What is a spondylolisthesis?
Figure 1 – Anatomy of Spondylolisthesis
Occasionally, anatomical structures of the spine responsible for holding the vertebra in alignment may not develop correctly during early childhood or birth or may be damaged during overuse or trauma. This may allow one vertebra to slip forwards relative to the vertebra below. When this occurs the condition is known as a spondylolisthesis.
A spondylolisthesis is graded according to the degree of slip of the vertebra relative to the vertebra below. A Grade I slip indicates a slip of less than 25%, Grade II – 50%, Grade III – 75% and Grade IV > 75%. A spondylolisthesis most commonly affects the L5 / S1 level of the spine (at the base of the lower back), with the L5 vertebra slipping forwards relative to the S1 vertebra below.
Causes of spondylolisthesis
Although uncommon, a spondylolisthesis may also occur due to stress fractures in each pars interarticularis. This may occur due to excessive athletic or sporting activity involving repetitive hyperextension (backward bending) of the spine (such as gymnastics or fast bowling in cricket).
Occasionally, patients may develop a spondylolisthesis following a traumatic injury to the lower back, (such as a motor vehicle accident), following significant degenerative changes to the joints and bones of the spine over time (usually associated with overuse or aging) or due to congenital abnormalities associated with malformation of the facets of the spine.
In rare cases, a spondylolisthesis may occur due to a defect in the bone associated with conditions such as a tumour.
Signs and symptoms of a spondylolisthesis
Generally, patients with this condition experience an increase in symptoms during activities that repetitively, continuously or forcefully straighten or extend the spine (figure 2). Symptoms may also increase during activities that place weight on the spine (such as lifting, prolonged standing, walking etc.). Conversely, symptoms tend to ease during activities that bend the spine forwards (e.g. sitting).
Diagnosis of a spondylolisthesis
Treatment for a spondylolisthesis
Prognosis of a spondylolisthesis
Most patients with more severe conditions (grades III and IV) can also have a great long term outcome, with appropriate conservative management. These patients can also generally remain active, with minimal symptoms, although they are more likely to require more significant lifestyle modifications (including avoidance of high speed or contact sports for all of these patients) and are more likely to experience more significant symptoms including neurological signs (such as pins and needles, numbness or weakness).
In patients with a grade III or IV spondylolisthesis, surgery may be indicated, particularly when there is evidence of slip progression, when symptoms are still experienced after a 6 month non-surgical period or in growing children with a slip of greater than 50%. Patients who undergo surgical intervention usually have a good outcome similar to those Grade III and IV spondylolisthesis patients who do not require surgical management. Rehabilitation following surgery (including appropriate physiotherapy) typically lasts many months.
Contributing factors to the development of symptoms of a spondylolisthesis
There are several factors that may contribute to the development of symptoms in patients with this condition. These need to be assessed and corrected with direction from a physiotherapist and may include:
poor core stability
muscle weakness (particularly of the core and back stabilizers)
poor flexibility (particularly of the hamstrings or hip flexors)
a sedentary lifestyle
excessive or inappropriate activity
inadequate recovery periods from activity
history of injury or trauma to the lower back
inappropriate lifting technique
Physiotherapy for a spondylolisthesis
Other intervention for a spondylolisthesis
Exercises for a spondylolisthesis
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should only take place provided there is no increase in symptoms.
Transversus Abdominus Retraining
Slowly pull your belly button in “away from your belt line” and breathe normally. Your rib cage should remain relaxed and should not elevate during this process. You should be able to feel the muscle contracting if you press deeply 2cm in from the bony process at the front of your pelvis (figure 3). Practise holding this muscle at one third of a maximal contraction for as long as possible during everyday activity (e.g. when walking etc.) provided it is pain free. Repeat 3 times daily.
Figure 3 – Transversus Abdominus Retraining
Rotation in Lying
Begin this exercise lying on your back as demonstrated (figure 4). Slowly take your knees from side to side as far as you can go without pain and provided you feel no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms.
Figure 4 – Rotation in Lying
Slowly take your knee towards your chest as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 5). Use your hands to gently bring your knee closer to your chest. Repeat 5 – 10 times on each leg provided there is no increase in symptoms.
Figure 5 – Hip Flexion
Knees to Chest
Begin lying on your back with your knees bent. Slowly take both knees towards your chest using your hands to assist as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 6). Repeat 5 – 10 times provided there is no increase in symptoms.
Figure 6 – Knees to Chest
Begin this exercise on your hands and knees, with your hands in front of you above the level of the head. Gently take your weight back towards your heels, bringing your bottom towards your ankles as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 7). Hold for 2 – 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free.
Figure 7 – Cat Stretch
Begin this exercise lying on your back in the position demonstrated (figure 8). Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a relatively straight line. Tighten your bottom muscles (gluteals) as you do this. Hold for 2 seconds then slowly lower your bottom back down. Repeat 10 – 20 times provided the exercise is pain free.
Figure 8 – Bridging
Swiss Ball Squats
Begin this exercise in standing with your feet shoulder width apart, your feet facing forwards and a Swiss Ball placed between a wall and your back, as demonstrated (figure 9). Alternatively, you can perform this exercises with your back against a wall (ideally with a low friction surface). Slowly perform a squat, keeping your back straight. Your knees should be in line with your middle toes and should not move forward past your toes. Perform 10 – 20 repetitions provided the exercise is pain free. Maintain activation of your transversus abdominis muscle throughout the exercise.
Figure 9 – Swiss Ball Squats
Sciatic Nerve Glide
Begin this exercise lying on your back, with your knee supported above your hip (by your hands) and your toes held up towards your shin. Slowly straighten your knee as far as you can go without pain and provided you feel no more than a mild to moderate stretch, then return to the starting position (figure 10). Repeat 5 – 10 times on each leg provided there is no increase in symptoms.
Figure 10 – Sciatic Nerve Glide
Rehabilitation Protocol for a spondylolisthesis
Physiotherapy products for a spondylolisthesis
Swiss Balls (for core stability exercises)
Spikey Massage Balls (for self massage)
TENS Machines (for pain relief)
To purchase physiotherapy products for a spondylolisthesis, click on one of the above links or visit the PhysioAdvisor Shop.
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A spondylolisthesis is a condition characterised by forward slipping of one vertebrae upon another. Many patients with this condition may be asymptomatic, others may experience lower back stiffness, loss of lower back range of movement and lower back pain or ache that may radiate into the buttocks, groin, legs or feet. In some cases pins and needles, numbness, muscle spasm and weakness may also be present. Assessment and treatment by a physiotherapist is essential for an optimal outcome.
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