From the Guidelines
The best next step in managing this patient is to refer him to physical therapy, as it is a non-pharmacological approach that can help strengthen core muscles, improve flexibility, and teach proper body mechanics to reduce pain associated with spondylolisthesis. This 34-year-old man presents with persistent low back pain and elevated CRP, with grade 1 spondylolisthesis at L4-L5, which can benefit from conservative management. According to the American College of Physicians and the American Pain Society, physical therapy is a recommended treatment for chronic low back pain, as it can help improve function and reduce pain 1. The patient's clinical picture is most consistent with mechanical back pain rather than inflammatory arthritis or infection, and physical therapy offers a long-term strategy for pain management and functional improvement.
Some key points to consider in this patient's management include:
- The use of non-pharmacologic therapy with proven benefits, such as exercise therapy, intensive interdisciplinary rehabilitation, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation 1
- The importance of addressing the underlying biomechanical issues contributing to the patient's pain, rather than just treating the symptoms
- The potential benefits of physical therapy in reducing pain and improving function in patients with spondylolisthesis, as well as its role in avoiding unnecessary medication or additional imaging at this stage
- The recent update from the American College of Radiology, which suggests that first-line treatment for chronic low back pain remains conservative therapy with both pharmacologic and non-pharmacologic therapy, and that imaging should be reserved for patients who have failed 6 weeks of conservative therapy or who are believed to be candidates for surgery or intervention 2
Overall, referring the patient to physical therapy is the most appropriate next step, as it addresses the underlying biomechanical issues contributing to the patient's pain and provides a long-term strategy for pain management and functional improvement.
From the Research
Managing Persistent Low Back Pain and Elevated CRP with Grade 1 Spondylolisthesis
- The patient's condition involves persistent low back pain, elevated CRP, and grade 1 spondylolisthesis at L4-L5, which is a condition where one vertebra slips forward over the one below it 3.
- The degree of vertebral body anterior displacement is rated from 1-4, with grade 1 being the least severe 3.
- Conservative management strategies are often recommended as the first line of treatment for symptomatic lumbar spondylolisthesis, including non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy 4.
Conservative Treatment Approaches
- Instruction in exercise and body mechanics, the use of back supports, and job modifications are documented conservative treatments for spondylolisthesis 3.
- Strengthening of the abdominals and paraspinal muscles, especially in the thoracic area, as well as occupational modifications and instruction in body mechanics, deep-heat therapy, and avoidance of maximal forward flexion of the lumbar spine, have been recommended 3.
- A flexion exercise program has been shown to be more effective than an extension exercise program in reducing pain and improving outcomes in patients with symptomatic spondylolisthesis 3.
- Postural reeducation, stretching, and strengthening exercises have also been used to improve outcomes in patients with low back pain and lumbar isthmic spondylolisthesis 5.
Assessment and Treatment Considerations
- Patients with lumbar symptomatic spondylolisthesis can be divided into stable and unstable, based on the level of mobility during flexion and extension movements 6.
- A comprehensive assessment, including history, imaging, physical exam, and questionnaires on disability and cognitive-behavioral components, is necessary to guide conservative treatment 6.
- Self-management approaches, graded supervised training, and primary therapeutic procedures for pain control, recovery of function, and mobility through therapeutic exercise, passive mobilization, and antalgic techniques may be beneficial 6.
- Surgical intervention may be considered for patients who fail conservative management strategies 4, 7.