What is Temporomandibular Joint Dysfunction Syndrome?

Temporomandibular Joint Dysfunction Syndrome (TMJD from herein), is a broad term that refers to the dysfunction of the articulation between the mandible and the cranium – aka the TMJ or temporomandibular joint. TMJD is not exclusively a disorder of the bony structures, but may also be a result of hypertonic muscles which affect the joint and therefore cause symptoms.

Temporo refers to the temporal bone of the cranium (skull), and mandibular refers to the mandible or jaw.

Symptoms of Temporomandibular Joint Dysfunction

In early stages there is often a clicking or popping noise when a client opens or shuts his or her mouth. As the condition progresses, there may be pain at the site, which is just in front of external auditory meatus (ear canal), the temple or the teeth. The noise or the discomfort usually presents unilaterally, however it can present bilaterally.

Poor coordination of the muscles leads to deviations in movement as the jaw opens or closes. For example, if looking in the mirror, a client may notice that when she opens her mouth, her jaw is pulled to one side.

In severe cases, the jaw may become dislocated and stuck open, and the surrounding muscles may spasm.

Who is at risk for TMJD ?

Temporomandibular Joint Dysfunction appears to occur more often in women, and in the age group of 20 – 40 years. It is common in people who have suffered trauma to the jaw and face, who have suffered whiplash (a WAD injury) or who may have had a lot of dental work or surgery. Other conditions such as excess muscle tension can lead to malocclusion, or arthritis may affect the joint.

TMJD also appears to worsen in those who have extreme postural deviations, such as scoliosis or anterior head carriage.

Anatomy of the Temporomandibular Joint

The TMJ is a hinged synovial joint, and is an articulation of the head of the mandible with the mandibular fossa and articular tubercle of the temporal bone.

Within the joint is an articular disc whose purpose is to cushion the bony surfaces during movement. This articular disc divides the joint capsule into a superior and an inferior compartment: superiorly between the disc and the mandibular fossa, and inferiorly between the disc and the head of the mandible.

The TMJ is located anterior to the external auditory meatus or ear canal, hence the ear pain in some cases of TMJD.

The mandible is suspended from the cranium primarily by the fibrous capsule of the TMJ and lateral ligament of the joint, in addition to the sphenomandibular and stylomandibular ligaments medially and inferiorly. The latter 2 ligaments serve to stabilize the joint during movement by opposing the pull of the capsule and lateral ligament.

Movement of the Temporomandibular Joint

The temporomandibular joint is moved by what are known as “the muscles of mastication”. There are 4 of these muscles, the temporalis, masseter, lateral and medial pterygoids.

The primary mover of the TMJ during opening (or depression) of the jaw is actually gravity – this is assisted by the lateral pterygoid muscle as well as the supra- and infrahyoid muscles. The lateral pterygoid is the only muscle of mastication that depresses the jaw.

The lateral pterygoid, and to a lesser degree, the masseter and medial pterygoids act to protrude the chin.

To elevate the mandible (close the mouth) the temporalis, masseter and medial pterygoid muscles contract.

To retract the chin, the temporalis and masseter contract.

Action of the disc during an opening/depressing movement of the TMJ

There are 2 movements which occur in the TMJ – first, the head of the mandible rotates anteriorly, secondly, the head of the mandible glides anteriorly as it continues to rotate anteriorly.

To open the mouth, the lateral pterygoids contract, and with the assistance of gravity, pulls the articular disc taut in the joint capsule.

As the head of the mandible moves anteriorly along the mandibular fossa of the temporal bone, the articular disc is pulled anteriorly as well, always staying between the two articulating bones. The correct end-range of this movement is at the articular tubercle of the temporal bone.

Dislocation of the TMJ occurs when the head of the mandible slips anteriorly to the articular tubercle. This may occur due to spasm of the lateral pterygoid muscle as the client opens their mouth.

Dislocation may also occur due to a sideways blow to the jaw when the mouth is open. It is not uncommon for the arm of the mandible to break instead of the actual TMJ dislocating.

Functional dislocation of the articular disc occurs when the disc is unable to move normally with movement of the head of the mandible. This dislocation may occur anteriorly or posteriorly to the head of the mandible.

An anterior dislocation can be differentiated by difficulty and pain with opening of the mouth, with the available movement being very limited. This is a result of the disc becoming compressed between the mandibular head and the articular tubercle and lateral pterygoid.

Difficulty and pain with elevation (closing) of the mandible, and a possible inability to close the mouth completely, is an indication of a posterior dislocation, where the articular disc is jammed against the posterior aspect of the joint cavity.

Failure of the disc to move properly within the joint capsule is believed to be the cause of the clicking sound which is often heard. The incorrect movement may be due to hypertonicity of the muscles of mastication, articular surface degeneration etc.

© Copyright 2010 Jodi Forsythe
www.whymassagetherapy.com
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How Can Massage Treat Patellofemoral Syndrome Knee Pain?

Patellofemoral syndrome is a term used to describe knee pain caused by improper movement, or tracking, of the kneecap over the femur. This condition often results from muscle imbalance in the quadriceps, or thighs. Massage therapy is useful in addressing this muscular imbalance, resulting in decreased pain and increased function of the patellofemoral (knee) joint.

The patellofemoral joint specifically refers to the articulation of the femur and the patella. The patella, or knee cap, is a sesamoid bone and is located within the quadriceps tendon. The patella glides over the boney prominences of the femur, or the femoral condyles, as the quadriceps contract or tighten during extension of the knee.

The quadriceps (aka, quads or thigh muscles) is really a group of four muscles, consisting of the rectus femoris, vastus lateralis, vastus intermedius and vastus medialis. The muscular imbalance which may be one cause of patellofemoral syndrome occurs when the vastus lateralis is stronger than the vastus medialis, and pulls the kneecap to the outside of the thigh during movement. This imbalance is often seen in athletes such as runners, though it is not limited to athletes, and may be caused by posture.

Pain occurs when the quadriceps tendon tightens during movement and pulls the kneecap “off track” – meaning that the underside of the kneecap articulates improperly with the femur. If left untreated, this misalignment can cause inflammation and degeneration of the bony surfaces, eventually leading to arthritic changes.

The treatment

Massage therapy is very useful in reducing the tone and myofascial trigger points of the quadriceps, specifically that of the vastus lateralis. Trigger points in this muscle, which refer pain to the lateral thigh along the iliotibial band area, as well as the lateral knee, may contribute to altered gait. During a massage therapy treatment, the therapist will address the involved and compensating muscle groups, as well as stretching and using hydrotherapy during treatment (heat) and post treatment (ice or cold). The application of cold post treatment will assist in the reduction of inflammation in the patellofemoral joint and surrounding muscle tissue.

Another important aspect of rehabilitation is the strengthening of the vastus medialis, specifically the lower, oblique fibres medial to the patella, known as the vastus medialis oblique (VMO). By strengthening this muscle, the normal position of the patella is regained and it will interact correctly with the femur.

The duration and frequency of the treatment will depend on the presentation of the condition, and how long it has been present.

© Copyright 2010
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Low Back Pain and Disc Herniation

The discs located between vertebrae are vulnerable to injury, and can cause debilitating pain when injured.  Disc herniation most commonly affects the lumbar spine, but it can also occur in the cervical spine, and rarely, in the thoracic spine.

What is disc herniation?

Disc herniation is a term that refers to displacement of the nucleus pulposus of the intervertebral disc, due to injury or weakening of the external portion of the disc (annulus fibrosis).  The term “slipped disc” often refers to this type of injury, as does bulging disc.

There are four stages of disc herniation, with various degrees of displacement of the nucleus pulposus. The final stage occurs when the annulus fibrosis is completely ruptured and there is a complete loss of integrity of the external structure.

Pain occurs due to increased pressure on the nerves exiting the spinal cord. Symptoms such as pain, numbness and tingling will occur in the area that is supplied by the affected nerves.

How does disc herniation occur

Disc herniation most often occurs due to injury, sometimes from a seemingly innocent action such as bending over or twisting to pick something up. These actions of sudden flexion or rotation often cause an increase in pressure which forces the nucleus pulposus in a posterior (toward the back) direction.

Signs & Symptoms of Disc Herniation

If you’ve ever had an issue with a disc, it is an unforgettable experience.

1. Sudden, excruciating pain – into the legs and buttocks if the herniation occurs in the lumbar spine; into the arms and hands if the herniation occurs in the cervical spine.
2. Muscle spasm will occur in the injured area – this is the body’s protective mechanism to prevent further injury by immobilizing the area.
3. certain actions will increase pain and symptoms, such as bending forward from the hips, side bending, or twisting. As the action causes the pain, a therapist can tell where the bulge is happening by the pain distribution.

How is disc herniation treated?

Disc herniation is a condition that must be managed in the initial stages, with a focus on removing pressure from the affected nerves and pain control.  As the condition progresses, the focus turns to strengthening the supporting structures – if the herniation has occurred in the lumbar spine, core muscle strengthening will be incorporated into a rehabilitation program.

Massage therapy itself is not a standalone therapy for disc herniation – it can help with pain control and removing some of the excess muscle spasm. It must be noted that removing all of the hypertonicity (excess muscle tone) in the muscles surrounding the injured area is not wise – the excess tone in this case is used to stabilize the area, and if it is completely removed, the area can become very unstable and make the injury worse.

If the injury to the intervertebral disc is severe, the condition can become chronic and progress to degenerative disc disease.

For more information, please see The Anatomy of Low Back Pain.

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The Anatomy of Low Back Pain

Understanding the anatomy of the lumbar spine is key to understanding and managing low back pain.

The lumbar spine, commonly called the “low back”, consists of 5 vertebrae, and is located between the thoracic spine (which articulate with ribs) and the sacrum. The vertebrae themselves are given numbers by which they are identified, for example – Lumbar Vertebra 1 = L1, Lumbar Vertebra 2 = L2 and so on.

The normal lordotic curve of the low back is known as a secondary curve, and starts to develop in infancy due to weight bearing caused by learning to sit up and walk.  The low back is especially vulnerable to injury due to its weight bearing task and mobility.

Between each vertebrae throughout the whole spine (except for C1 and C2) is a intervertebral or fibrous disc. The purpose of the disc is to provide cushioning and shock absorption from weight bearing and movement. The intervertebral disc is comprised of the annulous fibrosis and the gel-like centre called the nucleus pulposus – these structures are work together to provide the shock absorption, and are both implicated in disc dysfunction and neurological symptoms.

Facet joints are the articulating surfaces of bone between vertebrae. These synovial joints are known as “plane” joints because their flat surfaces glide over each other. These joints may become inflamed due to injury to the joint or joint capsule itself, or due to compression of the intervertebral discs, forcing them to interact in a “close-packed” position. This close packed position means that the joint surfaces are forced closer together than normal, and will irritate the bone and cartilage during movement as they contact each other and create friction.

During an acute injury, the inflamed tissue in the joints may irritate the nerve roots as they exit the spinal cord via the intervertebral foramina. Eventually, if facet irritation is untreated, bony spurs may develop due to chronic inflammation and cause spinal stenosis – a decrease in the size of the “vertebral foramen” or spinal canal.

In the case of a “bulging” or herniated disc, pressure is exerted on the nerve root as it leaves the spinal cord via the intervertebral foramina. This pinching or pressure on the nerve root will cause sharp, shooting pain, especially when the patient leans forward (flexes) from the hip.  Symptoms will present in the areas that the compromised nerves supply.

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Warm Hydrotherapy for Chronic Injury Pain

The use of warm hydrotherapy, also known in therapeutic massage as deep moist heat, is an excellent way to control and alleviate the pain and achiness associated with chronic injuries.

Most of us have experienced at one point or another the nagging achiness that comes with a chronic injury. Deep, moist heat is an excellent way to help control this pain as a part of homecare, and is also used pre-massage treatment to prepare and warm up the tissues.

Often when an injury has been long-standing, previously damaged muscle fibres have been replaced with tough collagen fibres, aka scar tissue, which reinforce and strengthen a muscle that has been damaged. Collagen fibres do not have the blood vessels that muscle has, and this avascular quality means that decreased blood flow in this tissue interrupts or decrease cell metabolism, oxygen delivery and metabolic waste removal. While scar tissue development is a normal part of the healing process, when collagen fibres are laid down, the muscle becomes more inelastic – unable to elongate and then return to its original length. This affects not only the comfort of the client, but also the power and strength of the affected muscle.

The goals, therefore of deep moist heat in the form of a hydrocollator or thermaphore are:

-         to warm up an area by increasing blood flow
-         increase the delivery of oxygen and nutrients to muscle cells, and speeding up metabolic processes. This decreases pain and achiness.
-         the heat itself will decrease the viscosity of the “ground substance” in muscle tissue, allowing the massage therapist to break down any scar tissue and realign the affected muscle fibres with those of the surrounding tissue

Contraindications for using heat:

-         uncontrolled high blood pressure
-         diabetes or any conditions with neuropathies or altered sensation – the client won’t be able to tell if the application is too hot, and tissue could be damaged
-         any condition where tissue is fragile or circulation has been compromised (i.e. immediately after a cast is removed) – the circulation may be too impaired for extreme heat, so mild applications can be used until the condition of the tissue improves
-         tissue is broken (i.e. a cut, or skin condition such as psoriasis – the tissue is likely already inflamed – heat will make it worse,  and infection can be introduced)
-         metal implants – pins, plates, rods, wire – these will heat up quickly and can really injure a client
-         heat sources should NEVER be placed over major arteries or over the heart

How to use heat properly

You may have never heard of a thermaphore or a hydrocollator, but if you have used a gel pack or grain-filled bag you can heat in the microwave, these same principles apply:

-        heat should only be left on for 20 minutes maximum – any longer and the tissue can get very congested and be even more painful.  You can take it off and use it on another area, or reapply after an hour or so.
-         For hygiene and to prevent burns, the heat source should always be wrapped in a clean towel. For a gel pack (I boil mine on the stove in a cooking pot), I wrap a clean, damp dishcloth around it when it is hot, then a thicker cloth over top. I get the benefit of the moisture that way.
-         it is a good idea to do any stretching that needs to be done after a heat application – you muscles will be much more pliable and stretch more easily.
- use caution if you have taken any analgesics (pain killers), your perception of heat and pain may be off and you could get burned.
-         NEVER lie on a heat source – in the case of a gel pack, hydrocollator or grain-filled bag, it could burst from your weight and you could get seriously burned.

The use of heat in this manner is a great way to control pain from a chronic injury, as well as prepare the muscles in the area for stretching.

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How Does Lactic Acid Affect Muscles?

Lactic acid buildup is often blamed for post workout muscle fatigue and pain, but just how true are these claims, and how exactly does lactic acid affect muscles, fitness and performance?

First of all, let’s get familiar with the basics of the chemical process of energy production in muscle.

In aerobic metabolism, the oxygen that is required by cells to create energy is obtained via respiration. The “energy” that is produced is ATP, or adenosine triphosphate, which is a molecule that is created and stored in all body cells and provides chemical energy for cellular function. ATP provides the energy required for a muscle to contract, and is also necessary for the operation of the muscle’s calcium pump, which is involved in the sliding filament mechanism responsible for muscle contraction.

When the body is no longer able to obtain oxygen from aerobic metabolism, the energy is obtained by a process known as anaerobic cellular metabolism. Activities such as weight lifting, sprinting, or prolonged maximum output activities achieve oxygen deficit quite quickly, where more oxygen is required for cellular reactions than is available. Lactic acid is a metabolic by-product of anaerobic processes.

During anaerobic activities, energy is produced in one of two ways, the first of which involves a reaction between the creatine phosphate that is stored in muscle cells, and adenosine diphosphate (ADP). The creatine phosphate gives its phosphate molecule to adenosine disphosphate, making it “triphosphate”; therefore, the by-products of this reaction are creatine and ATP. The energy produced from this reaction is enough to last about 15 to 20 seconds, or a 100 metre sprint, then it needs to be replenished.

The second process by which anaerobic metabolism occurs is known as glycolysis – the breakdown of glycogen, which is stored energy in muscle. (glycol = sugar or glucose; lysis = splitting). ATP is a by-product of glycolysis, as is pyruvic acid. If there is still not enough available oxygen to produce more ATP in conjunction with pyruvic acid, then the pyruvic acid is converted to lactic acid and is released into the blood stream.

And this is how it happens…

Maximum contraction of a muscle during quick bursts of power, or maximal sustained effort, increases lactic acid production in muscle because blood vessels are compressed and oxygen can’t be delivered to the cells – the aerobic, energy producing pathway is insufficient to allow oxygen to fuel the reaction. As a result, an anaerobic energy production is used, and ATP and pyruvic acid are produced. The pyruvic acid is then converted to lactic acid – therefore, during an oxygen deficit, lactic acid will be the primary by-product of glucose metabolism within a cell.

When lactic acid is released from the muscle cells into the bloodstream, it is taken to the liver usually within 30 minutes of cessation of activity. In the liver it is reconverted to pyruvic acid and released into the bloodstream for further use by muscles, or it is converted to glycogen or carbon dioxide via aerobic metabolism. It is important to note at this point that lactic acid is not necessarily the “bad guy” it has been made out to be, as it still plays an important role in energy production when sufficient oxygen becomes available again.

When large amounts of glucose are used in sustained anaerobic activity, lactic acid accumulates and is alleged to contribute to muscle soreness. The buildup of lactic acid increases muscle cell acidity (hence the burning feeling in muscle) and makes ATP production more difficult. ATP is also required for the sodium-potassium pump which maintains cellular homeostasis. In the absence of ATP, the sodium-potassium pump is unable to correct any ionic (sodium, potassium etc) imbalances in the cell environment, and muscle becomes unresponsive to stimuli.

And don’t forget that the calcium pump, used in muscle contraction, requires ATP to operate. When a deficit of ATP occurs, the muscle fibres are unable to release the “cross bridges” which are created during contraction.

As a result, in either one of the two above case scenarios, the muscle may not be able to relax, resulting in cramping and spasm.

How Can Massage Therapy Assist with Lactic Acid removal?

Ok, so maybe you don’t really care about how this all transpires, and that’s fine. Here is what you need to know about lactic acid if you are a fitness enthusiast:

The claim that lactic acid causes muscle pain has been disproven, as mentioned in the article Lactic Acid Does More Than Cause Fatigue , though it is known to cause fatigue. If this is the case, then my (educated) guess is that muscle pain is caused by micro-tearing and inflammation of muscle fibres due to over-exertion.

There is also some debate concerning the degree of assistance that massage therapy can lend to the removal of lactic acid from muscle. However, as mentioned in my previous article, Massage Therapy, Fitness and Optimal Performance , massage therapy has both a mechanical and chemical effect on the body, and I believe for these reasons, it can have a positive influence on the removal of lactic acid from muscle tissue.

Mechanically, the stretching, manipulation and kneading of tissue will assist in “unhooking” the cross bridge created during contraction and relieve some cramping and spasm. Increasing circulation by this mechanical effect will assist in oxygen delivery and waste removal to and from muscle respectively. In addition, the chemical effects of massage, causing increased blood vessel permeability, will also assist in the process. And, also, don’t forget about the release of endorphins as a benefit of massage, which can help alleviate pain.

To learn more about the physiology behind this topic, please refer to my source noted below:

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What Does Muscle Strain Mean?

Muscle strain is a very common injury treated effectively with massage therapy. What does muscle strain mean, and how does this type of injury happen?

Strain is a term used to describe an injury to the musculotendinous unit, or the muscle and the tendon which attaches it to bone.

Muscle and tendon is known as contractile tissue due to its ability to contract (shorten) and extend (lengthen). This contraction and extension of muscle causes movement, and because of this, muscle strain will be noticed when you attempt to use the muscle, either contracting or stretching it during movement.

There are basically 2 mechanisms of injury which cause muscle strain:  overloading the muscle (too much pressure or weight), or overstretching muscle (think of trying to catch a falling object that is really heavy – weight is suddenly applied to muscle that is stretched. It could also happen, for example, due to a sudden slip or fall.

Symptoms of Muscle Strain:

The symptoms of a muscle strain will depend on the severity of the condition. Muscle strains are classified as mild (1^st degree), moderate (2^nd degree) and severe (3^rd degree).

Mild muscle strains occur when there is some tearing of the muscle or tendon fibres.  While you may still be able to carry on activities at the time of the injury, there is obvious muscle stiffness the following day.  In spite of the discomfort (with or without palpation) and stiffness, there is no loss of function.

In addition to muscle stiffness and soreness, there may be some minor weakness, a decrease in normal range of motion, some minor swelling and spasm, and minor pain with either contraction or stretching of the affected muscle.

Moderate muscle strains may have considerably more (up to 75%) muscle tissue damaged.  At the time of injury, you will be unable to continue activity, and there will be considerable pain. Inflammation will be present at the injury site, with increased muscle spasm and possible bruising.

Severe muscle strains usually result in immediate and complete loss of function due to disruption of the tissue. There may be extreme pain, however, if there is a complete rupture of the muscle or tendon, there may be no pain due to the lack of muscle contraction.  There may be visible and palpable gapping of the muscle tissue.

You’ve just hurt yourself, what do you do now?

Whether you slipped and fell, or were being a hero rescuing Granny’s kitten from a tree, it doesn’t really matter at this point. Let’s just hope it’s a mild strain and nothing more serious.  If you are in a lot of pain, or the body part in question doesn’t look like it usually does, please see a physician or medical professional ASAP who can diagnose and treat the problem.

You should, however, do something about it quickly. “Quickly” is the key word here, as a muscle strain injury (or any other type of injury) that is addressed immediately often is less complicated and takes less time to heal.

For an acute injury, remember R.I.C.E:

R is for Rest – don’t aggravate an injury and cause more damage by continuing on. Stop what you’re doing. Now. Ok, if it’s a mild injury, you may be able to get back to mild activity in a day or two which is good for the body (“mild” is the key) If it’s more serious, then I probably didn’t have to tell you to stop, because you (hopefully) would have anyway.

I is for Ice – great for controlling the degree of inflammation, ice is also great for controlling pain, as we all know. And here is why:

When tissue is injured, inflammation begins immediately in response to the injury. Inflammation is not necessarily a bad thing, as it can stabilize an unstable joint, and will clean away cellular debris and dead cells, increase circulation and cellular metabolism by delivering oxygen and nutrients via blood flow.  Due to this increase in fluid build up in the area, pain is caused because tissue is stretched and the pain receptors (nociceptors) in the tissue are irritated.

I have been made aware by colleagues who are physiotherapists that the “newer” approach is to place heat on an acute injury. Why? you might ask. (I asked the same question). Apparently (in theory) to increase the blood flow will increase the rate of healing. However, I will take this opportunity to respectfully disagree;   based on my experience, my clients who have had this type of treatment have been in absolute agony, as if the injury wasn’t enough.  The use of cold and ice isn’t long term, but in the acute stage, it is a great tool to control pain.

C is for compression – once again, compression will control the degree of edema (swelling) which occurs. It is imperative that it be done correctly; bandages that are too tight will completely cut off circulation, and uneven bandage pressure can also damage tissue. My suggestion is that if you can’t find a medical professional trained in wrapping to do it, than it might be better to forgo it altogether. Remember, too, that the bandage will have to be removed and reapplied at least once a day.

E is for elevation – elevation will help the blood and lymph flow away from the injury site, reducing the edema and relieving pain.

Disclaimer: This information is provided for educational purposes only, and is not meant to replace the advice of your primary health care provider. When in doubt, please consult a qualified medical professional in your area.

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What are the Causes of Low Back Pain

Low back pain is one of the most common conditions treated by massage therapists. I have been asked by countless clients “what are the causes of low back pain?”, and I am afraid to say that there is no simple answer. The causes of low back pain are many, and it is important for clients to understand this, as appropriate treatment approaches differ as much as the causes themselves.

So common is low back pain that I decided to do a little research and try to get some statistics on it.

Here is what I found:

Back pain statistics from the Workers Compensation Board of British Columbia

From 2000 to 2004 WorkSafeBC (Workers’ Compensation Board) received over 107,000 claims for back strains

back strains account for just over 25% of all WorkSafeBC (Workers’ Compensation Board) claims.

Roughly 30% to 40% of all workplace absences in Canada are due to back pain

injuries may be caused by a single instance of overexertion or develop as a result of repeated motion over time.

Over two-thirds of back injuries are a result of overexertion

60% to 90% of the population will experience low back pain in their lifetime

More than 90% of low back pain cases have no specific cause (such as infection, osteoporosis, arthritis, etc.). In these cases the pain will usually subside without treatment in four to six weeks.

In the health care industry, injuries due to patient handling (lifting, transferring, or repositioning) account for about 35% of all accepted time loss claims and for about 40% of claim costs.

So, that’s all fine and well, but while “back strain” appears to be the most common cause of low back pain, and quite a generic term, there are other causes of low back pain. It is very important to identify the cause and contributing factors to low back pain for successful treatment, otherwise clients may just end up wasting time and money.

Falling into each of these 4 broad categories, which I am going to name as causes for low back pain, are several different conditions which I have seen in my practice.

Low back pain cause – Muscle fatigue or strain

Also referred to as a “pulled muscle”, this happens when muscles are overused or is weak. Muscles can also be torn from an injury, and of course, the more serious the damage, the longer it will take to heal …

This is also the primary participant in “soft tissue injuries” – the effects of which insurance companies have lead people to believe are minimal. The reality is that soft tissue injury, and the chronic inflammation which may accompany the more severe injuries, often take longer to heal than the ballpark figure in the insurance tables. However, I digress …

Pain can also be caused by an imbalance of muscle development, or a lack of “extensibility” or “stretch” of the muscles. This is very easy to see, for example, in athletes who may overuse and overdevelop one muscle group. This muscle imbalance is stressful for the body and may cause pain and spasm in the opposing muscle group as the body tries to maintain homeostasis. This lack of balance can lead to “mechanical dysfunction” of the joints of the back (see below). Muscle imbalance, can, however, be treated at home if you know what to do.

Low back pain cause – Joint and bone dysfunction

This type of back pain is often referred to as “mechanical back pain” or “mechanical joint dysfunction” when referring specifically to the joints. What this means is that a joint is not able to move as it is meant to, either from injury to the bone or joint, or hypertonicity of the surrounding muscles (hyper meaning ‘too much’, tone means the amount of tension in the muscle). Unfortunately, this can lead to several other issues and can be a self-perpetuating cycle if left untreated, often causing seemingly unrelated problems.

Of course, bones and joints can also be affected by fractures, breaks, arthritis and a multitude of other conditions which is well beyond the scope of massage therapy to diagnose and in some cases, treat. Massage therapy can, however, be used to alleviate symptoms and assist in recovery.

Low back pain cause – neurological

Low back pain from a neurological source can be a result of a variety of triggers, all of which are related to either the intervertebral disc, spinal cord, or the “nerve roots” as they exit the spinal cord. This type of pain can be excruciating and very debilitating, as anyone with a “slipped disc” will tell you. (this is a bit of a misnomer, and will be addressed in upcoming articles). This type of low back pain usually presents as symptoms in the area which the affected nerve root supplies, so the location of the symptoms is really dependent on the nerve root “level” where the injury or restriction happened. (and often the level of the injury is determined by the presentation of symptoms.) Pain which occurs in one area but originates from dysfunction in another area is called “referred” or “referral” pain.

Low Back Pain – Neurological from Bulging, or Herniated, Disc

Low back pain cause – visceral referral

In some cases pain can be a result of a dysfunction or infection of an internal organ. This happens because the “nociceptors” (pain receptors) of an organ are irritated and the pain is either felt in the skin or tissue which is superficial to (or just above) the organ, or in a classic “referral pattern”. Pain caused by visceral dysfunction can be quite severe.  A classic example is low back pain in the lumbar area which may wrap around a persons front, or extend down the sides of the thighs and into the groin.  This is a referral pattern of the kidneys, and should never be ignored.

Remember, most low back pain is a result of muscle weakness or imbalance. However, if you are not aware of any activity or cause of the pain, the pain is severe, or if the pain has been present for any length of time, I would urge you to see a physician immediately to rule out anything more serious than a muscular cause for the pain. You may also want to check out more information I have found on WebMD.

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My first massage therapy treatment – is it normal to be sore?

A frequent question that I hear from new clients is “My (Aunt Betty) had a massage, and she was so sore she could hardly move the next day. Will I be sore, too?”

We have all heard horror stories about the therapist who had bone-crushing pressure and didn’t listen when asked to back off. I’ve heard another client of mine tell me that when she asked her (previous) therapist to lighten up, the response was “I’m not using a lot of pressure, and it has to hurt to work.”

I’m hear to tell you that this is NOT the case – and that massage can be very effective when applied with moderate pressure. It takes intuition, experience and time to learn just how much pressure the tissue (and a client) can take, and this amount of time varies from therapist to therapist. I’d also like to add that your massage therapist should never brush off indications of pain – as a massage therapist myself I wouldn’t go to someone else who seemed to have no regard for my pain tolerance.

Does Massage Therapy “have” to hurt?

Let me put it this way – it is normal, especially if you’ve never had a therapeutic massage before, for muscles to feel a little stiff or sore after a treatment. I think of it much the same as working out, after all, muscle tissue is being manipulated and worked, so a little discomfort is not unusual. If a person has never been to the gym before, it is not a good idea to ask him or her to leg press 100lbs, any more than it is wise for a massage therapist to put all of his or her weight behind their elbow as they perform muscle stripping on the back of a new client. Either way you look at it, if you’ve never had a treatment before, you have NO idea how your body will react or how much pressure is “enough”, and the therapist really has NO idea what “deep” means to a client. Depth of pressure is very subjective, and pain is a subjective response – what hurts to client A might feel great to client B – there is just no way to tell.

It didn’t take me long to learn that the size of the client has absolutely no bearing on how much pressure he or she can take. I have been able to use deep pressure effectively and painlessly with some very small women, and much less pressure with some very muscular and burly men. My approach is now this – when I first start treating a new client, I use broad, firm pressure, and resist the urge to “go deeper” even at their request. What I tell them before they get on the table is that the first treatment I will be very moderate because I’m not sure of how they will react – they may feel great in the days following the treatment, in which case next time I will go deeper. (here’s a question to consider – does the saying “the customer is always right” apply in this scenario?) If my client feels not so great in the days following a treatment, then I know I need to do something different and will adapt subsequent treatments to suit my client.

In a nutshell, what I would tell a client is that while some discomfort is normal, your request to a therapist to lessen the pressure should never be ignored or brushed off. You are paying for a treatment, and you always have the right to stop or modify what is happening (an FYI in case your therapist doesn’t tell you this.) If you are a therapist, especially a new one, take the time to listen to your client and his or her muscle tissue – not everyone is created the same, and it does take time to learn how much is “enough”. Also, be sure to advise your client of any possible side effects or risks associated with the treatment (informed verbal consent), and let him or her decide what is right for their body.

Massage Therapy and Anatomy – Arthrology Definition

Arthrology is the study of joints.

Joints occur where the surfaces of 2 or more bones meet. An articulation is another term which refers to a “joint”

Why is arthrology important to massage therapy?

Massage therapists work with the musculoskeletal system. Clients may present with symptoms which may be confusing – it is necessary for a therapist to assess a client’s presentation and form a clinical impression – meaning, his or her opinion on the cause of the symptoms. (remember, massage therapists are not permitted to provide a diagnosis).

Muscles cross joints to produce movement, and any joint dysfunction may lead to muscular imbalance and pain. Muscle tone which doesn’t support a joint (hypotonic – meaning not enough tone), or restricts movement too much (hypertonic – meaning excessive tone), may cause pain in the joint itself.

For a therapist to successfully treat the underlying cause of any symptom, he or she must understand the relationship between muscles and the joints which they cross, as well as the anatomy of the joint itself.