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CLINICAL E XPLORATIONS 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. Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His texts and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com. Yo u r M & B i s w o r t h 2 C E s ! G o t o w w w. a b m p . c o m / c e t o l e a r n m o r e . 93 5 Client in the flexion protocol. Image courtesy Body Support Systems.