The effects of massage therapy The effects of massage therapy and remedial exercise on and remedial exercise on

decreasing low back pain, due to decreasing low back pain, due to a disk Herniation of L5/S1, and a disk Herniation of L5/S1, and increasing range of motion by increasing range of motion by

treating the lumbropelvic region treating the lumbropelvic region and its surrounding structuresand its surrounding structures

Mike ReochMike ReochWest Coast College of Massage TherapyWest Coast College of Massage Therapy

March 14th, 2007March 14th, 2007

INTRODUCTIONINTRODUCTION

RESEARCHRESEARCH There is a direct correlation between measured There is a direct correlation between measured

lumbar flexion and subjective scoring (i.e. Rolland-lumbar flexion and subjective scoring (i.e. Rolland-Morris or VAS score) before and after lumbar Morris or VAS score) before and after lumbar decompression surgery (Mannion, 14).decompression surgery (Mannion, 14).

There is a significant difference between massage There is a significant difference between massage and rest conditions on VAS scale for muscle and rest conditions on VAS scale for muscle fatigue. With EMG analysis, there was no fatigue. With EMG analysis, there was no significant difference to conclude that massage significant difference to conclude that massage has an effect on decreasing muscle fatigue has an effect on decreasing muscle fatigue (Tanaka, 2).There may be a difference in EMG (Tanaka, 2).There may be a difference in EMG outcome between type I and type II fibers. This outcome between type I and type II fibers. This needs further research (Tanaka, 6). needs further research (Tanaka, 6).

RESEARCHRESEARCH Chronic low back pain patients fatigue faster and are Chronic low back pain patients fatigue faster and are

weaker than healthy controls in regards to gluteus weaker than healthy controls in regards to gluteus maximus (a dynamic muscle) contraction. Paraspinal maximus (a dynamic muscle) contraction. Paraspinal muscle fatigability was similar in both groups muscle fatigability was similar in both groups (Kankaanpaa, 415)(Kankaanpaa, 415)

The impairments of paraspinal muscles (multifidus, The impairments of paraspinal muscles (multifidus, transversus abominis) are not of strength but motor transversus abominis) are not of strength but motor control of the spinal segmental support system. A control of the spinal segmental support system. A motor learning exercise program has a value to motor learning exercise program has a value to patients with chronic and acute LBP with respect to patients with chronic and acute LBP with respect to reducing the neuromuscular impairment and reducing the neuromuscular impairment and controlling pain controlling pain (Gwendolen, 115)(Gwendolen, 115)

There is a correlation between patients with sciatic leg There is a correlation between patients with sciatic leg pain due to disk herniation and latency for control of pain due to disk herniation and latency for control of paraspinal muscles in sudden movements paraspinal muscles in sudden movements (Leinonen, (Leinonen, e370)e370)

ANATOMYANATOMY

INTERVERTEBRAL DISKINTERVERTEBRAL DISK

Degenerative disk disease Degenerative disk disease involves the degeneration involves the degeneration of one or more of one or more intervertebral disks. intervertebral disks.

This is mainly due to a This is mainly due to a mechanical and chemical mechanical and chemical change in the nucleus change in the nucleus pulposus and annulus pulposus and annulus fibrosisfibrosis

The pathological disk may The pathological disk may press on a nerve root press on a nerve root which can cause radicular which can cause radicular pain, numbness, and/or pain, numbness, and/or muscle weakness.muscle weakness.

Decreasing the disk Decreasing the disk pressure on the nerve pressure on the nerve root and the over root and the over expanded disk should expanded disk should help return the patient to help return the patient to a more optimal condition. a more optimal condition.

MUSCLESMUSCLES

Several muscles, important in Several muscles, important in providing stability to the providing stability to the pelvic girdle, attach to this pelvic girdle, attach to this fascia and can affect tension fascia and can affect tension within itwithin it

They include:They include:

the transverse abdoministhe transverse abdominis internal obliquesinternal obliques gluteus maximusgluteus maximus latissimus dorsilatissimus dorsi erector spinaeerector spinae multifidusmultifidus biceps femorisbiceps femoris

TRANSVERSE ABDOMINISTRANSVERSE ABDOMINIS The transverse abdominis (TrA) is the deepest The transverse abdominis (TrA) is the deepest

abdominal muscleabdominal muscle It is proposed that the transverse abdominus It is proposed that the transverse abdominus

exerts an extensor torque due to the oblique fiber exerts an extensor torque due to the oblique fiber direction of the posterior layers of the fasciadirection of the posterior layers of the fascia

The suggestion is that the lateral tension of the The suggestion is that the lateral tension of the TrA is converted into longitudinal tension via the TrA is converted into longitudinal tension via the oblique upward deep fibers and the oblique oblique upward deep fibers and the oblique downward superficial fibers downward superficial fibers

The sum of these oblique angles creates a lateral The sum of these oblique angles creates a lateral pull on the vertebra, which helps in stabilization pull on the vertebra, which helps in stabilization of individual segments of individual segments

MULTIFIDUSMULTIFIDUS

At the lumbrosacral At the lumbrosacral junction, the multifidus is junction, the multifidus is the largest musclethe largest muscle

The superficial and more The superficial and more lateral multifidi at the lateral multifidi at the lumbar junction are lumbar junction are responsible for phasic responsible for phasic motion motion

the medial and deep fibers the medial and deep fibers are more tonic in functionare more tonic in function

therefore, they are therefore, they are responsible for stabilizationresponsible for stabilization

PELVIC FLOORPELVIC FLOOR The deep gluteal muscles The deep gluteal muscles

are comprised of the are comprised of the ischeococcygeus muscle ischeococcygeus muscle and the piriformis which lie and the piriformis which lie in the same planin the same plan

The Pelvic floor is The Pelvic floor is composed of the levator composed of the levator ani muscle, coccygeus ani muscle, coccygeus muscle, and the fascia muscle, and the fascia surrounding itsurrounding it

These muscles and facia These muscles and facia form a muscular form a muscular diaphragm which supports diaphragm which supports the pelvic viscera the pelvic viscera

PELVIC FLOORPELVIC FLOOR

DIAPHRAGMDIAPHRAGM The diaphragm is The diaphragm is

the primary muscle the primary muscle of respirationof respiration

Its secondary Its secondary function is to function is to increase intra-increase intra-abdominal abdominal pressure pressure

INTRINSIC STABILITYINTRINSIC STABILITY The role of the Diaphragm and the pelvic floor, in The role of the Diaphragm and the pelvic floor, in

spinal stability, are primarily to increase the intra-spinal stability, are primarily to increase the intra-abdominal pressure via an increase in facial tension abdominal pressure via an increase in facial tension

The TrA and the multifidus, with its surrounding fascia The TrA and the multifidus, with its surrounding fascia form a “corset of support” for the lumbropelvic regionform a “corset of support” for the lumbropelvic region

Unless the transverse abdominis is used with the Unless the transverse abdominis is used with the diaphragms it will only displace abdominal content diaphragms it will only displace abdominal content These muscles work together as a local system to These muscles work together as a local system to stabilize and control the lumbropelvic region in stabilize and control the lumbropelvic region in healthyhealthy

Any dysfunction in this local system will cause a Any dysfunction in this local system will cause a decrease in lumbar stability and it is integral that we decrease in lumbar stability and it is integral that we consider this in any rehabilitation program consider this in any rehabilitation program

INTRINSIC STABILITYINTRINSIC STABILITY

PATIENT HISTORYPATIENT HISTORY The patient is a 38 year old female The patient is a 38 year old female The patient presents with pain starting in The patient presents with pain starting in

the sacrum that travels down the right the sacrum that travels down the right buttock, down the lateral thigh, and into the buttock, down the lateral thigh, and into the lateral malleolus lateral malleolus

she had a CT scan which showed a right she had a CT scan which showed a right distal, posterior, lateral herniation of L5/S1 distal, posterior, lateral herniation of L5/S1

the patient reports the pain as a 6 or 7 out the patient reports the pain as a 6 or 7 out of 10 on the VAS scaleof 10 on the VAS scale

The pain feels like “a rubber bullet in my The pain feels like “a rubber bullet in my nerve” nerve”

ASSESMENTASSESMENT H.O.P.N.E.R.SH.O.P.N.E.R.S VAS scaleVAS scale Controlled intrinsic lumbar muscle Controlled intrinsic lumbar muscle

contraction via blood pressure cuffcontraction via blood pressure cuff

Treatment goals:Treatment goals:

Assess LspineAssess Lspine Patient exercise educationPatient exercise education Decrease and centralize pain that Decrease and centralize pain that

radiates down right legradiates down right leg Optimize Lspine ROMOptimize Lspine ROM

TREATMENTTREATMENT A hydrocollator is A hydrocollator is

placed on the patient’s placed on the patient’s low back and left low back and left gluteal. gluteal.

Facial heel pull, Facial heel pull, performed to assess the performed to assess the low back and decrease low back and decrease any facial restrictions. any facial restrictions.

Sacral float followed by Sacral float followed by caudal glide of the Ilium caudal glide of the Ilium of grade 2 and 3. of grade 2 and 3.

Passive hip extensions Passive hip extensions are done to help are done to help centralize the disc centralize the disc lesion. lesion.

The left sacral hiatus is The left sacral hiatus is mobilized with an mobilized with an anterior glideanterior glide

Sustained PA glides of Sustained PA glides of L-spine grade 2-3 L-spine grade 2-3 glides for 10 second glides for 10 second

Swedish techniques on Swedish techniques on the back. the back.

piriformis is treated for piriformis is treated for trigger points using trigger points using pressure point release. pressure point release.

The sacrotuberous The sacrotuberous ligament is assessed ligament is assessed and released. and released.

EXERCISEEXERCISE Biofeedback was performed using a blood Biofeedback was performed using a blood

pressure cuff to read pressure changes pressure cuff to read pressure changes with contraction of the Transversus with contraction of the Transversus AbominisAbominis

This was done with specific verbal cues to This was done with specific verbal cues to help facilitate a proper contraction. Over help facilitate a proper contraction. Over time the multifidus were exercised with time the multifidus were exercised with co-contraction of the Transverse co-contraction of the Transverse abominis. abominis.

BIOFEEDBACKBIOFEEDBACK

Verbal cue for contraction of Verbal cue for contraction of local stability systemlocal stability system

Slowly and gently draw lower abdomen in.Slowly and gently draw lower abdomen in. Imagine there is an elevator inside your pelvisImagine there is an elevator inside your pelvis If the elevator has 5 floors stop on the 3If the elevator has 5 floors stop on the 3rdrd floor floor Imagine a wire connecting your ASIS and Imagine a wire connecting your ASIS and

draw them together.draw them together. Imagine a wire connecting your PSIS and draw Imagine a wire connecting your PSIS and draw

them togetherthem together Pull the wire from your ASIS to your xyphoid Pull the wire from your ASIS to your xyphoid

processprocess

MULTIFIDUS CONTRACTIONMULTIFIDUS CONTRACTION The patient is on all fours on the groundThe patient is on all fours on the ground The wrists must be under the shoulders and The wrists must be under the shoulders and

the patient must have a neutral pelvisthe patient must have a neutral pelvis Cue the contraction of the transverse Cue the contraction of the transverse

abominis and multifidus musclesabominis and multifidus muscles The patient must keep breathing through The patient must keep breathing through

thisthis Arm is lifted off ground and then can add Arm is lifted off ground and then can add

contralateral leg lift contralateral leg lift

CONTRACTION OF CONTRACTION OF MULTIFIDUSMULTIFIDUS

AQUATHERAPYAQUATHERAPY

AQUATHERAPYAQUATHERAPY Ten minutes of pool walking in water Ten minutes of pool walking in water

at clavicleat clavicle Extensions while holding the side of Extensions while holding the side of

the pool, the water is at chest height. the pool, the water is at chest height. Hip abductions and adductions for 2 Hip abductions and adductions for 2

minutes, flexion and extension for 2 minutes, flexion and extension for 2 minutes, and internal external minutes, and internal external rotation of the hip for 2 minutes. rotation of the hip for 2 minutes.

AQUATHERAPYAQUATHERAPY Walk for 5 minutes with the water at the Walk for 5 minutes with the water at the

level of C6 to keep up body heat level of C6 to keep up body heat Neutral pelvis is assessed and establishedNeutral pelvis is assessed and established TrA is contracted while standing at water TrA is contracted while standing at water

up to the clavicle while maintaining balance up to the clavicle while maintaining balance The multifidi are exercised with hell The multifidi are exercised with hell

extensions into the wall while maintaining extensions into the wall while maintaining correct posture in clavicle deep watercorrect posture in clavicle deep water

AQUATHERAPYAQUATHERAPY The next multifidi The next multifidi

exercise has the exercise has the patient floating on her patient floating on her back with a floating back with a floating noodle under her necknoodle under her neck

The core is contracted The core is contracted while she lifts either while she lifts either her left or right arm her left or right arm for 20 repsfor 20 reps

Next the legs are lifted Next the legs are lifted with 15 repetitionswith 15 repetitions

AQUATHERAPYAQUATHERAPY The patient’s The patient’s

multifidi are shown multifidi are shown to be much weaker to be much weaker on her left sideon her left side

This is shown when This is shown when the patient the patient attempts to lift her attempts to lift her right leg or her left right leg or her left arm.arm.

AQUATHERAPYAQUATHERAPY Squats are performed while holding Squats are performed while holding

the wallthe wall The water is at xiphoid height while The water is at xiphoid height while

standingstanding Last is an active stretch of the gluteals Last is an active stretch of the gluteals

and quads. The stretch is held for 30-and quads. The stretch is held for 30-60 seconds per muscle group60 seconds per muscle group

OUTCOMEOUTCOME There is a centralization of the pain pattern There is a centralization of the pain pattern

back into the gluteal from the lateral ankleback into the gluteal from the lateral ankle The VAS was reduced from a 6.5 to a 4.5The VAS was reduced from a 6.5 to a 4.5 Flexion was increased from 7˚ to 11.5˚Flexion was increased from 7˚ to 11.5˚ extension was increased from 2˚ to 6˚extension was increased from 2˚ to 6˚ The patient learnt how to contract her local The patient learnt how to contract her local

spinal stability system but needs to increase spinal stability system but needs to increase her strength and hypertrophy of her her strength and hypertrophy of her multifidusmultifidus

Piriformis muscle testing increased a grade 4 Piriformis muscle testing increased a grade 4 with pain to a 5 without painwith pain to a 5 without pain

VAS score

0

1

2

3

4

5

6

7

october 142006

october 192006

october 212006

october 282006

october 302006

november 42006

november 152006

november 222006

december 62006

date

scor

e VASpre tx

ACTIVE FLEXION OVER TIME

y = 0.0973x - 3786.7R2 = 0.231

0

2

4

6

8

10

12

14

16

14/10

/2006

21/10

/2006

28/10

/2006

04/11

/2006

11/11

/2006

18/11

/2006

25/11

/2006

02/12

/2006

Date

Degr

ee

Series1

Linear (Series1)

EXTENTION OVER TIME

0

1

2

3

4

5

6

7

8

9

14/10

/2006

21/10

/2006

28/10

/2006

04/11

/2006

11/11

/2006

18/11

/2006

25/11

/2006

02/12

/2006

Date

Degr

ee

Series1

Linear (Series1)

CONCLUSIONCONCLUSION According to According to

McKenzie, lumbar McKenzie, lumbar flexion can increase flexion can increase by 11˚ between by 11˚ between morning and eveningmorning and evening

This may have This may have changed results as changed results as none of the none of the treatments were done treatments were done at the same time of at the same time of day.day.

The aquanetic exercises The aquanetic exercises done before any done before any measurements may measurements may have changed the pre-have changed the pre-treatment treatment measurements measurements

hydrostatic pressure hydrostatic pressure can reduce disk size can reduce disk size and pain will be reduced and pain will be reduced due to the effects water due to the effects water immersion has on the immersion has on the bodybody

CONCLUSIONCONCLUSION Aquatherapy is most beneficial to recovery Aquatherapy is most beneficial to recovery

during the initial treatmentsduring the initial treatments The goal is to return the patient to being The goal is to return the patient to being

able to perform dynamic and ballistic able to perform dynamic and ballistic movements, without pain, on landmovements, without pain, on land

The progression from low impact closed The progression from low impact closed chain exercises to a pre-injury ability is the chain exercises to a pre-injury ability is the optimal result for any rehabilitation outcomeoptimal result for any rehabilitation outcome

A study of this progression would be A study of this progression would be valuable. valuable.

CONCLUSIONCONCLUSION The patient’s quality of life increased. The patient’s quality of life increased.

She was happy to be able to sit in a She was happy to be able to sit in a car without disabilitating pain and car without disabilitating pain and was able to sit in a movie theatre was able to sit in a movie theatre through a whole show. through a whole show.

CONCLUSIONCONCLUSION This study should be repeated with a better This study should be repeated with a better

understanding of the BROM deviceunderstanding of the BROM device With the practice this practitioner now has, With the practice this practitioner now has,

a more precise set of measurements could a more precise set of measurements could be reachedbe reached

Rotation with the device should be done Rotation with the device should be done seated which was not done during this caseseated which was not done during this case

Seated measurements will eliminate the Seated measurements will eliminate the movement of the pelvismovement of the pelvis

CONCLUSIONCONCLUSION The device also showed that prior The device also showed that prior

movements affected the starting angle of the movements affected the starting angle of the lumbrosacral jointlumbrosacral joint

This movement, or creep, can be an This movement, or creep, can be an indication of intrinsic muscle weaknessindication of intrinsic muscle weakness

It could also be an indication of joint lock at It could also be an indication of joint lock at the SI joint or lumbrosacral jointthe SI joint or lumbrosacral joint

This creep could be reduced if each This creep could be reduced if each measurement was taken 3 times and measurement was taken 3 times and averaged. Unfortunately, due to perceived averaged. Unfortunately, due to perceived pain by the patient, this may not be practical. pain by the patient, this may not be practical.

CONCLUSIONCONCLUSION A constant recording of a VAS post A constant recording of a VAS post

treatment would also help to treatment would also help to demonstrate short-term benefits demonstrate short-term benefits from massage treatmentfrom massage treatment

Even a few hours or days of a Even a few hours or days of a vacation from pain could be vacation from pain could be beneficial to patient well-being. beneficial to patient well-being.