Spondylolisthesis and Physical Therapy
Spondylolisthesis is the ‘slippage’ or forward displacement on one vertebra over another. The slippage most commonly occurs at L4-L5 and the next most common level is L5-S1. The L5 and S1 nerve roots are the most commonly effected because of how they exit the intervertebral foramen at these levels. Women tend to be diagnosed with spondylolisthesis two to five times as often as men and African American women greater than any other ethnic group.
What Causes Spondylolisthesis?
In the general population the incidence is between 3-10%. It is thought that athletic activities that require repeated hyperextension and rotation or repetitive combined flexion-extension predisposes athletes to develop pars defects. There are multiple types of spondylolisthesis and the exact cause is unknown.
Isthmic and degenerative are the two types that are most common in adults. The three other types include traumatic, pathological, and dysplastic. The case study patient was a Lytic spondylolisthesis, which is always due to a fatigue fracture and is commonly seen in patients less than 50 years old.
Overall, as the vertebral body slips forward there is narrowing of the spinal canal and intervertebral foramen which results in stenosis. As stenosis occurs the typical presentation changes from one of back pain to one that includes radicular symptoms.
The typical clinical presentation of a spondylolisthesis is pain generally localized in the lumbar paraspinals, gluteals, and posterior aspects of the thighs.The symptoms usually increase with standing or walking.
As the slippage progresses there is typically more irritation of the nerve root and the hamstrings become tight. This may be of benefit to a patient because of the hamstring insertion into the ischial tuberosities which would support a posterior pelvic tilt and subsequently decrease lumbar lordosis. Patients tend to walk in a more flexed position and develop increased hip flexor muscle tension. Flattening of the sacrum can be seen as the patient attempts to stop the slippage.
Diagnosing and Treating Spondylolisthesis
Diagnosis usually occurs by radiographs and the slip can be graded by the Meyerding’s system. In this system a Grade I is up to 25% displacement, Grade II 50%, Grade III 75%, Grade IV 100%, and Grade V greater than 100% displacement.
It has been found that only 10-15% of these patients go on to have spinal surgery and that most improve with nonoperative treatment. Typical nonoperative care includes rest, NSAIDS, ESIs, and a physical therapy program. Clinical significant improvements have been found with interventions that included lumbar flexion exercises and walking, but even more substantial improvement was found with the addition of manual therapy (joint mobilization and manual stretching) when performed to the lumbar spine and lower extremities. Exercise with an emphasis on spinal stabilization has been shown to provide pain relief and decreased re-occurrence of symptoms.
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