Remedial massage, Deep tissue massage, Sports massage, Swedish massage, Myofascial release, Neuromuscular release, Soft tissue release, Trigger point massage, Lymphatic massage … the list seems endless. But what is the difference between the various types of massage?
When we were studying at the Northern Institute of Massage the then principal, Eddie Caldwell, would often be asked by new students what the difference was and if the Institute taught them. His answer was yes they ran courses for different types of massage but would add “do you know, at the end of the day it’s all skin rubbing”. Now this isn’t strictly true. There are differences, and they don’t just involve rubbing of the skin. But Mr Caldwell’s down-to-earth approach always manages to put things into perspective.
Massage, although an ancient art, is constantly being updated as variations in procedure or new therapeutic techniques are added to the toolbox. Unfortunately these new techniques are often padded out, inflated and given a new name in order to create a whole new therapy. It might be cynical to suggest that the reason for this is for marketing purposes or to sound more scientific and to distance themselves from the word ‘massage’. It’s hard not to think, when meeting such a therapist, ‘get over yourself you are a masseur!’
On the positive side, even if these techniques don’t justify the creation of a whole new therapeutic modality or proprietary brand, they can be useful tools to have at your disposal as a therapist.
Multiple types of massage can be used to treat a patient in the clinic. The skill is deciding what mix of techniques is best suited to an individual patient’s needs. A patient suffering from stress needs a different form of massage to someone with a frozen shoulder. These in turn requires a different treatment plan to an athlete who wants to improve performance. In some ways there are as many different types of massage as there are patients.
So, bearing this in mind, we can define the different types of massage recognising that each represents just one string to the therapist’s bow.
remedial : adjective
giving or intended as a remedy or cure. Example ‘remedial surgery’ Remedial masseurs are trained to recognise and treat musculoskeletal conditions such as back pain, stiff neck and shoulders, sciatica and knee injuries. A typical treatment may include massage, mobilisations, tractions, rehabilitation exercises/stretches, postural assessment and a mixture of the techniques described below used for therapeutic effect.
The classic massage. A straightforward, no frills but very effective massage for general aches and pains. Also an excellent stress buster. It usually incorporates the neck, shoulders, back and legs. The term isn’t recognised in Sweden. Not surprisingly they just call it massage. The popularisation of this type of massage is often wrongly accredited to Peter Henry Ling, a Swedish gymnastics teacher in the 1800s. In actual fact, it was Dutch practitioner Johan Georg Mezger who which developed ‘Swedish massage’ as we know it today, and adopted French names like ‘effleurage’ and ‘petrissage’ to denote the basic strokes that we perform.
A form of massage geared towards amateur and professional sports people. One of the oldest recorded forms of massage dating from early martial arts in the far east to the ancient Greek and Roman games. Homer writes in the poem The Odyssey of Greek soldiers being rubbed with oils to aid their recovery and regain strength on return from battle.
Deep Tissue Massage
Deep tissue massage is a type of massage aimed at the deeper tissue structures of the muscle and fascia. The term is often used to distance the therapist from the lightweight ‘beauty therapy massage’. A bit unfair to beauty therapists many of whom can give a perfectly decent massage. Getting through the layers of muscle is more subtle than you might imagine and requires persistence and coaxing as well as firm pressure. Just digging in demonstrates inexperience or a lack of training. Many people like a deep massage as the pain produces large amounts of endorphins (the body’s own painkiller) that gives a natural high. However, overdoing it can cause the muscle to react badly causing more tightness than before.
Soft Tissue Release
Soft tissue release (or STR massage) is a technique of assisted stretching of muscle fibres, tendon and fascia. STR involves repeatedly and quickly stretching small areas of the soft tissue. Precise pressure is applied to part of the muscle which is then moved to achieve a very specific stretch. An interesting and popular form of therapy, especially useful if adhesions are present in the tissue.
Trigger Point Therapy
A trigger point (TrP) is a small area of muscle that is exquisitely painful and tender to pressure. When pressed it produces a recognisable and reproducible pattern of referred pain away from the site of the trigger point. We use TrP therapy to get rid of these nasty little blighters.
As well as TrP release this also includes the very effective Muscle Energy Techniques (MET) and Positional Release. Neuromuscular techniques are a recommended and powerful skill set for any Remedial masseur.
A type of massage which encourages the natural drainage of the lymph, which carries waste products away from the tissues.
Fascia is a thin, tough, elastic type of connective tissue that wraps most structures within the human body, including muscle. Fascia supports and protects these structures. All types of massage will involve treating the fascia to some degree, it fact it would be hard not to! Myofascial techniques claim to isolate and release fascial tension by using gentle sustained pressure on the tissue.
Although it is a useful exercise to define the different types of massage, I have never understood a therapist defining or limiting themselves to a specific skill set. This would be like a carpenter limiting themselves to just using a hammer. As long as a therapist has taken the time to study and train in the therapy and as long as it is covered by their insurance and recognised by their professional body then there is no reason why a therapist shouldn’t expand their repertoire. The availability of high quality courses makes acquiring new skills and learning new types of massage a natural part of Continuous Professional Development.
Let’s cut to the chase. The answer to the question ’is massage an art or a science’ is that it is both. Massage is one of the oldest practical arts and one of the newest sciences.
Ok, that was easy enough but now we have answered that question let’s take a closer look at what we actually mean by massage being an art and a science.
Art in this context could be defined as: the application of human creativity and imagination using practical and personal skills. Science is the pursuit of knowledge and the exploration of the world based on evidence.
Put simply science teaches to ‘know’ and art teaches to ‘do’.
The Art of Massage
The art of massage involves more than the practical skill of a well developed sense of touch and may involve the following:
Being intuitive is not an excuse for woolly mindedness or delusional thinking. It is a practical way of making sense of a complicated and immediate situation. An instinctive strategy for dealing with novelty in an urgent and complex world. This may involve carrying out tasks and making decisions partially below the threshold of conscious awareness – this is very different from performing a task mechanically or mindlessly. It is a natural and very human ability that comes with experience. If you have ever learnt a musical instrument you will remember how at first you needed to concentrate hard on every note. Eventually you can play automatically without immediate focal awareness of individual notes. It could be argued that the tune has just been memorised but that doesn’t explain how experienced musicians can jam and play skillful variations in real time. Making clinical decisions intuitively, on the fly, is akin to this creative musical process.
“Therapists must be able to think along multiple lines and often think on different levels at the same time.”
Jones & Rivett (2004)
Finding relationships between signs and symptoms, joining the dots and seeing the big picture is an essential skill for any therapist. And just as importantly, recognising when a relationship doesn’t exist and interpreting the meaning of the relationship correctly.
Seeing patterns is a natural and extremely useful function of the brain, the downside to this is that we have a tendency to find patterns in random data that aren’t there. It even has a name – Apophenia is the spontaneous perception of connections and meaning in unrelated phenomena and figures prominently in conspiracy theories, pseudoscience and the misinterpretation of statistics and scientific data.
Taking an holistic approach
Few words will have science fundamentalists frothing at the mouth more than ‘holistic’. The holistic approach is often sneered at as hippy, new age nonsense. This is because science traditionally reduces and dissects the world to study it (we will look at why this is a useful thing to do later). An holistic view means recognising that natural systems should be regarded as a whole and not just as a collection of individual parts. The workings of biological systems are dependent in large measure upon the total setting in which they occur.
Few medical conditions are simple and straightforward and most involve the interplay of very many factors including physiological, psychological and socio-economic that require multifaceted solutions. Scientists are now beginning to investigate how our emotional state can affect our immune system and modern pain management models recognise that the patient’s fears, attitudes and beliefs are just as important factors as tissue damage. Research has demonstrated that for some patients just imagining movement of a painful joint can cause inflammation in that joint!
Empathy and communication skills
The ability to understand and share the feelings of another person is an art in itself. It’s often the case that those people who think they are good at this aren’t. Empathy is different from sympathy. Feeling pity and sorrow for someone else’s pain and misfortune isn’t necessarily helpful and may be viewed as patronising behaviour. Sympathy may be a driving force in wanting to help someone but empathy enables us to understand how we may best accomplish this. This is one advantage we have as masseurs. We get to spend time with people and can empathise and treat them as individuals. Therapists need strong verbal and nonverbal communication skills. Patients begin healing the moment they feel they are being listened to and understood.
A sense of salience
Recognising what is relevant and important. A new therapist may ask every question and carry out every measurement and every test in the book. An experienced therapist will know when it is expedient to cut corners and avoid an information overload. But we have to be careful. The risk here is that we have a tendency to see what we believe. If we make an early assumption about a patient’s condition we may only carry out tests and ask questions that confirm our beliefs rather than challenge them. This is the complacency of experience.
Use creative thinking
Creative thinking involves learning to generate and apply new ideas. Seeing existing situations in a new way, identifying alternative explanations and finding novel solutions to an individual’s unique problems. Eddie Caldwell from the Northern Institute of Massage needed to get creative when one of his elderly patients needed to carry out exercises on the vastus medialis as part of her knee rehabilitation. She wasn’t a member of a gym nor did she own any weights. The solution had to involve things she would have around the home. An oven glove hung over the leg with a tin of beans in each pocket did the job perfectly.
Being open minded
“Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won’t come in.” Isaac Asimov
Open-mindedness engenders a willingness to question current thinking and practice, to be receptive to emerging possibilities, to share ideas and to consider differing perspectives. Therapists need to be willing to revise firmly held views on the basis of evidence.
The Science of Massage
The science of massage involves a logical and analytical approach that could involve the following:
Quantifying and measuring
Much of science involves taking measurements. Massage therapists can record Range of Movement (ROM) using an instrument called a goniometer. Comparing these measurements to normal ranges has to be done with caution as what is normal for one person may not be for another. Measuring ROM is useful to monitor changes over time, to demonstrate improvement to a patient and also as evidence if conducting research and compiling case studies. To some degree pain can be quantified using numerical scales. Again this is useful to compare changes over time but has limited value when making comparisons between different patients as pain is subjective.
Care has to be taken when quantifying and recording data that the emphasis doesn’t shift from looking, thinking and understanding to depending on tables of measurements. We are health workers not accountants.
Taking a reductionist approach
Reductionism is the belief that the world can be explained by breaking it down into smaller component parts. It does not mean we are simplifying things: on the contrary the closer we look at something the more detail we see. Most special tests we use in the clinic aim to isolate specific body tissues in order to assess them, and whenever we study the physiology of the human body in close detail we are taking a reductionist approach. Reductionism gives us high definition whereas an holistic approach may allow us to see the interconnectedness between things but we will lose the detail. Being able to switch between the two ways of examining the world is a useful ability.
Using critical thinking skills
If being open minded is part of the art of massage then doubting and questioning everything we know and learn is part of the science of massage.
Doubt is the origin of wisdom
…or as G.P. Ann Robinson suggests “keep your skepticism wrapped around you like a cloak”. Critical thinking involves interpreting, analysing, evaluating, reasoning. This includes appraising, questioning and testing rather than just accepting new ideas. Being skeptical is not the same as being cynical! We may have our reservations about some techniques we come across but should be willing to give them a go. In this case we apply the “do no harm” rule. Some techniques may be dropped after a trial period if they prove to be ineffective, others may be excluded if we believe the risks outweigh the benefits such as spinal manipulation and ‘neck cracking’.
Being familiar with latest research
There is an increasing amount of research being carried out on the musculoskeletal system and on the various methods of treatment for the associated injuries and conditions. However care has to be taken. The scientific method is robust but it is still a human being who implements and interprets the research. All research will be flawed or limited to some degree (see a brief discussion of this in the notes below). It is a good idea to pool the evidence from lots of different trials and case studies. Luckily for us the Cochrane network carries out systematic reviews of health care research and is recognised as the highest standard in evidence-based health care resources.
This can be as simple as getting feedback from patients or using measurements as described above.
One way to monitor the success (or non-success) of a technique is to compile case studies. It is important to record the failures as well as the successes.
Using evidence based practice
EBP is an approach to making quality decisions and providing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic.
Keep training up-to-date
This involves not only learning new skills but also revisiting and revising old ones. Acquiring knowledge and being able to use and act on that knowledge as part of lifelong learning is important for any therapist.
Continuing Professional Development (CPD) refers to the process of tracking and documenting the skills, knowledge and experience that are gained both formally and informally as we work, beyond any initial training.
In conclusion, analytical thought and creativity are two sides of the same coin. It is unnecessary to place these disciplines into separate silos.
Most geniuses, from Da Vinci to Einstein seem to have been highly creative as well as logical and analytical. Research on Einstein’s brain (preserved in two jars apparently) has shown he had a very high degree of interconnectedness between areas of the brain associated with logic and creativity. Few of us fall into this category but it does suggest that massage therapists and other healthcare workers should develop this crossover thinking and find the balance between logic and intuition, science and art, in order to provide the best treatment for their patients.
Notes, References and Further Reading
Main Image: HEALTH, 2009, Get Color. Album cover detail.
Discussion: Limitations in research
The observer effect in science recognises that any observation will affect the system being observed. Think of measuring the pressure of a car tyre, impossible to do without letting out some air. In physics the observer effect can be minimised to make it almost insignificant but in biology and particularly medicine it is difficult to isolate the subject from the observation technique.
We like to think of science as being objective but the way we decide if the result of our research is significant is by using an arbitrary statistical figure! As a general rule, the significance level is arbitrarily set to 0.05 (5%)
There is a difference between recognising the limitations of research and flawed or fabricated data. If researchers or their sponsors have a vested interest in the results then this is almost certainly going to introduce bias. Researchers should always declare potential conflict of interest that might introduce bias. For most researchers a positive, significant or interesting result is normally going to be the preferred outcome and this could potentially introduce a subconscious bias; researchers are human after all. In surveys asking about the falsification of data, admission rates were 14.12% for falsification, and up to 72% for other questionable research practices. Sadly this is a conservative estimate of the true prevalence of scientific misconduct. Believing in research can be an act of faith and we are more likely to trust the research if it supports our own world view.
Different research is often contradictory, this is only to be expected and is a normal part of the scientific process. This is why we have to pool the results from many different trials. But until an adequate consensus is reached we are left trusting our instincts and making educated guesses.
In some cases, even when the evidence from research is overwhelming and when a rational consensus has been reached it may be dangerously ignored by policy makers. This is hardly the fault of science but it places a huge collective responsibility on all researchers to get it right as poor research that is uncovered, and it always is eventually, will very quickly be held up as counter evidence and other valid researchers will be guilty by association.
Sometimes the basic premise of the research is flawed. For example, a good deal of research on back pain and the efficacy of different treatments and techniques is flawed even before the research begins. Back pain is not a medical condition or disease it is a symptom. In the same way as a cough is a sign that can be caused by a many medical conditions from colds and allergies to cancer. A technique that helps with back pain caused by a prolapsed disc may not help with back pain caused by a tight psoas or tight quadratus lumborum or any of the multitude of other causes of back pain. Lumping together all these conditions makes the results from the research at best worthless and at worst misleading.
The reductionism of science works well for the physical sciences but in medicine it often takes the research so far out of context that it becomes meaningless.
Research can be limited by sample size and selection, duration and location amongst other factors.
After the research is complete the statistical analysis and interpretation of the results is often flawed and research can be overblown both by researchers and the press.
Despite all these limitations and flaws, science is still a very powerful tool and the best we have but perhaps its pedestal should be a little shorter.
The organism: A holistic approach to biology derived from pathological data in man. Goldstein, Kurt Salt Lake City, UT, US: American Book Publishing The organism: A holistic approach to biology derived from pathological data in man.(1939). x 539 pp. http://dx.doi.org/10.1037/10021-000
Pattern recognition Eysenck, Michael W.; Keane, Mark T. (2003). Cognitive Psychology: A Student’s Handbook (4th ed.). Hove; Philadelphia; New York: Taylor & Francis. ISBN 9780863775512
We all know that regular exercise has many health benefits, from improving mood, energy levels and self esteem to lowering the risk of developing dangerous conditions and diseases, but this knowledge isn’t always enough to put our best laid plans into practice! If it was as easy as that, we’d all be super fit, but the truth is that many people do not engage in regular exercise and many who start an exercise programme lose heart and drop out very quickly.
We’re much more likely to make a habit of behaviours that bring us pleasure, and to avoid behaviours associated with pain or displeasure. This is known as Hedonic Motivation.  People are far more likely to stick with a programme of exercise if they actually enjoy doing it. In a population-based mail survey of 1,332 adults, ‘respondents reporting high enjoyment and preference for physical activity were more likely to report high levels of activity’.  It’s much easier to invest precious time and energy into something that makes us feel happy.
An effective way to start getting into exercise is to find an activity that you enjoy doing, and that suits your personality and body type. A 2016 study  found ‘enjoyment of exercise to be a key factor associated with physical activity.’
The gym has many benefits, and we wouldn’t knock it – you can measure your development, use high-tech equipment, get personal training, and it’s a convenient, safe place to go on dark nights after a day at work. It’s not for everybody though. Some people get bored at gyms, find them intimidating, would rather learn a skill, or prefer to be outside. There is also the risk of isolating specific muscle groups for aesthetic purposes (e.g working solely on the biceps, pecs and abdominal muscles), which can cause imbalances and lead to injury. Body image and fitness are not the same thing. There are of course the usual alternatives such as running, football, cycling, yoga and pilates, but in this blog we are going to be looking at a few other activities that are fun, interesting and give you a full body workout.
“Walking is the nearest activity to perfect exercise.”
Professors Jerry Morris and Adrienne Hardman 
Walking is surprisingly effective for improving fitness – a recent study has even found that it is more effective than running for reducing heart disease risk when the same amount of energy is expended. 
Walking Works (PDF) is a recent report by the Ramblers and Macmillian Cancer Support which summarises the physical and psychological benefits of the simple walk.
Just 30 minutes walking per day will fulfil the Chief Medical Officer’s recommendations of 2 hours 30 minutes of moderate physical activity per week.  Currently In England, only 66% of men and 56% of women claim meet this recommendation. Most of us could make small changes to our routine to build half an hour of walking into our busy days – walking to work, swapping the ‘desk picnic’ for a walk round the block during lunchtime, taking the stairs, parking a bit further from the supermarket – we all know the drill! Try one of the many smartphone pedometer apps and wearables such as the Fitbit to keep track of your activities. Check out these 7 free walking apps recommended by the British Heart Foundation.
Walking is free, can be done anywhere, at any time, requires no special equipment, and you certainly don’t need to be ‘sporty’ to do it. If you need a bit more inspiration, listen to this 3 Minute Epiphany on the joy of walking by David Mitchell on the calming effects of walking, and how it helped his bad back – ‘I almost never don’t feel better after going for a walk.’
Another great benefit of walking is that you getting out and discover new places. If you live in the Plymouth area, have a look at the Visit Plymouth website for downloadable walking trails and maps.
Surfing is close to our hearts here at The Muscle Clinic. We are spoilt for choice for surfing beaches here in the South West and although we’re very far from being experts, we love to get out into the waves on a weekend.
Surfing is an intense, all over body workout that builds muscle strength, flexibility, and cardiovascular health. You quickly build strength in your arms and upper body from paddling out and in your legs when pushing up to a standing position and riding the waves. Standing up on the board quickly improves core strength, balance and proprioception. Proprioception  is the ability to sense where our body parts are in space without having to look, and balance is the ability to control this. This helps to prevent falls and injuries.
The image of the chilled-out surfer is not just a cliche. A 2009 study  showed that ‘a single 30-minute bout of surfing significantly increases positive affect and tranquility as well as significantly decreases negative affect and fatigue’. These findings were true regardless of age and skill level.
If you are new to surfing we’d recommend that you start with a few lessons as it’s not the easiest skill to pick up on your own. For those in the Plymouth area, try Discovery Surf at Bigbury. It’s a friendly surf school that runs surf clubs, kids’ lessons, and offers half price lessons for locals.
Archery relies very much on mental concentration and visualisation, and considerable emphasis has been placed on the psychological approach to training and performance. The absolute focus required from an archery session is the ultimate in mindfulness, and can have a very calming effect. ‘In fact, when it comes to archery remember that if what you are doing is instinctive, devoid of analytical thought, and pure in intent … then you are practicing a form of meditation.’  If you are interested in this, you might want to read the philosophy classic, Zen In The Art of Archery.
However, any archer will tell you that the sport is just as demanding on the body as it is on the mind, and both must work together to develop an effective technique. Drawing a bow builds strength in the shoulders, arms, hands, chest, and core. The correct placement of feet, hips, shoulders and head requires a good deal of co-ordination and with practice this can really help to improve the posture. You will do more walking that you expect as well, with all those trips back and forth to retrieve your arrows!
If you would like to try archery in Plymouth, contact Yelverton Bowmen. They are very welcoming and offer one off taster sessions and 6 week beginners courses. Anyone can get involved from children to senior citizens, disabled and able bodied.
Climbing can be really thrilling, and is an excellent full-body workout, combining strength, stamina, and cardio fitness. It’s great for building upper body strength but you don’t need huge biceps and shoulders to be a climber (take it from me!). From using core strength to keep your balance, to pushing off explosively with your legs, all of the muscle groups in the body are challenged during a climb. Climbing is low-impact – you’re not jumping or pounding along a pavement – so it is a good way to build strength and fitness without putting stress on your joints.
Stretching to reach foot and handholds is excellent for improving flexibility, and puts a lovely gentle traction on the spine. A 2016  study found that climbing has a positive effect on chronic low back pain. 30 low back pain patients between 18 and 45, with no climbing experience, climbed for at least an hour a week, for 8 weeks. The results were significant, showing increase in range of movement and decrease in disc protrusion. We have recommended climbing to some of our massage patients who suffer from chronic, non-specific muscle pain. They have absolutely loved it and found it to be a life-changing activity.
You can climb on an indoor wall or outside on a rock face. There are some great climbing locations in the UK from Dartmoor, to Snowdonia, the Peak District and Lake District. Climbing can be dangerous, so if you’re just starting out, we would recommend that you find an experienced partner, or get some lessons first, to get a good grasp of the basics of ropes, gear, and navigation.
Dart Rock Climbing Centre - YouTube
Stoke Dameral Climbing Club in Plymouth is a friendly and affordable way to get into climbing. Dartrock offer indoor climbing courses at Marjons and Buckfastleigh, and tuition on local outdoor routes.
Roller Derby isn’t something we have tried, but we have included it here because we know a few roller derby players, and they are passionate about their sport. Roller Derby is played on 4-wheeled roller skates, and is a full-contact team sport. It improves cardio fitness, all-over strength, balance and endurance, and is a great way to build self-confidence.
Roller Derby has a badass reputation and has been described as ‘team boxing on roller skates.’  It is great for developing teamwork skills and encourages fair play, cooperation and respect for one another. Although there are mens’ teams, Roller Derby made its name as a womens’ sport, empowering women to be strong, athletic and powerful, and part of a close-knit community that has loads of fun.
A January dip in the chilly sea is not as crazy as you might think. It provides many health benefits including a huge endorphin boost. Endorphins can make you feel euphoric, and are the body’s natural painkillers, so regular cold water swimming can help to soothe muscle aches and pains. It is also said to help relieve depression.
Getting into cold water causes a mild stress on the immune system, and this helps to strengthen it by giving it a bit of practice. Significant increases in white blood cell count were found when scientists from the Czech Republic immersed willing subjects in cold water for one hour, three times a week and monitored their physiology. 
Other long-term benefits of wild swimming include improved circulation, lower blood pressure and cholesterol, reduction of fat disposition, inhibited blood clotting and increased fertility and libido – so what are you waiting for?! Actually, it’s probably best to slowly acclimatise yourself to the cold – either use a wetsuit to start with, or begin at a warmer time of year and ease yourself into the colder weather.
‘If you like to swim under a blue sky with no barriers, no chlorine and no limits’ and would like to go out swimming with others, get in touch with Devon and Cornwall Wild Swimming.
The final item on our list is dancing. Whether it’s letting loose on the dancefloor on Saturday night, Salsa, Lindyhop or Ballet classes, dance brings many health benefits as well as being great fun. It’s brilliant for cardio fitness, improves balance and flexibility, and helps keep bones strong, preventing osteoporosis.
You might think dancing is just for young people, but it’s a really beneficial social and cultural activity for older people too. It keeps the mind sharp and the body active. Regular dancing is linked with a 76% reduction in dementia risk  and can help slow the development of Parkinson’s.
Dancing is a bit of a love/ hate activity – some people could never be persuaded to get up and dance, whereas others absolutely love it. This is sometimes a question of confidence, and if you feel you have two left feet but want to give dancing a try, give something like Jazzercise a go: you are guided through every move, it’s lots of fun, and no-one is judging your dancing skills.
We hope this list has helped provide some inspiration to try something a bit different. Have you found a sport or activity that you love? Let us know in the comments.
In cycling folklore, the man with the hammer is a mythical figure who waits around the next bend, or halfway up a steep hill and will hit you hard with his hammer. The effects of the blow come on suddenly, causing a total collapse of both body and mind.
Most endurance athletes will be familiar with the ‘wall’ when a perfectly good race will be ruined by a sudden onset of extreme fatigue. Our energy levels are depleted and every muscle in our body is shouting ‘stop’. The man with the hammer is a significant step up from this and is caused by the unholy triad of glycogen depletion, dehydration and a failure of thermoregulation that can rapidly become a medical emergency and can cause collapse and even death.
A meeting with the man with the hammer can be avoided. Here are a few things you can do to keep yourself going for longer:
The Man With The Hammer - Trailer - YouTube
Glycogen is a polysaccharide of glucose that serves as a form of energy storage. It provides the fuel your muscles need to work. Unfortunately the body can only store a certain amount of glycogen (up to 2000 calories worth). So you need to make sure your glycogen stores are full before setting out. This is known as ‘carb loading’ and requires you to increase your intake of high quality protein and carbohydrates, such as rice, oats, chicken, salmon and beans for up to three days before the event. This will last you about 90 minutes, so it’s also important to take in fast-release energy during the ride itself. Sports drinks, energy bars and dried fruit are great for this.
Dehydration occurs when your body loses more water than it takes in. When we lose too much water (more than about 3 or 4%), the balance of minerals in our bodies becomes upset. Symptoms of dehydration include being thirsty, having a dry mouth, feeling lightheaded and loss of strength. Extreme dehydration can cause hallucinations, heatstroke and collapse. So what can you do?
Don’t wait until you’re thirsty – drink before you start, and little and often from the beginning of your ride, and take a few good gulps every 10-15 minutes. Plain water is fine for rides of up to 60 minutes, but for anything longer than this you will need to replace the electrolytes and carbohydrates that you have lost. The best thing to do is experiment with different sports drinks and find one that suits you. Its essential to rehydrate after you have finished the ride. In recent research, milk has been shown to provide more effective rehydration after the event than sports drinks or water, due to additional energy, protein and sodium it contains.
In a road race pacing isn’t easy because tactics and team strategy complicate the issue but in a straightforward ride for a PB or a long training session finding the optimum pace can help avoid the man with the hammer. It’s tempting to set off quick and put a few miles in the bank for later but unfortunately you’re actually burning through your available energy store proportionally quicker and will burn out much sooner. Here is one interesting statistic from the world of running. Every world record distance event had been set by running the first half of the race slower than the second half.
Physical exertion in hot conditions can generate heat beyond the body’s ability to cool itself. Natural cooling mechanisms such as sweating are not as effective in high humidity. Alcohol and stimulant drugs such as amphetamines also reduce the body’s ability to cool itself.
If you are going to be cycling for an extended period in a hot climate, give yourself time to acclimatise. This is more than a psychological adjustment. The body’s salt content of sweat and urine decreases as people acclimatise to hot conditions.
How Not To 'Hit The Wall' Or 'Bonk' – GCN's Guide To Fuelling While Cycling - YouTube
The Man with the Hammer is a new play currently showing at the Theatre Royal Plymouth. It’s a uniquely physical piece of theatre, in that the three actors spend the entire play cycling. Here at The Muscle Clinic we are giving massage treatment to the three actors to help with their challenging and unusual training regime.
We watched the play this week and thoroughly enjoyed it. It is a compelling story on many levels, exploring the limits of human potential as well as the flaws that make us human. It is extremely well researched, and will appeal to cycling fans. As well as the complex relationship between father and daughter and existentialist issues such as obsession, addiction and lies, it deals head-on with many topical issues around cycling, such as the physiology of the sport, doping, the body’s response to pain… and the fabled ‘man with the hammer.’
The Man with the Hammer is unlike any play you’ve seen and is well worth a trip to the theatre. It is showing at the Theatre Royal Plymouth until March 26. It is written by Phil Porter and stars Timothy Chipping, Jonny Holden and Harriet Slater.
Our next blog will look at our addiction to pain and the body’s response to it.
A common question we hear at the Muscle Clinic is “How long will it take to recover from my injury ?” Managing recovery expectations is an important but difficult part of what we do as therapists and predicting recovery times, even providing ballpark figures, is not straightforward. As long as the patient is aware of the limitations it is OK to give general guidance on recovery times but if a formal prognosis is required they should be referred to a doctor.
In this blog I aim to discuss the main factors involved in recovery times for soft tissue injuries and in the next we will look at possible reasons why the recovery might be taking longer than expected.
The major recovery time factors are:
Cause of injury, location and tissues involved
Grade of injury
General health and medication
First aid and remedial treatment
Recent evidence suggests that the cause of an injury can affect healing time.
Compare running at high speed with overstretching – both can cause apparently similar soft tissue injuries at the same anatomical location, the hamstring for example, but have very different healing times. In this instance the overstretching injury can take much longer to heal.
The location of an injury makes a big difference to the healing time. Chest wall muscles involved in breathing and neck muscles involved in sustaining postural stability and controlling head movements, take longer to heal as they have little time to rest.
Different tissues regenerate at different rates. As a rule of thumb, the greater the blood supply to the tissue the quicker the recovery time. So muscle heals quicker than tendon and tendon heals quicker than ligament. It’s even been said that breaking a bone is preferred to spraining a ligament as ligaments have a very poor blood supply and can take some time to heal.
Grade of injury
Injuries are normally graded from one to three.
Grade 1 involves a tear of only a few tissue fibres with minor swelling and discomfort accompanied with a minimal loss of strength or range of movement.
Grade 2 involves greater damage with a substantial loss of strength and movement. These injuries are often the most painful and as you would expect there is a correlation between the volume of tissue injured and rehabilitation time.
Grade 3 occurs when a tear extends across the entire cross-section and completely ruptures the tissue. This can be a disturbing sight as the muscle bunches up at one end towards the joint. Interestingly the pain from a grade 3 can be less as the muscle cannot contract and put strain on the injury.
There is little doubt that aging negatively affects the recovery process and is responsible for an overall reduction in muscle mass (sarcopenia) but why should this be the case? I have heard the old car analogy used to explain this. Old cars get rusty and worn out and so do we. However this doesn’t explain why, as recent research has shown, transplanted muscle heals at the rate associated with the age of the recipient and not the donor. Other experiments have demonstrated that, when a younger animal shares its circulation with an older animal, this creates a reversal in the decline of regenerative capacity. Perhaps vampires had it right all along!
Recent studies suggest that oxytocin may be one of the secret ingredients in blood that promotes regeneration of muscle tissue. Dubbed the love hormone by the press due to its effects in modulating social behaviour including bonding between couples, creating trust and stress reduction. Oxytocin has been found to activate a cellular cascade that triggers growth and proliferation of tissue and is produced in lower quantities as we age.
However, until a safe and effective treatment has been developed to reduce the negative impact of aging we will have to include advancing years as a factor in calculating the recovery time for injuries.
General health and medication
A patient with generally poor health may expect a slower recovery time. Chronic illness will put added strain on the body and often the medication will exacerbate the problem. The use of anticoagulants and immunosuppressants, such as corticosteroids have been shown to inhibit the body’s repair process. The use of NSAIDS such as Ibuprofen have also been linked to slowed recovery times for soft tissue injuries There is a strong correlation between increased healing time and smoking, obesity and alcoholism. The general health of the patient is an important factor in estimating duration of recovery.
First Aid and remedial treatments
Speed of recovery might not be everything. The quality of the repair is also important and will be affected by early decisions in the remedial treatment of the injury.
Muscle healing involves two competitive processes, scar tissue formation and muscle regeneration. Scar tissue makes for a rapid repair but inhibits muscle formation. Immobilising an injury reduces scar tissue but the new muscle fibres will not be laid down in an orderly fashion, resulting in weaker muscle. A balance needs to be found, the ideal being a short period of immobilisation followed by early mobilisation. However, an exception may be made in cases of severe ankle sprains. Studies have found that people whose ankle joint was immobilised for 10 days with a short cast recovered normal ankle function more quickly than those who were treated using exercise soon after the injury occurred.
The application of ice, as an analgesic and to reduce inflammation, is the recommended first aid protocol. However, some inflammation is essential and is important for healing and protection from infection. Care is needed as over-icing may inhibit this process. Ice on its own (as opposed to alternating ice and heat) should only be used in the very early stages of an injury. Over-icing may also promote the formation of scar tissue and adhesions reducing the quality of the repair. Ice slows down the healing process and should be used sparingly.
Osteoarthritis is an inevitable consequence of getting older
It is commonly thought that osteoarthritis is due to wear and tear as we age – but this isn’t inevitable and is far from the full story. There are several factors thought to increase the risk of developing the condition including genetics and having a joint injury in the past, especially if it was overused before it was given enough time to heal. Recent studies suggest osteoarthritis may be caused by activation of a chain reaction in the bodies defence mechanism causing low grade chronic inflammation.
Regular massage therapy can lead to improvements in the sypmtoms of osteoarthritis
Recent studies on the effects of massage for arthritis symptoms have shown regular use of massage therapy led to improvements in pain, stiffness, range of motion, hand grip strength and overall function of the joints. Arthritis Foundation
Osteoarthritis is made worse by being big and heavy
It isn’t so much about how big you are and more about how much fat you are carrying. Interestingly, the loss of body fat is more closely related to symptom relief than the loss of body weight, it has been suggested that there may be a metabolic link to body fat as opposed to just excessive strain on the joint. British Medical Journal
Massage therapy is useful in the treatment of osteoarthritis of the knee
X-rays are the best way to diagnose osteoarthritis
In fact x-rays aren’t especially useful in diagnosing osteoarthritis and can be misleading. The severity of the symptoms may be totally unrelated to how the joint appears on x-ray. The majority of people over 40 show some signs of osteoarthritis (seven out of ten people over the age of seventy show signs) although most don’t develop symptoms. On the other hand some people have a perfectly normal x-ray but suffer excruciating symptoms.
Massage can lead to reduction in pain for people with arthritis
Regular massage of muscles and joints, can lead to a significant reduction in pain for people with arthritis, according to Tiffany Field, PhD, director of the Touch Research Institute at the University of Miami School of Medicine. Arthritis Foundation
Bats and sloths are the only known animals that do not develop arthritis
It has often been quoted that bats and sloths are the only known animals that do not develop arthritis – the reason being that they don’t put as much pressure on their joints because they hang upside-down. Nice theory, but not true – bats have been found with arthritis of the knee and carpal joints.
Osteoarthritis causes nodes on the finger joints
Bony enlargement on the end joints of the fingers (Heberden nodes) or on the middle joint of the fingers (Bouchard nodes) are a sign of osteoarthritis of the hand.
Joints are like the bearings on a car which wear out the more you use them
Cartilage in the joints isn’t inert; it is living tissue capable of regeneration. Recent research showed that running significantly reduced arthritis and hip replacement risk. The benefits of exercise include lower body fat and stronger muscles protecting the joint (studies have shown that people with weak thigh muscles are more likely to develop osteoarthritis).
Osteoarthritis pain usually worsens through the day
Osteoarthritis pain tends to get worse through the day whereas other types of arthritis tend to be worse in the morning or remain the same during the day.
However, osteoarthritis can cause stiffness in the morning but this usually lasts for less than half an hour.
Cracking your knuckles can cause arthritis
Doctor Donald Unger cracked the knuckles of his left hand every day for more than sixty years, but he did not crack the knuckles of his right hand. He did not develop arthritis or other ailments in either hand. This earned him the 2009 Ig-Nobel Prize in Medicine, a parody of the Nobel Prize. Researchers from the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA, carried out a study – “Knuckle Cracking and Hand Osteoarthritis” – published in the Journal of the American Board of Family Medicine (April 2011 issue). This did not show any link between knuckle cracking and osteoarthritis. If cracking is accompanied by pain, there could be underlying abnormalities of the structures of the joint, such as loose cartilage or injured ligaments. No one knows for certain what causes joints to crack but the most likely theory involves cavitation within the joint— where small cavities of partial vacuum form in the synovial fluid and then rapidly collapse, producing a sharp sound.
High heeled shoes can increase your risk of osteoarthritis
Although no type of shoe can prevent osteoarthritis some types are better than others. Flip flops and tennis shoes with flexible soles can ease the symptoms of OA and high heels can make it worse. MedicineNet
Cod liver oil ‘lubricates’ the joints
It’s not true that cod liver oil ‘lubricates’ the joints, but they have been found to help relieve pain and inflammation if you suffer from rheumatoid arthritis. They are also showing some promise in people who suffer from osteoarthritis.
Further reading and references
‘Medical Conditions and Massage Therapy – A Decision Tree Approach’
‘Massage for Orthopedic Conditions’
A Meta-Analysis of Massage Therapy Research
A meta-analysis was conducted of studies that used random assignment to test the effectiveness of Massage Therapy. Mean effect sizes were calculated from 37 studies for 9 dependent variables. Single applications of MT reduced state anxiety, blood pressure, and heart rate but not negative mood, immediate assessment of pain, and cortisol level. Multiple applications reduced delayed assessment of pain. Reductions of trait anxiety and depression were Massage Therapy’s largest effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy. American Psychology Association
Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy
In this article the positive effects of massage therapy on biochemistry are reviewed including decreased levels of cortisol and increased levels of serotonin and dopamine.
Department of Pharmacology, Duke University Medical School, Durham, North Carolina, USA
Correspondence: TIFFANY FIELD, Touch Research Institutes, University of Miami School of Medicine International Journal of NeuroScience
We are pleased to have moved into a new, larger treatment room at the end of November 2014. The Muscle Clinic is still based at The Millfields Trust HQ, but we have taken a bigger room, which is much nearer to the reception area. The new room is much quieter and warmer, with more space to move about.
We have been doing more double treatments recently, with couples, family members, or friends, and the new room makes this more comfortable.
We’d like to say thanks to the Millfields Trust in Plymouth for continuing to support The Muscle Clinic. Here are a couple of pictures of the new room:
Most of us will have heard friends or family say that they suffer from increased aches and pains in muscles and joints during cold, wet and unsettled weather, and some have personal experience of this. Others dismiss it as an old wives’ tale, but it’s a claim that pops up in cultures all over the world, and throughout history.
Hippocrates noted, around 400BC, the effects of winds and rains on chronic diseases in his book Air, Water, and Places (1).
In Asia and China, ‘rheumatism’ is translated as ‘wind wet disease.’ (2).
In Shakespeare’s A Midsummer Night’s Dream, Titania speaks of ‘contagious fogs’ and ‘distemperature’ in which ‘Rheumatic diseases do abound’
This is a good point to note that ‘rheumatism’ is an old-fashioned term for aches and pains anywhere in the body. It is no longer used in medical literature, but today ‘Rheumatology’ means the study of joint diseases, including the many types of arthritis.
The types of conditions and diseases which often said to be associated with ‘weather pain’ are indeed those which cause chronic pain in the muscles and joints.
These include rheumatoid arthritis, osteoarthritis, phantom limb pain, scar pain, gout, trigeminal neuralgia, and non-specific low back pain (3). Weather patterns that have been studied in relation to pain are: temperature, barometric pressure, precipitation, humidity, thunderstorms, sunshine, and increased ionization of the air.
So is there a link between the weather and muscle and joint pain? A number of studies have been conducted, with mixed results. It’s challenging for scientists to analyse something so subjective as peoples’ experience of pain, when other factors are undoubtedly involved, such as level of exercise, mood, and diet. Also, many arthritic conditions have a cyclical nature of flare and remission. Add this to the variable patterns observed in the weather, and it is likely that at some point these will match up. It’s human nature to look for patterns and to notice coincidences, and some of the more sceptical reports believe that this is what’s happening (4). However our own clinical experience tells us that there is a link between muscle and joint pain and weather conditions, and it’s worth taking a look at some specific studies to try to find out what’s really happening.
Recent research has focused on the possibility that changes in atmospheric pressure may be responsible for increased pain in those with arthritic conditions or chronic pain, specifically just before or during a spell of low pressure, and the cold and damp conditions that accompany it. As air pressure drops, air molecules and gases expand. The theory is that low pressure causes gases and fluids in our joints to expand in a similar way, causing pressure on nerves and sensitising them to pain. In addition, in an area of microtrauma, such as an arthritic joint or scarred muscle, tissues of different densities may expand and contract in different ways to those beside them, increasing stiffness and pain (3). There is no conclusive evidence to prove this theory. A 1995 study claimed of 557 people concluded that ‘changes in barometric pressure are the main link between weather and pain’ (5). A population-based survey of 2491 people between the ages of 25 and 60 living in the North West UK in 2005-6 found that
‘pain reporting was higher on days with the lowest average pressure, but the relationship with pressure was inconsistent and there was no evidence of any trend in the relationship. The strongest relationship with pain reporting was with hours of sunshine and daily average temperature.’ (6)
The survey discovered that
‘Participants who completed the questionnaire on days when the temperature and hours of sunshine were highest were significantly less likely to report any pain and were approximately half as likely to report pain that was chronic and widespread.’
In general, we feel happier and more relaxed when the weather is warm and sunny and perhaps less likely to notice or report pain.
We hunch ourselves up when we are cold, making muscles tighter and less mobile. When it’s sunny we have more exposure to vitamin D, which fortifies our bones and cartilage. Studies have shown that osteoarthritis patients with low levels of Vitamin D experience a worsening of their symptoms (7). We also know that warm muscles are longer and more supple – this is why we ‘warm up’ before exercising to avoid injury, and apply heat to sore muscles to relieve pain.
Packing up and moving somewhere with a warm, sunny climate is not the answer, although it can help temporarily. Evidence suggests that when people move to a warmer climate, they feel better for the first few months, ‘but then their body acclimates to that weather pattern and they start feeling just like they did before.’ (9) So don’t to pack your bags just yet, but there are actions that you can take to help minimise aches and pains through the winter months.
Crucially, on warm, sunny days, people are much more likely to exercise. The human body is built to move, and regular exercise is the best thing we can do for our general health. This is especially true for those who have arthritis and other painful conditions of the muscles and joints (8), though it is important to do a level of exercise that is appropriate for you. If you are already in pain, the idea of exercising may seem overwhelming, but gentle movement of any kind is better than no movement at all.
Regular exercise will ease stiffness, strengthen muscles, improve circulation, help to control weight – putting less strain on joints, help maintain bone density, improve sleep and boost mood. All of which help to prevent pain.
After a fantastically warm and sunny year, the nights have well and truly drawn in, there’s a chill in the air, and many of us are preparing to go into hibernation on the sofa, with a cosy blanket and a hot chocolate. It’s great to keep warm, but don’t be afraid to complement this with regular exercise and movement to help you feel fitter, healthier and happier, and stave off those aches and pains. And try to get outside on those rare sunny days!
So, while there is no definitive evidence as to whether the weather can influence musculoskeletal pain, there are many anecdotal reports that it is the case. What do you think? We’d be interested to read your comments.
There have been a number of occasions at the muscle clinic where a decision not to treat has been made, and instead, the patient was referred to a doctor or A&E. On two of these occasions there was a strong suspicion of Deep Vein Thrombosis in the leg and in both cases this proved to be correct.
A DVT is a blood clot that has formed in a deep vein, more often than not in the legs or pelvis.
Recognising the symptoms of DVT are important for any massage therapist as the condition can lead to serious complications including pulmonary embolism, where the blood clot breaks loose and travels to the lungs, a situation that is potentially fatal.
So what are the signs and symptoms of Deep Vein Thrombosis?
Unfortunately, in up to half the cases there may be no signs at all. But the following should make us alert:
Pain in one or both legs
Pitting edema. This is swelling that when pressed with a finger leaves an indentation for a few seconds when released.
Redness and warm to the touch.
Tenderness along path of deep veins
Engorged veins at the surface of the skin
Recent long haul plane flight
Period of immobilisation such as a stay in hospital or leg in a cast
Recent major surgery
Trauma or minor leg injuries
Active cancer or treatment within 6 months
Recent Venous Catheters in the neck, chest or groin
Inflammatory Bowel Disease e.g. Crohns
History of DVT
Blood group other than type O doubles the risk
Age over 40
Oral contraceptives or Hormonal Replacement Therapy
Pregnancy or postnatal (6 weeks)
Although passive dorsiflexion of the foot can elicit pain (Homan’s Sign) this cannot reliably confirm or exclude the condition. There are many other conditions that have symptoms similar to DVT including muscle strains and special diagnostic tests are required in order to confirm DVT and may include a D-dimer blood test and Doppler ultrasound.
So when should we refer a patient?
There is a useful scoring system we can use to assess the probability of DVT called the Wells Score. Questions are answered and points allocated accordingly. Wells scores can be categorized as high if greater than two, moderate if one or two, and low if less than one, with likelihoods of 53%, 17%, and 5% respectively.
Active cancer (treatment within last 6 months or palliative): +1 point
Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point
Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point
Unilateral pitting edema (in symptomatic leg): +1 point
Previous documented DVT: +1 point
Swelling of entire leg: +1 point
Localized tenderness along the deep venous system: +1 point
Paralysis, or recent cast immobilization of lower extremities: +1 point
Recently bedridden ≥ 3 days, or major surgery requiring regional or general anaesthetic in the past 12 weeks: +1 point
Alternative diagnosis at least as likely e.g Bakers cyst or muscle damage: −2 points
Low back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. 80% of the population will experience low back pain at some time in their lives.
Recent research suggests that the amount of benefit from a massage treatment was more than that achieved by joint mobilization, relaxation, physical therapy, self-care education or acupuncture. (see further reading and research below).
Most back pain is actually muscular or ligamentous in origin rather than skeletal, therefore vertebral manipulation or invasive surgical procedures (with the risk of adverse effects) is rarely necessary.
About 19 out of 20 cases of acute low back pain are classed by doctors as non-specific. It is called non-specific because it is usually not clear what is actually causing the pain. In the vast majority of cases it is not due to a serious disease or serious back problem, but the pain itself can be very severe and is debilitating as it hinders movement, strength and flexibility. It is only natural that we want to know the exact cause of the pain and it can be frustrating both for the doctor and the patient not to have a clear cut reason for it.
Surprisingly x-rays and other scans are not always helpful in this situation and may be misleading:
More than a third of people without back pain would show some signs of disc ‘abnormality’ such as bulging, herniated disc or degeneration. It would be tempting to identify a similar abnormality in a back pain sufferer as the cause of their symptoms when it may be a red herring and not the cause of their pain at all.
It works the other way too. There may be internal disc disruption (IDD), which may cause pain, without any anatomical distortion, so in this case the scans appear normal.
Also, the technical jargon you will see on scan reports can sound alarming, when in fact the scan is just showing results that are perfectly normal for your age. This can cause unnecessary worry that may hinder recovery.
Acute low back pain that isn’t associated with any kind of trauma is not normally something that requires a doctor’s visit and will normally improve with the help of massage and other conservative treatments.
We will discuss these and other self-help measures later but first we need to exclude other conditions that do require examination by a doctor and further tests would be strongly advised.
See a doctor if you have any of the following:
Loss of bladder or bowel control or an inability to pass urine.
Numbness around your genitals, buttocks or back passage.
Muscle weakness in the legs or feet.
Pain that is worse at night or is constant pain that isn’t relieved at all by lying down.
Fever or unexplained weight loss.
Swelling or bruising in the back.
Recent trauma such as a fall or car crash.
Any other unusual symptom that has appeared around the same time as your back pain.
If you are in any doubt whatsoever see your doctor for a checkup and advice.
What is the cause of non-specific low back pain?
Just because low back pain is described as non specific by a doctor doesn’t mean you are imagining it or that the pain and disruption associated with it isn’t severe. Muscular pain is by far the most common type of back pain. A professionally trained remedial massage therapist should be able to identify the tissues involved. It might also be necessary to look further afield than the back for the problem as many muscles refer pain to this area.
So who are the chief culprits; what tissues are commonly responsible for low back pain?
The paraspinal muscles are a muscle group on either side of the spine. They enable us to twist and bend as well as provide support for the spine and they are very powerful. A sudden unexpected twisting movement especially when lifting a weight can injure these muscles.
Quadratus lumborum muscles can cause pain in the sacroiliac joint, hips and buttocks and may easily be mistaken for arthritis of the spine, sciatica or disc problems.
Research suggests that gluteus medius is one of the main culprits for causing low back pain and hip problems. Weak gluteus medius or an altered reflex response of the gluteus medius muscle is associated with reduced hip stability which can also cause low back pain..
The piriformis muscle is notorious for causing low back and buttock pain. It can also irritate the sciatic nerve causing shooting pain down the leg mimicking sciatica caused by a bulging or herniated disc.
The iliopsoas muscle group is hidden deep inside the body and is a common source of low back pain. These muscles are large and powerful but unlike the hamstring and quads they are little known to the general public. The iliopsoas are difficult to reach and require a trained therapist using a variety of techniques to release them.
The serratus posterior inferior muscle connects the lower ribs to four vertebrae in the low back. The function of this muscle is unknown, it was originally thought to help with respiration but this is now in doubt. It is one of the muscles that aches and is stiff when you have slept on a mattress that is too soft. The pain from this muscle can be mistaken for kidney pain.
Abdominal muscles frequently refer pain to the back. Too many sit-ups, a chronic cough or emotional stress can provoke these muscles and set off referred pain in the mid and low back.
The ligaments are strong fibrous bands that hold the vertebrae together, stabilize the spine, and protect the discs. The ligaments are supplied with many nerves and are very sensitive. The pain is usually well localised and can be sharp in certain movements.
It would be wrong to look at the muscles in isolation. The functions of these muscles overlap and interact in one interconnected myofascial system. Generally more than one muscle will be involved and although the dysfunction will vary from person to person there are recognisable patterns of muscle imbalance. A remedial massage therapist will, as part of the treatment process, carry out a musculoskeletal assessment; identifying weakness, tightness or inappropriate recruitment of muscle.
How does massage help low back pain?
In the past, you would have been advised to rest until the pain eases. We now know that this was incorrect. The evidence from many research trials and case studies is that you are likely to recover much more quickly if you get moving again as soon as possible. Also, you are less likely to develop persistent (chronic) back pain if you keep active rather than resting or lying flat. Shuffling slowly around the house is better than taking to your bed. This is easier said than done. When a muscle becomes irritated or traumatised from being overstretched or misused it can lock up and may present as a gripping spasm that can be worse with active motion making it difficult to return to your daily routine. Massage works to relieve low back pain by releasing tightness, stiffness, spasms and restrictions in the muscle tissue. By overcoming this inertia and breaking the pain barrier you can start to follow the good advice and get moving again.
Current remedial massage theory also suggests:
Remedial massage and rehabilitation exercises and mobilisations will improve muscle tone and balance, reducing the physical stress placed on bones and joints.
Massage helps to free adhesions and break down scar tissue. As a result, it can help to restore range of motion to a stiff back. Massage can help increase joint mobility by reducing any thickening of the connective tissue and helping to release restrictions in the fascia.
There is some evidence to suggest that massage has an anti-inflammatory effect on tissue (although further research needs to be carried out in this area).
A deep tissue massage reduces pain by the release of endorphins (endorphins are also known to elevate the mood).
Reduces ischemia (ischemia is a reduction in the flow of blood to body parts, often marked by pain and tissue dysfunction)
Massage stimulates the parasympathetic nervous system, helping promote relaxation and the reduction of stress.
Passive mobilisations increase flexibility and can reset the muscle length of hypertonic, shortened muscle. Research has shown that mobilisation used as a therapy can produce significant mechanical and neurophysiological effects. The explanations of these effects – the mechanism of mobilisation – is still relatively unknown, especially in regards to the spine, and is subject to further research.
There are several theories that provide an explanation for the mechanism of action that makes massage and neuromuscular techniques effective in releasing tight muscle. Massage involves two types of response. A mechanical response as a result of pressure and movement as the soft tissues are manipulated, and reflex responses in which the nerves respond to stimulation.
Massage can break the pain-spasm-pain cycle in low back pain and there are well documented physiological principles that explain these effects including spinal inhibition, descending inhibition (Gate Control Theory) and trigger point inhibition. A remedial masseur has a toolbox of powerful and effective techniques to treat soft tissue in the low back. These include Deep Tissue Massage, Trigger Point Therapy, Positional release, Muscle Energy Techniques, tractions, passive joint movements and harmonic mobilisations, stretches and exercises. We will discuss these principles and techniques and the research evidence that support them in a future article.
Further Reading and Research
Professor Goldstone supervised a study of low back pain led by Elizabeth Dodd at Bradford University and Chris Caldwell at the Northern Institute published in 2003
A further low back pain study by Barbara Heron and Jean Kay, of the Massage Research Advisory Group (2008), involved practitioners from the Northern Institute in the practical work undertaken by the study.
http://www.nejm.org/doi/pdf/10.1056/NEJM199407143310201 On MRI examination of the lumbar spine many people have disc bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery MRI of bulges or protrusions in people with low back pain may frequently be incidental
http://www.ncbi.nlm.nih.gov/pubmed/23427384 Lumbar tender point deep tissue massage combined with lumbar traction produced better improvement in pressure pain threshold, muscle hardness and pain intensity in patients with chronic nonspecific low back pain than with lumbar traction alone.
http://www.ncbi.nlm.nih.gov/pubmed/21424336 Altered hip muscle activation in patients with chronic nonspecific low back pain. Healthy controls showed a significantly higher maximum amplitude of the gluteus medius muscle in comparison to patients with nonspecific low back pain. Patients showed an altered reflex response of the gluteus medius muscle which could be associated with reduced hip stability.
http://www.ncbi.nlm.nih.gov/pubmed/21328304 High quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain.
Manual massage is a long established and effective therapy used for the relief of pain, swelling, muscle spasm and restricted movement. Latterly, various mechanical methods have appeared to complement the traditional manual techniques. Both manual and mechanical techniques are described systematically, together with a review of indications for use in sports medicine.