I gave a presentation for a class the other night on back pain and how massage can help with it and decided to do an article with some of the concepts I covered in my presentation as well as some added info.
Low back pain is extremely prevalent today and its not unlikely that you have experienced or do experience issues; or know someone who has or does experience issues. Some interesting statistics on low back issues follow. These are taken from the amazing book Low Back Disorders by Stuart McGill, which is basically a must read for anyone who deals with client's backs in any way, shape or form.
The American Medical Association guidelines for quantifying degree of back disability are based largely on loss of spine range of motion although excess ROM has actually been shown to exacerbate and/or create problems in many people. This is something that appears to have been chosen for legal convenience rather than positive impact on low back troubles. (McGill, Low Back Disorders, P. 3)
Now, loss of spine ROM could be an issue for some individuals but could never apply for everybody across the board. It really is unfortunate that something like this is the case.
It is often said that 85% of back troubles are of unknown etiology. The limiting factor here is specialists and clinicians who only look in their area of expertise. The "one size fits all approach" simply does not work. Back troubles do not just magically come about. There is a reason that causes them. The reason that so many cases are of "unknown etiology" is that many specialists either don't know what to look for outside of their area of expertise or don't refer out where or when needed. For example, if an orthopedic doctor doesn't see something going on with someones passive tissues (discs, ligaments, vertebrae, etc.) they might simply assume that the pain is just there. In reality, it could come from a repetitive movement fault and/or soft tissue problem. This is not always the case but does occur across the health field in various professions.
There are many inadequacies in care and prevention of low back disorders. A few major ones follow.
Studies on "backache"
I'm going to go ahead and let this one speak for itself. A broad, garbage term equals broad, garbage studies.
Relationship of intensity, loading duration, and rest periods- "Years of specific sub failure activity can cause progressive development of conditions. This could possibly be avoided with evidence-based prevention strategies that include optimal loading, rest periods and controlling the duration of exposure” (Low Back Disorders, P. 8) An example of this is the mechanism for herniated discs in the lumbar spine. McGill has found that a large number of repeated flexions of the lumbar spine gradually leads to a herniated disc. The nucleus is pushed out of the annulus more and more until finally one day someone bends over the wrong way to pick up a pencil and it fully herniates. Correcting movement and doing the proper prevention exercises can prevent things like this from happening. It seems that many professionals miss this point and simply treat symptoms instead of using clinically proven prevention strategies. I have personally witnessed professionals in various fields giving clients exercises that have been clinically proven to cause spine issues (I know of someone who prescribed ill advised exercises from a friggin magazine!). This is a problem.
There are also plenty of bad prehab/rehab recommendations that are given out (as I just mentioned).
Strengthen torso muscles to protect the back- Although this can definitely help in certain situations, much research shows that muscular endurance is more important in the torso muscles when it comes to preventing and rehabbing back issues.
Sit up prescription- Each situp produces low back compression levels close to the National Institute of Safety and Health action limit!! and doing so repeatedly has been shown to cause issues. This occurs because of the attachment of the psoas muscle to the lumbar vertebrae. When you do a situp, the psoas contracts to flex the hip, which puts lots of compression on the lumbar spine (low back). Add in the fact that most people who do situps perform them incorrectly with a rounded low back and the problems get worse. If someone has back problems, situps are probably not their best bet.
Bend the knees, not the back when lifting things- As I've discussed many times, optimal movement patterns are absolutely essential to spare the back when lifting. Broadly saying to "bend the knees to lift things" is not a good recommendation by any means. It ultimately comes down to moving correctly through the hips while staying stable in the low back. Bending the knees can put excess stress on the knees and still allow the back to move into less than desirable positions. Furthermore, the optimal position and lifting pattern that is needed will vary depending on the situation at hand. What is the size of the object? What are the biomechanical leverages of the person doing the lifting? It will always depend.
Tight hamstrings lead to back troubles
While they can, this is not the case for everyone. As I've mentioned in previous articles, if someone's hamstrings actually are stiff (and are actually having a negative impact), then yes they may potentially need to be lengthened. In many cases, stiff hamstrings is a misdiagnosis. If any hip flexor muscles are stiff or short, the pelvis will be pulled into anterior tilt (see previous writeups to see more detail on anterior tilt). When the pelvis is pulled into this position, the hamstrings are put on stretch which will cause them to seem stiff; however, they are already on stretch. It is the hip flexors that need lengthening (could also be that something such as the obliques need strengthening, see post on relative flexibility). Once this is done and the pelvis is back to neutral, the hamstrings will be fine.
I have a client who went to physical therapy for around 3 years and never got rid of his back pain. He told me that they continued to stretch his hamstrings. I looked at him for five minutes and discovered that his hip flexors (particularly rectus and psoas in his case) were extremely stiff; not to mention that he had little to no movement coordination. By continually stretching his hamstrings, his pelvis was pulled farther and farther into anterior tilt, which made his back worse and worse. We lengthened his hip flexors, turned on his glutes, taught him how to move properly and within a couple of weeks his pain was gone. He is now in great shape and pain free. Everybody is an individual with their own individual needs. Simply doing something general like stretching the hamstrings for the heck of it is just unacceptable.
Single exercise or back stability program is good for all cases
This is a big mistake that many people make and pretty much ties in with the last point. Determine what needs to be strengthened, lengthened, stabilized, mobilized, etc. Specific training is the only way to make backs optimal.
(The bold points are from Low Back Disorders; my own explanations following the headings)
Through my own experience working with people and learning from the some of the best in the industry, some of the major causes and contributors to back issues follow. I have touched on much of this in other articles so I'll keep it brief.
Excess Movement in the Lumbar Spine
The lumbar spine should generally be stable and many people move way too much through it. Promoting motion here with bad stretches and exercises is not a good thing (certain yoga positions, cough:)
Poor Movement Patterns
We basically live in a society that has developed movement stupidity. Most people you come across have absolutely no clue how to move properly. You need to move and use the right muscles and joints at the right time. Training does no good if you are practicing bad patterns and habits.
Stiff Hips and Thoracic Spine
Ideally, there will be mobility in these areas and stability in the lumbar spine. Most people have the opposite. If you can't move in the hips and tspine, then more movement and stress will go to the lumbar spine. Another problem created.
Weak Gluteal Muscles and Stiff Hip Flexors (Lower crossed syndrome)
With overly stiff or short hip flexors, there is more stress on the back. This also will often shut off the glute muscles. No glute muscles equals less support for the low back which equals more back pain. YAY!!
Weak and Improperly Trained Trunk Muscles
Having no support from the wonderful muscles that form a corset around the trunk and are supposed to protect the low back is not a good trait to carry. The internal and external obliques, rectus abdominis (actually usually overdeveloped and dominant in many people), the quadratus lumborum and the transverse abdominis (very deep muscle that you can't see or touch) all need to be endurable and firing. They also need to be trained to stabilize; not round the back and move in bad ways like many people do.
Poor Endurance in the Low Back Extensors
The low back extensors need to have good endurance in order to continuously support the passive tissues in the low back. When they fatigue, things that we don't want to take up stress end up taking up stress and bad things happen.
So taking care of these things is all wonderful and great but what if there are tissue restrictions that prevent someone from moving optimally or turning on muscles that need to be turned on? This is where massage therapy and specialized soft tissue work is extremely effective and can play a huge role in developing an optimal back program.
I can try to teach you how to squat and pull correctly with quality hip movement and a stable trunk all day long but if your psoas is so stiff that you simply can't get lower than an inch into your squat then there is a problem. If I work on your psoas and get it to relax, getting you to move properly becomes a whole lot easier and more effective.
Following are some different things that massage can address in order to help with back issues. There are obviously tons of possibilities but here are a few common ones.
Stiff or Short Hip Flexors- If needed, treating psoas, rectus femoris, and/or tfl (whichever ones are overly stiff or short) can take tons of stress off of the low back and can free up the hips so that movement improves. This also can make it much more possible to activate and strengthen inhibited gluteal muscles. In some cases, glutes might need work. Always assess!
Getting rid of adhesions and bunched up low back tissue- As a result of cumulative trauma and stress, the low back tissues are often tensed up and fibrotic. Massage can provide great relief here by freeing up the tissue, clearing out toxicity and built up metabolites and bringing new oxygen and nutrients into the tissue by way of increased blood flow.
Stiff or short pecs/anterior shoulder muscles that are leading to hyperkyphosis- Treating these muscles can allow better thoracic mobility which can lead to a more stable low back and improve overall posture.
Neurological effects- Releasing adhesions and trigger points can allow shut down muscles to retain their firing capacity, fix relative imbalances and improve overall patterns of movement.
With a combination of the proper movement and strength training and soft tissue work, low back issues can be dealt with very effectively. While I have a lot to learn and a long way to go with massage therapy, I am very excited to be able to combine my own manual therapy with the strength and conditioning modalities that I already use in order to help people feel better, move better and perform better.
In conclusion, if you are dealing with back pain and have been tossed around and told that there isn't a "known cause," don't give up because it is very possible that your true underlying issues have just not been found. While there can sometimes be a possibility of an underlying issue such as arthritis, spondylosis, etc., dealing with components that I discussed in this article can go a very long way in both preventing and clearing up back issues. Proper training and tissue work seems to finally be getting closer to the frontline where it should be. Hopefully more and more people can begin to see beyond "disc disease" and other copout diagnoses and get better and better.
Low back pain is extremely prevalent today and its not unlikely that you have experienced or do experience issues; or know someone who has or does experience issues. Some interesting statistics on low back issues follow. These are taken from the amazing book Low Back Disorders by Stuart McGill, which is basically a must read for anyone who deals with client's backs in any way, shape or form.
The American Medical Association guidelines for quantifying degree of back disability are based largely on loss of spine range of motion although excess ROM has actually been shown to exacerbate and/or create problems in many people. This is something that appears to have been chosen for legal convenience rather than positive impact on low back troubles. (McGill, Low Back Disorders, P. 3)
Now, loss of spine ROM could be an issue for some individuals but could never apply for everybody across the board. It really is unfortunate that something like this is the case.
It is often said that 85% of back troubles are of unknown etiology. The limiting factor here is specialists and clinicians who only look in their area of expertise. The "one size fits all approach" simply does not work. Back troubles do not just magically come about. There is a reason that causes them. The reason that so many cases are of "unknown etiology" is that many specialists either don't know what to look for outside of their area of expertise or don't refer out where or when needed. For example, if an orthopedic doctor doesn't see something going on with someones passive tissues (discs, ligaments, vertebrae, etc.) they might simply assume that the pain is just there. In reality, it could come from a repetitive movement fault and/or soft tissue problem. This is not always the case but does occur across the health field in various professions.
There are many inadequacies in care and prevention of low back disorders. A few major ones follow.
Studies on "backache"
I'm going to go ahead and let this one speak for itself. A broad, garbage term equals broad, garbage studies.
Relationship of intensity, loading duration, and rest periods- "Years of specific sub failure activity can cause progressive development of conditions. This could possibly be avoided with evidence-based prevention strategies that include optimal loading, rest periods and controlling the duration of exposure” (Low Back Disorders, P. 8) An example of this is the mechanism for herniated discs in the lumbar spine. McGill has found that a large number of repeated flexions of the lumbar spine gradually leads to a herniated disc. The nucleus is pushed out of the annulus more and more until finally one day someone bends over the wrong way to pick up a pencil and it fully herniates. Correcting movement and doing the proper prevention exercises can prevent things like this from happening. It seems that many professionals miss this point and simply treat symptoms instead of using clinically proven prevention strategies. I have personally witnessed professionals in various fields giving clients exercises that have been clinically proven to cause spine issues (I know of someone who prescribed ill advised exercises from a friggin magazine!). This is a problem.
There are also plenty of bad prehab/rehab recommendations that are given out (as I just mentioned).
Strengthen torso muscles to protect the back- Although this can definitely help in certain situations, much research shows that muscular endurance is more important in the torso muscles when it comes to preventing and rehabbing back issues.
Sit up prescription- Each situp produces low back compression levels close to the National Institute of Safety and Health action limit!! and doing so repeatedly has been shown to cause issues. This occurs because of the attachment of the psoas muscle to the lumbar vertebrae. When you do a situp, the psoas contracts to flex the hip, which puts lots of compression on the lumbar spine (low back). Add in the fact that most people who do situps perform them incorrectly with a rounded low back and the problems get worse. If someone has back problems, situps are probably not their best bet.
Bend the knees, not the back when lifting things- As I've discussed many times, optimal movement patterns are absolutely essential to spare the back when lifting. Broadly saying to "bend the knees to lift things" is not a good recommendation by any means. It ultimately comes down to moving correctly through the hips while staying stable in the low back. Bending the knees can put excess stress on the knees and still allow the back to move into less than desirable positions. Furthermore, the optimal position and lifting pattern that is needed will vary depending on the situation at hand. What is the size of the object? What are the biomechanical leverages of the person doing the lifting? It will always depend.
Tight hamstrings lead to back troubles
While they can, this is not the case for everyone. As I've mentioned in previous articles, if someone's hamstrings actually are stiff (and are actually having a negative impact), then yes they may potentially need to be lengthened. In many cases, stiff hamstrings is a misdiagnosis. If any hip flexor muscles are stiff or short, the pelvis will be pulled into anterior tilt (see previous writeups to see more detail on anterior tilt). When the pelvis is pulled into this position, the hamstrings are put on stretch which will cause them to seem stiff; however, they are already on stretch. It is the hip flexors that need lengthening (could also be that something such as the obliques need strengthening, see post on relative flexibility). Once this is done and the pelvis is back to neutral, the hamstrings will be fine.
I have a client who went to physical therapy for around 3 years and never got rid of his back pain. He told me that they continued to stretch his hamstrings. I looked at him for five minutes and discovered that his hip flexors (particularly rectus and psoas in his case) were extremely stiff; not to mention that he had little to no movement coordination. By continually stretching his hamstrings, his pelvis was pulled farther and farther into anterior tilt, which made his back worse and worse. We lengthened his hip flexors, turned on his glutes, taught him how to move properly and within a couple of weeks his pain was gone. He is now in great shape and pain free. Everybody is an individual with their own individual needs. Simply doing something general like stretching the hamstrings for the heck of it is just unacceptable.
Single exercise or back stability program is good for all cases
This is a big mistake that many people make and pretty much ties in with the last point. Determine what needs to be strengthened, lengthened, stabilized, mobilized, etc. Specific training is the only way to make backs optimal.
(The bold points are from Low Back Disorders; my own explanations following the headings)
Through my own experience working with people and learning from the some of the best in the industry, some of the major causes and contributors to back issues follow. I have touched on much of this in other articles so I'll keep it brief.
Excess Movement in the Lumbar Spine
The lumbar spine should generally be stable and many people move way too much through it. Promoting motion here with bad stretches and exercises is not a good thing (certain yoga positions, cough:)
Poor Movement Patterns
We basically live in a society that has developed movement stupidity. Most people you come across have absolutely no clue how to move properly. You need to move and use the right muscles and joints at the right time. Training does no good if you are practicing bad patterns and habits.
Stiff Hips and Thoracic Spine
Ideally, there will be mobility in these areas and stability in the lumbar spine. Most people have the opposite. If you can't move in the hips and tspine, then more movement and stress will go to the lumbar spine. Another problem created.
Weak Gluteal Muscles and Stiff Hip Flexors (Lower crossed syndrome)
With overly stiff or short hip flexors, there is more stress on the back. This also will often shut off the glute muscles. No glute muscles equals less support for the low back which equals more back pain. YAY!!
Weak and Improperly Trained Trunk Muscles
Having no support from the wonderful muscles that form a corset around the trunk and are supposed to protect the low back is not a good trait to carry. The internal and external obliques, rectus abdominis (actually usually overdeveloped and dominant in many people), the quadratus lumborum and the transverse abdominis (very deep muscle that you can't see or touch) all need to be endurable and firing. They also need to be trained to stabilize; not round the back and move in bad ways like many people do.
Poor Endurance in the Low Back Extensors
The low back extensors need to have good endurance in order to continuously support the passive tissues in the low back. When they fatigue, things that we don't want to take up stress end up taking up stress and bad things happen.
So taking care of these things is all wonderful and great but what if there are tissue restrictions that prevent someone from moving optimally or turning on muscles that need to be turned on? This is where massage therapy and specialized soft tissue work is extremely effective and can play a huge role in developing an optimal back program.
I can try to teach you how to squat and pull correctly with quality hip movement and a stable trunk all day long but if your psoas is so stiff that you simply can't get lower than an inch into your squat then there is a problem. If I work on your psoas and get it to relax, getting you to move properly becomes a whole lot easier and more effective.
Following are some different things that massage can address in order to help with back issues. There are obviously tons of possibilities but here are a few common ones.
Stiff or Short Hip Flexors- If needed, treating psoas, rectus femoris, and/or tfl (whichever ones are overly stiff or short) can take tons of stress off of the low back and can free up the hips so that movement improves. This also can make it much more possible to activate and strengthen inhibited gluteal muscles. In some cases, glutes might need work. Always assess!
Getting rid of adhesions and bunched up low back tissue- As a result of cumulative trauma and stress, the low back tissues are often tensed up and fibrotic. Massage can provide great relief here by freeing up the tissue, clearing out toxicity and built up metabolites and bringing new oxygen and nutrients into the tissue by way of increased blood flow.
Stiff or short pecs/anterior shoulder muscles that are leading to hyperkyphosis- Treating these muscles can allow better thoracic mobility which can lead to a more stable low back and improve overall posture.
Neurological effects- Releasing adhesions and trigger points can allow shut down muscles to retain their firing capacity, fix relative imbalances and improve overall patterns of movement.
With a combination of the proper movement and strength training and soft tissue work, low back issues can be dealt with very effectively. While I have a lot to learn and a long way to go with massage therapy, I am very excited to be able to combine my own manual therapy with the strength and conditioning modalities that I already use in order to help people feel better, move better and perform better.
In conclusion, if you are dealing with back pain and have been tossed around and told that there isn't a "known cause," don't give up because it is very possible that your true underlying issues have just not been found. While there can sometimes be a possibility of an underlying issue such as arthritis, spondylosis, etc., dealing with components that I discussed in this article can go a very long way in both preventing and clearing up back issues. Proper training and tissue work seems to finally be getting closer to the frontline where it should be. Hopefully more and more people can begin to see beyond "disc disease" and other copout diagnoses and get better and better.
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