Sesiones a trabajar

In describing back pain, it is necessary also to enlarge upon its various forms and causes.

Discomfort in the region can range from a dull ache to a sharp pain. It can be localized to one area, or can radiate to other regions such as the groin or the leg. Movements can exacerbate the pain or, indeed, alleviate it. Some of these prob-lems fall into the realm of the more specialized musculoskeletal therapies; however, a number of the causes can be discussed within the scope of massage treatment.

Lumbago

Lumbago is synonymous with chronic back pain, and describes a non-specific dull ache across the loin area. At times, lumbago is persistent with no apparent cause; however, the most likely factor is the formation of nodules and adhesions, which impinge on nearby nerves. Massage is used to increase the local circulation and to relax the muscles. Deep effleurage and cross-friction tech-niques are of particular use for the reduction of nodules. The tissues can also be manipulated and lifted off the underlying structures; this helps to reduce the adhesions and to stretch the muscles and fascia.

Muscle tension and fatigue

Tightness of the muscles and fascia is the primary cause of back pain, generally a ‘dull ache’. Muscle tightness that is felt on palpation may be caused by extensive physical activity; for instance, a sporting pursuit. This is invariably accompanied by muscle fatigue. A similar situation may arise after a period of gardening or decorating, or from long periods of travelling. Allowing for such fac-tors, there should still be a certain amount of

‘yield’ when the muscles are palpated. Muscles which are ‘held rigid’ are indicative of anxiety, muscle strain or a disc problem.

Psychogenic factors causing back pain

Anxiety and depression are frequently associated with acute or chronic back pain; other regions may also be involved. Headaches and lethargy are also common symptoms of anxiety and depression.

Muscle strain

A strain of the lumbar muscles is a common occurrence, and results in acute and severe pain when the sufferer attempts to carry out certain movements. Bending forward is perhaps the most frequent movement, involving mostly the extensor muscles of the back; twisting or rotating the trunk is a similar manoeuvre, which causes the rotator muscles to stretch and contract at the same time—this also occurs when the sufferer is turning over while lying down. Pain is also elicited when the subject attempts to get into and out of a car. If the rupture is severe, the pain is elicited on palpation of the muscle and as the patient attempts to move or turn over on the treatment table. Complications such as spinal misalignments and a herniated disc may also be present in addition to the strain.

Widespread muscle spasm is likely to spread across the back. This occurs as a spontaneous and subconscious protective mechanism, and acts like a splint. Massage to relax the muscles is therefore counterproductive. The sufferer may manage to get onto the treatment table for the massage treat-ment; however, on attempting to move or get up again all of the back muscles may go into sudden spasm. The patient may end up being ‘stuck’ in one position. If this unfortunate situation arises, heat is applied to relax the muscles as the patient is assisted into a standing position; he or she is then advised to rest for a few days and to seek advice from a doctor. In the acute stage cold packs can be applied on the area of injury to reduce the pain and oedema. The muscle can be treated after the acute stage to prevent adhesions and exces-sive scar tissue formation.

Misalignments of the spine

In some cases of back pain, two or more adjoin-ing vertebrae may be misaligned. The misalign-ment or loss of mobility in these segmisalign-ments can lead to irritation of the nerve root(s) emerging from between the vertebrae. Corresponding muscles respond by contracting in an attempt to correct the abnormal posture. Back pain occurs as a result of the nerve root inflammation and the sustained contraction of the muscles.

Misalign-ment of the spinal column can be genetic and fixed, but more often it is episodic and results from bad posture or from scoliosis, bad lifting or strenuous activities. The condition can be moder-ate or even asymptomatic; on the other hand, it may be sufficiently painful to require treatment.

Palpation of the spinous processes can be used as a simple indicator of misalignments and immo-bility. A gentle pressure applied to the lateral side of the spinous process is likely to elicit pain if that segment of the spinal column is misaligned or malfunctioning; the more severe the discom-fort, the more acute the condition is likely to be (Fig. 5.1). Massage is indicated to deal with the associated muscle tightness but not as a means of correcting the deviations; however, spontaneous corrections of the spinal alignments can often fol-low the muscle relaxation. The treatment is con-traindicated on areas of considerable pain or if there is very severe radiating pain to the limbs.

Sciatica

A nerve root emerges through the intervertebral foramen, i.e. the aperture between two adjoining vertebrae. Dysfunction of the vertebral column can alter the integrity of the foramen, causing nerve root irritation and sciatica (see also Chapter 4). Occipital neuralgia and radiating pain down the arm are of a similar nature.

Figure 5.1 Palpation of the spinous processes. Pressure is applied to the lateral side, towards the midline.

Hypersensitivity in the superficial tissues, usu-ally the dermatomes near the spine, is another common consequence of the nerve root irritation.

Massage is contraindicated along a nerve route if it is inflamed (as occurs in sciatica). It is also car-ried out with great care or omitted altogether on hypersensitive areas close to the spine.

Intervertebral discs

Herniated or prolapsed discs present with severe pain, mostly in the lumbar area, which can make even the tiniest movement extremely difficult (see also Herniated disc in Chapter 4, p. 135).

Pronounced tenderness is found in the region of the dysfunction and along the dermatomes. All of these symptoms are severe and should imme-diately prompt the massage therapist to refer the patient to a doctor. Massage is therefore con-traindicated, particularly on the area of the lum-bar spine involved and along the path of nerve pain. Cold packs may be beneficial until the patient receives the appropriate treatment.

Osteoporosis

Osteoporosis refers to a loss of bone substance, leading to brittle and weakened bones. These changes can affect any bone, but the vertebral bodies are most susceptible and can undergo compression and collapse. In mild forms of osteoporosis the subject is able to move without discomfort; in more advanced stages there is pain on movement, and in severe cases the patient is unable to lie down. Palpation of the spinous processes can bring on the pain; this may be difficult to differentiate from the pain associ-ated with misalignments of the spine or that of nerve root problems. However, the muscle spasms that accompany misalignments are not always present in osteoporosis. Massage to the back is none the less contraindicated in severe cases of osteoporosis.

Osteoarthritis of the spine

A frequent cause of back pain, especially in those who have reached middle age, is osteoarthritis of

the vertebral column. The lumbar and cervical areas are the worst affected segments. While inflammation is not always present, the pain of osteoarthritis can be chronic and is exacerbated by activity. The patient is likely to be pain-free while lying down, but experiences great discom-fort on attempting to rise and move about.

Massage is indicated for this condition, as it does not involve movements of the spine. Effleurage techniques are used to increase the circulation to the muscles as well as to the joints; they also help to reduce any muscle tightness that may develop as a protective mechanism to the arthritic changes. Congestion may be prominent around the spinal column; this is treated with deep thumb effleurage. Cross-friction movements are applied across the fibres to reduce the adhesions of the soft tissues that can also develop close to and around the joints. In more advanced stages, and in some sufferers, the muscles may show signs of weakness. These tissues are more sensi-tive to pressure because of the reduction in bulk, and all massage movements are therefore carried out with this in mind. Spondylitis (arthritis) of the cervical area is a very painful condition, in which most movements can cause great discomfort, and massage is best avoided or applied only lightly owing to the fragility of the bony structures and vascular vessels. Rotation, side bending or flexion movements of the neck are to be avoided.

Rheumatoid arthritis

Rheumatoid arthritis is a systemic inflammatory condition affecting the joints and other tissues.

The spine is not always affected at the onset of the condition; if there is involvement, however, palpa-tion of the spinous processes will elicit pain. In the early stages of the disease the patient may still be able to lie down on the treatment table, although with some discomfort. As the condition pro-gresses, this position becomes less comfortable, and the massage is carried out with the patient in the sitting position. Systemic atrophy of the mus-cles occurs because of the reduced mobility; mas-sage is therefore applied with minimal pressure, and only during the non-inflammatory periods.

The benefits of the massage are to increase the

circulation, reduce pain, relax the patient (stress can bring on an attack) and maintain some tonic-ity in the musculature. Treatment is contraindi-cated during periods of inflammation.

Ankylosing (rheumatoid) spondylitis

This is a progressive disease similar to rheuma-toid arthritis. It affects mostly the costovertebral and sacroiliac joints, which are tender on palpa-tion. Ankylosing (immobility and fixation) of the back gives rise to the ‘poker back’, and sclerosis or fusing of the sacroiliac joints leads to immo-bility and low back pain. Muscle stiffness and shortening are likely to occur alongside the spinal column. Massage is indicated to improve the circulation, decongest the area and facilitate stretching. However, if the condition is chronic, massage may be ineffective and may even cause discomfort; in this case it is contraindicated.

Circulatory conditions

Heart problems can refer pain to the shoulder, chest, arm and back. The pain of angina, for instance, is felt in the midline of the back or in the area of either scapula. Tissue changes, for exam-ple tension relating to heart function, can extend to the whole left side of the thoracic region. The lower border of the rib cage is likely to be tight, as well as the area between the left scapula and the second and third thoracic vertebrae. If the circula-tion is systemically impaired, the tissues of the back will feel cold and dry. Conversely, an ele-vated blood pressure, the intake of alcohol or a fever can cause the tissues to redden and feel hot.

Another circulatory condition that can cause back pain is an aneurysm of the aortic arch, which refers pain to the mid-back; an aneurysm of the abdominal aorta can refer pain to the lower back.

Myocardial infarction, however, is rarely a cause of back pain. Massage is indicated to increase the venous return and assist the function of the heart.

Unless it proves uncomfortable, massage on areas of referred pain and tissue changes can help improve heart function via reflex pathways. Hot packs have the effect of increasing local circula-tion as well as relaxing the muscles.

Oedema

Oedema can often be observed and palpated in the lower back and the sacral region. The fluid build-up may be hormonally influenced in women (for example, premenstrual tension and pregnancy); it may also be associated with obe-sity, which can cause disturbances in the circula-tion and fluid retencircula-tion. Inflammacircula-tion is another cause, whether it is of the soft tissues, nerves or joints. Hodgkin’s disease is a condition that can result in back pain because of the disturbances in lymph flow as well as the enlargement of the lymph nodes, spleen and liver. Right heart fail-ure leads to fluid retention in the sacral area and, more significantly, in the legs and elsewhere. In this condition the muscle contractions on the right side of the heart may be too weak to pump the blood through to the lungs, and a back pres-sure in the veins builds up, which then causes fluid retention. Massage is indicated to the sacral area to enhance the lymph drainage, and gentle effleurage movements can be carried out on the back to assist the venous return. The treatment is contraindicated if there is persistent oedema, or if there is severe heat or tenderness on palpation;

these symptoms could indicate an underlying condition that may require further investigation.

Visceral organs

Pathology or severe malfunctioning of a visceral organ can cause referred pain, and frequently muscle spasms, in distant regions. Examples affecting the back include the following.

1. Problems in the liver and gallbladder can cause:

● Referred pain in the right side of the neck.

● Referred pain in the right scapula at the infe-rior part of its medial border.

● Tissue changes in the right thoracic region;

at the lower border of the rib cage on the right side; and in the area between the scapula and the spine on the right side at the level of the fifth and sixth vertebrae.

● Congestion at the level of the seventh cervical vertebra.

2. Stomach malfunction can refer pain to the upper thoracic area of the back. The tissues involved are those of the central region, between the fourth and ninth vertebrae. Changes in the tissues may also extend to the whole of the tho-racic back, on the left side; for example, gastric ulcers and gastritis can cause tissues changes in the left scapula region.

3. Constipation can cause tightness and ten-derness in the region of the piriformis muscle.

While massage to this area can be applied to encourage bowel movement, the changes in the tissues must not be mistaken for a malfunction of the piriformis muscle.

4. Other visceral organ malfunctions or condi-tions that can refer pain or cause tissue changes to the back include obesity, ulcerative colitis and pancreatitis.

Massage is indicated to reduce the referred pain and enhance the function of the associated organ via a reflex pathway. It is, however, con-traindicated if palpation of these referred pain areas causes very severe discomfort. A local mal-function of the musculoskeletal tissues may also be present; this would need further assessment and treatment.

Headaches

Aches and pains in the head can cause tissue changes in some regions of the back. The changes are mostly tight zones in the midline tissues, which can also be tender to palpation. Massage is applied to these tissue zones for its reflex effect on the head area. Changes occur in the following tissue zones:

1. The middle thoracic area, in between the two scapulae—this area is often related to

headaches and insomnia.

2. The central area of the spine at the level of the lower rib cage.

3. The lower region of the sacrum, which can be related to headaches arising from disorders of the digestive system.

4. The occipital border, which is often related to tension headaches.

Respiratory conditions

Conditions of the respiratory system that can cause back pain include carcinoma of the bron-chioles. The left lung (and possibly the right) as well as the diaphragm can also refer tenderness and pain to the back. Carcinoma of the oesopha-gus can have a similar effect. The regions involved are the left side of the upper thoracic area and the upper side of the left shoulder.

Massage applied to these regions helps to improve the function of the related organs.

Kidney malfunction and pelvic conditions Infection of the kidneys can lead to pain in the lower back and trunk, extending also to the lat-eral borders of the buttocks and upper thighs.

The pain can resemble that arising from spinal misalignments, nerve root irritation or lumbago;

the difference, of course, is that these disorders are not accompanied by the proteinuria and haematuria of kidney infection. The ureters descend from the kidneys and pass deep to the transverse processes of the lumbar spine, and tenderness on palpation of the paravertebral muscles may therefore be that of ureteralgia and not of muscular origin.

Kidney infections are generally accompanied by heat in the lumbar region. Oedema is another characteristic; it can be local, systemic or in the lower limbs. There may also be systemic toxicity, which can intensify the pain; as a result, the hypersensitivity can extend to the upper back.

Massage to the kidney area on the back is con-traindicated if there is a known kidney condition or if the area is very tender to palpation. It can otherwise be carried out for its reflex effect.

General massage can be applied as it enhances the systemic circulation; it also stimulates kidney function. Massage to the abdomen has the same effect and is likewise indicated.

Kidney disorders can also cause renal colic, with spasm in the region of the kidneys and towards the thigh. The passage of a calculus is accompanied by pain radiating from the kidney region and over the abdomen into the groin. In renal colic, massage on any of the referred pain

areas (maybe extending to the anterior abdomi-nal wall) is likely to be uncomfortable and is therefore contraindicated.

Some of the other conditions involving the uri-nary and reproductive systems that can cause back pain include:

1. Cystitis 2. Pregnancy

3. Malfunctioning ovaries 4. Dysmenorrhoea 5. Pelvic abscess 6. Chronic cervicitis 7. Carcinoma of the kidney 8. Pyelonephritis

9. Infection or new growth of the prostate.

Cancer

Chronic back pain can result from a primary or secondary tumour of the spinal canal and nerve roots, often associated with Hodgkin’s disease or myeloma. Massage, both local and systemic, is contraindicated.

MASSAGE TECHNIQUES FOR THE