Definition
Low back pain is defined as pain localized between the lower margin of the 12th ribs and the inferior gluteal folds.
It is important to note that the area covered by low back pain is considerably broader than the lumbar region alone. It includes also the sacral and gluteal region. While this may seem somewhat unusual, we will follow this widely accepted definition throughout the article.
This article focuses primarily on conditions commonly encountered in the practice of a registered massage therapist. Some causes of low back pain, including severe fractures, extensive metastatic disease, and active infections, fall outside the scope of this discussion.
Why Low Back Pain Is Not a Diagnosis
From a medical perspective, the term low back pain by itself provides very little information. Cases grouped under this umbrella may differ substantially in their causes, the structures involved, underlying mechanisms, diagnostic findings, and, of course, treatment approaches.
The practice of grouping such diverse conditions under a single term reflects the importance and prevalence of the problem. It is primarily a statistical and descriptive category used to measure the scope of the issue rather than a medical diagnosis.
For this reason, a diagnosis cannot simply be stated as “low back pain.” In one case, a patient may require little more than exercise and massage therapy, while in another, the appropriate treatment may involve complex surgery followed by prolonged rehabilitation.
Classification of Low Back Pain
Partly because the term low back pain encompasses many different conditions, numerous classification systems have been proposed. Each serves a particular purpose, and none is perfect.
A detailed review of all classification systems would add little practical value for a massage therapist. Instead, to illustrate the wide variety of conditions that may be grouped under this umbrella, we will use a simple structural and anatomical classification.
This approach is based on the structures involved and therefore reflects the tissue source of symptoms. For clarity, the major pathological mechanisms are also included.
- Muscles and tendons — strain, spasm, injury.
- Ligaments — sprains and microtears.
- Intervertebral discs — degeneration, tears, disc herniation.
- Facet joints — cartilage and capsular involvement, degeneration, and injury.
- Bones — osteoporosis, trauma, and tumors.
- Nerve roots and their coverings — compression and irritation. These are often affected as a consequence of processes listed above.
- Sacroiliac joints — dysfunction and inflammation.
It should be noted that in real clinical practice, several causes may coexist, creating a much more complex presentation.
Involved Structures
The classification above demonstrates the wide variety of structures and tissues that may be involved. As a result, both diagnostic approaches and treatment strategies can vary considerably, ranging from a simple history and physical examination to advanced diagnostic investigations.
Viewed from a slightly different perspective, some categories in the classification represent not so much the primary source of the problem as its consequences. The most important example is the involvement of nervous tissue, which may occur as a result of several different pathological processes.
Nervous Tissue Involvement
For example, Intervertebral disc disorders may produce symptoms directly, but they may also affect nearby nerves and cause a very different clinical presentation. A similar situation can occur with pathology involving muscles, ligaments, and other structures.
Regardless of the underlying cause, nerve involvement often produces a characteristic pattern of symptoms. Pain is typically sharp, burning, or “electric” in nature, radiates along the course of the affected nerve, and is frequently accompanied by numbness, tingling, or pins-and-needles sensations (paresthesia). For this reason, signs of nervous tissue involvement have important diagnostic value.
Other Tissues
In the absence of nervous tissue involvement, the clinical presentation is determined primarily by the affected structure and the nature of the underlying pathological process.
A detailed discussion of the characteristics associated with different tissues would require far more space than is justified and would provide limited practical value for a massage therapist.
In everyday massage therapy practice, the most common problems involve muscles and ligaments. Despite the significant differences between these conditions, a client interview alone is often enough to identify the most likely direction for further assessment, which can then be refined through physical examination and specific tests.
Pathological Mechanisms
Returning once again to the classification above, it is easy to see that the mechanisms underlying these pathological processes are not especially diverse. They include traumatic injury, tissue overload, muscle spasm, degenerative changes, and other similar processes.
These mechanisms are often associated with situations commonly encountered by massage therapists. Prolonged sitting in an office, physically demanding work, repetitive lifting, sports activities, and similar factors may all contribute to the development of the pathological processes described above.
The mechanism behind a condition can often be identified, or at least suspected, during the client interview and history taking. For this reason, the circumstances surrounding the onset of symptoms have important practical value.
Was the onset sudden or gradual? Were the symptoms preceded by physical activity, prolonged sitting, an awkward posture, or an injury? Answers to these questions help identify the most likely mechanism underlying the pathological process.
Massage Therapist’s Approach
Even if you do not diagnose medical conditions or attempt to fully determine the cause of low back pain, it is still worth spending a few minutes on a preliminary assessment before treatment. Doing so helps avoid obvious mistakes and provides a better understanding of the limits of your professional competence.
Why Perform an Assessment?
Before beginning treatment, it is useful to establish two key facts:
- How serious the condition may be.
- Whether the client has been evaluated by a physician.
If symptoms are severe, the condition is worsening, or other concerning signs are present, the massage therapist should carefully consider the limits of their role and competence.
If the client has already been examined by a physician, the most serious causes have often been considered or excluded. If no medical evaluation has been performed and the presentation raises concerns, recommending a medical consultation is a reasonable course of action.
If the client reports a traumatic injury, the possibility of damage to different structures and the associated limitations should be taken into account. It is also useful to clarify the extent of any previous evaluation. There is a significant difference between having X-rays, ultrasound imaging, or an MRI performed and receiving only a brief interview without a thorough examination.
This information is important not only for treatment planning but also for your own professional protection. For this reason, the information collected should be properly documented.
An Alternative Classification
While not strictly scientific, a massage therapist can often divide cases of low back pain into two broad categories for practical purposes.
Complex Causes — conditions that require medical evaluation and treatment. These include structural spinal disorders, degenerative conditions, systemic diseases, and other problems that fall outside the scope of massage therapy.
Simple Causes — relatively straightforward and self-limiting conditions associated with muscle overuse, excessive or unusual physical loading, prolonged sitting, awkward posture, and similar factors. In many cases, these conditions respond well to conservative management, self-care, and massage therapy.
Treatment Strategy
If there is reason to suspect a serious problem (Complex Causes) that requires further investigation, a cautious approach is advisable, and the client should be encouraged to seek medical evaluation.
It is important to explain the reasons for this recommendation and the potential consequences of delaying or avoiding further assessment.
In such cases, a registered massage therapist should proceed conservatively. Massage treatment for low back pain should avoid aggressive techniques, forceful joint mobilizations, and excessive stretching until the nature of the condition is better understood.
If the presentation is more consistent with Simple Causes, a more confident approach may be appropriate. A low back pain assessment can be performed to identify the most likely involved structures and any possible compensatory mechanisms.
Based on the findings, the massage therapist can develop a low back pain treatment plan and proceed with massage therapy. In many cases, therapeutic massage, exercise, and other conservative treatment approaches may be appropriate.
Throughout treatment at a massage clinic, the client’s response, symptoms, and overall progress should be monitored. If low back pain symptoms fail to improve, worsen, or new symptoms appear, the initial assumptions should be reconsidered and further medical evaluation may be warranted.