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Accepted Manuscript

Mobilisation of the thoracic spine in the management of spondylolisthesis

Dr P.P. Mohanty, MPT, FIAP, Ph. D., Associate Professor and Head of the
Department, Physiotherapy, Monalisa Pattnaik, MPT, Assistant Professor,
Physiotherapy

PII: S1360-8592(16)00017-6
DOI: 10.1016/j.jbmt.2016.02.006
Reference: YJBMT 1322

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 12 April 2015


Revised Date: 30 January 2016
Accepted Date: 7 February 2016

Please cite this article as: Mohanty, P., Pattnaik, M., Mobilisation of the thoracic spine in the
management of spondylolisthesis, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/
j.jbmt.2016.02.006.

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MOBILISATION OF THE THORACIC SPINE IN THE MANAGEMENT OF


SPONDYLOLISTHESIS

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Dr PP Mohanty, MPT, FIAP, Ph. D.

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Associate Professor and Head of the Department, Physiotherapy

Monalisa Pattnaik, MPT

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Assistant Professor, Physiotherapy

Swami Vivekanand National Institute of Rehabilitation Training and Research


Olatpur, Cuttack – 754010

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Odisha, India
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E mail: ppmphysio@rediffmail.com
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Abstract:

Introduction: Segmental instability due to lumbar spondylolisthesis is a potential

cause of chronic low back pain. Hypomobility of the spine results in compensatory

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segmental hypermobility of the segment above or below restricted segments. Therefore,

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the aim of the study is to determine the effects of mobilisation of the hypomobile upper

thoracic spine along with conventional flexion exercises and stretching of short hip

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flexors on the degree of slippage and the functions of the persons with lumbar

spondylolisthesis. Methodology: All patients with spondylolisthesis were randomly

assigned into two groups: Group I


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- Experimental group, treated with mobilisation of
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the thoracic spine along with the conventional physiotherapy and Group II - Conventional

group, treated with conventional stretching, strengthening, and lumbar flexion exercise
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programme. Results: The experimental group treated with mobilisation of the thoracic
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spine shows a significant reduction in the percentage of vertebral slip from pre-treatment
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to post-treatment measurements. Conclusion: Low back pain due to spondylolisthesis

may be benefited by mobilisation of the thoracic spine along with stretching of short hip
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flexors, piriformis, lumbar flexion range of motion exercises, core strengthening

exercises, etc.
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Key words: Mobilisation, thoracic dysfunctions, myofascial pain syndrome,


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spondylolisthesis , Muscle Energy Technique, Maitland


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INTRODUCTION: Segmental instability of the lumbar spine is a potential cause

of chronic low back pain, may be the result of spondylolysis and/or spondylolisthesis

(Fritz et al., 1998). Spondylolysis is a defect or a break in the narrow portion of the

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vertebral bone, lying between the superior and inferior articular facets of the vertebral

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arch (Johnson, 1993), called the pars interarticularis. Spondylolisthesis, on the other

hand, is the ‘slipping’ or forward displacement of one vertebra over another (Magee,

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1997). Although the two conditions are distinct radiographically, spondylolysis in the

lumbar spine is found in 50–81% of cases having spondylolisthesis (Szapalski et al.,

1999).
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The presenting signs and symptoms of spondylolysis include pain, restricted range of

motion, paraspinal muscle spasm, flattening of the sacrum and a peculiar gait (Magee,
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1982; Johnson, 1993; Osterman et al., 1993). Pain is usually reported as mild to
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moderate, and is initially a dull ache that gradually increases in intensity (Motley et al.,
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1998). Pain is commonly localized to the paraspinal region, gluteals (Hall & Brody,

1999) and posterior aspect of the thighs (Barash et al., 1970). Initially, the pain may be
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associated with a very mobile spine, with symptoms appearing at extremes of lumbar

range of motion only. Spondylolysis may progress into isthimic spondylolithesis, and
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results in hamstring tightness (Osterman et al., 1993), posterior tilting of the pelvis, and a
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flexed hip and knee posture (Barash et al., 1970). The individual may walk stiff legged

with a short-stride gait (Barash et al., 1970; Hensinger 1989) and a characteristic pelvic

‘waddle’ (pelvic rotation with stepping) may be observed (Hensinger, 1989). On

examination, pain is reproduced with one-legged standing, lumbar extension test and a
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step deformity in the lumbar spine may be observed or palpated (Magee, 1997). In

moderate to severe cases, a marked limitation of trunk flexion range of motion (Barash et

al., 1970) and a limited straight leg raise (Barash et al., 1970; Magee, 1982) are found.

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The degree of slip, slip angle, sacral inclination, chronicity of the slip and pelvic

incidence are all seen on the lateral radiograph (Serena et al., 2008). The degree of slip is

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the % of displacement, with a slip of > 50% considered to be unstable and associated

with progression. Flexion and extension lateral radiographs help to determine how much

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postural reduction of the lumbosacral angulation and translation can be obtained.

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Hypomobility of the spine results in compensatory segmental hypermobility of
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the segment above or below restricted segments. The cervico-thoracic and thoraco-

lumbar spine are often found to be stiff , with limitation of the extension range, which
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may lead to hypermobility of the lumbo-sacral spine and progressive degeneration over

time. The hypomobile spine must be mobilized, so that an even distribution of movement
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can be achieved all over the spine (Kessler & Hertling, 2005).
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AIM OF THE STUDY: The purpose of this study is to determine the relative efficacy of
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conventional treatment protocol compared to thoracic mobilization on the degree of

slippage and the functions of the persons with isthmic lumbar spondylolisthesis.
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METHODOLOGY: A total of 200 subjects (65 M, 135 F) within the age group of 29

to 58 years (mean age of 42.09 years; SD 6.11 years) suffering from chronic low back

pain for over 3 months were diagnosed to have lumbar spondylolisthesis, and those who

met the inclusion and exclusion criteria, were recruited from the outpatient department of
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Swami Vivekanand National Institute of Rehabilitation Training and Research

(SVNIRTAR), Cuttack. Written consent was obtained from each subject.

Inclusion Criteria: 1. Patients with low back pain due to spondylolisthesis with or

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without radiation to lower limb, 2. Pain aggravates by strenuous activity, and with lifting

and bending, relieved with rest, 3. Increase in lumbar lordosis, protruded abdomen, 4.

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Walks with hip and knee flexed, 5. Tenderness and irregularities in bony alignment, step

sign positive, 6. Limited spinal flexion, 7. Hamstrings, hip flexors tightness, 8. Plain

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Lumbosacral X-ray oblique view demonstrates fracture in pars interarticularis. Standing

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lateral X-ray lateral view was used to determine percentage of forward slip.
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Exclusion Criteria: 1. Neurological deficits, 2.Trauma, 3. Elderly patients above 60

year, 4. History of smoking, advanced age, weight loss and history of cancer increase the
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likelihood of malignancy, 5. Loss of lordosis and/or listing suggestive of intervertebral

disc prolapse, 6. Vertebral infection occurs most often in patients with diabetes, history of
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other infection or immunosupression drug abuse or urogenital instrumentation, etc., 7.


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Visceral diseases with history of chronic NSAID use or peptic ulcer may suggest the

presence of perforated ulcer with retroperitoneal abscess causing LBP, 8. Symptoms such
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as an escalating, unremitting course of pain not improved by rest, night pain, and the

symptoms of cauda equine syndrome - pain, saddle anesthesia bowel or bladder


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incontinence etc., 9. Not able to lie in prone with arms crossed across the chest, 10.

Uncooperative patients, 11. Any others contraindicated for manual therapy (Maitland,

2005, Cyriax, 1982).


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All patients were evaluated following detailed history taking in a systematic way.

The subjects who met the inclusion / exclusion criteria were made to sign an informed

consent and then were assigned into two groups by convenient sampling:

Group I -Experimental group (manual therapy protocol + conventional exercise

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program)

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100 patients = 34 M + 66 F, with age of 29 to 55 years (mean age of 42.42

years; SD 6.96 years)

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Group II -Conventional group (conventional exercises given as home exercise

programme)

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100 patients = 31 M + 69 F, with age of 30 to 52 years (mean age of
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41.76 years; SD 5.12 years)

Experimental group: 1. Passive stretching of bilateral hip flexors, bilateral hamstrings


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and bilateral piriformis, 2. William’s assisted spinal flexion exercises given by the
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Therapist, 3. Posterior pelvic tilt exercise for stabilization, 4. Myofascial release of


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levator scapulae that reproduced the patient’s original back pain and/or leg pain, 5.

Central posterior to anterior upper thoracic spinal mobilization over the hypomobile
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segments.

Conventional group: 1.Auto stretching of hip flexors, hamstrings, piriformis and levator
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scapulae, 2. William’s Flexion Exercises, 3. Posterior pelvic tilt exercise for


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stabilization.

Outcome measures:

1. X- rays LS spine: X-rays LS spine lateral view by using SIMENS was taken in

standing position by the Radiographer. The degree of slip was measured according to the
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method describing the slip in relative values. The dislocation is defined as the distance

between the lines through the posterior borders of S1 and L5 measured on a line through

the most cranial part of S1 perpendicular to the posterior border of S1 (A) by using

AutoCAD 2006. The distance was related to the sagittal length of the upper end plate of

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S1 (B). Percentage of slip = A/B × 100. Percentage of vertebral slip was measured in

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lateral radiograph by using AutoCAD 2006 software programme. Meyerding classified

the grades of vertebral slip; Tillard (1954) formulated a simple equation to calculate the

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percentage of slip.

Percent slip = the displacement of L5 on S1/width of S1X100.

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2. Functional Outcome Measured by Modified Oswestry Back Pain Questionnaire: Self -
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reported measurements of disability have been used as an outcome measure for people

with low back pain. Several disability scales have been developed for people with low
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back pain and their importance as measures of treatment outcome in clinical trials has
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been emphasized. One of the most commonly used scales in low back pain patients is

Oswestry Low Back Pain Disability Questionnaire. The measurement properties of this
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scale has been studied extensively, and a recent report of the International Forum for
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Primary Care Research in Low Back Pain contended that this scale is acceptable for
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measuring disability related to low back pain. Fritz J M et al., 2003 have shown excellent

reliability (ICC – 0.90) compare to Quebec Back Pain Disability Scale. Fairbank CTJ et

al., 1980 have also shown excellent test-retest coefficient of reliability (r=0.99, P<

0.001).
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PROCEDURE: The subjects who met the inclusion / exclusion criteria and willing to

participate in the study were recruited conveniently into experimental group or

conventional group after signing the written informed consent.

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The experimental group was treated by one therapist with passive William’s

flexion exercise ( Williams 1965), passive stretching of hip flexors, hamstrings,

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piriformis (Colby and Kishner 2007), stretching of levator scapulae by MET (Chaitow,

2006 ) that reproduced the patients’ original back pain and/or leg pain symptom ,

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Maitland’s rhythmical oscillatory central PA mobilization of hypomobile upper-thoracic

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spines that reproduced the patients’ original back pain and/or leg pain , and posterior
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pelvic tilting exercises.

The conventional group was advised to do auto hip flexors, hamstrings and
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piriformis stretching, William’s spinal flexion and posterior pelvic tilting exercises as

home exercise program. The patients were strictly instructed to perform exercises
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regularly and they were asked not to take any kind of medications (NSAIDS and any kind
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of analgesics) or any other adjunct therapy within the period of 4 weeks (except in case

worsening of the clinical status and increase in the pain intensity). They were told to
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perform their usual daily functional activities. The caregiver of each subject was also
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provided with special training sessions for better supervision and assistance during home
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exercise regimes.

Both the groups were given moist heat. Both the groups were also advised to

avoid all movement, exercises and activities involving spinal extension and use lumbo-

sacral brace in anti-lordotic posture during traveling and exertion. Postural awareness was

given to maintain normal posture.


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In the study the dependent variables were (1) percentage of slip by X-rays LS

spine lateral view and (2) level of functional activities by Oswestry back pain

questionnaire, measured by another therapist, who was blind to the interventions.

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DATA COLLECTION: Pre-treatment measurements of (1) percentage of slip by X-rays

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LS spine lateral view and (2) level of functional activities by Oswestry back pain

questionnaire were taken on recruiting the patient for the study. Treatment started from

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the next day for five days a week for four weeks. Post-treatment measurements were

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taken on the next day after completion of the treatment for 20 sittings.
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DATA ANALYSIS: The data was analyzed by using 2 X 2 ANOVA, where there was

one between factor , Treatment groups with two levels (experimental group and
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conventional group) and one within factor , Time with 2 levels ( Pre and Post). A 0.05

level of significance was used for all comparisons. Tukey's HSD post-hoc analysis was
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used for all pair wise comparison.


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RESULTS

PERCENTAGE OF VERTEBRAL SLIP:

Figure - 1: Change in percentage of vertebral slip

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35

30

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25

20

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15 Pre Test
Post Test
10

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5
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0
1 2
1- Experimental group 2 - Conventional group
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As depicted in figure 1, there was reduction in the percentage of vertebral slip in


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experimental group receiving treatment from pre-treatment measurements to post-

treatment measurements after a period of 20 sittings.


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Table - 1: ANOVA table for percentage of slip:

Between Sum of sq Df Mean F Significance


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subject Square
effect
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Group 998.560 1 1174.604 12.154 0.001

Error 18830.928 198 96.645

Within Time 2802.326 1 2526.520 404.160 0.000


subject
effect Time × 1616.844 1 1838.909 294.165 0.000
Group
Error 1324.880 198 6.251
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Table - 2: Tukey’s HSD post-hoc analysis for Slip

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Mean 1– Mean 2 ≥ minimal significance difference

≥ q ( √MSE/n) q ( r = 4, df∞, p=0.05) = 3.63

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≥ 3.63 (√6.251/100)

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≥ 0.907

Pre- test Post- test Pre- test Post- test


Group 1(mean) Group 1(mean) Group 2 ( mean) Group 2(mean)

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Pre - test 0
Group 1 17.706* 0.866 1.606*
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(mean)
Post - test
Group 0 8.45* 16.1*
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1(mean)
Pre - test
Group 0 0.74
2(mean)
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Post - test
0
Group
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2(mean)
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There was a main effect for the time F(1,98,0.05)= 404.160,P=.000 and group
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F(1,98,0.05)= 12.154,P=0.001 .This main effect did attain significant for the group x time
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interaction F(1,98,0.05)=294.165,P=0.000 (table1).

Tukey’s HSD analysis showed that at the completion of study experimental group

improved significantly and there was also a statistically significant difference between

both the groups (table - 2). Asterisk (*) indicates statistically significant difference

between the groups.


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FUNCTION:

Figure – 2: Change in functional score as measured by ODI

Change in function by ODI outcomes

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25
20

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Pre Test
15
Post Test
10
5

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0
1 2
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1- Experimental , 2- Conventional groups
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As depicted in figure 2, there was improvement in function in both the groups from pre-
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treatment measurements to post-treatment measurement after a period of 20 sittings.


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Table - 3: ANOVA table for function as measured by ODI

Between Sum of sq Df Mean F Significance


subject Square
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effect Group 1410.002 1 1410.002 21.325 0.000

Error 13091.975 198 66.621


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Within Time 37229.703 1 37229.703 1.903 0.000


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subject
effect Time × 7700.062 1 7700.062 393.577 0.000
Group
Error 3873.735 198 19.564
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Table - 4: Tukey’s HSD post - hoc analysis for function, measured by ODI

Mean 1– Mean 2 ≥ minimal significance difference

≥ q ( √MSE/n) q ( r = 4, df∞, p=0.05) = 3.63

≥ 3.63 (√19.564/100)

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≥ 1.6055

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Pre- test Post- test Pre- test Post – test
Group 1 Group 1 Group 2 Group 2
Pre- test 0

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Group 1 28.07* 5.02* 15.54*
Post- test
Group 1 0 23.05* 12.53*

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Pre - test
0 10.52*
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Group 2
Post- test 0
Group 2
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There was a main effect for the time F(1,98,0.05)= 1.903,P=.000 and group
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F(1,98,0.05)= 21.325,P=0.000 .This main effect did attain significance for the group x
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time interaction F(1,98,0.05)= 393.577,P=0.000 (table - 3).


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Tukey’s HSD analysis showed that at the completion of study experimental group

improved significantly and there was also a statistically significant difference between
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both the groups (table - 4). Asterisk (*) indicates statistically significant difference
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between the groups.

DISCUSSION: The overall results of the study showed that both the groups improved

in function as registered by the Modified Oswestry Disability Questionnaire from pre-

treatment to post-treatment measurement scores. This improvement in function might be

due to improvement in pain score, flexibility and strength.


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However, the experimental group treated with myofascial release, central PA

mobilisation of the thoracic spine improved to a greater extent than the control group

treated by home exercise programme. The experimental group showed a significant

reduction in the percentage of vertebral slip from pre-treatment to post-treatment

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measurements.

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Since the hamstrings are attached to the ischial tuberosity, they play an

important role in extrinsic pelvic stability. 80% of symptomatic spondylolisthesis patients

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have tight hamstring muscles which tilt the pelvis posteriorly and do not permit the hip to

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flex sufficiently for a normal stride (Phalen & Dickson, 1972). The iliopsoas is the only
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muscle group in the body that is directly attached to the spine, pelvis and femur.

Therefore, it has the potential to influence the movements of both the spine and the hip
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joint. When shortened, iliopsoas increases the lumbar lordosis (Janda 1983, Kendall &

Mcgreary, 1983) and may pull the mid-lumbar spine forward and inferiorly. A protective
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spasm of piriformis is seen in almost all the cases of sciatica, underneath which the
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sciatic nerve passes (Bourdillon et al., 1992), (Jull & Janda, 1987). In chronic cases,

adoptive shortening of piriformis develops giving rise to pain. Hypertrophic, fibrosed,


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thick piriormis may interfere in the excursion of the sciatic nerve.


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The results of the present study might also be due to the relationship between the
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changes in LBP severity and changes in the thoracolumbar spinal mobility which is in

agreement with several earlier studies (Kendall & Jenkins, 1968).

The thoraco-lumbar fascia acts as nature’s ‘back belt’ as described by Hyde, 2007. It

extends from the iliac crest and sacrum up to the thoracic cage. It has extensive

attachments starting from posterior nuchal fascia and levator scapulae muscle cephally to
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the biceps femoris and soleus muscle caudally. The superficial lamina gets tensed by

contraction of various muscles, such as the latissimus dorsi, gluteus maximus and erector

spinae muscle. It helps in transference of load through the trunk to lower extremities and

as a result effectively deloads the spine, if functioning appropriately. Inefficient

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functioning of TL fascia can be due to many causes like weakness of muscles attached to

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fascia, fibrotic changes of muscle with loss of elastic properties. This leads to an

increased load transferred to the spine gradually leading to extension loading and

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degeneration. Improving length of the fibrotic muscles will improve the mobility of the

lumbar spine and may help in pain relief. Stretching of the levator scapulae, which

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reproduces the original back pain and/ or radiating pain, was done in prone lying with the
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arms crossed on the chest, may help in low back pain with or without radiation to lower

extremity (Hammer, 2000).


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Huijbregts et al., 2001 mentioned that the greater is the thoracic kyphosis, the
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greater will be the tendency for both lumbar and cervical lordosis. With regard to the
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lumbar spine, the lower lumbar regions at L-4 and L-5 levels are most affected, primarily
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compression occurs at the facet joints and posterior discs. Severe thoracic kyphosis could

involve more lumbar levels in hyperlordosis. Hypomobility and restriction of extension at


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proximal levels can lead to extension loading of the lower lumbar spine giving rise to low
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back pain (Kessler & Hertling, 2005). Hypomobility of the spine results in compensatory

segmental hypermobility of the segment above or below the restricted segments. The

cervico-thoracic and thoraco-lumbar spines are often found to be stiff with limitation of

the extension range, which may lead to hypermobility of the lumbo-sacral spine and
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progressive degeneration over time. The hypomobile spine must be mobilized so that an

even distribution of movement can be achieved all over the spine.

Central PA mobilization of the thoracic hypomobile segments, which reproduces

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the original back pain and/ or radiating pain, increases thoracic extension (Lee & Evans

1994, 1997), (Harms & Bader ,1997), (Latimer & Maher, 2002), (Fritz et al. ,2005),

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(Johansson ,2006). Restoration of uniform spinal extension movements may be helpful in

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LBP.

Raymond & Evans, 1997 measured the intervertebral movements of the

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lumbosacral spine produced by PA mobilization - an in vivo radiographic study, which
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strongly suggests that the spine is subjected to 3-point bending under the application of
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mechanical loads. Under the mobilization load the lumbar motion segments were found

to be extending. In a series of cadaveric studies, Lee & Evans 1994, 1997 noted that
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spinal PA mobilization produced extension movements and shearing forces to lumbar


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motion segments. It has been reported that an increase in the extension range of

movement occurs, following spinal PA mobilization (McCollam & Benson, 1993).


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Correction of the thoracic extension fixations can result in correction of increased lumbar

lordosis and listheis. (Joseph & Kurnik, 2000).


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CONCLUSION: Low back pain due to spondylolisthesis may be benefited by stretching

of periscapular muscles and mobilisation of thoracic spine along with stretching of short

hip flexors, piriformis, lumbar flexion range of motion exercises, core strengthening

exercises etc. Mobilisation of the hypomobile thoracic spines restores uniform spinal
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mobility and corrects the posture, thereby reducing extension stress at the lumbo-sacral

area, and in turn prevents or corrects forward slippage of the vertebral column.

Limitation of the study includes short duration treatment and no follow up was

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done after the completion of treatment. Long term treatment would have shown greater

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reduction in percentage of vertebral slip and improvement in functional outcome

measures and follow up study would have shown the extent of sustainability of the effects

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of manual therapy in spondylolisthesis. Future recommendations include long term

treatment and follow up study after completion of the treatment.

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