Being Effective in the Subacute States of Healing

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Being Effective in the Subacute States of Healing

Intro to treating subacute clients

Hands massaging back

This blog is devoted to something I do a lot of: working in the subacute stage of healing. If you are working with people in pain one of the worst things you can do as a therapist is be ineffective. But how do you be effective when your patient is in a stage of healing where you cannot use deep pressure or move their limbs around? It’s easy to treat low back trigger points when you can apply some pressure, but what about when you can’t?

In massage school, we were taught that working in acute was cautioned, and that you were to use techniques such as lymphatic drainage, and working compensatory muscles (which usually translates to “far away from the injury”) to treat patients. These guidelines are taught with public health in mind, and by no means am I recommending that you simply ignore them, however, after working for years I found that there are many other steps you can take. They don’t break the rules, they just require more of an understanding of how the body and nervous system work. Today we will look at the low back as an example.

Assessment: making a subacute Symptom Picture

First, get your thinking cap on. In your assessment try to separate the injury itself from the symptoms of the injury. Every injury has a symptom picture, however some of the aspects of the injury are more secondary reflexes of the body, used to protect and heal itself. Let’s look at an example:

A client comes in with low back pain, slightly left of the spine at the SI joint. Yesterday, they were lifting an object and turning at the same time, and they felt a click in the left low back and now they cannot move. You are reasonably sure, based on the symptom picture, that they have done something undesirable to the SI joint area, but of course they can’t move to do special testing. Palpating the site reveals there is heat over the joint but no noticeable swelling and the low back is pretty fixed and seems splinted, as do the glutes. Other than the pain, there are no CI’s and they called their doctor and said it was fine to have a treatment.

So where to start? As I see it, the splinting and the actual injury are two separate things. The injury is that the joint has moved unfavorably to the body and it is irritated and cranky. The side effect of this injury is that the body is neurologically saying, “Oh boy, things are really unstable, we had better build some more structure for this guy fast or things might fall apart.” Most of the pain is actually caused by the splinting pulling on the injured joint.

Treatment of the compensatory muscles

To treat this type of injury, I start by making a plan based on the injury. In this case it’s that swollen hot joint that is being pulled on by glutes, quadratus lumborum, and the psoas/iliacus. Reducing the splinting would help take the tension off the joint, lower the tone of the fascia, and allow fluid movement in the area to boost healing. But all my text books say don’t manually remove splinting by force. So now what?

First I would try and get the tone down by working compensatory muscles. Managing pain is awful; it stresses the body out and often leads to more pain. Getting your client into a relaxed state through working the cervical muscles is a great start. We can do this in prone so that you client does not have to roll over on the table. Focus on getting the shoulders to relax and the scalenes moving. This will signal to the body that its not time to ‘fight or flight’ this should help not just relax the tone, but also  help reduce the pain.

Direct subacute treatment

I’d continue with the treatment by working towards the site of the pain, in this case that is the whole lower back. As we get to the site of the splinting I would have to switch to a much more gentle style of work. Often this is a very gentle and slow, feather light gliding touch over the skin or a light, skin-deep Swedish massage.

While you gently massage, you should be assessing the tone. While working this area, you might notice that although your client is breathing (I hope) the low back and glutes are not moving much. When you watch your client breathe, the chest goes up, but the air stops in the thoracic spine. This is due to the splinting, and while we, as the therapist, should not attempt to remove this manually, the patient can remove it on their own, thereby lowering their own tone, activating the normal muscle pumping and relieving some of their pain.

I want to stress that during this process your job is not to apply pressure in anyway, your hand contact is only enough to palpate the muscle, to cue the client as to where the air should move, and assess the tone. Placing our fingertips on the lateral edge of quadratus lumborum (make sure its the side of the muscle not downward) palpate just deep enough to feel the muscle, your client should feel no pain at your touch. Then ask your client to take a long slow breath. If the air does not move down to where the lower back expands, cue them by saying, “I want you to breath into where my hand is.”

As they breathe in and out, slowly expanding the area, you will likely notice that the tone in the low back falls as does the pain level. This process could take up to five minutes on each quadratus lumborum. This same technique can also be used along the iliac crest (or any area where the client can move air such as the cervical spine) following the line of the top the glutes as the pelvic floor and iliac spine are also affected by breathing. If at any time your client responds with pain, immediately discontinue. For some cases I also put a pillow under the stomach to limit the amount of belly expansion and increase back expansion. Never push the client past where they want to go; at all times they should be in control of this activity.

Analysis and conclusion

Beret Loncar Massage Therapist, Personal Trainer and Yoga TherapistWhat is happening when we do this? A few possibilities exist, actually!

  • In one sense it’s possible we’re not technically doing anything, but the client’s slow, steady breathing stimulates their parasympathetic system, reducing symptoms by proxy.
  • Secondarily, sometimes pain might be signaled due to immobility. By producing the stimulation of movement, the brain could register that the injury is healing and not loosen the tightness around it, giving relief to the client
  • Lastly, your lymph system and some of your circulatory system, is driven by muscle pumping. When you approximate the air flowing into an area, you are also working the fluids like pumping a bellows, which is how the body heals.

I find it extremely helpful to be upfront with subacute clients by managing their expectations. During the intake and consent I will almost always say something along the lines of “it sounds like _____ is happening, but I am not a doctor. We have to treat conservatively until you find out exactly what is going on. We can probably get you more comfortable while you wait however.”

Usually if it was nothing that serious, you have helped them a great deal and the next time you see them it will be to finish up the work that is headed for chronic. If that pain persists , you are confused by a symptom picture or feel unsure in any way, you always refer them out. But by taking these somewhat radical steps and thinking outside the box we have least armed ourselves with an option to treat the client to ease their pain 

Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Massage Therapy Treatments for Low Back Pain

Introduction to back pain

Low back pain is surprisingly common among all Americans and is one of the foremost reasons we miss work. Based on that it is not surprising that we are always looking for ways to solve, treat, or rid ourselves of nagging back pain. The truth is though, our medical system is not the best at treating it.

I am a massage therapist and I love massage therapy but I will be the first to tell you, the number one recommended treatment for back pain is not massage therapy; it is movement. Let’s first clarify what I mean by “recommended.” When I say that what I mean is supported by research and recommended by experts in back pain. Unfortunately that does not mean that recommendation is actually reaching the people in pain. Our medical system is so saturated with other noise that it’s hard for people navigating within the system to find what is best for them.

When you’re ready to a seek medical Massage Therapy Treatment

I gave a short list of questions to go through in a previous post so here’s a condensed version. If you are coming into Body Mechanics for back pain the first thing you need to know is; it is best to come in 3-5 days after an initial injury. You need to be able to lie comfortably on the table during treatment. Please come in unmedicated as well. It is very important that you can accurately feel what is happening to your body while receiving your massage. If you are coming in for more chronic kinds of back pain, the kind that rears its ugly head every once in a while but that you  are very familiar with, you can come anytime – but you may want to time your visit based on the cycle of this chronic pain.

Low back pain can be nonspecific but even without a diagnosis, we can divide it up into a few subcategories:

  • Back pain that is more related to the hip
  • Back pain that is more sacral
  • Back pain that is more located around the spine
  • Pain that is more muscle spasm related to the area between the hip and the last ribs.

We can get into the individual diagnosis, but it may not matter so much in terms of massage therapy because we are treating symptoms. For example, you may hear that massage therapy is treating any of the following: sacroiliac joint pain, labral tears, bursitis, tendinopathy, disc degeneration, disc herniation, nerve impingement or stenosis.

Saying we are treating a spesific pathogy is slightly off  base. We are more managing your body’s response to its pathology.

Massage Therapy for Back Pain that is hip-dominant or is stemming from labral tear, cam impingement or other hip dysfunction

It is important to note that even though the issue may be in the hip, the pain might be felt in other areas, this is called referred pain

We treat back pain that stems from the hip will in a slightly different way than a back injury. Functionally, this type of pain often appears to create spasm in the glutes, the rotators of the hip and the piriformis. It is essential that a massage address these areas fully. Ideally, and with sufficient time, the hamstrings and the back would also need to be treated.

The area should be thoroughly warmed with massage and/or a heating pad first. Restoring internal and external rotation to the hip through range of motion, active release and mobilizations often significantly helps relieve symptoms. Additionally, as the muscles have a lot of bulk, the glutes need to be treated. I frequently work by creating a lot of slack by putting clients into what I call the “froggy position.” I find it helps to relive the trigger points without causing the patient a lot of undue pain. Depending on the type of injury, relief might be temporary or longer-lasting.

Hands massaging the low back
Body Mechanic Licensed Massage Therapist treating hip-dominant pain

Using Massage Therapy Treatment to treat Back Pain that is from Acute injury

If you are coming in for an acute injury treatment is far different. Ideally you would be coming in after you have a diagnosis, and you are out of the initial stages of healing (again, we recommend 3-5 days after injury.) There must be no open wounds, active infection or swelling. That being said, if you are too uncomfortable for massage in the area that is directly affected, there is a fair bit of research that indicates that working with one area of the body can affect another. Check out this research on stretching the hamstrings affecting neck’s range of motion.

Essentially, a massage therapist who is skilled is going to be able to get you more comfortable while you heal. They’ll do this by working on another body part and by just generally relaxing the nervous system. 

Massage for acute areas of pain must be gentle, and focus on relieving discomfort rather than gaining function. Heat or ice may be applied to the back depending on what feels better. Soft strokes such as effleurage, scooping, and techniques that lift the surface of the skin like cupping, might all be utilized. As the massage expands towards the periphery, the strokes can become deeper. If movement is in the therapist’s scope of practice, breathing and tense and relax exercises can all help to signal to the body that it is time for the area that is affected to relax and un-brace. 

Addressing chronic back pain with Massage Therapy Treatment

Massage for back pain that is from a chronic injury is where massage therapy really excels. It is generally safe to use a wide variety of depth, massage strokes and movement. The hips, low back, glutes, and mid-back can all be treated safely and effectively. Ideally, due to their size and potential to create tension in the back, the glutes and rotators are treated first with both movement and massage. Then the therapist would move on to treat the erector muscles along the spine and quadratus lumborum (the deepest abdominal muscle) with stripping and trigger point therapy.

Since therapists have the option to choose from many massage therapy modalities, the best techniques to use are the ones that 1) The patient enjoys, and 2) Are most effective for the situation. Some people naturally respond better to movement, tense and relax, stroking, trigger point or fascia work. Here good listening skills both with the hands and the ears are very useful in deciding how to proceed.

Sacroiliac joint issues and Massage Therapy Treatments

Massage therapy for SI joint issues has a very different plan than other massage therapy plans. The SI joints are small joints to the left and right sides of the sacrum. They have very little movement, and in fact over time, the movement reduces, but they cause a great deal of pain for many people. Since the pain is radiating from a bony area that often feels inflamed and pinched, many people feel relief through ice application to the joint.

Additionally, since it is a joint, we can relieve the tension on it by making sure the muscles around it are relaxed. Treating the quadratus lumborum and the glutes (specifically the cute medius) seem to provide the most relief. Massage and stretching can be applied to these areas to provide the sensation of even pressure across the joint, which helps to relieve the pain.

Summing up

Beret Loncar Massage Therapist, Personal Trainer and Yoga Therapist

There are many different kinds of low back pain and they can present in different ways. While movement is the best way to address it, I think I’ve pointed out some specific and effective ways Massage Therapy can be used to help people in pain. Provided the therapist pays close attention to what kind of massage techniques are safe. Based on where the issues are stemming from and listening closely to the patient’s body and preferences, massage therapy can be a helpful treatment. If you would like to talk to us about what treatment options are right for you, you can reach out to us, send an email at info@BodymechanicsNYC.com!

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Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Can Massage Therapy Help My Lower Back Pain?

Can Massage Therapy Help My Lower Back Pain?

Can massage therapy help my pain? The answer to this question is more complicated than you would think. Massage Therapy research is all over the map. For starters, there are some inherent conflicts with the studies because people LIKE massages. And people are more likely to choose massage over another treatment that they do not like, even if something else could be more effective.

Back Pain is Common

To examine how others have answered the question, let’s start by taking a look at lower back pain in general. Did you know it is normal to have some pain sometimes? Lower back pain is the 2nd most common cause of disability in the USA and a surprisingly common cause of missed work. 80% of Americans will have an episode of low back pain in their lifetime. So you are not alone if your back is feeling achy and sad. 

Back Pain is Often Non-Spesific

Medical professionals are historically bad at treating lower back pain. You might have experience with a doctor suggesting a list of seemingly unrelated treatments for your pain, like throwing a dart at a target with their eyes closed, hoping for a bullseye. That may be because the WHO lists that 60-70% of back pain is “Non-specific,” meaning the cause is unknown. cause.  If we do not know what the cause is, planning the treatment becomes extremely difficult. The National Institute for Neurological Disorders and Stroke lists about 30 different possible causes and contributing factors to back pain alone. 

Research is Complicated and Low Quality

To complicate matters, though massage has excellent research supporting the treatments of both depression and anxiety, the research is rather underwhelming in the area of back pain. Instead, movement is often the recommended treatment. However, massage can incorporate things that are not massage; On table exercise, stretching, mobilizations, and resistance might also be included in your message. So the research that measures the effectiveness of just massages on back pain, isn’t really accurate when a therapist is including these other treatments to help you recover.

Body Mechanics Sports Massage Therapist Matt performing a lower back massage NYC
Sports Massage Therapist Matt massaging a client’s back. Photo credit Adam Ninyo

Pain is Complicated

Muddying the matter further, pain in your back may not solely be caused by an injury. Going back to that WHO the number of 60-70% of back pain being nonspecific, many of us have back pain that chronically exists and isn’t a reaction to a movement or standing or bending. Pain is generated for a number of reasons, the number one being to protect you. Your nervous system takes into a number of variables such as your medical history, your environment, your mental state, your sensitivity, your general physical health and more, before it generates pain as a warning. 

So how do you know if massage is for you and your  back pain?

It is a hard question. I suggest you ask yourself the following:

Massage therapist treating low back pain

  1. Is it safe? I recommend having a diagnosis from a doctor and being out of the range of acute pain before coming in. Even when the diagnosis is “non-specific back pain,” it’s important to rule out other injury as the culprit. Being able to lay still and be touched for the duration of the massage is important, so if your back is too sensitive to touch, wait a day or two.
  2. Am I seeking an alternative route of pain management? When natural and over-the-counter options aren’t up to the task, massage can be a powerful ally in pain mitigation.
  3. Do I like it? If you enjoy being touched and it makes you feel safe, that can be advantageous. Our mental well-being affects the physical, so the boost from treating yourself and the physical connection of massage could help with your pain.
  4. Am I using it in addition with another rehab? If you are in physical therapy, massage can loosen up tight muscles and make a big difference in increasing ease of movement.
  5. Am I additionally stressed or depressed? If you’re burning the candle at both ends or in a stressful time, massage might really help. The trauma of being injured itself can be very stressful and so managing that can be a huge boost to recovery.
  6. Has massage worked for me before? If you have a history of massage working for you it is a good bet that it will work again!

If you answered yes to a few of those questions, then massage therapy might be a great choice for you and your back pain. Check out our booking options for medical massage to see if is right for you:) 

Stay tuned for our next blog on what goes into a good massage for back pain.

Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Medical Massage Therapist Profile – Meagen

Body Mechanics Orthopedic Massage is proud to bring you a profile on another new New York licensed massage therapist that has recently joined our team, Meagen! If you’re suffering from from chronic pain, stuff joints or have had a crick in your neck for a few months, medical massage therapy with Meagen might be for you.

We chatted with Meagen to learn about what makes her personal approach to medical massage stand out and while being effective!


What is your back ground and what drew you to science?

MeagenI have a degree in Occupational Studies of Massage Therapy and outside of that, did some coursework in psychology. I am endlessly fascinated by the human body and physiology, so massage therapy was a natural career choice. 

Can you share one experience treating someone that really impacted your view of treatment?

MeagenI once had a 3-hour session with a pro-lacrosse player with adhesive capsulitis — a frozen shoulder. The treatment was unlike any spa session I’ve done. It included a visual assessment, friction, passive range of motion, and Proprioceptive Neuromuscular Facilitation. The amount of mobility he regained afterward was incredible and it really highlighted just how much bodywork can be implemented in a medical way to achieve quantitative AND qualitative results! 

What is your best “Uh-oh!” story? A time you really F-d up doing something with your body that helped inform your medical massage technique.

MeagenAt one point I got mild ulnar neuropathy* from excessive forearm usage at some clients’ request. It made me realize that a conversation must be had with certain clients for them to understand that deep is not always ‘more effective’ when treating the body with massage. I changed my habits and no longer have the condition. 

*Neuropathy is numbness or pain caused by compression or damage to the nerves.

Do you have a bad science joke you like?

Meagen Why don’t ants get sick?  Because they have little anty bodies!  That one has been gotten more laughs now that we hear about antibodies every day.

If you could try any sport/or amazing physical activity what would it be?

MeagenDiving.

Or What was your favorite class in high school?

MeagenCollege Writing.

What are your favorite kinds of people to work with/what kind of injuries do you like to work with?

Meagen I love to work on people with myofascial restrictions because they get so much relief from each myofascial session! Their joy is contagious!

What sets your medical massage apart from anyone else?

MeagenIt is detail oriented and galvanizing. I don’t just absent massage a body; I can pinpoint the issues clients came in to address and the ones they didn’t know where causing the issues in the first place. Then I teach them how to recognize these matters before they become more significant.

Is there anything we do not know about you we should? (Odd ball facts?)

MeagenAlthough I call New York my home I’m a world traveler, and the one thing I might enjoy more than myofascial release is hula hooping. In fact, I’m a hula hoop champion!

Missed our earlier profiles? Check out our other blogs.

If you want to check out our other massage therapists you can head over to our massage therapist profile page.

Body Mechanics Orthopedic Massage

1 W 34th St
#204,
New York, NY 10001
Phone: 212-600-4808
Email: info@bodymechanicsnyc.com