Lumbar Treatment

There are fewer treatment tips in this chapter than in other chapters. The reason is that those that are provided here cover important aspects of lumbar spine treatment that are often neglected, and which require greater explanation. They include tips such as how to really facilitate a posterior pelvic tilt (and why), how to overcome spasm in lumbar muscles, and methods to traction the lumbar spine safely. An exercise to reduce the effects of a mild scoliosis, which I have termed “Klapp’s creeping crawl,” is included as a super example of thinking outside of the box, as the saying goes. We really do need to start to think in different ways about the treatment of the lumbar spine, not just in the techniques we use, but also in the contribution we can make as therapists over and above the delivery of hands-on treatments. The crawling exercise has not been validated, nor has the reliability of the technique been established. Yet it demonstrates how someone many years ago (around 1904) was brave enough to propose an exercise that may have seemed strange but for which there was a sound rational.

The tip on treating clients with back pain is another example of how we as therapists can put our advanced knowledge to good use to help inform our clients. It can be all too easy to forget that the knowledge we gain while training and through years of experience that subsequently follow is not familiar to the majority of our clients, despite the enhanced availability of health information in today’s society. Treatment for symptoms in the low back can certainly be hands-on, but more than ever, providing support in the form of education about the management of back pain, or the prevention of symptoms occurring in the first place, is paramount.

The ideal pelvic posture is for the pelvis to rest in a neutral position (a) with the anterior superior iliac spines (ASIS) on the same vertical plane as the pubis. In this position, the lumbar spine rests with a slight curve, concave posteriorly.

However, some people have an increased lumbar curve (hyperlordosis), and this can cause pain due to compression of soft tissue structures posteriorly. Being able to actively reposition the pelvis from an anterior pelvic tilt position (b) in which the ASIS fall anterior to the pubis, to a posterior pelvic tilt position (c) in which the ASIS fall posterior to the pubis is useful for three reasons:

• The movement itself serves as a form of mobilization, increasing mobility in this region of the spine and reducing stiffness.

• In order to bring about the movement, it is necessary to contract the abdominals, something which can be done in either standing or supine positions and which is a safe abdominal strengthening exercise, even for people with lumbar problems.

• Once in the posterior position (c), the lumbar extensor muscles begin to relax and the overlying fascia is stretched slightly, sometimes reducing discomfort.

Unfortunately, many clients do not know what the posterior pelvic tilt position feels like and therefore struggle to bring this about. One way you can facilitate this is to manually move the pelvis for your client. Some osteopaths and chiropractors place their hands on the sacrum and move the pelvis manually, but this could be considered inappropriate when performed by a massage therapist. A less intrusive method is to use a towel.

1. With your client in the supine position, hip and knees flexed, ask them to help position a towel beneath their back. The most effective position is for the towel to begin at the base of the thorax, high up on the lumbar spine.

3. Using a series of short tugs, tug the towel from beneath your client. In doing so, you will gently tug on the pelvis, repositioning it so that it rests in the posterior tilt position. Ask your client for feedback: they should report that their back feels more straight and some may report now being able to feel the couch with their back, which they were unable to feel before.

Question: Why can’t I just pull the towel out from the client? Why do I need to tug it out?

Gentle rocking can have a relaxing, sedative effect and reduce tone in muscles. Using a towel to rock the body in the tip described here is one way to facilitate this.

1. Fold a towel such that its width approximately matches the size of the space between your client’s iliac crest and their rib cage.

2. Next, lay the towel across your couch and help your client to get comfortable in the supine position with the towel positioned behind their waist.

3. Standing to one side of the couch, take up the end of the towel on the opposite side from you. Holding this end of the towel, very gently pull the towel towards you and notice that it gently lifts one side of your client’s waist from the couch.

Use this technique to apply a gentle, rhythmic motion and thus “rock” your client on one side before repeating the technique on the other side of the body.

Question: For how long should I “rock” the body like this and during which part of the treatment?

In 1970, Swedish researchers Nachemson and Elfström published data they had obtained from inserting pressure needles into the L3 disk of different subjects and recorded the change in disk pressure when their subjects performed movements associated with everyday activities (walking, jumping, standing, and carrying, for example). Results (see bar chart on the following page) revealed that some activities considerably increased disk pressure. Where there is an underlying problem, increased pressure can result in pain and neurological symptoms such as sciatica. Therefore, it is helpful to share this information with clients and encourage them to avoid activities likely to increase pressure on lumbar disks.

“Lifting wrong” is used to mean lifting with knees extended, bending at the waist, not keeping the load close to body.

Based on Nachemson, A. and G. Elfström. 1970. Intravital dynamic pressure measurements in lumbar discs. Scand J Rehabil Med 2. suppl 1: 1-40.

Nachemson and Elfström found that in a simple standing posture (A) pressure increased significantly when their subjects stood holding a 10-kg weight in each hand (B) and increased further still when they attempted to lift these weights with bent legs (C) and with straight legs (D).

Many clients report wanting to lose weight and to tone their abdominal muscles. It is popularly believed that increasing tone in abdominal muscles contributes to core stability and that core stability lessens the chances of experiencing back pain. While the exercises shown here are probably safe for healthy athletes, they place considerable pressure on disks of the lumbar spine and should therefore be avoided by people with a history of back problems or those who are currently in pain.

Tractioning is useful for reducing spasm in lumbar muscles: separating vertebrae reduces pressure on neural tissues and may therefore be helpful in treating radicular symptoms in conditions such as sciatica. Described here are five methods of tractioning, each with a subtly different effect. Each method is performed with your client in the supine position and a chart has been provided at the end of this tip so that you can record your findings when practicing each method.

Question: Are there any contraindications to these techniques?

Gentle Lumbar Traction Stretch with Sheet/Towel

Tractioning using this method provides a direct stretch to the lumbar spine. Wrapping a sheet around the pelvis of your client as shown in the illustration below, use your body weight as you lean backward, applying gentle traction to the pelvis. Guard against injury to your own spine when performing this technique.

TIP: You may find that this stretch is best applied with your client resting on a mat on the floor rather than on a massage couch.

An alternative is to use a seat belt as a stretching aid. With your client in the supine position, hips and knees flexed and feet resting on the couch, place a looped seat belt around your own hips, at about buttock level. Then place the other end of the loop over your client’s knees so that it rests on their upper thighs, a towel between their thighs and the belt. Once in place, all you need to do is to lean back gently, using your body weight to apply the traction.

Gentle Gravity-Assisted Lumbar Traction Stretch

This stretch is best performed with your client on the floor, their hips and knees flexed as in the previous stretch. Providing they have no issues affecting their lower limbs, place your thigh beneath the legs of your subject and use it to support the weight of their lower limbs as you gently use the strength in your own limb to raise your client’s hips off the floor and in so doing, provide gentle traction to the lumbar spine. If you are much shorter in stature than your client, then this stretch may not work. An alternative is to use a gym ball.

This indirect stretch produces a very mild stretch in the lumbar spine on the side to which the traction is applied. Holding the ankle of one leg as shown in the illustration below, apply gentle traction by leaning backward.

Gentle Bilateral Lower Limb Traction Stretch

This is also an indirect stretch and produces a mild stretch to the lumbar region as a whole. Place your client’s legs together and with one hand cupping each heel, slowly lean back. It is difficult to exert much traction when holding both legs in this manner, which is why the stretch is mild.

An alternative handhold, and one which produces slightly greater traction, is to place a towel horizontally beneath the ankles (a) and then to wrap it around the ankles, crossing it over the dorsum of the feet (b) as your client rests supine on the couch. Then, hold the ends of the towel (instead of the ankles) when leaning backward.