Spondylolisthesis: Physiotherapy Management

Spondylolisthesis is described as when one vertebra in the spine shifts or slips anteriorly or posteriorly in relation to the vertebrae above or below it. This condition is mostly found in the lumbar (lower back) region of the spine and can be categorized into different grades based on the degree of slippage. It can result from various factors and can be associated with anatomical, physiological, and biomechanical aspects of the spine.

  

                   

Anatomy:

The human spine, or vertebral column, is made up of individual bones called vertebrae. The spine is divided into five regions, with the lumbar spine comprising the lower back and consisting of five lumbar vertebrae (L1 to L5). Between each vertebra are intervertebral discs that act as shock absorbers and allow for flexibility and movement in the spine.

The spine's primary functions include supporting the body's weight, protecting the spinal cord, and allowing for various movements, such as bending and rotational movements.

 

Physiology:

Spondylolisthesis occurs due to various causes, such as congenital defects, degenerative changes, stress fractures, or other abnormalities. This displacement can result in compression or irritation of nearby spinal nerves, leading to symptoms like lower back pain, leg pain, numbness, and weakness.

Physiotherapists play a crucial role in the management and treatment of spondylolisthesis. It includes comprehensive assessment to determine the extent of the condition, identify contributing factors, and assessing patient's functional limitations.

 

Grades of Spondylolisthesis

Spondylolisthesis is typically graded on a scale from I to IV, with each grade indicating the severity of vertebral slippage. These grades are as follows:

1. Grade I (Mild) - the affected vertebra has slipped forward by up to 25% of its length relative to the one below it
2. Grade II (Moderate) - involves a slippage of 25% to 50% of the affected vertebra's length relative to the one below it
3. Grade III (Severe) - the affected vertebra has shifted forward by 50% to 75% of its length relative to the one below it
4. Grade IV (Very Severe) - it represents the most severe level of slippage, the affected vertebra has slipped forward by more than 75% of its length relative to the one below it and it is associated with significant spinal instability and compression of spinal nerves or the spinal cord

Grading Criteria:

X-rays are a valuable tool for assessing spondylolisthesis and determining its grade. The lateral (side-view) of the spine shows the degree of vertebral slippage. The physiotherapist can measure the percentage of slippage by comparing the position of the affected vertebra relative to the one below it.

 

Wiltse Classification

It is a specific system used to categorize spondylolisthesis based on the anatomical location of the defect or fracture in the pars interarticularis (the part of the vertebra affected in isthmic spondylolisthesis). It is particularly useful in distinguishing different types of isthmic spondylolisthesis based on their location. The Wiltse classification includes three main categories:

1. Dysplastic Spondylolisthesis (Type I):

This category represents congenital abnormalities of the upper sacral facets and the inferior facets of the fifth lumbar vertebra. These abnormalities create a predisposition to vertebral slippage. It is typically characterized by a defect in the upper sacral facets, causing the slipping vertebra to slide forward.

2. Isthmic Spondylolisthesis (Type II):

This type corresponds to the classic form of isthmic spondylolisthesis, where the slippage occurs due to a stress fracture or non-union in the pars interarticularis. The defect is located at the isthmus or the "neck" of the lumbar spine on an oblique view X-ray. This is the most common type of isthmic spondylolisthesis.

3. Degenerative Spondylolisthesis (Type III):

This category is related to degenerative changes in the spine, particularly in the facet joints and intervertebral discs. It is not associated with a specific defect or fracture in the pars interarticularis. Instead, it occurs as the result of age-related changes and is often seen in older adults.

 

Classification of Spondylolisthesis

Differentiating between Spondylolisthesis, Spondylosis and Spondylolysis

Common Symptoms of Spondylolisthesis

• Persistent and often localized pain in the lower
• Radiating pain from the lower back into the buttocks and thighs
• Numbness and tingling in the buttocks, thighs, and legs
• Muscle weakness particularly in the legs which affect mobility and the ability to perform certain activities
• Changes in gait
• Altered Posture such as an exaggerated lower back curve (lordosis) or a forward-leaning stance
• Difficulty standing or sitting due to increased pressure on the affected area of the spine
• Bowel or bladder dysfunction
• Tightness or discomfort in the hamstrings especially in cases of spondylolisthesis with posterior slippage

 

Causes of Spondylolisthesis

Isthmic Spondylolisthesis:

This is the most common type and is often associated with a defect or stress fracture in the pars interarticularis, a bony bridge that connects the upper and lower facets of a vertebra. Causes of isthmic spondylolisthesis include:

• Congenital defects
• Repetitive stress - hyperextension of the lower back, often seen in activities like gymnastics or weightlifting, can lead to stress fractures and slippage.
• Acute fractures

 

Degenerative Spondylolisthesis:

This type is typically associated with the aging process and degenerative changes in the spine, including:

• Disc degeneration
• Facet joint arthritis
• Ligamentum flavum hypertrophy

 

Traumatic Spondylolisthesis:

Spondylolisthesis can result from traumatic injuries, such as fractures, dislocations, or severe hyperextension of the spine due to accidents or falls.

 

Pathological Spondylolisthesis:

Pathological conditions affecting the spine, such as tumors, infections, or metabolic bone disorders (e.g., osteoporosis), can weaken the spinal structures and contribute to spondylolisthesis.

 

Iatrogenic Spondylolisthesis:

This type is caused by surgical interventions, such as laminectomies, discectomies, or spinal procedures that may compromise the stability of the spine.

 

Dysplastic Spondylolisthesis:

This is a type of isthmic spondylolisthesis and is associated with congenital abnormalities in the facet joints.

 

Diagnosis and Tests

Diagnosis and tests for spondylolisthesis typically involve a combination of clinical assessment, medical history, and various imaging studies to confirm the presence of the condition, determine its cause, grade its severity, and plan appropriate treatment.

Medical History - which may include questions about your symptoms, their onset, duration, and any relevant medical conditions or injuries.

Physical Examination - to assess your posture, gait, range of motion, muscle strength, reflexes, and any signs of nerve compression or muscle weakness.

Neurological Examination - evaluates nerve function by assessing sensation, reflexes, and muscle strength in the affected area.

Imaging Studies:

• X-rays - help in grading the degree of slippage
• Magnetic Resonance Imaging (MRI) - evaluation of soft tissues, nerve compression
• Computed Tomography (CT) Scan - identify fractures
• Bone Scan - identify areas of increased bone activity, which  indicate stress fractures
• Myelogram - involves injecting a contrast dye into the spinal canal, followed by a series of X-rays or a CT scan, it helps in identifying spinal cord or nerve compression
• Dynamic Imaging - assess how the spine behaves during different postures and movements
• Electromyography (EMG) - determine nerve damage or compression.
• Bone Density Test - determine if osteoporosis is a contributing

 

Differential Diagnosis

• Spinal Stenosis
• Herniated Disc
• Sacroiliac Joint Dysfunction
• Ankylosing Spondylitis
• Degenerative Disc Disease
• Sciatica
• Musculoskeletal Disorders
• Osteoarthritis
• Referred Pain - originating from organs in the abdomen or pelvis can sometimes be felt in the lower back

 

What makes spondylolisthesis worse

Spondylolisthesis can worsen or become more symptomatic due to various factors or behaviors. Below are some factors that can make spondylolisthesis worse:

• If the spondylolisthesis is allowed to progress, the degree of vertebral slippage can increase, leading to more severe symptoms. Regular monitoring and appropriate treatment can help prevent or manage the progression.
• Engaging in activities that place excessive stress on the spine, such as heavy lifting, bending, and twisting, can exacerbate spondylolisthesis. It's important to avoid or modify activities that may strain the lower back.
• Excess body weight can add pressure on the lumbar spine, worsening symptoms. Maintaining a healthy weight through diet and exercise can help alleviate this issue.
• Maintaining poor posture, such as excessive arching of the lower back (hyperlordosis), can increase stress on the affected area. Proper ergonomics and posture can help reduce strain.
• Weak core muscles can lead to poor spinal stability, making the spine more vulnerable to slippage and related symptoms. Physical therapy to strengthen core muscles may be beneficial.
• Spondylolisthesis can be aggravated by degenerative changes in the spine, such as disc degeneration or facet joint arthritis. These age-related factors can contribute to worsening symptoms.
• Tightness in the hamstrings or ligamentum flavum can contribute to spondylolisthesis symptoms. Stretching and flexibility exercises may help alleviate this.
• Lack of physical activity can lead to weakened muscles and reduced flexibility, which can exacerbate spondylolisthesis symptoms. Maintaining an active lifestyle within recommended guidelines can be beneficial.
• Smoking can negatively impact bone health and reduce the body's ability to heal, potentially impacting spondylolisthesis symptoms.
• Delaying or neglecting appropriate medical treatment or physical therapy can allow the condition to worsen over time.
• In cases where surgery is performed, inadequate post-surgical rehabilitation or failure to follow a prescribed rehabilitation plan can lead to suboptimal outcomes.

 

Spondylolisthesis Physiotherapy Treatment Strategies

Therapeutic Exercise: 

Exercise is a central component of physiotherapy for spondylolisthesis. Specific exercises are designed to strengthen the core muscles, stabilize the spine, and improve flexibility. Exercises may include:

Core Strengthening: Strengthening the abdominal and lower back muscles to provide support to the spine.

• Pelvic Tilts
• Bridge Exercise
• Quadruped Arm and Leg Raise
• Planks - Be cautious not to overextend your lower back!
• Seated Marching - sit on a sturdy chair and march your legs, engaging your core muscles to maintain balance and stability

 

Stretching: Targeted stretching exercises to improve flexibility and reduce muscle tightness.

• Child's Pose
• Cat-Cow Stretch
• Knee-to-Chest Stretch
• Piriformis Stretch
• Hamstring Stretch
• Calf Stretch
• Hip Flexor Stretch
• Shoulder Blade Squeeze
• Neck Tilt and Rotation
• Seated Spinal Twist - sit with your legs extended. Bend one knee and cross it over the other leg. Twist your torso gently in the opposite direction of the bent knee. This stretch can help improve spinal mobility.

 

Aerobic Conditioning: Low-impact activities like walking or swimming to maintain overall fitness and reduce the risk of weight gain.

• Walking - maintain proper posture and wear comfortable, supportive shoes and gradually increase your duration and pace.
• Swimming - buoyancy of the water reduces the impact on the spine while providing a full-body workout.
• Stationary or recumbent biking can provide a low-impact cardiovascular workout.
• Rowing is a low-impact aerobic exercise that engages the entire body. Maintain proper form and use a rowing machine with adjustable resistance settings.
• Stair Climbing or stair-stepping machines offer a good cardiovascular workout with relatively low impact

When starting an aerobic conditioning program with spondylolisthesis, it's essential to:

1. Begin with short, low-intensity sessions and gradually increase the duration and intensity.
2. Maintain proper posture and form to minimize strain on the lower back.
3. Listen to your body and stop any exercise that causes pain or discomfort.
4. Consider working with a physical therapist to create a tailored exercise plan.

 

Electrotherapy:

• Therapeutic Ultrasound
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Heat or cold therapy may be used to reduce pain and inflammation

Manual Therapy: 

Physiotherapists use hands-on techniques to mobilize and manipulate the spine and surrounding structures. Manual therapy can help improve joint mobility, reduce muscle tension, and alleviate pain. It is usually done in Grade I and Grade II keeping in mind severity of condition.

In some cases, manual traction is used to relieve pressure on the spine. This technique involves gentle pulling or stretching of the spine to decompress the affected area.

Bracing

In some cases brace is prescribed to provide additional stability and reduce pain.

• Lumbosacral Orthosis (LSO)
• Boston Brace - often used for adolescents
• Milwaukee Brace
• TLSO (Thoracolumbosacral Orthosis)
• Custom-Made Braces

Physiotherapists help provide guidance on maintaining proper posture during daily activities, work and exercise. Correct posture can help reduce strain on the spine and alleviate pain. They educate patients about proper body mechanics and ergonomics. Physiotherapists work on improving specific functional activities, such as lifting, bending, and sitting, to minimize stress on the spine.