Spondylolisthesis

Question:

I'm wondering if you could provide me with some good information on training core stability, flexibility and strength specifically related to spondylolisthesis? It is not a severe case, and as of now, surgery does not seem to be an option. What should I watch out for, be aware of and specifically work on?

Answer:

Spondylolisthesis is an anterior translation of one vertebrae relative to another. This generally occurs between the L-5/S-1 junction. Spondylolisthesis is often associated with spondylolysis which is a fracture of the pars articularis, a portion of the vertebral arch midway between the superior and inferior articular processes. Spinal alignment is dependent on two main parts of the spine, the disc and the facet joints. The facet joints anchor the vertebrae posteriorly. When there is a bilateral fracture of the pars articulares, the facet joints can’t prevent anterior translation of the vertebrae and the intervertebral disc can slowly stretch under applied stress and allow the upper vertebrae to slide forward. There is some intense debate on the speculation of what causes spondylolisthesis, whether it is congenital, caused by an anomaly of the bones of the spine, isthmic, a genetic defect of the pars articulares, or if it is degenerative, caused by an arthritic condition associated with spinal stenosis. Whatever the cause, the result can lead to lower back discomfort, numbness of the glutes, and can even lead to referred pain or numbness to the leg and/or foot. Spondylolisthesis can be classified into four grades based on the level of severity of a disc’s anterior translation. Starting at grade one, there is 75 percent or more contact between the adjoining discs, grade two indicates 50 to 75 percent contact, grade three indicates 25 to 50 percent contact, and grade 4 indicates less than 25 percent disc contact. Based on this scale, the higher the grade of slip, the more serious the problem. In most cases, however, the severity is not such that surgery is deemed necessary. Only in cases where the anterior translation is impinging or compressing spinal nerves is surgery a viable option. Based on this, other means of therapy are necessary to help alleviate symptoms of discomfort.

One of the main problems to address is core stability. Generally, in clients who are experiencing lower back pain there is pelvic dysfunction, usually an anterior pelvic tilt. Consequently, the intrinsic stabilizers of the spine, such as the transversus abdominis and multifidi, are inhibited. This phenomenon decreases spinal stability, and hence, recruitment from the nervous system is altered. Instead of the local, stabilizing muscles being recruited to help stabilize and disperse forces encountered by the spine, the global, movement muscles (latissimus dorsi, iliopsoas, erector spinae, rectus abdominis) have to take on that role. These muscles are not mechanically or neurologically sufficient for this task. In order to achieve a neutral hip position, flexibility of the global muscles attached to the hips and thoracolumbar fascia is necessary. Self-myofascial release and static stretching are two ways to help release tightness through the hips. Self-myofascial release utilizes the concept of autogenic inhibition to override the muscle spindles which helps to alleviate muscle spasms that can occur due to tightness. This supplement to flexibility also breaks up collagen adhesions that form within the muscle tissues as a result of the cumulative injury cycle. Inevitably, these “knots” inhibit true elongation of muscle tissue. Static stretching, used after self-myofascial release, will work to elongate the muscle tissue, which will help release tightness in the hips.

Start by teaching the client how to move the hips from an anterior tilt position to a posterior tilt, without moving the rest of the body. This will allow the client to disassociate the pelvis from the rest of the body. In doing so, teach the client how to find neutral hip. Position them in the quadruped – four point position, and instruct them to acquire neutral hip. Have the client draw their belly button up towards the spine (the drawing in maneuver). Watch for motion from the chest or hips. When the drawing-in maneuver is done correctly, no movement should be observed throughout the spine or hips. This is where the client should start. Once the client is able to draw-in and hold it for 20-30 seconds, progress the client to limited movement (i.e., arm movement in the quadruped position) while maintaining activation of the core.

When addressing flexibility, teach the client how to statically stretch on their own. The muscles that need to be addressed are the muscles that surround the hips (i.e. the femoral external rotators, psoas, lats, and adductors). Flexibility is a key, but if done too aggressively, it can become more harmful than helpful. Due to the position of the spine, incorrect stretching can put more strain on spondylolisthesis. Begin a flexibility program conservatively, starting first with self-myofascial release to relieve the muscle spasms. Continue from there when the client is able to get into a posterior tilt correctly and can assume a stretching position without pain. Watch for any hyperextension of the back as this will place more strain on the sensitive lumbar area.

If the client has pain during movement, refer them out. Keep in close contact with a specialist who can help oversee the client’s progress. Remember to progress a client slowly and carefully, and place them in an environment that they can safely handle.