Treatment options for spondylolisthesis
I had an e-mail this week from a blog reader who asked whether the Sarah Key exercises I’ve blogged so far would be good for spondylolisthesis.
Spondylolisthesis is a condition which affects 3–6% of the population in which one vertebra — most commonly the L4 or L5, at the bottom of the spine — slips forward on the one below it. Left uncontrolled, it produces a more exaggerated curve of the low back, like those you often see in men with really big tummies or pregnant women. The grade of spondylolisthesis is determined by an X-ray to see how far the upper vertebra has slipped — a grade I being a forward slippage of 1/4 of a vertebral body, grade II being half, and so on. Surgeons tend to get involved with grade II+ spondylolistheses as the slippage is more likely to be a danger to the spinal cord.
There is a fair amount of evidence in the literature for strengthening the core muscles of spondylolisthesis patients, particularly the transversus abdominis which acts like an internal corset, and the multifidus which acts like the guy ropes of a tent to shore up and stabilise the slipped vertebra. I’ll go through some useful exercises for these in future posts as they are excellent for any form of instability, but incidentally this is one situation where I think exercise methods such as Pilates can be really useful.

As well as core exercises, I really rate the back block for spondylolisthesis patients. Traditional physiotherapy extension exercises are carried out from the prone (face down) position, where the patient pushes up onto elbows or hands to extend the spine. I don’t use this for spondylolisthesis patients because gravity, as you can see from the top diagram, acts on the vertebrae to produce an anterior (forward) shear — exactly the same force that causes spondylolisthesis! Lots of physiotherapists have therefore moved away from prescribing extension exercises to spondylolisthesis patients.
By contrast, however, the back block exercises are done in a supine (face up) position. This results in gravity pulling the vertebrae towards a position of backward shear, as you can see in the lower diagram — and thus into a more neutral position away from the spondylolisthesis slip.
The effect of this tends to be (gradual, cumulative) better alignment of the spondylolisthetic segment, and also reduced muscle spasm and reduced pain.
Of course, not every case is that simple: longstanding spondylolisthesis problems often lead to altered muscle control and movement patterns, as you start to compensate for the discomfort of the injury. Using a back block doesn’t replace a proper assessment and treatment plan in every case. But if your physio isn’t already getting you onto a back block, it might be something to discuss.
