Massage and Bodywork Magazine for the Visually Impaired - Stand Up Against Low-Back Pain

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September/October 2013 Issue

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Stand Up Against Low-Back Pain

By Whitney Lowe
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In the last column (“Take a Stand Against Plantar Fasciitis,” July/August 2013, page 102), we looked at one of the detrimental effects of standing occupations. In addition to plantar fasciitis, numerous other biomechanical challenges may develop from standing occupations. In this installment, we explore the impact on the low back and pelvis  and the role of massage therapy in addressing these disorders. 

Low-Back and pelvic Challenges

Standing occupations create chronic soft-tissue problems resulting from improper posture, often with additional challenges caused by the movement and position required for the work. In addition to chronic muscular demands, there are detrimental effects on bones and joints from the compressive loads sustained during long periods of standing. 

The junction between the low back and pelvis is a key biomechanical junction because this is where the upper-body weight is transmitted to the pelvis and eventually distributed down the lower limbs. Biomechanical imbalances in this region lead to numerous problems, such as chronic low-back pain, disc pathology, facet-joint dysfunction, myofascial trigger points, sacroiliac-joint dysfunction, and more. Let’s take a look at how these problems develop.

The spine has a natural lordotic curve in the lumbar region, primarily for shock absorption. However, standing for long periods can often exaggerate that lordotic curvature. Consider the female salesclerk who stands all day in high-heeled shoes. Not only must she overcome the challenges of standing on a hard floor, which exaggerates the impact of the ground reaction force on the body, but her high-heeled shoes increase the anterior pelvic tilt and lumbar lordosis. 

Lower-Crossed Syndrome

The challenging posture of the anterior pelvic tilt and exaggerated lumbar lordosis is perpetuated by muscle tightness (Image 1). There is a pattern referred to as the lower-crossed syndrome that demonstrates this biomechanical challenge. The lower-crossed syndrome is characterized by tightness in the lumbar extensor muscles (primarily erector spinae, multifidus, and quadratus lumborum) and iliopsoas. Hypertonicity in the iliopsoas muscle pulls the lumbar vertebrae forward, while tightness in the lumbar extensor muscles exaggerates the lordosis. At the same time, there is a functional inhibition of the abdominal and gluteal muscles. Connecting those paired patterns of hypertonicity and functional inhibition produces a crossed pattern in the lumbopelvic region (Image 2). 

A common suggestion to address this postural dysfunction is to encourage strengthening of the abdominal muscles to offset the anterior pelvic tilt. However, if the tightness in lumbar musculature is not addressed first, strengthening will only have minimal effectiveness. Massage and stretching are excellent tools for addressing the hypertonicity and dysfunction of the lower-crossed syndrome. Treatment strategies are most effective when massage and stretching are used to reduce muscle tightness prior to core strengthening and muscular reeducation.

When the lumbar lordosis is increased in the lower-crossed syndrome, it also throws the center of weight distribution through the lumbar spine in a posterior direction. The lumbar spine is designed so that the large and substantial bodies of the lumbar vertebrae carry the primary weight load from the upper body. However, when this weight load moves in a posterior direction with an exaggerated lumbar lordosis, the posterior vertebral arch structures carry a greater amount of that weight (Image 3). 

When greater amounts of weight are borne by the posterior vertebral arch structures, there is increased compression on the lumbar facet joints, which can lead to joint irritation and early arthritis in the spinal joints. 

In addition, degenerative changes in the lumbar vertebrae may result. Increased weight load on the posterior vertebral arch can cause small stress fractures, leading to a condition called spondylolysis. In more severe cases, the anterior vertebral body may actually separate from the posterior arch structures and slip forward, which occurs in a condition called spondylolisthesis

Treatment Strategies

Treatment strategies for the lower-crossed syndrome focus on the lumbar extensors and iliopsoas muscles. Various techniques, such as deep stripping methods, myofascial approaches, and trigger point treatment, are aimed primarily at the erector spinae, multifidus, and quadratus lumborum muscles, as these are the main ones that perpetuate the problem. It is crucial for the practitioner to have a solid understanding of where these muscles lie, as they are not always easy to palpate due to their depth.

These key lumbar extensor muscles are most effectively treated with a small contact surface (thumb, finger, knuckle, pressure tool, or other small-diameter surface) and a treatment method that is highly specific to the involved tissues. These targeted treatment methods make very good massage treatment more effective than many of the other general or superficial approaches that are routinely used.

Deep stripping methods performed with the thumb or fingers produce excellent results, but can cause overload and fatigue of the thumb and finger muscles if used too extensively or improperly. It is important to use good hand and thumb alignment and proper body mechanics to deliver these strokes effectively. 

Keep in mind that the lumbar extensor muscles blend into the broad lumbodorsal fascia that extends across the top of the sacrum and connects with the posterior sacroiliac ligament complex. While the lumbodorsal fascia is not primarily muscular contractile fiber, it is still a very important part of the myofascial complex throughout this region, and so it should be treated. 

The iliopsoas is also a key focus of treatment when its tightness contributes to the exaggerated lumbar lordosis dysfunction. Traditionally, the iliopsoas is treated by applying pressure deep into the abdomen to contact the muscle, then applying static compression, cross-fiber movements, or short stripping strokes to the muscle. However, this technique can be quite uncomfortable for many clients. 

Applying pressure to the iliopsoas means you are pinning the small intestines against the muscle, no matter how much you try to move them out of the way. Another potential problem is inadvertent pressure on the external iliac artery, which lies directly adjacent to, or on top of, the iliopsoas muscle. Pressure on the external iliac artery can have serious adverse consequences if the client has any type of aortic aneurysm, which he or she may not know about. 

A safer, alternative treatment of the iliopsoas is to use the modified Thomas Test position, from which you can use a muscle energy technique (also called PNF stretching) to reduce tightness in the muscle. The client is supine on the treatment table with the leg dropped off the end or side of the table (Image 4). Instruct the client to hold the thigh in partial flexion for about 5–7 seconds while you push down on the client’s distal thigh. After the contraction is held, instruct the client to immediately relax the contraction as you push the thigh into extension and stretch the iliopsoas muscle. This technique can be repeated three to four times for maximum effectiveness.

Sacroiliac-Joint Dysfunction

Another key structural issue that results from the increased lumbar lordosis and long periods of standing is sacroiliac-joint dysfunction. As the lumbar lordosis is increased, the sacrum tilts in an anterior direction. The increased anterior tilt puts additional stress on the closely fitting sacroiliac joints, causing sacroiliac-joint pain, which can sometimes mimic other low-back conditions, such as nerve root compression from disc herniation. The condition is notoriously difficult to identify and is often confused with other conditions of the low-back or pelvic regions. 

Sacroiliac-joint dysfunction can also result from standing occupations if the individual has a structural or functional leg-length discrepancy. A structural leg-length discrepancy occurs when there is an actual difference in length between the bones of one leg compared to the other. In a standing position, the pelvis is pushed higher on the side of the longer leg, causing unequal forces to be applied to the sacroiliac region. 

A functional leg-length discrepancy results when the pelvis is tilted to one side due to muscular forces pulling on the pelvis. The most common example is when the quadratus lumborum on one side pulls on the pelvis and causes a lateral pelvic tilt. If examined in a supine position, it will appear as if one leg is shorter than the other, but in fact lateral pelvic tilt is causing the discrepancy. 

In either case, there is an imbalance of force load on the sacroiliac joint. The weight-bearing relationship of the sacroiliac joint is adversely affected by standing at work for long periods and can lead to significant low-back, pelvic, or lower-extremity pain. 

Sacroiliac-joint dysfunction requires a different perspective than many other joint disorders that might be treated with massage therapy, as there are some unique anatomical considerations in this area. In most cases, we treat joint dysfunction by addressing the specific muscles that span between the two bones that make up the joint. However, at the sacroiliac joint there are no muscles that span directly between the sacrum and ilium. Consequently, treatment should focus on other muscles crossing this joint and also address the numerous connected myofascial chains that span this region.

Primary attention should focus on the quadratus lumborum because, when hypertonic, it has the greatest potential to perpetuate the lateral pelvic tilt. Deep, specific stripping, static compression, and active engagement methods are particularly effective for addressing tightness that occurs in this muscle. After soft-tissue treatment, thorough stretching, performed in a side-lying position, will be of great benefit to further encourage effective tissue lengthening. 

Another muscle that should be examined and treated is the piriformis, because it attaches to the anterior sacrum. Tightness in the piriformis will not exaggerate the anterior or lateral pelvic tilt, but movement of the sacrum could produce an increased tensile load on the piriformis and lead to other biomechanical challenges in this region. Helping to reduce tightness in the piriformis muscle can then also remove restrictions to the sacrum and help it resume its correct position. 

Sacroiliac mechanics can be adversely affected by excessive tightness in the gluteus maximus and other lumbar muscles. There is a fascial connection between the gluteus maximus and the opposite-side thoracolumbar fascia. Tightness and constriction generated through these tissues can limit proper mobility at the sacroiliac joint and exacerbate chronic back or pelvic and lower-extremity pain. Myofascial approaches that address the thoracolumbar fascia are particularly helpful in this region.

The piriformis is deep to the gluteus maximus, so it will be most effective if the gluteus maximus is worked thoroughly prior to working the piriformis. Because of its depth, methods that increase density in the muscle while it is being worked, such as pin and stretch or active engagement stripping techniques, will be much more effective in addressing tightness in the piriformis.

Also crucial are the fascial connections between the hamstring muscles and sacrotuberous ligament. The hamstrings attach to the ischial tuberosity, but also have fascial continuity with the sacrotuberous ligament, which spans from the ischial tuberosity to the sacrum (Image 5). 

In the lower-crossed syndrome, the anterior tilt of the pelvis increases the resting length of the hamstring muscles because their proximal attachment at the ischial tuberosity is pulled in a superior direction. The increased tensile load on the hamstrings can cause them to play a prominent role in lower-extremity discomfort that is felt from standing on the job for long periods.

Ongoing Strategies 

Biomechanically, humans were designed to be moving—not stationary for hours at a time. Because individuals with standing occupations may have few options for changing how much they stand, they are frequently in need of strategies to help them address the cumulative soft-tissue trauma they experience from work. Once you understand the key biomechanical stressors of the client’s workstation (see Orthopedic Assessment in Massage Therapy [Daviau Scott, 2006] for assessment protocols for these problems), you can craft the most effective strategy to address his or her complaint. Massage therapy, combined with home-care practices such as stretching and conditioning, still remains one of the most beneficial methods to address this cumulative work trauma. 

Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe’s next free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com. 

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