Spondylolisthesis

Spondylolisthesis

 

Article by J.Miller, I.Kelly, J. Ferguson

back-pain

Spondylolisthesis

What is Spondylolisthesis?

Spondylolisthesis refers to a slippage of a vertebral body relative to an adjacent vertebra. Spondylolisthesis (or anterolisthesis) is the forward displacement of a vertebral body in relation to the vertebrae beneath it. The slippage may occur following structural changes (eg fracture or spondylolysis) or degenerative changes in the spine (eg spondylosis or degenerative disc disease). Approximately 5% of the population has a spondylolisthesis.

Retrolisthesis is the opposite. The upper vertebral body is displaced backwards relative to the vertebrae below. Laterolisthesis is a side ways shift that is rare. It can occur in advanced degenerative spines or after asymmetrical fractures or severe scoliosis.

Spondyloptosis refers to dislocated vertebrae. In these instances, your spondylolisthesis is so extensive that the upper vertebrae translates entirely forward and off the vertebrae below.  See Grade V below.

What are the Symptoms of Spondylolisthesis?

Spondylolisthesis may not cause any symptoms for years (if ever) after the slippage has occurred. If you do have symptoms, they may include:

  • insidious onset low back pain, buttock or leg pain
  • pain arching your back
  • increased sway back
  • tight hamstrings – 80% of cases
  • a limp (walking)

More severe cases are those that reproduce neurological signs eg

  • numbness, tingling, (sciatica) pain, muscle tightness, muscle weakness in the leg and/or diminished reflexes.

A step deformity may also be observed or palpated in the lower back.

What Causes a Spondylolisthesis?

Isthmic vs Degenerative Spondylolisthesis

The two major causes of spondylolisthesis are isthmic spondylolisthesis associated with spondylolysis and degenerative spondylolisthesis associated with degeneration of the posterior facet joints (spondylosis) and/or intervertebral disc (degenerative disc disease).

Degenerative spondylolisthesis occurs mostly (88.5%) at the L4-5 level as opposed to isthmic spondylolisthesis, which occurs most often at the lumbosacral level (L5-S1) (84.6%). Approximately 75% of spondylolisthesis occur at L5 on S1 and 20% at L4 on L5. One study showed that 26% had suffered a fall.

Dysplastic & Other Spondylolisthesis

Dysplastic or congenital spondylolisthesis is caused by poorly formed facet joint structure at birth leading to the vertebral slippage.  Other causes related to traumatic or pathological fractures and post-surgical failure are rare.

Spondylolisthesis and Your Age?

Congenital or dysplastic spondylolisthesis has an early childhood onset as mentioned above.

Isthmic spondylolisthesis is more prevalent in the pre-teen and adolescent years in the athletic youth populations. Sports that involve hyperextension and rotation. eg gymnastics, fast bowling (cricket), hurdling, tennis, wrestling and other throwing or overhead racquet sports are higher risks. Spondylolysis (back stress fracture) initially occurs and about 50% of cases slip to develop into a spondylolisthesis.

Most isthmic spondylolisthesis stabilise at skeletal maturity. The fractures themselves may not heal but it is thought that the muscles controlling the spondylolisthesis provide sufficient functional control to avoid painful symptoms.

Degenerative spondylolisthesis is more common with advancing age.  The vertebrae slip forwards without a fracture present. The slippage is related to chronic spinal segment instability due co-existing pathologies such as degenerative disc disease or facet joint arthritis (spondylosis). They are also more likely to cause recurrent symptoms.

Due to the whole vertebrae and arch slipping forwards degenerative spondylolisthesis can cause spinal stenosis and compromise spinal nerve roots. Compromise of the spinal nerve roots may result in a radicular pain syndrome such as sciatica or significant develop motor power deficits (radiculopathy). In extreme cases, the stenosis and slippage could compromise the cauda equina and develop cauda equina syndrome, which is a medical emergency and will require immediate surgical intervention.

Spondylolisthesis Risk Factors

Known risk factors include:

  • Sports involving hyperextension and rotation
  • Genetic predisposition. You have a 26% chance if a parent has one.
  • Spondylolisthesis: Females 2-3 times
  • Spondylolysis (no slip): Males 2-3 times
  • Generalised hypermobility.
  • Spina bifida occulta
  • Facet joint morphology
  • Inuit population
  • Degenerative spondylolisthesis is more prevalent in pregnant women and black individuals.

How is Spondylolisthesis Diagnosed?

Your physiotherapist will begin by taking a history and performing a physical examination. A palpable step or depression may be present to indicate the likelihood of a spondylolisthesis. Your physiotherapist may order X-rays of your back.

A CT scan or MRI scan can show a fracture or pars defect more clearly, plus exclude other potential pathologies such as malignancy, infections or spinal stenosis. They will also show whether any of the nearby facet joints or discs have suffered any degeneration.

If spondylolisthesis is present, it is graded as I (mild), II, III, IV or V based on how far forward the vertebra has slipped.

Classification by degree of the slippage, as measured as a percentage of the width of the vertebral body:

  • Grade I: 0-25%
  • Grade II: 25- 50%
  • Grade III: 50-75%
  • Grade IV: 75-100%
  • Grade V: greater than 100% (Spondyloptosis)

Please consult your doctor or physiotherapist for your specific diagnosis, grading and recommended treatment plan.

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Spondylolisthesis Treatment

If your physiotherapist or doctor determines that a spondylolisthesis is causing your pain, non-surgical treatment is the primary choice. Treatment will include activity modification plus some specific exercises. Please consult your physiotherapist for a thorough assessment and prescription of the best exercises for your spondylolisthesis. The prognosis is very good for low-grade spondylolisthesis. (Hardwick et al., 2012)

However, the type of exercise that you perform can significantly alter your outcome. One study showed a 73% improvement at 3-months with one exercise group versus only 33% improvement in the alternative exercise group. For advice specific to your spondylolisthesis, please consult with your physiotherapist.

Physiotherapy Treatment

As you begin a physiotherapy treatment regimen your physiotherapist may prescribe manual therapies or other pain relieving techniques to reduce your pain and muscle spasms.

Because your muscles are the only effective way of controlling your slipping vertebrae, exercises will be aimed at the recruitment of your deep spinal stabilising muscles. You may also be prescribed gentle stretches to improve your posture and help to reduce your back pain or leg symptoms.

Flexion based and localised stabilisation/motor control exercises have been shown to improve both pain and disability. (Hardwick et al., 2012, Nava-Bringas et al., 2014)

When you have less pain and improving neurological signs, your exercises will be progressed to improve your flexibility, strength, endurance, and the ability to return to a more normal lifestyle. A comprehensive program may require several weeks or a few months of supervised treatment. For specific advice relative to your spondylolisthesis, please consult your physiotherapist for an individualised assessment.

Spondylolisthesis Prognosis

The presence of a spondylolisthesis by itself usually does not represent a dangerous condition in the adult. Outcomes are excellent for low-level spondylolisthesis with the vast majority of cases having favourable short-term and long-term outcomes.

Most spondylolisthesis Grade I-II patients respond favourably within a few weeks of commencing treatment. A Swedish study showed no significant difference in a long-term randomised study that compared 111 patients who underwent an exercise program versus fusion surgery in adult isthmic spondylolisthesis patients. Patients improved in the short and long-term. Follow-up mean was 9 years. (Ekman et al., 2005)

Grade III+ patients have less favourable outcomes and may require surgery if they do not respond positively to conservative treatment.

Secondary Spondylolisthesis Treatment Options

In recalcitrant cases, Pulsed Radio Frequency (PRF) is a pain management technique that can be administered to your facet joint nerves. Researchers have found it is more effective than epidural steroid injections, which is another short-term pain relieving option. (Hashemi et al., 2014)

Spondylolisthesis Surgery?

Surgery is occasionally warranted if you have failed your exercise-based conservative treatment. 10-15% of patients with degenerative spondylolisthesis have surgery. Surgery is considered when there is a failure to improve a radiculopathy eg muscle weakness, poor function or another neurological deficit such as loss of bowel or bladder function. Persistent severe pain is also a consideration for surgery.

Surgery for isthmic spondylolisthesis is considered for athletes with Grade III+ slips if they have failed 6-months of conservative exercise rehabilitation. (Radcliff et al., 2009)

Your surgery options are best discussed with your Spinal Surgeon, but they would normally involve a spinal decompression +/- spinal fusion.

Fortunately, conservative exercise options are successful in the vast majority of Grade I-II cases. Please consult with your physiotherapist for their professional assessment and specific treatment guidance for your spondylolisthesis.

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FAQs about Spondylolisthesis

Common Lower Back Pain Causes

The following conditions may cause lower back pain.

General Information

Muscle-related Injuries

Bone-related Injuries

Disc-related Injuries

Back Joint Injuries

Nerve-related Injuries

Pelvis-related Injuries

Pregnancy-related Pain

Systemic Diseases

Nerve Pain

Nerve pain is pain that is caused by damage or disease that affects the nervous system of the body. It is also known as neuropathic pain or neuralgia. Nerve pain is a pain that comes from problems with signals from the nerves. It is different to the common type of pain that is due to an injury. This is known as nociceptive pain.

What Causes Nerve Pain?

nerve pain Neuropathic pain is caused by a problem with your nerves themselves, which sends pain messages to the brain.

What is Nerve Pain Symptoms?

Nerve pain is often described as burning, stabbing, shooting, aching, or like an electric shock.

What Causes Nerve Pain?

Various conditions can affect your nerves and cause nerve pain. Common sources of nerve pain include:
  • Shingles (post-herpetic neuralgia).
  • Trigeminal neuralgia.
  • Diabetic neuropathy.
  • Phantom limb pain following an amputation.
  • Cancer.
  • Multiple sclerosis.
  • Chemotherapy.
  • HIV infection.
  • Alcoholism.
  • Other nerve disorders.

Nerve Pain & Nociceptive Pain

You can suffer both nerve pain and nociceptive pain simultaneously. Both pain types can be caused by the same condition.

Nerve Pain Treatment

Nerve pain is less likely than nociceptive pain to be helped by traditional painkillers such as paracetamol, anti-inflammatories and codeine.  However, other types of medicines often work well to ease the pain. Nerve pain is often eased by anti-depressant or anti-epileptic medicines. Please ask your doctor for more advice.

Pain Links

Pain & Injury

Tens Machine

What is a TENS Machine?

Pins and Needles - Paraesthesia

What Causes Pins & Needles?

A moderately pinched nerve is the most common cause of "pins and needles". Pins and needles are referred to as "paraesthesia" in the medical community. Did you know that feeling "pins and needles" can be a worse sign than having pain in your arm or leg? The reason is that you can't even feel pain anymore when you significantly squash the nerve.

Even worse than "pins and needles" is "numbness" or "anaesthesia", which is a total lack of sensation. You will experience anaesthesia when there is severe nerve compression. Anaesthesia or numbness that persists for more than a few hours can be a sign of permanent nerve compression. Please seek prompt medical attention to prevent the nerve from permanent damage and the muscles it innervates to weaken drastically.

The majority of pinched nerves and nerve compressions are only transient and quickly reversed with early treatment. However, neglect can lead to permanent nerve compression injuries, which may never recover.

Common Causes of Pinched Nerves

The most common forms of nerve compression are in the spinal joints where either a disc bulge or a bony arthritic spur can irritate and compress the nerve. Compressions can also occur as the nerve passes through or around muscles. Your physiotherapist will know where to look.

How Can You Fix "Pins and Needles"?

If you know of someone who is experiencing chronic or permanent "pins and needles", "numbness" or "muscle weakness", please encourage them to seek urgent professional advice. The secret to quick success is the correct diagnosis. A highly trained health practitioner such as your physiotherapist or doctor is your best port of call.

More info

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Youth Spinal Pain

Teenager Neck & Back Pain

teenager back pain Teenagers can be particularly vulnerable to back pain, mainly due to a combination of high flexibility and low muscle strength and posture control.  The competitive athlete and most individuals who exercise regularly or maintain a level of fitness and core stability control are less prone to spine injury and problems due to the strength and flexibility of supporting structures. Your physiotherapist can assist the resolution of any deficits in this area. Luckily, issues involving the lower lumbar spine are rare in athletes and account for less than 10% of sports-related injuries. Injuries do occur in contact sports and with repetitive strain sports. Sports such as gymnastics, cricket fast bowlers, and tennis have a higher incidence of associated lumbar spine problems related to repetitive twisting and hyper-bending motions. Spondylolisthesis is a significant concern and needs to be appropriately treated by a physiotherapist with a particular interest in these type of injuries. Luckily, most injuries are minor, self-limited, and respond quickly to physiotherapy treatment.

Common Adolescent Spinal Injuries

Lower Back (Lumbar Spine)

Midback (Thoracic Spine)

Neck (Cervical Spine)

Pelvis

For specific advice regarding youth neck or back pain, please seek the professional advice of your trusted spinal physiotherapist or doctor. Common Youth & Teenager Sports Injuries Common Youth Leg Injuries Common Youth Arm Injuries

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Back Muscle Strains

Back muscle injuries are the most common form of back injury. Muscle fatigue, excessive loads or poor lifting postures are the most common problems. Inefficient back muscles can lead to poor joint stabilisation and subsequent injury. More info: Back Muscle Pain

Ligament Sprains

Ligaments are the strong fibrous bands that limit the amount of movement available at each spinal level. Stretching ligaments too far or too quickly will tear them with subsequent bleeding into the surrounding tissues, causing swelling and pain. Awkward lifting, sports injuries, and motor vehicle accidents are very common causes. Just as in other regions of the body, physiotherapy hastens ligament healing and relieves pain so that you can enjoy life again as soon as possible. More info: Back Ligament Sprains

Bulging Discs

A bulging disc injury is a common spine injury sustained to your spine's intervertebral disc. Spinal discs are the shock-absorbing rings of fibrocartilage and glycoprotein that separate your bony vertebral bodies while allowing movement at each spinal level, and enough room for the major spinal nerves to exit from the spinal canal and travel to your limbs. The annulus is the outer section of the spinal disc, consisting of several layers of multi-directional fibrocartilaginous fibres all densely packed to create a wall around the glycoprotein filled jelly-like disc nucleus. A disc bulge (commonly referred to as a slipped disc), can potentially press against or irritate the nerve where it exits from the spine. This nerve pinch can cause back pain, spasms, cramping, numbness, pins and needles, or pain in your legs. More info: Bulging Discs

Bone Injuries

You can also fracture your spine if the force involved is highly traumatic or you have a low bone density (e.g. osteoporosis). More info: Osteoporosis

Poor Posture

Poor posture when sitting, standing or lifting at work can place unnecessary stress on your spine. Muscles fatigue, ligaments overstretch, discs stretch and this places spinal joints and nerves under pain-causing pressure. More info: Poor Posture

What Can Cause Severe Low Back Pain?

A sudden injury most often causes acute low back pain. The most common injury sources are the muscles and ligaments supporting the back. The pain may be caused by muscle spasms or a strain or tear in the muscles and ligaments. But occasionally, it can have a more sinister cause.

Warning Signs of a More Serious Back Injury?

In these instances of neurological deficit, please urgently consult your nearest hospital, doctor or physiotherapist. The following neurological signs warrant prompt assessment:
  • pins and needles (paraesthesia),
  • numbness (anaesthesia),
  • leg muscle weakness,
  • altered reflexes,
  • difficulty walking,
  • loss of control of bladder or bowels.

Non-Musculoskeletal Causes of Low Back Pain

Although most low back pain is musculoskeletal in origin, other health conditions can cause low back pain.
  • Abdominal aortic aneurysm
  • Infection of the spine (osteomyelitis, discitis)
  • Kidney infection or kidney stones
  • Spondyloarthropathies: e.g. rheumatoid arthritis, psoriatic arthritis.
  • Female reproductive organs: e.g. pregnancy complications, ovarian cysts or cancer, endometriosis
Please seek the professional advice of your trusted and experienced healthcare practitioner to diagnose the cause of your lower back pain.

What Causes Lower Back Pain?

Researchers and spinal health care practitioners categorise lower back bain into the following categories: 1. Specific Spinal Pathologies  (<1%) 2. Radicular Syndromes (5-10%) 3. Non-Specific Lower Back Pain (NSLBP) (Bardin et al., 2017)

Specific Spinal Pathologies

Some conditions that cause back pain do require an urgent and specific referral and treatment. These conditions include: These conditions do require early diagnosis and prompt referral to the appropriate medical specialist.  Luckily these conditions account for less than 1% of back pain sufferers, but you don't want them missed. Some referrals should be IMMEDIATE!

Radicular Syndromes

Lower back pain can result from structural damage that can irritate or pinch a nerve. Researchers believe that radicular syndrome causes 5-10% of the presentations of back pain to general practitioners.

Radicular pain (e.g. sciatica)

The most common pinched nerve in the lower back is your sciatic nerve. You may be diagnosed with sciatica if you are suffering radicular pain down your leg due to a back injury. While the sciatic nerve is the most common nerve that can be affected by a spinal injury, you can modify any spinal nerve function (e.g. femoral nerve). The following back injuries may cause radicular pain: Pain is due to swelling or space-occupying material adjacent to the spinal nerve. The affected nerve may be simply irritated, resulting in radicular pain. Or, even worse, become pinched or compressed, resulting in radiculopathy.

Radiculopathy

Lumbar radiculopathy can result in functionally disabling conditions such as foot drop, foot slap or eversion muscle weakness that can affect your ability to walk.

Spinal Stenosis

Spinal stenosis is a slightly different condition and relates to the narrowing of the spinal canal. Spinal stenosis is usually more prevalent as you age.

Non-Specific Lower Back Pain (NSLBP)

Non-Specific Lower Back Pain (NSLBP) is the diagnostic term used to classify sufferers of lower back pain with no specific structure injured. It is a diagnosis of exclusion. In other words, your spinal health care practitioner has excluded specific spinal pathologies and any of the radicular syndromes mentioned above as the cause of your back pain or symptoms. Fortunately, these conditions account for approximately 90-95% of lower back pain and can nearly always successfully rehabilitate without the need for surgery. Most improve within two to six weeks. They can be fast-tracked with pain relief and physiotherapy techniques such as manual therapy and back exercises.

NSLBP Causes

  The causes of NSLBP are numerous but roughly fall into either a sudden (traumatic) or sustained overstress injuries. Most people can relate to traumatic injury such as bending awkwardly to lift a heavy load that tears or damages structures. However, sustained overstress injuries (e.g. poor posture) are probably more common but also more straightforward to prevent. In these cases, positional stress or postural fatigue creates an accumulated microtrauma that overloads your lower back structures over an extended period to cause injury and back pain. Most commonly, NSLBP causes include back muscle strain or back ligament sprain. Other chronic back conditions such as degenerative disc disease may underly your acute disc health and predispose you to the severe pain. The good news is that you can take measures to prevent or lessen most back pain episodes. Early diagnosis and specific individualised treatment is the easiest way to recover quickly from lower back pain and to prevent a recurrence.

What is Back Muscle Pain?

Back muscle pain or its aliases: pulled back muscle, back muscle spasm, torn back muscle or back muscle strain, is very common. Back muscle pain is the most common source of back pain. The good news is that it is also one of the quickest to heal and rehabilitate.

What Causes Back Muscle Pain?

Most causes of low back pain are muscle, ligament or joint-related. Commonly, these muscular strains, ligament sprains and joint dysfunction arises suddenly during or following physical loading of your spine. Muscle fatigue, excessive loads, high speeds or poor lifting postures are the most common causes. The causes of pure back pain are numerous but roughly fall into the following categories.

Back Muscle Strains

Muscle pain is the most common source of back pain. Muscle fatigue, excessive loads or poor lifting or sitting postures are the most common problems. Inefficient, weak, or back muscles that lack endurance or normal contraction timing can lead to reduced joint stabilisation and subsequent injury to your back muscles, ligaments, joints or even spinal discs.

Poor Posture

Poor posture, when sitting, standing and lifting at work, can place unnecessary stress upon your spine. With muscle fatigue or overstretching, your ligaments and discs can stretch, and this puts spinal joint muscles and nerves under pain-causing pressure or strain, that results in back pain.

Ligament Sprains

Ligaments are the durable, fibrous bands that limit the amount of movement available at each spinal level. Stretching ligaments too far or too quickly will tear them with subsequent bleeding into the surrounding tissues, causing swelling, muscular spasm and pain. Awkward lifting, sports injuries and motor vehicle accidents are prevalent causes. Just as in other regions of the body, physiotherapy hastens ligament healing and relieves pain so that you can enjoy life again as soon as possible.

What are the Symptoms of Back Muscle Pain?

Back muscle pain symptoms may range from a mild ache to sudden debilitating back pain. Typical back muscle pain symptoms include:
  • Localised back pain, with no radiation into your buttock or leg.
  • Back muscle tenderness and spasm.
  • Protective back stiffness.
  • Sudden back pain onset.
You will usually feel better when resting and may find a change of position painful, e.g. sit to stand, rolling in bed, walking or bending.

How is Back Muscle Pain Diagnosed?

Differentiating a back muscle strain from a ligament sprain can be difficult, as both injuries will show similar symptoms. In general, it doesn't significantly matter what you call the problem because the treatment and prognosis for both back muscular strains and ligament sprains are similar. Most spinal practitioners refer to both injuries as a category called a "Back Strain" or "Musculoligamentous Strain". X-rays and CT scans do not identify muscle or ligament injury. MRI scan is probably the best diagnostic test to determine the muscle or ligament structures injured.

What is Back Muscle Pain Treatment?

Seek a Professional Diagnosis!

A spinal healthcare practitioner, such as your physiotherapist, should thoroughly; examine you to exclude more severe sources of back pain. Numerous injuries can cause back pain, and the treatment does vary significantly depending on your diagnosis. Physiotherapy treatment aims to protect your damaged tissue while hastening your muscle and ligament healing and then look at strategies to prevent a recurrence. Your physiotherapist has some nifty tricks for quickly relieving your back pain so that you can enjoy life again as soon as possible.

Back Strain Causes

We do know that some people are vulnerable to repeated lower back sprains and strains. While it is easier to understand that lifting a heavy load in an awkward position can cause back pain, it's harder to comprehend how a simple movement can hurt your back. Yes, it can happen by merely leaning forwards to pick up your teacup or when bending to brush your teeth! The reason is poor local joint control. The main reason for this is inadequate or non-existent muscle activation of the deep core stability muscles. These muscles are small but are right next to the joint to control excessive slides and glides. When they don't work correctly, the joint can slide too far and strain its supporting ligaments. Ouch! That hurts. The good news is poor core stability can be easily corrected to prevent back pain. Please contact your physio for more information or to have your core activation accurately assessed. High-risk factors of back pain include:
  • sudden forceful movement
  • lifting a heavy object
  • twisting the back
  • coughing or sneezing
  • prolonged sitting with poor posture
More information about Back Pain More information about Deep Core Stability

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What is Physiotherapy Treatment?

Physiotherapists help people affected by illness, injury or disability through exercise, manual joint therapy, soft tissue techniques education and advice.  Physiotherapists maintain physical health, help patients to manage pain and prevent disease for people of all ages. Physiotherapists help to encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing activities of daily living while assisting them to remain functionally independent.

There is a multitude of different physiotherapy treatment approaches.

Acute & Sub-Acute Injury Management

Hands-On Physiotherapy Techniques

physiotherapy treatment

Your physiotherapist's training includes hands-on physiotherapy techniques such as:

Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, just to name a few.

Physiotherapy Taping

Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.

Alternatively, your physiotherapist may recommend a supportive brace.

Acupuncture and Dry Needling

Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.

Physiotherapy Exercises

Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the "best exercises" for you and the most appropriate "exercise dose" for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.

Biomechanical Analysis

Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.

Hydrotherapy

Aquatic water exercises are an effective method to provide low bodyweight exercises.

Sports Physiotherapy

Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.

Vestibular Physiotherapy

Women's Health

Women's Health Physiotherapy is a particular interest group of therapies.

Workplace Physiotherapy

Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstation set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.

Electrotherapy

Plus Much More

Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.

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What is Therapeutic Ultrasound?

Therapeutic ultrasound is an electrotherapy modality which has been used by physiotherapists since the 1940s. Via an ultrasound probe through a transmission coupling gel in direct contact with your skin, ultrasound waves are applied. ultrasound Therapeutic ultrasound may increase:
  • healing rates
  • tissue heating
  • local blood flow
  • tissue relaxation
  • scar tissue breakdown.

How Could Ultrasound Help?

Ultrasound increases local blood flow. This increase may help to reduce local swelling and promote soft tissue healing rates. A higher power density may soften scar tissue.

Specific Ultrasound Uses

Mastitis or blocked milk ducts successfully respond to therapeutic ultrasound. The effect is quite dramatic, with improvement within 24 to 72 hours. The most common conditions treated with ultrasound include soft tissue injuries such as muscle, ligament injuries or some tendinopathies. Phonophoresis uses ultrasound in a non-invasive way of administering medications to tissues below the skin. This method may assist patients who are uncomfortable with injections. With phonophoresis, the ultrasonic energy forces the drug through the skin.

What is an Ultrasound Dose?

A typical ultrasound treatment will take from 3-10 minutes. Where scar tissue breakdown is the goal, this treatment time could be much longer. During the procedure, the head of the ultrasound probe is in constant motion. If kept in continuous motion, the patient should feel no discomfort at all. Some conditions treated with ultrasound include soft tissues injuries such as muscles or ligament injuries, tendinopathy, non-acute joint swelling and muscle spasm.

How Does an Ultrasound Work?

A piezoelectric effect, caused by the vibration of crystals within the ultrasound head of the probe creates the sound waves. The ultrasound waves generated then pass through the skin cause a vibration of the local soft tissues. This repeated cavitation can cause a deep heating locally though usually no sensation of heat will be felt by the patient. In situations where a heating effect is not desirable, an athermal application occurs. Athermal doses are typical during acute fresh injury and the associated acute inflammation.

When Should Ultrasound be Avoided?

Contraindications of ultrasound include:
  • local malignancy,
  • over metal implants,
  • local acute infection,
  • vascular abnormalities,
  • active epiphyseal regions (growth plates) in children,
  • over the spinal cord in the area of a laminectomy,
  • over the eyes, skull, or testes
  • and, directly on the abdomen of pregnant women. Treatment ultrasound differs from diagnostic ultrasound!
Like all medical equipment, when used by highly trained professionals, such as your physiotherapist, therapeutic ultrasound is very unlikely to cause any adverse effects. Please consult your physiotherapist for their opinion on whether therapeutic ultrasound could assist your injury. Therapeutic Ultrasound differs from Real-Time Ultrasound Treatment.

Lower Back Pain Treatment Guidelines?

While lower back pain treatment will vary depending on your specific diagnosis, your physiotherapist will have the following aims.

PHASE I - Back Pain Relief & Protection

Managing your back pain is the main reason that you seek treatment for lower back pain. In truth, it was the final symptom that you developed and should be the first symptom to improve. Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These include ice, electrotherapy, acupuncture, de-loading taping techniques, soft tissue massage. A course of non-steroidal anti-inflammatory drugs such as ibuprofen may also help in this phase.

PHASE II - Restoring Normal ROM and Strength. Early Back Exercises.

As your lower back pain and inflammation settles, your lower back pain may feel better. Still, you are more vulnerable to re-injury during this honeymoon period when you don't have pain, but your muscles and ligaments are weak. During this phase, your physiotherapist will turn their attention to restoring your normal lumbar spine motion. Plus they'll assess your muscle length and resting tension, muscle strength and endurance, proprioception, balance and gait (walking pattern). Your physiotherapist may commence you on a lower abdominal core stability program to facilitate your important muscles that dynamically control and stabilise your lower back and pelvis. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best back exercises for your specific needs.

PHASE III - Restoring Full Function

Depending on your chosen work, sport or activities, your physiotherapist will aim to restore your back's function to allow you to return to your desired activities safely. Everyone has different demands for their lower back that will determine what specific treatment goals you need to achieve. For some, it is merely to walk around the block. Others may wish to run a marathon or be a fast bowler. Your physiotherapist will tailor your back pain rehabilitation to help you achieve your own functional goals.

PHASE IV - Back Exercises - Preventing a Recurrence

Recurrence of lower back pain can occur. The main reason for a recurrence is due to insufficient rehabilitation. In particular, poor compliance with deep abdominal core muscle exercises. You should continue a version of these back exercises routinely a few times per week. Your physiotherapist will assist you in identifying the best activities for you to continue indefinitely.

Suffering Back Pain. What Should You Do?

While lower back pain is commonplace, the diagnosis of the cause of your back pain is specific to you, and therefore, the treatment or investigation pathway varies for each case. A spinal health care professional can assist you with a prompt diagnosis, early referral, acute and chronic back pain relief, plus long-term self-management or back pain prevention strategies specific to you. You should feel confident that your practitioner has screened you particular pathologies that require urgent medical attention. They should assess you for neurological deficits such as:
  • loss of bowel or bladder function,
  • leg muscle weakness,
  • loss of sensation,
  • diminished reflexes,
  • and, day-to-day function.
A thorough assessment will determine whether you have radiculopathy or stenosis. This diagnosis is essential since treatment usually differs from NSLBP or radicular pain. For specific recommendations, please consult a musculoskeletal physiotherapist or another spinal healthcare practitioner. You probably already know that back pain has a nasty habit of returning within a few months of the initial injury. Research has shown that you have an 80% chance of recurring back pain within 12 months of the first episode.  The good news is that you can reduce your chances significantly if you do the right thing early.

What Should You Do When You Suffer Back Pain?

Rest?

The latest research recommends that you only spend a day or two resting in bed. More extended periods cause muscle weakness which ultimately makes repeat back pain more likely.

Ice or Heat?

We recommend ice treatment for 20 minutes every 2 or 3 hours for the first 48 hours. The ice should help reduce your pain, swelling and back spasms. After a few days, you are safe to use heat packs. We usually recommend avoiding heat (and heat rubs) in the first 48 hours. Heat packs encourage bleeding, which could be detrimental if used too early.

Should You Use a Back Brace?

A back brace can help you to get back on your feet or allow you to return to work sooner. We don't encourage long-term use because research has shown that your stomach and back muscles will weaken as you become reliant on the brace.

What Medication Should You Use?

Your Doctor or Pharmacist may recommend pain relief in the form of paracetamol or an anti-inflammatory.  You are best seeking their advice as certain drugs can interfere with other health conditions.

When Should You Commence Physio?

In severe cases, when the slightest movement causes unbelievable pain or spasm, it may be best to wait a day or two to start treatment. This delay will allow the majority of swelling to settle.  Slight niggles or "my back feels out" sufferers can usually commence treatment (and maybe fixed) on the day of injury.  If you are not sure what to do, please call us for advice. We'll happily guide you in your time of need.

What About Core Stability Training?

The current trend in physiotherapy and fitness training is 'core stability training' (back and abdominal muscle control).

What If You Do Nothing?

Research tells us that symptoms lasting longer than three months become habitual and are much harder to solve. The sooner you get on top of your symptoms, the better your outcome and the quicker you'll get back to living your life."Back pain is something you could be suffering needlessly".

What Results Should You Expect from Physiotherapy?

Not only will your physio diagnose the cause of your pain and give you the "peace of mind" associated, but they'll also help you to:
  • Relieve your pain quicker
  • Cope better with your pain using proven strategies and tips
  • Get you back to work and play quicker through faster healing rates
  • Loosen and strengthen your back with individually prescribed exercises
  • Prevent future bouts of back pain via our holistic back pain management approach
Think about it. Back Pain is Something You Could be Suffering Needlessly. Please use our expert advice to guide you out of pain quicker and for a lot longer. If you have any questions regarding your back pain (or any other condition), please call us now to discuss your situation. You'll find our friendly staff happy to point you in the right direction.

Core Exercises

While all back exercises that strengthen the muscles that traverse your back are essential, back pain researchers have emphasised retraining your deep core muscles as a priority. "Core Stability" is your body's ability to control and support your spine via specific muscles dynamically. Your spine is an inherently unstable area of your body. Your lower back has five vertebrae that allow twisting, bending and arching with no other bones to assist. They sit on top of a triangular bone called the sacrum, which wedges itself into the pelvis. Unfortunately, without strong support, all of these bones would fall in a heap on the ground. Your deep core muscles are the main structures that support, control and move your lower spine and pelvis. They are also the most energy-efficient and best-positioned muscles to do the job for 24 hours a day. However, when they turn off, your spine is not fully supported by its usual muscular corset. This lack of support makes it quite vulnerable to injury and chronic pain. Research has shown that our back pain causes your "deep core stability" muscles to STOP working in EVERY case. The first time you experience low back pain, your brain automatically inhibits the regular activity of the Transversus Abdominis (TA) muscle. This inhibition occurs in 100% of sufferers. Unfortunately, even once the back pain has eased the TA muscle does not automatically switch on again. Inhibition of the TA muscle exposes your spine to further trauma and hence "recurrent back pain". Each incident becomes a little more severe, and consequently, further wasting of the TA occurs. Other causes of muscle inhibition include previous abdominal surgery, pelvic pain and post-pregnancy.

What are the Benefits of Core Stability Training?

Researchers have shown that the correct use of your core stability muscles not only prevents pain but also alleviates pain if you're already suffering. Also, your body's strength, power, endurance and performance will improve. You'll be able to run faster, jump higher and even throw further when these muscles work correctly. For more information, please contact your physiotherapist.

Core Stability Muscles

The deep core stability muscles of the lower spine include:
  • Transversus Abdominis (TA)
  • Multifidus (MF)
  • Pelvic Floor (PF)

Transversus Abdominis

core.stability.muscles The Transversus Abdominis (TA) is the deepest abdominal muscle. It is the "corset muscle" of the spine and pelvis. In the typical situation, TA contracts in anticipation of body motion to guard the spinal joints, ligaments, discs and nerves.

Multifidus

Multifidus (MF) muscles are very short muscles running from the transverse processes (on the sides) of one vertebra up to the spinous process (the middle of the back) of the next vertebra upwards. Their primary function is back stability. They do not produce an extensive range of movement, but work to provide small, "fine-tuning" postural changes, all day long.

Pelvic Floor & Diaphragm

The TA and the MF work in conjunction with your pelvic floor and diaphragm to make a flexible but stable region around your lumbar spine. It is this ability to stabilise your lumbar spine in its many positions that enable you to overcome back problems and reduce your chances of a reoccurrence.

What Are The Ideal Core Exercises?

Your deep core stability muscles retraining uses specific low-level activation exercises. While a very skilled physiotherapist who has training in deep core activation can observe and palpate for the correct muscle contraction, the best way is to see them working on a real-time ultrasound scan. Real-Time Ultrasound Physiotherapy guidance allows you to see how your muscles are contracting in real-time. This visual feedback will enable you to correct your specific deep core muscles inside your stomach, lower back, and pelvic floor as you attempt to contract those muscles.

Beware of “Core Stability” Exercises!

The fitness industry is full of fitness instructors who profess to know how to activate your core stability muscles. Unfortunately, the wrong core exercises will do you harm. Most progress your core exercises far too quickly and bypass these critical muscles to strengthen your outer abdominal muscles further and leave your deep core muscles weak. Research evidence has found that this renders you vulnerable to lower back pain and injury.

How Good is Your Core Stability?

Research clearly shows that core stability retraining has short and long-term benefits for low back pain sufferers. The good news is that we also know that core stability training markedly reduces your chances of re-injury. Research on lower back pain sufferers has shown us that if you can re-activate your core stability muscles, your chance of recurring back pain reduces. Your chances of not experiencing another bout of low back pain (LBP) within twelve months are almost three times better if you have undertaken an ultrasound-guided exercise program; 84% vs 30%. After three years, you still have a two in three chance of not experiencing low back pain if you did the exercises. Adding even more research support, if you didn't do the exercises, you only have a one in four chance of being pain-free. You're still over twice as likely to not experience another episode of back pain. Hides et al. (2001). PhysioWorks physiotherapists have professional knowledge in the training of core stability muscles. The difficulty has always been how to quantify a patient's level of stability control. That is, until now. The solution has been to develop a useful and clinically practical method of assessing your level of core stability. We can then determine and at what level it fails to cope when the demands placed upon your body. That is, what is the individual client's functional Back Stability Score (BSS)?

How Do We Assess Your Core Stability?

Your PhysioWorks physiotherapist will assess you to determine your current symptoms, pathology and functional requirement. Then, they'll physically test you to decide on your back stability based your ability to activate your core control muscles (transversus abdominis, multifidus and gluteals). If you can isolate these muscles, we are then able to test further when your core stability muscles lose control of your spine, become inhibited or fatigue. This testing assists us in determining what tasks make you vulnerable to back pain or injury.

What Happens After Your Core Stability Score is Determined?

Based on your functional needs, your treatment directs towards your specific areas of weakness. The result is a much stronger, stable and pain-free back. If you would like to know your Back Stability Score, please contact PhysioWorks.

What are the Benefits of the Functional Back Stability Score?

For Patients

  • You have a quantitative guide to your functional goals
  • You have a current status score. Progress is measurable.
  • You can progress quickly through the BSS levels to maintain motivation and self-esteem
  • Individualised treatment. Different retraining options depending upon desired outcomes.
  • You can self manage in long-term
  • Your goals are functional (task-related) rather than merely a strength score.
  • Quantitative Feedback for You, Your Health Practitioners and Insurers.
  • Achieve stepped goals and sensible, steady exercise and treatment progressions.
  • We'll educate you on how to prevent future injuries.
  • You'll be introduced to ergonomics and understand the best postures for you
  • You will prevent future bouts or at least minimise their severity
  • It's a research-backed solution.
  • It's perfect for all ages and physical ability.
  • There is a clear path for progression.
  • You perform your exercises in the comfort of your own home without expensive gym equipment or membership
  • You'll have personalised professional guidance for assessment, reassessments and progressions.
  • You'll be pain-free ASAP

For Clinicians & Insurers

  • It's a precise measure of your functional capacity
  • It allows better judgments on patient directions, e.g. returns to work
  • It offers better-individualised advice and treatment
  • It reduces jargon through measurable standardisation
  • It's a practical measure that can be related to other outcome measures such as Oswestry Disability Score
  • There is a clinically relevant correlation between subjective and objective findings
  • It reduces malingering.

What Conditions Does the Back Stability Program Improve?

  • Spinal Pain
  • Spinal Posture
  • Pelvic floor function
  • Sciatica
  • Spondylolisthesis
  • Spondylosis
  • Degenerative Disc Disease
  • Poor Balance or Fall History
A British Medical Journal study found that pre-event stretching does not reduce the overall risk of injury. However, stretching does slightly reduce the risk of specific kinds of damage (injuries to muscles, ligaments and tendons). These soft tissue injuries are common in both elite and recreational sportspeople. It seems reasonable and common sense that stretching may not prevent you suffering a broken bone or a joint dislocation, but it could reduce your chance of a soft tissue injury. The other main finding was that stretching reduces the risk of experiencing soreness, which always makes exercising more enjoyable! While sustained stretches in isolation may not be the answer, other studies have shown that warming up does reduce your injury rate. While there is no "absolutely proven"method of warming up yet, the preferred options appear to be a graduated progression to prepare you for your sport. In simple terms, warm-up steadily from gentle exercises that increase in intensity and speed as you progress through your warm-up period. It makes common sense for you to warm things up slowly to start and then prepare with replicate skills, to what you will require shortly on the field, at the end of your warm-up. For more specific warm-up and injury prevention advice particular to your sport or work, please ask your physiotherapist to prescribe a warm-up and warm-down routine specific to you and your sport or physical activity.

What Causes Back Pain?

Back pain is often the result of having weak stabilising muscles supporting your joints. Without strong support, your joints simply collapse. Your bony skeletons don't stand up by themselves. The bones are held upright by efficient, supportive muscles that work across every joint in your body.

Research has shown us that pain causes these supportive muscles (known as your "stabilisers" or "inner core stability" muscles) to stop working. Research on sufferers of lower back pain has found that these muscles stop working every time you experience back pain.

Even worse, in most cases, these muscles don't automatically start working again when your pain goes. They need to be deliberately re-started by your brain.

How Can You Reactivate Your Core Stability Muscles?

There are several ways to reactivate your core stability muscles. One of the most effective is to use a Swiss Exercise Ball. Usually, some simple Exercise Ball exercises can often automatically 'kick start' these stabilising muscles.

Your physiotherapist is an expert at the reactivation techniques of these stabilising muscles. For more advice, please contact your physiotherapist. Alternatively, you can download or eBook on Back Pain Rehabilitation using a Swiss Exercise Ball.

How Does a Swiss Exercise Ball Eliminate Pain?

Your Exercise Ball is an unstable surface. When you sit or exercise upon one of these balls, your body will automatically recruit your natural balance reactions. One of the critical most components of your balance reaction system is the activation of your stabilising muscles. With repeated use over just a few days, your stabilising muscles will automatically start working again in most cases.

Researchers have discovered that by merely activating the inner core stability muscles, you have two to three times less likelihood of recurring lower back pain.

What Can You Do?

If you want to fix your back pain, you can do something. The Exercise Ball could be just the solution you need to avoid future bouts of lower back pain.

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