Many people book in for remedial and therapeutic massage because of lower back pain. However, the causes of lower back pain can vary considerably and they are poorly understood. Massage therapy can be appropriate for a significant proportion of those who present with lower back pain due to muscular tightness and/or trigger points. However, massage therapists are not permitted to diagnose conditions and there are some patients for whom massage is contraindicated or for whom massage should only be performed under the direction of a suitable physician.
One such condition for which massage therapists should be extremely cautious is spondylolisthesis. If you think or suspect that a client may be presenting with spondylolisthesis then you should consider that the massage is contraindicated.
Spondylolisthesis arises from a stress fracture in the vertebrae, most typically in the L5-S1 region and occurs when one vertebra actually slides forward relative to another because of the fracture.
Activities that cause repeated flexion and extension of the spine are considered to be risk factors for the development of spondylolisthesis. Gymnasts, butterfly swimmers, weightlifters, for example, are particularly susceptible. In addition excessive lumbar lordosis is often considered to be a contributing factor as the greater curvature of the spine can place increase loads and the tilt angles at various parts of the spine.
Clients who present with spondylolisthesis will likely complain of dull pain in the lower lumbar or upper sacral areas and this pain will normally occur after the person has been performing the repeated flexion/extension activities. If a therapist tries to palpate the area then pain levels can increase if there is anterior forces being applied to the spine that can further contribute to forward slipping. X-rays or MRI scans may be required to confirm the presence of an anterior slipped vertebra.
Treatment for spondylolisthesis will normally begin with rest and refraining from carrying out any activities that flex/extend the spine. Some physical therapists may suggest bracing of the back to prevent further movement. It is likely that some strengthening and flexibility training may be incorporated into a rehab programme and it is at this point that a massage therapist is most likely to become involved. Under direction, the therapist may target muscles that have become hypertonic in response to compensating for pain.
However, a word of caution is that hamstrings will often tighten in those who are suffering from the condition. The reason for this is that they are effectively trying to rotate the pelvis posteriorly and minimise further vertebral slipping. Releasing tight hamstrings in spondylolisthesis patients would generally not be recommended, particularly in the early stages of rehabilitation.