Low back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. 80% of the population will experience low back pain at some time in their lives.
Recent research suggests that the amount of benefit from a massage treatment was more than that achieved by joint mobilization, relaxation, physical therapy, self-care education or acupuncture. (see further reading and research below).
Most back pain is actually muscular or ligamentous in origin rather than skeletal, therefore vertebral manipulation or invasive surgical procedures (with the risk of adverse effects) is rarely necessary.
About 19 out of 20 cases of acute low back pain are classed by doctors as non-specific. It is called non-specific because it is usually not clear what is actually causing the pain. In the vast majority of cases it is not due to a serious disease or serious back problem, but the pain itself can be very severe and is debilitating as it hinders movement, strength and flexibility. It is only natural that we want to know the exact cause of the pain and it can be frustrating both for the doctor and the patient not to have a clear cut reason for it.
Surprisingly x-rays and other scans are not always helpful in this situation and may be misleading:
More than a third of people without back pain would show some signs of disc ‘abnormality’ such as bulging, herniated disc or degeneration. It would be tempting to identify a similar abnormality in a back pain sufferer as the cause of their symptoms when it may be a red herring and not the cause of their pain at all.
It works the other way too. There may be internal disc disruption (IDD), which may cause pain, without any anatomical distortion, so in this case the scans appear normal.
Also, the technical jargon you will see on scan reports can sound alarming, when in fact the scan is just showing results that are perfectly normal for your age. This can cause unnecessary worry that may hinder recovery.
Acute low back pain that isn’t associated with any kind of trauma is not normally something that requires a doctor’s visit and will normally improve with the help of massage and other conservative treatments.
We will discuss these and other self-help measures later but first we need to exclude other conditions that do require examination by a doctor and further tests would be strongly advised.
See a doctor if you have any of the following:
- Loss of bladder or bowel control or an inability to pass urine.
- Numbness around your genitals, buttocks or back passage.
- Muscle weakness in the legs or feet.
- Pain that is worse at night or is constant pain that isn’t relieved at all by lying down.
- Fever or unexplained weight loss.
- Swelling or bruising in the back.
- Recent trauma such as a fall or car crash.
- Any other unusual symptom that has appeared around the same time as your back pain.
If you are in any doubt whatsoever see your doctor for a checkup and advice.
What is the cause of non-specific low back pain?
Just because low back pain is described as non specific by a doctor doesn’t mean you are imagining it or that the pain and disruption associated with it isn’t severe. Muscular pain is by far the most common type of back pain. A professionally trained remedial massage therapist should be able to identify the tissues involved. It might also be necessary to look further afield than the back for the problem as many muscles refer pain to this area.
So who are the chief culprits; what tissues are commonly responsible for low back pain?
The paraspinal muscles are a muscle group on either side of the spine. They enable us to twist and bend as well as provide support for the spine and they are very powerful. A sudden unexpected twisting movement especially when lifting a weight can injure these muscles.
Quadratus lumborum muscles can cause pain in the sacroiliac joint, hips and buttocks and may easily be mistaken for arthritis of the spine, sciatica or disc problems.
Research suggests that gluteus medius is one of the main culprits for causing low back pain and hip problems. Weak gluteus medius or an altered reflex response of the gluteus medius muscle is associated with reduced hip stability which can also cause low back pain..
The piriformis muscle is notorious for causing low back and buttock pain. It can also irritate the sciatic nerve causing shooting pain down the leg mimicking sciatica caused by a bulging or herniated disc.
The iliopsoas muscle group is hidden deep inside the body and is a common source of low back pain. These muscles are large and powerful but unlike the hamstring and quads they are little known to the general public. The iliopsoas are difficult to reach and require a trained therapist using a variety of techniques to release them.
The serratus posterior inferior muscle connects the lower ribs to four vertebrae in the low back. The function of this muscle is unknown, it was originally thought to help with respiration but this is now in doubt. It is one of the muscles that aches and is stiff when you have slept on a mattress that is too soft. The pain from this muscle can be mistaken for kidney pain.
Abdominal muscles frequently refer pain to the back. Too many sit-ups, a chronic cough or emotional stress can provoke these muscles and set off referred pain in the mid and low back.
The ligaments are strong fibrous bands that hold the vertebrae together, stabilize the spine, and protect the discs. The ligaments are supplied with many nerves and are very sensitive. The pain is usually well localised and can be sharp in certain movements.
It would be wrong to look at the muscles in isolation. The functions of these muscles overlap and interact in one interconnected myofascial system. Generally more than one muscle will be involved and although the dysfunction will vary from person to person there are recognisable patterns of muscle imbalance. A remedial massage therapist will, as part of the treatment process, carry out a musculoskeletal assessment; identifying weakness, tightness or inappropriate recruitment of muscle.
How does massage help low back pain?
In the past, you would have been advised to rest until the pain eases. We now know that this was incorrect. The evidence from many research trials and case studies is that you are likely to recover much more quickly if you get moving again as soon as possible. Also, you are less likely to develop persistent (chronic) back pain if you keep active rather than resting or lying flat. Shuffling slowly around the house is better than taking to your bed. This is easier said than done. When a muscle becomes irritated or traumatised from being overstretched or misused it can lock up and may present as a gripping spasm that can be worse with active motion making it difficult to return to your daily routine. Massage works to relieve low back pain by releasing tightness, stiffness, spasms and restrictions in the muscle tissue. By overcoming this inertia and breaking the pain barrier you can start to follow the good advice and get moving again.
Current remedial massage theory also suggests:
Remedial massage and rehabilitation exercises and mobilisations will improve muscle tone and balance, reducing the physical stress placed on bones and joints.
Massage helps to free adhesions and break down scar tissue. As a result, it can help to restore range of motion to a stiff back. Massage can help increase joint mobility by reducing any thickening of the connective tissue and helping to release restrictions in the fascia.
There is some evidence to suggest that massage has an anti-inflammatory effect on tissue (although further research needs to be carried out in this area).
A deep tissue massage reduces pain by the release of endorphins (endorphins are also known to elevate the mood).
Reduces ischemia (ischemia is a reduction in the flow of blood to body parts, often marked by pain and tissue dysfunction)
Massage stimulates the parasympathetic nervous system, helping promote relaxation and the reduction of stress.
Passive mobilisations increase flexibility and can reset the muscle length of hypertonic, shortened muscle. Research has shown that mobilisation used as a therapy can produce significant mechanical and neurophysiological effects. The explanations of these effects – the mechanism of mobilisation – is still relatively unknown, especially in regards to the spine, and is subject to further research.
There are several theories that provide an explanation for the mechanism of action that makes massage and neuromuscular techniques effective in releasing tight muscle. Massage involves two types of response. A mechanical response as a result of pressure and movement as the soft tissues are manipulated, and reflex responses in which the nerves respond to stimulation.
Massage can break the pain-spasm-pain cycle in low back pain and there are well documented physiological principles that explain these effects including spinal inhibition, descending inhibition (Gate Control Theory) and trigger point inhibition. A remedial masseur has a toolbox of powerful and effective techniques to treat soft tissue in the low back. These include Deep Tissue Massage, Trigger Point Therapy, Positional release, Muscle Energy Techniques, tractions, passive joint movements and harmonic mobilisations, stretches and exercises. We will discuss these principles and techniques and the research evidence that support them in a future article.
Further Reading and Research
Professor Goldstone supervised a study of low back pain led by Elizabeth Dodd at Bradford University and Chris Caldwell at the Northern Institute published in 2003
A further low back pain study by Barbara Heron and Jean Kay, of the Massage Research Advisory Group (2008), involved practitioners from the Northern Institute in the practical work undertaken by the study.
Research report on benefits and efficacy of massage for low back pain.
Research report conclusion: Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Massage might be an effective alternative to conventional medical care for persistent back pain.
Research Conclusions: Massage therapy is effective in reducing pain, stress hormones and symptoms associated with chronic low back pain.
On MRI examination of the lumbar spine many people have disc bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery MRI of bulges or protrusions in people with low back pain may frequently be incidental
Lumbar tender point deep tissue massage combined with lumbar traction produced better improvement in pressure pain threshold, muscle hardness and pain intensity in patients with chronic nonspecific low back pain than with lumbar traction alone.
Altered hip muscle activation in patients with chronic nonspecific low back pain. Healthy controls showed a significantly higher maximum amplitude of the gluteus medius muscle in comparison to patients with nonspecific low back pain. Patients showed an altered reflex response of the gluteus medius muscle which could be associated with reduced hip stability.
Certain muscle impairment patterns could contribute to chronic LBP, but probably not by changing the degree of lumbar lordosis as has been previously suggested with Lower Crossed Syndrome.
High quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain.
We suggest that the serratus posterior muscles function primarily in proprioception.
Neural structural/functional and physiological correlates of massage therapy in response to physical stress.
Increase of plasma β-endorphins in connective tissue massage.
Mobilisations primarily consist of passive movements which can be classified as physiological or accessory. The purpose is to provide short term pain relief and to restore pain-free, functional movements by achieving full range at the joint.
Manual massage is a long established and effective therapy used for the relief of pain, swelling, muscle spasm and restricted movement. Latterly, various mechanical methods have appeared to complement the traditional manual techniques. Both manual and mechanical techniques are described systematically, together with a review of indications for use in sports medicine.