Comparison of lumbar segmental stabilization and general exercises on clinical and radiologic criteria in grade-I spondylolisthesis patients: A double-blind randomized controlled trial.

OBJECTIVES: The effects of different physiotherapy protocols on patients suffering from grade-I spondylolisthesis have been thus far examined in a limited number of clinical trials. Therefore, the main purpose of this study was to compare the effects of lumbar segmental stabilization and general exercises on clinical and radiologic criteria in grade-I spondylolisthesis patients. METHODS: This study was a double-blind randomized controlled trial (RCT) with a test-retest design and parallel groups. A total of 26 patients with grade-I spondylolisthesis were thus randomly assigned to experimental group (13 patients, lumbar segmental stabilization exercises) and control group (13 patients, general exercises). Subsequently, pain, functional disability, kinesiophobia, translational motion, angular motion and slip percentage of the vertebra were investigated. RESULTS: Of the 120 people recruited in this study, only 26 patients were eligible. According to pre/post-intervention comparison, a statistically significant decrease was observed in the experimental group in terms of pain (p = 0.000), functional disability (p = 0.004), kinesiophobia (p = 0.002), translational motion (p = 0.043) and angular motion (p = 0.011), but not for slip percentage (p = 0.122). Considering the control group, a statistically significant decline was reported for pain (p = 0.043) and functional disability (p = 0.002). However, no significant differences were found for other variables in the control group. With regard to inter-group comparison, there was no statistically significant difference between the two groups regarding the given variables except for kinesiophobia (p = 0.040). CONCLUSION: Both lumbar segmental stabilization and general exercises led to reduction in pain and functional disability of patients with grade-I spondylolisthesis. Therefore, lumbar segmental stabilization exercises seemed to be better than general ones with reference to improving kinesiophobia and intervertebral movements.

Case manager-assisted rehabilitation for lumbar spinal fusion patients: an economic evaluation alongside a randomized controlled trial with two-year follow-up.

OBJECTIVE: To examine the cost-effectiveness of case manager-assisted rehabilitation as an add-on to usual physical rehabilitation after lumbar spinal fusion, given the lack of any clinical benefits found on analysing the clinical data. DESIGN: Economic evaluation alongside a randomized controlled trial with two-year follow-up. SETTING: Patients from the outpatient clinics of a university hospital and a general hospital. SUBJECTS: A total of 82 lumbar spinal fusion patients. INTERVENTIONS: Patients were randomized one-to-one to case manager-assisted rehabilitation programme as an add-on to usual physical rehabilitation or to usual physical rehabilitation. MAIN MEASURES: Oswestry Disability Index and EuroQol 5-dimension. Danish preference weights were used to estimate quality-adjusted life years. Costs were estimated from micro costing and national registries. Multiple imputation was used to handle missing data. Costs and effects were presented with means (95% confidence interval (CI)). The incremental net benefit was estimated for a range of hypothetical values of willingness to pay per gain in effects. RESULTS: No impact of case manager-assisted rehabilitation on the Oswestry Disability Index or estimate quality-adjusted life years was observed. Intervention cost was Euros 3984 (3468; 4499), which was outweighed by average reductions in inpatient resource use and sickness leave. A cost reduction of Euros 1716 (-16,651; 20,084) was found in the case manager group. Overall, the probability for the case manager-assisted rehabilitation programme being cost-effective did not exceed a probability of 56%, regardless of willingness to pay. Sensitivity analysis did not change the conclusion. CONCLUSION: This case manager-assisted rehabilitation programme was unlikely to be cost-effective.

Does adding case management to standard rehabilitation affect functional ability, pain, or the rate of return to work after lumbar spinal fusion? A randomized controlled trial with two-year follow-up.

OBJECTIVE: To examine the effect of a case manager-assisted rehabilitation programme as an add-on to usual physical rehabilitation in patients undergoing lumbar spinal fusion. DESIGN: A randomized controlled trial with a two-year follow-up. SETTINGS: Outpatient clinics of a university hospital and a general hospital. SUBJECTS: In total, 82 patients undergoing lumbar spinal fusion. INTERVENTIONS: The patients were randomized one-to-one to case manager-assisted rehabilitation (case manager group) or no case manager-assisted rehabilitation (control group). Both groups received usual physical rehabilitation. The case manager-assisted rehabilitation programme included a preoperative meeting with a case manager to determine a rehabilitation plan, postsurgical meetings, phone meetings, and voluntary workplace visits or roundtable meetings. MAIN MEASURES: Primary outcome was the Oswestry Disability Index. Secondary outcomes were back pain, leg pain, and return to work. RESULTS: Of the 41 patients in the case manager group, 49% were men, with the mean age of 46.1 (±8.7 years). In the control group, 51% were male, with the mean age of 47.4 (±8.9 years). No statistically significant between-group differences were found regarding any outcomes. An overall group effect of 4.1 points (95% confidence interval (CI): -1.8; 9.9) was found on the Oswestry Disability Index, favouring the control group. After two years, the relative risk of return to work was 1.18 (95% CI: 0.8; 1.7), favouring the case manager group. CONCLUSION: The case manager-assisted rehabilitation programme had no effect on the patients' functional disability or back and leg pain compared to usual physical rehabilitation. The study lacked power to evaluate the impact on return to work.

Comparison of Posterior Lumbar Interbody Fusion and Microendoscopic Muscle-preserving Interlaminar Decompression for Degenerative Lumbar Spondylolisthesis With >5-Year Follow-up.

STUDY DESIGN: Retrospective analysis of prospectively collected observational multicenter data. OBJECTIVE: To compare the clinical results and rates of revision surgery after posterior lumbar interbody fusion (PLIF) and microendoscopic muscle-preserving interlaminar decompression (ME-MILD) in patients with single-level, mild degenerative lumbar spondylolisthesis (DLS) and follow-up of at least 5 years. SUMMARY OF BACKGROUND DATA: Surgery for symptomatic DLS remains controversial. Evaluating long-term results may reveal problems such as adjacent segmental diseases of the PLIF and decreased quality of life because of slippage and restenosis of the ME-MILD. METHODS: We enrolled 116 patients who underwent PLIF (79 patients) or ME-MILD (37 patients). Operative times, blood losses, surgical complications, Short-Form 36 (SF-36), Japanese Orthopedic Association (JOA) score, the JOA Back Pain Questionnaire (JOABPEQ), visual analog scales (VAS), and Zurich Claudication Questionnaire (ZCQ) were evaluated. RESULTS: PLIF was observed to require significantly longer operative times and entailed greater operative blood losses than did ME-MILD (151.1 vs. 119.9 min; 202.2 vs. 6.4 mL, respectively). Surgery-related complications were identified in 3 cases in the PLIF group and 2 cases in the ME-MILD group. Seventy-eight patients (50 and 28 patients in the PLIF and ME-MILD groups, respectively) were successfully followed-up for >5 years. The follow-up rate was 67.2%. No significant differences between the groups were found in terms of preoperative and postoperative JOA scores, postoperative JOABPEQ, VAS, or ZCQ. Significant improvements in JOA scores were observed in both groups. Significant improvements in the SF-36 were observed in all subscales except in role physical, general health, vitality, and mental health in the ME-MILD group. Revision surgical procedures were performed in 2 patients in the ME-MILD group and 4 patients in the PLIF group. CONCLUSIONS: PLIF and ME-MILD resulted in equivalent improvements in SF-36 and JOA scores. There were no differences in revision surgery rates among patients with single-level, mild DLS. LEVEL OF EVIDENCE: Level III-a retrospective analysis.

The importance of proximal femoral angle on sagittal balance and quality of life in children and adolescents with high-grade lumbosacral spondylolisthesis.

PURPOSE: Previous studies did not specifically assess the influence of proximal femoral angle (PFA) on sagittal balance in high-grade spondylolisthesis (HGS). In addition, the relationship between PFA and quality of life (QOL) remains unknown. This study determines if increased PFA is associated with decreased QOL and sagittal balance in lumbosacral HGS. METHODS: This retrospective case-control study was performed on a cohort of 56 normal subjects and 42 patients with HGS. Initially, PFA was measured twice by 3 raters in a random subset of 30 subjects (15 normal and 15 HGS) to determine the intrarater and interrater reliability of the measurement technique. PFA was then measured for all subjects. For the 42 patients with HGS, QOL was assessed from the SRS-22 questionnaire, in addition to the evaluation of the spino-pelvic balance. RESULTS: The intrarater and interrater intraclass correlation coefficients for the measurement of PFA were, respectively, 0.951 and 0.958, suggesting excellent reliability. PFA was significantly higher in HGS patients (8.3° ± 6.7°; range - 5° to 24°) when compared to normal subjects (3.0° ± 3.1°; range - 6° to 10°). The PFA in HGS was 5.6° ± 5.6° (range - 5° to 18°), 8.9° ± 6.7° (range - 2° to 24°), and 14.0° ± 6.0° (range 7°-23°) in type 4 (balanced pelvis), type 5 (unbalanced pelvis/balanced spine), and type 6 (unbalanced pelvis and spine) subjects, respectively. There were, respectively, 23.5% (4/17), 26.3% (5/19), and 83.3% (5/6) of HGS patients with abnormal PFA ≥ 10° in type 4, type 5, and type 6 subgroups. Increased PFA in HGS patients was related with deteriorating self-image, pain, function and total SRS-22 score, as well as with increasing pelvic tilt and decreasing sacral slope. CONCLUSION: A PFA ≥ 10° is proposed as a criterion to define abnormal PFA. PFA was increased in HGS and increased along with deteriorating sagittal balance and QOL. PFA is a clinically relevant parameter of sagittal balance, and can be useful in the evaluation and management of patients with HGS.

How many physical therapy sessions are required to reach a good outcome in symptomatic lumbar spondylolisthesis? A retrospective study.

BACKGROUND: There is a lack of conclusive information about the optimal dosage of physical therapy treatments in Spondylolisthesis (SPL) patients. PURPOSE: The present study attempted to evaluate the comparative effectiveness of two different doses in reaching similar clinical outcomes. METHODS: A retrospective cohort study of 64 consecutive patients admitted for physical therapy with symptomatic lumbar grade I SPL (42 ± 15years, 57% female) was conducted. At the end of the treatment, all participants were retrospectively assigned to one of two groups, receiving either 5-8 or 9-12 sessions (experimental or control group, respectively) of physical therapy treatments. The Prone Bridge Test (PBT) and the Supine Bridge Test (SBT) were used to measure muscular endurance. RESULTS: The area under the ROC curve for the PBT was 0.64 (95% CI 0.45-0.83) and for the SBT was 0.57 (95% CI 0.33-0.80). The optimal cutoff points were 25.5s for the PBT and 55.0s for the SBT. Logistic regression revealed that PBT (OR = 1.062) was associated with SPL. The final regression model explained 77.4% (R2 = 0.341; p = 0.024) of the variability. CONCLUSIONS: In this sample, the number of sessions required to achieve satisfactory outcomes ranged from 5 to 12. The clinical results of the subjects in the 5-8 sessions group were similar to the 9-12 sessions group. Individual's coping mechanisms could be considered in future studies to understand which patients will require more therapeutic sessions.

Effectiveness of postoperative home-exercise compared with usual care on kinesiophobia and physical activity in spondylolisthesis: A randomized controlled trial.

OBJECTIVE: To study the effectiveness of a 12-month exercise therapy on kinesiophobia and physical activity in patients with spondylolisthesis after lumbar spine fusion. DESIGN: Randomized controlled trial. SUBJECTS: Patients (n = 98) with spondylolisthesis who had undergone lumbar spine fusion. METHODS: All patients (mean age 59 years) had received lumbar spine fusion surgery and identical postoperative instructions. Three months postoperatively, they were randomized into an exercise group (n = 48) or usual care group (n = 50). The exercise group received 12-month progressive home-based training with regular booster sessions, and the usual care group a single session of physiotherapy instruction. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK) and physical activity by the International Physical Activity Questionnaire (IPAQ) preoperatively, 3 months after lumbar spine fusion, and at the end of the 12-month intervention. RESULTS: Before the intervention, the median (first quartile; third quartile) of TSK was 32.5 (29.0; 37.0) in the exercise group and 30.0 (25.8; 36.0) in the usual care group, changing to 30.0 (25; 36) in the exercise group and to 30.5 (24; 36.3) in the usual care group (between-group p = 0.17). IPAQ metabolic equivalent minutes per week increased from 1,863 (1,040; 3,042) to 3,190 (1,634; 6,485) in the exercise group and from 2,569 (1,501; 4,075) to 3,590 (1,634; 6,484) in the usual care group (between-group p = 0.92). CONCLUSION: Progressive 12-month home-exercise starting 3 months postoperatively was not superior to usual care in decreasing kinesiophobia or increasing physical activity in spondylolisthesis.

A minimal soft tissue damage approach of spondylolysis repair in athletes: preliminary report.

PURPOSE AND HYPOTHESIS: Both spondylolysis and spondylolisthesis come in second place in the causes of pain among athletes. Treatment options include both conservative management and different operative methods. Athletes and adolescents are groups where the priority is to protect tissues from perioperative damage. OBJECTIVE: We present our modification of the Buck's, direct pars repair method, which we believe offers maximum protection of tissues. We used the modified surgical method in young, competitive athletes, in whom non-surgical treatment was not effective. METHOD: Eight pars defects in five patients were treated using suggested method. All of them were young males (aged between 13 and 18 years), who practice soccer professionally. We use modified method of direct repair pars through the cannulated screw fixation, first proposed by Buck. Preoperative preparation consists of proper analysis of computer tomography images in multiplanar reconstruction mode: measuring screw length, measurement of inclination angle of the optimal screw trajectory in the frontal and sagittal plane. During the operation, the wire proper direction is performed by usage of the predetermined angles. Starting point for guide wire was also changed to the lower end of the facet. The fusion takes place with a screw of 3 mm diameter. After the operation patient need to use thoracolumbar spinal orthosis as a primary immobilization for 6 weeks and appropriate rehabilitation for another 6 weeks. We used these methods in eight pars fixations. RESULTS: All of the patients were painless in first week after surgery. All of them underwent total rehabilitation programme and returned to sport. CONCLUSIONS: Direct pars repair using Buck's method with proposed modification, including adequate radiographic preparation, the use of a thin cannulated screw and changing the point of screw entry, allows precise and safe screw placement, regardless of the size of the bone at the defect site.

Responsiveness and minimum important change of the Oswestry Disability Index in Italian subjects with symptomatic lumbar spondylolisthesis.

BACKGROUND: This study aims to investigate the responsiveness and the minimum important change of the Italian version of the Oswestry Disability Index (ODI-I) in subjects with symptomatic specific low back pain associated with lumbar spondylolisthesis (SPL). MATERIALS AND METHODS: One hundred and fifty-one patients with symptomatic SPL completed the ODI-I, a 0-100 numerical rating scale (NRS), and performed the prone and supine bridge tests. The global perception of effectiveness was measured with a 7-point Likert scale. Responsiveness was assessed by distribution methods (minimum detectable change [MDC], effect size [ES], standardized response mean [SRM]) and anchor-based methods (ROC curves). RESULTS: The MDC was 4.23, the ES was 0.95 and the SRM was 1.25. ROC analysis revealed an area under the curve of 0.76 indicating moderate discriminating capacity. The best cut-off point for the dichotomous outcome was 7.5 (sensitivity 90.3%, specificity 56.7%). . CONCLUSIONS: The ODI-I proved to be responsive in detecting changes after conservative treatment in subjects with lumbar SPL. LEVEL OF EVIDENCE: II.

Responsiveness of the bridge maneuvers in subjects with symptomatic lumbar spondylolisthesis: A prospective cohort study.

BACKGROUND AND PURPOSE: To date no study was made on the responsiveness of Bridge tests (BTs) in subjects with low back pain and spondylolisthesis (SPL) submitted to a physical therapy program. The objective of this study is to examine the responsiveness of the BTs in subjects with symptomatic lumbar SPL. METHODS: One hundred twenty patients with symptomatic SPL received physical therapy treatments for a number of sessions depending on the individual patient's needs. Each session included supervised exercises and the teaching of home exercises aiming to improve the lumbar stability, for about 1 hr in total. At the beginning and immediately after the last session of treatment, participants completed the Oswestry Disability Index - Italian version and the Pain Numerical Rating Scale, and performed the supine bridging (SBT) and the prone bridging (PBT). The global perception of effectiveness was measured with a seven-point Likert scale Global Perceived Effect questionnaire. RESULTS: The mean post-treatment change score (95% confidence interval [CI]) was 18.2 s (14.5; 21.9) for the PBT and 43.9 s (35.1; 52.8) for the SBT, all p < .001. The area under the receiver operating characteristic curve for the PBT was 0.83 (95% CI 0.74-0.91) and for the SBT was 0.703 (95% CI 0.61-0.80). The optimal cutoff points were 19.5 s for the PBT and 62.5 s for the SBT. Logistic regression revealed that PBT (odds ratio = 0.952) was associated with the type of SPL. The final regression model explained 36.4% (R2  = 0.36; p = .001) of the variability. DISCUSSION: Bridge maneuvers proved to be responsive, because their results were significantly related to pain and disability changes. BTs may be suggested to detect clinical changes after physical therapy treatment in symptomatic SPL. Copyright © 2017 John Wiley & Sons, Ltd.

The effects of muscle weakness on degenerative spondylolisthesis: A finite element study.

BACKGROUND: Whether muscle weakness is a cause, or result, of degenerative spondylolisthesis is not currently well understood. Little biomechanical evidence is available to offer an explanation for the mechanism behind exercise therapy. Therefore, the aim of this study is to investigate the effects of back muscle weakness on degenerative spondylolisthesis and to tease out the biomechanical mechanism of exercise therapy. METHODS: A nonlinear 3-D finite element model of L3-L5 was constructed. Forces representing global back muscles and global abdominal muscles, follower loads and an upper body weight were applied. The force of the global back muscles was reduced to 75%, 50% and 25% to simulate different degrees of back muscle weakness. An additional boundary condition which represented the loads from other muscles after exercise therapy was set up to keep the spine in a neutral standing position. Shear forces, intradiscal pressure, facet joint forces and von Mises equivalent stresses in the annuli were calculated. FINDINGS: The intervertebral rotations of L3-L4 and L4-L5 were within the range of in vitro experimental data. The calculated intradiscal pressure of L4-L5 for standing was 0.57MPa, which is similar to previous in vivo data. With the back muscles were reduced to 75%, 50% and 25% force, the shear force moved increasingly in a ventral direction. Due to the additional stabilizing force and moment provided by boundary conditions, the shear force varied less than 15%. INTERPRETATION: Reducing the force of global back muscles might lead to, or aggravate, degenerative spondylolisthesis with forward slipping from biomechanical point of view. Exercise therapy may improve the spinal biomechanical environment. However, the intrinsic correlation between back muscle weakness and degenerative spondylolisthesis needs more clinical in vivo study and biomechanical analysis.

Quality of life and disability: can they be improved by active postoperative rehabilitation after spinal fusion surgery in patients with spondylolisthesis? A randomised controlled trial with 12-month follow-up.

PURPOSE: The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF). METHODS: Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n = 48) or usual care group (UCG) (n = 50) 3 months after LSF. EG patients had home-based progressive strength and aerobic training program for 12 months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1 year after intervention. RESULTS: The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p = 0.69). At 1-year follow-up, 25 % of the EG and 28 % of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95 % CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention. CONCLUSIONS: The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients.

Correction of Grade 2 Spondylolisthesis Following a Non-Surgical Structural Spinal Rehabilitation Protocol Using Lumbar Traction: A Case Study and Selective Review of Literature.

OBJECTIVE: Discuss the use of non-surgical spinal rehabilitation protocol in the case of a 69-year-old female with a grade 2 spondylolisthesis. A selective literature review and discussion are provided. CLINICAL FEATURES: A 69-year-old female presented with moderate low back pain (7/10 pain) and severe leg cramping (7/10 pain). Initial lateral lumbar x-ray revealed a grade 2 spondylolisthesis at L4-L5 measuring 13.3 mm. INTERVENTIONS AND OUTCOMES: The patient completed 60 sessions of Mirror Image® spinal exercises, adjustments, and traction over 45 weeks. Post-treatment lateral lumbar x-ray showed a decrease in translation of L4-L5 from 13.3 mm to 2.4 mm, within normal limits. CONCLUSIONS: This case provides the first documented evidence of a non-surgical or chiropractic treatment, specifically Chiropractic BioPhysics®, protocols of lumbar spondylolisthesis where spinal alignment was corrected. Additional research is needed to investigate the clinical implications and treatment methods.

Can physical therapy centred on cognitive and behavioural principles improve pain self-efficacy in symptomatic lumbar isthmic spondylolisthesis? A case series.

PURPOSE: Pain-related self-efficacy is defined as "the beliefs held by people with chronic pain that were able to carry out certain activities, even when experiencing pain", and it is considered a relevant mediator in the relationship between pain and disability in chronic low back pain. This case series describes a treatment aiming to improve pain self-efficacy in patients with symptomatic lumbar spondylolisthesis. METHOD: Ten consecutive outpatients with lumbar spondylolisthesis and chronic LBP referred to a rehabilitative clinic participated in this study. Cognitive and behavioural principles were integrated with functional and graded approach in each individual physical therapy program. The outcome measures concerned clinical instability and endurance tests, pain, disability and self-efficacy. RESULTS: Pain self-efficacy and lumbar function improved in 7 out of 10 patients; clinical tests improved in 9 out of 10 patients. CONCLUSION: A rehabilitation program carried out by a physical therapist, centred on cognitive and behavioural principles, appeared useful in improving pain self-efficacy and lumbar function. These results may be interesting for future controlled trials.

Effects of the Pilates method on variables related to functionality of a patient with traumatic spondylolisthesis at L4-L5: A case study.

INTRODUCTION: Traumatic spondylolisthesis at L4-L5 is a rare complication in the spine, which impairs variables related to the functionality of the person affected. OBJECTIVE: To verify the effects of the Pilates method on strength and muscular resistance, flexibility, postural balance and level of pain in a patient with traumatic spondylolisthesis at L4-L5. METHODS: The following evaluations were performed pre and post-intervention: resistance of the flexor and extensor muscles of the trunk; isokinetic peak torque of the extensor and flexor muscles of the knee; hip and torso flexibility; static postural balance; and the visual analog scale of pain. The treatment consisted of three weekly sessions of Pilates, performed over 12 weeks. RESULTS: There was improvement in all the tests, except for one variable related to postural balance. CONCLUSIONS: The Pilates method was effective for improving muscle resistance and strength, flexibility, postural balance and pain, in a patient with traumatic spondylolisthesis at L4-L5.

Workers' Compensation, Return to Work, and Lumbar Fusion for Spondylolisthesis.

Lumbar fusion for spondylolisthesis is associated with consistent outcomes in the general population. However, workers' compensation is a risk factor for worse outcomes. Few studies have evaluated prognostic factors within this clinically distinct population. The goal of this study was to identify prognostic factors for return to work among patients with workers' compensation claims after fusion for spondylolisthesis. The authors used International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes to identify 686 subjects from the Ohio Bureau of Workers' Compensation who underwent fusion for spondylolisthesis from 1993 to 2013. Positive return to work status was recorded in patients who returned to work within 2 years of fusion and remained working for longer than 6 months. The criteria for return to work were met by 29.9% (n=205) of subjects. The authors used multivariate logistic regression analysis to identify prognostic factors for return to work. Negative preoperative prognostic factors for postoperative return to work included: out of work for longer than 1 year before fusion (P<.001; odds ratio [OR], 0.16); depression (P=.007; OR<0.01); long-term opioid analgesic use (P=.006; OR, 0.41); lumbar stenosis (P=.043; OR, 0.55); and legal representation (P=.042; OR, 0.63). Return to work rates associated with these factors were 9.7%, 0.0%, 10.0%, 29.2%, and 25.0%, respectively. If these subjects were excluded, the return to work rate increased to 60.4%. The 70.1% (n=481) of subjects who did not return to work had markedly worse outcomes, shown by higher medical costs, chronic opioid dependence, and higher rates of failed back syndrome, total disability, and additional surgery. Psychiatric comorbidity increased after fusion but was much higher in those who did not return to work. Future studies are needed to identify how to better facilitate return to work among similar patients with workers' compensation claims.

Espondilolisis y espondilolistesis en niños y adolescentes / Spondylolysis and spondylolisthesis in children and adolescents

El dolor lumbar es causa frecuente de cese de actividades deportivas en atletas jóvenes, y la espondilolisis es su causa identificable más común. Aunque los avances en las técnicas radiológicas permiten su diagnóstico en fases precoces, en algunos casos la progresión a espondilolistesis es asintomática y no se detecta hasta fases avanzadas. No hay consenso en el objetivo del tratamiento, que consiste en la resolución clínica, radiológica, biomecánica o funcional, según autores. También hay falta de acuerdo en el tratamiento conservador ideal, en las indicaciones quirúrgicas y en la necesidad de reducción de la espondilolistesis, y muchas recomendaciones establecidas no están avaladas por la evidencia. Presentamos una revisión de la bibliografía que resume el conocimiento actual de la espondilolisis y espondilolistesis en niños y adolescentes (AU)

Low back pain is a common cause of lost playing time in young athletes, and spondylolysis is its most common identifiable cause. Despite technological advances in radiology, which can lead to an early diagnosis with better prognosis, progression to spondylolisthesis is sometimes asymptomatic and may not be detected until late stages. There are wide variations, suggesting lack of consensus as regards the objective of treatment, which consists of clinical, radiological, biomechanical or functional improvement. There is also a lack of agreement regarding the ideal conservative treatment, surgical indications and need of slip reduction, and most of the established recommendations are not evidence based. We present a review of literature, which summarizes the current knowledge of spondylolysis and spondylolisthesis in children and adolescents (AU)

Pain, disability, and diagnostic accuracy of clinical instability and endurance tests in subjects with lumbar spondylolisthesis.

OBJECTIVE: The aims of this study were (1) to investigate the relationship between the main clinical tests to detect spinal instability, the perceived pain and disability, and symptomatic spondylolisthesis (SPL) characteristics, (2) to investigate the relationship between endurance and instability tests, and (3) to measure the diagnostic accuracy of these tests in unstable SPL diagnosed against dynamic radiographs. METHODS: Four instability tests were evaluated on 119 subjects: aberrant movements, active straight leg raising (ASLR), prone instability test, and passive lumbar extension test (PLE); and 2 endurance tests, prone bridge test and supine bridge test (SBT). The results were compared with the numeric rating scale for pain and the Oswestry Disability Index for disability. These tests were used as index tests and compared with dynamic radiographs as reference standard on 64 subjects. RESULTS: A significant relationship between disability and all the clinical tests but ASLR was observed. The relation between tests and pain was weaker, not significant for prone instability test and aberrant movement and critical for ASLR (P = .05). There was a low relationship between endurance tests and instability tests. Only PLE showed a significant association with dynamic radiographs (P = .017). CONCLUSION: Endurance and instability tests appear to be weakly related to the amount of pain but significantly related to the disability in symptomatic SPL. Of the tests evaluated, PLE exhibited the best ability to predict positive dynamic radiographs.

The effects of a global postural reeducation program on an adolescent handball player with isthmic spondylolisthesis.

This report describes and evaluates a physical therapy intervention in a 15-year-old male handball player with low grade isthmic spondylolisthesis and associated spinopelvic misalignment (shear-stress type). Upon examination, increased lumbar lordosis, horizontal sacrum and anterior pelvic tilting were mainly associated with altered resting length and extensibility of the iliopsoas, hip adductors and erector spinae muscles. The intervention was directed at improving the muscles resting length and extensibility balance within a global postural alignment perspective (global postural reeducation). After the treatment period, lumbar lordosis, sacral slope and anterior pelvic tilting decreased 17.2°, 16.5° and 15.1° respectively. Global postural reeducation was effective in changing spinopelvic alignment related to low grade isthmic spondylolisthesis. This treatment option should be considered as a potential nonsurgical alternative for this condition.

Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial.

PURPOSE: To evaluate the effect of a rehabilitation programme including the management of catastrophising and kinesiophobia on disability, dysfunctional thoughts, pain, and the quality of life in patients after lumbar fusion for degenerative spondylolisthesis and/or lumbar spinal stenosis. METHODS: This was a parallel-group, randomised, superiority-controlled study in which 130 patients were randomly assigned to a programme consisting of exercises and cognitive-behavioural therapy (experimental group, 65 subjects) or exercises alone (control group, 65 subjects). Before treatment (T1), 4 weeks later (post-treatment analysis, T2) and 12 months after the end of treatment (follow-up, T3), all the patients completed a booklet containing the Oswestry Disability Index (ODI, primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophising Scale, a pain Numerical Rating Scale, and the Short-Form Health Survey. A linear mixed model for repeated measures was used for each outcome measure. RESULTS: The ODI linear mixed model revealed significant main effects of group (F(1,122.8) = 95.78, p < 0.001) and time (F(2,120.1) = 432.02, p < 0.001) in favour of the experimental group. There was a significant group × time interaction effect (F(2,120.1) = 20.37, p < 0.001). The analyses of all of the secondary outcome measures revealed a significant effect of time, group and interaction in favour of the experimental group. CONCLUSION: The rehabilitation programme, including the management of catastrophising and kinesiophobia, was superior to the exercise programme in reducing disability, dysfunctional thoughts, and pain, and enhancing the quality of life of patients after lumbar fusion for degenerative spondylolisthesis and/or LSS. The effects lasted for at least 1 year after the intervention ended.