A clinical synthesis based on the NASS guideline, the SPORT trial, the RESTORE-CFT trial (Lancet 2023) and the most recent 2023-2025 meta-analyses.

Degenerative lumbar spondylolisthesis (DLS) is a frequent cause of low back pain and of neurogenic claudication in adults over 50. It differs radically from the isthmic spondylolisthesis of the adolescent: here there is no stress fracture, but a cascade of facet joint osteoarthritis and disc degeneration that ends in an anterior vertebral slip. Understanding this mechanism, its true prevalence and its slow natural history is the essential precondition for any coherent management.

How is this condition defined, who is affected and what are the risk factors?

Degenerative lumbar spondylolisthesis is defined as an anterior slip of one lumbar vertebra over the one beneath it, in the absence of a defect of the pars interarticularis (hence without spondylolysis)¹,². This operational definition, adopted by the NASS guideline¹, is fundamental because it governs both prognosis and treatment strategy. The level most frequently affected is L4-L5, because of its considerable mobility and of the mechanical loads it carries, followed by L3-L4 and L5-S1².

Epidemiologically, DLS is far more frequent than people think. The Framingham community study (Kalichman 2009)³ finds a radiographic prevalence of degenerative spondylolisthesis of 19.1 % in men and 25.0 % in women aged 65 and over in the Hong Kong MsOS/MrOS cohort (Wang 2013)⁴. A systematic review focusing on age and sex (Wang 2017)⁵ confirms an overall prevalence of around 11-12 % in adults, rising linearly with age. 👩‍⚕️

The female predominance is one of the most firmly established risk factors. In the general population the F:M ratio is about 1.3:1; in clinical series (patients seeking care for symptoms) it can reach 3:1 to 6:1². This difference is attributed to post-menopausal hormonal factors (increased ligamentous laxity), to anatomical differences (facet orientation) and to multiparity⁴.

In summary, the risk factors firmly established by the recent literature are:

• Female sex : a major factor, above all after the menopause⁴,⁵.
• Age > 50-60 years : prevalence rises linearly with age².
• Sagittal facet orientation : the Liu 2017 meta-analysis⁶ finds a weighted mean difference (WMD) of −10.5° between DLS and controls, facets more parallel to the sagittal plane offering less resistance to anterior shear.
• High body mass index : obesity increases lumbar mechanical loads².
• Increased lumbar lordosis : raises shear forces at L4-L5⁷.
• Multiparity : a cumulative hormonal and biomechanical effect².

What happens in the body and how does DLS evolve naturally?

The pathophysiology of DLS is a four-step degenerative cascade, now well described in recent narrative reviews (Akkawi 2022⁸, Gagnet 2018⁹). ⚙️

1. Degeneration of the intervertebral disc : loss of disc height and hydration, reduced shock absorption and reduced segmental stability⁸.
2. Overloading of the facet joints : the loss of disc height transfers excessive load onto the posterior facets, leading to facet osteoarthritis (cartilage erosion, subchondral sclerosis, osteophytes)².
3. Segmental instability and slip : osteoarthritis and facet remodelling, combined with laxity of the ligamentum flavum and of the capsule, allow the progressive anterior slip⁸.
4. Canal or foraminal stenosis : facet hypertrophy, disc bulging and thickening of the ligamentum flavum reduce the space available for the neural structures, generating neurogenic claudication. It is this stenosis, more than the slip itself, that causes the neurological symptoms⁷.

📈 The natural history is slow. The seminal study by Matsunaga (Spine 1990)¹⁰, which followed 40 patients for 10 years, is the universally cited reference. It showed that:

• The slip progresses in only about 30 % of patients over 10 years, and usually remains modest¹⁰.
• Above all, worsening of the clinical symptoms is not correlated with an increase in the radiographic slip¹⁰,⁸.
• General joint laxity was observed in 65 % of patients, suggesting a constitutional component¹⁰.

This last point is fundamental in the consultation : a patient may see their slip stabilise while developing more severe symptoms (through worsening stenosis) or, conversely, see their slip progress slightly while remaining asymptomatic. This clinical and radiological dissociation is the pivot of an approach centred on function rather than on the image.

Criticism and controversy: the trap of the "radiological diagnosis"

One major controversy in DLS is the discordance between images and clinical picture. Many imaging studies in asymptomatic people show that radiographic DLS is very frequent in older people with no complaint. Brinjikji (AJNR 2015)¹¹ and the ACP/Chou guideline (Ann Intern Med 2011) call for caution in interpreting incidental findings. The risk of an anxiety-provoking incidental finding is real: a patient told "you have a slipped vertebra" may develop an iatrogenic kinesiophobia that complicates management.

Another controversy is the very definition of "symptomatic" DLS. Should there be a minimum radiographic threshold (≥ 3 mm, ≥ 5 mm)? The NASS guideline¹ imposes no threshold and gives priority to clinical correlation. The practical consequence is that imaging must never be requested "to look for a DLS" ; it confirms a prior clinical hypothesis of neurogenic claudication or of sciatica.

The diagnosis of DLS is above all clinical. Imaging confirms it. The trap works the other way round: finding a spondylolisthesis on an MRI scan does not mean the patient is suffering from it. The reference diagnostic approach (NASS 2009/2016) rests on a rigorous triad: a history targeted on neurogenic claudication, a standardised physical examination with a walking test, and relevant imaging (dynamic radiographs and MRI), always correlated with the clinical picture.

Which questions should you ask to understand the patient and their history?

The history is the cornerstone of the diagnosis. 🔍 The most characteristic picture in symptomatic DLS is intermittent neurogenic claudication, whose features must be explored systematically¹,².

• Description of the symptoms : pain, heaviness, cramping, paraesthesia or weakness, most often bilateral but sometimes asymmetrical, radiating into the buttocks, the thighs or the legs³. These symptoms are classically worsened by walking or by prolonged standing, postures that place the spine in extension and reduce the diameter of the spinal canal².
• Relieving factors : neurogenic claudication is relieved by lumbar flexion. The patient reports relief on sitting down, on leaning forward or on leaning on a trolley (the "shopping trolley sign")⁴. This flexed posture increases the space available for the neural structures.
• Walking distance : quantifying it (distance, time to the onset of symptoms) is the most useful objective measure for tracking change. To be recorded in the notes in metres or in minutes¹.
• Associated mechanical low back pain : often present, worsened by activities in extension, relieved by rest or by flexion.
• Risk factors and comorbidities : age, sex, BMI, history of pregnancies, osteoporosis, diabetes (which can produce a peripheral polyneuropathy mimicking claudication)⁵.

One crucial question, often neglected, is that of the patient's beliefs and representations. What is their interpretation of the condition? Have they seen their MRI scan? What were they told? The word "instability" can be anxiety-provoking and generate an iatrogenic kinesiophobia⁶. Anticipating this educational work starts with the history itself.

Which clinical tests should you perform and which other conditions should you rule out?

The physical examination aims to confirm the hypothesis raised by the history, to assess any neurological involvement and to rule out the differential diagnoses. 🚶‍♂️

• Postural inspection : look for a loss of lordosis and an antalgic posture in flexion (trunk slightly bent, hips and knees flexed).
• Full neurological examination : motor strength testing (in particular tibialis anterior L4, extensor hallucis longus L5, triceps surae S1), dermatomal sensation, tendon reflexes (knee L4, ankle S1), straight leg raise (often negative because the compression is central or foraminal, not discal)⁷.
• Two-stage treadmill walking test (Fritz 1997) : the patient first walks on the level until symptoms appear, then, after a rest, on an inclined treadmill (which favours flexion). A significant improvement in walking time on the inclined treadmill is highly suggestive of neurogenic claudication, with a sensitivity of about 50 % and a specificity of ≈ 92 %⁸. A simple tool to build into physiotherapy practice.
• Functional assessment : actual walking distance, standing tolerance, Schober test (lumbar mobility), single leg squat to assess neuromuscular control.

The essential differential diagnosis is vascular claudication (peripheral arterial disease of the lower limbs). The distinction is fundamental and has a direct impact on management:

Other differential diagnoses to consider: hip osteoarthritis (pain referred to the groin), sacroiliac osteoarthritis, piriformis syndrome, peripheral diabetic neuropathy, meralgia paraesthetica (compression of the lateral femoral cutaneous nerve), trochanteric bursitis, gluteal tendinopathy.

As regards imaging, the NASS guideline¹,² and Kreiner's guideline on lumbar stenosis¹⁰ recommend:

• Weight-bearing dynamic radiographs (standing flexion-extension) : the first-line examination for visualising the slip and identifying any segmental instability (mobility > 3-4 mm in flexion and extension).
• Lumbar MRI : the gold standard for assessing central and foraminal stenosis, root compression, and the state of the discs and facets. Recommendation: to be requested only if the treatment decision depends on it (surgery under consideration, red flag)¹⁰.
• CT scan : useful in addition if MRI is contraindicated or to plan surgery (fine bone analysis).

Should DLS patients be classified, and for what benefit?

Yes, but by abandoning purely radiographic classifications in favour of clinically informative ones. 💡

The Meyerding classification (grade I: < 25 %, II: 25-50 %, III: 50-75 %, IV: 75-100 %, V: complete ptosis) is historically the most used. But in DLS almost every case is grade I or II, and the correlation between grade and symptoms is weak¹¹. It is therefore not enough to guide treatment.

The CARDS classification (Clinical And Radiographic Degenerative Spondylolisthesis, Kepler 2015)¹² is more modern and clinically relevant. It distinguishes 4 subtypes according to the combination of disc height, sagittal alignment and amount of translation, together with a clinical modifier for the absence of radiculopathy (0), unilateral radiculopathy (1) or bilateral radiculopathy (2):

• CARDS A (≈ 16 % of cases) : advanced disc collapse, without kyphosis.
• CARDS B (≈ 37 %) : disc height partly preserved, translation ≤ 5 mm.
• CARDS C (≈ 33 %) : disc height partly preserved, translation > 5 mm.
• CARDS D (≈ 14 %) : kyphotic segmental alignment.

Karamian (2023, Clin Spine Surg)¹³ showed that the CARDS subtypes predict functional outcomes (PROMs) after lumbar fusion at L4-L5, thereby validating the prognostic usefulness of this classification.

Criticism and controversy: MRI, overdiagnosis and the clinical threshold

The major controversy in DLS diagnosis remains the weak specificity of MRI on its own. Brinjikji (AJNR 2015) showed that a degenerative spondylolisthesis is seen in a substantial share of the completely asymptomatic older population¹⁴. Excessive requesting of MRI, above all in patients with no red flag, generates anxiety-provoking incidental findings and can paradoxically increase the risk of unnecessary surgery.

Another tension concerns the use of complex classifications in everyday practice. Kepler's CARDS¹² is validated in surgical centres but remains little used by community physiotherapists. For the first-line clinician, a simplified classification centred on the severity of the claudication (walking distance, ODI) is often more workable. The point is not to memorise a nomenclature but to stratify patients according to their functional impact.

The management of DLS rests on a solid international consensus: conservative treatment is the first line (NASS), with a fair trial of at least 3 to 6 months before surgery is discussed. Lumbar stabilisation exercise is the most effective modality, completed by patient education and by the management of psychosocial factors. Surgery remains reserved for documented failures and for progressive neurological deficits.

Where do you start and what is the hierarchy of interventions?

The treatment hierarchy is codified by the NASS guideline (Watters 2009, updated by Matz 2016)¹,² and supported by a recent network meta-analysis (2024). The logic is "stepped care" : start with the least invasive interventions and step up the intensity if the response is insufficient.

1. Patient education + adapted physical activity (weeks 1-4): deconstruct catastrophic beliefs, explain the pathophysiology, encourage the patient to keep up whatever physical activity is tolerated³.
2. Supervised exercise programme (weeks 2-12): segmental stabilisation, motor control, functional exercises, the heart of the treatment⁴.
3. Adjunct manual therapy if pain limits participation in the exercises (short term).
4. Step 1-2 analgesics during a painful flare (paracetamol, a short course of NSAIDs if not contraindicated).
5. Epidural injection : a modest and transient effect, a weak NASS recommendation; to be discussed case by case¹,².
6. Surgery : after a fairly conducted conservative failure of ≥ 3-6 months OR in the presence of progressive neurological deficits or cauda equina⁵.

What place does exercise hold and is there a superior approach?

Therapeutic exercise is the most solid intervention in the conservative arsenal for DLS. 🎯 The meta-analysis by Lin (2024, Spine)⁶, which includes 6 RCTs on the efficacy of segmental stabilisation exercise in spondylolisthesis (isthmic and degenerative combined, about 350 patients), shows a significant improvement in ODI and in VAS compared with conventional exercise.

Beyond the type of exercise, what emerges from the recent analyses is this:

• Motor control and segmental stabilisation exercises (transversus abdominis, multifidus, pelvic floor) are superior to general exercise in DLS⁶,⁷.
• Individualisation and gradual progression matter more than the exact protocol.
• Long-term adherence is probably the factor that best predicts success, which argues for activities the patient enjoys (Pilates, yoga, Nordic walking, swimming, cycling)⁸.
• The flexion exercises (Williams) have been used historically and can relieve radicular symptoms by increasing the foraminal diameter; they are neither to be preferred nor to be ruled out systematically⁹.
• The extension exercises (McKenzie) are to be used with caution when neurogenic claudication predominates (they can worsen the symptoms).

Manual therapies and passive modalities: what is their real efficacy?

Manual therapies (joint mobilisation, manipulation) play an adjunct and short-term role²: they can reduce pain and improve mobility, thereby opening a window for engaging the patient in an active programme. Their efficacy as monotherapy is very limited¹.

Flexion-distraction techniques (the Cox technique) have shown some benefit in reducing pain, always alongside an exercise programme, but the level of evidence remains modest¹³.

The passive physical modalities (electrotherapy, ultrasound, heat, ice, TENS) carry a very low to non-existent level of evidence in the medium and long term in DLS⁴. Their use, where it occurs, must remain occasional and always subordinate to setting up an active programme. 🧘

Beyond the physical: how do you educate the patient and act on psychosocial factors?

Patient education is a pillar as important as exercise¹⁴. It must cover:

• The nature of the condition in simple, non-catastrophic terms: a slip does not mean a spine that "is going to break".
• The clinical and radiological dissociation : the images are frequent in healthy older people (Brinjikji 2015).
• The importance of movement and of a graded return to activity: inactivity worsens chronicity.
• The pacing strategies (alternating activity and rest) and the relief techniques (flexion postures during a flare).

The psychosocial factors , catastrophising, fear of movement (kinesiophobia), anxiety, depression, are powerful predictors of chronicity, independently of radiographic severity¹⁵,⁵. To neglect them is to guarantee treatment failure despite the best manual technique or the best exercises. 💪

The RESTORE trial (Kent 2023, Lancet)¹⁰ is the major scientific contribution of the past decade on chronic low back pain. It randomised 492 adults with chronic disabling low back pain between Cognitive Functional Therapy (CFT, with or without biofeedback) and usual care. At 13 weeks the CFT arm achieved a greater reduction in disability (RMDQ) of −4.6 points (95% CI −5.9 to −3.4), with the effect maintained at 1 year and now validated at 3 years (Lancet Rheumatology 2025)¹⁶. CFT is now the most validated cognitive-behavioural approach for chronic disabling low back pain and is relevant to DLS with a marked psychosocial component.

When should surgery be considered and what do the major trials say (SPORT, Försth)?

Surgery remains an effective option in DLS after a fairly conducted conservative failure or in the presence of progressive neurological deficits or cauda equina. Two randomised trials have transformed the decision:

• The SPORT trial (Weinstein 2007, NEJM)¹¹ compared surgery (decompression ± fusion) with conservative treatment in 304 DLS patients with stenosis. At 2 years the surgical arm had clearly better outcomes (pain, SF-36, ODI). The 8-year follow-up (Abdu 2017)¹² confirms the lasting benefit of surgery on pain and function, BUT with a reoperation rate of 22 % at 8 years (most often for recurrent stenosis or progression of the slip). Note that the SPORT patients were highly selected (failure of ≥ 12 weeks of conservative care).
• The Försth trial (NEJM 2016)¹⁷ randomised 247 patients (50-80 years) with lumbar stenosis ± DLS between decompression alone and decompression + fusion. Its major conclusion: adding fusion does not significantly change the outcomes at 2 years (Oswestry, EQ-5D, walking). This study revived the debate on the value of routine fusion in DLS and points towards decompression alone in the well-selected patient.

The surgical decision must therefore be shared with the patient, discussing explicitly the expected benefit for walking, the reoperation rate, the length of recovery, and the continuing alternative of conservative treatment (which remains effective in many).

Criticism and controversy: the paradoxes of "stabilisation"

Several paradoxes persist in the management of DLS.

1) The word "instability" is misleading: the vertebral slip is often chronic and stable, and insisting on the mechanics can generate an iatrogenic kinesiophobia. The benefits of "stabilisation" exercises may come less from mechanical re-stabilisation than from improved neuromuscular control, reduced central sensitisation and restored confidence in movement¹⁸.

2) The importance of exercise type remains debated. While recent RCTs tend to show a modest superiority of motor control exercise, several broad meta-analyses on chronic low back pain conclude that adherence to a regular programme matters more than the type of exercise¹⁹. This chimes with the CFT philosophy: individualise, give meaning, build adherence.

3) The surgical decision remains heterogeneous between countries and centres. Surgery rates for DLS vary considerably, a sign that indications are not standardised. The Försth trial calls for instrumental restraint (preferring decompression alone in the well-selected patient).

Resolving the acute symptoms is only one step: the real key to treatment success lies in the transition from passive management to active self-management. Since DLS is a chronic degenerative condition, the patient must become the main guarantor of their own spinal health. This chapter sets out how to build that autonomy and how to plan a return to activity based on functional criteria, not on imaging or on a calendar.

How do you make the patient an active player in their own recovery through self-management?

Empowering the patient is the cornerstone of preventing recurrence¹. Management limited to passive treatments, with no active involvement of the patient, is bound to fail in the long term². The aim is to provide the knowledge and the tools needed for independent management. 🧑‍🏫

The education of the patient (therapeutic patient education) is shown to be effective in improving pain and function in chronic low back pain³,⁴. It must cover:

• Understanding the condition : explain DLS simply, insist that the image does not define the suffering, since an asymptomatic slip is frequent (Brinjikji 2015)⁵. Demystify the fear attached to MRI.
• Pain management strategies : recognise the provocative activities, identify the relieving postures (forward flexion), understand the importance of movement even in the presence of moderate discomfort⁶.
• A home exercise programme : the transition to an independent programme is fundamental. Lumbopelvic stabilisation (transversus, multifidus, pelvic floor) is shown to be the most effective modality for reducing the ODI in DLS⁷.
• Lifestyle : sleep, stress management, regular physical activity (walking, cycling, swimming), weight control, all modifiable factors that influence chronicity.

Long-term adherence is the main challenge. To improve it:

• Co-build the programme with the patient (preferences, personal goals)⁸.
• Set progressive and realistic goals (the SMART technique).
• Plan spaced but regular follow-ups (at 1, 3, 6 and 12 months) to adjust.
• Build in health technologies (mobile reminder apps, exercise diaries) if the patient wants them⁹.
• Identify and treat early the psychosocial barriers (catastrophising, kinesiophobia), possibly through CFT (Kent 2023)¹⁰.

When and how do you plan a safe return to activity and sport?

The return to intense physical or sporting activity after a symptomatic episode of DLS must be an approach based on criteria, not on a rigid calendar¹¹. 🏃‍♀️ A return that is too early or poorly prepared increases the risk of symptomatic recurrence.

Progression is built around 4 phases:

1. Symptom control (prerequisite): pain almost absent in activities of daily living, walking distance restored, no disabling claudication¹².
2. Functional recovery : functional spinal mobility, adequate trunk and lower limb strength, good neuromuscular control. Tests: plank (isometric hold > 60 s), a good single leg squat, the ability to climb 2 flights of stairs without pain¹³.
3. Progressive reintroduction of loading : gradual increase in volume, intensity and complexity. Start with low-impact activities (swimming, cycling, Nordic walking) before impact activities (running) or twisting ones (racket sports, golf)¹¹. The "10 % per week" rule for progressing intensity.
4. Validation by performance criteria : the ability to perform the sport-specific movements without pain, without apprehension, with good movement quality¹⁴.

The physiotherapist's role is to guide this progression, making sure the patient keeps up the stabilisation programme alongside it. That programme becomes a lifelong preventive routine, not a one-off course of rehabilitation.

Criticism and controversy: beyond protocols

Three tensions structure the recovery phase:

1) Which type of exercise matters most? Broad meta-analyses on chronic low back pain suggest that the specific type of exercise matters less than regular adherence¹⁵. The point is not to defend "the best protocol" but to find the activity the patient will keep up over time. Pilates, yoga, general strengthening, pure stabilisation, all have their place if they are actually practised.

2) Imaging must not guide the return to activity. The literature shows that the radiological parameters (Meyerding grade, dynamic instability) are weak predictors of functional outcomes in conservatively treated patients⁵,¹⁶. Basing activity restrictions on an image alone is a major source of iatrogenic kinesiophobia.

3) Sport is protective, not dangerous. Moderate-impact sports (running, racket sports), well prepared, are not contraindicated in stable DLS. On the contrary, prolonged sedentary behaviour is a major factor in chronicity. The message to pass on: "moving remains the best thing you can do for your back".

Randomised trials and meta-analyses give the general framework; the published case reports illustrate the real complexity of practice. Three major lessons stand out: well-conducted conservative management often gives excellent results, DLS can present in deceptive guises (through referred hip pain in particular), and psychosocial factors can turn a "simple" file into a complex case. 🧐

Analysis of a "classic" case: from assessment to resolution

The published literature illustrates, through many randomised trials and patient series, the potential of a well-conducted conservative approach. The narrative review by Akkawi and Zmerly (2022, Acta Biomed)¹ recalls that a majority of patients with symptomatic DLS improved their pain and their function significantly with a structured rehabilitation programme, with no need for surgery.

A typical management pattern, validated by the NASS guidelines (Watters 2009 / Matz 2016)²,³ and supported by the Lin meta-analysis (2024)⁴, is built over 12 weeks:

• Weeks 1-2 : patient education (deconstructing catastrophic beliefs, explaining the clinical and radiological dissociation), pain management, relieving postures, introduction to lumbopelvic stabilisation (activation of transversus, multifidus).
• Weeks 3-6 : progression of the stabilisation programme, adding motor control exercises in functional positions (bridge, progressive plank, dead bug), adjunct manual therapy if a segment is restricted.
• Weeks 7-12 : functional exercises specific to the patient's goals (progressive walking, stairs, carrying light loads), reintroduction of the activities they enjoy (cycling, swimming, Nordic walking), transition to an independent home programme.

Recent RCTs on exercise in DLS typically report clinically significant reductions in the ODI (Oswestry Disability Index) of the order of 15 to 25 points and VAS reductions of 3 to 5 points⁴,⁵, well beyond the thresholds of clinically important difference (MCID: ODI ≥ 12 points, VAS ≥ 2 points). These results last when a home programme is kept up. The key is therefore less the specificity of the protocol than regularity and long-term adherence⁶.

The diagnostic challenge: when DLS mimics another condition

One of the most useful lessons drawn from clinical practice is the capacity of DLS to present in deceptive guises. 🎭 The foraminal or lateral stenosis that accompanies the slip can compress a root and cause pain referred to unexpected territories, in particular the groin, the anterior thigh or the greater trochanter.

Devin et al. (2012)⁷, in a detailed review of the "hip-spine syndrome", stress how difficult the differential diagnosis is between hip osteoarthritis and upper lumbar pathology (L2-L3, L3-L4). An L3 radiculopathy can produce pain exactly superimposable on hip osteoarthritis: groin + anterior thigh + medial side of the knee. The clinical risk is to focus the assessment and the treatment on the hip and to miss the lumbar cause, which explains the "failures" of total hip replacement in patients who in fact have an upper DLS.

Prather et al. (2017)⁸ prospectively examined 101 consecutive patients consulting for low back pain: 80 % had limited hip flexion and 75 % limited hip internal rotation, and those with a positive hip examination reported more intense pain and worse function. The clinical overlap between hip and spine is therefore frequent, and the rule that follows from it is plain: in any hip or anterior thigh pain that persists despite well-conducted local treatment, examine the lumbar spine systematically. Tests to build in: straight leg raise, femoral nerve stretch test, palpation of the posterior superior iliac spine, a search for neurogenic claudication, and lumbar imaging if the clinical findings agree.

Other "masks" of DLS are worth knowing:

• Piriformis syndrome : can be superimposed and mask a true neurogenic claudication.
• Meralgia paraesthetica (compression of the lateral femoral cutaneous nerve): numbness of the anterolateral thigh, to be distinguished from an L2-L3 radiculopathy.
• Trochanteric bursitis / gluteal tendinopathy : can coexist with a DLS in the older woman.
• Peripheral diabetic neuropathy : bilateral stocking-distribution numbness; frequently overlaps with DLS in older people.

A complex case with psychosocial factors

Complex cases remind us that a "simple" DLS on MRI can become extremely disabling when psychosocial factors dominate the picture. That is precisely the situation documented by the RESTORE programme of Kent et al. (Lancet 2023)⁹: patients with chronic disabling low back pain, often carrying modest radiological signs but a heavy psychosocial load (catastrophising, kinesiophobia, anxiety, mistaken beliefs).

The RESTORE trial (492 patients, 20 clinics in Australia) compared Cognitive Functional Therapy (CFT, with or without biofeedback) with usual care. At 13 weeks CFT achieved a reduction in disability (RMDQ) of −4.6 points (95% CI −5.9 to −3.4), with the effect maintained at 1 year and now at 3 years (Lancet Rheumatology 2025)¹⁰. CFT brings together:

• Shared understanding of the meaning of the pain (sense-making);
• Graded exposure to the avoided movements;
• Regaining confidence in the body through guided experiment;
• Work on lifestyle habits (sleep, activity, stress).

For DLS with a marked psychosocial component, building a cognitive functional approach in from the start of rehabilitation is now a recommendation drawn from the best available evidence¹¹,¹². This does not mean the physiotherapist must become a psychologist, but that they must know how to:

• Screen for yellow flags (brief questionnaires: STarT Back, ÖMPSQ-SF);
• Adapt their words so as not to reinforce catastrophic beliefs;
• Refer to a psychologist or to a CBT programme specialising in chronic pain when the psychosocial load exceeds their competence.

Criticism and controversy: the place of the case report in the evidence-based era

Three important points on the use of case reports:

1) A case report represents level 5 evidence (the lowest GRADE level, Oxford CEBM 5). It describes the experience of one individual and allows no generalisation. ⚠️

2) The main bias is publication bias : cases with spectacular results (resounding successes or failures) are over-represented, whereas the "average" cases, the majority, go unpublished.

3) Despite these limits, case reports remain indispensable as a teaching tool : they illustrate how the principles of SRs and MAs apply in the "disorder" of the real world (comorbidities, preferences, life context), they generate hypotheses (atypical cases), and they engrave in the clinician's mind the need for a systematic differential assessment (for example DLS mimicking hip osteoarthritis).

In short, case reports do not tell us "what works" in general, but they show us "what is possible" in a particular situation and they train us in clinical reasoning. They are the bridge between the rigour of meta-analyses and the humanity of each patient.

Applying the evidence in clinical practice is the bridge between science and care. For DLS it translates into three concrete requirements: knowing how to refer (red flags, yellow flags), knowing how to measure (validated PROMs) and knowing how to overcome the barriers to implementation. This chapter provides the practical tools for structuring those three axes in a practice or in a rehabilitation centre. 🧑‍⚕️

When, and to which other health professionals, should you refer?

The physiotherapist is often the first-line professional, which gives them a major responsibility for triage and referral. Identifying the situations that lie beyond their scope of competence is an essential component of safe care.

The detection of red flags is the non-negotiable step. The international reference framework is the International Framework for Red Flags for Potential Serious Spinal Pathologies (Finucane 2020, JOSPT)¹, a consensus tool that structures screening to identify infections, fractures, tumours and cauda equina syndromes. When a red flag is confirmed, medical referral is immediate (prompt medical consultation or emergency department depending on severity)².

Beyond the emergencies, assessment of the psychosocial factors (yellow flags) is just as fundamental. Catastrophising, kinesiophobia and avoidance beliefs are powerful predictors of chronicity³,⁴. Simple tools:

• STarT Back Tool (Hill 2008)⁵: 9 questions, stratification into low / medium / high risk.
• ÖMPSQ-SF (Örebro Musculoskeletal Pain Screening Questionnaire): the short 10-item version.
• FABQ (Fear-Avoidance Beliefs Questionnaire): 16 items, a score > 14 on the "Work" subscale predicts chronicity.
• PCS (Pain Catastrophizing Scale): 13 items, a score > 30 = marked catastrophising.

If the score is high, referral to a psychologist specialising in chronic pain or to a CBT programme is indicated. The physiotherapist can open the discussion as part of shared decision-making⁶.

Modern management of DLS is part of integrated multidisciplinary care models. The physiotherapist can refer to:

• General practitioner / rheumatologist : if progress stalls, for medication adjustment, epidural injection, or an opinion on whether an MRI is warranted.
• Orthopaedic spine surgeon : conservative failure ≥ 6 months OR a progressive neurological deficit. The shared discussion must include the SPORT figures (Weinstein 2007, Abdu 2017) and the Försth NEJM 2016 trial on the absence of benefit from routine fusion⁷,⁸,⁹.
• Pain physician : if a neuropathic component dominates or the chronic pain is refractory to standard treatment.
• Psychologist / psychotherapist : high yellow flags (catastrophising, kinesiophobia, associated depression), for CBT or ACT.
• Occupational therapist : adapting the workstation, the home, the vehicle.
• Sports physician : return to regular sporting practice, planning the resumption.

Referral ideally fits into a stepped care model ("stepped care"), where the intensity of the treatment and the number of professionals involved are adjusted to the patient's response and to the complexity of their condition¹⁰. The pathway physiotherapist → GP → specialist → surgeon is not a linear route but a modular network.

How do you measure outcomes and overcome the barriers to implementation?

Applying the recommendations is effective only if its results are measured. 📈 The PROMs (patient-reported outcome measures) have become the standard for judging the efficacy of a treatment from the patient's point of view¹¹. For DLS, the validated PROMs are:

• Oswestry Disability Index (ODI) : 10 items, score 0-100 %. The reference in low back pain. MCID estimated at 12 points¹².
• Zurich Claudication Questionnaire (ZCQ) or Swiss Spinal Stenosis Questionnaire: specific to lumbar stenosis (including DLS). Three domains: symptom severity, physical function, satisfaction. MCID estimated at 0.5 point per domain¹³.
• Roland-Morris Disability Questionnaire (RMDQ) : 24 items, simpler than the ODI; used in the RESTORE trial¹⁴.
• EQ-5D : generic quality of life, used in the Försth NEJM 2016 trial⁹.
• NPRS (Numeric Pain Rating Scale) or VAS: pain intensity.
• Walking distance : a simple functional measure, very useful in everyday practice.

Implementing PROMs requires standardised procedures, clinician training, and ideally integration into the electronic patient record for longitudinal follow-up¹¹. Failing that, a simple paper record at 4 key points (baseline, 6 weeks, 3 months, 6 months) is already a major advance on measuring nothing at all.

Several barriers hold back the adoption of evidence-based practice (EBP). The barriers most frequently cited by physiotherapists¹⁵:

• Lack of time : critical reading and putting it into practice demand unpaid time.
• Lack of research skills : initial training is sometimes insufficient in methodology.
• Lack of resources : access to the scientific databases is limited outside the university.
• Patient beliefs : expectations of passive modalities, requests for imaging, fear of moving¹⁶.
• Tension between guidelines and the patient-centred approach : the need to adapt the recommendations to the singularity of each case.

To overcome these barriers, a multifaceted approach is needed¹⁷:

1. At clinician level : continuing education in EBP, subscribing to 1-2 newsletters from key journals (BJSM, JOSPT, Spine), taking part in a peer group.
2. At organisation level : the organisational support is a key factor¹⁵. Allocate dedicated time for training, provide access to the databases, promote a culture in which EBP is valued.
3. At system level : discourage low-value care (routine imaging, prolonged rest), promote evidence-based models in initial and continuing training¹⁸.

Criticism and controversy: the tensions of modern practice

Applying the recommendations rigorously raises several debates:

1) The paradox of the practice guideline : guidelines are essential for standardising, but they risk promoting a "cookbook medicine" that neglects individual complexity. The tension between applying a protocol validated for a population and adapting it to a unique individual is a permanent challenge.

2) The persistent "implementation gap" : despite solid evidence, low-value practices (excessive imaging, prolonged rest) persist, while high-value interventions (education, exercise) are under-used¹⁸. The gap is not down to the clinician alone: it rests on systemic factors, reimbursement, patient expectations, and a lack of time for in-depth patient education.

3) The utopia of interprofessional collaboration : while everyone agrees on its benefits, the reality often remains one of silos. Waiting lists, difficult communication between professionals, records that are not shared, the structural obstacles limit the efficacy of the collaborative model.

4) The burden of measurement : integrating PROMs is an advance, but it represents an extra administrative load for clinicians who are already overloaded. Without smooth technological integration and recognition, financial and in time, of the time spent, PROMs risk becoming a "box-ticking" exercise rather than a true improvement tool.

Physiotherapy for DLS must therefore navigate between scientific rigour and human flexibility, while campaigning for the systemic changes that support high-quality practice.