Key Points

• Incorporating massage therapy into a comprehensive treatment plan for lumbar disc and myofascial pain can help clients achieve improved function, reduced pain, and a better quality of life.

• Massage reduces overall low-back pain, providing greater freedom of movement, an essential part of effective treatment.

Back pain is a prevalent health concern affecting millions of individuals worldwide. Nearly 8 in 10 people will experience some form of low-back pain during their lifetime. Back pain is also a common reason for seeking care from a massage therapist.

The severity of back pain can range from mild discomfort to chronic pain that significantly affects daily activities. Understanding the underlying causes of back pain is crucial for effectively managing these conditions, particularly for massage therapists who provide relief for their clients.

In this article, we explore two of the most common causes of back pain—disc pathology and myofascial pain. We’ll examine the causes and symptoms and the role of soft-tissue therapy in treating these conditions.

Lumbar Disc Pathology

Lumbar disc pathology refers to abnormal conditions affecting the intervertebral discs, with the most common type being herniated nucleus pulposus, also known as a herniated disc. Although often called a slipped disc, this term is a misnomer since the disc does not slip out of position.

The disc serves as a shock-absorbing structure, consisting of concentric rings of fibrocartilage (annulus fibrosus) surrounding a gel-like substance called the nucleus pulposus. Prolonged pressure can cause the inner nucleus to press against the outer annular fibers, leading to the nucleus protruding and changing the disc’s shape. Due to nearby restraining ligaments, the disc typically protrudes in a posterior-lateral direction, often compressing the lumbar nerve roots.

Degenerative disc disease (DDD) is another term for lumbar disc pathology, usually associated with age-related disc degeneration. As we age, the discs lose water content, causing them to shrink and the adjacent vertebrae to move closer together. The reduced space between vertebrae narrows the intervertebral foramen, the opening through which the nerve roots pass, potentially compressing the nerves.

Common symptoms of lumbar disc pathology and DDD include low-back pain, radiating pain or numbness in the legs, and increased discomfort in certain positions. Poor posture and prolonged periods of compressive load on the lumbar spine can exacerbate these symptoms. People with lumbar disc pathology often report relief when moving and discomfort when maintaining static postures.

Physical examination signs, such as shooting nerve-type pain down the lower extremity and a positive straight-leg raise test, may indicate the possibility of lumbar disc pathology or nerve compression caused by DDD. However, high-tech imaging such as MRI is needed for a more accurate diagnosis. It’s worth noting that lumbar disc herniations are frequent among asymptomatic individuals, which means that disc protrusion on MRI doesn’t necessarily correlate with pain complaints.

Nonsurgical treatments for lumbar disc pathology commonly include physical therapy, pain medication, and chiropractic care. Surgery is less frequently used today because of poor outcomes and moderately high recurrence rates. Although massage does not directly affect disc protrusions or DDD, it can still effectively address these problems. For instance, treating tightness in the lumbar muscles may reduce disc compression because when they are hypertonic, these muscles’ angle of pull can contribute to disc compression. Massage also reduces overall pain, providing greater freedom of movement, an essential part of effective treatment.

When developing a rehabilitation protocol for lumbar disc pathology, keep in mind several considerations. The primary focus of treatment is to reduce compression on neurological structures. Massage therapy can be performed concurrently with other traditional conservative treatments, such as manipulation or mobilization, and it is especially valuable if performed before those treatments. Reducing muscle and soft-tissue tension allows these other techniques to be applied with greater ease and less resistance. Movement reeducation to reduce postural stress is also an important aspect of treatment and can be performed along with massage.

Which techniques will be most helpful for lumbar disc pathology depends on the pathology’s location, how sensitive the local tissues are, what movements aggravate the pain, and how long the condition has been present. Treatment strategies to reduce tightness in the lumbar muscles are generally beneficial. Especially valuable are techniques that target the quadratus lumborum and paraspinal muscles because they often increase disc compression forces (Image 1).

The main concern for massage treatment is whether the therapy can aggravate an existing disc condition or further press on the affected nerve roots. Although the protruding disc and affected nerve root are both anterior to the transverse processes of the spine (Image 2), minor amounts of movement of the individual vertebrae can occur as one applies pressure to the lumbar spine. If a disc protrusion is severe, that spinal movement could be enough to slightly move the nerve and disc against each other and aggravate symptoms. Therefore, avoid using a lot of pressure and keep in close communication with your client about symptom changes.

Another concern when considering massage therapy for these problems is that symptoms associated with herniated discs often involve neurological sensations, such as paresthesia, numbness, or motor disturbance in the lower extremity. It is wise to investigate other possible causes of neurological pain. If symptoms are bilateral, cauda equina syndrome (pressure directly on the spinal cord) could exist, and the client should be immediately referred to a physician. 

Myofascial Pain

The most common cause of back pain is myofascial pain, which can result from dysfunction or pathology of the myofascial tissues. Multiple problems fall within that definition and are divided into two categories: mechanical disruption of tissue and neuromuscular dysfunction.

Mechanical tissue disruption occurs when mechanical forces cause injury or damage to the myofascial tissues. Most commonly, these injuries occur from excessive compression or tension forces, such as a high-impact contusion, leading to damaged tissue, bruising, and impaired function. This type of injury is less common than tension injuries due to the nature of the forces the back is designed to withstand.

Tension injuries occur when myofascial tissues are exposed to high tensile loads. The most common pathology resulting from high tensile loads is muscle strain. Remember that a muscle strain is a particular type of injury that indicates overstretching and potential tearing of muscular or tendinous fibers. People are often diagnosed with a muscle strain when they may have hypertonicity or spasm in the back muscles.

Neuromuscular dysfunction is the second category of myofascial pain and includes the most common causes of back pain. Chronic tightness without a specific inciting incident is the most common low-back pain complaint and is often caused by chronic mechanical overload, leading to hypertonicity, which refers to an increase in muscle tension and stiffness. This condition develops when the muscles are trying to protect the spine from injury or strain, which can result from poor posture, prolonged sitting, repetitive lifting, or sudden twisting movements.

Pain from hypertonicity can occur from an acute incident in which the muscles reach a tipping point with a particular movement. The back may have been under chronic loads for some time, and one awkward action was enough to go past the back’s tolerance limit for that particular load. The result is a high-level protective muscle contraction that perpetuates, becoming chronic back pain.

When the muscles in the low back become chronically hypertonic, they can cause discomfort, pain, and limited range of motion. These symptoms can affect a person’s ability to perform daily activities, such as bending, lifting, and walking. The muscles may also develop trigger points, areas of increased sensitivity, and tenderness that can refer pain to other parts of the body.

Symptoms of myofascial back pain can range from mild discomfort to severe pain and disability. In addition to localized pain and muscle tenderness, individuals may also experience decreased range of motion, muscle weakness, and difficulty sleeping.

A detailed client history and comprehensive physical examination remain the most effective way to evaluate myofascial pain problems. No specific assessment test is considered the gold standard for identifying the specific source of pain in the low back.

Massage treatment for myofascial pain has a significant advantage—hands-on therapy allows you to assess changes in the tissue and adapt throughout the treatment. Treatments generally begin with broad gliding applications or superficial myofascial-type approaches. These techniques promote general tissue relaxation and encourage local tissue fluid movement.

After the initial broad gliding techniques, using a more specific and focused treatment strategy with a small contact surface, such as the fingertip, knuckle, or thumb, is often helpful. The thumbs are an excellent simultaneous palpation and treatment tool.

Unfortunately, doing too much work with the thumbs can lead to pain and overuse injury for the therapist. Pressure tools are an excellent substitute for the thumbs because they can still deliver that small contact surface pressure without wear and tear on the joints. Keeping one thumb or finger next to the pressure tool will allow you to feel how the tissues respond so you can adjust accordingly (Image 3).

Working just up to the pain/pleasure threshold is generally safe and preferred when working on hypertonic muscles. Clients usually enjoy the treatment, but if it becomes too painful, the therapist should reduce the pressure or move to another location. The therapist can focus on specific areas or trigger points in the hypertonic muscles to help release the tension.

Stretching and range-of-motion techniques are also essential to restore movement, improve muscle function, and increase range of motion, further reducing muscular hypertonicity.

Conclusion

Massage therapy can play a valuable role in treating lumbar disc pathology and myofascial back pain. Massage therapy is not a substitute for medical treatment, and individuals with severe or bilateral neurological symptoms should seek medical attention immediately. Massage therapy should not aggravate disc herniation symptoms, and one should use caution when performing techniques close to the spine. Techniques that put anteriorly directed pressure on the spine could move vertebrae in a way that aggravates nerve root compression, so pay attention to changing symptoms.

As a massage therapist, it is important to thoroughly understand the underlying anatomy and pathology of these conditions and use appropriate massage techniques to help address them. By incorporating massage therapy into a comprehensive treatment plan, massage therapists can help clients achieve improved function, reduced pain, and a better quality of life.