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40 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 6 Several different types of spondylolisthesis have been identified: • Congenital spondylolisthesis occurs when a person's lumbar facet joints are not vertical enough to prevent slippage. • Isthmic spondylolisthesis happens when the pars interarticularis is weak and activity causes multiple microfractures. This type is usually seen in athletic adolescents. • Degenerative spondylolisthesis is the most common type in adults. In this case, the pars may be fine, but thinning discs and arthritis at the facets allow the vertebrae to shift anteriorly, stretching the joint capsules. • Traumatic or pathologic spondylolisthesis occurs when an accident or a situation like cancer or infection damages the affected vertebrae at the pars interarticularis. Spondylolisthesis occurs on a continuum of severity, so mild cases may not present major symptoms, but more severe cases may create serious complications. Most patients with mild to moderate slippage experience central low-back pain, tight hamstrings, muscle spasms, and possible pain radiating into the leg. More severe cases can compress the distal end of the spinal canal, where the extensions from the spinal cord, resembling a horse's tail, may be injured. This is called cauda equine syndrome, and it can cause long-term problems with bladder and bowel control as well as many other problems. TYPICAL TREATMENT OPTIONS When we consider the fact that most adults will experience back pain at some point, and many will be temporarily or permanently limited by this problem, it is surprising that we have so few possible interventions, and many of those interventions are, overall, not well supported by research. Noninvasive options for managing back pain include medication, physical therapy, and other manual therapies, including chiropractic and massage. Medication, ranging from NSAIDs to opioids, tends to be effective in reducing the severity of pain, but the risks and possible complications make their long-term use problematic. Manual therapies vary in their effectiveness, but large-scale comparative effectiveness studies suggest low levels of evidence for most interventions, especially when compared to placebo or no intervention. Carefully gauged exercise (at a level that a client can and will do reliably) is an outlier here: pain-free movement is consistently helpful for back pain—if a person can get to the point of being able to engage in this kind of activity. Surgery is reserved for cases that do not respond to other interventions. It can range from implanting pain management devices to procedures designed to restore adequate space for the spine or spinal nerves to full spinal fusions. Frustratingly, the research on spinal surgery effectiveness for back pain has the same limitations as research for other interventions: because back pain varies so greatly from one case to another, it is difficult to predict whether surgery is likely to be successful for an individual just from looking at the data. Overall, the effectiveness of some spinal surgeries does not appear to be dependable; spinal fusions in particular do not show long-term outcomes substantially better than other interventions. MASSAGE THERAPY FOR BACK PAIN? As we have seen, back pain is one of those conditions that defies expectations. It is notoriously difficult to study, and many studies conclude that most treatments are not substantially better than doing Since we see that establishing and maintaining pain-free movement is a high priority for almost all people with back pain, it makes sense to think about massage therapy as an adjunct to this goal. Some Relief If you have pain—let's say a headache—and you take an aspirin, the headache is likely to subside. But the chances are good that someday you'll have another headache. In this way, taking an aspirin is not better than doing nothing—except it allows you to function when you would otherwise be limited. Arguably, that is a substantial benefit. Massage is similar: a welcomed massage seems to offer at least temporary relief from back pain. It has not been shown to prevent future back pain, but that doesn't mean it isn't useful.