Stabilization exercises versus flexion exercises in degenerative spondylolisthesis: a randomized controlled trial

Key Points

1. Exercise is a common treatment for low back pain and leg pain associated with degenerative spondylolisthesis.
2. Stabilization type exercises are particularly popular for this population.
3. This trial found that flexion exercises had similar effectiveness to stabilization exercises in terms of pain and disability levels.

BACKGROUND & OBJECTIVE

In the physiotherapy world, it is difficult not to think of stabilization exercises when we hear of a diagnosis of spondylolisthesis. A past trial (1) on 44 patients with a radiologic diagnosis of spondylolysis found that a stabilization exercise programme yielded better effects on pain and disability levels compared to usual care provided a physiotherapist. Yet, there is little consensus on whether stabilization exercises are the best form of exercise to prescribe for this group of patients.

This randomized controlled trial compared the effect of stabilization exercise on pain and disability levels compared to a lumbar flexion exercise programme.

There is little consensus on whether stabilization exercises are the best form of exercise to prescribe for patients with spondylolisthesis.

The clinician should use his/her own judgement based on clinical presentation, aggravating and easing factors, and patient preferences to decide on exercise selection for this condition.

METHODS

Study design: Randomized controlled trial

Population: 92 patients over the age of 50 with degenerative spondylolisthesis at L4-L5 and chronic low back pain with or without radicular pain

Intervention: Six month home exercise programme

The home exercise program included an initial phase, with use of therapeutic heat via a hot pack for 15 minutes at the lumbosacral region, stretching exercises of the thoracolumbar fascia, hip flexors and hamstrings, plus stabilization exercises to encourage stabilizing motor patterns and determine the neutral position of the spine. Progressions of these stabilization exercises included lateral and anterior bridges, leg raises in a supine position, and arm and leg lifts in a quadruped position (bird dog).

This was compared to a six month home exercise programme of Williams flexion exercises and a hot pack for 15 minutes.

See the video below for demonstration of these two different exercise protocols.

Flexion and stabilization exercises

Outcome: The primary measures were pain intensity (Visual Analogue Scale, from 0-100mm) and disability (Roland Morris Disability Questionnaire, from 0 to 24 points). These outcomes were measured at baseline, one month, three months, and six months.

RESULTS

This trial found no significant difference for lumbar pain, radicular pain, or disability between the stabilization and flexion exercise groups at the different follow-ups.

LIMITATIONS

• This is one trial, in one clinic, with a relatively small sample size.
• Comparison to other studies (2) on physiotherapy treatments (including exercise) for spondylolisthesis is difficult as this trial focused on individuals over 50 years of age with a degenerative type condition.
• The results may not necessarily apply to individuals with a spondylolysis or a non-degenerative spondylolisthesis.

CLINICAL IMPLICATIONS

Exercise should be considered a mainstay treatment for individuals with low back pain presenting with radiologic degenerative spondylolisthesis. Exercise can be helpful for radicular pain, as well as the lumbar pain associated with this condition.

Stabilization exercises are frequently prescribed for this group of patients, particularly in younger patients. We unfortunately cannot use this trial to comment on how stabilization exercises compare to flexion exercises in this younger age group. According to this study, flexion exercises appear to be as effective as stabilization exercises in individuals over the age of 50 with a degenerative spondylolisthesis. However these results should be interpreted with the sample size limitation kept in mind.

If both stabilization and flexion exercises are equally effective, the clinician should use his/her own judgement based on clinical presentation, aggravating and easing factors, and patient adherence/preference to decide on exercise selection.

Bigger trials are required to further examine the best exercise type for this group of patients. In the meantime, we can be confident that exercise is a safe treatment and focus on encouraging patients to better adhere to exercise.

+STUDY REFERENCE

Nava-Bringas T, Romero-Fierro L, Trani-Chagoya Y, Macías-Hernández S, García-Guerrero E, Hernández-López M, Roberto C (2021) Stabilization Exercises Versus Flexion Exercises in Degenerative Spondylolisthesis: A Randomized Controlled Trial. Phys Ther. Epub ahead of print.

SUPPORTING REFERENCE

1. O'Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997 Dec 15;22(24):2959-67.
2. McNeely ML, Torrance G, Magee DJ. A systematic review of physiotherapy for spondylolysis and spondylolisthesis. Manual therapy. 2003 May 1;8(2):80-91.