Non-surgical treatment for spondylolisthesis

There are lots of things you can try to help you cope better with any pain or negative impacts you’re experiencing:

• Staying active: It is a good idea to stay as active as possible and keep exercising in your day-to-day life despite the symptoms. Lack of exercise weakens the muscles and bones and can cause additional problems. So doctors recommend sticking to your normal routine if your symptoms allow or if painkillers help. Exercise often has a positive effect on your mood too.
• Doing sports: Some activities are better than others if you have a narrowed spinal canal. A brisk walk outdoors or on a treadmill or walking uphill are often still possible because your upper body bends forward automatically, expanding the space between your lower vertebrae. Cycling is also a good option because you bend forward a little on a bike anyway. Swimming on your back and aqua aerobics are also worth trying. The German-language tala-med website has lots of videos with exercises you can do at home to relieve back pain.
• Being aware of your posture: Bending your upper body forward slightly and tilting your pelvis relieves the pressure on your spinal canal. Physical therapists can help you learn how to do this, especially if your lumbar region is weak or stiff and needs toning. It is also a good idea to change your position and posture regularly during the day.
• Learning relaxation techniques: Techniques like progressive muscle relaxation and autogenic training can also bring some relief.
• Using medical aids: Medical aids (“Hilfsmittel”), like gadgets to help you put on your socks, tights, or trousers, make it easier to cope with your everyday routines. Walking aids like frames can give you something to rest your weight on or sit down on if you’ve been walking a while and need to take a break. In Germany, public health insurers cover the costs of these aids (apart from a fixed co-payment which you pay yourself) if the aid was prescribed by a doctor and the device has been approved by the insurer.

Doctors can prescribe rehabilitation exercise classes or functional training classes to help people who have back problems start getting or stay active. The prescription is usually for 12 months though it can be longer. These classes focus on activities like general and targeted exercise, water exercises, and swimming. The aim is to improve stamina, strength and overall mobility. Rehabilitation and functional training classes are done in a group, with a physical therapist showing you what to do. They’re often organized by sports clubs or support groups.

Not usually. Many people worry they’ll hurt their back if they do exercise despite being in pain. Acute pain is often the body’s way of warning us about something so it’s understandable they’re worried. But most people with back pain don’t have anything dangerously wrong with their spine.

Less than 1% of people who see a doctor because of back pain are diagnosed with an acute problem requiring emergency treatment (like an infection). If there’s reason to think you have a problem like this, it’s important to get a doctor to check. Usually though, back pain isn’t anything to worry about even if it is unpleasant.

By the way: Research shows that people who stay confident about their ability to do things don’t see their symptoms as such an obstacle. But people who spend a lot of time thinking about the pain tend to have more problems.

Finding the right balance is easier said than done. Some people completely stop doing a lot of things. One reason is that they’re worried it will hurt. But that can weaken your muscles, bones, and your cardiovascular system. It can cause psychological stress too because you’re giving up things that are important to you. Other people carry on as normal, despite their condition, and end up overdoing it.

It can be useful to find a healthy balance and to increase your physical resilience again by doing things like:

• dividing tasks and activities into smaller, more manageable chunks,
• deciding what’s important and what’s not as important and giving priority to the important things,
• adapting your personal goals, and
• generally making sure you’re prepared for the pain instead of just reacting to it.

Physical therapy can provide some relief, at least temporarily, for people with a narrowed spinal canal. It includes manual therapy plus strengthening and posture improvement exercises.

Manual therapy involves the therapist using special techniques to stretch and move your muscles and joints. When used for spondylolisthesis, this treatment aims to

• strengthen and mobilize the affected section of the spine and the nerve roots in the lower back,
• move around and stretch the joints in the hip, pelvis and spine to make them more flexible, and
• stretch muscles that affect spinal posture, like the front thigh muscles and the hip flexors.

There are also exercises to strengthen muscle groups that ensure good posture, including the core and leg muscles. These types of exercise are good for your general fitness and mobility too. The important thing is to keep doing the exercises when you’ve finished physical therapy and make them part of your everyday routine.

Other treatments are available, including massage, heating and cooling, acupuncture, ultrasound and electrotherapy, but there hasn’t been much research on how effective they are.

Which treatment is effective differs from person to person. For instance, some people like heat treatments or massages and find them soothing.

Sometimes the doctor will prescribe a brace with the aim of aligning the spine and pelvis properly to stop you overarching your spine. Experts disagree about the use of braces. Whatever the case, you definitely shouldn’t wear one for a long period or all the time. They can cause the muscles that stabilize your upper body to weaken, making the symptoms worse. Braces need to be prescribed by a doctor. Then the statutory health insurer will usually review your case to see whether they can cover the costs.

Back pain or pain that spreads to the legs (sciatica) can be treated with medication. The recommended medication is usually anti-inflammatory painkillers like diclofenac, ibuprofen or naproxen. These are also known as NSAIDs (non-steroidal anti-inflammatory drugs). Ideally, any medication should be in addition to other treatments.

You can get low-dose anti-inflammatory painkillers from a pharmacy without a prescription. The most common side effects are stomach problems like stomach ache. NSAIDs can also cause stomach ulcers and bleeding in the stomach if you take them regularly or over a long period. If you do take them over a long period or often have gastrointestinal problems, it might be a good idea to take medication to protect your stomach too. It’s best to discuss this with your doctor.

Paracetamol is available over the counter too, but it doesn’t help relieve back pain.

In addition, there are medications that your doctor has to prescribe for you. Opioids like fentanyl, morphine, oxycodone or tramadol should only be used very rarely, for a short time and under close medical supervision. Taking these drugs for a longer time can lead to habitual use and physical dependence. Opioids aren’t more effective at relieving back pain than anti-inflammatory painkillers like ibuprofen anyway.

Possible side effects range from nausea, vomiting and constipation to dizziness, breathing problems, and blood pressure fluctuation.

Medications to relax the muscles (muscle relaxants) are not recommended either because of side effects like drowsiness, gastrointestinal problems, dizziness, and an increased risk of falls. Muscle relaxants can also affect your ability to drive. They shouldn’t be taken for longer than two weeks.

Anti-epileptic drugs, like pregabalin, are typically prescribed for epilepsy but are thought to ease nerve pain (neuralgia) too. However, there hasn’t been enough research on whether they’re an effective treatment for sciatica. In addition, they tend to cause side effects like drowsiness and fatigue. Anti-epileptic drugs can also affect your ability to drive.

Antidepressants are typically used to treat depression. Some of these medications have also been approved for the treatment of chronic pain. But there is no good-quality research into how effective they are for treating back pain or spondylolisthesis.

Another possibility is to inject anti-inflammatory medications like steroids and/or anesthetics near to the narrowed section of the spinal canal to ease any irritated nerves. There are different ways of doing this:

• In lumbar spinal nerve analgesia, the medication is injected directly at the point where the nerve root leaves the spinal canal. This has a numbing effect on the irritated nerve root. This procedure is also known as periradicular therapy (PRT).
• In lumbar epidural analgesia, the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. The doctor uses computed tomography (CT) or x-ray imaging to see where the medication needs to be injected.

There hasn’t been enough good-quality research into whether injections near the spine can help people with spondylolisthesis or spinal stenosis. Generally speaking, they only provide limited relief and only for a few weeks. They can have side effects such as bleeding, infection and nerve damage.

If you’ve tried various treatments but the symptoms don’t go away and they’re causing you a lot of distress, it might be a good idea to take a look at how you deal with the pain. How we perceive pain and how well we cope with it is influenced by many factors, including our mind.

So it can be useful to use a method like behavioral therapy to recognize unhelpful ways of thinking or behaving and try to change them. You can combine behavioral therapy with other treatments too. The aim is to help you understand chronic pain better so you can cope with it in your day-to-day life.

People with chronic pain can also use Digital Health Applications (“DiGAs”) instead of behavioral therapy methods. DiGAs are therapy programs that you do on your own on a computer or with an app though some of them do include support from a psychologist. DiGAs can be prescribed by a doctor.

People who have chronic pain can benefit from multimodal pain management. That means they’re supported by specialists from various areas of expertise, such as doctors, physiotherapists and psychotherapists. They can help you stay active and cope with your symptoms.

Which treatment will help if you have spondylolisthesis depends on various factors, including how bad your symptoms are, any other health problems you have and what benefits you want and expect.

There isn’t any good-quality research on the treatment options. That’s another reason why it makes sense to talk to a doctor before and during treatment about what’s right for you. Things you might discuss include which treatments are suitable, how they can be combined, and which are not suitable. The approach you take will depend on your symptoms and your state of health.

If you’ve had spondylolisthesis symptoms for a long time and haven’t gotten enough relief from conservative treatment, surgery to reduce the pressure on the affected nerve may be an option. But there is no good-quality research that proves whether surgery really does provide more relief than conservative treatment. If your doctor recommends surgery, it’s a good idea to get a second medical opinion before making a decision.