physio for spondylolisthesis and spondylolysis

Systematic review

A systematic review of physiotherapy for spondylolysis and spondylolisthesis

Margaret L. McNeely, G. Torrance, D. J. Magee

Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Canada

SUMMARY. The purpose of this systematic review was to assess the evidence concerning the effectiveness of

physiotherapy intervention in the treatment of low back pain related to spondylolysis and spondylolisthesis. A

literature search of published and unpublished articles resulted in the retrieval of 71 potential studies on the subject

area. Fifty-two of the 71 articles were studies, and these studies were reviewed using preset relevance criteria. Given

the inclusion and exclusion criteria chosen for this systematic review, there were very few acceptable studies and

only two studies met the relevance criteria for the critical appraisal. Both studies provide evidence to suggest that

specific exercise interventions, alone or in combination with other treatments, have a positive effect on low-back

pain due to spondylolysis and spondylolisthesis; however, the type of exercise used was different in the two studies.

In this review, very few prospective studies were found that examined the efficacy of physiotherapy on the topic

area; therefore, few conclusions can be made, and further research is warranted.

r 2003 Elsevier Science Ltd. All rights reserved.

INTRODUCTION

A systematic review is an evaluation of existingliterature using a research format. As such itconstitutes research; it poses a question, identifies apopulation and draws a sample (Magee 1998).Published and unpublished studies are assembledusing explicit searching methods, and a predeter-mined protocol of evaluation is used with inclusionand exclusion criteria (Jefferson & Deeks 1999, p225). Research papers are read selectively andcritically, measurements are analysed, and conclu-sions are drawn based on the scientific merit of theresearch findings. It is hoped that the findings of asystematic review will help guide practitioners inprescribing effective interventions for their patients(de Vet et al. 1997) and provide insight into futureresearch directions.

When doing a systematic literature review, largerandomized controlled trials (RCTs) are sought, asthey provide the strongest evidence (Stein & Cutler1996; Magee 1998). Internal validity of the study,with an RCT, is enhanced as extraneous factors arecontrolled, and as randomization of subjects reducesselection bias (Portney & Watkins 2000, p 167). Validand reliable measures, as well as valid, reliable, andsensitive measurements and instruments insure thatdata are accurate and meaningful (Warren 1994). Inaddition, having outcomes measured by independent(blinded) observers, or by the patients themselves,further enhance the validity of the study. To controlfor confounders and to assess the external validity ofthe study, inclusion and exclusion criteria should beclearly stated and details provided on the studypopulation. Among these details, such things asagreement to participate, attrition and the reasonsfor subjects being lost to follow-up must be included.In treatment studies, pretreatment clinical signs andsymptoms have to be documented, and treatmentinterventions explained in enough detail to allow forreplication of the study (Magee 1998).The purpose of the present systematic review

was to examine research studies assessing the efficacyof physiotherapy interventions in the treatment oflow-back pain related to spondylolysis and spondy-lolisthesis.

Manual Therapy (2003) 8(2), 80–91r 2003 Elsevier Science Ltd. All rights reserved.1356-689X/03/$ - see front matterdoi:10.1016/S1356-689X(02)00066-8

Received: 30 October 2001Revised: 17 June 2002Accepted: 2 July 2002

Margaret L. McNeely, MSc, PT, Graduate Student, Grace

Torrance BSc PT, Graduate Student, Dr David J. Magee PhD,

BPT, Professor, Department of Physical Therapy, Faculty ofRehabilitation Medicine, University of Alberta, CanadaCorrespondence to: MM, Department of Physical Therapy,

Faculty of Rehabilitation Medicine, University of Alberta, 250Corbett Hall, Alberta, Canada T6G 2G4. Fax: +1 780 492 1626;E-mail: [email protected]

80

THE PROBLEM

Low-back pain has become a significant healthproblem and continues to be a major expense to thehealthcare system (Linton et al. 1989; Cherkin et al.1998). Segmental instability of the lumbar spine isa potential cause of low-back pain, and particularly,in children and adolescents, may be the resultof spondylolysis and/or spondylolisthesis (Fritz et al.1998). Spondylolysis is a defect or break in thenarrow portion of the vertebral bone, lying betweenthe superior and inferior articular facets of thevertebral arch (Johnson 1993), called the parsinterarticularis. Spondylolisthesis, on the other hand,is the ‘slipping’, or forward displacement, of onevertebra over another (Magee 1997). Though the twoconditions are distinct radiographically, spondyloly-sis in the lumbar spine is found in 50–81% of casesof spondylolisthesis (Szapalski et al. 1999), withspondylolytic spondylolisthesis the consequence ofspondylolysis progressing to spondylolisthesis. Thusthe two conditions are often reviewed and studiedtogether (Lonstein 1999).Over the years there has been considerable interest

in, and controversy over, both the aetiology andtreatment of these conditions. This is because, todate, the correlation between radiographic evidenceand clinical symptoms has been poor (Osterman et al.1993). As well, many individuals with radiographicevidence of lumbar instability, spondylolysis andspondylolisthesis are asymptomatic (Magora 1976).Though the significance of lumbar instability inlow-back pain remains unclear (Fritz et al. 1998),treatment, which may include surgery, is routinelyprescribed (Spratt et al. 1993).

Incidence

Spondylolysis occurs in approximately 6% of thepopulation (Hensinger 1989). While defects in thepars interarticularis have not been found in new-borns, the prevalence is approximately 5% by the ageof 7 years (Hensinger 1989), and 6% by adulthood.These defects are twice as common in boys as in girls(Hensinger 1989). Interestingly, a high incidence ofspondyloysis is found in certain subgroups of thepopulation. A prevalence rate of 26% is found in theInuit population (Lonstein 1999), for example, and ahigher incidence is also found in those with a familyhistory of spondylolysis (Johnson 1993). Of particu-lar concern is that damage to the pars interarticularisis observed in 25–39% of sports-related low-backpain (Johnson 1993). This damage is especiallycommon in young athletes in certain competitivesports, including power and weight lifting, skiing,racquet sports, football, gymnastics, diving, wrestingand rowing (Johnson 1993).

The reported incidence of spondylolisthesis isestimated to be between 2% and 6% (Magora 1976;Osterman et al. 1993). An increased prevalenceof spondylolisthesis is found between the ages of10 and 15 years, and the forward displacement,or ‘slip’, is believed to occur during the adolescentgrowth spurt. Though spondylolisthesis is reportedto rarely progress after skeletal maturity (Lonstein1999), a recent study by Floman reported documen-ted slip progression ranging from 9% to 30%in adults in the third decade of life (Floman 2000).The increased slip was associated with disc degenera-tion (spondylosis) and, as a result, previouslyasymptomatic lesions became symptomatic. Spondy-lolisthesis is normally divided into five categories:dysplastic or congenital, isthmic or spondylolytic,degenerative, traumatic and pathologic (Lonstein1999).

Aetiology

Though the exact cause of spondylolysis is unknown,theories have evolved implicating both congenitaland developmental causes (Hensinger 1989). Thebasis of the ‘congenital theory’ is that there is agenetically predisposed weakness in the pars inter-articularis (Motley et al. 1998), and evidence for thetheory is found in the increased incidence of bothspondylolysis and spondylolisthesis in first-degreerelatives of children with these conditions (Lonstein1999). Genetic predisposition alone, however, isunlikely to be the sole cause, as lesions are notpresent in infants or pre-ambulatory children, andare also not found in those who have never walked(Newell 1995).The basis of the ‘developmental theory’ is that

a fatigue fracture develops as a gradual responseto mechanical usage (Newell 1995). It is believedthat microtrauma or microstress causes this fractureof the pars interarticularis (Lonstein 1999)and though an episode of minor trauma ofteninitiates symptoms, there is seldom a history ofsevere injury to the low back (Hensinger 1989).Supporting this hypothesis further, pars defectscan be reproduced by fatigue loading in vitro (Newell1995). However, these reproduced defects havebeen bilateral, and, thus, the presence of unilateraldefects may suggest a congenital association (Newell1995).Mechanically, the interarticular area, particularly

that of the fifth lumbar vertebra, is in a position ofspecial vulnerability, absorbing the force of weightdue to the lumbo-sacral alignment and the normallumbar lordosis of the spine (Newell 1995). Thenormal flexion contractures of the hip seen inchildhood (Hensinger 1989) and/or poor postureresult in an accentuated lumbar lordosis, and furtherincrease the impact forces in this region. The pars

Spondylolysis and spondylolisthesis 81

Manual Therapy (2003) 8(2), 80–91 r 2003 Elsevier Science Ltd. All rights reserved.

interarticularis is especially susceptible to damage inthe growing child, due to incomplete ossification ofthe neural arches (Johnson 1993). In young athletes,it is believed that repetitive motions and/or overuse,on an already compromised region of the vertebra,cause fracture or elongation of the pars interarticu-laris (Johnson 1993). In summary, though geneticfactors may predispose to spondylolysis, it is likelythat mechanical forces related to normal weightbearing, posture, repetitive activities and mild trau-ma, especially on an immature spine, combine toproduce the initial defect (Hensinger 1989; Lonstein1999).Spondylolisthesis, as stated previously, usually

results from spondylolysis. The normal resistance toforward displacement of the vertebra is provided bythe posterior facets, ligaments and the intervertebraldisc (Magee 1982). With fracture or elongation of thepars interarticularis, however, the posterior elementsare compromised (Lonstein 1999) and the vertebralbody is allowed to slip forward, resulting ininstability (Magee 1982). Narrowing of the spinalcanal will occur if posterior elements also slideforward (Magee 1982) and, as a result, symptomsmay develop.

Signs and symptoms

The presenting signs and symptoms normally includepain, restricted range of motion, paraspinal musclespasm, flattening of the sacrum and a peculiar gait(Magee 1982; Johnson 1993; Osterman et al. 1993.Pain is usually reported as mild to moderate, and isinitially a dull ache that gradually increases inintensity (Motley 1998). Pain is commonly localizedto the paraspinal region, gluteals (Hall & Brody 1999)and posterior aspect of the thighs (Barash et al. 1970).Initially pain may be associated with a very mobilespine, with symptoms appearing at extremes oflumbar range of motion only. In the adolescentathlete, extension- and rotation-type movements,specific to the individual’s sport, are reported toexacerbate symptoms (Johnson 1993). Progressionresults in hamstring tightness (Osterman et al. 1993),posterior tilting of the pelvis, and a flexed hip andknee posture (Barash et al. 1970). The individual maywalk with a stiff legged, short-stride gait (Barash et al.1970; Hensinger 1989) and a characteristic pelvic‘waddle’ (pelvic rotation with stepping) may beobserved (Hensinger 1989).On examination, pain is reproduced with the one-

legged standing lumbar extension test, and withspondylolisthesis, a step deformity in the lumbarspine may be observed or palpated (Magee 1997). Inmoderate to severe cases, marked limitation of trunkflexion range of motion is often seen (Barash et al.1970) and a limited straight leg raise found (Barashet al. 1970; Magee 1982).

Treatment

In the majority of symptomatic cases of spondylolysisand spondylolisthesis non-operative treatment isrecommended. Physiotherapy is the most commonmethod used to apply non-operative treatment andmay include the use of modalities for pain relief,bracing, exercise, electrical stimulation and activitymodification (Fellander-Tsai & Micheli 1998; Sza-palski 1999). Physiotherapy treatment is recom-mended to reduce pain, to restore range of motionand function, and to strengthen and stabilize thespine (Fritz et al. 1998; Hall & Brody 1999). Thoughnon-operative treatment is reported as being effectivein relieving the symptoms of back pain due tospondylolysis and spondylolisthesis (Szapalski1999), few studies have been done examining theefficacy of the various treatment interventions.Operative treatment is indicated to alleviate pain in

patients not responding to conservative treatment,and to prevent progression of the slip in those withsevere slip (>40%) of the vertebrae (Fritz et al. 1998;Szapalski 1999). As costs and complications due tosurgery are high and long-term benefits uncertain(Fritz 1998), further study into the efficacy of non-operative treatment is warranted.

METHODS AND MATERIALS

The process of systematic reviewing involves thor-ough detective work aimed at identifying all studieson a specific topic. Studies are chosen based on presetcriteria that may include, for example, study design,type of experimental intervention and specific out-come measures. For this review, the literature wassearched for published studies and unpublishedstudies on physiotherapy interventions in treatingspondylolysis and spondylolisthesis. Two indepen-dent investigators screened the titles of articles foundon the databases, and if available, the abstract of thearticle as well. If either or both investigator felt thatthe article potentially met the inclusion criteria, or ifthere was inadequate information to make a decision,copies of the article were obtained.

Search strategy

A literature search was conducted to identify appro-priate studies using numerous databases includingMEDLINE and CINAHL (Table 1). Keywords andmedical subject headings related to the condition andpotential treatment were identified prior to initiatingthe search. If any of the searches resulted in less than300 titles, then all articles found in the particulardatabase were assessed for potential inclusion; other-wise, terms related to treatment such as ‘exercise(s)’,‘physiotherapy’ and ‘rehabilitation’ were used to

82 Manual Therapy

r 2003 Elsevier Science Ltd. All rights reserved. Manual Therapy (2003) 8(2), 80–91

narrow the search. For the purposes of this review,the literature search was conducted from January2000 to February 2001.The next phase of the search strategy involved

searching for studies potentially overlooked or absentfrom the databases and for unpublished studies. Thisinvolved hand-searching the references of all re-trieved articles for potential studies and hand-searching the journal Spine. Citation indexing wasused to track referencing of key authors in the field,conference abstracts were reviewed, and local expertswere contacted for further information.

Criteria development

Criteria were developed at the beginning of the studyto determine keywords to use in the search strategy,and to help determine whether the studies found wererelevant to the topic area of this systematic review.The inclusion and exclusion criteria were deemedimportant for ensuring internal validity of the study.The base criterion required that the study includeactivities that could be classed as physiotherapyinterventions within the scope of practice of physio-

therapists in Canada. This requirement meant that aresearcher from any discipline could undertakethe study, as long as one or more of the interventionswas within the scope of practice of Canadian physio-therapists.Although randomized controlled studies were

sought, because of the clinical nature of the topicand the paucity of research in the physiotherapy fieldin general, other research methods were consideredeligible for the review. The investigators felt thatother research methods might demonstrate differ-ences and suggest important research hypotheses.However, to ensure that some degree of scientificrigour was maintained it was determined that onlyprospective studies would be included and thatquantitative studies were required to have a controlgroup (Lohr & Carey, 1999).Further inclusion criteria used to determine

whether the study was relevant for this overviewwere: (a) male and female humans; (b) symptomaticlow-back pain; (c) within the age of 10–60 years; (d)lumbar spine involvement and (e) radiographicevidence of spondylolysis or spondylolisthesis in thelumbar spine. The exclusion criteria were developed

Table 1. Search strategy

Search for published studiesKeywords (medical subject headings are in italics):

* Terms related to the condition: Spondylolysis, Spondylolisthesis, Pars interarticularis, Lumbar instability, Low-back pain, Spinal vertebra

(lumbar vertebra)* Terms related to the intervention: Physical therapy (physiotherapy), Rehabilitation, Exercise(s) (Therapeutic exercise, Stabilization

exercise(s), Pilates, McKenzie, Feldenkrais).

The Medical Librarian provided assistance on appropriate use of truncation, query and set operators (use of OR/AND) for combiningterms. To allow for a broad search of the literature, limits for publication types were not used

Databasen

Medline: 1966–February 2001CINAHL: 1982–February 2001ERIC: 1986–2000EMBASE (Excerpta Medica) (1982–March 2000)Sport Discus: 1975–l999Best Evidence: 1991–1999Dissertation Abstracts: 1999Biological Abstracts: 1997–1999Library of CongressCochrane Collaboration: Database of RCT and systematic reviews

Expanded search/search for unpublished studies

1. Hand-searching reference lists of all retrieved articles (including review articles)

2. Hand-search of the journal SPINE: 1994–2000

3. Citation searching: key authors—Rossi F, Davis IS, Farfan HF, Jackson DW, Magora A, Batts M, King AB, Verbostad A, Meyerding

HW, Szapalski M, Gunzburg R, Pope M, Grieve GP

4. Local experts were contacted for additional information:

* ISSL (International Society for the Study of the Lumbar Spine) abstracts were provided* Management of Low Back Pain: Beyond Rhetoric Toward Outcomes (September 1999): conference abstracts were provided* Dr David Magee: permission to access personal orthopaedic research database

5. Research: Federal Research in ProgressUniversity of Iowa, USACurtin University of Technology, AustraliaUniversity of Alberta, Canada

nFor some of the databases, slight modification in search strategy was required.



to limit the influence that extraneous factors mighthave on the results of the treatment intervention(confounding variables), and in an attempt to limitthe study to true symptomatic spondylolysis andspondylolisthesis. Exclusion criteria for this overviewwere: (a) no neurological or autonomic deficits; (b) noother fracture or bony abnormalities; (c) no rheu-matic disease and (d) no other spinal problems. Foroutcome measurements, the study had to include oneor more of the following: range of motion, pain,functional outcome measure or patient satisfaction.The information was developed into a relevance

tool (Table 2) that was used by the investigators toindependently evaluate the retrieved papers. Eachcriterion was graded on a yes/no basis—that is, thepublished study had to provide enough informationto adequately meet the criterion. All criteria on therating form had to be met for the study to beevaluated at the next level, the Critical Appraisal.Once the criteria were developed, a group of 10studies were gathered. Interrater reliability of inde-pendent initial grading of these papers using therelevance tool was 100%.The next level of the systematic review, the Critical

Appraisal, involved rating the accepted studies to

determine internal and external validity (Table 3).The two investigators independently reviewed thestudies. Each study was analysed based on specificpredetermined criteria. These criteria were then ratedas pass (P), moderate (M) and fail (F). The ratingsystem was based on a similar rating system devel-oped by de Vet et al. (1997). The Critical Appraisalwas then taken to the final stage for an overallassessment of the study (Table 4). At this point, thestudy was graded as weak, moderate or strong,depending on how well it met each of the criticalappraisal criteria. All criteria were weighted equally.

Results

A total of 71 articles were obtained through theliterature search; 52 articles were studied and werereviewed using the relevance tool (Table 2). Out ofthe 52 studies reviewed, only two studies met allselection criteria (Spratt et al. 1993; O’Sullivan et al.1997). Clarification was required by one author(Spratt et al. 1993) to verify that one specific criterionwas met and this was done by e-mail communication.None of the other studies came close to meeting all

Table 2. Physiotherapy effectiveness project relevance tool—primary studies (Study: Physiotherapy intervention for low-back pain relatedto spondylolisthesis and spondylolysis)

Instructions for completion1. Circle Y or N for each relevance criterion2. Record inclusion decision: article must satisfy all relevant criteria3. Ensure that no exclusion criteria are included4. Record if additional references are to be retrieved5. Complete validity form for articles to be included

Relevance criteria1. Does this article evaluate a physiotherapy intervention or program? Y N2. Is the intervention within the scope of physiotherapy practice in Canada? Y N3. Are the subject inclusion criteria covered?a. male/female humans Y Nb. low back pain Y Nc. age 10–60 Y Nd. lumbar spine involvement Y Ne. radiographic evidence of spondylolisthesis and spondylolysis Y N

4. Are patient exclusion criteria included?a. no neurological/autonomic deficits Y Nb. no other fracture/bony deformities Y Nc. no rheumatic disease Y Nd. no other spinal problems Y N

5. Is one or more appropriate outcomes (ROM, Pain, outcome measure, patient satisfaction) measured? Y N6. Is the article a prospective study?� (allocation, exposure to intervention occurs during research period and prior to measurement of outcome) Y N

7. If a quantitative study, is there a control group? Y N

Reviewer decision1. Include in critical appraisal (Yes = Y to all relevance criteria) Y N

If yes, please complete validity form2. Additional references Y N

If yes, mark items on reference list of article

If discreepancy inclusion decisionReason for discrepancyOversight Y NDifferences in interpretation of criteria Y NDifferences in interpretation of study Y Y

Final decision: include in study Y N

84 Manual Therapy


criteria. There was 100% agreement between re-viewers about the rating of all papers.The two studies that were evaluated at the

Critical Appraisal level were initially rated as ‘weak’.However, after e-mail communication with oneof the authors, one study (O’Sullivan et al. 1997)was re-rated as strong. The results of the CriticalAppraisal for each of the two studies are providedin Table 5.

DISCUSSION

In this systematic review, few prospective studieswere found that addressed the question of the efficacyof physiotherapy interventions in the treatment oflow-back pain related to spondylolysis and spondy-lolisthesis. The strict criteria established for inclusionand exclusion criteria, as well as the requirement for a

prospective study, eliminated many potential studiesfor review.The two studies that did meet our criteria were

both randomized controlled trials and each studyprovided evidence of improvement in outcomemeasures from the physiotherapy intervention. Adescriptive review of the two studies is provided inTable 6.O’Sullivan and colleagues provided evidence sup-

porting the use of very specific exercise treatmentregime for subjects with spondylolysis and spondylo-listhesis. The treatment group (TG) demonstratedstatistically significant decreases in pain (both inintensity and in description) and functional disabilitywhen compared to the control group (CG). Theresults were effective in the short term (3 months)as well as the long term (30 months). A statisticallysignificant difference was found within the CGfollowing the treatment period for pain descriptors

1. Type of studyi. random/quasirandom (I) (P)ii. cohort/before-after (II) (M)iii. case control/cross-sectional (III) (F)iv. descriptive (IV) (F)

2. Confounders controlledi. age Y Nii. sex Y Niii. classification Y Niv. medication Y N

Differences between groups notstatistically controlledP=all M=2–3 F=0–1

3. Agreement to participatei.>80% (P)ii. 60–80% (M)iii.o60% (F)iv. cannot tell (F)

4. Interventioni. acupunctureii. mobilizationiii. manipulationiv. massagev. superficial heatvi. bracingvii. deep heatviii. iceix. ultrasoundx. tractionxi. exercisexii. educationxiii. TNS/IFC/HVGxiv. Other, pls. specify

5. Physiotherapy treatmenti. well described Y Nii. specific to tested groups Y N

P=2 M=1 F=O(well described: dosage, time, placement)

6. Sample sizei. large >100 (P)ii. medium 20–100 (M)iii. small o20 o20 (F)

7. Data collection methodsi. self-reported (pain, functional outcome)� inter-rater reliability Y N N/A� intra-rater reliability Y N N/A� reliable test inst. Y N� validity test inst. Y N� sensitivity Y N� well described Y N

ii. single blind assessor (pain, ROM, functional outcome)� inter-rater reliability Y N N/A� intra-rater reliability Y N� reliable test inst. Y N� validity test inst. Y N� sensitivity Y N� well described Y N

iii. clinician performed (ROM, functional outcome)� inter-rater reliability Y N N/A� intra-rater reliability Y N� reliable test inst. Y N� validity test inst. Y N� sensitivity Y N� well described Y N

Outcome: 6 or all=P, validity +(3–4)=M, validity + (0–2)=FN/A is not a fail for this category

8. Subjects starting and finishing studyi. immediate >80% (P)

60–80% (M)>60% (F)

ii. post-treatment >80% (P)60–80% (F)

o60% (M)iii. follow-up >80% (P)

60–80% (M)>60% (F)

9. External validity Y N10. Limitations

i. Majorii. Minor

11. Was there statistical test(s) of the intervention effects?Y N

Table 3. Critical appraisal—included studies (Study: Physical therapy intervention for low-back pain related to spondylolisthesis andspondylolysis (included studies))



only. No significant change was found in the CG forthe follow-up period.Spratt et al. (1993) examined the efficacy of flexion

and extension treatments, incorporating braces forlow-back pain, in patients with retrodisplacement,spondylolisthesis and normal sagittal translation. Thestudy used a mixed-model repeated measures designwith the three classification categories, three treat-ment groups (flexion, extension and control) and pre-test/post-test measures (3� 3� 2 design). The mostimportant finding in this study was the reduction inpain in the extension treatment group. This findingoccurred across all translation types and wassignificant.The primary concerns of the two studies identified

by this review were as follows: (a) interventions/control group activities were not well described; (b)the chosen outcome measure was not well describedespecially in terms of validity and reliability; (c)inadequate information was provided in regard totraining of the individuals responsible for adminis-tering the outcome measures and (d) sample sizeThe exercise description in the O’Sullivan study

was well described and could be reproduced based onthe published description; however, the control groupactivities were not clearly outlined or standardized.As the control group received many different,uncontrolled treatments, it is difficult to determinethe actual effect of ‘conservative treatment’ onoutcome.

The exact treatment provided to the groups inthe Spratt study was also not explained in detail.For example, though the flexion group received aflexion brace, flexion exercises and education onavoiding lordotic postures, detail was not providedon the type, intensity, frequency and duration ofthe exercise programme, nor on instructions forexpected brace wearing-time. The control group wasprovided with a ‘sham’ brace and subjects wereassigned to a physiotherapist. It is not clear if thecontrol group received alternate forms of physiother-apy or if monitoring of control group activities wasdone.The outcome measures utilized in the O’Sullivan

study were: the McGill pain questionnaire, theOswestry disability questionnaire, lumbar spineand hip sagittal range of motion (using a Cybexelectronic digital inclinometer) and surface electro-myography of abdominal muscle recruitment pat-terns. An independent assessor administered theoutcome measures. The same assessor was used atthe pre- and post-10-week treatment period and self-rated mail-out questionnaires were used during thefollow-up period of the study. The chosen outcomemeasures were not well described in terms ofreliability, and of concern was the validity of theOswestry. However, in communication with theauthor, testing for reliability and validity of measureswas done and intra-rater reliability of the indepen-dent assessor was reported as ‘good’ (O’Sullivan,personal communication, 2000).In the Spratt study, outcome measures included

range of motion, trunk strength, compliance totreatment, patient perception of treatment effective-ness and pain assessment using a visual analoguescale. The primary outcome measure was pain. Avisual analogue scale was used, which is a valid andsensitive measure, and was well described in thisstudy. The subject’s assigned physiotherapist (whoalso provided the treatment) was responsible formeasurement of range of motion and trunk strength.Information was not provided on the measurementmethods or on the intra- and inter-rater reliability ofthe physiotherapists performing these measures.Independent assessors were not used but would havestrengthened the study. As well, inadequate informa-tion was provided with respect to the questionnaireused to evaluate subject perception of treatmenteffect.The review findings also suggest that in future

more attention should be given to the size of thestudy populations. In the two studies reviewed,information was not provided on how the samplesize was predetermined. Specifically in the Sprattstudy, the final sample size of 56 subjects wasinadequate for the study design. As well, there wereonly 19 subjects in total with spondylolisthesis andthis classification included both degenerative and

Table 4. Critical appraisal—final decision (Study: Physiotherapyintervention for low back pain related to spondylolisthesis andspondylolysis (final decision))

Overall assessment of the study1. Type of study P M F2. Confounders controlled P M F3. Agreement to participate P M F4. Intervention P M F5. Physiotherapy treatment P M F6. Sample size P M F7. Data collection methods

i. Pain P M Fii. ROM P M Fiii. Patient satisfaction/outcome P M F

8. Subjects starting and finishing studyi. Immediate P M Fii. At end of treatment

interventionP M F

iii. At follow-up (6 month) P M F

Review rating

Weak Moderate Strong(any F) (No F;

o4 P)(No F;4+P)

If discrepancy in validity decision between reviewersReason for discrepancy

i. Oversightii. Differences in interpretation of criteriaiii. Differences in interpretation of study

Final decisionWeak Moderate Strong

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spondylolytic types. As there is limited knowledge ofthe aetiology of low-back pain related to spondylo-lysis and spondylolisthesis, a potential difficultywould be to obtain a homogeneous study population

(Koes 1992). A larger sample size would providemore confidence that randomization of subjects hadadequately controlled for known and unknownconfounding factors (Koes 1992).

Table 5. Results of critical appraisal

O’Sullivan et al. Rating:O’Sullivan

Spratt et al. Rating:Spratt

Type of study Randomized controlled trial P Randomized controlled trial PConfounderscontrolled age, sex,classification,medicine

Age: 16–49, sex: males >femalesClassification: limited to isthmicspondylolysis and spondylolisthesis(degree of slip: 0–2)Medication: monitorednNo significant differences betweengroups

P Age 18–60 years: age and gendernot equal across groupsClassification: both spondylolytic(isthmic) and degenerativespondylolisthesis includednStringent inclusion criteria tocontrol for age-related conditions

F

Medication: no informationprovided

Agreement toparticipare

100% P 100% P

PhysiotherapyIntervention

Stabilization exercises Yes BracingExercise

Yes

Interventiondescribed in enoughdetail to allow forreplication

Treatment group: well described andcould be reproduced based ondescriptionControl group: not clearly outlined orstandardized

M Insufficient details on interventionto allow for replication

M

Sample size 44 subjects M 65 subjects MPrimary outcomemeasure

McGill Pain Questionnaire: self-reported, valid measure, reliable,sensitive

P VAS:� Self-reported� Valid measure: yes, reliable: yes,sensitive: yes

P

Additional outcomemeasure

Oswestry Disability Questionnaire:self-reported, concurrent validity:unclear, reliable, sensitive

P ROM: F* Independent (blinded) assessors

not used

ROM: validity, reliability,

sensitivity: unclear, not

described* No information on inter-rater

and intra-rater reliability

testingAdditional outcomemeasure

Range of motion: single independentassessor (blinded), valid measure,reliable, sensitive, intra-rater reliabilityreported as ‘good’

M Patient perception of treatmenteffect: Self-administered: yesValidity, reliability, sensitivity ofmeasure: unclear

F

Subjects starting andfinishing

44 subjects randomized: immediate P 65 subjects randomized: immediate P42 subjects completed the treatmentperiod (21 SEG and 21 CG)=95%

P 56 finished treatment=86% P

41 subjects completed 3-monthsfollow-up (21 SEG and 20 CG)=93%

P

40 subjects completed 6-month follow-up (21 SEG and 19 CG)=90%

P

34 subjects completed full protocol (30months) (19 SEG and 15 CG)=77%

(M)

External validity/limitations

* Generalizability of results to those

with isthmic spondylolysis and

spondylolisthesis from 0 to 2nd

degree ‘slip’

Yes * Reason not provided for loss

for loss to follow-up

� Authors acknowledge

limitations: small sample size

No

* Reasons provided for loss to

follow-up

Yes

* Control group treatments not

standardized

Minor

Statistical tests TG showed a significant improvementat 30 months when compared to theCG

Yes Significant improvement in pain inthe extension treatment group (alltranslation categories)

Yes

Overall rating: Strong WeakWeak (any F) F=0 F=3Moderate (No F;o4 P)

M=3 M=3

Strong (No F; 4+P) P=8 P=4



Table

6.Comparativesummary

ofstudiesmeetingrelevance

criteria

Reference

Key

features

Intervention

Outcomemeasures

Statistics

Authors

conclusions

Comments

O’Sullivanetal.

(1997)

Location:

Australia

RCT

44subjects>3months

history

oflow-back

pain

10-weekintervention

pre-post-testdesignwith

follow-upat3,6,30

months

Singleindependent

assessor(blinded)

Randomized

toone

of:

1.Treatm

entgroup:

Strengtheingof

deepabdominal

muscleswith

coactivationof

lumbar

multifidus

2.Controlgroup:

Treatm

entas

recommended

by

medical

practitioner

Pain:VAS

Function:Oswestry

ROM:cybex

digital

inclinometer

Abdominalmuscle

recruitment:surface

electromyography

TG

showed

asignificant

improvem

entat30

monthswhen

comparedto

theCG

Pain

intensity:

F=14.4,

Po0.0006

Pain

descriptors:

F=6.1,

P=0.0187

Oswestrydisability:

F=4.2,

Po0.0481

Specificexercise

totrain

trunkstabilizer

musculature

iseffectiveto

decrease

pain,functional

disability,reduce

use

ofpain

medication

Exercise

effectivein

longterm

:to

30

months

Studyratedasweak

initiallyuntilfurther

inform

ationobtained

from

theauthor

Exercise

program

lends

itselfto

reproducibility

within

clinicsetting

Controlgroupactivities

notstandarized

Sprattetal.

(1993)

Location:

United

States

RCT

65subjects

Subacuteandchronic

low-back

pain:4weeks

tounder

5years

3�3�2design

*3instability

categories

*3treatm

ents

*pre-post-test

measures

Threecategories

of

instability

1.Retrodisplacement

2.Spondylolisthesis

3.Norm

altranslation

Randomized

toone

of:

1.Flexionexercises

andflexion

brace

n

2.Extension

excercises

and

extensionbrace

n

3.Control(sham

treatm

ent

group)n

Pain:

modified

VAS

ROM:

Strength:

Compliance

monitoredPatient

perceptionof

treatm

enteffect

Pain:extension

groupshowed

improvem

entover

time:

F=11.61,

Po0.03

Patientperception:

flexiongroup

reported

lowbenefit

from

treatm

ent,

whereasextension

groupreported

large

benefitfrom

brace

andeducation

components:

F=3.65,

Po0.04

Significant

improvem

entin

pain

intheextension

treatm

entgroup(all

translation

categories)

Authors

suggestthat

improvem

entfound

withextension

treatm

entmay

indicate

advanced

disease

ofthediscas

underlying

pathology

Both

spondylolyticand

degenerative

spondylolisthesisstudied

(oneclassification)

Poorcompliance

with

theflexiontreatm

ent

especiallyin

those

with

spondylolisthesis

Inadequatesamplefor

studydesign:lowpower

nAllgroupsreceived

educationonlow-back

care.

88 Manual Therapy


Limitations

The findings of this review are specific to low-backpain due to spondylolysis and spondylolisthesis andto the field of physiotherapy. As time and resourceswere limited, the focus of the search was on studieswritten in the English language. Attempts were madeto identify unpublished studies; however, no suchstudies were found. Therefore, the studies identifiedin this review may not represent all existing researchin the area but a representative sample. As it wasanticipated that very few acceptable studies wouldbe found, this systematic review was open to theinclusion of any prospective study. As a result,the Critical Appraisal focused more on the metho-dological criteria related to clinical significance(subjects, description of treatments, and the validityand reliability of the chosen outcome measures).Therefore, an additional limitation of this review isthat it did not consider criteria that have been shownto discriminate between biased and unbiased rando-mized controlled trials such as the random allocationprocedure and method of concealment of allocation.

CONCLUSION

Systematic reviews in physiotherapy are used toassess the literature to determine the efficacy oftreatment. In this review, very few prospective studieswere found that examined the efficacy of physiother-apy on the topic area. The two studies undergoingcritical appraisal were both initially rated as weak.Despite this, there is evidence suggesting that specialtrunk stabilizing exercises have a positive effect onlow-back pain related to spondylolysis and spondy-lolisthesis. There was also evidence indicating thatcombined extension exercise, extension bracing andeducation are beneficial, though it is not possible toseparate the individual effects of this combinedprogramme.Future research is needed in examining the

aetiology of the two conditions and the relationshipbetween instability and presenting symptoms. Thiswill hopefully allow for prevention, early detectionand appropriate treatment. Specifically, in physio-therapy, randomized controlled trials are needed andshould extend to examining the efficacy of treatmentmodalities. As well, to effectively study these condi-tions, treatment response should be evaluated withsubjects of different ages and in different stages of‘slip’ and therefore may necessitate multicentre trials.Increased exposure time and sports participation,

among children and adolescents, have been corre-lated with an increase in reported low-back pain(Motley 1998). In present-day society, rising numbersare participating in the new acrobatic variations ofsnowboarding, cycling, skate boarding and roller

blading. As the current sporting trend is likely toresult in an increased number of individuals present-ing with spondylolysis and spondylolisthesis, furtherstudy is needed specifically within the young athleticpopulation. It is also apparent from this review thatauthors of clinical trials need to publish studymethods and results in enough detail to allow foranalysis of scientific rigour. In conclusion, as theresults of this systematic review are very limited, thefield is wide open for further research in this area.

Acknowledgements

The authors would like to acknowledge the assistance of librarianSandra Shores, BA, MLS, Reference Librarian, John W. ScottHealth Sciences Library at the University of Alberta. Herassistance in the search component of this systematic review wasinvaluable. The authors would also like to thank Trevor McNeely,MA, English Professor, Brandon University for his review of themanuscript.

References

Barash HL, Galante JO, Lambert CN, Ray RD 1970 Spondylo-listhesis and tight hamstrings. Journal of Bone and JointSurgery 52-A(7): 1319–1328

Cherkin DC, Deyo RA, Battie M, Street J, Barlow W 1998 Acomparison of physical therapy, chiropractic manipulation, andprovision of an educational booklet for the treatment ofpatients with low back pain. New England Journal of Medicine339(15): 1021–1029

de Vet HCW, de Bie RA, van der Heijden GJMG, Verhagen AP,Sijpkes P, Knipschild PG. 1997 Systematic reviews on the basisof methodological criteria. Physiotherapy 83(6): 284–289

Fellander-Tsai L, Micheli LJ 1998 Treatment of spondylolysis withexternal electrical stimulation and bracing in adolescentathletes: A report of two cases. Clinical Journal of SportMedicine 8(3): 232–234

Floman Y 2000 Progression of lumbosacral isthmic spondylo-listhesis in adults. Spine 25(3): 342–347

Fritz JM, Erhard RE, Hagen BF 1998 Segmental instability of thelumbar spine. Physical Therapy 78(8): 889–896

Hall CM, Brody LT 1999 Therapeutic Exercise: Moving towardFunction. Lippincott Williams and Wilkins, Philadelphia, Ch18, pp 344–345

Hensinger RN 1989 Spondylolysis and spondylolisthesis in childrenand adolescents. Journal of Bone and Joint Surgery 71(7):1098–1107

Jefferson T, Deeks J 1999 The use of systematic reviews foreditorial peer reviewing: A population approach. In: Godlee F,Jefferson T (eds) Peer Review in Health Sciences. BMJ Books,London, p 225

Johnson RJ 1993 Low-back pain in sports: Managing spondylo-lysis in young patients. The Physician and Sports Medicine21(4): 53–59

Koes BW, Bouter LM, Beckerman H, van der Heijden GJMG,Knipschild PG 1992 Physiotherapy exercises and backpain: A blinded review. British Medical Journal 302:1572–l576

Linton SJ, Bradley LA, Jensen I, Spangfort E, Sundell L 1989 Thesecondary prevention of low back pain: A controlled study withfollow-up. Pain 36: 197–207

Lohr KN, Carey TS 1999 Assessing ‘best evidence’: Issues ingrading the quality of studies for systematic review. Journal ofQuality Improvement 25(9): 470–479

Lonstein JE 1999 Spondylolisthesis in children. Spine 24(24):2640–2648



Magee DJ 1982 Orthopaedics: Conditions, Assessment andTreatment, 4th edn, Volume I manual, Course Manual.University of Alberta

Magee DJ 1997 Orthopedic Physical Assessment, 3rd edn. W.B.Saunders Company, Philadelphia

Magee DJ 1998 Systematic Reviews (Meta-analysis) andFunctional Outcome Measures, Course Manual. Universityof Alberta

Magora A 1976 Conservative treatment in spondylolisthesis.Clinical Orthopaedics 117: 74–79

Motley G, Nyland J, Jacobs J, Caborn DNM 1998 The parsinterarticularis stress reaction, spondylolysis and spondylo-listhesis progression. Journal of Athletic Training 33(4):351–358

Newell RLM 1995 Historical perspective: Spondylolysis. Spine20(17): 1950–1956

Osterman K, Schlenzka D, Poussa M, Seitsalo S, Virta L 1993Isthmic spondylolisthesis in symptomatic and asymptomaticsubjects, epidemiology, and natural history with specialreference to disk abnormality and mode of treatment. ClinicalOrthopaedics 297: 65–70

O’Sullivan PB, Twomey LT, Allison GT 1997 Evaluation ofspecific stabilizing exercise in the treatment of chronic low backpain with radiologic diagnosis of spondylolysis or spondylo-listhesis. Spine 22(24): 2959–2967

Portney LG, Watkins MP 2000 Foundations of Clinical ResearchApplications to Clinical Practice. Appleton and Lange, EastNorwalk, CT, p 167

Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H 1993Efficacy of flexion and extension treatments incorporatingbraces for low-back pain patients with retrodisplacement,spondylolisthesis, or normal sagittal translation. Spine 18(13):1839–1849

Stein F, Cutler SK 1996 Clinical Research in Allied Health andSpecial Education, 3rd edn. Singular Publishing Group, SanDiego

Szapalski M, Gunzberg R, Pope M 1999 Lumbar SegmentalInstability. Lippincott, Williams and Wilkins, Philadelphia

Warren S 1994 Research Theory in Rehabilitation. RehabilitationResearch Centre, Faculty of Rehabilitation Medicine,University of Alberta

Further Reading

Arnold P, Winter M, Scheller G 1996 Clinical and radiologicalresults of osteosynthesis of the vertebral lamina for lumbarspondylolysis and minor form of spondylolisthesis in childhoodand adolescents. Zeitschrift fur Orthopadie und IhreGrenzgebiete 134(3): 226–232

Bell DF, Ehrhich MG, Zaleske DJ 1988 Brace treatment forsymptomatic spondylolisthesis Clinical Orthopaedics andRelated Research 236: 192–198

Blanda J, Bethem D, Moats W, Lew M 1993 Defects of parsinterarticularis in athletes: A protocol for nonoperative treat-ment. Journal of Spinal Disorders 6(50): 406–411

Buswell J 1982 Low back pain: A comparison of two treatmentprogrammes. New Zealand Journal of Physiotherapy August:13–17

Cherkin DC, Deyo RA, Battie M, Street J, Barlow W 1998 Acomparison of physical therapy, chiropractic manipulation, andprovision of an educational booklet for the treatment ofpatients with low back pain. New England Journal of Medicine339(15): 1021–1029

Crawford JP, Noble WJ, Vernon H 1988 Chiropractic managementof spondylolisthesis with spondylosis of the pars interarticu-laris: An example of the singlecase study experimental design.Journal of Manipulative and Physiological Therapeutics 11(2):89–93

Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA1993 Evidence for use of an extension–mobilization category inacute low back syndrome: A prescriptive validation pilot study.Physical Therapy 73: 216–228

Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S1990 A controlled trial of transcutaneous electrical nerve

stimulation (TENS) and exercise for chronic low back pain.New England Journal of Medicine 322(23): 1627–1634

Dixon M, Fricker P 1993 Injuries to elite gymnasts over 10 yrs.Medicine Science Sports Exercise 25(12): 1322–1329

Elnaggar IM, Nordin M, Sheikhzadel A, Parnianpour M,Kahanovitz N 1991 Effects of spinal flexion and extensionexercises on low-back pain and spinal mobility in chronicmechanical low-back pain patients. Spine 16: 967–972

Evans C, Gilbert JR, Taylor W, Hildebrand A 1987 A randomizedcontrolled trial of flexion exercises, education, and bed rest forpatients with acute low back pain. Physiotherapy Canada 39:96–101

Faas A, Chavannes AW, van Eijk JThM, Gubbels JW 1995 Arandomized, placebo-controlled trial of exercise therapy inpatients with acute low back pain. Spine 18: 1388–1395

Farrell JP, Twomey LT 1982 Acute low back pain: Comparison oftwo conservative treatment approaches. Medical Journal ofAustralia 1(4): 160– 164

Fellander-Tsai L, Micheli LJ 1998 Treatment of spondylolysis withexternal electrical stimulation and bracing in adolescentathletes: A report of two cases. Clinical Journal of SportMedicine 8(3): 232–234

Frennered A, Danielson B, Nachemson AL 1991 Natural history ofsymptomatic isthmic low-grade spondylolisthesis in childrenand adolescents: A seven-year follow-up study. Journal ofPediatric Orthopaedics 11(2): 209–213

Gramse RR, Sinaki M, Ilstrup DM 1980 Lumbar spondylolisth-esis: A rational approach to conservative treatment. MayoClinical Proceedings 55: 68l–686

Halpern BC, Smith AD 1991 Catching the cause of low-back pain.The Physician and Sports Medicine 19(6): 7l–79

Handa N, Yamamoto H, Tanis O, Kawakami E, Takemasa Y 2000The effect of trunk muscle exercises in patients over 40 years ofage with chronic low back pain. Journal of Orthopaedic Science5: 210–216

Hansen FR, Bendix T, Skov P, Jensen CV, Kristensen Jh, KrohnL, Schioeler H, 1993 Intensive, dynamic back-muscle exercises,conventional physiotherapy, or placebo-control treatment oflow-back pain. Spine 18: 98–107

Herkowitz HN 1995 Degenerative lumbar spondylolisthesis. Spine20(9): 1084–1090

Johanssen F, Remvig L, Kryger P, Beck P, Warming S, Lybeck K,Dreyer V, Larsen LH 1995 Exercises for chronic low back pain:A clinical trial. Journal of Orthopaedic Sports Physical Therapy22: 52–59

Lindgren KA, Sihnoven T, Ieino E, Pitkanen M, Manninen H 1993Exercise therapy effects on functional radiographic findings andsegmental electromyographic activity in lumbar spine instabil-ity. Archives of Physical Medicine 74(9): 933–939

Linton SJ, Bradley LA, Jensen I, Spangfort E, Sundell L 1989 Thesecondary prevention of low back pain: A controlled study withfollow-up. Pain 36: 197–207

Lusins J, Elting JJ, Cicoria AD, Goldsmith SJ 1994 SPECTevaluation of lumbar spondylolysis and spondylolisthesis. Spine19(S): 608–612

Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, KoskenniemiL, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V,Hernberg S 1995 The treatment of acute low back pain—bedrest, exercises, or ordinary activity? New England Journal ofMedicine (6): 351–355

Manniche C, Hesselsoe G, Bentzen L, Christensen I, Lundberg E1988 Clinical trial of intensive muscle training for chronic lowback pain. Lancet: 2(8626–8627): 1473–1476

Mardjetko SM, Connolly PJ, Shott S 1994 Degenerative lumbarspondylolisthesis: A meta-analysis of literature 1970–l993.Spine 19(205): 22 565–22 655

Martin PR, Rose M, Nichols PJR, Russell PL, Hughes IG 1980Physiotherapy exercises for low back pain: Process and clinicaloutcome. International Rehabilitation Medicine 8: 34–38

Matsunaga S, Ijiri K, Hayashi K 2000 Nonsurgically managedpatients with degenerative spondylolisthesis: A 10- to 18-yearfollow-up study. Journal of Neurosurgery: Spine 93(2 suppl):194–198

McCarroll JR, Miller JM, Ritter MA 1986 Lumbar spondylolysisand spondylolisthesis in college football players: A prospectivestudy. The American Journal of Sports Medicine 14(5):404–406

90 Manual Therapy


Micheli LJ, Hall JE, Miller ME 1980 Use of modified Boston bracefor back injuries in athletes. The American Journal of SportsMedicine 8(5): 351–356

Mierau D, Cassidy DC, McGregor M, Kirkaldy-Willis WHA 1987Comparison of the effectiveness of spinal manipulative therapyfor low back pain patients with and without spondylolisthesis.Journal of Manipulative and Physiological Therapeutics l0(2):49–55

Moller H, Hedlund R 2000 Surgery versus conservativemanagement in adult isthmic spondylolisthesis. Spine 25(13):1711–l715

Morita T, Ikata T, Katoh S, Miyake R 1995 Lumbar spondylolysisin children and adolescents. The Journal of Bone and JointSurgery 77B(4): 620–625

Nelson BW, Carpenter DM, Dreisinger T, Mitchell M, Kelly CE,Wegner JA 1999 Can spinal surgery be prevented by aggressivestrengthening exercises? A prospective study of cervicaland lumbar patients. Archives of Physical Medicine andRehabilitation 80: 20–25

Nwaga G, Nwaga V, 1985 Relative therapeutic efficacy of theWilliams and Mckenzie protocols in back pain management.Physiotherapy Practice 1: 99–105

Nwaga VCB, 1982 Relative therapeutic efficacy of vertebralmanipulation and conventional treatment in back pain man-agement. American Journal of Physical Medicine and Rehabi-litation 61: 273–287

O’Sullivan PB, Twomey LT, Allison GT 1997 Evaluation ofspecific stabilizing exercise in the treatment of chronic low backpain with radiologic diagnosis of spondylolysis or spondylo-listhesis. Spine 22(24): 2959–2967

Peretto L, Gambaretti R, Berlusconi M, Silvestrini E 1992Spondylolysis-lysthesis: An approach toward sports activity.Medicina Della Sport 45(4): 523–539

Perugia L, Rossi F 1998 Spondylolysis and spondylolisthesis insport: review of a case series. Journal of Sports TraumatologyRelated Research 20(4): 209–212

Pettine K, Salib R, Walker S 1993 External electrical stimulationand bracing for treatment of spondylolysis: A case report. Spine18(4): 436–439

Pizzutillo PD, Hummer CD 1989 Nonoperative treatment forpainful adolescent spondylolysis or spondylolisthesis. Journalof Pediatric Orthopaedics 9(5): 538–540

Poussa M, Tallroth K 1993 Disc herniation in lumbar spondylo-listhesis: Report of 3 symptomatic cases. Acta OrthopaedicScandinavia 64(1): 13–16

Rupert RL, Wagnon R, Thompson P, Ezzeldin MT 1985Chiropractic adjustments: Results of a controlled clinical trialin Egypt. International Review of Chiropractic Winter: 58–60

Sachs BL, Ahmad SS, Lacroix M, Olimpio D, Heath R, David J,Scala AD 1994 Objective assessment for exercise treatment onthe B-200 isostation as part of work tolerance rehabilitation.Spine 19: 49–52

Seitsalo S, Schlenzka D, Poussa M, Osterman K 1997 Discdegeneration in young patients with isthmic spondylolisthesistreated operatively or conservatively: A long-term follow-up.European Spine Journal 6(6): 393–397

Sinaki M, Lutness MP, Ilstrup DM, Chu CP, Gramse RR 1989Lumbar spondylolisthesis: Retrospective comparison and three-year follow-up of two conservative treatment programs.Archives of Physical Medicine and Rehabilitation 70: 594–598

Soren A, Waugh TR 1985 Spondylolisthesis and related disorders:A correlative study of 105 patients. Clinical Orthopaedics andRelated Research 193: 171–l77

Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H 1993Efficacy of flexion and extension treatments incorporatingbraces for low-back pain patients with retrodisplacement,spondylolisthesis, or normal sagittal translation. Spine 18(13):1839–1849

Stankovic R, Johnell O 1995 Conservative treatment of acute lowback pain: A 5-year follow-up study of two methods oftreatment. Spine 20: 469–472

Stankovic R, Johnell O 1990 Conservative treatment of acute lowback pain: A prospective randomized trial: McKenzie methodof treatment versus patient education in ‘Mini back school’.Spine 15(2): 120–123

Steiner ME, Micheli LJ 1985 Treatment of symptomaticspondylolysis and spondylolisthesis with the modified bostonbrace. Spine 10(10): 937–943

Tokuhashi Y, Matsuzaki H, Sano S 1993 Evaluation of clinicallumbar instability using the treadmill. Spine 18(15): 2321–2324

Waterworth FR, Hunter IA 1985 An open study of diflunisal,conservative and manipulative therapy in the management ofacute mechanical low back pain. New Zealand Medical Journal95: 372–375



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