Spondylolisthesis

Spondylolisthesis is defined as an anterior displacement of a vertebral body in relation to the segment immediately below (1). There are several types of spondylolistheses, with the most common being spondylolysis of the pars interarticularis, occurring in the young, and degenerative, which occurs in older patients (2). The vast majority of spondylolistheses are found in the lower lumbar region, with rare occurrences in other spinal regions. This condition, which affects adolescent athletes, adults, and the geriatric population, is not necessarily associated with a pars defect and has a wide range of treatment options - from bracing to spinal manipulation to fusion surgery.


The most common type of spondylolisthesis seen in chiropractic offices is the stable pre-existing type (PSS-S). Response to chiropractic care is often excellent. Studies have shown that when a spondylolisthesis is found in an adult, specific side-posture manipulations to the dysfunctional joints are quite effective, and that the prognosis is not significantly different from other patients (3) These researchers reported that the spinal segments most commonly needing adjustment were the ones above or below the spondylolisthetic segment, as well as the sacroiliac joints. Flexion-distraction also has been found to be a successful treatment method.


An important approach to the treatment of patients with spondylolisthesis is to strengthen and re-coordinate the deep support muscles of the lumbar spine. An attempt is made to improve the dynamic stability and segmental control of the spine. These muscles include the multifidus muscles and the internal oblique and transverses abdominus muscles (4). Exercises to train the co-contraction patterns of these muscles often are called "spinal stabilization" exercises. Specific maneuvers include: posterior pelvic tilt; lower abdominal hollowing; and abdominal bracing.


The exercises are started non-weight-bearing while lying supine and/or prone, and then progress to quadruped (on all fours) if the position does not worsen symptoms, and finally to upright sitting and standing positions. They are described as low-resistance, isometric exercises whose focus is on precision of performance and re-learning of function. A 10-week program of supervised exercise sessions designed to progressively incorporate these postures into daily activities was found to reduce back pain and disability levels significantly over more than two years in subjects with spondylolisthesis (5).




Postural Correction


Many patients with spondylolisthesis develop postural asymmetries over time. One important factor in treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. While there is no standard "spondylo posture," it is not unusual to see a change in pelvic alignment (often a forward-flexed pelvis) or in lumbar spinal curve. The lumbar changes can be either a hyperlordosis or (in some cases) a lack of normal lumbar lordosis. Patients will need to be shown corrective exercises specific for the postural imbalances they have developed.




Maintenance and Support


Patients with spondylolisthesis should be taught to perform a general fitness exercise program for the lumbar support muscles on a once-a-week basis. A general and usual recommendation for maintenance exercising is a series of exercises using heavy-duty elastic tubing. These isotonic resistance exercises, performed in an upright (seated) position, will activate all of the stabilizing and major mobility muscles of the lumbar spine.


Early intervention is the most important part in helping these patients achieve the best and fastest results possible. Chiropractic is an essential ingredient in treating this debilitating injury for our patients.






References 
1. Yochum TR, Rowe LJ, eds. Essentials of Skeletal Radiology, 2nd ed. Baltimore: Williams & Wilkins; 1996:327.
2. Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg, MD: Aspen Pubs; 1997:132.
3. Mierau D, Cassidy JD, McGregor M, Kirkaldy-Willis WH. A comparison of the effectiveness of spinal manipulative therapy for low back patients with and without spondylolisthesis. J Manip Physiol Therap 1987;10:49-55.
4. Richardson C, Jull G. Muscle control-pain control. What exercises would you prescribe? Man Therapy 1995;1:2-10.
5. O'Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercises in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;2:2959-2967.