Stabilization Exercises Versus Flexion Exercises in Degenerative Spondylolisthesis: A Randomized Controlled Trial.

OBJECTIVE: Exercise is the mainstay of treatment in individuals with low back pain and the first-line option in degenerative spondylolisthesis (DS); however, there is still no consensus surrounding the superiority of any specific exercise program. Thus, the primary aim of this study was to compare the effectiveness of lumbar stabilization exercises and flexion exercises for pain control and improvements of disability in individuals with chronic low back pain (CLBP) and DS. METHODS: A randomized controlled trial was conducted in a tertiary public hospital and included 92 individuals over the age of 50 years who were randomly allocated to lumbar stabilization exercises or flexion exercises. Participants received 6 sessions of physical therapy (monthly appointments) and were instructed to execute exercises daily at home during the 6 months of the study. The primary outcome (measured at baseline, 1 month, 3 months, and 6 months) was pain intensity (visual analog scale, 0-100 mm) and disability (Oswestry Disability Index, from 0% to 100%). Secondary outcomes were disability (Roland-Morris Disability Questionnaire, from 0 to 24 points), changes in body mass index, and flexibility (fingertip to floor, in centimeters) at baseline and 6 months, and also the total of days of analgesic use at 6-month follow-up. RESULTS: Mean differences between groups were not significant (for lumbar pain: 0.56 [95% CI = -11.48 to 12.61]; for radicular pain: -1.23 [95% CI = -14.11 to 11.64]; for Oswestry Disability Index: -0.61 [95% CI = -6.92 to 5.69]; for Roland-Morris Disability Questionnaire: 0.53 [95% CI = -1.69 to 2.76]). CONCLUSION: The findings from the present study reveal that flexion exercises are not inferior to and offer a similar response to stabilization exercises for the control of pain and improvements of disability in individuals with CLBP and DS. IMPACT: Exercise is the mainstay of treatment in individuals with CLBP and DS; however, there is still no consensus surrounding the superiority of any specific exercise program. This study finds that flexion exercises are not inferior to and offer a similar response to stabilization exercises. LAY SUMMARY: Exercise is the mainstay of treatment in individuals with CLBP and DS, but there is no consensus on the superiority of any specific exercise program. If you have DS, flexion exercises may provide similar effects to stabilization exercises.

Nonoperative versus operative treatment of patients with degenerative spondylolisthesis / Tratamento conservador versus cirúrgico de pacientes com espondilolistese degenerativa / Tratamiento conservador contra quirúrgico de pacientes con espondilolistesis degenerativa

ABSTRACT Objective: To evaluate clinical and functional results of patients with lumbar degenerative spondylolisthesis treated with operatively or nonoperatively. Methods: Patients with degenerative spondylolisthesis treated either nonoperatively or operatively from 2004 to 2014 were selected from databases and a cross-sectional evaluation was performed. Outcome measures included back and leg visual analogue scales (VAS), Fischgrund criteria, Short Form-36 (SF-36) function score, and the modified Oswestry Disability Index (ODI). Results: 43 patients were evaluated: 20 with nonoperative treatment and 23 with operative treatment. Baseline characteristics were similar without significant differences between groups. Mean follow-up time was 43 months (range 10 - 72) for the nonoperative group and 36 months (range 6-80) for the operative group. Significant statistical difference in favor of operative group were found in back VAS (mean 4 versus 8, p = 0.000), leg VAS (mean 3 versus 6, p = 0.0015), SF-36 function score (mean 77 versus 35, p = 0.000), and ODI (mean 17 versus 46, p = 0.000). On the basis of the Fischgrund criteria, only 10 % of patients reported excellent or good health post nonoperative treatment versus 83% for those treated operatively (p = 0.000). Conclusion: In this cross-sectional study, we observed that symptomatic patients with degenerative spondylolisthesis who underwent operative treatment have superior clinical and functional scores compared to those that underwent nonoperative treatment.

RESUMO Objetivo: Avaliar os resultados clínicos e funcionais dos pacientes com espondilolistese degenerativa lombar tratados de maneira conservadora ou cirúrgica. Métodos: Foram selecionados pacientes com espondilolistese degenerativa tratados conservadoramente ou submetidos à cirurgia, durante 2004-2014, à partir da coleta de dados que possibilitou a realização da avaliação transversal. As medidas de avaliação da dor lombar e das pernas foram escalas analógicas visuais (VAS), critérios Fischgrund, Short Form-36 (SF-36) pontuação funcional, e o Índice de Incapacidade Oswestry modificado (ODI). Resultados: 43 pacientes foram avaliados: 20 do tratamento conservador e 23 do tratamento cirúrgico. As características de base foram similares, sem diferenças significativas entre os grupos. O tempo médio de acompanhamento foi de 43 meses (intervalo 10-72) para o grupo não-cirúrgico e 36 meses (intervalo 6-80) para o grupo cirúrgico. Diferenças estatísticas significativas em favor do grupo cirúrgico foram encontrados no VAS lombar (média de 4 versus 8, p = 0,000), VAS pernas (média 3 contra 6, p = 0,0015), SF-36 pontuação funcional (média 77 versus 35, p = 0,000), e ODI (média 17 versus 46, p = 0,000). Com base nos critérios Fischgrund, apenas 10% dos pacientes relataram excelente ou boa saúde de após o tratamento conservador contra 83% para aqueles tratados no cirúrgico (p = 0,000). Conclusão: Neste estudo transversal, observou-se que os pacientes sintomáticos com espondilolistese degenerativa que se submeteram ao tratamento cirúrgico têm escores clínicos e funcionais superiores em comparação àqueles que foram submetidos a tratamento conservador.

RESUMEN Objetivo: Evaluar los resultados clínicos y funcionales de los pacientes con espondilolistesis degenerativa lumbar tratados quirúrgicamente o sin cirugía. Métodos: Se realizó una evaluación transversal de los pacientes con espondilolistesis degenerativa, registrados en la base de datos, tratados conservador o quirúrgicamente desde 2004 hasta 2014. Las medidas de desenlace incluyeron: Escala Visual Análoga (EVA) de dolor lumbar y las piernas, criterios de Fischgrund, Short Form-36 (SF-36) e Índice de Discapacidad Oswestry modificado (IDO). Resultados: Se evaluaron 43 pacientes: 20 con tratamiento no quirúrgico y 23 con tratamiento quirúrgico. Las características de base fueron similares, sin diferencias significativas entre los grupos. El tiempo medio de seguimiento fue de 43 meses (rango 10-72) para el grupo no quirúrgico y 36 meses (rango 6-80) para el grupo quirúrgico. Diferencias estadísticamente significativas a favor del grupo quirúrgico fueron encontrados en EVA lumbar (media 4 contra 8, p=0,000), EVA pierna (media 3 contra 6, p=0,0015), SF-36 función (media 77 contra 35, p=0,000), e IDO (media 17 contra 46, p=0,000). Con respecto a los criterios de Fischgrund, sólo el 10% de los pacientes del grupo que recibió tratamiento no quirúrgico informo excelente o buen estado de salud en comparación con 83% de los que recibieron manejo quirúrgico (p = 0,000) Conclusión: En este estudio de corte transversal, se observó que los pacientes sintomáticos con espondilolistesis degenerativa que se sometieron a tratamiento quirúrgico tienen puntuaciones clínicas y funcionales superiores en comparación con los que se sometieron a tratamiento no quirúrgico.

Association of strength, muscle balance, and atrophy with pain and function in patients with degenerative spondylolisthesis.

PURPOSE: To analyze the relationship of strength, muscular balance, and atrophy with pain and function in patients with degenerative spondylolisthesis. STUDY DESIGN: Transversal, descriptive, and observational. PATIENTS AND METHODS: Institutional review board approval was obtained for this study. Twenty six patients ages 50 years and older, with degenerative spondylolisthesis at L4-L5. Measurements included Pain Visual Analogue Scale scores (VAS), Oswestry Disability Index scores (ODI), and isokinetic trunk testing; assessment of multifidus atrophy and spinal stenosis was performed by Magnetic Resonance Imaging (MRI). STATISTICS: Statistical analysis was performed using SPSS version 17.0 software for Windows. Pearson's correlation was used to ascertain the correlation between variables. ANOVA with analysis of covariance was used to determine the correlation between the remainder variables. Significance was set at p < 0.05. RESULTS: Of the 26 patients studied, with an average age of 60.23 ± 7.6 years, 20 had grade I spondylolisthesis and 6 were grade II. Correlation between the ODI scores and spondylolisthesis grading was significant (r=0.576, p=0.005); correlation between agonist/antagonist ratio in the isokinetic test (predominant extensor muscles over flexors) with the ODI scores was also significant (r=0.446, p=0.02), regardless of spinal stenosis. No correlation was found between functionality and pain with strength or multifidus atrophy. CONCLUSION: Muscle trunk imbalance with predominance of extensor over flexor muscles is associated with functional disability. Rehabilitation programs should be designed to improve muscle balance rather than muscle strength alone.

Effects of a stabilization exercise program in functionality and pain in patients with degenerative spondylolisthesis.

OBJECTIVE: To determine the effects of stabilization exercises on pain and function in patients with degenerative spondylolisthesis. STUDY DESIGN: Nonrandomized clinical trial, with 6 months of follow up. METHODS: Twenty patients over 50 years of age with degenerative spondylolisthesis underwent a 6-month, home-based training program of stabilization exercises. We applied functional and pain scales (Visual Analogue Scale [VAS] and Oswestry Disability Index [ODI]), and conducted an isokinetic trunk test. Statistical analysis included a T test for quantitative variables, a chi-squared test for qualitative data, and Pearson correlations. The significance alfa level was 0.05. RESULTS: Both pain and Oswestry Index scores were significantly decreased. Initial and final VAS "back pain" results were 63.50 ± 18.05 mm and 43.4 ± 22.09 (p=0.007) respectively. Initial and final VAS "sciatic pain" results were 53.65 ± 29.03 mm and 36.65 ± 27.21 (p=0.035) respectively. Oswestry Index at the beginning of the study was 30.35 ± 15.6%, decreasing to a final 20.15 ± 13.6% (p=0.007). The results of VAS and ODI scores correlated significantly with improvement in the isokinetic test. CONCLUSION: Lumbar stabilization exercises could be an effective treatment option in controlling pain and improving function in patients with degenerative spondylolisthesis. Further investigation with randomized controlled trials is necessary to obtain confirmation of these results.