ATTENTION!!! The physician responsible for the patient’s treatment must be informed of the MEDICAL MASSAGE PROTOCOLs that will be used in manual therapy, and the practitioner must obtain the physician’s permission prior to the initiation of such therapy.
This video is a presentation of the MEDICAL MASSAGE PROTOCOL in cases of Lower Back Pain Due to Tension in the Short Rotators. It is based on scientific publications reviewed in Medical Massage, Volume I. Please refer to pp. 240-262 of the Medical Massage, Vol. I textbook to learn more about pathology, clinical symptoms and diagnostic evaluation of tissue in cases of Lower Back Pain Due to Tension in the Short Rotators.
In the videos, we will repeat each technique and approach only two or three times to save time and space. Follow the time guidelines shown at the beginning of each step.
MEDICAL MASSAGE PROTOCOL IN CASES OF LOWER BACK PAIN (LUMBALGIA) DUE TO TENSION IN THE SHORT ROTATOR MUSCLES
Duration: 45 to 60 min
ATTENTION!!! If the patient is in a lot of pain as a result of the acute spasm of, or injury to, the short rotator muscles, place a pillow under his or her lower abdomen while working on the back.
Step 1. Work on the middle back
Duration: 1 min
Pressure: below the pain threshold
Begin with superficial, and later add the deep effleurage in the direction of drainage from the middle back, on the same side, first to the pelvis several times, then to the shoulder joint several times.
Apply techniques for the relaxation of the paravertebral muscles (Big Fold technique and General technique).
Step 2. Work along the vertebral column in the middle back
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Begin with friction on the lateral surface of the spinous processes of the thoracic vertebrae (to review this technique step by step, click here).
Add circular friction along the thoracic paravertebral muscles. Another helpful technique is Sirasini’s friction along the paravertebral muscles (to review this technique step by step, click here). Apply this technique 2 to 3 times along the middle back.
Step 3. Work on the lower back
a. Stimulate lymphatic drainage and relax the paravertebral muscles
Duration: 2 min
Pressure: below the pain threshold
Begin with the superficial, and later add deep, effleurage on the lower back in the direction of drainage.
Apply the techniques for the relaxation of the paravertebral muscles (Big Fold technique and General technique).
b. Effleurage along the edges of the erector spinae muscles
Duration: 2 min
Pressure: below the pain threshold
Apply deep effleurage along the lateral edge of the erector spinae muscles. Notice in the video that the thumb moves forward while applying the pressure in the medial direction, i.e., against the vertebral column. The small bulge of the tissue seen between the thumb and the vertebral column is the compressed erectors.
Now apply deep effleurage and friction along the medial edge of the erectors. Place the thumb into the groove between the medial edge of the erectors and the line of the spinous processes, and slide it forward applying pressure laterally, or away from the vertebral column.
End this part with the application of electric vibration in the permanent, mobile mode along medial and lateral edges of the erector spinae muscles.
c. Friction on the lateral surface of the spinous processes of the lumbar vertebrae
Duration: 1 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Apply this technique on the lateral surface of the spinous process of those lumbar vertebrae which are painful during the application of direct pressure. Employ the one-hand or the bi-manual variant of the technique (to review these step by step, click here).
d. Friction across the lateral edge of the erector spine muscles
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Apply cross-fiber friction on the lateral edge of the erector spinae muscles. Notice the change in the positioning of the thumbs depending upon whether friction is being applied below the last rib, to the middle of the muscle belly, or above the iliac crest.
e. Work on the L5-S1 vertebral segment
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Anatomical landmarks in the video: the dashed line indicates the iliac crest; the two solid lines indicate the sacroiliac joint; the “x” sign indicates the spinous process of the 4th lumbar vertebra; the black dot indicates the spinous process of the 5th lumbar vertebra.
Begin with lateral stretching of the erectors’ tendon between spinous process of the 5th lumbar vertebra and the sacroiliac joint. Place both thumbs in front of the medial edge of the tendon and push it laterally. Try to keep the tendon in front of the thumbs and don’t let them to slide over the tendon.
Apply friction to the lateral surface of the spinous process of the 5th lumbar vertebra. Pay attention to the position of the thumb and notice that the pressure applied horizontally.
Apply the friction along the medial surface of the sacroiliac joint. Again, pay attention to the position of the thumb and the direction of the pressure.
Apply friction along, and after this across, the tendon of the erector muscles. Notice that the thumb does not slide along the skin itself but that friction is applied rather with the thumb and skin moving together along and across the tendon. Also be sure that the thumb stays on the tendon and does not slide off of it.
Step 4. Stretching of the sacroiliac joint
Duration: 1 min
Pressure: below the pain threshold
Place the base of the hand on the sacroiliac joint and place the other hand on top of the first. During the patient’s prolonged exhalation, apply 2 to 3 vertical compressions. Be careful not to activate the pain analyzing system. Notice the pillow under the pelvis.
Step 5. Work on the lumbar erectors
a. Stimulation techniques on the erectors
Duration: 2 min
Pressure: below the pain threshold
Apply the several stimulating techniques on the lumbar erectors: intense circular friction, friction along and across the fibers of the erectors, ridged effleurage and the manual vibration. Observe the patient’s reactions and be careful not to activate the pain analyzing system.
b. Local stretching
Duration: 1 min
Pressure: below the pain threshold
Place one hand on the lower rib cage and the other hand on the sacrum. Apply pressure horizontally. During the patient’s prolonged exhalation, pull your hands apart so as to locally stretch the erector muscles. Try to fit 3 to 4 local stretches into one exhalation.
c. Traction-rotation technique
Duration: 1 min
Pressure: below the pain threshold
Carefully apply the traction-rotation technique (to review this technique step by step, click here). If the patient has acute pain in the lower back be sure that your active hand (the right hand in the video) directs pressure horizontally.
The white arrow indicates the direction of the pressure for the pelvis stabilization.
Step 6. Work in the quadratus lumborum muscle
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Apply bimanual cross-fiber friction on the lateral edge of the QL muscle using the thumbs. Notice the change in the direction of the friction depending upon whether work is being conducted on the upper, middle, or lower third of the QL muscle.
Also, pay attention to the difference between cross-fiber friction as applied to the lateral edge of the QL muscle or to the lateral edge of the lumbar erector muscle.
Step 7. Work on the lumbar rotators
Duration: 4-5 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
This is the main part of the protocol. All steps above were preparation to this treatment. The therapy includes the combination of circular friction and repetitive compression. However, the most difficult part is to access the affected lumbar rotators in order to conduct the treatment. Pay close attention to the video.
The treatment is performed only on the affected short rotators. To find out which short rotators are affected, before beginning the protocol, apply vertical compression on the spinous process of each lumbar vertebra and notice which ones are painful.
Anatomical landmarks in the video: the black dot indicates the tip of the spinous process of the second lumbar vertebra; the dashed line indicates the medial edge of the lumbar rotators.
The short rotators are located under the lumbar erectors. Thus, to access them you will need to use a special approach.
Begin with the application of friction on the lateral surface of the spinous process. Place the thumb on the tip of the painful spinous process, and after this slide the thumb into the groove between the spinous process and the medial edge of the lumbar erectors. Keep pressure in the horizontal direction, against the spinous process, while applying friction.
The next step is to access the short rotator muscles. Find the medial edge of the lumbar erectors, and place the thumb flat in front of the medial edge just opposite to the spinous process. Now, move only the skin forward, placing the thumb into the groove. When the thumb is the groove, begin to rotate the hand and thumb, pushing the medial edge of the lumbar erectors laterally using the medial edge of the thumb.
In the video, notice that the dashed line becomes curved around the thumb. This is the medial edge of the erectors pushed laterally. Only at this moment should you increase the vertical pressure and apply friction and compression, without allowing the medial edge of the erectors to slip back and cover the short rotator.
Step 8. Passive stretching of the lower back and both lower extremities
Duration: 1 min
Pressure: below the pain threshold
Apply passive stretching of the lower back during the prolonged exhalation. Ask the patient to grasp the end of the table with both hands as shown in the video, and hold his or her lower extremity above the ankle joints. Now, ask the patient to slowly exhale, and begin to pull the patient’s lower extremities backwards using the weight of your body.
Cutaneous Reflex Zones
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Cutaneous reflex zones may form in the lower back and in the lower extremity along the affected dermatomes (see Fig. 8 in the Medical Massage, Vol. I textbook). The video shows the treatment of the cutaneous reflex zones in the lower back using superficial friction, skin kneading and skin rolling. Add this treatment at the end of the Step 5.
Connective Tissue Zones
Duration: 3 min
Pressure: below the pain threshold
In cases of Lumbalgia, the connective tissue zones usually form in the lower back. On the first and second level of the connective tissue zones, employ the connective tissue massage protocol shown in the video.
For the treatment of the connective tissue zones of the third level, employ the technique for the relaxation of the paravertebral muscles (see Step 1 of this protocol).
Apply connective tissue massage at the end of the Step 5 after the treatment of the cutaneous reflex zones.
Reflex Zones in the Skeletal Muscles
a. Trigger Point Therapy for the lumbar erectors
Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
Anatomical landmarks in the video: the dashed line indicates the last rib; the solid line indicates the iliac crest; the four solid dots indicate trigger points in the erector spinae muscle. To review the trigger pont therapy protocol click here. Apply trigger point therapy at the end of Step 6 of this MEDICAL MASSAGE PROTOCOL.
b. Postisometric Muscular Relaxation (PIR)
Rotation
Duration: 3 min
Pressure: below the pain threshold
The patient is on the unaffected side with the knees and hips bent and the opposite upper extremity behind the back. Pay attention to the placement of the pillows.
On the first level of PIR, ask the patient to rotate the upper body backward against your resistance. The white arrows indicate the direction of the contraction.
On the second level of PIR, increase the initial rotation in the lower back by pushing the upper body forwards and asking the patient to rotate it backwards from this position.
Apply three passive stretches after the each level of PIR. These stretches are similar to the passive stretches during the lateral rotation part of the PIR protocol.
Apply PIR at the end of Step 7 of this MEDICAL MASSAGE PROTOCOL.
Periostal Reflex Zones
Duration: 3-4 min
Pressure: exceeds the pain threshold maximally
The video shows the possible location of the periostal reflex zones associated with Lower Back Pain Due to Tension in the Short Rotators.
Periostal trigger points may be found on the spinous process of the L1 to L5 vertebrae, on both sides of the sacroiliac joint, and on the sacrum.
If periostal trigger points are detected, employ periostal massage. However, never apply periostal massage at the beginning of the treatment. Employ it only after acute spasm and pain have been eliminated; otherwise it will worsen the clinical picture. Add periostal massage at the end of the 3rd or 4th session.
Full Protocol: