Orthopedic Manual Physical Therapy for Spondylolisthesis
Image of an asymptomatic [pain-free] grade IV spondylolisthesis from the study by Elliot et al [14]
How Does An Orthopedic Manual Physical Therapist Treat Spondylolisthesis?
Spondylolisthesis is a displacement of one segment of the spine either forward or backward (retrolisthesis) in relation to the segment below it. There are several types of spondylolisthesis:
Type 1 – Dysplastic or Congenital: an abnormal development before birth.
Type 2 – Isthmic: from a defect (spondylolysis) of the pars interarticularis (isthmus) of the vertebral arch (a thin segment of bone that connects the facet joints). It may be lytic (a fatigue fracture), elongated but still intact, or an acute fracture. Isthmic spondylolistheses can be symptomatic or asymptomatic (1).
Type 3 – Degenerative: from disc degeneration and/or chronic segmental hypermobility. This type occurs in approximately 50% of individuals 60 years of age and older.
Type 4 – Traumatic: from a car accident, a fall, a sports-related injury, etc.
Type 5 – Pathological: from local or systemic disease.
Where does spondylolisthesis usually occur?
85-95% of the time, spondylolisthesis occurs at L5 (the lowest segment in the lumbar spine), and the second most common location for spondylolisthesis is L4 – the segment just above L5 (2).
What are the signs and symptoms of spondylolisthesis?
Most people with spondylolisthesis are asymptomatic – they do not have any pain or symptoms (3). A spondylolisthesis that is symptomatic may present with low back pain, pain in the buttocks or legs, pain that worsens after physical activity, and/or pain that worsens as the day goes on (4). It is worth noting, however, that these symptoms are not unique to spondylolisthesis – several other clinical conditions may have a similar presentation.
How is spondylolisthesis diagnosed?
Some professionals elect to use X-rays to diagnose spondylolisthesis. An MRI or CT scan may be ordered if neurological signs are present (1,2,4). While imaging can identify a defect, imaging can never determine if the defect is definitively contributing to a patient’s symptoms – imaging simply cannot correlate the picture to the pain. If you had imaging for back pain and a spondylolisthesis has been identified, there’s still no way of knowing whether the spondylolisthesis itself is responsible for your pain. Again, most individuals with spondylolistheses are pain-free. You're also invited to learn more about the limitations of imaging such as X-rays and MRIs in managing orthopedic conditions.
A skilled orthopedic manual physical therapist would spend considerable time talking with the patient about the history and behavior of symptoms followed by a comprehensive physical examination. It is this combination of discussion and comprehensive examination that is the most reliable way of guiding effective treatment.
How is spondylolisthesis treated?
Spondylolisthesis can usually be treated successfully with conservative interventions as the following studies show:
Blanda et al had 82 patients perform activity restriction, bracing, and physical therapy, and 84% had excellent results (5).
O'Sullivan, et al, found significant improvement with pain and functioning in patients with spondylolisthesis that received deep abdominal and multifidi training (6).
d’Hemecourt et al performed a study aimed at returning the athlete to sport after being diagnosed with spondylolysis (7). Patients were treated with both a Boston brace and physical therapy and over 80% of these athletes had good to excellent results.
Spratt, et al, compared flexion based exercises and bracing with extension-biased exercises and a control group (8). They found significant reduction in pain in the extension group.
Is surgery required for spondylolisthesis?
Surgery may be indicated if conservative treatment fails or if neurological deficits progress despite treatment with orthopedic manual physical therapy. However, bony healing can occur with or without bracing, and pain relief can be achieved with or without fracture healing (5). Here are some scientific studies comparing surgery with conservative care for spondylolisthesis:
Moller, et al, found that surgery for adult isthmic spondylolisthesis improved function and relieved pain more efficiently than an exercise program in patients aged 18-50 (9).
Seitsalo et al found no difference between surgery and nonoperative treatment in regard to spondylolisthesis, L4-L5 disk damage, and low back pain (10).
In a systematic review by Garet et al, they concluded that there is no clear advantage of surgery versus conservative care for spondylolisthesis (11).
Weinstein et al followed 304 individuals over 4 years and found no significant difference in outcome of the surgical (decompressive laminectomy with or without fusion) versus the nonsurgical groups (12).
Do not give up if your previous conservative treatment has not met with success! Sometimes an attempt at treatment in physical therapy may not be enough to get the job done. Skill levels and practice setting dynamics vary significantly between practitioners and companies alike. It is therefore necessary to find a skilled orthopedic manual physical therapist that is knowledgeable about spondylolisthesis and how best to treat it. Here are some tips for choosing the best orthopedic manual physical therapist for you.
Orthopedic Manual Physical Therapy for a non-traumatic spondylolisthesis
It is estimated that 3-8% under 40 years old have spondylolisthesis, 8-23% of those between 40 and 60 years old have spondylolisthesis, and 23-50% of those 60 and over have spondylolisthesis - whether or not symptoms are present (13). Orthopedic manual physical therapy should therefore be based on each patient’s unique presentation and its characteristics known as Severity, Irritability, Nature, Stage, and Stability (SINSS) – not based on an image (X-ray, MRI, etc). As mentioned above, many patients with a spondylolytic lesion are asymptomatic and the lesion may or may not be the source of their symptoms. In addition, some patients have responded well to stabilization exercises, some patients responded well to flexion-biased exercises, and other patients responded well to extension-biased exercises and/or bracing. Patients should be evaluated and treated on an individual basis using a test-treat-retest approach.
Orthopedic Manual Physical Therapy for an acute or traumatic spondylolisthesis
As mentioned above, orthopedic manual physical therapy should be based on the individual patient seeking care, and emphasis should be on the SINSS (see paragraph above) of their unique presentation. In an acute case, patients are more likely to have severe and/or irritable symptoms so the choice of interventions will more likely be gentler and may include lower grades of mobilizations. However, as with non-traumatic lesions, patients should be evaluated thoroughly, as some patients may still respond to extension-biased exercises. Again, patients should be evaluated and treated individually using a test-treat-retest approach, but more caution may be indicated due to the Nature of the condition.
Further Information on Orthopedic Manual Physical Therapy
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Do patients need an MRI or X-ray before beginning physical therapy?
What should you consider when choosing a physical therapist for an orthopedic condition?
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Dr. Damon Bescia is a fellowship-trained Doctor of Physical Therapy, board certified in orthopedics and sports physical therapy, who specializes in Orthopedic Manual Physical Therapy and serves Naperville and its surrounding communities by way of his Concierge Practice, providing private one-to-one orthopedic manual physical therapy for his clients. For more information, please visit https://www.napervillemanualphysicaltherapy.com.
5. Blanda J, Bethem D, Moats W, et al. Defects of pars interarticularis in athletes: a protocol for nonoperative treatment. J Spinal Disord1993; 6:406–11
6. O'Sullivan, P. B., Phyty, D. M., Twomey, L. T., & Allison, G. T.Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain with Radiologic Diagnosis of Spondylolysis or Spondylolisthesis. Spine. 1997, 22(24):2959-2967.
