Lumbar Spondylolysis and Spondylolisthesis Protocol

Initial Evaluation Evaluate

Hx:  Phase 2 static stability +1-4 weeks

 Review HEP
Spondylolysis – rest and protect o Pain management
o Neutral spine with daily activities
 Is it Acute traumatic vs repetitive stress spondylolysis due
o Core bracing techniques
to hyperextension?  If patient wasn’t braced initially are they a candidate for
o Can be unilateral or bilateral occurring L5 bracing?
vertebrae between 85-95% of the time; L4 5-15% o If rest and activity modification wasn’t successful for
of the time. pain management
 Most are unable to identify any particular traumatic  Re-assess neuro system
incident o Better /worse/same?
 Twice as common in male verse females  Joint mobility
 Genetic predisposition- seen within families (1st degree o Above and below site (hip and thoracic spine)
relatives)  Soft tissue restrictions locally or regionally due to potential
compensation
 Range of motion
o Full UE and LE range of motion w/ neutral spine
Is Spondylolisthesis present?

 Is it from spondylolysis or degenerative spondylolisthesis?

o Degenerative slippage seen at L4
o Rarely seen under age 40
o Progression of spondylolisthesis after age of 20 is
much less common compared to progression
during childhood and adolescence.
 Degree of anterolisthesis present may be of minimal
clinical importance, degree of LBP experienced has good
correlation with the degree of instability
 Prominent instability with minimal anterolisthesis is more
problematic then stable segments with prominent
anterolisthesis.

Imaging
 Xrays, flexion/extension, oblique
o CT/MRI
 Instability with segment?

Pain: Chief Complaint LBP seen in 47% of adolescents who

have spondylosis and 5% adults.

Location: Low back pain with radiculopathy (leg pain); pain

down one or both legs especially with extension positions;
Gluteals and posterior aspect thighs

 Spondylosis: Asymptomatic in majority of people.

o Active and inactive lesions: can be incidental
finding
 Back pain in child/adolescence raise suspicion newly
developed or impending spondylolysis
 o Especially athletes 15-47% of the population in
sporting activities that involve hyperextension and
rotation such as gymnastics, diving, wrestling,
dancing, throwing sports, soccer and baseball.
 Adults: look for concurrent instability with spondylolysis
 Low back pain usually worse with extension; most
common symptom
o Aggravated with lifting or walking
o Relieved with sitting

Posture:

 Child/adolescents: visual inspection may reveal

hyperlordosis
 Adult: Focal kyphosis at lumbosacral junction with
exaggerated lumbar lordosis

Palpation:

 Paraspinals muscle spasm

 Tender to palpation spinous process

Flexibility:

 Contracture/tight hamstrings
 Tight hip flexors

Gait:

 Flexed hips and knees

 Stiff legged, short stride, pelvic waddle

ROM:

 Limited/restricted active and passive motion

Neuro: more seen in spondylolisthesis

 Lumbar radiculopathy (irritation, stretching, compression

of the nerve root foramen): leg Numbness, tingling,
weakness.
o Assess dermatomes, myotomes, reflexes
o Central canal stenosis – neurogenic claudication
o cauda equina (higher grades spondylolisthesis)
 bowel and bladder changes
 neural tension
o Special tests:
 Step off deformity (high grade
spondylolisthesis)
 Limited SLR
 Pain with one legged standing lumbar
extension test

Patient Education Patient Education

 HEP  HEP
 Log rolling  Avoiding hyperextension
 Abdominal bracing  Good lifting mechanics
 Activity modifications/restrictions: avoiding
hyperextension and rotation
o Rest 8-12 weeks – acute spondylolysis
 Lifting techniques
 If in sports no sports

Therapeutic Exercise* Therapeutic Exercise*

Phase 1: rest and/or protect; first ~8-12 weeks for acute Phase 2: static stabilization weeks +1-4
spondylolysis/spondylolisthesis, week 0 degenerative
spondylolisthesis  general exercise:
o light to moderate stationary biking; deep water
 General exercise jogging with floats
o light stationary biking, TM walking with incline,
 bridges, sidelying hip abd, clamshells, side plank, UE/LE
Nustep
 Strengthening deep abdominal muscles and back muscles movements with abdominal bracing start supine/sitting and
(transverse abdominis and multifidi) progress to standing exercises (hip abd, hip extension,
o abdominal bracing (multiple positions)- be sure marching, pull downs, rows)
not over recruit w/ superficial abdominal muscles  Progression criteria: pain free static exercises, pain free lumbar
 Stretching in neutral positions (supine 90/90 active knee flexion or lateral flexion, maintain neutral spine with LE/UE
extension hamstring stretch, piriformis stretch, sidelying movements.
quad/hip flexor stretch)
o avoid hip flexor based strengthening
 Pain control
o Nsaids
o Analgesics
o Injections-after 4-6 weeks if other conservative
measures fail
 Bracing
o Usually not needed for most people, no clinical
significant differences seen with wearing
o Can be used to decrease lumbar lordosis and
manage pain if 2-4 weeks of rest/activity
modification alone don’t reduce pain.
o Worn 23 hours/day for 6 months
 Modalities
o Low intensity pulsed ultrasound (LIPUS)
 Early studies thus far have been
promising for increasing healing times
frames especially with progressive stage
fractures.
 Heat/ice
 TENS

Manual Techniques Manual Techniques

 Stretching hip flexors/hamstring (keep hip mobility intact)  Continue stretching PRN
 Dry needling pain relief  STM any muscular restrictions/pain
 Thoracic manipulation for pain relief  Joint mobilization grd 1-2 for pain alleviation thoracic spine;
 Gentle STM to paraspinals/other tender areas based on manipulation for global pain modulation and neuromuscaular
palpation facilitation
 Segmental traction for pain relief  Dry needling pain relief

Goals Goals
 Independent with pain management strategies  Maintain pain free (nearly) range, pain free daily activities,
o pain free daily activities increase core strength, normal hip and thoracic mobility,
 Independent with HEP (general exercise, core bracing, progress flexibility and lumbar stabilization to WB postures,
neutral spine, gradually increase flexibility upper and improve proprioception.
lower extremities)
 Understanding importance of activity
restriction/modifications- avoiding hyperextension

* Exercises within each category are to provide the clinician with examples based on evidence based research, but are not all inclusive
 Evaluate Evaluate

Phase 3: dynamic stabilization; +4-6 Phase 4: coordination, athletic development; +6-8

 Is patient progressing as expected?  ROM: spine/UE/Le should be WNL

 ROM spine  Joint mobility- WNL
o Progressing towards full range, no restrictions  Soft tissue- no restrictions
 Joint mobility  Neuro - WNL
o Progressing towards normal mobility globally
 Soft tissue Progression criteria: pain free with all motions
o Decreased protective tone, restore normal tension
Phase 5: return to sport +3-6 months
 Neuro screening – WNL
o If persistent neuro- referral out? Is Non- Precautions: may need to be cautious with returning to Olympic
union/instability present? lifting (power lifting)
Precautions: avoid prolonged pain with initiation lumbar
extension AROM

Progression criteria: no increase in pain with lumbar range of

motion.

Patient Education Patient Education

 Pain management with increased lumbar range of motion  Importance of good mechanics with high level activities

Therapeutic Exercise* Therapeutic Exercise*

 General exercise: mod intensity stationary biking or  Phase 4: Suggested exercises: chopping/lifting patterns
elliptical machine, shallow water (chest deep water) (diagonals), body weight suspension exercises TRX,
 Suggested exercises: single leg brides, plank, squats/hip progression impact loading (sport specific), gradual exposure to
sport specific activities/drills
hinge, upper body lifting w/ spine neutral, lunges, oblique
 Phase 5: Suggested exercises: squats with medicine ball
rotations starting in HL/supine, OH reaching. throw/rotations, single leg DL with weight, front squat, lunges
with twist, hip sleds, plyometrics, abdominal workouts, sports
specific exercises.
Manual Techniques Manual Techniques
 Joint mobilizations/manipulation pain relief, mobility,  Joint mobilization grade 3-4 – mobility
neuromuscular facilitation  Dry needling
 Dry needling pain/neuromuscular facilitation  STM
 STM  Stretching PRN
 Stretching PRN
Goals Goals
 normal joint mobility in thoracic spine and hip, resume  Phase 4: maintain strength and flexibility, lumbar extension in
lumbar extension NWB, maintain flexibility, and continue WB, impact loading
increasing strength and coordination.  Phase 5 Goals: full participation in sports

* Exercises within each category are to provide the clinician with examples based on evidence based research, but are not all inclusive
 Special Considerations

 Conservative management: depends on the grade, high success for early and progressive spondylosis, and impact on daily life
o Can take 3-6 months to heal majority of unilateral fractures and 50% bilateral
 Surgery
o Symptoms persistent > 6months
o neurological complications (persistent )
o Segmental Instability
o Progression slippage grade III or higher

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