My student Thesis from WCCMT 2007

1. The effects of massage therapy andThe effects of massage therapy and
remedial exercise on decreasing lowremedial exercise on decreasing low
back pain, due to a disk Herniation ofback pain, due to a disk Herniation of
L5/S1, and increasing range ofL5/S1, and increasing range of
motion by treating the lumbropelvicmotion by treating the lumbropelvic
region and its surrounding structuresregion and its surrounding structures
Mike ReochMike Reoch
West Coast College of Massage TherapyWest Coast College of Massage Therapy
March 14th, 2007March 14th, 2007

2. INTRODUCTIONINTRODUCTION

3. RESEARCHRESEARCH
 There is a direct correlation between measured lumbarThere is a direct correlation between measured lumbar
flexion and subjective scoring (i.e. Rolland-Morris or VASflexion and subjective scoring (i.e. Rolland-Morris or VAS
score) before and after lumbar decompression surgeryscore) before and after lumbar decompression surgery
(Mannion, 14).(Mannion, 14).
 There is a significant difference between massage andThere is a significant difference between massage and
rest conditions on VAS scale for muscle fatigue. Withrest conditions on VAS scale for muscle fatigue. With
EMG analysis, there was no significant difference toEMG analysis, there was no significant difference to
conclude that massage has an effect on decreasingconclude that massage has an effect on decreasing
muscle fatigue (Tanaka, 2).There may be a difference inmuscle fatigue (Tanaka, 2).There may be a difference in
EMG outcome between type I and type II fibers. ThisEMG outcome between type I and type II fibers. This
needs further research (Tanaka, 6).needs further research (Tanaka, 6).

4. RESEARCHRESEARCH
 Chronic low back pain patients fatigue faster and areChronic low back pain patients fatigue faster and are
weaker than healthy controls in regards to gluteusweaker than healthy controls in regards to gluteus
maximus (a dynamic muscle) contraction. Paraspinalmaximus (a dynamic muscle) contraction. Paraspinal
muscle fatigability was similar in both groupsmuscle fatigability was similar in both groups
(Kankaanpaa, 415)(Kankaanpaa, 415)
 The impairments of paraspinal muscles (multifidus,The impairments of paraspinal muscles (multifidus,
transversus abominis) are not of strength but motortransversus abominis) are not of strength but motor
control of the spinal segmental support system. A motorcontrol of the spinal segmental support system. A motor
learning exercise program has a value to patients withlearning exercise program has a value to patients with
chronic and acute LBP with respect to reducing thechronic and acute LBP with respect to reducing the
neuromuscular impairment and controlling painneuromuscular impairment and controlling pain
(Gwendolen, 115)(Gwendolen, 115)
 There is a correlation between patients with sciatic legThere is a correlation between patients with sciatic leg
pain due to disk herniation and latency for control ofpain due to disk herniation and latency for control of
paraspinal muscles in sudden movementsparaspinal muscles in sudden movements (Leinonen, e370)(Leinonen, e370)

5. ANATOMYANATOMY

6. INTERVERTEBRAL DISKINTERVERTEBRAL DISK
 Degenerative disk diseaseDegenerative disk disease
involves the degeneration ofinvolves the degeneration of
one or more intervertebralone or more intervertebral
disks.disks.
 This is mainly due to aThis is mainly due to a
mechanical and chemicalmechanical and chemical
change in the nucleuschange in the nucleus
pulposus and annulus fibrosispulposus and annulus fibrosis
 The pathological disk mayThe pathological disk may
press on a nerve root whichpress on a nerve root which
can cause radicular pain,can cause radicular pain,
numbness, and/or musclenumbness, and/or muscle
weakness.weakness.
 Decreasing the diskDecreasing the disk
pressure on the nerve rootpressure on the nerve root
and the over expanded diskand the over expanded disk
should help return theshould help return the
patient to a more optimalpatient to a more optimal
condition.condition.

7. MUSCLESMUSCLES
 Several muscles, important inSeveral muscles, important in
providing stability to the pelvicproviding stability to the pelvic
girdle, attach to this fascia andgirdle, attach to this fascia and
can affect tension within itcan affect tension within it
 They include:They include:
 the transverse abdoministhe transverse abdominis
 internal obliquesinternal obliques
 gluteus maximusgluteus maximus
 latissimus dorsilatissimus dorsi
 erector spinaeerector spinae
 multifidusmultifidus
 biceps femorisbiceps femoris

8. TRANSVERSE ABDOMINISTRANSVERSE ABDOMINIS
 The transverse abdominis (TrA) is the deepestThe transverse abdominis (TrA) is the deepest
abdominal muscleabdominal muscle
 It is proposed that the transverse abdominus exerts anIt is proposed that the transverse abdominus exerts an
extensor torque due to the oblique fiber direction of theextensor torque due to the oblique fiber direction of the
posterior layers of the fasciaposterior layers of the fascia
 The suggestion is that the lateral tension of the TrA isThe suggestion is that the lateral tension of the TrA is
converted into longitudinal tension via the obliqueconverted into longitudinal tension via the oblique
upward deep fibers and the oblique downward superficialupward deep fibers and the oblique downward superficial
fibersfibers
 The sum of these oblique angles creates a lateral pull onThe sum of these oblique angles creates a lateral pull on
the vertebra, which helps in stabilization of individualthe vertebra, which helps in stabilization of individual
segmentssegments

10. MULTIFIDUSMULTIFIDUS
 At the lumbrosacral junction,At the lumbrosacral junction,
the multifidus is the largestthe multifidus is the largest
musclemuscle
 The superficial and moreThe superficial and more
lateral multifidi at the lumbarlateral multifidi at the lumbar
junction are responsible forjunction are responsible for
phasic motionphasic motion
 the medial and deep fibers arethe medial and deep fibers are
more tonic in functionmore tonic in function
 therefore, they are responsibletherefore, they are responsible
for stabilizationfor stabilization

11. PELVIC FLOORPELVIC FLOOR
 The deep gluteal muscles areThe deep gluteal muscles are
comprised of thecomprised of the
ischeococcygeus muscle andischeococcygeus muscle and
the piriformis which lie in thethe piriformis which lie in the
same plansame plan
 The Pelvic floor is composedThe Pelvic floor is composed
of the levator ani muscle,of the levator ani muscle,
coccygeus muscle, and thecoccygeus muscle, and the
fascia surrounding itfascia surrounding it
 These muscles and facia formThese muscles and facia form
a muscular diaphragm whicha muscular diaphragm which
supports the pelvic viscerasupports the pelvic viscera

12. PELVIC FLOORPELVIC FLOOR

13. DIAPHRAGMDIAPHRAGM
 The diaphragm is theThe diaphragm is the
primary muscle ofprimary muscle of
respirationrespiration
 Its secondary functionIts secondary function
is to increase intra-is to increase intra-
abdominal pressureabdominal pressure

14. INTRINSIC STABILITYINTRINSIC STABILITY
 The role of the Diaphragm and the pelvic floor, in spinalThe role of the Diaphragm and the pelvic floor, in spinal
stability, are primarily to increase the intra-abdominalstability, are primarily to increase the intra-abdominal
pressure via an increase in facial tensionpressure via an increase in facial tension
 The TrA and the multifidus, with its surrounding fasciaThe TrA and the multifidus, with its surrounding fascia
form a “corset of support” for the lumbropelvic regionform a “corset of support” for the lumbropelvic region
 Unless the transverse abdominis is used with theUnless the transverse abdominis is used with the
diaphragms it will only displace abdominal content Thesediaphragms it will only displace abdominal content These
muscles work together as a local system to stabilize andmuscles work together as a local system to stabilize and
control the lumbropelvic region in healthycontrol the lumbropelvic region in healthy
 Any dysfunction in this local system will cause aAny dysfunction in this local system will cause a
decrease in lumbar stability and it is integral that wedecrease in lumbar stability and it is integral that we
consider this in any rehabilitation programconsider this in any rehabilitation program

15. INTRINSIC STABILITYINTRINSIC STABILITY

18. PATIENT HISTORYPATIENT HISTORY
 The patient is a 38 year old femaleThe patient is a 38 year old female
 The patient presents with pain starting in theThe patient presents with pain starting in the
sacrum that travels down the right buttock, downsacrum that travels down the right buttock, down
the lateral thigh, and into the lateral malleolusthe lateral thigh, and into the lateral malleolus
 she had a CT scan which showed a right distal,she had a CT scan which showed a right distal,
posterior, lateral herniation of L5/S1posterior, lateral herniation of L5/S1
 the patient reports the pain as a 6 or 7 out of 10the patient reports the pain as a 6 or 7 out of 10
on the VAS scaleon the VAS scale
 The pain feels like “a rubber bullet in my nerve”The pain feels like “a rubber bullet in my nerve”

19. ASSESMENTASSESMENT
 H.O.P.N.E.R.SH.O.P.N.E.R.S
 VAS scaleVAS scale
 Controlled intrinsic lumbar muscleControlled intrinsic lumbar muscle
contraction via blood pressure cuffcontraction via blood pressure cuff

20. Treatment goals:Treatment goals:
 Assess LspineAssess Lspine
 Patient exercise educationPatient exercise education
 Decrease and centralize pain that radiatesDecrease and centralize pain that radiates
down right legdown right leg
 Optimize Lspine ROMOptimize Lspine ROM

21. TREATMENTTREATMENT
 A hydrocollator is placedA hydrocollator is placed
on the patient’s low backon the patient’s low back
and left gluteal.and left gluteal.
 Facial heel pull,Facial heel pull,
performed to assess theperformed to assess the
low back and decreaselow back and decrease
any facial restrictions.any facial restrictions.
 Sacral float followed bySacral float followed by
caudal glide of the Iliumcaudal glide of the Ilium
of grade 2 and 3.of grade 2 and 3.
 Passive hip extensionsPassive hip extensions
are done to helpare done to help
centralize the disc lesion.centralize the disc lesion.
 The left sacral hiatus isThe left sacral hiatus is
mobilized with an anteriormobilized with an anterior
glideglide
 Sustained PA glides of L-Sustained PA glides of L-
spine grade 2-3 glides forspine grade 2-3 glides for
10 second10 second
 Swedish techniques onSwedish techniques on
the back.the back.
 piriformis is treated forpiriformis is treated for
trigger points usingtrigger points using
pressure point release.pressure point release.
 The sacrotuberousThe sacrotuberous
ligament is assessed andligament is assessed and
released.released.

22. EXERCISEEXERCISE
 Biofeedback was performed using a bloodBiofeedback was performed using a blood
pressure cuff to read pressure changespressure cuff to read pressure changes
with contraction of the Transversuswith contraction of the Transversus
AbominisAbominis
 This was done with specific verbal cues toThis was done with specific verbal cues to
help facilitate a proper contraction. Overhelp facilitate a proper contraction. Over
time the multifidus were exercised with co-time the multifidus were exercised with co-
contraction of the Transverse abominis.contraction of the Transverse abominis.

23. BIOFEEDBACKBIOFEEDBACK

24. Verbal cue for contraction of localVerbal cue for contraction of local
stability systemstability system
 Slowly and gently draw lower abdomen in.Slowly and gently draw lower abdomen in.
 Imagine there is an elevator inside your pelvisImagine there is an elevator inside your pelvis
 If the elevator has 5 floors stop on the 3If the elevator has 5 floors stop on the 3rdrd
floorfloor
 Imagine a wire connecting your ASIS and drawImagine a wire connecting your ASIS and draw
them together.them together.
 Imagine a wire connecting your PSIS and drawImagine a wire connecting your PSIS and draw
them togetherthem together
 Pull the wire from your ASIS to your xyphoidPull the wire from your ASIS to your xyphoid
processprocess

25. MULTIFIDUS CONTRACTIONMULTIFIDUS CONTRACTION
 The patient is on all fours on the groundThe patient is on all fours on the ground
 The wrists must be under the shoulders and theThe wrists must be under the shoulders and the
patient must have a neutral pelvispatient must have a neutral pelvis
 Cue the contraction of the transverse abominisCue the contraction of the transverse abominis
and multifidus musclesand multifidus muscles
 The patient must keep breathing through thisThe patient must keep breathing through this
 Arm is lifted off ground and then can addArm is lifted off ground and then can add
contralateral leg liftcontralateral leg lift

26. CONTRACTION OFCONTRACTION OF
MULTIFIDUSMULTIFIDUS

27. AQUATHERAPYAQUATHERAPY

28. AQUATHERAPYAQUATHERAPY
 Ten minutes of pool walking in water atTen minutes of pool walking in water at
clavicleclavicle
 Extensions while holding the side of theExtensions while holding the side of the
pool, the water is at chest height.pool, the water is at chest height.
 Hip abductions and adductions for 2Hip abductions and adductions for 2
minutes, flexion and extension for 2minutes, flexion and extension for 2
minutes, and internal external rotation ofminutes, and internal external rotation of
the hip for 2 minutes.the hip for 2 minutes.

29. AQUATHERAPYAQUATHERAPY
 Walk for 5 minutes with the water at the level ofWalk for 5 minutes with the water at the level of
C6 to keep up body heatC6 to keep up body heat
 Neutral pelvis is assessed and establishedNeutral pelvis is assessed and established
 TrA is contracted while standing at water up toTrA is contracted while standing at water up to
the clavicle while maintaining balancethe clavicle while maintaining balance
 The multifidi are exercised with hell extensionsThe multifidi are exercised with hell extensions
into the wall while maintaining correct posture ininto the wall while maintaining correct posture in
clavicle deep waterclavicle deep water

30. AQUATHERAPYAQUATHERAPY
 The next multifidiThe next multifidi
exercise has the patientexercise has the patient
floating on her back withfloating on her back with
a floating noodle undera floating noodle under
her neckher neck
 The core is contractedThe core is contracted
while she lifts either herwhile she lifts either her
left or right arm for 20left or right arm for 20
repsreps
 Next the legs are liftedNext the legs are lifted
with 15 repetitionswith 15 repetitions

31. AQUATHERAPYAQUATHERAPY
 The patient’s multifidiThe patient’s multifidi
are shown to be muchare shown to be much
weaker on her leftweaker on her left
sideside
 This is shown whenThis is shown when
the patient attemptsthe patient attempts
to lift her right leg orto lift her right leg or
her left arm.her left arm.

32. AQUATHERAPYAQUATHERAPY
 Squats are performed while holding theSquats are performed while holding the
wallwall
 The water is at xiphoid height whileThe water is at xiphoid height while
standingstanding
 Last is an active stretch of the gluteals andLast is an active stretch of the gluteals and
quads. The stretch is held for 30-60quads. The stretch is held for 30-60
seconds per muscle groupseconds per muscle group

33. OUTCOMEOUTCOME
 There is a centralization of the pain pattern backThere is a centralization of the pain pattern back
into the gluteal from the lateral ankleinto the gluteal from the lateral ankle
 The VAS was reduced from a 6.5 to a 4.5The VAS was reduced from a 6.5 to a 4.5
 Flexion was increased from 7˚ to 11.5˚Flexion was increased from 7˚ to 11.5˚
 extension was increased from 2˚ to 6˚extension was increased from 2˚ to 6˚
 The patient learnt how to contract her localThe patient learnt how to contract her local
spinal stability system but needs to increase herspinal stability system but needs to increase her
strength and hypertrophy of her multifidusstrength and hypertrophy of her multifidus
 Piriformis muscle testing increased a grade 4Piriformis muscle testing increased a grade 4
with pain to a 5 without painwith pain to a 5 without pain

34. VAS score
0
1
2
3
4
5
6
7
october 14
2006
october 19
2006
october 21
2006
october 28
2006
october 30
2006
november 4
2006
november 15
2006
november 22
2006
december 6
2006
date
score
VAS
pre tx

35. ACTIVE FLEXION OVER TIME
y = 0.0973x - 3786.7
R2
= 0.231
0
2
4
6
8
10
12
14
16
14/10/2006
21/10/2006
28/10/2006
04/11/2006
11/11/2006
18/11/2006
25/11/2006
02/12/2006
Date
Degree
Series1
Linear (Series1)

36. EXTENTION OVER TIME
0
1
2
3
4
5
6
7
8
9
14/10/2006
21/10/2006
28/10/2006
04/11/2006
11/11/2006
18/11/2006
25/11/2006
02/12/2006
Date
Degree
Series1
Linear (Series1)

37. CONCLUSIONCONCLUSION
 According to McKenzie,According to McKenzie,
lumbar flexion canlumbar flexion can
increase by 11˚ betweenincrease by 11˚ between
morning and eveningmorning and evening
 This may have changedThis may have changed
results as none of theresults as none of the
treatments were done attreatments were done at
the same time of day.the same time of day.
 The aquanetic exercisesThe aquanetic exercises
done before anydone before any
measurements may havemeasurements may have
changed the pre-changed the pre-
treatment measurementstreatment measurements
 hydrostatic pressure canhydrostatic pressure can
reduce disk size and painreduce disk size and pain
will be reduced due to thewill be reduced due to the
effects water immersioneffects water immersion
has on the bodyhas on the body

38. CONCLUSIONCONCLUSION
 Aquatherapy is most beneficial to recoveryAquatherapy is most beneficial to recovery
during the initial treatmentsduring the initial treatments
 The goal is to return the patient to being able toThe goal is to return the patient to being able to
perform dynamic and ballistic movements,perform dynamic and ballistic movements,
without pain, on landwithout pain, on land
 The progression from low impact closed chainThe progression from low impact closed chain
exercises to a pre-injury ability is the optimalexercises to a pre-injury ability is the optimal
result for any rehabilitation outcomeresult for any rehabilitation outcome
 A study of this progression would be valuable.A study of this progression would be valuable.

40. CONCLUSIONCONCLUSION
 The patient’s quality of life increased. SheThe patient’s quality of life increased. She
was happy to be able to sit in a car withoutwas happy to be able to sit in a car without
disabilitating pain and was able to sit in adisabilitating pain and was able to sit in a
movie theatre through a whole show.movie theatre through a whole show.

41. CONCLUSIONCONCLUSION
 This study should be repeated with a betterThis study should be repeated with a better
understanding of the BROM deviceunderstanding of the BROM device
 With the practice this practitioner now has, aWith the practice this practitioner now has, a
more precise set of measurements could bemore precise set of measurements could be
reachedreached
 Rotation with the device should be done seatedRotation with the device should be done seated
which was not done during this casewhich was not done during this case
 Seated measurements will eliminate theSeated measurements will eliminate the
movement of the pelvismovement of the pelvis

42. CONCLUSIONCONCLUSION
 The device also showed that prior movementsThe device also showed that prior movements
affected the starting angle of the lumbrosacralaffected the starting angle of the lumbrosacral
jointjoint
 This movement, or creep, can be an indication ofThis movement, or creep, can be an indication of
intrinsic muscle weaknessintrinsic muscle weakness
 It could also be an indication of joint lock at theIt could also be an indication of joint lock at the
SI joint or lumbrosacral jointSI joint or lumbrosacral joint
 This creep could be reduced if eachThis creep could be reduced if each
measurement was taken 3 times and averaged.measurement was taken 3 times and averaged.
Unfortunately, due to perceived pain by theUnfortunately, due to perceived pain by the
patient, this may not be practical.patient, this may not be practical.

43. CONCLUSIONCONCLUSION
 A constant recording of a VAS postA constant recording of a VAS post
treatment would also help to demonstratetreatment would also help to demonstrate
short-term benefits from massageshort-term benefits from massage
treatmenttreatment
 Even a few hours or days of a vacationEven a few hours or days of a vacation
from pain could be beneficial to patientfrom pain could be beneficial to patient
well-being.well-being.