Core-engaging exercises that protect the back against pain are sweeping the fitness industry.
Although a typical massage therapy session for back-pain relief doesn’t include core-stabilization work, it certainly can—and should.
Many massage therapists likely agree we help clients relax the dense, tense muscles and connective tissue that contribute directly to back pain. Many of us also look at patterns of inelasticity in the body, such as short posterior chain muscles in the legs and hips that overload the low back. But how many of us feel we have a role in awakening and facilitating muscular recruitment in our clients?
The Multifidus Muscles
Imaging studies have documented neuromuscular inhibition and fatty infiltration of multifidus muscles in many clients with back pain. This often arises from an episode of spinal pain, but then can lead to recurrence of the back pain months or years later.
Multifidus muscles run deep in the laminar groove on either side of the spinous processes of the vertebrae. If we include the deeper lying rotatores, these muscles run from the base of each spinous process and attach just below the margin of the facet joint from one to five vertebrae below. These muscles support the spine on a segment-by-segment basis to provide a strong, flexible and resilient axis for support.
When a client has an episode of acute spinal pain, the multifidus muscles become inhibited at that spinal level. They rapidly waste and lose muscle mass. As the client recovers from the acute episode, all their muscles gradually regain strength and engagement. However, imaging studies have shown multifidus muscles remain weaker at that segment, even if the client practices global strengthening exercises of the trunk.
When multifidus muscles lack strength, they fail to support that segment of the spine. When a person flexes forward, for example, the vertebral segments that the weakened multifidi cross tend to flex too much and excessively load the intervertebral disc.
While the original injury might be a strain of the disc, resultant inhibition of the multifidi tends to lead to recurrence. It is the recurrence of back pain that is so disheartening and costly on an emotional, financial and social basis.
Massage therapists can play a vital role in identifying weakened, sleepy and ineffective multifidus muscles. We can then refer the client out or help them ourselves.
An Active Role
If we are going to help our clients in this manner, then we may have to revise how we think about ourselves and how we interact with our clients.
Is our role as a massage therapist to soothe, comfort and caress clients? Or is it to encourage, support and activate them to action? These two contesting conceptions of massage therapy are similar to stereotypical roles of the mother and father. In this view, mothers provide caring and comfort, while fathers dust their children off and encourage them to get back on the proverbial horse.
Stereotypical roles for mothers and fathers are inadequate for parents and children, just as simplistic ideas of what a massage therapist is does a disservice to both massage therapists and clients.
Here are some ways core-stabilization work may seem unusual at first, for many massage therapists:
1. Palpating for low tone, or lack of tone, also called muscle atrophy.
2. Asking clients to contract muscles when on the treatment table.
3. Use of massage manipulations to awaken, rather than put muscles to sleep.
4. Encouragement and coaching of clients to do homework.
Let’s look at each of these components separately.
Palpate for Low Tone and Muscle Atrophy
My fingers have a palpatory prejudice toward high tone. They can identify high tone and tension in muscles so easily. All I need to do is run my fingers along someone’s myofascia and the tense elements practically jump into my fingers. Looking for low tone is different, but relatively easy to learn.
Here is how to identify weak and wasted multifidi: Place your thumbs in the laminar groove on either side of your client’s spinous processes and sink down with soft thumbs using your body weight from your hips. Sink in segment by segment from the sacrum through the lumbar spine and up into the low thoracic region.
Rather than noticing high tone or tension, look for places where it feels like there is less muscle. The segment will feel softer, less supported and it will be easier to feel the underlying bone.
Ask Clients to Contract Muscles
It can be tricky to ask clients to contract muscles and work with you actively during treatment on the massage table. This is especially so when they have the preconception you are there to actively take care of them while they passively receive care.
When this type of orientation arises in a client, I tell them the significance of muscle atrophy in the multifidi. I call the muscle soft and draw their attention to the lack of support and vulnerability they feel at that level of the spine when I gently, but firmly, push into the multifidi.
Then, the bridge to having them become more active is simply to ask them to take a deeper breath. As they do, I strum the multifidi at a higher or lower level, where the multifidi are working more normally, and draw their attention to how the muscle is denser, feels less vulnerable and actually swells with contraction when they exhale.
Then, I show the client, in a felt sense, how this is not happening at the level of the multifidi wasting. This usually gets the client’s attention.
Use Stimulating Techniques
As a massage therapist for more than 30 years, I’ve spent a lot of time soothing, relaxing and easing clients with tense muscles. It was such a challenge to use my fingers in a way that was more stimulating to help facilitate temporary muscle-fiber recruitment. But this is what is needed in this situation.
Using finger tapotement, or brief provocative cross-fiber motions, I ask the client to contract their multifidi as he exhales. These provocative manual techniques help the client learn how to contract weakened multifidifibers. There is a whole protocol around how to do this, which involves contraction of the transversus abdominus and the pelvic floor as well.
This can be the most difficult thing for massage therapists to do. We need to encourage and coach our clients in appropriate home care to sustain and deepen the changes that were achieved on the massage table.
When clients have felt the softness and lack of support of the multifidi for a segment of their spine and know how that relates to their spine being vulnerable to injury or re-injury, they may be ripe to act on your suggestions for building strength and endurance in their multifidi.
The nice thing about multifidi training is it doesn’t involve movement of the spine, so it can be done even when the back is in a subacute stage. There should be no motion of the spine and no recruitment of the erector spinae or gluteal muscles. In fact, it can be relaxing and can sometimes relieve back pain at the time it is done.
It is interesting to find clients shift their awareness from “My back hurts and feels sore,” to “It hurts and feels weak right here,” to “I can feel the muscle swell or contract” to “I can get my back out of acute pain” to “With these simple exercises, I can restore resiliency to my back.”
I encourage you to palpate for weak, soft segments of multifidus muscles in your clients right away. It can be a useful exercise to just check for muscle weakness and try to correlate that with your client’s history of back pain.
There is a bridge between what happens on massage tables and what happens in the gyms and various boot camps around the U.S.
For those clients who are in back pain or are too weak and vulnerable to ramp up with a regular core-strengthening program, the type of protocol described here can set the stage for clients to gradually become competent enough in their spine to be able to do the more exciting and athletic core conditioning that has gained popularity in this country.
About the Author:
Doug Alexander, RMT, holds a biology degree from Carleton University and is a graduate of Sutherland-Chan School and Teaching Clinic. He teaches in the Algonquin College Massage Therapy program and authored DVDs on nerve mobilization.