Spondylolisthesis and disc protrusion

[guru_utkarsh]

hey guys,

This is one of the toughest cases i've come across in my clinicals.. plz help !!
The patient a 55 year old male has an anterolisthesis of L5 over Sacrum ( GRADE I) and Disc protrusion at L3-4 . Patient is also a Bronchitis patient.

The patient presents with buttock pain left sided with radiating pain down the whole lower limb. i've not assessed him completely for muscle strength, sensation.. etc.. Pain increases on sitting and walking short distances. Also dyspnoea on exertion.

I'm sooooooo confused wat to do.. give flexion exercises or extension exercises.. traction or mobilization.. god plz help..

Thanks a lot..

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[spud1976]

Hi
In general you wouldn't mobilise as this would make things worse. Also due to the biomechanics of the anterolisthesis you would want to avoid extension. I generally strengthen global flexors (Rectus abdominis etc) to help him control extension.

hope this helps

Paul

[physiobob]

Hi
In general you wouldn't mobilise as this would make things worse. Also due to the biomechanics of the anterolisthesis you would want to avoid extension. I generally strengthen global flexors (Rectus abdominis etc) to help him control extension.

hope this helps

Paul

I agree, extension usually aggravates a spondylotithesis. Do you know what grade. Are there bilateral fractures? What is the age of the patient etc.

P.S If you have the X-rays some general grading info is as follows:

In anterolisthesis, the upper vertebral body is positioned abnormally compared to the vertebral body below it. More specifically, the upper vertebral body slips forward on the one below.


The amount of slippage is graded on a scale from 1 to 4. Grade 1 is mild (20% slippage), while grade 4 is severe (100% slippage).

[harjotrayat]

u shud go for core muscle stabilization (both flexors as well as extensors)

[junior_physiotherapist]

Ammmm,

so u gave ur attentions to anterspodylolithesis ,but what about disc protrusions (i'm wondring it's direction!! is being what),
also the patient painful position is sitting i don't know if this is a sign of canal stenosis !!

IF so what would be the appropriate positions and physical therapy approach for this patient ??


Really this is an intersting case so plz any could give useful inputs really would be great....

Regards

[asha]

The patient a 55 year old male has an anterolisthesis of L5 over Sacrum ( GRADE I) and Disc protrusion at L3-4 . Patient is also a Bronchitis patient.

The patient presents with buttock pain left sided with radiating pain down the whole lower limb. i've not assessed him completely for muscle strength, sensation.. etc.. Pain increases on sitting and walking short distances. Also dyspnoea on exertion.

There are a lot more details needed in this case. It is pretty simple.
1- Does the pain increase with cough & sneeze? as the patient is bronchitic.
2- what does sitting on soft surfaces or on hard surfaces do to his pain?
3- what does supine & prone positions do to his pain.
4- what is his SLR & his other examinations throw up?
What could be giving him his symptoms may be the disc or the listhesis. spondy's are better sitting. central disc protrusions are better walking. stenosis is out because they are better sitting not worse. This seems to be a case of a symptomatic postero-lat disc, from the limited information I have . Reduce it & the job is done. It has to be done carefully though, as the listhesis seem's to be silent now, dont make it symptomatic with your treatment. Core work up will do well at the end of the session, but it should be done without loading the disc.
asha

[alophysio]

Hi,

Peter O'Sullivan did his PhD work in this area. The relevant is...

O'Sullivan PB, Twomey LT and Allison GT (1997) Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis. Spine, Volume 22(24). December 15, 1997.2959-2967

Abstract

Study Design. A randomized, controlled trial, test-retest design, with a 3-, 6-, and 30-month postal questionnaire follow-up.

Objective. To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain
and a radiologic diagnosis of spondylolysis or spondylolisthesis.

Summary of Background Data. A recent focus in the physiotherapy management of patients with back pain has been the specific training of muscles surrounding the spine (deep abdominal muscles and lumbar multifidus), considered to provide dynamic stability and fine control to the lumbar spine. In no study have researchers evaluated the efficacy of this intervention in a population with chronic low back pain where the anatomic stability of the spine was compromised.

Methods. Forty-four patients with this condition were assigned randomly to two treatment groups. The first group underwent a 10-week specific exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects. The activation of these muscles was incorporated into previously aggravating static postures and functional tasks. The control group underwent treatment as directed by their treating practitioner.

Results. After intervention, the specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at a 30-month follow-up. The control group showed no significant change in these parameters after intervention or at follow-up.

Summary. A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.

Hope this helps!

[guru_utkarsh]

Hey.. thanks everyone.. well i've been working on the core stabilizers and the exercises seem to help.. Relieving the pain by giving Interferential currents and heat..

One query remains in my mind.. that in general when we treat a disc protrusion with continuous bed or machine traction then how well do we assess that it has gone in.. and wat r the chances it wont come back out.. does core stabilization help after traction is done.. thanks a lott..

And this really is one of those cool cases one wud die for.. by the way got another interesting one.. a head injury.. will discuss it in the neuro section sometime.. Thanks..

[alophysio]

Hi,

I wouldn't bother with the other treatments including the traction. They would only be for short term relief only.

Traction is not going to "get something back in". What is out in the first place?

Peter O'Sullivan's work showed quite clearly that the active approach is the way to go.

All the other modalities are ok but don't contribute to the solution. These would have been included in his control group (usual care from practitioner).

But specific stabilisation exercises are the way to help these people. That is why his study was published in Spine - A journal for spinal surgeons.

BTW, what do you consider core exercises to be???

[asha]

Traction & interferential wont do anything much. It would just give a temporary feel better read up with the patient. Mckenzie methods would give quicker results in such cases. When functional mobilization is started, it would take care of the patients spondy status. Keep working on the spine stabilizers it would give results when functional mobs are started. This would also improve load bearing strategies of the patient.

[guru_utkarsh]

hey,

well spinal stabilization exercises include all exercises which work on abs and muscles of the back.. those done in bridging, quadruped position, kneeling, also isometrics to lower back and abdominals.. there can be progression of these from a lower grade to increasing difficulties.. a gym ball can also be used.. we basically strengthen the core stabilizers..

[alophysio]

Hi.

You are right about strengthening the stabilisers. However, most patients are progressed to advanced stages too quickly.

One of the things addressed in the specific study that O'Sullivan did was ensure effective isolation of the TA and Multifidus before integration into functional movements and activities.

Using global muscles strategies (all the other abdominal muscles apart from TA, erector spinae, lats, gluts, hams, etc) are inappropriate if isolation cannot be achieved.

This includes Swiss balls. I know people who have come to see me after being given Swiss ball exercises who cannot even stand on one leg properly yet are doing high load exercises - they are fine when doing weights in the gym or hard Swiss ball exercises but stand them against a wall and lift one leg up and they struggle to do so.

With the research that is out there concerning core stability training, the weight of it tends towards isolation before integration into functional activities.

For a good summary on this topic, www.back-exercises.com has a nice summary about progressions of exercises.

Thanks

[osmangony]

Listhesis itself is completely asymptomatic untill it exertes pressure on nurvous system. In many radiograph provide subjective element of having listhesis. But most of them are completely asumptomatic.

So, dont rely on radiograph somuch for clinical decession making.

In very rare situation listhesis can produce unilateral pain. So, in ur case, lets think again about symptomatic listhesis.

The clinical image shows that the patient has postero-lateral disc harniation or protrution exerting pressure on left nerve root. No matter where. Because it is not possible to say even with clear visualized herniation on MRI that this or that disc is producing symptoms. In many cases there are big protrusion with associated smaller protrution beside its level. Who can say by any objective physical examination that this disc is producing the symptom?

So, u can perform rotation manipulation of the Lx spine under manual traction. That will be safe.

[alophysio]

Hi,

With all due respect, if there is a Xray showing a pars defect causing the anterolithesis, then DO NOT MANIPULATE. The person can be considered to have spinal instability. The disc would be the only structure providing a physical barrier to rotation.

If it is a degenerative anterolithesis - that is no pars defect, then that is a different matter.

UNlikely to be a big disc bulge or protrusion since there seems to be investigations such as CT or MRI already done. More likely to be annular compromise leading to chemical sensitisation of the nerve roots if the source of the symptoms is disc or nerve root irritation.

Don't forget his SIJ...

[sdkashif]

Physiotherapy should not be started until after an adequate rest period and once pain with daily activities has subsided.

In acute case, the goal of physiotherapy is to reduce the extension stresses and to promote the strengthening of elements that promote the antilordotic posture. So the exercises prescribed are that strengthen the abdominal muscles ( Williams' flexion biased exercises); and the exercises that increases the flexibility to stretch the spinal extensor muscles, hamstrings and dorsolumbar fascia.

Thoracolumbosacral orthosis ( Boston type antihyperlordotic brace) is very effective in those who do not respond to activities of daily living restriction with slippage less than 50% and is worn for 3-6 months.

In the recovery phase, the antilordotic strengthening and flexibility exercises for spine and lower extremity ( progressive spinal stabilization) is emphasized.

In maintenance phase, patient should continue to do the spinal stablization programme which include stretching and strengthening of spinal and lower extremity.

[aussie]

with regards to "core stability" exercises, does anyone have any tips/advice on teaching lumbar multifidus?

[alophysio]

Ah, the million dollar question...

The general principles / options are:
1. Isolated Activation
2. Co-Contraction Activation
3. Functional Activation

Depending on what philospohy school you come from determines what you do.

From Uni QLD, you would go in the order listed - isolate, co-contract, functional integration

I think this is a nice easy way to start - it makes simple sense and rarely will you ruin a patient. However, it is probably the most frustrating because if you can't isolate a lumbar multifidus (LM) contraction, then you are stuffed because you don't progress...

The easiest way to show people what it should feel like is to sit in neutral sitting. Place fingers over lower L/S near Spinous Processes. The lean back maintaining hip flexion angle. Your will feel LM turn OFF. As you come back forward, it will turn on. This is a normal postural activation of LM

Alternatively, you can use a gentle pelvic floor contraction and aim the pull up to the L/S at L5 if you like.

Or ask patient to poke their finger into their back and then try to slowly squeeze it out - quick contraction is likely to be ES aponeurosis.

There are so many ways to do this.

I assume you are in Australia - try to see if a uni library has "therapeutic exercise for lumbopelvic stabilisation" bu Richardson, Hodges and HIdes.

Good luck

[aussie]

thanks for that! i haven't been shown the "leaning fwds in the chair" technique before - works nicely!

yep, am in australia, studied at uq and have been lectured by richardson, hodges and hides! just always have difficulty teaching multifidus!! so many people can't "get it"!!

[charlize29]

Hi guys,

Here is the multifidus rehabilitation principles.

1. Isolation of the multifidus
2. Strengthen/Train co-activiation of the Core
3. Incorpration to other activites

Try it!!!

[alophysio]

hi. Diane Lee has taken that article off her website so i haven't passed it around...

The key thing is that if you try 4 different ways to get it and the person still can't do it, fix the other problems like the joints and muscle spasms etc. Then try again.

Some people actually have LM that works just fine - have you tried the prone hip extension timing assessment? It should be LM, then Gluts then Hams. I think you will find most people with dysfunction usually have LM first then Gluts and Hams.

To isolate you LM is a Motor Learning Skill - it is a test of skill learning! You can ask some athletes who have perfectly fine LM contractions to isolate it and they can't - that is because it is a backward step for them to do it.

However, since people with dysfunction have a motor pattern in which they are limited to, learning to isolate breaks that pattern. It is then you can reintegrate the new pattern into the movement.

So rather than following a receipe of isolate, co-contract, integrate, we should actually assess whether people have all the muscles working as a team during a task like Active SLR then assess at what stage they need to begin their rehab.

I find that i start at co-contract more often than not and go from there.

Thanks!

[asha]

with regards to "core stability" exercises, does anyone have any tips/advice on teaching lumbar multifidus?

other ways of working the multifidus :
1-get the patient to lie prone. All that they have to do is just think/imagine they have extended their lower extremity unilaterally at the hip. Just the thought fires the multifidus. This could be done as a beginners exs.
2-The exs explained by alophysio to be done in sitting can also be done in standing. As the multifidus fires, come back to neutral & try to hold a isometric contraction. But this can be done as a progression & the technique needs to be mastered.
asha

[ina]

hi I have quastion is traction is benefit for patient with spo nylolisthesis? plz answer my quastion with my best regard
ina from iraq

[linbin]

hi
as already discussed traction gives temporary relief.it will reduce spasm,cause movement of discal pressure to negativity.
for long term results,evidence supports use of core spinal stabilization exercises.its logical too.
as you might be aware that core functioning will be altered due to pain in the back irrespective of the sourse of pain.so our main role i feel is to help to enhance core muscle functioning

[alophysio]

Hi,
I agree with limbin.

The question i always ask myself when i choose a treatment is "why would this help my patient?".

In spondylolithesis, there is a physical defect allowing bones to move where they don't usually move. That is, there is usually too much movement.

Traction is essentially stretching. Or mobilisation in a craniocaudad direction. Either way, it will INCREASE movement which is not necessarily desirable.

Short term may be helpful as outlined by limbin above. But long term, research shows that core stability exercises are the recommended treatment action.

As limbin says, it makes sense. Stabilising hypermobile segments is sensible. Mobilising hypermobile segments is not.

Hope that helps!

[ina]

hi
so which exactly stabilizing exercises that i can give it to my pt.
plz iam waiting for your answers
thanks