Lumbar Treatment

Chapter VIII

Lumbar Treatment

Chapter 8 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.

Tip 1: Trick to Facilitate a Posterior Pelvic Tilt

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.


2. Still with hips and knees flexed, feet on the couch, encourage your client to relax. (You do not want them to lift their bottom off the couch as if performing a bridging exercise.)

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?

The tugging method seems to produce a greater posterior tilt position, but you could experiment with towel removal and select the method that works best for you.

TIP: Some clients may wish to hold their trousers if these are loose, as the trousers sometimes get pulled down at the back by the towel.

Tip 2: Using a Towel to Passively Relax and Stretch the Lumbar Spine

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.

TIP: Notice that if your client reaches one arm above their head, this facilitates a stretch on that side of the body.

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

You do not want to make your client feel seasick by rocking too vigorously—too frequently or with too much force—the idea is to relax, not stimulate. Most clients cannot feel that there is a towel placed horizontally beneath their waist if you position it here at the start of the treatment, so you can make use of the technique whenever it feels appropriate.

Tip 3: Minimizing Lumbar Disk Pressure

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.

Question: Which clients would benefit most from this information?

When a person suffers back pain, they do not need anyone to tell them that moving in a certain way will aggravate their pain; they know that leaning forward to put on their shoes, for example, is impossible, or that the jolt from a sudden cough exacerbates their pain. These kinds of clients tend to self-manage their symptoms by avoiding postures that worsen their pain. Clients who are currently pain free but who experience frequent reoccurrences have usually also learnt how to manage episodes of pain and can often tell when they have “overdone things,” a “niggling pain” being the precursor to more debilitating symptoms. The kinds of clients who may benefit most from your advice are those who may only have experienced one episode of pain, which may be attributable to compression of a lumbar disk or facet joint, or overstretching of a lumbar ligament, and who have not yet experienced a reoccurrence. These clients may be unaware that some everyday activities are potentially harmful.

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).


Tip 4: Avoiding Potentially Harmful Abdominal Exercises

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.

You learnt in Tip 3 that researchers Nachemson and Elfström measured interdiskal pressure in the lumbar spine during everyday activities. In the same study, they also measured pressures when subjects performed exercises that were commonly used at that time (1970) to strengthen abdominals. Findings revealed that in all exercises, disk pressure rose considerably. These findings indicate that these exercises are likely to be unsafe for subjects with lumbar problems and are not suitable for early-stage rehabilitation.

Nachemson and Elfström found that in bilateral straight-leg raising (a), lumbar disk pressure rose approximately 50% compared to standing, and by 100% in both flexed-knee (b) and extended-knee (c) sit-ups. When performing isometric abdominal contraction in the crooklying position (d), pressure increased approximately 40%.


Tip 5: Five Ways to Traction the Lumbar Spine in Supine

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?

Yes. They should not be used on hypermobile clients or during pregnancy. Care is needed when using them within 12 months following pregnancy when ligaments may still be lax. Lower limb tractioning should be avoided if your client has a problem affecting their hip, knee, or ankle, or if holding the foot as described would be problematic. None of these techniques would be used to treat an acute injury. You should be certain that the cause of the back pain is muscle spasm, rather than another pathology. The methods described here are specifically for the purposes of reducing spasm in lumbar muscles.

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.


Gentle Lumbar Traction Stretch with Seat Belt

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.


Gentle Unilateral Lower Limb Traction Stretch

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.



My findings

Lumbar traction using a towel


Lumbar traction using a seat belt


Gravity-assisted lumbar stretch


Unilateral lower limb traction


Bilateral lower limb traction (hands)


Bilateral lower limb traction (towel)


TIP: When performing traction using the leg techniques, you can achieve a greater reduction in muscle tone in the lumbar spine if you ask your client to perform a posterior pelvic tilt once you have applied the traction. This maneuver requires contraction of abdominals, the muscles opposing the erector spinae, and contraction of the opposing muscle reduces tone in the spasming muscles.

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Aug 25, 2019 | Posted by in MANUAL THERAPIST | Comments Off on Lumbar Treatment

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