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 SPORT | Back pain

learning

JANE JOHNSON OFFERS

TIPS AND TRICKS FOR
THERAPISTS WORKING
WITH THE LUMBAR SPINE

T
here are many ways to
assess the lumbar spine,
and a huge number of
treatment options. Here is
a selection of assessment,
treatment and aftercare tips for
managing a client who seeks to
ease low back pain with a course
of massage.

28 INTERNATIONAL THERAPIST SUMMER 2017 FHT.ORG.UK

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CASE STUDY
A 35-year-old woman complains of a
12-month history of worsening low back
pain. She otherwise feels ‘well in herself’,
with no underlying medical conditions, and
has had no trauma to her back. When asked,
this client is not able to describe the pain
on a scale of 1 to10 but says it is a constant
‘aching’ and that in the last four weeks it has
become much worse by the end of the day.
She does not think she is particularly
active, as she plays no sport. However, she
used to accompany a friend for dog walks
once or twice a week; she stopped this
around two months ago as she is concerned
it may make her back worse. The reason she
has sought treatment is that on waking up
in the morning last week, she had stiffness
in her lower back for the first time ever.
A The lumbar spine retains its natural curve
in normal, upright sitting with hips and knees at
approximately 90 degrees.
LOOK FOR
TIP 3 UNUSUAL SIGNS
Look for anything unusual in the
client’s posture, particularly in
the lumbar spine. Some people believe that
a pelvis in an anterior or posterior position
contributes to low back pain: in the anterior
position the spinous processes start to
approximate and soft tissues of the posterior
spine are compressed; in the posterior
position there is loss of the lumbar curve
and the spine is less able to absorb shock.
The following ‘trick’ can help determine
whether your subject is standing with their
pelvis in a neutral, anterior, or posterior
pelvic position.
1. In a standing position, begin by
PICTURES: THIEME PUBLISHERS
demonstrating to your client how to
perform a posterior pelvic tilt and, if
necessary, help reposition their pelvis
into a posterior position when they are
resting supine.
Pelvic positions when standing:
(D) Neutral (E) Anterior (F) Posterior
FHT.ORG.UK
Sport back pain__International Therapist 29
ASSESSMENT
Assessment is used to formulate your
opinion as to the causes of the client’s
pain, to help inform your treatment, and
as a baseline against which to measure
your effectiveness.
GET MORE INFORMATION
TIP 1 What happened 12 months
ago, or thereabouts? If this
client’s pain came on 12
months ago, why didn’t she have pain
before this? Did anything change a
year ago in her home life, work, hobbies
or sporting activities?
The client changed jobs 18 months ago.
The bakery she worked in relocated, so she
took a job in a call centre. In the bakery,
she was standing all day serving customers,
B Leaning forward to rest the arms on a desk
produces flexion at the hip and spine, reducing the
lordotic curve.
2. Next, demonstrate an anterior pelvic tilt,
again in a standing position.
3. Once certain that the client understands
how to change the position of their pelvis,
ask them whether it feels easier to move
into an anterior pelvic tilt or into a posterior
pelvic tilt position. If a client finds it difficult
to move into one of the pelvic positions,
they could already be in that position.
D E
Back pain | SPORT
whereas in the call centre she sits all day.
She used to walk to work, a 20-minute
journey, but now takes the bus.
OBSERVE THE CLIENT’S
TIP 2 SITTING POSTURE
How we sit determines the
stresses we feel in the lumbar
spine. In many cases, retention of a static
posture may be the main cause of pain,
rather than the shape of the posture.
However, it is useful to observe sitting
posture in this example.
When demonstrating how she sits, the
client seems to be sitting fairly upright to
work, but tends to lean forward or slouch
when in meetings, some of which last up to
an hour.
Sitting postures are illustrated below.
C When the client is slumped with knees extended,
the pelvis tilts posteriorly and the lumbar
curve reduces.
Following assessment, you decide the
client has an increase in the curve of her
lumbar spine. This is because she finds
it easy to move from her current pelvic
position into a posterior pelvic tilt, but
almost impossible to move from her current
position to an anterior pelvic tilt. This
suggests she is already in an anteriorly tilted
pelvic position.
F
29
07/07/2017 12:36
 SPORT | Back pain

CHECK RANGE
TIP 4 OF MOVEMENT G H
Check for any reduction in
movement in the lumbar spine.
Is stiffness contributing to her pain?
There are many ways to test the range of
movement in the lumbar spine. The client
says she feels stiff when she tries to turn
around (rotation).

CONSIDER MUSCLE
TIP 5 LENGTH TESTING
A client who sits all day is
likely to have shortened hip
flexor muscles. Hip flexors pull the pelvis
anteriorly, increasing the lordotic curve.
Although the client was not found to have
a particularly anteriorly tilted pelvis, when
performing a simple prone knee bend test,
you discover that you cannot take her heel
comfortably to her bottom on either side as
this causes tension in the anterior thigh and
the lumbar lorodosis to increase, increasing
her back pain.

PALPATE THE AREA

TIP 6 Palpation of the area is not
particularly revealing. There are
no specific areas of tenderness.
The client reports that the pressure of the
palpation actually feels slightly comforting.

MEASURE RESULTS I
TIP 7 Finally, decide how to measure
the treatment’s effectiveness.
Will this be on one aspect
only – such as whether the pain is reduced
in intensity, frequency or duration – or a
combination of aspects? For example, if
pain comes on after sitting for an hour, you
might decide that an effective outcome
would be for pain to come on much later, if
at all. If pain is daily, an effective outcome
might be for pain to come on alternate days.
Decide before treatment how to determine
if the client is improving with the treatment
and advice you provide.

LUMBAR AND THORACIC MOVEMENTS

MO

ROTATION (RIGHT) ROTATION (LEFT)

LATERAL FLEXION (RIGHT)

LATERAL FLEXION (LEFT) FLEXION EXTENSION

30 INTERNATIONAL THERAPIST SUMMER 2017 FHT.ORG.UK

Sport back pain__International Therapist 30 07/07/2017 12:37


“Your advice to
the client is a critical
part of the overall
treatment and can often
have a greater effect than
the hands-on treatment”
TREATMENT
You decide that the cause of the client’s
pain is likely to be the retention of static
work posture, brought about by her having
changed jobs in the past 18 months. It
is unknown if the stiffness in her ability
to rotate her lumbar spine was present
before she changed jobs, but this could be
a contributing factor to her discomfort. It
is also unknown whether she had tight hip
flexors previously, but again this could be
a contributing factor, as could her reduced
physical activity. The aim therefore is to
reduce pain and facilitate a more neutral
pelvic position, which can be done in a
combination of ways.
Treatment will entail massaging the
back, massaging and stretching the hip
flexors, and rocking the pelvis into a neutral
position to stretch the lumbar extensor
muscles. It is hoped that the combination of
these treatments will relieve the immediate
symptoms and improve mobility in the low
back and hip flexors.
There are many ways to stretch hip flexors.
For example:
(G) Passive stretch to quadriceps, including hip flex
or rectus femoris, in the prone position.
(H) Side-lying hip flexor stretch.
(I) Supine stretch of rectus femoris.
(J) Supine stretch of hip flexors.
FHT.ORG.UK
Sport back pain__International Therapist 31
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Back pain | SPORT
K L
To passively stretch the lumbar extensors, begin
Introduce routine stretches
with the client in the supine position, hips and knees
Could you introduce some stretches
flexed to about 90 degrees (K). Place your hands on
to increase rotation of the lumbar
the client’s knees and gently increase hip flexion,
rocking the knees towards the client and back again spine? To be effective, stretches
over the course of around two minutes (L). This should be carried out frequently.
movement facilitates a posterior pelvic tilt, reducing
the lumbar curve and passively stretching the
Consider providing stretches for use
during the day as well as at home.
lumbar extensors. These might be stretches for the
lumbar spine – such as lying on the
AFTERCARE AND ADVICE
Your advice to the client is a critical part of
back and hugging the knees – or hip
flexors, or both.
the overall treatment and can often have a
greater effect than the hands-on treatment. CONCLUSION
The tips provided here may be helpful
Offer specific advice in the assessment and treatment of a
Do not offer general advice, but advice client with low back pain deriving from
specific to the problem. In this case, you the retention of a static posture for
believe that keeping the spine in the same prolonged periods of time, and an
position for prolonged periods of time could increased lumbar lordosis due to an
be causing or contributing to this client’s anteriorly tilted pelvis,
pain. Therefore, how might this client combined with reduced
increase mobility of the spine daily in a way physical activity.
that is functional? For tips and tricks for
One of the simplest pieces of advice is to treatment of the neck,
suggest that the client increases the amount thorax or lumbar spine,
of walking she does. For example, could she please refer to The Big
walk to and from work? Or part of the way? Back Book, by
Or walk one way and take public transport Jane Johnson.
the other way? Maybe she could walk when
the weather is fine and take the bus if it’s
raining? Guidelines from the National
Institute for Health and Care Excellence Jane Johnson is a
sports massage therapist,
recommend that people with low back pain
chartered physiotherapist
keep physically active.
and author of a number
of books designed
Consider introducing movement specifically for therapists.
If retention of a static sitting posture is an This includes The Big Back
aggravating factor, how could movement be Book, on which
introduced during the day? Does this client this article is based, available from
get up and walk around during her breaks thieme.co.uk. Contact Jane at
and at lunch or does she remain at her desk? jane@janejohnson.co.uk
Try to encourage movement of the spine
during the day.
REFERENCES
Encourage the client to make changes For references and further
If the shape of the spine while sitting is a reading, visit fht.org.uk/
contributing factor, could she use a different IT-references
chair at work or alter her posture?
SUMMER 2017 INTERNATIONAL THERAPIST 31
07/07/2017 12:38