Today I would like to touch on a topic which some massage therapist might find a little surprising. I remember back in school learning about different conditions and how to treat them. Some were obvious conditions which could be affected by soft tissue manipulation, like piriformis syndrome, carpal tunnel and thoracic outlet syndrome( all the classics). We learned how to treat these early on and I have used that knowledge throughout my career to help many people. Okay, great! Then there were the ones we learned about that were basically labeled the untouchables. They were considered far and beyond our scope of practice and, if suspected, should have stayed as far away from treating those patients as possible and referred to a primary care physician for treatment. Now I’m not here to rip apart the massage therapy educational system but I would like to talk about one of these “untouchable” conditions and demonstrate how just knowing a deeper knowledge of anatomy can open up our own ability to treat more complex pathologies, which in turn can help our current and prospective clients.
I want to premise this by stating that I am in no way downplaying the seriousness of this pathology. Also, I completely understand a massage therapist referring a client out if they are uncomfortable with treating any condition, even if it IS within our scope of practice. The Hippocratic Oath does state “first, do no harm” and anyone uncomfortable with any condition should always practice caution. That being said, let us continue.
In school we learned that disc injuries were to be considered a contraindication, and if suspected to refer out to a physician. Now I do agree with this…partially. If a client makes an appointment with you and is in acute pain and unable to stand with shooting pain and numbness in his/her legs, yes we are going to refer them to another practitioner. However, let us present a different scenario. Say a new client books an appointment with you and on the health history sheet writes that they have a diagnosed previous disc herniation in the lumbar region and would like to have his/her low back worked on. What do you do? If I was going by what I learned in massage therapy school, and what many massage therapists consider normal limits, I would have to refuse to work on the low back because a disc herniation is a contraindication. I may work on the rest of their body but treating the low back would be off limits.
In my opinion, this is where we can veer from what our current thoughts are about disc injuries and start helping people with pain. First of all, it is important to know that just because someone has a disc injury, does not make their spine made out of fragile glass. Their spine is still a functioning, operating machine with most of its functionality left. It simply has an area where its a bit more susceptible to instability and injury. Second, we CAN work on it and make big changes in the functionality of the spine, thus helping a client who has maybe never had relief before. Yes, certain disc herniations are very serious and contraindicated and should be referred out to another practitioner, however, many times we as massage therapists can truly help and should so when possible.
Let us use the lumbar spine as our example since it is where a great number of disc injuries occur. Statistically speaking, the L4-L5 intervertebral disc is the most common level of the lumbar spine to be injured. This is true simply because it is the disc with the most load bearing responsibility being at the bottom of the spine. This being said, disc injuries can happen regularly at the higher levels as well, simply because it is where the load is put on the spine when lifting objects.
Now in order to understand why lumbar disc injuries occur in the first place, we need to know what the spine is doing when the injury takes place. As a general rule, increased disc pressure is present when the spine is in a flexed position. In other words, when we are sitting or bending over there is more weight on the anterior side of the spine where the discs are located. Think of the inside of a “C” shape. There is more compression on the inside of the “C” than the outside. In the opposite manner, when we extend the spine or arch back, there is less pressure on the disc. Think of the “C” opening up, decreasing the compression. The increased pressure on the discs when in a flexed position ( bending over) is what makes these positions detrimental to the spine when under increased load. So, an injury occurs when that anterior loading becomes too much and the disc either bulges or herniates. This can, of course, be a single traumatic event or due to chronic degeneration. In the case of degeneration, the disc space has lessened due to chronic pressure on the discs, usually from improper posture, instability, or just wear and tear. With either example, the intervertebral space is compacted. This narrowing is what causes pain and leads to nerve pressure and many painful symptoms.
Now, knowing the basics of what a disc injury is, we can look to see what we as massage therapists can do to help. We are not, of course, going to cure the disc, but we can affect the structures by around the disc and make the spine, and along with it, the discs, function better. This better functionality will usually alleviate many painful symptoms, and bring relief to a client. The key to treating disc injuries is remembering the location of the disc itself. Earlier I stated that there is an increased load on the disc when in a flexed position due to the anterior location in the spine. This is extremely important to know. The ability to take pressure off the disc and decompress the spine is what is going to help restore function to the disc and spine. Knowing that the discs are located on the anterior portion of the spine means that, in order to create decompression around the disc, we are going to treat any structure that will lesson flexion of the spine and allow for extension. In the lumbar spine, this muscle is the psoas.
For a massage therapist, releasing the psoas is truly the best treatment for disc injuries in the lumbar spine. By treating this muscle, we are successfully decompressing and restoring mobility to the lumbar spine. Many times clients with disc injuries with have a complete inability to extend the hips and lumbar spine due to chronic or acute psoas hypertonicity. In fact, one the signs that a client is has an acute disc injury is a forward lean, usually to one side (antalgic posture). This is because the psoas is in spasm and pulling them into this posture. If we can successfully release the psoas, whether it is an acute or chronic disc injury, we can decompress the spine, and in the process decompress the afflicted disc. If done correctly the process of releasing the psoas muscle in no way compromises the safety of the client in terms of harming the affected region of the spine, and as I have stated actually helps the patient. In my opinion, that means that it is not contraindicated.
The same principle of decompression can be applied to the cervical spine as well (also a common location for disc injuries). Once again, since the disc is on the anterior side of the spine we are going to treat anterior structures in order allow for extension and decompression of the disc spaces. These include scalenes, Sternocleidomastoid, and longus colli. Even platysma can have a positive effect. By releasing these tissues, we are allowing the cervical spine to extend fully and create as much space as possible for the affected disc, restoring function to the spine and disc.
The rule to follow is that decompression is the most important goal we are trying to achieve when treating disc injuries, and we do this by treating the anterior aspect of the spine and its musculature.
I will point out that certain types of massage WOULD be contraindicated for disc injuries. For example, I would not do any deep tissue work in the lumbar region with a patient prone. The compressive nature of any lumbar massage can make it very irritating to the discs and facet joints which could make your client very uncomfortable and possibly make their condition worse. Any work done to the lumbar spine should be done either side lying or supine with a pillow underneath the knees.
Also, working in the cervical region, take care not to flex or laterally flex too much as this can irritate the disc. However, these movements can easily be avoided and should not inhibit your treatment.
These examples are very basic and certainly do not cover all the details of disc injury and treatment. However, I have found in my practice that even though these ARE simple principles, they are also what help improve symptoms for the majority of disc problems. It may seem too simple, but spinal decompression is an amazing tool to treat disc injuries and we can promote it greatly by treating the correct musculature.
As therapists need to expand our knowledge base in order to realize that we are capable of treating some fairly serious conditions. Not only can we work on them, but we can affect them in a positive way which will hopefully lead to clients with reduced pain. All it takes is a commitment to learning and then applying our knowledge.
Note: For anyone, who does not feel comfortable treating the psoas muscle, I highly recommend learning how. Whether it be continuing education or simply watching YouTube videos, deepen your knowledge of this muscle so the next time you need to treat it there is no hesitation on your part. It really is that important of a muscle!
- For an awesome decompression exercise regimen, check out Foundation Training. Truly amazing stuff! https://www.foundationtraining.com/
- Also, Here is a Lumbar Decompression Exercise which I have written.
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