Low Back Pain

[Questioner]

I have a client who is suffering low back pain and down the legs as well
as reduced mobility due to spondylolysis and spondylolisthesis. He has
suffered from it for over a year and can not say precisely what brought it
on although he feels strongly that negative energy is a key factor. He has
trouble lifting his legs, walks with a shuffling gait, and has great trouble
with stairs. He tries to limit the muscle relaxants and anti-inflammatory
meds but they are the only treatment that gives relief. He has tried physio
but did not find it helpful. He is in his forties and not physically
active.



The MRI report is as follows:


The L1-L2 and L2-L3 disc spaces are normal.

At L3-L4 the disc is normal. The neural foramina are patent bilaterally. The
spinal canal is patent. There are some hypertrophic degenerative changes of
the facet joints and ligamentum flavum at this level.

At L4-L5 the disc is normal. The neural foramina are patent bilaterally. The
spinal canal is patent. There are hypertrophic degenerative changes of the
facet joints and ligamentum flavum.

At L5-S1 there are degenerative and plate changes and a grade I
anterolisthesis of L5 on S1. There is loss of disc space height. There is a
diffuse disc bulge associated with the anterolisthesis. This results in mild
narrowing of the neural foramina bilaterally. The spinal canal remains
widely patent. Although it is not well seen on these images, there appears
to be a bilateral pars defect of L5.

IMPRESSION - There is a spondylolysis with a grade I spondylolisthesis of L5
on S1. This results in narrowing of the neural foramina bilaterally. The
spinal canal remains patent.


I think I understand that this is fundamentally a mechanical problem: the
bilateral pars defect of L5. (www.back.com <http://www.back.com/> was very
helpful in deciphering the MRI findings). My inclination is to recommend
hamstring stretches and gentle core strengthening to start. I am unsure how
to proceed considering the disk bulge and pars defects. Any advice and
insight into this condition, that you are able to offer, would be much
appreciated. Namaste, M

[Mukunda]

First let us define what are spondylolysis and
spondylolisthesis. The former, according to Taber's Cyclopedic Medical
Dictionary, is a general term meaning a "breaking down of the vertebrae
structure" and the latter is "any forward slipping of one vertebrae on the
one below it. Predisposing factors include the previous, degeneration and
birth defects such as spina bifida". Thanks for the details medical
assessment accompanying your summary of this client. You say he is not
physically active. That is a major hurdle to overcome. He needs to be
given a program that he will do one that will motivate him to attempt to
overcome with self effort the pain and limited range of motion that he is
blessed with learning from. In general I start this type of client with
simple recommendations for exercising and lifestyle changes that will
support lessening his stress. That would focus on joint freeing series to
increase circulation, increase water intake, and regulation of sleeping,
resting, eating habits especially getting to bed on time. If he will not do
this then I would refer him back to physical therapy or other modalities
that will take care of him. Having the initiative to work on himself cannot
be a burden for a yoga therapist otherwise you are a yoga teacher trying to
do physical therapy. A major distinction for me is that a yoga therapist
should focus on clients doing yoga sadhana to improve his entire lifestyle
not merely exercise therapy. Let us leave that to the PT and OT world.



That said my experience of these conditions is that they respond
well to a combination of deep tissue bodywork and personalized yoga routine
based on an assessment of what is weak with yoga to strengthen the specific
muscles and an assessment of limited range of motion so that program will
also focus on increase joint range of motion (not stretching muscles; as
that intention will heighten inflammation due to increasing pitta). Rarely
are the hamstrings tight enough to cause limited range of motion except in
this type of chronic condition. But still I find more relief not from
stretching what yoga teachers find tight, better is to strengthen what is
weak. In this combination of skills I have counseled a client to 11 years
of relative comfort, that is, when he followed my advice. I should admit
that he didn't always do that and when he did what he knew wasn't good, he
got into pain. It is a condition of management, not elimination of the
difficulty. Blessings.