Back pain – you gotta love it – it’s so good for business its almost worth having. Almost. Low back pain is a multi-billion dollar industry. Over 80% of the US Adult population under 50 reports experiencing at least one significant episode of acute onset low back pain in their life. Reoccurring episodes are not uncommon. Sometimes back pain results from a specific injury or a traumatic event like an accident or a fall. Other times it comes on while standing at the sink, bending over to reach a dropped pencil, getting out of bed, sneezing or any other number of common daily activities. Back pain can be mild, dull, or sharp and intense. There is good news for most people with low back pain. Most events resolve by themselves in 90 days. Of course that is a miserable 90 days! Unfortunately, about 10% of the people have conditions which do not resolve in 90 days and become chronic, sometimes life long. What can we as hands on providers do to help people recover from acute onset low back pain faster than 90 days? How can we help them prevent future episodes of back pain? This article will hopefully give you some things to consider as you address low back complaints

While the allopathic community attempts to place the blame for low back pain on spinal abnormalities. A very interesting study gives us something to consider. It was found that 2/3 of all people who had never had low back pain had spinal abnormalities, disc bulges, herniations and degenerations. (1) If these problems exist without causing pain, what does cause the pain?

As long as the spinal nerve roots are not being compressed or otherwise intruded upon by disc or bone structure, and visceral and disease causes have been ruled out, the pain will most likely be in the soft tissues. In these cases, soft tissue therapy can usually help.


Muscle spasm is one of the most common causes of pain. Spasm is defined as increased tension with or without shortening of a muscle due to nonvoluntary motor nerve activity.(3) Spasm may be attended by pain and interference with function, involuntary movement, and distortion. (2) An involuntary contraction of a muscle cannot be stopped or controlled consciously. It causes pain and is often accompanied by ischemia and trigger points.


Ischemia is defined as a deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. (2) A great way to functionally constrict blood flow is to have the muscle a blood vessel flows through go into spasm. Spasm causes ischemia and ischemia contributes to further spasm as the lack of blood flow decreases the oxygen levels in the muscle tissue. Ischemic tissue is tender upon palpation and fatigues easily. Ischemia is one of the major predisposing factors to the formation of trigger points.

Trigger Points:

Trigger points are areas of metabolic distress in the tissues. The most common form is myo-fascial trigger points. Trigger points are isolated areas of abnormal physiology. They are hyperirritable, with a hypersensitive palpable nodule in a taut band that when compressed (palpated) are not only locally painful but also give rise to referred pain, referred tenderness, motor dysfunction and autonomic phenomena.(3)

To simplify all this, ischemic tissue is tender at the point you touch it, the tender point (TeP). It is local pain. A trigger point (TrP) is tender where you touch it and causes the patient to experience some sensation somewhere else besides where you are touching (referred pain). This referred sensation may be perceived as pain, but may also be described as ache, tingling, numbness or other autonomic sensations. If it doesn’t refer, it isn’t a trigger point.

To find TeP’s and TrP’s you have to thoroughly, carefully and precisely palpate and examine the tissues. You must go muscle by muscle, virtually inch by inch to find the problems which are often small, isolated spots. To do this you must learn anatomy and continue to study it. After you learn the strokes of massage and what they do, anatomy has the answers to helping people. No bathroom should be without and an anatomy book!


Here are two major muscles you should become very efficient at examining for your the low back patients and a few thoughts on each:

Quadratus lumborum (Q-L)

Q-L is involved in most cases of low back pain.
Lateral or forward bending, rolling over in bed, sneezing or coughing are all usually painful but may even hurt at rest.
Patient gets relief by pressing inferior on their iliums with both hands, one on each side.
This muscle is more lateral than most people think. It is lateral to the erector spinae group in the lumbar region.
If Q-L will not relax or respond to your treatment, move to the hip and treat gluteus medius. Upon returning to Q-L it will usually respond.

These muscles, part of the deep paraspinal layers, are involved in every movement of the lumbar spine.
They are a primary contributor to hyperlordosis.
Multifidi usually cause that deep ache in the low back (Lumbago).
A multifidus in spasm makes it hard to find a comfortable position.
You must palpate through the superficial paraspinal muscles (erector spinae) to access the multifidi. Therefore, the deep friction stroke, done within the patient’s tolerance range (discomfort but never pain) is the best way to examine.
These muscles are very thick on the posterior sacrum and in the lumbar region.
If pressing straight anterior on a Multifidus causes reactive spasm, as will often be the case in disc injuries, access it from its lateral side, pressing medial-anterior at a 45 degree angle. Work along the ”edge” of the paraspinal band of muscle.
If Multifidi does not respond to your treatment, work gluteus maximus, hamstrings and possibly the superficial abdominal muscles.
Patient – Therapist Communication:

When a patient reports low back pain, we, as trained professionals think lumbar 1 – 5. However to the anatomically disenfranchised, the low back is any posterior discomfort between the shoulder blades and the knees. To be sure to understand their complaint, always have them point to where they feel the source of the pain is. This is sometimes very interesting as they will point to their hip or up onto their rib cage. It is all low back to them. Now have them demonstrate the movement that causes the pain or that makes the pain worse. This not only helps you identify the problem, but gives them a reference to their pain level before your treatment. Be sure to have them do this demonstration again after the treatment to verify your effectiveness. (Hopefully you were!)

The lumbar region is not an isolated area of the body. Sometimes it is really more a symptom of other problems rather than the true cause of pain. Often muscles of the anterior thigh, abdominal wall, and hip put forces on the low back which cause it to cry out in pain. However, any attempt to calm it will be short lived, as the problems in the other muscles start up again as soon as the patient walks out of your treatment area.


The pronation syndrome is a devastating pattern of postural distortion that causes knee, lumbar, shoulder and cervical degeneration which often leads to pain. You should always assess low back pain patients for over-pronation. While over-pronation is a very complex pattern, try these simple assessments as a basic screening:

Stand behind the barefoot standing patient. Their Achilles tendons should be virtually straight up and down. If they are curved, there is reason for concern. If one side has more curve than the other, there is more likely a connection to pain further up in the body.
Check the ASIS of each ilium on the front side of the patient. If they are not equal height from the floor, there is a problem. If the more inferior ASIS is on the same side of the greatest Achilles deviation over-pronation is probably at least one significant causative factor in their pain complaint.
Exercises, massage/bodywork therapy and possibly corrective foot-beds can help the over-pronated patient gain relief from their pain and prevent re-occurring episodes.

This subject could take up more pages than this catalog has, leaving no room for the videos, books, face favors and those great Bio-Tone oils, lotions and potions we depend on in our professional practices. So before I devour those pages, I better let you go shopping. Hopefully this discussion will stimulate your interest, especially in the over-pronation pattern and will motivate you to research it further. If you can become successful in helping people gain relief from low back pain, you will become a very successful, sought after practioner. It will be well worth your investment to continue your studies in this area. So, be sure to check out the books and videos. Best wishes for a successful 2003!

(1) Jensen, et all, New England Journal of Medicine, 1994

(2) Dorland’s Illustrated Dictionary, 24th Edition, W.B. Saunder’s Company, 1965

(3) Travell & Simons, Myofascial Pain and Dysfunction The Trigger Point Manual, Volume 1, Upper Body, second edition, Williams & Wilkins, Baltimore, MD 1999

Ralph R. Stephens, BS, LMT, NCTMB, is an internationally recognized massage therapist, author, educator and video producer. He presents seminars on medical massage, sports massage and seated therapeutic massage. Ralph is published in magazines, textbooks, videos and newsletters.

Ralph Stephens Seminars, Inc.
P. O. Box 8267
Cedar Rapids, IA 52408-8267
Permission is hereby given by the sole author of this article, Ralph R. Stephens, to Biotone for the unlimited use of this article and to publish this article in their product catalog. Biotone may, at it’s discretion, edit, abridge, re-title, and/or use only excerpts. Author reserves the right to use this article but agrees to never publish it in a manner that would compete with Bio-Tone or detract from the exclusiveness of its appearance during the life of the catalog in which it is used.