Top 3 exercises for Lumbar Spondylosis, Spinal stenosis and Spondylolisthesis

By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, C-IASTM
Pinnacle Training & Consulting Systems

Background

There are a multitude of exercises available at the fingertips of a fitness professional. Choosing
the most accurate and objective exercise should be the cornerstone of any fitness
programming. Working with any client who has a spinal injury, should involve a thorough
history, fitness assessment and most importantly, a sound understanding of the pathophysiology
and programming of that movement dysfunction. In this article, we will review and clarify
the differences between spinal conditions that include spondylosis, spinal stenosis and
spondylolisthesis discussing the pathophysiology, common rehabilitation, and post
rehabilitation training.

Clarifying the differences

Spondylosis is the degeneration of one joint on another also known as degenerative disc
disease (DJD). The patient will typically present with tightness in the lower lumbar and may or may
not present with radicular symptoms in their legs. Physical therapy addresses these impairments
by conducting a comprehensive examination, using manual therapy, and targeted exercises. 

Spinal Stenosis

Spinal stenosis is a narrowing within the vertebral canal coupled with hypertrophy of the
spinal lamina and ligamentum flavum or facets as the result of age-related degenerative process.
The patient who has spinal stenosis usually has very tight hamstrings and lumbar extensors.
They often will complain of unilateral vs. bilateral numbness in their legs due either having central
lateral (to side) foraminal stenosis. Physical therapy addresses these areas with myofascial release,
stretching, and joint mobilizations to address mobility then teach flexion-based exercises which
will improve the opening of the spinal lamina.

Spondylolisthesis is an anterior (forward) slippage or posterior (back) slippage of one vertebra on another following bilateral fracture of the pars interarticularis. The slippage is graded from 1-4 (25% to 100%) from an x-ray. In degenerative spondylolisthesis, as the intervertebral disc loses height, the annulus may bulge circumferentially and the ligamentum flavum can buckle. These types of injuries are seen in wrestlers, due to the combined extension and rotation movements seen in the sport as well as in older patients due to their lifestyle. Physical therapy/training emphasis is on elimination of extension-based exercise (back extension, press-ups, etc.). Biomechanically, this will force the vertebra forward causing more translation and instability. Training emphasis is on flexion-based exercises (strengthening of abdominals). Flexion based exercises will decrease shearing force and translation on the effected segment. Postural education is key, static and dynamic core strengthening should also be included. Core strengthening using medicine balls, cables and physio balls shoulder be personalized to the client.

Recommendations

All of the spinal conditions discussed previously are unique, requiring a thorough understanding, while designing a program that is personalized for the client. With respect to spondylosis, the three top exercises for this client are: 

Abdominal bracing with alternate leg lift (as seen in Fig. 1) 

Fig. 1 

Bridging with physioball (as seen in Fig 2) 

Fig 2

Prone alternate leg lift/arm lift over physioball (as seen in Fig 3)

Fig 3

All three exercises target the multifidus and transverse abdominis; two essential muscles of the core.

With respect to both spinal stenosis and spondylolisthesis, the focus is on flexion exercises.

My top three for both include:

 Reverse abdominal crunch (as seen in Fig 4)

Fig 4

Dead bug (as seen in Fig 5)

Fig 5

Prone alternate leg and arm lift over physioball, stopping at neutral (as seen in Fig 6)

Fig 6

Summary

Lumbar Spondylosis, Spinal stenosis, and Spondylolisthesis are three common spinal conditions affecting most adults today. Understanding the pathophysiology, mechanism of injury, common physical therapy treatments, and a few targeted exercises, should help you, the fitness professional while designing a program for your client. If you should have any questions, please feel free to contact PTCS at ptcg1999@verizon.net or visit our web site at www.pinnacle-tcs.com.

By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, C-IASTM

There are a multitude of assessments at the fingertips of a fitness professional. Choosing the most accurate and objective assessments should be the cornerstone of any fitness assessment. 3 that we recommend starting with are, the plank, the side plank and the Multifidus Test. These 3 tests are MUST HAVES in your fitness arsenal.

Planking

The plank is an isometric core strength exercise that involves maintaining a position similar to a push-up for the maximum possible time.  

Figure 1

Figure 2

The four-point plank test (Fig. 1) challenges the erector spinae and paraspinal muscles

While the side plank test (Fig 2) challenges the obliques and

quadratus lumborum muscles.

Grading for both tests is as follows:

Normal: Able to lift pelvis off and hold straight 15-20 second count.

Good: Able to lift pelvis off but has difficulty holding spine straight for 15-20 seconds.

Fair: Able to lift pelvis off but has difficulty holding spine straight for 10-15 seconds.

Poor: Able to lift pelvis off but cannot hold for 1-10 seconds.

Trace: Unable to lift pelvis

Multifidus Test

This test assesses the client’s ability or inability to properly contract the multifidi. Have the client lie prone, then palpate multifidi muscle which is ~1” above ilium. Provide instructions asking the client to extend their hip 1-2” off the table and observe what muscles the client elicits. 

Normal Movement (Figure 3):

To teach the client to contract the multifidi first, palpate the muscle (figure 1) (instruct the client to perform an anterior pelvic tilt (which shortens and contracts the multifidi), and then have them lift one leg straight up into the air.

Figure 3

Abnormal Movement (Figure 4):

Common compensatory movement is to activate the glutes or hamstrings first, then contract the lower back (this is dysfunctional) as seen in figure 4. 

As we stated above these are 3 techniques that we strongly recommend but there is a multitude of core assessment tests to choose from. Choose those that are client-specific, safe as well as personalized to the client. In the next article, we will talk about common lumbar conditions..