Spondylolisthesis is a condition that will be all too familiar to chiropractors. Occurring due to overuse, injury or congenital defect (among other factors), the condition ranges in its presentation from asymptomatic to painful and debilitating.
Most often, it occurs in the lumbar and sacral areas of the spine (usually at L5-S1) when the lumbar spine slips off the sacrum. Usually, “Spondy” patients are told NSAIDS, discontinuation of contributing activities and (potentially) surgery are their best options in terms of management. But are they the only options? A range of chiropractic case studies suggest that chiropractic care and the correction of subluxations via a variety of protocols can impact this condition and offer hope beyond surgery and painkillers.
Currently, estimates as to the prevalence of Spondylolisthesis range between 3% and 11.5% of the general population, with a female to male ratio of 3:1 [1]. Its prevalence appears to increase among in older adults due to wear-and-tear induced stress fractures [2].
Regardless of the cause, Spondylolisthesis can cause debilitating pain. The laundry list of possible symptoms includes back and buttock pain, pain in one or both legs, leg weakness/numbness, difficulty walking, bending and in some cases, loss of bowel and bladder control [2]. Of course, there are the luckier cases where the condition causes no symptoms at all.
Unsurprisingly, those who are symptomatic (often due to higher ‘grades’ of the condition) are more likely to seek treatment to help improve their mobility, regain quality of life, and lower their pain. Many do indeed seek surgery, but those patients do so having considered the risks involved. These include, but are not limited to, a failure of the surgery to relieve symptoms [3].
Despite naysayers claiming that chiropractic care could cause more harm than good for the condition, a 1987 comparison study found that “the results of manipulative treatment are not significantly different in those patients with or without lumbar Spondylolisthesis [4].” This finding has not yet been scientifically debunked, which is encouraging news for chiropractors and their ‘spondy’ practice members.
Whilst we still lack larger studies (or randomised control trials) to confidently measure the impact of chiropractic care on the condition, there is more recent peer-reviewed literature available in the form of case studies examining chiropractic care and patients suffering from the condition. These all indicate that being under chiropractic care, whatever the specific clinical protocol used, can have a positive impact on pain, mobility and disability for patients.
Cue the Case Studies
The most recent of these was published in May of this year. It covered the case of a 69-year old female who presented with a grade 2 Spondylolisthesis at L4-L5 measuring 13.3mm [5]. Her condition left her suffering from severe leg cramping and moderate low back pain. The case provided “the first documented evidence of a non-surgical or chiropractic treatment, specifically Chiropractic BioPhysics®, protocols of lumbar Spondylolisthesis where spinal alignment was corrected [5].” Whilst further research is desired in order to further investigate the methods and implications, it does represent a significant contribution of the body of knowledge surrounding chiropractic care and Spondylolisthesis.
As part of her chiropractic care program, she completed “60 sessions of Mirror Image® spinal exercises, adjustments and traction over 45 weeks.” (Full details of the patients care, including measures to correct the impacts of maladaptive posturing, can be found at the reference below [5].)
After 60 sessions had been undertaken, a new set of x-rays revealed significant and encouraging results.
- “The L4-L5 spondylolisthesis was reduced 4.7 mm from 7.1 mm to 2.4 mm of anterior translation from re-exam 1 and a total of 10.9 mm from 13.3 mm to 2.4 mm of anterior translation from pre-treatment.
- The L4-L5 intersegmental translation was within normal levels. RRA L5-S1 improved 3.2° from -15.6° to -18.8° and the sacral base angle improved 3.5° from 33.5° to 37.0° from re-exam 1 to re-exam 2.
- RRA L5-S1 improved a total of 4.0° from -14.8° to -18.8°, the translation of L1-S1 improved a total of 6.0 mm from 29.3 mm to 23.3 mm, and the SBA improved a total of 7.6° from 29.4° to 37.0° from pre-treatment to re-exam 2.”
This is not the first time a case study has revealed a marked improvement in the condition for a person under chiropractic care. A 2004 case study examined a rare case of multi-level isthmic Spondylolisthesis (which occurs secondary to a defect of the pars interarticularis) [6]. Multi-level Spondylolisthesis is believed to be quite rare and reported cases, at the time of the studies publication, had all been treated surgically.
At the onset of acute pain, the 26-year old male patient presented at chiropractic clinic, where radiographs and a patient history revealed a long standing history of low back pain and a hyperextension injury causing a hairline fracture of the spine. Since that original injury, he had experienced sporadic pain, and (despite medical advice to avoid sports) wore a back brace during sports. He had noted that, at the massage school where he studied, deep tissue massage caused pain for weeks afterward [6].
It was a simple sneeze while lying prone that saw the acute pain set in. Initially, he exhibited limited range of motion in all directions (to approx. 10% and with considerable pain). In the acute phase, he underwent care every day for four days and then three times a week for three more weeks. His care involved “soft tissue massage, trigger point therapy, spinal mobilization techniques to the restricted areas and cryotherapy [6].” During the latter part of this period, he was “able to tolerate positioning and spinal manipulation at the sacro-iliac joints and thoraco-lumbar junction. Muscle energy techniques and Active Release Techniques were used on the muscles that were tight. As the patients condition improved treatment frequency dropped to twice a week for another 4 weeks.”
He was also placed on a rehabilitation program to improve strength, flexibility, proprioception and spinal stability. The case study reveals that, 2 months later, he was able to return to his usual activities including rock climbing, golf, gym and hockey. Ordinarily, it could be expected that such a serious and acute onset of symptoms would require more aggressive (i.e. surgical) interventions and permanent discontinuation of such activities.
Lucky for this young man, he was able to access care.
Yet another case study described a 43-year old male patient with a 20-year history of back pain due to an injury sustained in military duty [7]. Whilst reports of military personnel or athletes sustaining parachuting injuries leading to Spondylolisthesis isn’t uncommon, this particular case was traced back to an injury sustained falling from an amphibious vehicle. The case report described the approach to the patient and his condition as ‘conservative.’ Radiographs taken at the beginning of the mans chiropractic care program revealed “A grade I spondylolisthesis of L3 in regard to L4 and a grade II Spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects.” The authors of the case study also noted a narrowing of the L4-5 disk space with subchondral sclerosis.
Whilst this patient was fortunate in that his condition did not create problems for him in terms of sleep, bladder or bowel control, or increased pain during strain, he did report a 4/10 on the pain scale. He also reported pain with seated axial loading with lateral bending and rotation, and soft tissue hypertonicity was noted.
A care plan of 10 sessions over 8 weeks was undertaken at which point he was reassessed. At this point, his pain was reduced by 25%, with a 22% reduction in perceived disability related to lower back pain.
These are but a handful of examples detailing chiropractic interventions that have reaped successful outcomes for patients who happened to be suffering from the condition. Whilst the protocols and techniques used by the practitioners varied in all cases, they did all arrive at some improvement in a condition that may otherwise result in serious alterations to lifestyle, or even surgery. These provide strong indications that chiropractic care can and does have a role in the management of Spondylolisthesis.
Of course, more research on the matter would be desirable. As you can see, the evidence is in its infancy. If you have similar cases you are currently working with, your stories may be able to build up the evidence bank. As we know, more evidence is always good for the profession.
(Side note: Most journals put case study ‘How-To’ guides on their website, thus making the whole process a lot more straight forward. We will be running a story on that soon. Stay tuned.)
Far from being a condition that should preclude someone from being able to access the multiple benefits of chiropractic care, this evidence shows us that conservative measures could indeed have a role in preventing surgical interventions for spondylolisthesis.
A randomised control trial has not yet lit up our headlines, but it does show us that not only is chiropractic care not harmful for this condition [4], it can certainly be beneficial. A chiropractic intervention may be regarded as ‘conservative’ for this particular condition, and yet no one said ‘conservative’ was bad.
References
[1] Kalichman L, Kim D, Li L, Guermazi A, Berkin V and Hunter D (1976), “Spondylolysis and Spondylolisthesis: prevalence and association with low back pain in the adult community based population,” Spine (Phila Pa 1976). 2009 Jan 15; 34(2): 199–205. doi: 10.1097/BRS.0b013e31818edcfd
[2] Staff Writer, (2017), “Spondylolisthesis – Topic Overview,” Web MD, http://www.webmd.com/back-pain/tc/spondylolisthesis-topic-overview#1, retrieved 24 July 2017
[3] Ullrich, P, (2011), “Surgery for Degenerative Spondylolisthesis,” Spine Health, https://www.spine-health.com/conditions/spondylolisthesis/surgery-degenerative-spondylolisthesis retrieved 24 July 2017
[4] Mierau D, Cassidy JD, McGregor M, Kirkaldy-Willis WH, (1987), “A comparison of the effectiveness of spinal manipulative therapy for low back pain patients with and without Spondylolisthesis,” JMPT 1987: 10(2): 49-55
[5] Fedorchuk C, Lightstone DF, McRae C, Kaczor D: Correction of Grade 2 Spondylolisthesis Following a Non-Surgical Structural Spinal Rehabilitation Protocol Using Lumbar Traction: A Case Study and Selective Review of Literature. Radiology Case. 2017 May; 11(5):13-26. http://www.radiologycases.com/index.php/radiologycases/article/view/2924/fulltext
[6] Wong L, (2004), “Rehabilitation of a patient with a rare multi-level isthmic Spondylolisthesis: a case report,” Journal Canadian Chiropractic Association, Jun; 48(20): 142-151 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1840041/
[7] Dunn A, Baylis S and Ryan, D (2009), “Chiropractic Management of mechanical low back pain secondary to multiple-level lumbar spondylolysis and Spondylolisthesis in a United States Marine Corps veteran: a case report,” Journal of Chiropractic Medicine, Volume 8, Issue 3, September 2009, pp 125-130, http://www.sciencedirect.com/science/article/pii/S1556370709000662
[8] Leboeuf C, Kimber D, White K, “Prevalence of Spondylolisthesis, transitional anomalies and low intercrestal line in a chiropractic patient population,” Journal Manipulative and Physiological Therapeutics, June 1989, 12(3):200-204 http://europepmc.org/abstract/med/2526193
[9] Ferrari S, Vanti C, O’Reilly C (2012), “Clinical presentation and physiotherapy treatment of 4 patients with low back pain and isthmic Spondylolisthesis,” Journal Chiropractic Medicine, Volume 11, Issue 2, June 2012, pp. 94-103 http://www.sciencedirect.com/science/article/pii/S1556370712000119
[10] Excoffon S and Wallace H (2006), “Chiropractic and Rehabilitative Management of a Patient with Progressive Lumbar Disk Injury, Spondylolisthesis and Spondyloptosis,” Journal of Manipulative and Physiological Therapeutics, Vol. 29, Is. 1 January 2006, pp. 66-71, http://www.sciencedirect.com/science/article/pii/S0161475405003520
