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Journal of Bodywork & Movement Therapies (2014) 18, 244e258 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/jbmt CASE STUDY The effects of a global postural reeducation program on an adolescent handball player with isthmic spondylolisthesis* Carlos Barroqueiro, PT, BSc a,*, Nuno Valente Morais, PT, MSc b FisioBaroq, Rua do Bom Sucesso, 223, 3 drt, 4150-150 Porto, Portugal Private practice, Rua Engenheiro Duarte Pacheco 19C, Fração AC, 3850-040 Albergaria-a-Velha, Aveiro, Portugal a b Received 28 March 2013; received in revised form 17 September 2013; accepted 17 September 2013 KEYWORDS Lumbar spine rehabilitation; Muscle imbalances; Global stretching Abstract This report describes and evaluates a physical therapy intervention in a 15-year-old male handball player with low grade isthmic spondylolisthesis and associated spinopelvic misalignment (shearestress type). Upon examination, increased lumbar lordosis, horizontal sacrum and anterior pelvic tilting were mainly associated with altered resting length and extensibility of the iliopsoas, hip adductors and erector spinae muscles. The intervention was directed at improving the muscles resting length and extensibility balance within a global postural alignment perspective (global postural reeducation). After the treatment period, lumbar lordosis, sacral slope and anterior pelvic tilting decreased 17.2 , 16.5 and 15.1 respectively. Global postural reeducation was effective in changing spinopelvic alignment related to low grade isthmic spondylolisthesis. This treatment option should be considered as a potential nonsurgical alternative for this condition. ª 2013 Elsevier Ltd. All rights reserved. * Carlos Barroqueiro followed this case at FisioBaroq, Rua do Bom Sucesso, 223, 3 drt, 4150-150 Porto, Portugal. The authors state that this report has no financial affiliation, including research funding, or any involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. They also affirm that there is no other conflict of interest, i.e., personal associations or involvement as a director, officer, or expert witness in any part of this document. * Corresponding author. Tel.: þ351 913288243; fax: þ351 234521047. E-mail addresses: [email protected] (C. Barroqueiro), [email protected] (N.V. Morais). 1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.10.002 Global Postural Reeducation Program and isthmic spondylolisthesis Introduction Low grade isthmic spondylolisthesis is found in up to 50% of athletes with persistent back pain. Its overall prevalence is 4e5% in children at the age of 6 and this number rises to approximately 6% by the age of 18. 75% of all individuals showing spondylolysis or stress fracture of the pars interarticularis on plain radiographs by the age of 6 also show evidence of a slipped vertebra at that time (Fredrickson et al., 1984). The incidence of spondylolysis is higher in sports that require repetitive lumbar hyperextension and/ or rotation, such as gymnastics and throwing sports (Watkins and Watkins, 2010; Wimberly and Lauerman, 2002). Halvorsen et al. (1996) found a higher occurrence of spondylolisthesis/spondylolysis in handball players between 15 and 19 years old. The etiology is not totally understood. However, lumbar hyperlordosis appears to play an important role in the development of the isthmic defect, because the repetitive lumbar hyperextension, combined with anatomical characteristics of young athletes (thinner pars, immature isthmus, and diminished resistance to disc shear), results in a high concentration of forces at the pars interarticularis (Ikata et al., 1996; Sairyo et al., 1998). This frequently is the most affected structure, although the pedicle or articular process may also be impaired (Watkins and Watkins, 2010). The vertebral slip occurs when the facet joints are unable to support the anterior shearestress, causing isthmic spondylolisthesis (Herman et al., 2003). The most affected segment is L5eS1, because the position of the sacrum creates anterior shear and compressive forces that increase the tensile forces on the spinal ligaments and shear forces on the neural arch (Alexander, 1985; Swärd et al., 1989). Imaging techniques can clarify the diagnosis and assist in the clinical decision. First line imaging consists of plain radiographs (frontal and lateral views) of the lumbar spine and pelvis in the upright standing position. The radiographs show the amount of vertebral slip (or slip grade, usually expressed in percentage of slip) and the alignment of the lumbar spine and pelvis (spinopelvic alignment). Even though the slip grade is essential for assessing the severity of the deformity, over the last decade several publications have furthermore stressed the value of spinopelvic alignment for the assessment and management of L5eS1 spondylolisthesis. Accordingly, proper sagittal alignment of the spine should be considered along with spondylolisthesis in order to help prevent slip progression and adjust the biomechanics of the lumbosacral region (Bourghli et al., 2011; Kim et al., 2011; Labelle and Mac-Thiong, 2011; Labelle et al., 2008, 2011; Mac-Thiong and Labelle, 2006; Sevrain et al., 2012). Spinopelvic alignment refers to morphological and positional (postural) parameters of the spine and the pelvis that can be measured on radiographs by a number of metric or angular parameters. It is comprised of three components, one morphological, the pelvic incidence (PI), and two positional, the sacral slope (SS) and the pelvic tilting (PT). PI refers to the sacropelvic morphology (anatomy) specific to each individual, which is unaffected by changes in human posture. It will remain the same whether the subject is standing, sitting or lying down, assuming that there is no 245 significant motion occurring at the sacroiliac joints or deformation of the sacral plate (Labelle and Mac-Thiong, 2011). SS and PT measure the sacropelvic orientation in the sagittal plane. SS is the angle between the sacral plate and the horizontal line. The orientation of the sacral plate is the base of the lumbar spine thereby determining its sagittal orientation (r2 Z 0.646), i.e., the lumbar lordosis (LL) (Boulay et al., 2006). PT represents the spatial orientation of the pelvis, which varies according to position, with a greater or lesser degree of anterior or posterior tilting in relation to a transverse axis passing through the two femoral heads. PI, SS, and PT are all interrelated as PI represents the arithmetic sum of the PT and SS angles (PI Z SS þ PT). PI is an important determinant of the spatial orientation of the pelvis in the standing position: the greater the PI, the greater has to be SS, PT, or both have to be. As the value of PI is fixed for a given patient, the sum of PT and SS is likewise invariable, so as one increases, the other decreases (Labelle and Mac-Thiong, 2011; Le Huec et al., 2011a; Mac-Thiong et al., 2007; Vaz et al., 2002). Postural alignment exercises, stretching and manual therapy are often recommended to change LL and PT, improve abnormal motion patterns and the range of motion (ROM) of the lumbopelvic region, and reduce pain and disability associated with impairments of the lumbar spine (Bonetti et al., 2010; Chaitow, 2006; Gajdosik et al., 1994; Halpin, 2012; Kendall et al., 2005; Kisner and Colby, 2002; Liebenson, 2007; Sahrmann, 2002; Scannell and McGill, 2003). However, to the best of our knowledge, the effects of conservative interventions on spinopelvic alignment parameters (PI, PT, SS and LL) have not been investigated yet. In this report we describe a global postural reeducation program and evaluate its impact on spinopelvic alignment, slip grade and mobility of the lumbar spine of a young athlete with low grade isthmic spondylolisthesis. Case description The patient was a 15-year-old male Caucasian handball player (height Z 1.73 m; body mass Z 59.0 kg; body mass index Z 19.7 kg/m2), who was referred to physical therapy with a medical diagnosis of low back and buttock pain and grade II L5eS1 isthmic spondylolisthesis, lumbar hyperlordosis and verticalization of the sacral plate. Informed consent was obtained and the rights of the patient were protected. History and presentation The patient fell on his lower back during a handball game in April 2011, which triggered acute low back and buttock pain accompanied by stiffness. He was assisted just after the fall, was told to rest, take painkillers and put ice on the injured area. Over the following days, the team’s medical staff examined him and decided to investigate further using X-ray scans (15-04-2011). The radiographs revealed a grade II L5eS1 isthmic spondylolisthesis (radiologist diagnosis). The patient continued to take painkillers and was told to stop playing handball until the pain disappeared and that he would be reevaluated some months later to check the 246 progression of the spondylolisthesis. On 20-12-2011, the new X-ray scans showed a similar slip grade but with an increase in the LL and verticalization of the sacrum plate. The patient and his parents were then informed that he would have to stop playing handball in order to prevent future complications (e.g., stress fracture of the pars, persistent low back pain). On 12-01-2012, the parents sought the assistance of a physical therapist (C.B.). At the time of physical therapy evaluation the patient no longer complained of low back pain. Physical examination Assessment of joint mobility, body alignment, movement and muscle balance in the standing, forward bending, and seated positions was conducted to differentiate between the mechanisms that are potentially related to spinopelvic misalignment (Chaitow, 2006; Janda et al., 2007; Magee, 2006; Sahrmann, 2002; Souchard, 1989, 1991). Body alignment, movement, and muscle balance were assessed both locally and globally, as postural and movement impairments are often related to a systemic chain reaction of the whole C. Barroqueiro, N.V. Morais muscle system (Chaitow, 2006; Janda et al., 2007; Kendall et al., 2005; Sahrmann, 2002; Souchard, 1987, 1990, 1991). Thus, when a correctional maneuver is applied to improve body alignment or test the activity, resting length and extensibility of muscles, there are compensatory movements above and/or below the area of interest. Figs. 1e3 and 7 (first two frames) exemplify those chain reaction mechanisms. Table 1 summarizes the major findings from body alignment, movement and muscle balance assessment. Similar assessment procedures demonstrated satisfactory reliability (inter-rater percentage of agreement Z 81%; kappa coefficient Z 0.71) in another study (Kim et al., 2013). Imaging techniques Lateral and frontal views and functional (lumbar fullextension and full-flexion positions) radiographs in the standing position were all performed at the same diagnostic imaging center. Radiographs before the intervention are shown in Figs. 4 and 5. The anterior slip of L5 in relation to the sacrum, an increased lumbar lordosis and a more horizontal position of Figure 1 Example of chain reaction mechanisms of the muscle system to corrective maneuvers. Dark green straight arrows represent corrective manual actions of the therapist. Red straight arrows represent the chain reaction mechanism of the muscle system. Global Postural Reeducation Program and isthmic spondylolisthesis 247 Figure 2 Alternative assessment of hip flexors tightness in the anterior tilting of the pelvis and lumbar spine. The peripheral attachments are moved to assess the magnitude of compensatory movements in the pelvis and lumbar spine. Dark green straight arrows represent corrective manual actions of the therapist. Red arrows represent the chain reaction mechanisms. Top: all hip flexor muscles start in a shortened condition. Center: assessment of hip adductors tightness. Bottom: Assessment of iliopsoas muscle tightness. the sacrum are noticeable. Measurements performed on the digitized radiographs revealed low grade L5 spondylolisthesis with high PI and high SS (see Table 3 for values). Based on spinopelvic alignment classification, this pointed to a shearestress type or type 3 spondylolisthesis (Labelle et al., 2011). Type 3 is regarded as having the highest risk of progression in patients with low grade spondylolisthesis (Labelle et al., 2011; Sevrain et al., 2012). Some segmental mobility imbalances were also identified on the functional radiographs (Fig. 5). A relative hypomobility of the lower lumbar segments in the fullflexion position (already noticeable during physical examination) and of the upper lumbar segments in the fullextension position was identified, as well as a relative hypermobility of the lower lumbar segments in the fullextension position and of the upper lumbar segments in the full-flexion position. Physical therapy diagnosis The pathomechanical diagnosis of this case was low grade shearestress type L5 spondylolisthesis associated with muscle imbalance. Increased LL and anterior PT were mainly related to decreased resting length and extensibility of the iliopsoas and adductor muscles of the hip, the erector spinae, and the diaphragm muscle. Shoulder position also influenced the impaired alignment of the lumbar spine and pelvis, particularly the adductor/medial rotator muscles of the shoulder (latissimus dorsi and pectoralis major) and the pectoralis minor muscle. Intervention A global postural reeducation program was implemented to (re)gain balanced postural alignment and flexibility (Bonetti et al., 2010; Ciaccio et al., 2012; Fernández-delas-Peñas et al., 2005, 2006; Silva et al., 2012; Souchard, 1987, 1990, 1991). A weekly treatment was carried out for 5 months. A summarized description of the treatment protocol is outlined in Table 2. During each treatment session, the tight muscles related to the postural misalignment were smoothly and progressively stretched into a particular position (treatment postures), followed by the active contraction of the antagonist 248 C. Barroqueiro, N.V. Morais Figure 3 Assessment of shoulder positioning in the alignment of the lumbar lordosis and of the thorax. Dark green straight arrows represent corrective manual actions of the therapist. Red straight arrows represent the chain reaction mechanism. Abduction of the shoulders further increases lumbar lordosis and elevates the thorax due to tightness of the latissimus dorsi and pectoralis minor and major muscles (curvilinear red arrows) (center). Re-alignment of the thorax and lumbar lordosis decreases shoulder abduction (tightness of the latissimus dorsi muscle) and a forward movement of the arms is observed (tightness of the pectoralis minor and major muscles). muscles. This way the therapist and the patient were able to control and harmonize compensatory movements along with a three-dimensional global alignment of body segments and joints. Examples of the treatment postures applied to this case are illustrated in Figs. 6e8. Outcomes To evaluate the effects of the intervention, the radiographs performed on 20-12-2011 and 6 months later, on 18-062012, were used for preepost-intervention comparison. The slip grade, spinopelvic alignment and ROM of the lumbar spine were measured on digitized radiographs using Osirix Imaging software, version 5.0.2 32-bit (Pixmeo SARL, Switzerland). The definition and selection of slip grade and spinopelvic alignment radiological parameters were established according to previous studies (Boulay et al., 2006; Bourghli et al., 2011; Kim et al., 2011; Labelle and MacThiong, 2011; Labelle et al., 2008, 2011; Le Huec et al., 2011a; Mac-Thiong and Labelle, 2006; Mac-Thiong et al., 2007; Sevrain et al., 2012; Vaz et al., 2002). Fig. 9 (left image) illustrates the angular and metric measurements used to assess the slip grade and spinopelvic alignment in this patient. The reliability of these measurements using computer-assisted methods is highly satisfactory, with intra- and inter-observer intraclass correlation coefficients (ICC) superior to 0.97 in most of the radiological parameters (Berthonnaud et al., 2005; Glavas et al., 2009). Only LL had a slightly lower inter-observer reliability, with an ICC (95% confidence intervals) of 0.88 (0.64e0.95) (Berthonnaud et al., 2005). The angular measurements used to assess the ROM of the lumbar spine on the functional radiographs are shown in Fig. 9 (right image). The extension and flexion ROM of the lumbar spine were calculated using the difference between the neutral position (LL angle in the standing position) and the full-extension position (end-range extension angle), and the difference between the neutral position and the full-flexion position (end-range flexion angle), respectively (Thoumie et al., 1998). The total ROM of the lumbar spine was calculated as the difference between the two maximal positions (Thoumie et al., 1998). The repeatability of this measuring system was estimated in less than 2 (Thoumie et al., 1998). To assess the segmental contribution to the end-range extension and flexion angles, the segmental ROM of the lumbar spine was measured using the intervertebral rotation angle as described elsewhere (Pearson et al., 2008). Pearson et al. (2008) citing Lurie et al. (2006) reported an ICC of 0.89, which is suggestive of a very good inter-observer reliability for this measurement. Slip grade and spinopelvic sagittal alignment At baseline, the LL angle was 66.0 and about 6 months later it had reduced by 17.2 . Following the same pattern, SS had changed from 65.3 to 48.8 . PT changed by 15.1 over this same time period, which represents a reduction in the anterior tilting of the pelvis. PI remained unchanged as expected and the slip grade was relatively unaltered (Table 3). Range of motion of the lumbar spine After the intervention, the end-range extension angle of the lumbar spine decreased by 6.3 , whereas the end-range flexion angle increased by 8.4 (Table 3). This represents a gain of approximately 2 in the total ROM (45.5 beforee47.6 after). At first sight, this could be interpreted as an improvement of the lumbar flexion ROM with a decrease in the extension ROM, but this was actually a gain in the extension ROM with a relative decline of flexion ROM. Since there was a shift in LL orientation in the standing Global Postural Reeducation Program and isthmic spondylolisthesis position (66.0 beforee48.2 after), we observed an increase in the lumbar extension ROM of 11.7 (13.5 beforee25.2 after) coupled with a relative decrease of 9.4 in the lumbar flexion ROM (32.0 beforee22.6 after). Segmental measurements revealed that the extension ROM increased in the upper lumbar segments, whereas the flexion ROM mostly decreased in the upper lumbar segments with a small increase in the lower segments (Table 4). Discussion The aforementioned global postural reeducation program for this patient was effective in reducing postural misalignment 249 associated with spondylolisthesis of L5. Specifically, a decrease in SS, LL and anterior PT in the standing position was observed. The pathogenesis of spondylolisthesis appears to have been altered, as an increase of SS, anterior PT and LL in the standing position (Fig. 4 and Table 3) is observed from the first to the second radiograph (pre-intervention period). This points toward an ongoing compensatory mechanism of the muscle system to cope with the anterior spinal unbalance caused by the defect, which is believed to have a negative biomechanical impact in the lumbosacral region (Lamartina et al., 2012; Mac-Thiong and Labelle, 2006). The reduction in SS and LL combined with such a high PI after the intervention, had potentially lowered the shear and compression forces in the lumbosacral junction (Sevrain Table 1 Body alignment, compensatory movements and muscle balance related to postural misalignment and interpretation (Chaitow, 2006; Janda et al., 2007; Kendall et al., 2005; Sahrmann, 2002; Souchard, 1987, 1989, 1991). Testing Outcomes Interpretation Increased lumbar lordosis and anterior pelvic tilting In standing: Reduction only possible if flexion of the hips was allowed (exemplified in Figs. 1 and 7 e first two frames) In supine: misalignment increased with abduction and external rotation of the hips, but more importantly with extension of the hips (exemplified in Fig. 2) No noteworthy side-to-side differences were found Forward head posture The patient elevated the thorax and further increased lumbar lordosis (exemplified in Figs. 1 and 7, and second and third frames respectively) Abduction of the shoulders Lumbar hyperlordosis increased further after 90 of shoulder abduction along with elevation of the thorax (exemplified in Fig. 3) Any attempt to correct the increased lordosis was very difficult and coupled with a decreased range of shoulder abduction and a forward motion of the arms No noteworthy side-to-side differences were found The angle between the legs and the feet (relative plantar flexion at the ankle joint) changed little in relation to the standing position, hands were at mid-distance to the legs while keeping the knees extended Spinal flexion occurred mainly in the low thoracicehigh lumbar region with hip flexion reaching approximately 60e70 Two relatively flat zones (hypomobilities) were observed, one at the mid-thoracic region and the other at the low lumbar level Associated with adaptive shortening or tightness of the flexor muscle group of the hip joint The iliopsoas muscle was shown to have more relation to excessive lumbar lordosis and anterior pelvic tilting than adductor muscles of the hip joint Associated with excessive tension of the fibrous system of the mediastinum which pulled on the phrenic center and the diaphragm muscle, thereby transmitting this force to its lumbar and rib insertions, causing an augmented thoracic diameter and further lumbar hyperlordosis Upper thorax elevation during the test was also related to the tightness of the sternocleidomastoid and scalene muscles Associated with the tightness of the adductors-medial rotators of the glenohumeral joint, but there was also involvement of the scapulothoracic joint (pectoralis minor muscle) and the diaphragm muscle Reduced hip flexion and relative hypermobility of the low thoracicehigh lumbar segments associated with the tightness of the hamstring muscles Associated with the tightness of the paraspinal muscles in those regions, also demonstrating the contribution of the lumbar back muscles to augmented lumbar lordosis Forward bending in standing 250 C. Barroqueiro, N.V. Morais Figure 4 Radiographs (lateral view) of the lumbar spine in the standing upright position before (left and center) and after (right) the intervention. et al., 2012) as well as the risk of developing degenerative conditions of the spine (Funao et al., 2012; Schuller et al., 2011). Shearestress and compressive forces can increase the risk of slip progression by augmenting the deformity of the sacral dome (Sevrain et al., 2012) and by causing elongation and stress fracture of the pars interarticularis (Cyron and Hutton, 1978). According to estimates based on a study by Sevrain et al. (2012), the reduction of 16.5 in SS could represent a reduction of 11% and 10% in the shearestress and compressive forces on the sacral end plate respectively. A decline in SS is always coupled with a change in PT as they are mathematically related through PI, the morphological component of sagittal spinopelvic alignment (Labelle and Mac-Thiong, 2011; Le Huec et al., 2011a; MacThiong et al., 2007; Vaz et al., 2002). The reduction of 16.5 in SS after intervention was thus paired with the increase of 15.1 in PT, corresponding to a more neutral positioning of the pelvis in the standing position. This was accomplished by progressively promoting regional balance between muscles that tend to increase LL and tilt the pelvis anteriorly (e.g., hip flexors and erector spinae) and those that reduce LL and tilt the pelvis posteriorly (e.g., hamstrings and abdominal muscles), while harmonizing compensatory movements in the segments above and below the relevant area. This clinical approach is essential in such cases because when changes in sacropelvic orientation occur, the body constantly tries to readjust to the new position to keep a horizontal gaze (Lamartina et al., 2012; Mac-Thiong and Labelle, 2006). This might not always occur through energy saving mechanisms, and thus involve increased muscle effort for standing (e.g., flexion of the hips and knees; sway back), which is not clinically desirable and Figure 5 Functional radiographs (lateral view) of the lumbar spine in the standing position before (left) and after the intervention (right). First and third frames show full-extension condition. Second and fourth frames show full-flexion condition. Global Postural Reeducation Program and isthmic spondylolisthesis Table 2 251 Treatment protocol used to gain good postural alignment and improve muscle imbalances. Treatment Posture Objectives Duration/ Progression Lying posture with progressive extension of the lower limbs, and abduction of the shoulders (Fig. 6) Starting position: patient in the supine position, elbows extended and shoulders at 45 of abduction, hips in flexion, abduction and lateral rotation, knees bent, feet touching each other Standing against the wall with progressive extension of the lower limbs (Fig. 7) Starting position: lumbar spine in full contact with the wall, hips slightly flexed and laterally rotated, feet and toes in a normal alignment with the floor, arms at 30 of shoulder abduction, elbows extended Note: this treatment posture was only introduced after two weeks of treatment Lying posture with flexion of the lower limbs, and abduction of the shoulders (Fig. 8) Starting position: patient in the supine position, elbows extended and shoulders at 45 of abduction; hips flexed, in slight abduction and external rotation, ankles in slight dorsiflexion with the feet supported by a sling To gain good postural alignment and to balance the iliopsoas, hip adductors, paraspinal, pectoralis minor, pectoralis major, latissimus dorsi and respiratory muscles 25 min Manual traction was applied to the sacrum and to the occiput to align the curves of the spinal column Progressive abduction and lateral rotation of the hips, then extension, adduction and neutral rotation Progressive abduction of the shoulder joints Deep rhythmic expiratory breathing throughout 3 5 min Progressive extension, adduction and neutral rotation of the hips Manual traction was applied to the occiput throughout Feet and toes in a normal alignment with the floor throughout Progressive adduction with neutral rotation of the shoulder joints Deep rhythmic expiratory breathing throughout 25 min Manual traction was applied to the sacrum and to the occiput to align the curves of the spinal column Progressive increase of flexion, adduction and neutral rotation of the hips, knees extension and dorsiflexion of the ankles Progressive abduction of the shoulder joints Deep rhythmic expiratory breathing throughout The same as above, but with increased challenge on the active control of postural alignment and muscle balance To gain good postural alignment and to balance the paraspinal, gluteus maximus, deep pelvic-throcantheric, hamstrings, triceps surae, pectoralis minor, pectoralis major, latissimus dorsi and respiratory muscles should be taken into account (Lamartina et al., 2012; MacThiong and Labelle, 2006). Because the patient always had a posterior reference during the sessions (the treatment table for the lying treatment postures or the wall for the standing treatment posture), the segmental corrections were constrained so that the sagittal re-alignment was aimed at keeping the line of gravity within the feet and behind the hip joints (Le Huec et al., 2011b). This required muscle work, but the patient reported feeling comfortable and effortless in the standing position at the end of each session and the therapist observed that spinal misalignment had improved. Re-balancing procedures were progressively much easier to perform, with less significant muscle chain reaction mechanisms and effort. The magnitude of LL in the standing position is believed to be strongly determined by the morphology of the pelvis, the lumbosacral disc and the vertebral body of L5, and by the positional parameters SS and dorsal kyphosis (Bogduk, 2005; Boulay et al., 2006). However, in this paper it is demonstrated that muscles resting length and extensibility balance might also play an important role and should be considered in musculoskeletal problems in which postural alignment is impaired. This is supported by another study, where successful changes in the lumbar lordosis of asymptomatic subjects were also found after the implementation of a 12-week exercise program aimed at increasing the muscle activity of the abdominal and gluteal muscles and the length of the hip flexor muscles (Scannell and McGill, 2003). For some patients though, our approach might be preferable to that of Scannell and McGill (2003). Using our case as an example, as the slip of L5 tends to shift the center of mass away from the coronal midline (augmented flexion moment of force), the muscles that try to counteract this tendency (e.g., erector spinae and hamstrings) need to increase their activity to keep the sagittal balance with a horizontal gaze. The misbalance provokes a general tightness in the region with increased contact forces in the spinal joints (type I lever mechanism). By first using lying positions and reducing tightness in the muscles associated with the postural misalignment through stretching, and concomitantly applying manual spinal traction and segmental mobilization, the therapist progressively improved postural alignment while relieving pressure from the spinal joints (Beattie et al., 2009; Cholewicki et al., 2009; Kroeber et al., 2005; Lee and Evans, 2001; Pellecchia, 1994; Saunders, 1979). This is poorly 252 C. Barroqueiro, N.V. Morais Figure 6 Example of the starting position (top), progression, and manual action of the therapist or gravity (dark green straight arrows) in the “Lying posture with progressive extension of the lower limbs and abduction of the shoulders”. Light green arrows represent the muscles being stretched (hip adductors, iliopsoas, latissimus dorsi, pectoralis minor and major). The orange arrow represents the action of the antagonists of the hip flexor muscles (abdominal muscles) in maintaining the reduction of the lumbar lordosis. accounted for, though recognized, in Scannell and McGill’s (2003) study. The inclusion of proper diaphragmatic dynamics during all re-alignment procedures was deemed essential to improve the outcomes in this case. Some authors have emphasized the potential role of diaphragmatic mechanics (positioning, recruitment, excursion and synergies) and breathing patterns in the (abnormal) postural control and (mis)alignment of the spine (Chaitow et al., 2002; Kolar et al., 2010; Souchard, 1987, 1990), which we believe is often overlooked. Recently, impaired diaphragmatic mechanics during postural tasks was found to be involved in the pathogenesis of chronic low back dysfunction (Kolar et al., 2012), supporting the need to assess and reestablish proper diaphragmatic dynamics in musculoskeletal problems related to postural misalignments of the spine, as in this case. Research methods, using sophisticated instruments (e.g., electromyographs, motion tracking devices, isokinetic dynamometers, imaging techniques), showed that muscle imbalances can often be associated with postural misalignment, movement impairments and pain syndromes (Beer et al., 2012; Borstad, 2006; Borstad and Ludewig, 2005; Hashemirad et al., 2009; Kebaetse et al., 1999; Kim et al., 2006, 2013; Kolar et al., 2012; Ludewig and Cook, 1996; Oddsson and De Luca, 2003; Scannell and McGill, 2003; Thigpen et al., 2010). However, transposing this knowledge to clinical practice can be challenging. This is in part because validity and reliability studies of the clinical methods used to assess several muscle balance determinants such as muscle activity, resting length and extensibility are scarce and often show conflicting results (Cuthbert and Goodheart, 2007; Gajdosik et al., 1994; Haas et al., 2007; Kim et al., 2013; Peeler and Anderson, 2007; Silva et al., 2010; Uhl et al., 2009). For example, a test commonly used to assess the length of the iliopsoas muscle, the Thomas test, showed poor reliability in the measurement of the hip ROM either by means of goniometry (intra-rater ICC Z 0.52; inter-rater ICC Z 0.60) or dichotomous “pass” (testing leg remains on the plinth)/“fail” (testing leg rises off the plinth) scoring Global Postural Reeducation Program and isthmic spondylolisthesis 253 Figure 7 Example of the starting position (left), progression, and manual action of the therapist and/or patient action (dark green straight arrows) in the “Standing against the wall with progression of the lower limbs”. Red straight arrows represent the chain reaction mechanism of the muscle system. Light green arrows represent the muscles being stretched (hip adductors, iliopsoas). The orange arrow represents the action of the antagonists of the hip flexor muscles (abdominal muscles) in maintaining the reduction of the lumbar lordosis. system (intra-rater ICC Z 0.47; inter-rater ICC Z 0.39) (Peeler and Anderson, 2007). Further investigation is needed to improve the validity and reliability of clinical methods used to assess muscle balance. This will likely improve the pathomechanical diagnosis and the selection of therapy(ies) in several musculoskeletal conditions. The effects of this global postural reeducation program on the slip grade of L5 were limited, in accordance with other conservative approaches, including bracing (Klein et al., 2009). The decline of 2 in the lumbosacral angle after the intervention period was small, but might in fact represent some change, as the standard error using Figure 8 Example of the starting position (left), progression, and manual action of the therapist and/or patient action (dark green straight arrows) in the “Lying posture with flexion of the lower limbs, and abduction of the shoulders”. Light green arrows represent the muscles being stretched (paraspinal muscles, gluteus maximus and deep pelvic-trocanteric muscles, hamstrings and triceps surae). 254 C. Barroqueiro, N.V. Morais Figure 9 Example of the metric and angular measurements made on standing upright (left) and functional (right) X-rays. These were defined as: SS, sacral slope (the angle between the horizontal and the sacral plate); PI, pelvic incidence (the angle between the perpendicular to the sacral plate at its midpoint and the line connecting this point to the femoral heads axis); PT, pelvic tilting (the angle between the vertical and the line through the midpoint of the sacral plate to the femoral heads axis); LL, lumbar lordosis (the angle between the superior end plate of L1 and the inferior end plate of L5. The same was used to measure lumbar end-range extension and flexion angles at full-extension and full-flexion in standing); LSA, lumbosacral angle (the angle between the tangent in the posterior edge of S1 and the tangent in the cranial end of L5); % slip, percentage of slip [the quotient between the sagittal displacement (a) and the sagittal length (b) of the slipped vertebral body expressed in percent (a/b 100)]. computerized measurements for this angle was estimated at 1 (Berthonnaud et al., 2005). Whether slip reduction is necessary for a correct and successful management of spondylolisthesis remains controversial, especially in low grade forms, as it may be of relative importance to improve clinical outcomes related to pain, disability, and healthrelated quality of life (Audat et al., 2011; Labelle and Mac-Thiong, 2011; Labelle et al., 2008; Schlenzka et al., 2011). Though slip reduction can be achieved by surgery (Bourghli et al., 2011; Jalanko et al., 2011; Labelle et al., 2008), many surgeons and researchers argue that the major goal of the intervention is to improve the spinopelvic alignment and not the slip grade itself (Audat et al., 2011; Labelle and Mac-Thiong, 2011; Labelle et al., 2008; Table 3 Pre- and post-intervention measurements of slip grade [% slip (Laurent and Einola, 1961) and LSA (Dubousset, 1997)], spinopelvic alignment (Bourghli et al., 2011) (SS, PI, PT, LL) and end-range of motion of the lumbar spine on digitized radiographs ( ). Measurements SS PI PT LL LSA % slip End-range extension angle End-range flexion angle Pre-Intervention 15-04-2011 20-12-2011 Post-Intervention 18-06-2012 Preepost differencea 57.9 80.3 21.0 59.1 111.1 19.8 N/A N/A 65.3 80.7 16.3 66.0 112.0 19.8 79.5 34.0 48.8 80.2 31.4 48.2 110.0 19.4 73.2 25.6 16.5 0.5 15.1 17.2 2.0 0.4 6.3 8.4b Abbreviations: SS, sacral slope; PI, pelvic incidence; PT, pelvic tilting; LL, lumbar lordosis; LSA, lumbosacral angle; % slip, percent of slip; N/A, not available a Difference was calculated between the radiological values measured on 20-12-2011 and 18-06-2012. b This should be interpreted as increased flexion, as a reduction in the lordotic shape of the lumbar spine was achieved by a flexion movement. Global Postural Reeducation Program and isthmic spondylolisthesis Table 4 Level L1eL2 L2eL3 L3eL4 L4eL5 L5eS1 255 Pre- and post-intervention segmental mobility of the lumbar spine measured on digitized radiographs ( ). Full-extension position Full-flexion position Extension ROM from neutral position Flexion ROM from neutral position Total ROM from neutral position Pre Post Pre Post Pre Post Pre Post Pre Post 12.3 14.8 18.6 16.4 12.1 10.7 15.3 13.6 17.3 7.5 3.3 4.0 4.8 7.0 3.6 2.9 1.9 2.5 4.2 1.7 2.7 0.4 5.2 1.9 7.2 8.8 9.5 4.0 4.0 2.5 6.3 10.4 8.6 7.5 0.9 1.0 3.9 7.1 9.4 3.2 9.0 10.8 13.8 9.4 7.9 9.8 13.4 11.1 13.4 5.7 Abbreviations: ROM, range of motion Schlenzka et al., 2011). The changes in the spinopelvic alignment with surgical reduction and/or fusion of the spondylolisthesis were considered positive when showing a range of mean differences preepost intervention between 8 and 14 for LL and approximately 4 for PT and SS (Bourghli et al., 2011; Jalanko et al., 2011; Labelle et al., 2008). These values are to some extent comparable with the ones obtained in this case. Hence, it would be worth investigating the effects of global postural reeducation programs in controlled trials with subjects of different ages and with different stages of slip and morphological pelvic types. The total ROM of the lumbar spine did not change after the intervention. This was somewhat expected because patients with isthmic spondylolisthesis tend to have a normal lumbar ROM (McGregor et al., 2001). On the other hand, the ratio between the flexion and extension ROM in relation to the standing position and the contribution of each segment to the total ROM did changed. Impaired segmental mobility is often associated with aberrant lumbar mechanics and pain, and likely to be more relevant in assessing abnormal stresses in lumbar tissues than total ROM (Abbott and Mercer, 2003; Bogduk, 2005; Cardin and Hadida, 1994; Fritz et al., 2005; Sahrmann, 2002). With this in mind, one purpose of the intervention was to increase mobility in the spinal segments that tended to show hypomobility (lower segments in flexion; higher segments in extension) and to increase stability in those identified as hypermobile (lower segments in extension; higher segments in flexion). Measurements in the functional radiographs showed that the intervention modified segmental mobility at full-extension and full-flexion positions in the intended clinically reasoned direction (Table 4). In combination with a relative gain of lumbar extension “reserve” ROM and a reduction of flexion “reserve” ROM, this might be biomechanically advantageous in protecting lumbosacral junction tissues from abnormal stresses. For example, in postural tasks performed in the standing position (e.g., walking, reaching), where the spinal ROM is somewhat reduced, the joints of the lumbar spine may more often be in a loosepacked position or “neutral zone”, which reduces the shearestress in the intervertebral disks and contact forces in the facet joints. This way, biomechanical benefits obtained for the standing posture might be extended to several activities of daily living. This might also be relevant to reduce the biomechanical impact of repetitive lumbar extension combined with axial rotation movement cycles related to handball throwing on the lumbar spine in the patient’s sporting activity (Stanitski, 2006; Watkins and Watkins, 2010; Wimberly and Lauerman, 2002). As more degrees of lumbar extension are available to properly cock the arm, the patient may not need to reach the end-range of extension where axial rotation can cause more torsion and lateral shear on the intervertebral disk (Bogduk, 2005). As dynamic analysis was not performed in this case, this conclusion can only be speculative. However, given that posture-dynamics association related to adaptive shortening of muscles has been linked to pain and disability in other parts of the body, this should be tested in the future (Borstad, 2006; Borstad and Ludewig, 2005). One final remark should be made in follow-up to this case. In pediatric ages, where growth and maturation of the musculoskeletal system are still in progress, vigilance is important. Home exercises were prescribed to maintain a proper postural alignment, muscles resting length and extensibility balances. Self-global alignment was taught and twice-weekly sessions of 20 min were recommended (Grau, 2002; Souchard, 1996a,b). Some core exercises were also suggested, along with an adequate positioning and overload restrictions for some gym exercises in full agreement with his parents and the team’s medical staff, and under the coaches’ supervision. The core exercises included abs, “superman”, one- and two-leg stance “bridge”, and plank exercises (the last three were performed with neutral lumbar spine alignment). Overload restrictions for gym machines were advised for pullover, leg press and curl, and shoulder press. In the absence of further symptoms or high-grade slip, full participation in sporting activities ought to be allowed (Stanitski, 2006; Watkins and Watkins, 2010). A multidisciplinary approach to obtain a correct diagnosis and management of the condition is essential for the best interest of the young athlete. Ethical Approval The participant and his parents were informed about the aims of the physical therapy assessment and treatment protocols. They were also informed that data concerning the case would be submitted for publication and they signed a consent form. Protection of the participant’s rights and confidentiality of the data were assured. 256 Funding None. Conflict of interests None. 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