable amount of research has been done in the field of gymnastic equipments to establish the standards (EBSCO). Equipments used may be of latest technology to reduce the effect of force experienced by the body and consequently decrease the incidence of injury (2).

Write more about equipment from (24)

Trunk Muscles TRAINING IN PRECAUTION :trunk mus blab bla reported reduce the chances of spond

According to Durall et al there was a decrease in the incidence rate of low back ache in the female gymnast after preseason training of trunk muscle. Study includes 15 college level female

Gymnasts as a training group and 15 college level female’s non gymnast as control group. Lateral flexors, extensors and trunk flexors are checked for static endurance prior and after the test. Along with their general trunk flexor exercises, side bridging and back extension without foot support was added to exercise regime. The regime was conducted twice weekly for ten weeks. No special training for the trunk muscle was performed by the control group. The endurance of the trunk muscles of the female gymnasts improved

Conclusion: still to write suggestions are welcome.

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