Massage & Bodywork

JANUARY | FEBRUARY 2019

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92 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 9 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 3 4 Nerve root vulnerable to being stressed when a vertebra slips. Image is from 3D4Medical's Complete Anatomy application. Nerve roots pulled or compressed when vertebra slides forward. One leg extension test.

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