essential skills BY BEN E. BENJAMIN 98 massage & bodywork november/december 2008 078-105_MNB_ND_08.indd 98 9/19/08 12:25:56 PM THE LIGAMENTS OF THE SACRUM The Primary Cause of Low-Back Pain, Part 2 In the previous article, we INJURY VERIFICATION Test 1. Flexion A pain in the low back can mean Ask the client to bend forward slowly, began our discussion of the many things, varying from simple to stopping if and when pain is felt and serious, and figuring it out can be a immediately returning to the upright ligaments of the sacral area complicated process. In addition to a starting position. If there is pain, ligament or muscle injury, low-back ask the client to point to the area by examining the anatomy of pain may be caused by cancer, a nerve or areas that hurt. With a normal root compression, spinal stenosis, or range of motion, the person can these structures and the various another serious condition. Whenever touch the floor (image 1, page 101). a client has apparent muscle atrophy, pain patterns they cause when bladder or bowel incontinence, extreme Test 2. Extension limitation of movement, severe pain, Ask the client to bend backward from injured. Here, we’ll move or symptoms of numbnesss, advise that the waist. Again, if there is any pain, person to consult a physician right away. have the client stop, return to the on to look at the assessment The evaluative tests and treatments starting position, and point to the place described below should be used only or places that hurt. With a normal and treatment of these after a physician or other fully trained range of motion, the person can bend healthcare practitioner has ruled out at least 30 degrees (image 2, page 101). injuries. We’ll cover testing the more serious causes of back pain. Tests 3–4. Side-Flexion procedures to determine LOw-BACK ASSESSMENT TESTS Ask the client to bend to one side as far A full assessment of the low back— as possible, stopping if and when there is which structures are injured which distinguishes between injuries pain. Be sure the knees remain straight. to discs, ligaments, muscles, and other Take note of where any pain is felt, and and a range of treatment structures—includes 27 assessment then have the client bend toward the tests and is beyond the scope of this opposite side. With a normal range of options, from exercises and article. Here, we’ll focus on ligament motion, the person’s hand can touch the injuries, which are among the most side of the knee (image 3, page 101). manipulation to specific common and least known causes of chronic low-back pain. Damage to UNDERSTANDING TEST RESulTS friction therapy techniques. ligaments in the sacral area is indicated When the ligaments of the sacrum by the results of three tests: flexion, are injured, there is usually pain with extension, and side-flexion. For each one or more of these movements, with of these tests, have the client begin the worst pain felt in either flexion or in a standing position with the knees extension. The individual generally straight and the feet a few inches apart. feels pain right at the sacrum and may Ask whether the person feels any pain also feel some discomfort across the in this basic standing position. If the lowest part of the back and/or in the answer is no, you’ll be testing whether buttock, thigh, and lower leg. In cases each assessment test brings on pain. where pain is felt only in the posterior If the answer is yes, you’ll be testing thigh and lower leg, it is usually caused whether each test increases the pain. by strains of the sacrotuberous and/ or sacrospinous ligaments. (See images 4-8, pages 102–105, for referred pain patterns from each of these ligaments.) visit massageandbodywork.com to access your digital magazine 99 078-105_MNB_ND_08.indd 99 9/19/08 12:26:07 PM ESSENTIAL SKILLS The most telling sign is the absence exercises can be added as the person’s of certain symptoms that would indicate condition begins to improve. a disc injury. Sprained ligaments cause All of these exercises are done on no weakness or pins and needles, hands and knees. The client will begin just pain and sometimes a numblike with a straight back, with shoulders sensation (not numbness). With a disc relaxed and hands on the floor, injury, pain is almost never referred shoulder-width apart. Have the client down both legs at once and does not do 8–10 repetitions of each exercise, alternate between right and left legs. unless otherwise stated below. With a sacroiliac ligament injury, pain is frequently referred down both 1. The Cat. Arch the back up toward legs and may alternate legs as well. the ceiling and then return to the neutral position, with the spine parallel TREATMENT CHOICES to the floor. Then reverse the curve of Ancient stone carvings of traction the spine into hyperextension, moving devices suggest that human beings the belly toward the floor. Return have received treatment for back pain to the neutral position and repeat. for thousands of years. The sections below give just a partial introduction 2. Side-Flexion. Starting in the same to the range of available treatments, neutral position, move the hips side to covering only those with which I have side like a dog wagging its tail. Think had personal experience. As with all of moving the right greater trochanter treatments, they work some of the toward the right ear, and then the left time, but certainly are not effective greater trochanter toward the left ear. in every case. Often a combination of modalities is required—especially if 3. Weight Shift. Slowly shift so that the client’s body is tense, nutritionally most of the body’s weight is on the deficient, or out of alignment. right hand and right knee, still keeping good contact with the floor with the REST left hand and left knee. Alternate Often a period of bed rest—for shifting weight from left to right. anywhere from a few days to a week— will permit inflamed ligaments to heal, 4. Leg Extension. Slowly extend the at least temporarily. If the person’s back right leg backward, extending the hurts only when doing athletic activities knee and foot so they are parallel or lifting things, the rest period may to the floor and in line with the consist of just avoiding those activities. hip. Return to the neutral position and repeat on the other side. EXERCISE A daily exercise regimen for the low 5. Arm Extension. Extend the back and abdominal muscles can reduce right arm slowly forward until it pain or keep it at bay. I have found comes up to shoulder height, then exercises alone to be only temporarily return to the neutral position. effective, but I often use the ones Repeat with the left arm. described here with my clients as an adjunct to massage and friction therapy. 6. Arm/Leg Extension. Combine Have the client move slowly when the actions described in exercises 4 doing these or any other exercises. and 5, simultaneously extending the He or she should stay within a right leg backward and the left arm pain-free range of motion. In the first forward. Hold for a moment and week, assign exercises 1 through 3, then return to the neutral position. plus the pelvic tilt. The remaining Repeat on the other diagonal. visit massageandbodywork.com to access your digital magazine 101 078-105_MNB_ND_08.indd 101 9/19/08 12:28:17 PM ESSENTIAL SKILLS 7. Pelvic Tilt. Still on all fours, tilt the lower back and pelvis so that the sacrum moves up to the ceiling and then down toward the floor. Keep alternating this motion rhythmically 10–15 times. DEEP MASSAGE Deep massage of the entire low-back and sacral region helps to reduce the tension in this area and speed the healing process. If the client experienced any difficulty or pain on extension (bending backward), Massage tables & linens be sure to place a pillow under the abdomen when working on to body wraps & scrubs. the low back. Also avoid bearing down on the low back with your REFErrED PAIN PATTERNS: massage techniques; this increases ® SUPRASPINOUS LIGAMENTS L4–L5–S1 the extension and can cause pain. REFErrED PAIN PATTERNS: Work on the erectors, quadratus It’s All Here. lumborum, all the gluteus muscles, SACROILIAC LIGAMENTS along the edge of the bony attachment, the piriformis, the hamstrings, starting at the posterior superior iliac and the tensor fascia latae muscles. spine (PSIS). This technique can The gluteus medius muscle needs be tricky to learn without seeing it particular attention; it tends to in person or on video. (To view the get very tight, sometimes develops instructions on video, visit Massage & adhesive scar tissue, and may even Bodywork’s digital edition link available refer pain to the lateral lower leg. on Massageandbodywork.com for a clip from my low-back DVD series.) FRICTION THERAPY To treat the sacrotuberous ligament, Deep massage will be most helpful have the client lie on one side with the if the scar tissue in the ligaments knees curled up as far as possible in is reduced simultaneously through a fetal position. Apply friction along friction therapy. Friction therapy is an the edge of the sacrum between the effective treatment for the superficial PSIS and the coccyx. Work at the sacroiliac ligaments and for the site of tenderness for 5–10 minutes, sacrotuberous ligaments.