Download the effects of a global postural reeducation program on an adolescent handball player with isthmic spondylolisthesis

Journal of Bodywork & Movement Therapies (2014) 18, 244e258
Available online at www.sciencedirect.com
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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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