- Correction of Spondylolithesis by
- the Correction of Global Posture
by Donald W. Meyer, D.C.
Dr. Donald W. Meyer graduated with honors from the Los Angeles College
of Chiropractic in 1981. He maintains a full-time practice in Fountain
Valley, CA. In 1986, he founded Circular Traction Supply, Inc. to
provide extension traction-oriented products to the chiropractic
profession. In 1999, he developed a wearable head retraction brace
called Cervical Remodeling Collar™. Last year, he introduced a wearable
thoraco-lumbar, posture corrective, traction brace called the Lumbar
Remodeling Brace™. This year, Dr. Meyer has created a new design for
posture corrective body weighting called the Posture Corrective Exercise
Belt™. He has combined these devices into a new therapy entitled
Ambulatory Postural Remodeling™.
INTRODUCTION
T here is ample evidence in the literature that abnormalities of global
posture can account for spinal histopathology, myopathology,
neuropathophysiology and kinesiopathology.1 There is also increasing
evidence that the correction of global posture could have strong
implications for the prevention of disc, ligament, myofascial and bony
degenerative changes.1 The case report presented here demonstrates the
possibility of reducing and stabilizing a common spinal pathology by the
correction or improvement of global posture and raises the question
whether the pathology caused the aberrant posture or the aberrant
posture caused the pathology?
CASE REPORT
A 60-year-old female presented for treatment of chronic, intermittent
right buttock and lower lumbar pain that she rated as a four on a 0-10
visual pain scale. She also denoted having
chronic low back tension and tightness. The patient is moderately
overweight, but physically active.
A computerized range of motion test was performed on her lumbar spine as
well as a visual postural inspection. The lateral global posture
revealed anterior translation of the thorax in relation to the pelvis
and a hypokyphotic thoracic region. The AP global posture demonstrated a
right lateral translation of the thorax to the pelvis with a left axial
rotation of the entire pelvic girdle. Because of the axial rotation of
the pelvis, inspection of the foot stance was performed and found a
collapse of the medial longitudinal arch of the right foot with
associated pronation. Flexibility testing of the piriformis muscles
revealed bilateral increased tonus with restricted mobility, especially
on the right. Straight leg testing was negative for radicular
involvement as was reflex and dermatome testing of the legs. There was
some increase of buttock pain on standing lumbar flexion, no increase of
pain on left lateral flexion and there was mild lower lumbar pain with
extension and right lateral flexion. Increased tenderness was elicited
upon digital pressure to the lower right lumbar paraspinal region and
the piriformis musculature, especially on the right.
Standing radiographic studies demonstrated an anterior thoracic
translation of 42 millimeters with an associated increased sacral base
angle of 51 degrees. The segmental analysis
of the lumbar spine revealed an increased mid to upper lumbar lordosis
with a decreased L5/S1 angle. An eight millimeter spondylolisthesis was
also observed.(See X-ray A) A bilateral pars defect was noted on the
oblique views. The AP view showed a nine and a half degree right
lumbosacral angle and a two degree right superior sacral base line.
The diagnosis was as follows:
1. Right-sided lower lumbar facet syndrome secondary to the patient’s
altered thoraco-pelvic posture and associated L5/S1 isthmic
spondylolisthesis (grade 1).
2. Right-sided piriformis syndrome secondary to the collapsed
longitudinal arch of the right foot.
A treatment plan of CBP® Mirror-Image® diversified spinal adjustments,
Ambulatory Postural Remodeling™ utilizing the Lumbar Remodeling Barace™
with lateral translation traction belts, transverse abdominis
strengthening on a Torso-Track™, home lumbar and piriformis stretching
exercises and Spenco™ shoe orthotics was initiated. The Lumbar
Remodeling Brace™ is an adjustable, padded steel device that is wore by
the patient and can pre-stress the patient’s thoraco-lumbo-pelvic
posture back to a normal lateral alignment (eliminating either anterior
or posterior thoracic translation) while also applying an anterior
traction force into the mid to lower lumbar spine to restore its normal
elliptical configuration (See Picture 1).
Lateral translation traction belts were also used to Mirror-Image® her
thoracic translation during the treatment. The patient should be
ambulatory during this therapy, so it was applied with the patient
walking at two to three miles per hour on a treadmill. These
closed-chain, weight-bearing traction/exercise sessions were started at
five minutes and progressed to 15 minutes in length. The patient would
then perform a 10 repetition set of abdominal strengthening on a
Torso-Track™. She started with cable assistance and progress to no cable
assistance on this device. The patient then received a CBP®
Mirror-Image® spinal adjustment. Treatment was rendered at a frequency
of three times per week.
After 18 treatment sessions, the first re-evaluation revealed an
improvement in lumbar extension, left lateral flexion and rotation.
Flexion remained mildly restricted at 52 degrees. The patient’s buttock
pain had been eliminated. She now rated her lower lumbar pain as a one
on the 0-10 visual pain scale. Her Revised Oswestry pain questionnaire
demonstrated only an eight percent interference with her activities of
daily living. Her post lumbar radiographic findings denoted a reduction
of anterior thoracic translation to 28 degrees, a decrease of the
excessive sacral tilt to 46 degrees and a reduction of the
spondylolisthesis to five millimeters (See X-Ray B). The AP lumbosacral
angle (and therefore the lateral translation) reduced to seven degrees
and the sacral base line remained two degrees right superior. Because
the patient’s sacral base line did not level and there were indications
on the x-ray of a left anatomical leg length deficiency, a left-sided
seven millimeter heel lift was prescribed.
After 12 more treatments, a second re-evaluation showed improvement in
lumbar flexion to 57 degrees, no lumbar pain and only occasional, mild
right buttock pain. The patient rated
her improvement at 90 percent. Her new post lumbar radiographic findings
exhibited no further change in anterior thoracic translation, sacral
tilt or spondylolisthesis slippage. The patient’s AP lumbosacral angle
reduced to four degrees and the sacral base line reduced to level. Since
no further structural improvement of the spondylolisthesis or the
anterior thoracic translation had occurred, the patient was released to
monthly maintenance care.
DISCUSSION
Spondylolisthesis among the Caucasian population is estimated to be five
to seven percent with an equal sex distribution.2 Approximately 90% of
all spondylolistheses involve the fifth lumbar vetebra.3 Common
non-degenerative spondylolisthesis is classified as either dysplastic or
isthmic.3 Dysplastic includes those spondylolistheses with a congenital
abnormality in the upper sacrum or the neural arch of L5 that allows
displacement to occur.
Isthmic involves an alteration to the pars interarticularis either by an
acute fracture, lytic or stress fracture or an elongated but intact
pars. The source of the symptomatology associated with an L5/S1 isthmic
spondylolisthesis is considered unclear, although it appears that the
facet joint pain referral patterns of the lumbar spine parallels those
of “classic” spondylolisthesis and that it is highly likely that this
joint is a major source of the pain.2 The etiology of the spondylolysis
that allows the spondylolisthesis to occur is also controversial.
Presently, the most commonly proposed etology leading to a pars
interarticularis defect is that of a stress fracture that commonly
occurs in childhood.3
Except for a single case reported at C4 in a gorilla, the defect of
spondylolysis has not been reported in mammals other than man.3 Because
of this, the upright posture of man combined with additional repetitive
mechanical stress is considered the significant etiological
factor.3 Upon examination, Yochum and Rowe state that distinct postural
changes will be seen. A hyperlordosis of the lumbar spine and an
anterior shift of the gravitational weightbearing
line is often noted. Decreased anterior trunk flexion and reduced
straight leg raising are often present due to hamstring muscular
tightness that is often associated with spondylolisthesis.
These findings are also found in patients with chronic anterior thoracic
translation with or without spondylolisthesis. Anterior thoracic
translation will cause a hyperlordotic tendency with an increased pelvic
tilt and sacral inclination.4 This posture is also generally associated
with a decrease of the thoracic kyphosis. Some bio-mechanical
researchers, such as Berlemann, et al., now are concluding that further
studies should focus on the analysis of spinal alignment and lower
lumbar end-plate orientation to identify patients at risk for
development of Degenerative Spondylolisthesis or lower lumbar
retrolisthesis. They have found that the overall lordosis of the
lumbar spine and end-plate inclination were considerably reduced in
patients with retrolisthesis and that the end-plate inclination in
patients with DS was greater.5,6 In another study, the sacral base angle
was found to be greater in spondylolisthesis patients and a
significantly greater incidence of hyperextension at L4/L5 was found in
symptomatic spondylolisthesis patients.2 These recent findings raise the
question whether chronic thoracic anterior translation with its
associated increased sacral inclination and hyperlordosis is not the
underlying cause of the additional repetitive mechanical shear stress
that results in pars interarticularous stress fractures in children as
well as being a main cause of Degenerative Spondylolisthesis in the
elderly.
CONCLUSION
Muscles attaching onto the rib cage have been found to be important for
control of the overall spinal posture and maintenance of equilibrium.7
The deep Transverse Abdominis muscle is now being considered vital to
lumbar spine stability.8 The Torso-track™ is an excellent, progressive,
in-office method to tone and strengthen this deep superior abdominal
muscle. Stretching of the hamstrings and strengthening of the back
extensor musculature has also been found to encourage a more normal
lumbar lordosis and thoracic kyphosis.9,10,11,12 These two benefits
occur naturally during ambulatory exercise.
Weight bearing activities require the co-contraction of accessory and
stabilizing muscles. They also stimulate proprioceptive input from
receptors in the muscles, connective tissues, and joint capsules. This
is why it is so important to perform spinal rehabilitative exercises in
a closed-chain, weight bearing posture that is closer to real life
positions. The specific adaptation of imposed demands (SAID) concept
tells us to expect that closed chain, weight bearing exercises generally
will be more effective.13
I hope that it is clear from these references, and this article, that
adopting a weight-bearing, posture corrective rehabilitation program in
the treatment of your patient will not only result in improved patient
outcomes, but also allow you to better deal with numerous spinal
pathologies that are directly influenced by global posture.
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