March 2, 2021

Massage Tutorial: 8 tips for low back pain

Hi everyone. I’m Ian Harvey, massage therapist. Today we’re going to talk about some tips and tricks for working with the low back.

I’ve already talked about how to work with a low back that’s in acute spasm, but something that has come up for me before is that I’ve worked with a low back, I’ve used my best practices but the client still stands up from the table either with stiffness or even with spasm. And over the years I’ve figured out some ways to counteract that and we’ll talk about that today. If you’d like to skip ahead, click down in the table of contents. Now if you’ve ever had a client stand up from a low back session with more pain, then you might have blamed yourself. You might have blamed your massage, and there are some things that we can change about the massage to make that less likely.

But my prime suspect when clients stand up feeling a little bit worse is positioning. Having them flat on their stomach for 30, 45 minutes can be a little unpleasant for a back that’s usually used to having some curvature. The same thing for being in the supine position and not having enough support under the knees when they get up, that can create a little bit of crisis in the low back and these are things that are easily fixed.

The easiest and most effective alteration you can make is just offering your low back pain clients a pillow for under their lower abdomen. So this is Madison. Hi.

So Madison, I’m going to have you start face down and I’m going to have you lay on a pillow, so this is going to be about right here, and if you need to move this up or down please do so.https://mingle2.com/user/view/39481029 Where I would like it to end up is somewhere right around here, so lower abdomen. Again if that’s uncomfortable we can move it and if you don’t like it at all, we can just throw it out, okay?

When I work with the low back, I always want to work with the hips so it’s important to have a conversation with your client about that before the massage. So Madison, I’m going to have you start face down under the sheet. It’s good to be as undressed as you’re comfortable with.

I would like to work directly with your hips so if you chose to be completely undressed that would help me out, but if you choose to leave your underpants on, I may ask you to scoot them down so that I can work with this upper hip region, okay? I do like to point out on my own body when I’m talking about the hips so that there is no confusion about what I’m talking about. Alright, so we’ve got the pillow applied. Madison, how does that pillow feel under your abdomen? Great.

Okay. Just let me know if you ever want that to move up or down, okay? Uh-huh. My second tip for working with the low back other than including this abdomen pillow is to not be hyper-focused on the QL. It can be very tempting if your client has pain right here or right near this lumbosacral junction to focus right here on the QL, to spend a lot of time working with trigger points here, to sink in in this lateral tissue and push toward the spine.

That’s all good work and that’s all stuff that you can include in future sessions, especially once you see how your client responds to broader less focused work. But that first session, hyper-focusing on this QL, I’ve seen some clients have negative outcomes from that, soreness the next day or even standing up with some stiffness. When I work with this region I like to do so broadly. I’ve got a little jojoba oil on my hands right here.

Hi everyone. I’m Ian Harvey, massage therapist. Today we’re going to talk about some tips and tricks for working with the low back.

I’ve already talked about how to work with a low back that’s in acute spasm, but something that has come up for me before is that I’ve worked with a low back, I’ve used my best practices but the client still stands up from the table either with stiffness or even with spasm. And over the years I’ve figured out some ways to counteract that and we’ll talk about that today. If you’d like to skip ahead, click down in the table of contents. Now if you’ve ever had a client stand up from a low back session with more pain, then you might have blamed yourself. You might have blamed your massage, and there are some things that we can change about the massage to make that less likely.

But my prime suspect when clients stand up feeling a little bit worse is positioning. Having them flat on their stomach for 30, 45 minutes can be a little unpleasant for a back that’s usually used to having some curvature. The same thing for being in the supine position and not having enough support under the knees when they get up, that can create a little bit of crisis in the low back and these are things that are easily fixed.

The easiest and most effective alteration you can make is just offering your low back pain clients a pillow for under their lower abdomen. So this is Madison. Hi.

So Madison, I’m going to have you start face down and I’m going to have you lay on a pillow, so this is going to be about right here, and if you need to move this up or down please do so. Where I would like it to end up is somewhere right around here, so lower abdomen. Again if that’s uncomfortable we can move it and if you don’t like it at all, we can just throw it out, okay?

When I work with the low back, I always want to work with the hips so it’s important to have a conversation with your client about that before the massage. So Madison, I’m going to have you start face down under the sheet. It’s good to be as undressed as you’re comfortable with.

I would like to work directly with your hips so if you chose to be completely undressed that would help me out, but if you choose to leave your underpants on, I may ask you to scoot them down so that I can work with this upper hip region, okay? I do like to point out on my own body when I’m talking about the hips so that there is no confusion about what I’m talking about. Alright, so we’ve got the pillow applied. Madison, how does that pillow feel under your abdomen? Great.

Okay. Just let me know if you ever want that to move up or down, okay? Uh-huh. My second tip for working with the low back other than including this abdomen pillow is to not be hyper-focused on the QL. It can be very tempting if your client has pain right here or right near this lumbosacral junction to focus right here on the QL, to spend a lot of time working with trigger points here, to sink in in this lateral tissue and push toward the spine.

That’s all good work and that’s all stuff that you can include in future sessions, especially once you see how your client responds to broader less focused work. But that first session, hyper-focusing on this QL, I’ve seen some clients have negative outcomes from that, soreness the next day or even standing up with some stiffness. When I work with this region I like to do so broadly. I’ve got a little jojoba oil on my hands right here.

And so I like to use these soft fists that conform to the shape of this lumbar region, dragging toward myself and down toward the table. This is creating some fascial traction in the QL region and is tractioning it outward away from the spine. It’s an interesting new stimulus for this area.

Just be careful not to sink in too much with these knuckles. I like to use this entire dorsal surface of these phalanges as well as these knuckles. Of course you can work with these spreading techniques.

Here we’re affecting the QL and this serratus posterior inferior. I’m moving kind of fast with these, but you can always slow way down, or even turn these into static holds. And as your client breathes and changes the shape of that lumbar region, this is doing work. So don’t feel like you need to rush through this low back work.

Sometimes just holding and hanging out can do work that this more active massage isn’t able to accomplish. My third tip is to think hips and pelvis more than you think the lumbar region. So every move that I do pretty much with a client who has low back pain is going to extend down into this posterior pelvis and into the lateral pelvis. Madison, how is that pressure? Would you like more or less?

It feels good. Okay, good. As I continue this move I’d like to work on your upper hips a bit, so if I’m ever too far into your personal space, please do let me know, okay? So I am extending this move into the upper hips. I make sure to announce that I’m doing so and to let the client know that I am concerned about their comfort.

This allows me to work with these upper hips without having them exposed and it keeps me from something I call “invisible jean short syndrome,” where massage techniques stop right here and it’s maddening. As someone who has hip problems myself, I want these low back techniques to extend further onto the hips. Now if you have that conversation with your client and would prefer to undrape this hip region so that you can work down into that hip region, that works too, but I haven’t had any problems extending these moves slightly under the drape. Just make sure to keep the drape low so that there’s never any sort of draft, and keep the direction of your fingers in mind.

Make sure that they are gliding outward rather than inward. When I move to unilateral I do like to work with the undraped hip, so in this case I’ve got it folded down and away. When I work from the other direction I’ll show you how I drape there. I make sure to work slowly and conscientiously.

If the client has pain along this SI joint, this traction away from it can feel really good, and I can use this other hand to traction in the other direction. Again we can use the open fist here. Just make sure to once again use that broad surface of those dorsal phalanges rather than just sinking in with those knuckles.

Too much direct stimulation of the SI joint, too much direct fine work can potentially provoke spasm. So I want to keep that 45-degree angle working away from that SI joint, working toward it, and if I am going to do any work directly with this SI joint, I like to use a nice broad tool like the palmar surface of my hand, sinking in just a little bit with this carpal region, with the heel of the hand. Again I can make this a static move, just hanging out for a minute or two. Just stay in good communication with your client.

Make sure that the pressure isn’t too much, and have them let you know if this is ever uncomfortable or provoking those back pain sensations that they’ve grown so used to. My next tip is to remember this lateral pelvis. So don’t just work with the posterior pelvis.

Don’t just work with the QL. Also remember about gluteus medius and minimus. While they’re likely not directly involved in low back pain, a lot of my low back pain sufferers really identify with pressure here. They feel like it’s important and some even feel some referral to those other places in their low back or near their SI joint. It’s not working directly with the low back, but that’s not a bad thing.

My next tip is much the same. Just work with other related structures. Work with the hamstrings. Do nice slow myofascial moves in this area. These long slow compressions can have a very interesting effect on the hips and on the low back.

Take your time here. Work around to the side once again, working all the way up into that lateral pelvis. And when you’re working with the hamstrings, this is an opportunity to come at those hips from another direction. I think that working from the top down is great. I think that working from the leg up has value as well, so I like to do both.

My next tip is to use a big bolster when your client is face up. So I had Madison flip, I had her hand me out that pillow while I had her covered, and then I took this tiny insignificant bolster away and I put this under her knees. So I did have to ask her lift her knees up because this is quite a bolster.

This has revolutionized my work with my low back clients because this takes a lot of pressure off of the low back. So this allows them to come into a bit more of a fetal position, which can just be kinder to the low back, especially over the course of a half hour or 45 minutes. It allows the low back to flatten just a little bit, which, when you’re supine, can offer some relief.

Again I’m just working with the related structures, the ones that might be interacting with these hips. If there’s a bunch of tension in the quads, that can be translated into the hips and there can be a tug of war there. So again, you can do those nice slow myofascial moves and even some static contacts. Now, in future sessions I might want to experiment with other stimuli. I might want to experiment with working with these hip flexors, so we could work with psoas and iliacus.

You can work with tensor fasciae latae and with the position of the leg as you work. Just keep in mind that too much stretching, too much movement can be too much for some clients with sensitive low backs. Just think broadly. Keep all of these related structures in mind. Think of all of the things that pull on the pelvis.

Think of all of the muscles that connect to this ASIS. Think of these hip flexors and hip extensors and all of the rotators. By working broadly and not just hyper-focusing on that low back, that can gradually work with that low back pain and spasm. Two more things before we go. First, consider limiting the amount of time that you have your client face down in that prone position.

I find that too much of that can be pretty provocative to this low back. So even though we’re giving some extra work to this low back, consider limiting that portion of the massage to a half hour at most. Finally, if nothing else works, if your client keeps getting up from the table with that extra bit of stiffness or tightness, try different positions. Try side-lying, and if you need to, try seated massage.

The factors that can change how the client feels when they stand up, how their low back feels, differ from client to client. Every case of low back pain is different, so make the changes that you need to, and if you’re the one massage therapist who’s willing to make those changes, you’re going to have a client for life. So that’s my low back tips and tricks video. If you’ve got any tips of your own, any ways that you change your massage for certain clients, leave those down in the comments.

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