spondylolysis

[christine joy]

i have a 51 year old patients who was diagnosed to have a spondylolysis on L4L5. Patients experienced pain upon prolong standing and walking. experienced pain during the night. pain releived thru stooping forward. Rx includes TENS + HMP on paralumbar area for 20 mins, US @ 2.0 w/cm2 for 5 mins at paralumbar area. William flexion exercises. After 2 weeks of daily PT treatment, there was no progress. the pain still feel the burning sensation on the lower extremeties. I would welcome any suggestions that would help my patient at least eliminate the pain or is there a chance for them to achieve their functional capability? How many weeks or months of tx in order to see progress or results?

[perfphysio]

What is the actual dermatomal distribution of the altered lower limb sensation? It might not be the result of the L4/L5 spondylosis. Best to map it out to try and implicate the root level or peripheral level and let us know if this coincides with the investigations. Just about anyone over the age of 50 has a degree of spondylosis creeping in and it's not always the cause of the symptoms. I think it is wise that if you are treating a problem the best way you see fit, and there is no progress, then perhaps you should reassess what the actual problem is and revise your initial diagnosis. No offense intended

:smokin

[somasimple]

Hello Christine,

After 2 weeks of daily PT treatment, there was no progress. the pain still feel the burning sensation on the lower extremeties. I would welcome any suggestions that would help my patient at least eliminate the pain or is there a chance for them to achieve their functional capability? How many weeks or months of tx in order to see progress or results?

As Perphysio said it, if there is no progress perhaps there is a problem with the diagnosis or approach.

In my view, using TENS is certainly a good thing for a trial 4/5 session but if it fails to improve the condition of the patient => discard. TENS makes only one thing, masking pain signal it does not really care!

You're using William flexions but my actual knowledge about spine problems let me think that any flexion may increase problems without some chance of success. Perhaps try the opposite way => extension combined with inhaling?

Hope this help?

[nickhedonia]

Dear Christine,
re your 50 year old fellow with low back and referred pain. You mentioned spondylolysis, did you really mean this or are you referring to the more common spondylosis, if it is A, then one would expect instability leading to spondylolisthesis, with the prospect of pain dependant on the stage of this seriously unstable shifting forward event , of one vertebral body.
If instead there is spondylosis, which remember is a common phenomenon and not related necessarily to spondylolistheses or spondylolisis. Whew!, so many L's and esses. I wonder on what basis was the diagnosis made , was this by yourself or is it yet another doctor's " I don't know " couched in scientific jargon.

[somasimple]

Geoff,

the stage of this seriously unstable shifting forward event

A spondy is only instable in extension, flexion augments pressure and stops movement (and hurts).

It is myth! And I never saw or heard a story where the trunk of a patient went on the floor. Simply never!

[nickhedonia]

dear Bernard, do you mean a trunk like an elephant or the kind my mum uses to store her old clothes in?

[somasimple]

Dear Geoff,

Excuse me for my poor English and I was, of course, meaning a trunk = torso. (And I'm sure that you found by yourself the signification of the term, already).

[nickhedonia]

Dear Bernard, it's not your variable command of english that is an issue, it is the stream of non sequiturs that get me giggling.
you must keep your patients amused.
Have a great day

[somasimple]

Geoff,

My Latin is so far from me that I did a search on google about non sequitur
www.gcse.com/english/non_sequitur.htm

It's fits perfectfy the guy you're =>

people who think they're clever use this far too frequently.

And the other part lets me a bit perplex =>

is sometimes used to indicate that an illogical conclusion has been made from something!

Concluding that I wasn't logical let me hope that you'll bring some arguments that prove it!

[somasimple]

Geoff,
here is an animation of the myth you cited =>
www.somasimple.com/flash_...stab03.swf

[somasimple]

www.ncbi.nlm.nih.gov/entr...s=12779297

Ann Intern Med. 2003 Jun 3;138(11):871-81. &nbsp &nbsp &nbsp &nbsp
Comment in:

* Ann Intern Med. 2004 Apr 20;140(8) :665; author reply 665-6.
* Ann Intern Med. 2004 Apr 20;140(8) :665; author reply 665-6.
* J Fam Pract. 2003 Dec;52(12):925-9.


Summary for patients in:

* Ann Intern Med. 2003 Jun 3;138(11):I33.

Click here to read
Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies.

Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.

The Cochrane Back Review Group, Toronto, Ontario, Canada.

BACKGROUND: Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. PURPOSE: To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. DATA SOURCES: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews. STUDY SELECTION: Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure. DATA EXTRACTION: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). DATA SYNTHESIS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.

Publication Types:

* Meta-Analysis
* Review


PMID: 12779297 [PubMed - indexed for MEDLINE]

Sorry Geoff, but you're simply promoting myths!

[Physiobase]

Sorry somasimple but there are just as many studies like this that have shown "general physio" and "manipulative therapy" are in fact superior to GP management and placebo (a detuned ultrasound machine). In fact this study, a double blind RCT (Scandinavian I think) was repeated with the same effect.

Interestingly the general physio had no different effect to the manip group although the manip group did have better numbers. Perhaps the funniest result was that the placebo did better than the GP's.

I should think that RCT's are in effective in proving the effectiveness in a back pain population and that single case designs are far more appropriate. I will try to find the study I am referring to though and post it in the forum later today

PhysioBob 8o

[somasimple]

Hi,

Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar.

I agree totally and it is why I put this paper in front of a guy saying that all could be healed by manipulations.

We aren't more powerfull than placebo or Nature, we are just enhancing their powers!

[Physiobase]

uthor/Association: Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren K, Sarna S, Hurri H

Title: A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain.
Source: Spine. 28(19):2185-91, 2003 Oct 1.
Method: clinical trial

Method Score: 8/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has not yet been confirmed*

Abstract: STUDY DESIGN: A prospective randomized controlled trial. OBJECTIVES: To examine the effectiveness of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain. SUMMARY OF BACKGROUND

DATA: Strong evidence exists that manual therapy provides more effective short-term pain relief than does placebo treatment in the management of chronic low back pain. The evidence for long-term effect is lacking. METHODS: Two hundred four chronic low back pain patients, whose Oswestry disability index was at least 16%, were randomly assigned to either a manipulative-treatment group or a consultation group. All were clinically examined, informed about their back pain, provided with an educational booklet, and were given specific instructions based on the clinical evaluation. The treatment included four sessions of manipulation and stabilizing exercises aiming to correct the lumbopelvic rhythm. Questionnaires inquired about pain intensity, self-rated disability, mental depression, health-related quality of life, health care costs, and production costs. RESULTS: At the baseline, the groups were comparable, except for the percentage of employees (P = 0.01). At the 5- and 12-month follow-ups, the manipulative-treatment group showed more significant reductions in pain intensity (P < 0.001) and in self-rated disability (P = 0.002) than the consultation group. However, we detected no significant difference between the groups in health-related quality of life or in costs.
CONCLUSIONS: The manipulative treatment with stabilizing exercises was more effective in reducing pain intensity and disability than the physician consultation alone. The present study showed that short, specific treatment programs with proper patient information may alter the course of chronic low back pain.

For more information on this journal, please visit www.lww.com

[Physiobase]

Here's another RCT. As you can see RCT's are so varied in their approach and most often find it difficult to award effectiveness to one single treatment application. Afterall who only uses one treatment approach in the low back pain patient?

Author/Association: Hsieh CY, Adams AH, Tobis J, Hong CZ, Danielson C, Platt K, Hoehler F, Reinsch S, Rubel A

Title: Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial.
Source: Spine. 27(11):1142-8, 2002 June 1.

Method: clinical trial
Method Score: 8/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*

Abstract: STUDY DESIGN: A randomized, assessor-blinded clinical trial was conducted. OBJECTIVE: To investigate the relative effectiveness of three manual treatments and back school for patients with subacute low back pain. SUMMARY OF BACKGROUND DATA: Literature comparing the relative effectiveness of specific therapies for low back pain is limited.

METHODS: Among the 5925 inquiries, 206 patients met the specific admission criteria, and 200 patients randomly received one of four treatments for 3 weeks: back school, joint manipulation, myofascial therapy, and combined joint manipulation and myofascial therapy. These patients received assessments at baseline, after 3 weeks of therapy, and 6 months after the completion of therapy. The primary outcomes were evaluated using visual analog pain scales and Roland-Morris activity scales.

RESULTS: All four groups showed significant improvement in pain and activity scores after 3 weeks of care, but did not show further significant improvement at the 6-month follow-up assessment. No statistically significant between-group differences were found either at the 3-week or 6-month reassessments.

CONCLUSIONS: For subacute low back pain, combined joint manipulation and myofascial therapy was as effective as joint manipulation or myofascial therapy alone. Additionally, back school was as effective as three manual treatments.

For more information on this journal, please visit www.lww.com

[nickhedonia]

Dear Bernard, I wholeheartedly agree with the comments by physiobase and your self about manipulation . This is a short term and often inneffective manual treatment. I do not advocate manipulation any more than for a quick rom improver .The studies you and physiobase have mentioned bear out my own comments made in other posts about manipulation.
I do however advocate MOBILISATION treatments for its powerful and lasting effects in both spinal pain and its associated referred events. It is not uncommon for doctors and others untrained in joint treatment to lump all manual therapies together and consider all as effective or ineffective as another. Nothing could be further from the truth. As a scientist you are no doubt trained , as I am , to remain objective and somewhat sceptical about claims made without substantiation. Mobilisation is well covered in the literature. The methods taught and often used in clinical trials however , are of a number of different varieties of the early Maitland model. I have found this model to stop well short of ideal.
My own work , on both the better mobilisation method, and the theory to explain its effectiveness , have been posted here over the last few weeks. While not setting out to achieve the impossible , I am always happy to engage in a discussion with those , like yourself who have yet to experience the best effects of mobilisation. The more I reach out , the more likely someone will listen. Perhaps even you.

[somasimple]

Geoff,

I do however advocate MOBILISATION treatments for its powerful and lasting effects in both spinal pain and its associated referred events.

I agree with mobilisation but why are limiting your action to spinal mobs and why are you limiting pain to reffered?

In my view, the best candidate to achieve a mobilisation (movement of a joint) is patient.

[onpc]

hi christine,
well for ur l-4,l-5 case i think i have gota light for u since even i was goin through the same problem which u facing for one of my patients.i came to know certian points which i m sharing wid u
1. never use tens and ultrasound therapy together in same place as it can increase the pain
2. bets was is use swd in the lower back tens one head placed in l4 region another in calf muscle of patient.
3. try giving int. lumbar traction as it will reduce the radiating pain for ur patinet
i have done all these and cam out as a happy man
gud luck honey

[neurospast]

Christine, after the bantering of some people...
As someone wrote: Is the radiation according to a L4_L5 problem? Or below? If not rethink, What about triggerpoints in the gluteal area and lumbar area? Some might trigger pain in the legs. And not always according to Travell.
Is it possible having an orthosympathetic involvement, check mobility and pain from T8 to L1 (T11-L1 should cause pain on overpressure and deep palpation paravertebral) What about muscle length/ strength?
Best effect by traction, specific mobilisation of effected vertebraes. Mobilization ala Butler. Muscle strengthening in semi flexion, e.g. push lower part of back down onto the floor.
Best of luck.

[sdkashif]

Pain which is worsened by increasing the lumbar lordosis, standing and walking is called posterior element pain. Posterior element pain is eased by maintained forward flexion, sitting, hip flexion ( with or without knee extended). Patients who have structural or postural hyperlordosis, who have facet arthropathy, and who suffer from foraminal stenosis show feature of posterior element pain. Pain from extension and rotation are usually of facet origion. Flexion treatment frequently improve the facet disease, spondylolysis, flexion dysfunction and certain types of derangement. Prescription of hyperextension exercises may make the condition worse. The goal of exercises should be to improve the abdominal strength and flexibility. As the hamstring muscles are often tight, so the stretching exercises for the hamstrings should also be emphasized. Pelvic tilt exercises also help to reduce any postural component causing increased lumbar lordosis. Myofascial release may also play a role in reducing pain from the surrounding soft tissues.

The role of bracing for reducing the pain of acute spondylolysis is controversial. The most commonly prescribed braces are thoracolumosacral spinal orthosis (TLSO) or modified Boston Brace.

The use of modalities can be given. These are used in isolation or in combination therapy according to the experience of the therapist. Superficial heating methods like Infra reds, electrical heating pads, moist heat pads & deep heating methods like Short wave Diathermy, Microwave Diathermy, ultra sound therapy & electrical stimulation like TENS, Interferential, high voltage pulsed current generators and diadynamic currents all can be used accoring to individual choice and case selections.

So advice about the spinal flexion exercises, bicycling and walking on sloped treadmill will improve the condition of patient. Patient should be restricted from the provocative activities that increase pain. Activities and exercises that reduces the extension stress are helpful in reducing pain especially in the acute episodes.