Of all the individuals with spondylolisthesis, the majority (79%) have low-grade slippage (Grade I), 20% have moderate slippage (Grade II) and 1% have severe slippage (Grade III).
It is important to appreciate that the majority of individuals presenting with radiographic evidence of spondylolisthesis are, in fact, asymptomatic. 1
I have now had 3 patients with persistent low back pain whom have had repeated lumbar manipulations while they had an underlying undetected spondylolisthesis. I was able to help the patients with their recovery by telling them to
(i) discontinue all manipulations & aggressive mobilizations to their lumbar spine,
(ii) avoid aggressive back stretches,
(iii) temporary use a lumbar brace and
(iv) focus on progressive stabilization exercises.3
If needed, I also focus on increasing mobility at the hips and the thoracic spine to reduce the stresses at the lumbar spine. Basically if the hips and thoracic spine are stiff, the body will move through the path of least resistance, the unstable L4-5.
If I suspect the patient of having a symptomatic spondylolisthesis, I refer them to their MD and request an oblique x-ray, as radiology is currently the only method we have for diagnosing spondylolisthesis.
I suspect this condition in my younger patients who fail to demonstrate a centralization or peripheralization phenomenon. I specially get suspicious if they have catching pain and have been involved in lumbar extension and rotation activities such as dancing, diving, gymnastics, pitching, etc.
To warrant an x-ray I need more than just a history of certain sports, I look for a “step deformity”.
What is the step deformity?
Palpate the lumbar spine spinous processes and look for an unusually protruding spinous process. The step deformity can be very mild or very obvious in some patients. The step deformity sign has been shown to have 81% sensitivity and 89% specificity, which is excellent.3
To warrant an x-ray I need more than just a little step deformity, I also need a +ve PLE test.
What is the PLE test?
The Passive Lumbar Extension (PLE) test, described by Kasai et al (2006) was designed to detect radiological instability of the lumbar spine.
With the patient in a prone lying, the PT applies a slight traction to both legs and lifts both of the patient?s legs approximately 30 cm off the table. The test is considered positive if LBP is elicited.
The PLE test was shown to have 84% sensitivity and 90% specificity in detecting radiological instability. 4 To warrant an x-ray I need more than just a +ve PLE test, I also need a +ve sacral-abdominal compression test.
What is the sacral-abdominal compression test?
Step #1: In standing, request the patient to flex forward or backward and ask them to rate their back pain (0-10) and then return to neutral again.
Step #2: In neutral standing, the PT applies an opposing compressive force through the sacrum with one hand and through the abdomen with the other hand.
With the opposing compression force sustained, the patient is once again requested to flex forward or backward. If significantly reduced pain is reported during the sacral abdominal compression force, it is considered a +ve test. (Sorry, I have no reference for this test, only anecdotal clinical experience).
To warrant an x-ray I need more than just a +ve sacral abdominal compression test, I also need a +ve Modified Prone Instability (PI) test.
What is the Modified PI Test?
Step #1: With the patient in relaxed prone lying, do a PA on the most symptomatic level; have the patient rate their pain, then let go the PA.
Step #2: Request the patient to tighten their stomach and squeeze their buttocks together; perform the PA on the exact same level again.
If symptoms are the same, the PI test is ?ve.
If symptoms dramatically improve or are resolved, then the Modified PI test is considered +ve.
The PI test has been to shown to be able to predict patients who are more likely to benefit from stabilization exercises.5 Clinical Relevance: To warrant a referral to an MD for an oblique x-ray, look for
Younger individual with low back pain of longer than 3 months + catching pain
Inability to centralize symptoms
Dancer, diver, figure skater, pitcher, etc.
+ve step deformity
+ve sacral abdominal compression test
+ve modified prone instability test
An MRI is warranted if a patient also has +ve neurological signs. Surgery is considered only in desperate cases where neurological deficits are progressing despite good PT care.
Although this is going to sound controversial, I do not believe in 100% avoiding extensions for individuals diagnosed with spondylolisthesis. I recall being taught in school and on courses to avoid extensions like the plague as lumbar extension exercises were an absolute contra-indication… but, based on what study?
In fact, I am perfectly fine extending patients with spondylolisthesis as long as they show symptomatic improvements. In fact one paper supports this concept.6
In my experience, rotation is more of an aggravating factor than extension; hence I recommend temporary taping and bracing to limit extreme rotations during golf swings, when getting in and out of a car or other ADLs involving rotations.
1. Osterman K, et al Isthmic spondylolisthesis in symptomatic and asymptomatic subjects, epidemiology, etc.. Clin Orthop Relat Res. 1993 Dec;(297):65-70.
2. Garet M et al Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review.Sports Health. 2013 May;(3):225-32.
3. Ahn K et al New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change. BMC Musculoskelet Disord. 2015 Apr 22;16:97.
4. Kasai Y, Morishita K, Kawakita E, Kondo T, Uchida A. A new evaluation method for lumbar spinal instability: passive lumbar extension test. Phys Ther. 2006;86:1661?7.
5. Rabin A et al The interrater reliability of physical examination tests that may predict the outcome or suggest the need for lumbar stabilization exercises. J Orthop Sports Phys Ther. 2013 Feb;43(2):83-90.
6. Spratt KF, et al Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis. Spine (Phila Pa 1976). 1993;18:1839-1849
Posted on: July 03, 2015
Categories: Lumbar Spine