Isthmic spondylolisthesis: physical therapist viewpoint

By: Ron S. Miller, PT
October 10, 2000

This patient's subjective history and physical exam both point to the fact that placing his lower lumbar spine in a relatively forward flexed position tends to relieve symptoms. Although we know he has a disc bulge present at L4-L5 on MRI, we have found symptoms to be more consistent with his spondylolisthesis at L5-S1 and will treat accordingly.

One of the most important factors in this patient's response to physical therapy is having a good sense of body awareness. The patient is instructed that we are not trying to correct his spondylolisthesis, but he can be taught to continue performing all of his activities with greatly diminished if not completely resolved pain. The patient feels best in forward flexion. However, standing and walking in a forward flexed position is not practical, nor is it safe. Therefore, he is taught to perform a posterior pelvic tilt, flexing the lower lumbar spine from below and allowing him to maintain an erect posture.

Physical therapy treatment program

To achieve this position, a home program of stretching the trunk extensors and strengthening the trunk flexors (especially lower abdominals) will help. However, this exercise program alone will likely not improve his situation. This patient is then taught to recognize and maintain the pelvic tilt to his optimal position, which must be determined by the patient according to his symptoms. For this he must have a good sense of body awareness, which the therapist can help him develop through exercise. The most difficult task the patient has is to maintain this position with activity, especially those activities done in standing or walking. This is also his most beneficial task. For this, abdominal strength is important, though control is imperative.