Is exercise safe with spondylolisthesis?

What is spondylolisthesis?

Spondylolisthesis means that one vertebra has slipped forwards relative to the one below it, most often in the lower back. The degree of slip is graded from mild to severe. Many people with mild slips have no symptoms and discover the condition by chance on an X-ray.

There are two common types. Isthmic spondylolisthesis results from a stress fracture in a small bridge of bone at the back of the vertebra, called spondylolysis, and often starts in childhood or adolescence, particularly in sports with repeated backward bending. Degenerative spondylolisthesis develops later in life because of wear in the discs and small joints.

What symptoms can it cause?

Symptoms may include lower back pain, stiffness, tight hamstrings, and pain that worsens with standing, walking or bending backwards. When the slip narrows the spaces for the nerves, people can develop leg pain, numbness or heaviness when walking that eases with sitting or leaning forwards.

Symptoms often do not correspond closely to the size of the slip on imaging, so treatment decisions are based on symptoms and function.

Which exercises are usually recommended?

Exercise programmes commonly include strengthening of the deep trunk muscles, buttock and hip muscles, stretching of tight hamstrings and hip flexors, and aerobic activity such as walking, cycling or swimming. Movements that bend the spine forwards, such as knee-to-chest stretches, often feel more comfortable for people whose symptoms worsen with standing.

An evidence-based guideline on degenerative lumbar spondylolisthesis reviews the evidence for non-surgical and surgical treatments and notes that high-quality studies of specific non-surgical treatments are limited 1. In practice, exercise is individualised according to symptoms and tolerance.

Are there movements to avoid?

In the early stages, repeated or heavy backward bending, such as certain gymnastics, back extension exercises with heavy loads or overhead lifting with an arched back, may aggravate symptoms, particularly in isthmic spondylolisthesis.

This does not mean all movement is harmful. As strength and control improve, many activities can be reintroduced gradually. Young athletes with a stress fracture may need a period of modified sport, guided by a sports medicine specialist.

When is surgery considered?

Surgery, such as decompression of the nerves with or without fusion, may be considered when leg pain, walking limitation or neurological symptoms persist despite a good course of non-surgical care, or when the slip is progressing.

In a study that followed 607 people with degenerative spondylolisthesis and spinal stenosis, including 304 in a randomised cohort, intention-to-treat analysis of the randomised group showed no significant difference, partly because about 40 per cent crossed over between treatments 2. Combined as-treated analysis showed greater improvement in pain and function with surgery over two years 2.

Can spondylolisthesis get worse?

Many slips remain stable over years, particularly in adults. Progression is more likely during growth spurts in adolescents with isthmic spondylolisthesis, which is why young people are monitored more closely.

Maintaining strength, a healthy weight and general fitness supports the spine, although exercise cannot reverse the slip itself.

How can I build core strength safely?

Core strengthening for spondylolisthesis usually starts with gentle exercises that teach control of the abdominal and back muscles in comfortable positions, such as lying on the back with knees bent. Exercises progress to bridging, bird-dog movements and side planks as tolerated.

Holding positions with good control is emphasised more than performing large, repeated back movements. If an exercise increases leg symptoms or back pain lasting into the next day, it should be adjusted.

Which symptoms need urgent assessment?

Seek urgent medical attention for new numbness around the buttocks or genitals, difficulty passing urine or controlling the bladder or bowel, or rapidly progressive weakness in the legs.

Worsening leg pain, numbness or reduced walking distance should be reviewed by a clinician, as it may indicate increasing nerve compression.

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