Common lower back injuries and therapeutic strategies.
On July 1, 2004 I was returning to work following a quiet lunch. As I was driving through a residential neighbourhood on a one-way street, a car failed to stop at the next intersection's crossing stop sign and instead entered the intersection at high speed, slamming into my car on the driver's side door. I felt the impact lift my car momentarily and then realized that I was spinning counter-clockwise in the middle of oncoming traffic. Luckily, the other cars avoided colliding with me and I came to a standstill half a block further down the road and facing in the opposite direction. As I tried unsuccessfully to open my door, a stabbing pain registered across my lower back and around the left side of my ribcage. Thirty minutes later the Fire Department's Rescue Team was cutting the doors off of my vehicle and manoeuvring me into the ambulance. Later that day in the emergency room I was diagnosed with five fractured ribs, skull lacerations, and undetermined lumbar injuries. Following an MRI several weeks later, the painful truth was revealed that I had incurred bilateral tears to the spinal discs between L3 and L4 and between L4 and L5.
For the first time since I became a massage therapist in 1978, and a structural integration practitioner in 1979, I was unable to practise my craft for an extended period of time. My volunteer role as co-director of the international sports massage team of the 2004 Athens Summer Olympics that would begin in mid-August was also in jeopardy. I was experiencing severe pain and spasm throughout the lower and mid-back, and I had shooting pain from my left hip to foot with every step I took. I finally knew what many of my clients had reported to me for many years was true, as this multiple injury had not only robbed me of physical comfort, but also of psychological well-being, patience, and optimism.
The Lower Back
The framework of the lower back includes five spinal vertebrae, which house and protect the lumbar portion of the spinal column. The vertebral discs of the lower back are responsible for cushioning the vertebral column and minimizing the impact from the various movements of the axial and lower appendicular regions of the body. Strong, fibrous ligaments surround the discs and attach the vertebrae to each other. The muscles that are attached to the lumbar vertebrae provide flexion, extension, hyperextension, and rotation of this region of the body, as well as hip flexion for leg movement. These same muscles also support the majority of the body's weight while standing.
The 5th lumbar vertebra (L5) sits on the base of the sacrum, directly between the sacroiliac joints. Movement of the lumbar spine is therefore linked to movement of the pelvic girdle. (1) The whole of the lower back, its bones, ligaments, muscles, and tendons, are surrounded and protected by the thoracolumbar fascia, the thickest layer of dense fibrous connective tissue in the human body. (2) Diamond shaped and covering the full length and width of the lumbar and sacral regions, this fascia is often at the center of traumatic damage to the lower back. (3) A recent finding showed the nociceptive potential of the lumbar fascia: in patients with nonspecific lower back pain, fascial tissue may be a more important pain source than lower back muscles or other soft tissues. (4)
Many massage therapists work with clients who have acute or chronic lower back pain. The lifetime prevalence of lower back pain is reported to be as high as 84%, and the prevalence of chronic lower back pain is about 23%, with about 10% of the population being disabled by lower back pain. (5)
The common causes of lower back pain include lumbar strain or sprain, nerve irritation, and degenerative bone or disc syndromes. (6) While traumatic injury is often the culprit, work- and sports-related overuse could also play a decisive role. (7) A study published recently in Annals of the Rheumatic Diseases showed that, globally, lower back pain arising from ergonomic exposures at work was estimated to be responsible for a third of work-related disability. In Australia, back pain is the leading cause of work loss days with 25% of sufferers taking 10 or more days off per year, and costing Australia around $4.8 billion each year for health care. (8)
There are other causes as well, including obesity, (9) pregnancy (10), kidney or ovarian problems, and tumours (benign or malignant).11
Considered the most common form of lower back pain, lumbar strain is often caused by sudden overstretching of the ligaments, tendons, and muscles of the lower back. (6) Whether from improper use, work-related overuse, or trauma, lumbar strain results in microscopic tears in any or all of the soft tissues. The degree of tearing can result in minor acute conditions that heal in a matter of weeks, or chronic conditions that can affect the client for months or years. Massage therapy, hydrotherapy, and thermal therapy can be successfully used in many cases. (11,12)
The nerves of the lumbar spine can be irritated by traumatic impingement or by degenerative disease. The impingements are often at the spinal roots adjacent to the bodies of the vertebrae, but they can also occur along the nerve pathway or on the outer layer of the thoracolumbar aponeurosis. (13)
Lumbar disc disease, or radiculopathy, is caused by damage to the discs between the vertabrae. This 'wear and tear' syndrome most often affects people over 40 years of age. These syndromes may cause a compression of the lumbar discs, commonly called bulging' discs. The irritation often affects the denser ring surrounding the disc (annulus fibrosus). The most common form of bulging disc may not cause as much pain as other nerve irritations. (11)
Excessive bulging may cause a herniation of the nucleus of the disc. This 'slipped' or 'ruptured' disc can cause tears towards the soft, jellylike center of the disc (nucleus pulposus), forcing a fragment of the nucleus to rupture the outer layer of the disc. (11)
In either case there is a narrowing of the space between the vertabrae, resulting in local pain of the lower back, or pain that shoots further down the posterior or lateral side of the leg. The most common severe lumbar radiculopathy is called sciatica, as it has irritated portions or branches of the large sciatic nerve whose pathway extends from the lumbar and sacral areas to the lower leg and foot.
[FIGURE 1 OMITTED]
The narrowing of the central spinal canal is called spinal stenosis. (11) This occurs in the lumbar region more often than in the thoracic or cervical spine. The narrowing of the spinal foramen can be a part of the normal degenerative ageing process, but can also be accelerated by falls or arthritic conditions. Stenosis is often accompanied by a narrowing of the disc space, due to dehydration of the cartilaginous material. The symptoms of stenosis may often start as generalized pain in the lower back or legs, but may also cause weakening of the soft tissues. (14)
Chronic vs Acute
Many people experience lower back pain, with some national estimates stating that two out of three people will experience an acute episode during their lifetime. (6) It is the second most common reason for missed work (colds are first). The figure for chronic situations is dramatically different, with one in 50 people experiencing long-term disability from lumbar injuries. As stated earlier, lower back pain becomes chronic after four to six weeks of painful symptoms. Multiple episodes of acute lower back injury may lead to a more severe chronic condition. The difficulty in diagnosing the causes, and therefore the best treatment plan, is that many symptoms of different injuries look remarkably similar and only very expensive diagnostic strategies are likely to pinpoint the injured tissues with any level of specificity.
Because most massage therapists will initially see clients with acute lower back pain, it is important to have a comprehensive treatment plan organized for the safe treatment, exercise, and wellness initiatives that surround the most common acute injuries. Patients with radiating pain should be referred for assessment. Here are other treatment modalities that may be integrated with various forms of massage therapy when the patient's condition permits.
* Range of motion exercises keep the soft tissues more limber and less restricted.
* Strengthening exercises for the waistline musculature, commonly called the 'core' of the body.
* Stretching exercises with an accent on hyperextension, forward and lateral flexion, and spinal rotation.
* Hydrotherapy and thermal therapy to limit inflammation and to diminish pain (cryotherapy or contrast therapy).
* A nutritional plan that safely lowers caloric intake if obesity is involved.
These modalities need to be a part of a universal treatment plan that educates clients on biomechanical issues, postural improvements and other wellness initiatives.
Massage Therapy Treatment Strategies
Many disciplines of massage therapy can be utilized to eradicate the painful, and often lingering, symptoms of sub-acute and chronic lower back injuries. (12) A recent review demonstrated that massage therapies are effective to provide short-term improvement of sub-acute and chronic lower back pain symptoms. (12) When it is combined with therapeutic exercise and education, the treatment becomes more effective. (15)
Many clients have seen other health care professionals before visiting a massage therapist and have tried various forms of relief, including prescription pain medications, over-the-counter analgesics, steroid injections, and various physical (or physio-) therapy modalities. Massage therapy treatment strategies should include the following to improve the soft tissue dysfunction commonly found in lower back injuries:
* Treat the whole body--all soft tissue is interconnected through the multiple layers of fascia that surround and support the body.
* Spend sufficient time warming the tissues of the full length of the back, and include treatment for the abdomen, hips, and thighs.
* Balance the treatment of the lower back by working these tissues from all sides, including prone, supine, and side-lying.
* Check for postural distortions, including excessive lordosis, obvious rotation of the pelvis, and extra weight on one side of the body.
* Test range of motion of the lumbar spine in flexion, hyperextension, and spinal rotation.
* Bear in mind that massage therapy is most effective when delivered in a progressive series of sessions that gradually work deeper tissues that are less sensitive.
* Go slow, nurturing the parasympathetic reflexes of the autonomic nervous system.
* Incorporate gentle strengthening exercises for the back, abdominal, and legs, and also stretching exercises.
The Lower Back Routine
From the supine position with support under knees
Start with broad palm strokes to the full length of the quadriceps, moving from knee to hip. For deeper work apply strokes across the musculature with palms, finger pads, or soft fists.
Release tension on the abdomen by stretching the rectus abdominus to either side from its lateral borders. This can also be coordinated with movement of the legs to the opposite side in a rocking motion.
Reach across the abdominal region and pull forward on the lateral waistline. Keep your hands spaced between the iliac crest and lower ribs. Work both sides thoroughly.
Bring one leg superior into deeper hip flexion and move the leg in ever-increasing circles, testing the tightness of the hip rotators. Move each leg in clockwise and counter-clockwise directions.
From the side-lying position
Stretch the sacroiliac joint and lengthen the lumbar spine by pulling the ilium posteriorly from the ASIS while pushing the sacrum anteriorly. Hold for several seconds with each stretch.
With both hands apply palm pressure across the oblique region. Include pressure on the superior aspect of the iliac crest and further up the lower ribcage. Work the tissues in both horizontal directions at the same time.
Apply palm or soft-fist pressure on the lateral edge of the lumbar region, moving slowly across the tissues towards the spine. Try to capture as much of the lateral aspects of the thoracolumbar aponeurosis, iliocostalis lumborum, and quadratus lumborum, with each successive stroke moving deeper and slower.
Apply palm or soft fist strokes across the lateral thigh beginning at the greater trochanter and covering the full length of the iliotibial band. For deeper work use the forearm in slow, broad strokes.
Apply a cross-armed stretch from the mid-portion of the lateral ribcage to the iliac crest and hold for several seconds.
Stretch the same two regions in a spinal twist. When maximizing each stretch have the client exhale fully.
From the prone position
Apply broad palm strokes down the full length of the thoracic and lumbar erector spinae. Use moderate force initially and continue on either side with forearm and then elbow for deeper work.
Using the thumbs, trace either laminar groove from mid-thoracic region to the base of the sacrum.
Apply inferior pressure to the full width of the sacral base.
Apply palm, finger pad, or soft fist strokes across the lumbar region, moving laterally from the laminar groove to the oblique muscles.
Reverse the direction and apply gradually deeper strokes moving medially across the same region. Start with broader techniques and eventually use more specific techniques for deeper work.
Release tension throughout the hip rotators using compression strokes with soft fist or finger pads while moving the iliofemoral joint through moderate external and internal rotation.
Apply broad palm or soft fist strokes across the hamstrings, moving inferiorly from hip to knee.
Effective treatment for acute lower back pain can help return your client to a more active, pain free lifestyle. Any red flag conditions (see Table 1) or chronic conditions that do not respond as expected should be referred to a primary contact medical practitioner for verification that massage therapy can be safely included in a multidisciplinary treatment plan. Enjoy the challenge!
(1.) Esola MA, McClure PW, Fitzgerald GK, Siegler S. Analysis of lumbar spine and hip motion during forward bending in subjects with and without a history of low back pain. Spine. 1996;21(1):71-8.
(2.) Bogduk N, Macintosh JE. The applied anatomy of the thoracolumbar fascia. Spine. 1984;9(2):164-70.
(3.) Roy SH, De Luca CJ, Casavant DA. Lumbar muscle fatigue and chronic lower back pain. Spine. 1989;14(9):992-1001.
(4.) Schleip R, Mechsner F, Zorn A, Klingler W. The Body wide Fascial Network as a Sensory Organ for Haptic Perception. Journal of Motor Behavior. 2014;46(3):191-3.
(5.) Balague F, Mannion AF, Pellise F, Cedraschi C. Non-specific low back pain. The Lancet. 2012;379(9814):482-91.
(6.) Andersson GB. Epidemiological features of chronic low-back pain. The lancet. 1999;354(9178):581-5.
(7.) Pasanen K, Rossi M, Heinonen A, Parkkari J, Kannus P. Low back pain in young team sport players: a retrospective study. British Journal of Sports Medicine. 2014;48(7):651ff.
(8.) Driscoll T, Jacklyn G, Orchard J, Passmore E, Vos T, Freedman G, et at. The global burden of occupationally related low back pain: estimates from the Global Burden of Disease 2010 study. Annals of the rheumatic diseases. 2014:2013-204631.
(9.) Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. American Journal of Epidemiology. 2010;171(2):135-54.
(10.) Fast A, Shapiro D, Ducommur EJ, Friedmann LW, Bouklas T, Floman Y. Low-back pain in pregnancy. Spine. 1987;12(4):368-71.
(11.) Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760-5.
(12.) Kumar S, Beaton K, Hughes T. The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. International Journal of General Medicine. 2013:6:733.
(13.) Borenstein DG, Calin A. Fast Facts: Low Back Pain: Health Press; 2012.
(14.) Manchikanti L, Cash KA, McManus CD, Pampati V, Abdi S. Preliminary results of randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 4. Spinal stenosis. Pain Physician. 2008;11(6):833-48.
(15.) Brosseau L, Wells GA, Poitras S, Tugwell P, Casimiro L, Novikov M, et al. Ottawa Panel evidence-based clinical practice guidelines on therapeutic massage for low back pain. Journal of Bodywork and Movement Therapies. 2012;16(4):424-S5.
(16.) Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians. Australian Academic Press Pty Ltd; 2004.
George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has been a leader in the massage therapy field over his 30-year career. He helped bring sports massage to the 2000 and 2004 Summer Olympic Games, and is a past president of the Massage Therapy Foundation. He is the General Manager of the 1996 British Olympic Preparation Camp Sports Massage Team and a Co-Director of the 2004 Athens Health Services Sports Massage Team. He has supported the inclusion of massage therapy at the highest levels of international sports. George teaches throughout the world and has given keynote and motivational presentations to national and international organisations. He will travel to Australia in September presenting the Core Myofascial Therapy Certification program. See www.terrarosa.com.au
George P. Kousaleos | LMT, NCTMB
Table 1. "Red-flag" or alerting features of serious conditions associated with acute lower back pain that should prompt referral to medical practitioner. (From Table 5.1 of Evidence-based Management of Acute Musculoskeletal Pain) (16) Feature or risk factor condition Condition Symptoms and signs of infection (e.g. fever) Risk factors for infection (e.g. underlying disease Infection process, immunosuppression, penetrating wound) History of trauma Minor trauma (if greater than 50 years, history Fracture of osteoporosis and taking corticosteroids) Past history of malignancy Age greater than 50 years Failure to improve with treatment Unexplained weight loss Pain at multiple sites Pain at rest Absence of aggravating features Aortic aneurysm