With the development of pain science research, we regularly are seeing studies come out the show a lack of correlation between pathological findings on imaging and pain. Arthritis can start as early in the teenage years. Bulging discs and spinal stenosis are another sign of aging. One is almost abnormal for not having these findings. The only types of diagnoses that seem to benefit from imaging include fractures, infections, tethered cord syndrome, tumors and similar ones.
As I've mentioned recently, I've been reading the McKenzie texts to build a better understanding of the foundation of repeated motions. One of the diagnoses that many believe indicates we should not perform repeated extensions is spondylolisthesis. For those of you unfamiliar with the pathology, it typically represents a fracture of the pars interarticularis and slippage of the vertebra relative to the adjacent ones. The theory is that repeated forceful lumbar extension is the cause of spondylolisthesis via repetitive microtrauama, as this is frequently seen in gymnasts, volleyball players, dancers, and more. In the book, spondylolisthesis was actually not presented as a contraindicated. According to Spratt et al 1993, those with spondylolistheses have actually been shown to have an excellent response to repeated lumbar extensions. Now this can be interpreted in a couple different ways. It's possible people had an asymptomatic spondylolisthesis while also presenting with a symptomatic "disc injury" (excuse the pathological explanation). More appropriately, the patient may still have an extension directional preference, meaning they improve with repeated extensions.
Given this information, it's hard to know if we should associate spondylolistheses with repetitive microtrauma and "true pathology" or if it is simply another sign of aging. In my opinion, we should take any potential imaging findings and see if they connect with our clinical examination to determine if we should consider if a potential spondylolisthesis is pertinent to our patient's presentation. Simply because a patient has a spondylolisthesis doesn't necessarily mean that the specific pain episode they are presenting with doesn't have a directional preference of extension. Be sure to look at overall mobility deficits to decide which direction is most likely to respond.
-Dr. Chris Fox, PT, DPT, OCS
Spratt KF1, Weinstein JN, Lehmann TR, Woody J, Sayre H. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine (Phila Pa 1976). 1993 Oct 1;18(13):1839-49.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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