back trigger points self care pose

By Mary Biancalana, LMT

Even with the best body mechanics, a massage therapist can be affected by the physical demands of hands-on work. Low back pain is a common complaint.

Myofascial trigger points are a clinically recognized etiology for lower back pain. Research is pointing to the impact that myofascial dysfunction has on our everyday lives. Doctors are now using low-cost intervention strategies prior to surgical or high-risk procedures, because we now know that many cases of lower back pain will resolve with soft-tissue treatment. Research increasingly indicates that manual intervention reduces lower back pain.

Manual intervention is applied by a massage therapist or by using self-care tools to apply the treatment to ourselves. We instruct our clients to practice self-care, and now it’s time for us to take our own advice.

Knowing how to identify and self-treat some key muscles can reduce your current lower back pain and can prevent it from reoccurring.

An important key in eliminating lower back pain is to be sure to get to the cause of the problem.This can mean the difference between chronic, multi-episodic occurrences of lower back pain, or a pain-free, fully functioning life with minimal flair ups in the future. Causative factors can also be called perpetuating factors, or those things we do every day that are keeping our muscles in a state of dysfunction and overuse.

In this article, we will consider the impact of muscular, postural and occupational perpetuating factors on the development of lower back pain for the massage therapist, and we will learn some self-care techniques to eliminate trigger points in the muscles that refer pain to the lower back.

Trigger point locations in the gluteus medius. Illustrations courtesy of New Harbinger
Trigger point locations in the gluteus medius. Illustrations courtesy of New Harbinger

The Low Down on Low Back Pain

Consider this scenario: a 43-year-old massage therapist named Kathy reports two-to-three-times-per-year severe low-back-pain episodes. She reports that this pain is felt up and down her lower back near and just lateral to her spine and also radiates into her upper buttocks. Imaging studies are unremarkable.

 “My back just goes out and I’m stuck crawling on all fours to go to the bathroom,” Kathy told me. “There is no rhyme or reason, it just grabs me and I’m off work for a week flat on my back, in bed, too painful even to roll over and get up.

“This time, all I did was bend down to pick up a tissue. Not a heavy box or anything!” she said. “Then on my way to stand up, pain shot into my low back, and I was so mad and fearful, I just crawled into bed and stayed there.”

Upon further investigation, we learn more about Kathy: She is a stressed-out massage therapist, and she has a 45-minute commute each way to and from work in a car with bucket-style seats. She sleeps in the fetal position.

She is so busy at work slouching over her treatment table that she does not even break for lunch. She watches two-and-a-half hours of TV sitting in her favorite recliner each night, and has not been to an exercise class in 15 years.

Her standing torso extension is minus 5 degrees and side-lying hip extension measures 12 degrees with discomfort into the low back at end range.

What we have here is a classic case of chronically shortened iliopsoas, rectus abdominis and gluteus medius muscles harboring trigger points that are referring pain into Kathy’s back.

Trigger point locations in the iliopsoas
Trigger point locations in the iliopsoas

The Furious Five Perpetuating Factors

Kathy’s history includes some key perpetuating factors that have contributed to the development of trigger points in her muscles.

The Furious Five described below are the most important, but certainly not the only, key factors that perpetuate myofascial dysfunction and set people up for acute or chronic pain in the low back and upper buttocks.

Massage therapists should try to avoid or eliminate these factors in their life if possible:

1. Poor sleep posture.

It is important to try to sleep in the most neutral posture possible. Scrunched-up sleep posture puts the pecs, anterior neck, abdominals, hip flexors and hamstrings into the shortened position, while other muscles are of course in the stretched position. The stomach-sleeping position is the worst, followed by­­­ the fetal position.

2. Too much time spent sitting overall.

Total time spent sitting should be a little as possible. Many of us, however, have a long commute to work. Add to that time spent sitting for gaming or watching TV, meals and hobbies. The massage therapist gets to have a standing job, thank goodness. We just need to watch out for other sitting habits that can easily creep in.

3. Poor occupational posture.

The massage therapist spends a great length of time flexed over the treatment table every day. This shortens the abdominals and hip flexors and chronically eccentrically loads the gluteus maximus, medius and minimus.

The massage therapist should demand a hydraulic table that can be raised or lowered many times during the treatment day. If this is not possible, a static treatment table could be varied in its height during the week’s appointments.

4. Too little water and too much caffeinated or sugary drinks.

Getting energy from beverages is usually a hollow proposition. Many of these drinks are loaded with sugar and lead us down a cyclical pattern of needing more and more to keep us going.

It is best to drink plenty of water, eat a well-balanced diet, and derive calories from whole-food, homemade meals. Taking breaks between clients is a good way to practice self-care and allows for small snacks and water breaks.

5. Low amount of dynamic movement or exercise

The massage therapist who is dedicated to practicing healthy self-care should engage in some kind of exercise outside of the workday at least three times per week. Full, active range of motion is important to fully rehabilitate muscles and keep them in tip-top working order.

Trigger point locations in the rectus abdominis
Trigger point locations in the rectus abdominis

Self-Care for Everyone

Janet Travell, MD (1901–1997), and David Simons, MD (1922–2010), co-authors of Myofascial Pain & Dysfunction: The Trigger Point Manual (with various volumes dedicated to specific areas of the body) thought the perpetuating factors to myofascial trigger points were important to identify and remediate.

Travell was a pioneering female physician. From her very early writing in the 1950s until the day she passed away in her 90s, she advocated for self-care for everyone to ensure full and pain-free muscle function.

Having practiced over 18 years in this field, I can attest to the amazing improvement in my treatment outcomes and in my own muscles once these factors are identified—and more importantly, eliminated in myself and in my clients.

Seated hip extension for stretch of psoas and rectus abdominis. Photography: Dan Curley. Model: AnnMarie Biancalana
Seated hip extension for stretch of psoas and rectus abdominis. Photography: Dan Curley. Model: AnnMarie Biancalana

Muscles in the Front Cause Pain in the Back

While the healthy and conscientious massage therapist may not have any of the Furious Five perpetuating factors, I’m sure we all can agree that we often forget to take care of ourselves.

As we provide massage therapy for clients, we can develop low back pain, due to trigger points in the abdominals (iliopsoas, rectus abdominis and obliques), the gluteals and spinal erectors. Our driving, sitting and sleeping posture can cause trigger points and chronic shortening of those muscles, which then become stuck in a metabolic crisis and chronic myofascial dysfunction.

This leads to the potential for acute activation pain after being in the shortened position all day as the massage therapist stands flexed over the treatment table. When home, we may simply bend down to pick up something, our abdominals passively shorten, and when we go to stand up, segments of the abdominals remain shortened and the trigger points in them can cause strong referred pain into the low back.

It is my observation that the iliopsoas, rectus abdominis and gluteus medius are the most probable muscles implicated in referred pain into the lumbar back and upper buttocks.

They certainly are the muscles that are kept in a shortened position for extended periods of time and rarely are fully stretched. The iliopsoas has a referred pain pattern that runs up and down along the spine at the lower back.

Trigger point #2 in the rectus abdominis has a referred pain pattern that runs horizontally across the low back.

The gluteus medius trigger points can refer pain into the sacral area and up into the lower back along the iliac crest.

How or why these referred patterns follow these predictable patterns is not completely understood, but Robert Gerwin, M.D., noted that the referral patterns are usually segmentally distributed; that is, the referred pain patterns are often located in sites innervated by adjacent or nearby spinal cord segments.

Seated self-applied trigger point pressure release of gluteus medius (and gluteus minimus and piriformis) using 5” FitBall body rolling ball
Seated self-applied trigger point pressure release of gluteus medius (and gluteus minimus and piriformis) using 5” FitBall body rolling ball

Apply Self-Care to The Correct Muscles

In their books, Travell and Simons divided the body by region and have listed the muscles that can refer pain to each particular region. For our purposes, the first step is to identify the muscles that can cause pain in the lumbar back and upper buttocks.

For this article, I have chosen to focus on the iliopsoas, rectus abdominis and gluteus medius.

Self-applied trigger point pressure release is just one portion of my full 7–Step Trigger Point Protocol. (For the full treatment outline, watch this video on this self-care trigger point protocol.)

Treatment of the iliopsoas or rectus abdominis usually begins with heat on the abdominal area as well as heat on the antagonist erector spinae group. This will reduce the chances of the spinal erectors contracting on the passive short when we stretch the abs or psoas in seated hip extension.

We can perform an intermediate-level position for self-treatment of the psoas, rectus abdominis and the oblique abdominals. Beginner level would be standing with compression of the abs with the ball against a wall.

Trigger point pressure release should be applied to the upper-most two iliopsoas trigger point locations near the belly button and just under the anterior hip crest, as well as to trigger point #2 in the rectus abdominis (located just above the pubic bone). Self-treatment should also be applied along the full length of the muscles.

After trigger point pressure release, a full stretch and movement series should follow.

Seated hip flexed and adducted stretch for gluteus medius (and gluteus minimus and piriformis).
Seated hip flexed and adducted stretch for gluteus medius (and gluteus minimus and piriformis).

Use Gravity to Apply SelfCare

In the trigger point therapy model, self-applied compression for the above named muscles is added to the stretch and range of movement home program so as to ensure full pain-free muscle lengthening as well as full pain-free stretch and to continue to normalize the contracted muscle tissue.

Self-care treatment of the gluteus medius: We can perform an intermediate-level position for self-treatment of the gluteus medius (and gluteus minimus and piriformis).

A beginner-level treatment would be standing with compression of the glutes with the ball against a wall. Trigger point pressure release should be applied to the upper-most gluteals just below the iliac crest to focus on the gluteus medius muscle.

After trigger point pressure release, a full stretch and movement series should follow.

Prevent Future Pain

Performing self-care compression and focused stretch of key muscles can eliminate lower back pain in the massage therapist. Regular practice of these self-care techniques can also prevent future low back pain episodes from occurring.

It is important that the massage therapist eliminates the Furious Five perpetuating factors to ensure muscular and fascial health. A full protocol—of remediating negative postural influences, added home self-care compression on key identified muscles that are referring pain to the area, stretching and full range of motion exercises—is critically important in improving outcomes and eliminating the myofascial trigger points that can be responsible for low back pain in the massage therapist.

Stay out of pain so that you can be available to your practice, your clients—and your life.

About the Author:

Mary Biancalana, LMT, MEd, CMTP, is a board-certified myofascial trigger-point therapist, personal trainer and past president of the National Association of Myofascial Trigger Point Therapists. She is also founder and owner of the Chicago Center for Myofascial Pain Relief, Advanced Trigger Point Seminars and Trigger Point Sports Performance. She wrote “ The 7-Step Trigger Point Protocol” for MASSAGE Magazine’s June 2017 issue, and “Self-Care of Trigger Points and Referral Patterns” for massagemag.com.

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