One of the most common chronic conditions in nearly every clinic is related to low back pain

A broad range of complaints bring clients to our treatment tables every day, including chronic pain, injury, mobility issues and the desire to relax.

Several issues are common across diverse client populations, however, which warrants taking a closer look at the methods we use for treatment and an analysis of the possible reasons for those issues’ repetitive nature.

The Low Back Pain Problem

One of the most common chronic conditions in nearly every clinic is related to low back pain. According to the Global Burden of Disease, low back pain is the single leading cause of disability worldwide. The nature of this condition is not only physically debilitating; it also takes a toll on the mental and emotional well-being of those suffering.

This mental and emotional response is often overlooked, but it has a significant effect on the client’s ability to recover. As clinicians, it’s vital to take into consideration the psychosocial aspect of the condition as it pertains to our treatment approach.

As a species, we are devolving when it comes to our durability and susceptibility to injuries—especially as modern day conveniences evolve.

Oftentimes, the chronic low back pain clients suffer is more from a global deficiency of stability and mobility; eventually these imbalances and weaknesses reach their limits.

A Clinical Approach

There are several clinical approaches that can be used for low back pain, as no two cases are exactly alike, nor are the clinicians treating them. However, there are a few tools we can use consistently when it comes to assessment and treatment.

After a thorough intake of medical history from the client, a global view of the client’s posture and movement is a good starting point. This can be as simple as observing the client standing, walking at his or her normal gait, or a more in-depth clinical screen, such as with a Selective Functional Movement Assessment (SFMA), which is a movement-based screen used to help find the source of a client’s pain.

Your decision regarding which movement screen you will use depends largely on your level of training and ability to assimilate what you observe, but it doesn’t need to be overcomplicated either.

Taking a broader observation lens to the condition you’re addressing, even by simply assessing your client in a seated position, will reveal important clues. The type of screen will also depend on your client’s pain levels and abilities at the time of the session.

If the client is capable of moving without significant pain, it serves both of you to attain as much information as possible, even if the assessment isn’t formal. Obvious care is to be taken to not create more discomfort, so common clinical sense should be exercised.

Identifying Dysfunctions

Often, in the case of low back pain, we see postural dysfunctions such as Upper Crossed Syndrome, anterior pelvic tilt, a forward head posture, medially rotated knees and pronation of the feet.

Dysfunction in the diaphragm, obliques, pelvic floor and glutes are also some of the prime suspects to investigate. These aren’t hard-and-fast absolutes with every client that complains of low back pain, but they are landmarks to look for when taking a broader view.

Observing how the feet and ankles articulate through the pattern of gait is underutilized when dealing with painful conditions farther up the chain as well. More often than not, successful treatment starts with correcting a breathing pattern, restoring stability and addressing postural dysfunction from the ground up.

As we continue to have a greater understanding of pain science, thanks to pioneers such as Robert Schleip, Ph.D., and Lorimer Mosely, we have the tools to build our treatment plan from the perspective of our client’s nervous system. Working with this inherently intelligent system rather than against it sets the tone for success.

When a client comes in with pain, his or her central nervous system is on guard and in a protective state to prevent any further damage to the area. This is often expressed as limited ranges of motion beyond the affected area, such as shallow, apical breathing, depending on the severity of pain; basic breathing dysfunction; or some degree of hypertonicity throughout their entire body.

It’s important to recognize that these are protective mechanisms that the brain is employing. Failure to recognize this will likely have you addressing the site of pain with soft tissue techniques, to which the body will potentially become resistant if the nervous system still perceives a threat and until function and stability are restored.

When we take a step back from the site of pain, a holistic view of mechanics can often lead us closer to the major causes or contributors to the problem, barring any known spinal conditions or disc issues.

A broad range of complaints bring clients to our treatment tables every day, including chronic pain, injury, mobility issues and the desire to relax. Several issues are common across diverse client populations, however, which warrants taking a closer look at the methods we use for treatment and an analysis of the possible reasons for those issues’ repetitive nature. The Low Back Pain Problem One of the most common chronic conditions in nearly every clinic is related to low back pain. According to the Global Burden of Disease, low back pain is the single leading cause of disability worldwide. The nature of this condition is not only physically debilitating; it also takes a toll on the mental and emotional well-being of those suffering. This mental and emotional response is often overlooked, but it has a significant effect on the client’s ability to recover. As clinicians, it’s vital to take into consideration the psychosocial aspect of the condition as it pertains to our treatment approach. As a species, we are devolving when it comes to our durability and susceptibility to injuries—especially as modern day conveniences evolve. Oftentimes, the chronic low back pain clients suffer is more from a global deficiency of stability and mobility; eventually these imbalances and weaknesses reach their limits. A Clinical Approach There are several clinical approaches that can be used for low back pain, as no two cases are exactly alike, nor are the clinicians treating them. However, there are a few tools we can use consistently when it comes to assessment and treatment. After a thorough intake of medical history from the client, a global view of the client’s posture and movement is a good starting point. This can be as simple as observing the client standing, walking at his or her normal gait, or a more in-depth clinical screen, such as with a Selective Functional Movement Assessment (SFMA), which is a movement-based screen used to help find the source of a client’s pain. Your decision regarding which movement screen you will use depends largely on your level of training and ability to assimilate what you observe, but it doesn’t need to be overcomplicated either. Taking a broader observation lens to the condition you’re addressing, even by simply assessing your client in a seated position, will reveal important clues. The type of screen will also depend on your client’s pain levels and abilities at the time of the session. If the client is capable of moving without significant pain, it serves both of you to attain as much information as possible, even if the assessment isn't formal. Obvious care is to be taken to not create more discomfort, so common clinical sense should be exercised. Identifying Dysfunctions Often, in the case of low back pain, we see postural dysfunctions such as Upper Crossed Syndrome, anterior pelvic tilt, a forward head posture, medially rotated knees and pronation of the feet. Dysfunction in the diaphragm, obliques, pelvic floor and glutes are also some of the prime suspects to investigate. These aren’t hard-and-fast absolutes with every client that complains of low back pain, but they are landmarks to look for when taking a broader view. Observing how the feet and ankles articulate through the pattern of gait is underutilized when dealing with painful conditions farther up the chain as well. More often than not, successful treatment starts with correcting a breathing pattern, restoring stability and addressing postural dysfunction from the ground up. As we continue to have a greater understanding of pain science, thanks to pioneers such as Robert Schleip, Ph.D., and Lorimer Mosely, we have the tools to build our treatment plan from the perspective of our client’s nervous system. Working with this inherently intelligent system rather than against it sets the tone for success. When a client comes in with pain, his or her central nervous system is on guard and in a protective state to prevent any further damage to the area. This is often expressed as limited ranges of motion beyond the affected area, such as shallow, apical breathing, depending on the severity of pain; basic breathing dysfunction; or some degree of hypertonicity throughout their entire body. It’s important to recognize that these are protective mechanisms that the brain is employing. Failure to recognize this will likely have you addressing the site of pain with soft tissue techniques, to which the body will potentially become resistant if the nervous system still perceives a threat and until function and stability are restored. When we take a step back from the site of pain, a holistic view of mechanics can often lead us closer to the major causes or contributors to the problem, barring any known spinal conditions or disc issues. An Effective Approach Helping your client diaphragmatically breathe while on the treatment table is a non-invasive way to decrease tension, as is using lighter strokes the pain receptors would respond to without resistance. As the tension decreases, a graded scale of depth and pressure can be applied based on the client’s tolerance and if deemed clinically necessary. However, based on your initial assessment of posture and movement you should have a good idea of where there are imbalances and dysfunctions. In many cases, the low back is merely the victim of dysfunction elsewhere (disregarding any traumatic injuries or spinal conditions). With this in mind, your treatment approach might start with work to restore function to the diaphragm, the pelvic floor, the obliques and the glutes. Often, when these mechanics are recovered, the hypertonicity in the other musculature will greatly decrease simply by way of balancing the load on the system and decreasing the body’s perceived threat to further injury. This is a prime example of working with a client’s nervous system rather than against it—the opposite of aggressive soft tissue methods trying to force tight and rigid tissues into submission. A balanced system is more receptive to treatment aimed at downregulating tone and pain. Musculature obeys the command of the nervous system, not the other way around. The mechanoreceptors within the dermal layers send information to the brain and respond to touch differently. Tools of the Trade A relaxing touch versus a touch designed to up-regulate a loss of tone will produce a different result in the tissues being addressed. In the case of upper crossed syndrome for example, using an Instrument Assisted Soft Tissue Mobilization (IASTM) tool to produce a rapid stimulating stroke to the erectors of the spine and the middle and lower traps, followed by a slower, more relaxing (down-regulating) stroke on the tighter tissues of the neck extensors and pec minors can create balance by feeding the right information to the brain. Using kinesiology tape as an extension of your work is an extremely effective tool to manage pain and neurosensory feedback in the areas requiring restored function. In the case of low back pain presentation, an application of tape to the site of pain as well as two stabilization strips to the spinal erectors may help decrease pain while simultaneously creating more circulation and lymph flow to the area due to the mechanical creation of distance between tissues. Tape applications to the diaphragm and obliques may also be warranted, since this will directly affect the client’s stability. By bringing more sensory awareness to these areas (with kinesiology tape on the skin), correction of postural imbalances and function may be more readily achieved—especially when coupled with educating the client on breathing, movement mechanics and corrective exercise if that falls within your scope of practice. In each taping application, the tissue being addressed is stretched by passively or actively positioning the client according to his or her pain tolerance and movement ability. When taping the low back at the site of pain, have the client gently lean into a supported position of forward flexion, gently rounding the low back outside the margin of pain. This can be as simple as having the client seated on the table and leaning over to put the hands or elbows on the knees or standing in a rounded forward position with the hands on a stable surface such as the back of a chair. At the site of pain, place a decompression strip with approximately 50 percent stretch over the area and then no stretch whatsoever on the ends of the tape. In all taping applications the ends should have no tension on them to avoid any skin irritation. Two longer strips are placed on either side of the spine over the erectors. No stretch is necessary, as these are not serving as decompression strips but rather stabilizers. Having the client return to a normal stance will reveal small ripples in the tape representing the mechanical lifting effect on the tissue. Taping applications will last anywhere between three to five days. Using soap and water or baby oil can help emulsify the adhesive for an easier removal process. In the case of special populations such as geriatrics, pediatrics, pregnant women or clients with sensitive skin issues, use of a more gentle tape designed for these demographics is recommended. Before any extensive application of kinesiology tape, it’s wise to place a 2-inch test strip either at the intended site or on the forearm to determine tissue tolerance. For more information regarding the use of kinesiology taping in your practice, seek out a qualified training course. Many Approaches As this article indicates, there isn’t just one approach to take when assessing a client’s low back pain. Utilizing a screen such as the SFMA as your basis for evaluation accompanied by the use of IASTM or taping are all valuable interventions to help you address the low back pain that plagues so many of today’s clients. About the Author Stacey Thomas, L.M.T., S.F.M.A., F.M.S., N.K.T., C.F.-L2, has been dedicated to human movement and athletic performance since 1997 and certified as a sports massage therapist since 2005. She holds certification in Functional Movement Screen, Selective Functional Movement Assessment, Neurokinetic Therapy and CrossFit Level 2, as well as other training and soft tissue modalities. She is credentialed by educational organizations regarding human movement and soft tissue treatment. You can find her in one of her three Front Range, Colorado, clinics treating athletes or teaching courses for RockTape. If you enjoyed reading this MASSAGE Magazine online article, subscribe to the monthly print magazine for more articles about massage news, techniques, self-care, research, business and more, delivered monthly. Subscribe to our e-newsletter for additional unique content, including product announcements and special offers

An Effective Approach

Helping your client diaphragmatically breathe while on the treatment table is a non-invasive way to decrease tension, as is using lighter strokes the pain receptors would respond to without resistance. As the tension decreases, a graded scale of depth and pressure can be applied based on the client’s tolerance and if deemed clinically necessary.

However, based on your initial assessment of posture and movement you should have a good idea of where there are imbalances and dysfunctions.

In many cases, the low back is merely the victim of dysfunction elsewhere (disregarding any traumatic injuries or spinal conditions). With this in mind, your treatment approach might start with work to restore function to the diaphragm, the pelvic floor, the obliques and the glutes.

Often, when these mechanics are recovered, the hypertonicity in the other musculature will greatly decrease simply by way of balancing the load on the system and decreasing the body’s perceived threat to further injury.

This is a prime example of working with a client’s nervous system rather than against it—the opposite of aggressive soft tissue methods trying to force tight and rigid tissues into submission.

A balanced system is more receptive to treatment aimed at downregulating tone and pain. Musculature obeys the command of the nervous system, not the other way around. The mechanoreceptors within the dermal layers send information to the brain and respond to touch differently.

Tools of the Trade

A relaxing touch versus a touch designed to up-regulate a loss of tone will produce a different result in the tissues being addressed.

In the case of upper crossed syndrome for example, using an Instrument Assisted Soft Tissue Mobilization (IASTM) tool to produce a rapid stimulating stroke to the erectors of the spine and the middle and lower traps, followed by a slower, more relaxing (down-regulating) stroke on the tighter tissues of the neck extensors and pec minors can create balance by feeding the right information to the brain.

Using kinesiology tape as an extension of your work is an extremely effective tool to manage pain and neurosensory feedback in the areas requiring restored function.

In the case of low back pain presentation, an application of tape to the site of pain as well as two stabilization strips to the spinal erectors may help decrease pain while simultaneously creating more circulation and lymph flow to the area due to the mechanical creation of distance between tissues.

Tape applications to the diaphragm and obliques may also be warranted, since this will directly affect the client’s stability.

By bringing more sensory awareness to these areas (with kinesiology tape on the skin), correction of postural imbalances and function may be more readily achieved—especially when coupled with educating the client on breathing, movement mechanics and corrective exercise if that falls within your scope of practice.

In each taping application, the tissue being addressed is stretched by passively or actively positioning the client according to his or her pain tolerance and movement ability. When taping the low back at the site of pain, have the client gently lean into a supported position of forward flexion, gently rounding the low back outside the margin of pain.

This can be as simple as having the client seated on the table and leaning over to put the hands or elbows on the knees or standing in a rounded forward position with the hands on a stable surface such as the back of a chair.

At the site of pain, place a decompression strip with approximately 50 percent stretch over the area and then no stretch whatsoever on the ends of the tape. In all taping applications the ends should have no tension on them to avoid any skin irritation.

Two longer strips are placed on either side of the spine over the erectors. No stretch is necessary, as these are not serving as decompression strips but rather stabilizers. Having the client return to a normal stance will reveal small ripples in the tape representing the mechanical lifting effect on the tissue.

Taping applications will last anywhere between three to five days. Using soap and water or baby oil can help emulsify the adhesive for an easier removal process. In the case of special populations such as geriatrics, pediatrics, pregnant women or clients with sensitive skin issues, use of a more gentle tape designed for these demographics is recommended.

Before any extensive application of kinesiology tape, it’s wise to place a 2-inch test strip either at the intended site or on the forearm to determine tissue tolerance.

For more information regarding the use of kinesiology taping in your practice, seek out a qualified training course.

Many Approaches

As this article indicates, there isn’t just one approach to take when assessing a client’s low back pain.

Utilizing a screen such as the SFMA as your basis for evaluation accompanied by the use of IASTM or taping are all valuable interventions to help you address the low back pain that plagues so many of today’s clients.

About the Author

Stacey Thomas, L.M.T., S.F.M.A., F.M.S., N.K.T., C.F.-L2, has been dedicated to human movement and athletic performance since 1997 and certified as a sports massage therapist since 2005. She holds certification in Functional Movement Screen, Selective Functional Movement Assessment, Neurokinetic Therapy and CrossFit Level 2, as well as other training and soft tissue modalities. She is credentialed by educational organizations regarding human movement and soft tissue treatment. You can find her in one of her three Front Range, Colorado, clinics treating athletes or teaching courses for RockTape.

 

If you enjoyed reading this MASSAGE Magazine online article, subscribe to the monthly print magazine for more articles about massage news, techniques, self-care, research, business and more, delivered monthly. Subscribe to our e-newsletter for additional unique content, including product announcements and special offers.

 

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