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>From: John Willenbruch <[log in to unmask]> >Reply-To: - for physiotherapists in education and practice <[log in to unmask]> >To: [log in to unmask] >Subject: Re: spondylolisthesis! >Date: Fri, 8 Aug 2003 18:08:40 +1200 > >I would agree that in a case where it appeared that if a person had a symptomatic discogenic problem and an asymptomatic spondylolisethesis limiting there extension would be unnecessary, and encouraging extension may even be advisable, but Nabil describes a situation with a symptomatic spondylolisethesis and no other pathology. I don't really understand why you would advocate either a McKenzie assessment or promoting extension in treatment epecially when it is painful. > >I may have got the wrong end of the sticvk from the abstract but isn't the extension treatment they talk about in Spratt et al a brace to prevent that movement rather than exercises to promote it? > >Cheers, > >John > > > Dear Nabil, > > Regarding the 5 reps that all increased pain: that makes it (much) less likely that an extension regime will be helpful. But there is a catch: in case of (primarily) unilateral complaints, the side-gliding needs to be checked and (over)corrected first, before repeated extension. This is a basic McKenzie principle; otherwise there is a chance of sort of false-positive pain increase. (And to make things more difficult: that side-gliding should not be corrected in case of a ipsilateral latshift...) > > Nevertheless, it must be emphasized that McKenzie does not advocate an extension regime in all cases. In fact, while in adults with so-called non-specific LBP, 40% of patients found on-the-spot significant relief with repeated extension during a McKenzie assessment, 7% did so with repeated flexion (1). Let's presume that those who do not find on-the-spot relief would still respond to a 3-day trial, and divide them according to the found percentages, that means that in theory a significant percentage (> 14%) should be treated with a flexion regime, not with an extension. At that's exactly what McKenzie therapists do, with respect to ROM-exercises and posture correction: assessment first. > > Add to that that I'd think that those percentages could well be reverse in juvenile spondy-correlated LBP, and see that the only reason why I responded to John's message was that one should not *exclude* or prohibit extension in juveniles without prior assessment. That assessment, however, should be done in full and correctly; otherwise it is no use. > > Regarding the stabilization: have you build in enough static moments, and have you given her a home exercise program? The first can count on enough evidence to put the emphasis on it (2), and the second seems logical to me: twice a week isn't as effective as daily exercises. > > > References: > 1. Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion. A prospective, randomized, multicentered trial. Spine. 1991 Jun;16(6 Suppl):S206-12. > 2. www.ptitup.com | Archive & Search | Editorial June 2001 (free). > > > F.J.J. Conijn, PT > Editor, Physical Therapist's Literature Update > The Internet Journal of Literature Updates for Clinicians in Primary Care Orthopaedic Medicine & Rehabilitation > www.ptlitup.com > > > ----- Oorspronkelijk bericht ----- > Van: nabil keshavjee > Aan: [log in to unmask] > Verzonden: donderdag 7 augustus 2003 22:01 > Onderwerp: Re: spondylolisthesis! > > > Thanks for the additional info, John and Frank. > > When doing repeated tests, ie extensions, I only made > her do 5 repetitions, as the pain increased, after the > second rep, and continued increasing after each > repetition. I do not know whether I should push this > further. I guess being somewhat cautious given the > x-ray diagnosis. > As for lumbar stabilization, my knowledge is maybe > somewhat limited. I started with recruiting, > transverse abdominus, in supine, for teaching and > awareness of the patient. This followed by being able > to recruit in sitting and standing. Also doing > alternate leg lifts, in supine while contracting > transverse and maintaining a neutral spine. > Teaching multifidi, first in sidelying, or in prone. > Sidelying during this case. Have followed that by > going on all 4s, concracting transverse, then > simultaneously lifting the arm and alternate leg, > maintaining neutral spine. In this case I am not > allowing full leg extension. > Should I be adding anything to this regime.... > Was thinking of adding some ball exercise when I am > confident in her recruitment of lumbar stabilizers. > > Nabil >