As massage therapists, we often run into conditions that may not be directly effected through our treatment and are helped through creating the most supportive environment in the body to facilitate healing.
Two conditions that fall into this category are sponylolysis and spondylolisthesis. Nicknamed the “Scottie Dog” fracture because of the resemblance to a Scottish Terrier, these conditions create a lot of controversy in their etiology and treatment because of poor correlations between clinical symptoms and radiographic evidence.
Spondylolysis stems from the Greek words spondylos, which means vertebra, and lysis, which means break. It is a defect or break in an area of the vertebra between the superior and inferior facets of the vertebral arch known as the pars interarticularis.
There are two theories that have been developed to explain the causes of spondylolysis. The congenital explanation proposes that there is a predisposed weakness in the pars interarticularis, a theory which is supported through the studies of family histories. The developmental theory is that a fracture in the pars occurs as a result of continued microtraumas which weaken the structure. These microtraumas can occur from a variety of sources including postural conditions, activities, and repetitive movement patterns.
There is a higher rate of occurrence in the adolescent population which is primarily believed to be caused by these microtraumas being placed through immature spines. Another demographic that has a higher than normal occurrence is the young athletic population. Up to 40 % of sports-related back pain can be attributed to pars damage and is common in sports which combine extension with rotation. The most common site of a fracture is at L5 but defects can occur at L4 and above. The common symptoms that are associated with spondylolysis include:
- Loss of mobility
- Paraspinal muscle spasm
- Flattening of the lumbar curve
- Changes in gait
The pain is usually very localized over the spine, gluteals and posterior thigh.
Spondylolisthesis is a very similar condition and is characterized by the forward slippage of one vertebra on another and the spine’s inability to resist the shear forces that are associated with this. It was first described in the late 1700′s by obstetricians who noted it caused a barrier to the passage of the infant through the birth canal. The reported incidence of occurrence is estimated to be between 2 and 6 percent with the most common level affected being L5-S. There is a higher rate of occurrence in the adolescent population, especially girls. This is thought to be due to the increased mobility of the adolescent spine and the fact that facets are more horizontal in orientation than adults. Despite being a different condition than spondylolysis, the two frequently occur together. Radiographic studies have reported that 50 to 81 percent of cases of spondylolisthesis also contain a fracture of the pars interarticularis.. This shows that one condition will typically lead to the other.
There are five classifications of spondylolisthesis that were created by the International Society for the Study of the Lumbar Spine (ISSLS). The first is dysplastic or congenital spondylolisthesis and affects the posterior facets of L5-S1 and will only occur at that level. Elongation of the pars interarticularis allows for significant slippage up to 100% if bilateral fractures occur. The second classification is known as isthmus spondylolisthesis. This occurs secondary to a defect in the pars and may be attributed to hormonal influences since the slippage can progress during adolescence along with postural and gravitational forces. The next classification is degenerative spondylolisthesis. This occurs as a result of the degeneration of the posterior facet joints and is more likely to occur at the L4-L5 level. Because of its etiology, it is not seen in the under 50 population and the degree of slippage does not exceed 30 degrees. The last two classifications, traumatic and pathological spondylolisthesis have other conditions that are associated with them. Traumatic spondylolisthesis occurs as a result of fractures through other parts of the vertebra such as the body and pedicles and are not discrete entities within the pars. Pathological spondylolisthesis also occur as a result of an overall process and do not result from isolated defects in the pars. A disease process will affect the entire segment and indirectly affect the pars and causing the slippage. Clinical presentation can vary depending on the type of deformity that is present. Some common symptoms are:
- Chronic midline ache at the lumbosacral junction that is exacerbated with extension
- Hamstring tightness
- Abnormal gait
- Cramping in the legs
Depending on the degree of slippage, neurologic symptoms may occur along the L5 nerve root and there is a “giving way” feeling when moving from flexion into extension. There is a high incidence of disc herniations associated with spondylolisthesis, up to 25%; therefore care should be taken to make sure all the possible causes of dysfunction are investigated.
How can we assess this in our clients? The test is actually quite simple and can guide us in our decision to treat them or refer out to a different health care practitioner.
The test is called the Stork (single-leg) Standing Test and here is how it is performed:
- Have the client stand on one leg.
- Stand behind the client to prevent him or her from falling
- Have the client extend the spine.
- Repeat on the other leg.
- A positive test is pain in the low back, which is associated with a fracture of the pars.
Note: If the fracture is only on one side, standing on the ipsilateral leg will cause more pain. Have the client perform true extension; combining movements will not give an accurate result.
So how do we treat this?
The primary structure involved with these two conditions cannot directly be treated with massage; however, massage therapy can support the normal healing process of the skeletal system by affecting the surrounding tissue directly. Muscle spasm, congestion in the tissues, and pain in the area are all treated effectively through massage. The focus of soft-tissue treatment is to relieve pressure on the site of the fracture caused by tight tissues, and assist with correcting posture, which will reduce the force causing the slippage of the vertebra. Use caution not to cause hyperextension of the spine, which can exacerbate the condition. Place a pillow or cushion across the front of the hips when the client is in the prone position or under the knees when in the supine position to add to the client’s comfort if necessary.
Always remember…When in Doubt – Refer Out!