Retrolysthesis

[Dashrath]

Hi I want to share a case with you guys. One of my patient is having minimal retrolysthesis only 7.5 % without any neurological signs and symptoms with mild reduction of L5-S1 disc space.He his having paraspinal muscle spasm and back pain with tenderness over L5.
SLR test negative. so tell me the treatment plan and which type of exercise should be given flexion or extension? why?
Please help me

[sdkashif]

According to Cyriax, retrospondylolisthesis is usually symptomless and is more often seen at the upper lumbar vertebra and lower thoracic levels than at the fourth or fifth vertebral joints. It results from congenital laxity or gradual stretching of the ligaments at the lateral articulations.

During spinal extension the lateral facets of the upper vertebra tend to move backward partly owing to the force of gravity and partly because the surface of lamina slopes downwards and backwards and thus, when the end of articular surface is reached by the point of facet, this is carried backwards until the stretched ligament becomes taut. By bending his trunk forwards, the patient approximates the surface of joints once more. Such instability at these lateral joints, although itself symptomless, leads to attrition of the disc. At the upper lumbar levels it is usually a benign phenomenon but, particularly at the fourth level, may give rise to disc symptoms- backache, lumbago and sciatica.

You need to determine whether your patient is suffering from anterior element pain, posterior element pain, movement related pain or mechanical pain without postures or movement exacerbation (static sensitive).

Anterior element pain

Anterior element pain has been defined as pain made worse by sustained flexion of lumbar spine. Anterior element pain is made worse by sitting and is relieved by standing. Patients assume hyperlordotic posture to relieve their pain. Fracture of vertebral bodies and prolapsed intervertebral discs produce anterior element pain. Extension exercises and press ups are more likely to produce remission than flexion exercises. This is because flexion exercises increase the intradiscal pressure whereas extension exercises unload the discs. Therefore, extension exercises advocated by Cyriax and McKenzie are logical for patients with anterior element pain. Lesions resulting in chronic anterior element pain are obscure; it is tempting to assume that anterior element pain is discogenic in origin, but there is no evidence for this. Unlike the acute group, the patients with chronic anterior element pain may respond to manipulative techniques.

Posterior element pain

Pain is worse by increasing the lumbar lordosis, standing and walking. It is eased by maintained forward flexion, sitting and hip flexion (with or without knee extended). Patients who have structural or postural hyperlordosis, who have facet arthropathy, and who suffer from foraminal stenosis show features of posterior element pain. Pain from rotation and extension is usually of facet origin. Flexion treatment frequently improves the facet disease, spondylolysis, flexion dysfunction and certain types of derangement. Prescription of hyperextension exercises may make the condition worse.

Movement related pain

Patients with movement related pain are most comfortable at rest; pain is precipitated only by activity and jarring. Heavy manual work, repeated twisting, fast walking and running (especially on hard surfaces) and traveling in car on rough grounds all precipitate pain. Movement related pain occurs in traumatic fracture dislocations, in symptomatic spondylolysis or spondylolisthesis and as a result of chronic degenerative segmental instability. Diagnosis may be confirmed by lateral flexion and extension roentengenograms of the lumbar spine and noting abnormal translational movement. A basic scheme of progressive stabilization by strengthening regional and segmental musculature isometrically should be considered. According to Grieve mature patients and those in most pain may need to start abdominal exercises with knee bent and progress more slowly. Side lying stabilization techniques and dynamic abdominal bracing may also be used. Home exercises should be efficiently monitored and the patient taught avoidance of posture and activities known to constitute his specific additional stimuli.

Mechanical pain without posture and movement exacerbation ( Static Sensitive)

Patient with static sensitive low back pain have the have an inability to maintain any one position ( other than lying) for a normal length of time and obtain relief by changing position and moving. Many of these patients appear to have a discrete structural disease, such as scoliosis.

Altered pattern of muscle recruitment have been clearly delineated. One of the most common of those is overuse and early recruitment of low back muscles. Another pattern associated with low back pain is over use of hip flexor (iliopsoas) and weakness of abdominals. It is frequently important to retrain the gluteal muscles and inhibit overuses of lumbar extension, a maladaptive pattern.

Dynamic trunk stabilizers, aside from gluteal maximus which originates or inserts into the lumbodorsal fascia, are the latissimus dorsi, transversus abdominis and internal obliques muscles. The main purpose of strengthening these muscles is to produce a forceful couple that is designed to stabilize the trunk and effectively controls the antigravity weight line or the way in which this area bears weight.

There are many types of isometrics exercises and Grieve provides some good examples to improve power of gluteal and abdominal muscles in the treatment of chronic low back pain, including abdominal wall and abdominal bracing exercises. These exercises avoid the higher intradiscal pressure and emphasize the eccentric control, free breathing and maintenance of functional position of spine. When performing exercises for upper abdominals, the feet should be plantar flexed to inhibit action of psoas.

Isotonic exercises can be helpful for some patients and may be used in all patients as progression of exercise programme, with or without manual or mechanical resistance.

Spinal Bracing:

A number of mechanical supports have been advocated. Spinal bracing seems justified in patients with osteoporotic compression fractures, spondylolisthesis, or segmental instability and in some patients with spinal stenosis- although no controlled studies have demonstrated its efficacy precisely. Approximately 80 to 90 % patients wearing a simple support describe some benefit. The mechanical effect includes prevention of excessive motion and a reminder to wearer not to exaggerate the lumbar load. Thoracolumbosacral corset has been prescribed in spondylolisthesis patients for a period of 3-6 months. This decreases pain in many patients during the acute episodes. In the mean time exercise programme to stretch the lumbar extensors, hamstrings, psoas, lumbodorsal fascia, teach pelvic tilting and strengthening programme for abdominals and avoidance of lumbar extension helps in relieving the condition.

References:

1-Management of Common musculoskeletal disorders, Physical therapy Principles and methods, 2nd edition, By Darlene Hertling and Randolph M. Kessler

2-Tidy's Physiotherapy, 12th Edition, By Ann Thomson, Alison Skinner, Joan Piercy

3- Textbook of Orthopaedic Medicine, Volume 1, Diagnosis of Soft Tissue Lesions, By James Cyriax

4-Mobilisation of Spine, A primary handbook of clinical methods, By Gregory P. Grieve, Fifth Edition

[alophysio]

Hi Dashrath,

In addition to the information provided by sdkashif, I would like to ask why you think the retrolithesis is significant. 7.5% is fairly small and you state that the neuro signs are negative.

Are you able to tell us more about his objective examination? What aggravates his pain? What eases his pain? How long has he had pain for? Why does he have pain now (accident or insidious onset)? What is FF/E/LF like? What is his sacral positioning like (since L5 is involved)? What about muscle tests and accessory movements?

Simply giving an exercise because someone has a retrolithesis doesn't make sense to me...

The answers to the above questions will be able to give you a more accurate guide as to what exercises to prescribe. I would see if he has restrictions in motion throught his ROM in the L/S and then seek to restore them. If for example extension is blocked at L5/S1 and it was painful, i wouldn't be giving extension exercises, i would seek to restore the segmental extension ROM then teach him simple exercises to maintain the ROM gained. etc etc.

Let us know how you get on...

[Dashrath]

Thanks both of you for guiding me.

My patient is having pain during extension and walking and it relieves after rest in supine lying with knee flexed. Prone lying is also painful.
His orthopaedic had advised not to wear corset as it would cause extension of the spine and he has to prevent extension at this stage.
His lumbo sacral angle is also increased about 10 degree.
His hamstrings are also tight and pelvis is posteriorly tilted.
As stated by sd kashif I think it is posterior elemental pain and we have to start flexion exercise as the acute stage of pain subsides.

[MANU PHYSIO]

Hello,dashrath.as already said above 7.5% retrolisthesis is not a matter to worry.provide rest in his acute stage.once spine become stable & painfree u can start static exs & progess later on to both flexion & extension exs. but gradually..