Flexion vs. Stabilization Exercises for Degenerative Spondylolisthesis | Podcast Ep. 453

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we are back with more research. This one is all about stabilization exercises versus flexion exercises for degenerative spondylolisthesis. It's an rct, It's a good one. There's a lot of take home messages that we're going to touch on on this episode. Of course I'll drop a link down in the show notes, but before we get started, today's episode is sponsored by Jane, my favorite emr. The Jane team knows that when your workday is spent providing care for your patients, it can feel like there aren't enough hours in the day for the rest of your admin tasks. That is where Jane Emrehr can help you just free up a ton of time with great workflows, awesome templates and a streamlined system. They'll hook you up with a one month grace period if you use the code EBC for evidence Based Chiropractor one mo. That's EBC one mo. So you can click the link down in the show notes, have a chat with their team and see how Jane can help your practice run. But as I said at the top, we're talking research today. Study came out a couple years back and again the title is Stabilization Exercises versus Flexion Exercises in Degenerative Spondylolisthesis. A randomized control trial. I'll drop a link down in the show notes so you can head over and check out the paper. But there's, there's just a lot of good stuff here. One is that degenerative spondylolisthesis. What is it? Well, of course it is when there's displacement of one vertebra over the other due to degenerative changes. Why does this happen? Well, there's a lot of different reasons. As with most things in the spine, there are multiple factors that can cause or contribute to degenerative spondylolisthesis. However, there's a couple things that we can kind of pull out and say, well, these are some things that we see more often than others is that it's more common in people over 50 years old rather than those individuals under 50. Well, it's a degenerative condition, so of course it takes time. So that makes total sense. What is really interesting, and I don't know enough to say that it makes total sense right off the bat is that it's four times, four times more common in women than men, which is really, really shocking. That is a big difference the most commonly affected area is L4, L5, as you can imagine, that is sort of the precipice of motion, as I like to say. It's probably a better way to say that. But L4, L5 is maximum load. L4, L5 typically is maximum angle. So makes sense that you'd see it there. It's going to be the place of maximum degeneration when things aren't moving appropriately. So the displacement rarely exceeds 25 to 35% of the width of the underlying vertebra. So that's really, you know, 25% really is where you jump from a grade one to a grade two. And most are in that, it seems like, according to this study, most are kind of in that grade, you know, high grade one, low grade two. That's the most common. Now, of course, we've probably all seen grade 3 and grade fours, but more commonly is those high ones, low level 2s. And because this slippage literally is biomechanical, so to speak, you can develop, as you could imagine, the symptoms of compression as that bone slides forward. You got those foraminal canals on the left and the right side, the superior aspect of that canal at the top bone, the inferior aspect of that canal, bottom half of the hole is the inferior bone. So when the top bone slides, that offsets that hole just like a keyhole. And you're going to end up with potential for foraminal compression. Of course, going down the backside behind the vertebral body is the spinal cord spinal canal. So. So as you see that shift there as well, remember we're talking about a healthy spinal canal. You're talking about 10 millimeters of diameter there in the foraminal canals. You may be talking 7, 8 millimeters by 4 to 5 millimeters somewhere in that vicinity. Obviously, everybody's a little bit different, but you can see where this gets tight real quick, right? You start to see 2 millimeters, 3 millimeters. I mean, you're talking. If you have 5 millimeters of slippage, you could be in a severely. You could have severe stenosis as a result of that, with over 50% occlusion with just a 5 millimeter slip. So really important to keep that in mind. Even minor slippages, as they're saying here, grade one, grade two, grade one, the borderline between grade one, grade two being 25%, that could be bringing a spinal canal from 10 millimeters to seven and a half. You're already in a moderate, moderate severe type situation. And in terms of the stenosis and the compression so things can, you know, small changes can add up really quick when you're talking about tight spaces, specifically amongst the spine. And some common things associated with that are what you would imagine. Chronic low back pain, foraminal stenosis, central stenosis, radiculopathy, neurogenic claudication. All of this is sort of a natural course of history with this challenge because of the compression. So treatment is usually conservative to begin with. Makes a lot of sense in the absence of obviously red flags. And surgical indications are really only if somebody has had non surgical care for at least three to six months. Now, that's the way it's supposed to happen. Important to keep in mind that's not always the way that it happens. When somebody goes to visit their doctor and they're moved towards a surgical intervention, maybe more quickly than that, but that's, it's important for us to know you're really looking for at least three to six months of care. So again, as we've talked about many times on this episode, this is about setting great expectations for your patients so they don't get ants in their pants after like two to three visits. It's like, I'm not miraculously better, it might take some time. And you don't even really wanna start in the absence of red flags, even thinking about surgical intervention until you've gone through a pretty substantial course of conservative care. So exercise is one of those really go to interventions. It also has a lot of evidence to say that it does a really good job in people that have a degenerative spondylolisthesis. And lumbar stabilization exercises specifically have become really popular over the last 30 years. And these exercises prioritize progressive training of the stabilizing muscles of the trunk, which is really kind of taking the world by storm, so to speak. And one of the most popular exercise programs, routines for individuals with chronic low back pain, which has been used actually for 100 years, is the Williams flexion exercises. Most of the time just called flexion exercises. And Williams came up with these exercises for people that have chronic low back pain, specifically actually for younger individuals with lumbar hyperlordosis. That was the seeds of everything. And we've expanded our knowledge and what this can help with over time. The primary objective of Williams exercises, flexion exercises was to activate the abdominal muscles and relax the paraspinal lumbar muscles. Again, when you're working one set of these, the opposing set of muscles should relax as you're working one set, which makes sense on the surface. And I think many of US have seen with patients that that can be beneficial. So in this study, they were really looking at a narrow, maybe not super narrow, but a window of individuals that were older than 50 that had x rays confirming degenerative spondylolisthesis at specifically L4, L5, and also have suffered from chronic low back pain for more than three months and that could be with or without radicular pain. So those were the individuals that they were looking at. They ended up with 85 participants in this study. 42 were in the experimental group and 43 were in the control group. Those are the number that completed the trial in total, and no differences were found between the groups in terms of their intake of analgesics. The stabilization exercise group had a mean of 39 days during the previous six months that they took an analgesic. The flexion group had a mean of 34 days in the last six months that they took an analgesic. During the six months of follow up, both treatment groups showed progressive improvements in both disability scores, ODIs and and in reduction of pain, those VAS scores. And these changes were shown to be clinically relevant for lumbar pain. In 44 study participants, 20 from the stabilization group, 24 from the flexion group, and for improvement in disability, 53 total participants had benefit. 26 were from the stabilization group, 27 were from the flexion exercise group. So, interestingly, whether these individuals were doing flexion or extension exercises, and they seem to have some pretty substantial benefit, and these were randomized and they came in pretty similar to begin with. So the findings from this study do show that flexion exercises are not in any way inferior and they can actually offer a similar response to stabilization exercises. And the similarity of response between both exercise programs, specifically in terms of pain control and improvement, they highlight it might come from the ability of the flexion exercise program to again perform what they refer to as a mechanical release of the posterior structures of the spine, where facet degeneration is one of the primary pathophysiological indicators of degenerative spondylolisthesis. And that's a really important point we'll come back to in a moment. In the late 1980s, there was a DOC that proposed flexion exercises could be superior to extension exercises in terms of spine biomechanics and actually discouraged the use of extension programs. Cramps. So when you're talking about being able to mechanically release the posterior structures of the spine, this is a really, really key component because. And this is. This can get complicated really quickly. I readily admit that. But I think about areas that might have hypermobility. You're always going to end up with compensation. So you might have areas that then have hypomobility. And just because an area is hypermobile, the doesn't necessarily mean that every aspect of that segmental unit is hypermobile. Again, even within a spinal segment, you can have compensations if one facet, let's say, has less mobility or is more stuck or fixated than another, or if the disc is allowing a substantial amount of motion, but that's actually going to in many cases close down the facet joints. As something slides forward, that disc might lose a lot of integrity in the ability to hold the unit together. But as that slides forward, you have to remember that's pulling one of those facets forward, forward into the one in front. So you can also end up with facet loading, which almost seems counterintuitive when it's an unstable segment. I'm not talking surgically unstable, but I'm saying having hypermobility. So these are all really important super nuanced things to keep in mind as you're taking care of people in your practice. And the reduction in pain. The increase in disability with a home based program does coincide as they highlight with previous studies in the same institute and suggest that active conservative care program must be the first line treatment before other options. And when I say increase in disability, that's on an ODI score. So it actually means people are functionally less disabled. They are more functional, just for clarity's sake. So here's the key takeaways. Both lumbar stabilization exercises and flexion exercises do have a similar response in terms of reduction in pain and improving functional ability. For both people that have chronic low back pain and degenerative spondylolisthesis with no statistically significant difference between the groups over six months. And as they bring up here example is the flexion. So which one do you use? Well, that's where it comes down to you. That comes right down to the patient, right? Understanding that patient and understanding how you like to approach it. The good news that I take out of this is we have you have two different paths. Minimum you have flexion hand extension obviously. So you can really pick and choose based upon what's going on with the patient. For example, flexion exercise program as they highlight may be a good option for people who don't tolerate positions with weight placed on the joints. While stabilization exercises could be ideal for individuals who wish to scale up their exercise loads even further and incorporate them into other exercise activities. So I Love that take home message at the end because it really sets the stage for how you want to approach this in practice and knowing that you really have three to six months. Obviously, we hope to get people well as quickly as possible, help people feel better, function and get back to those activities that they really want to get back to. What's that life impact or life effect that drove them into your practice? That's what they want to get back into. Whether it's, you know, they're trying to get out there on the golf course, they're trying to play with their kids, whatever it might be, we want to get them back to that, knock on wood, well before three to six months. But knowing that three to six months really is the minimum before surgical intervention. Important keynote there. The second component is understanding you have two different ways that you can approach this and if one's not working, try the other one or star. And, and I should say start with a basis of understanding. Hey, does this person want to scale up their exercise? They're trying to do a variety of other things. Maybe stabilization exercises are better. Are they not tolerating really that weight and gravity? Well, flexion exercises might be better. So it gives us a really great sandbox to play in as providers, knowing that both of these can work really well. And it's really going to be furthering the research and also taking into account the patient and your experience, you listening your experience, to be able to say, hey, I think this is the way we should go about helping you find relief. And with all of these, this is not outcome based in terms of are you really pulling back that spondylolisthesis? Quite often most of the time you don't need to for somebody to find relief. What you need to really focus on is providing people, number one, decreasing inflammation in the area. Because if they have a compromised canal and they're already tight, as we would say, in other words, they're already getting a pinch foraminally or in the central canal. Inflammation of 1 to 2 millimeters, quote unquote of inflamed tissue on an area that's compromised, excuse me, by 2, 3, 4 millimeters already. That can really, really be the straw that breaks everything. So decreasing inflammation, absolutely critical. Improving the segmental biomechanics to the best of your ability and their ability, absolutely critical. Ensuring that the joint does have the proper motion. And again, it could be considered hypermobile, but there might be some structures that are hypomobile within that segment. So really, really analyzing the facets, understanding what's going on as they move through the range of motion, doing all of your movement assessments, absolutely critical. And then moving from there to be able to help people gain as much stability as possible in that area. Long term, really, really great way to help people with degenerative spondylolisthesis. So I love this study. Again, I'm going to drop that link down in the show notes and we're going to move, I'm going to say superior up the spine right now to talk a little bit about the cervical spine. If you are looking for the best objective assessment of the cervical spine, we're talking neuromusculoskeletal control, proprioception, range of motion, sensory motor integration. Neck care is the tool. It's awesome. I'm looking at the one I have right now shooting this podcast so neckcare.com, i'll drop that link down below, connect their team, ask some questions. Great resource for you. And if you're looking to generate more patient reactivations this quarter, who out there is not, head over to the smartchirobregner.com chances are you have received emails from me and quite a few of them potentially. And the reason is because we want to help you and there's thousands upon thousands of docs on my list and thousands of docs, maybe you right now listening that haven't really checked out. 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