Massage therapy has consistently demonstrated benefit for numerous muscular back pain conditions. Sometimes, though, there can be more serious underlying structural issues causing pain and limited movement. In this issue, we examine two common conditions, spondylolysis and spondylolisthesis, that massage therapists should be familiar with to provide appropriate care.
These conditions admittedly have names that are tongue twisters. Let’s look how the names actually help us better understand the conditions. Spondyl- refers to the spine and -lysis refers to breaking down or disintegrating, while -listhesis means sliding down a slope, which is essentially what is happening to the lumbar vertebrae in this condition. Now, let’s explore the spinal structure and function that help illustrate these two conditions.
Anatomical and Biomechanical Considerations
Both spondylolysis and spondylolisthesis are conditions involving structural breakdown of the vertebrae, most commonly in the lumbar spine. Both conditions’ severity lies on a continuum. Spondylolysis often develops into spondylolisthesis if it is not properly treated. In both cases, the primary problem involves the posterior arch of the vertebrae.
The bodies of the lumbar vertebrae bear most of the responsibility for distributing the lumbar spine’s compressive load (Image 1). Under normal conditions, the line of compressive force travels mostly through the lumbar vertebrae and intervertebral disk. However, when the spine is in greater extension (such as an exaggerated lordosis), the line of force for compressive load on the spine moves posteriorly and the posterior vertebral arch structures carry greater weight.
Activities like gymnastics that involve extensive spinal extension often predispose participants to damaging compressive stress on the posterior arch structures (Image 2). Other sporting activities that frequently produce similar compressive loads on the posterior arch structures include football, wrestling, and weight lifting. Various occupational activities may also cause similar biomechanical stresses on the posterior vertebral arch.
The region between the superior and inferior articular facets of the vertebrae is called the pars interarticularis (or pars for short). The pars is an area of structural weakness when the posterior vertebral arch takes on a greater compressive load. Repeated compressive loading of the posterior arch can cause small stress fractures to develop in the region of the pars. These small fractures are spondylolysis. Structural weakness in the pars is estimated to occur in about 6 percent of the population.1
If those stress fractures progress, a larger fracture develops and the body of the vertebra may separate from the posterior vertebral arch structures. When it separates, there is a tendency for the vertebra to move in an anterior direction because of the lumbar lordosis. The sliding of the vertebral body is spondylolisthesis. Anterior sliding of the vertebra is most common and is often called anterolisthesis. Vertebrae may slide in other directions, but this is rare. The vast majority of spondylolisthesis cases occur with the L5 vertebra sliding anteriorly on the sacrum. Biomechanics plays a key role in the forward slippage of the vertebra, but it is not the only factor. The different classification systems described on page 91 indicate other factors, such as genetics, that can also play a major role in these conditions’ development.
Categorizing the Types
Spondylolisthesis is divided into five categories.2 These categories designate the primary cause and pathological progress of the condition.
Type 1 (Dysplastic)
This variation occurs as a result of genetic abnormalities in the facet joints of the spine. Excessive loading of the spine may not be necessary to cause problems because this is a genetic structural defect in the architecture of the spine.
Type 2 (Isthmic)
Type 2 or isthmic spondylolisthesis results from advancing spondylolysis. Stress fractures in the pars lead to the eventual vertebral slippage. There may be some overlap between genetic factors in Type 1 and Type 2. For example, Type 2 occurs with increased frequency in northern Native American and Eskimo populations.3
Type 3 (Degenerative)
In some cases, degeneration of the intervertebral disks, usually accompanied by exaggerated lumbar lordosis, can cause forward slippage of the vertebrae. This variation is more common in women. One possible cause of the increased incidence with females is hormone-induced ligamentous laxity that does not provide adequate stabilization and support for the vertebrae.
Type 4 (Traumatic)
This type is not common but can occur as a result of sudden violent injury to the spine. In this instance, there is usually a very high force load that causes an acute fracture to the pars or neural arch of the vertebrae and there is subsequent forward slippage.
Type 5 (Pathological)
This variation results from bone diseases, tumors, or infections that lead to a breakdown in spinal structures and eventual vertebral slippage.
Assessment and Evaluation
Spondylolysis and spondylolisthesis can both have very similar symptoms. The most common complaints include localized low-back pain in the lumbosacral region. The pain can extend into the buttock or posterior thigh region. Pain usually increases during activities involving spinal extension, whether performed actively or passively. Pain is likely to decrease in activities involving spinal flexion, such as bending forward. This position takes the posterior load off the spinal structures.
During palpation, there may be localized tenderness of muscles and other soft tissues in the region. Soft-tissue tenderness is not likely related to damage of the soft tissues themselves. This tenderness is more likely a result of increased sensitivity of neural structures in the area.
In more severe cases, there may be neurological symptoms that mimic lumbar nerve root pathology. If the fracture site in the pars interarticularis is in a certain position, the edge of the bone may snag the nerve root as it slides forward (Image 3). Pulling the nerve root along with the moving vertebra is what produces the neurological symptoms.
Stress fractures in spondylolysis may not be symptomatic, so a client could already have some degree of spinal degeneration without even knowing it. Imaging studies such as X-ray may show indication of spinal fracture or movement of vertebral position. However, some early stage stress fractures in the pars do not show up on X-ray, so this evaluation strategy is not definitive. In these cases, the condition may evolve into full-blown listhesis (forward slippage) before any significant symptoms are recognized.
During physical examination, one of the more common findings is pain reproduction with the one-leg extension test. In this procedure, the client attempts to stand on one leg and bend slightly backward (Image 4). The practitioner can place their hands lightly on the client’s torso to make them feel more comfortable if they have a sense of feeling unstable standing on one leg.
Another interesting clinical characteristic that often accompanies spondylolysis and spondylolisthesis is hamstring tightness. The predominant theory is that the hamstrings become hypertonic to pull on the pelvis and keep it from tilting more anteriorly, which would exaggerate the forward slippage of the vertebrae. Essentially, these muscles are acting as protective guy wires that are trying to mitigate excessive movement of the vertebrae.
Massage therapists generally view hypertonic muscles as something that should be corrected with massage. However, in this case, the muscular hypertonicity is serving a beneficial function of maintaining mechanical stability in the lumbar region and thereby helping to reduce pain. So, this is a situation where reducing muscle tightness may not be the best goal.
Treatment Considerations
A crucial factor at the beginning of any treatment regimen is to find ways to reduce the offending activities and dysfunctional biomechanical load on the spine. In addition, the primary approach for addressing both spondylolysis and spondylolisthesis in traditional orthopedics is through conservative measures, such as graded movement and exercise. Exercise and gentle movements can usually resolve many pars defects if they are not very advanced and if there is not significant fracture and listhesis.
In more advanced cases of spondylolisthesis, the vertebrae may have moved too far forward to respond effectively to restricted movement and exercise. This may also be the case if there is a serious structural challenge, such as that existing in many congenital Type 1 cases. In these more advanced cases, surgery may be necessary. The surgery usually attempts to fixate the spinal structures so the forces causing further forward slippage of the vertebrae are countered.
Our primary concern is the role of massage in treatment of these conditions. There is no indication that massage or other soft-tissue treatments can halt development of stress fractures or reverse the forward slippage of the vertebrae. However, there does appear to be a beneficial role for soft-tissue treatment.
Our goal is not to fix or correct spinal positions, but instead to help support proper biomechanics and reduce neurological irritation in the region. A wide variety of techniques and modalities can help accomplish that task. In general, stick with techniques that don’t include much pressure in the lumbar region but still provide a good sense of soothing relaxation.
Massage will not reverse the forward slippage of the vertebrae, but it can greatly help in pain management and restoration of biomechanical balance in the area. Because increased pressure in the lumbar region can be painful, treatment techniques, such as lighter myofascial applications, are often helpful. The primary physiological goal of these methods is to simply settle down the nervous system so there isn’t a continual aggravation of pain, which often leads to more muscle tightness, restricted movement, and greater pain.
There really isn’t any one ideal technique for accomplishing these goals. The primary goal should be to find the position that brings the greatest degree of pain relief for the client and do your work in that position. Often, the side-lying position is most comfortable. Our work should focus mainly on neurological responses of reducing pain and encouraging a greater sense of proprioceptive awareness in the region. This can greatly help as clients do exercise or movement strategies to reduce any vertebral slippage.
There are important precautions for massage in these conditions. Many clients with spondylolysis and spondylolisthesis will have increased pain when lying prone on the treatment table. This position can exaggerate the effects of lumbar extension and forward vertebral slippage. It is also common to see increased pain when pressure is applied in the lumbar region, as this can push the affected vertebra farther forward.
One of the most helpful strategies for increasing client comfort and reducing painful pressure while prone is to put the client in a position called “flexion protocol.” In this position, there is a pillow, bolster, or cushion under the abdomen that keeps the spine in a slightly flexed position and therefore decreases discomfort during treatment (Image 5).
As noted earlier, hamstring tightness often accompanies this condition. Because it is serving a protective function and helping to reduce instability, it may not be wise to focus too much on reducing tightness in the hamstring muscles. The hamstrings may be playing this same role in other biomechanical situations and it is worth considering that we may be putting too much emphasis on always trying to decrease tightness and increase flexibility in the hamstrings. They may actually be “tight” for a reason.
Because back pain is so common, massage therapists are likely to have clients with a multitude of conditions, ranging from simple muscle tightness to more complicated biomechanical conditions such as spondylolisthesis. This condition can become a serious problem if not recognized and addressed early on. A greater understanding of the degenerative process in spondylolysis and spondylolisthesis can help the massage practitioner find the appropriate care for their clients much quicker.
Clients may come to see you who have this condition after being referred from other health professionals. But they may also seek you out without seeing a doctor first. If you are suspicious that spondylolisthesis may be occurring, refer the client to a physician. The better you understand the pathological progression of spinal dysfunction in this condition, the more helpful to your clients you can be.
Notes
1. E. Syrmou et al., “Spondylolysis: A Review and Reappraisal,” Hippokratia 14, no. 1 (2010): 17–21.
2. T. Koreckij and J. S. Fischgrund, “Degenerative Spondylolisthesis,” Journal of Spinal Disorders and Techniques 28, no. 7 (2015): 260–64. https://doi.org/10.1097/BSD.0000000000000298.
3. S. S. Tower and W. B. Pratt, “Spondylolysis and Associated Spondylolisthesis in Eskimo and Athabascan Populations,” Clinical Orthopaedics and Related Research 1990, no. 250 (January 1990): 171–5.