Massage eases pain and post-exercise inflammation

Tarnopolsky D. J Science translational medicine. 2010

Massage not only feels good and produces a relaxation response but appears to promote new mitochondria growth in skeletal muscle. Investigators analyzed biopsies from the quadriceps of men who exercised on bikes to exhaustion. After the exercise one leg was massaged. A second biopsy was taken at 25 hours post the (10) minute massage. The researchers found that massage reduced the activity of inflammation-inducing cytokines in the muscle cells and promoted new mitochondria. This pain reduction may involve similar mechanisms as those targeted by common NSAIDs.

Evaluation of load transfer ability: Active straight leg raising. The malalignment syndrome (p. 82). Schamberger, W. Churchill Livingstone 2002.

ASLR with or without ‘reinforcement’ (pelvic compression) to engage the form & force closure can be used to evaluate a patients’ ability to transfer load from the LS junction thru the pelvic girdle and hip joint to the lower extremity. A (right) supine ALR results in:

PI rotation of right innominate, anterior rotation of sacral base with nutation of right SI.

A tendency for the whole pelvis to rotate around the vertical axis toward the raised leg as well as a rotation at the LS junction in the opposite direction which decreases SI joint motion.

The overall effect is a stabilization of both LS and (in this case) right SI joint. A decreased ability to perform the ASL test while supine seems to correlate with abnormally increased mobility of the pelvic girdle. If dysfunction is found it can be assessed as to whether the problem is with the active or passive restraint systems. If contraction of the “inner core” (e.g. TrA, pelvic floor etc contraction) stabilizes and improves ROM and symmetry of leg-raise the clinician can focus there…If the anterior oblique system (tested via restraint of opposite trunk rotation) is at issue then that area  can be addressed. The Posterior oblique system can be better evaluated via the prone ALR challenge”.

Effects of external pelvic compression on form-closure, force-closure and neuromotor control of the lumbopelvic spine—A systematic review.

Arumugan A, et al JOSPT Jan2012

Optimal LP stability is a function of form closure (FmCl), force closure (FcCl) and neuromotor control. Impairment can result in pain, instability, altered LP kinematics and changes in muscle strength and control. External pelvic compression (EPC) has been hypothesized to have an effect on FcCL and neuromotor control.

Conclusion: There is moderate evidence to support the role of EPC in decreasing laxity of the SI joint, changing LP kinematics, altering selective recruitment of stabilizing musculature and reducing pain.

There is limited evidence for the effects of EPC on decreasing sacral mobility.

Comment: So the effects of “SI” bracing are likely results of recruitment/firing pattern changes as opposed to simply added “support”…which is unlikely sufficient via a belt to add substantial mechanical alterations.

However the pelvis appears to have an “upper” & “lower” section either of which can be provocative or relieving in a bracing scenario in certain patients, i.e. some patients feel better with a tight belt at the pelvic brim, others with the support at the hip etc. The ATM2 has shown electrical quiescence of asymmetrical firing patterns with the use of its support belts. The assumption being IF “bad” or inefficient (painful) firing patterns/neuromotor control can be silenced via external bracing, the addition of painless exercise during the bracing appears to have great potential. 

Artificial disc Mulholland R. Scientific basis for treatment of LBP Am Surg Royal college. 2007

The introduction of the artificial disc, producing results similar to fusion provides strong support for the hypothesis that loading is central to back pain. The artificial disc does not create a pattern of normal movement, and is not designed to do so. It does not necessarily require removal of the posterior innervated annulus, often regarded as a primary source of back pain, which continues to be moved and stressed after surgery. The one mechanical effect it has is to alter load Transmission while allowing movement.
The interface between implant and underlying vertebra is critical. It is here that load is transmitted. Bony integration must not only stop movement, but must be sufficiently extensive that the area of bone transmitting is adequate. Cages demonstrate that a small area of bony integration sufficient to stop movement, but insufficient to transfer load over a wide footprint is associated with continued pain.
With the artificial disc with a larger footprint transfer of load is thru plates resting on the vertebra…a universal feature of currently used disc replacements. This load transfer may be abnormal if the bone-plate interface is a mixture of fibrous tissue and bone, producing an irregular pattern of load.
This could be one reason the procedure is showing no better results than fusion.
The artificial disc must be focused on its role as a transmitter of load, not an enabler of movement. It seems one cause of clinical failure could be due to the failure to establish a normal loading pattern at the plate-bone interface.

A case of potential manipulation responder whose back pain resolved with Flexion exercises.

May S et al JMPT Sept 2007.

According to mechanical diagnosis classification of McKenzie the patient categorized as having a derangement with a DP for flexion exercises (this is unusual, accounting for 5% or less of derangement presentations). A derangement is characterized by; a response to repeated movements, centralization, abolishment or decrease with the change in pain location or decrease or abolition of pain maintained and accompanied by improvements in the presentation (ROM). A DP for flexion describes a patient who is responding in one of these ways to self-mobilization flexion movements. This patient was advised to repeat 10 flexion exercises while supine every few hours. She was advised to maintain a neutral spine position and in this case, avoid spinal extension. The exercise was a knee-to-chest motion with over pressure applied to the legs once at the chest. The presenting exam revealed back pain with all single motions creating pain and a major loss of flexion and a moderate loss of extension. When flexing from the waist there was NO loss of lordosis. With repeated standing & lying extension her pain increased as did her loss of flexion ROM. With supine lying she had no symptoms…motion progressed to knee-to-chest which became painless with repetitions. After several repetitions her flexion ROM was restored. After this repeated motion restored ROM and a DP was established the exam was concluded. The patient was pain free in 2 days.

The authors point out that though the patient was positive for 4 of 5 “manipulation responsive” clinical prediction rules repeated, self-engaged motions gave full restoration of ROM thus manipulation was unnecessary in this case.

The myth of lumbar instability: the importance of abnormal loading as a cause of LBP

Mulholland R Eur Spine May 17(5) 2008

The cause and hence the treatment of “mechanical” LBP remains unsolved, despite a century of endeavor. It is generally accepted that some form of failure of the disc is central to causation. In the latter 20th century failure of the disc leading to abnormal movement i.e. “instability” legitimized fusion as a treatment. However the result of fusion remain unpredictable. Despite progressively more rigid fusions results failed to improve, casting doubt on the concept that back pain was movement related…and stopping movement was central to success.
Is it more likely back pain is “load related” and not movement related?
Is instability as a cause of back pain a myth?
At the beginning of the 1950’s abnormal movement was not mentioned as a cause of pain.
Then how did the term “instability” become used as a diagnostic term?
Barr in 1950 appears to be the first reference to the term stating: “it is becoming evident that backache is often associated with mechanical instability of a degenerate disc lesion”. Harris and Macnab in 1954
further the concept that the disc plays a central role in Sciatica & LBP however it was not suggested that excessive movement is present, and translational movement is deemed to be unusual.
Conclusion: Abnormal movement of a degenerated segment may be associated with LBP but it is not causative….the concept of instability as a cause of back pain is a myth.

Clinical evidence for treatment of acute-onset LBP with Heat Wrap Therapy Musculoskeletal disorders 2010 Mcintosh G, Hall H.

We have posted at least 3 well done studies on the effectiveness of Heat-Wrap therapy (Therma-care & others) done since their inception in early 2000. These studies suggest efficacy. When compared to placebo they show consistent benefit at 5 days (moderate-quality evidence). At 1 and 4 days they are apparently more effective than acetaminophen (but what isn’t!?). The same results were found with other nSAIDS including IB though high-quality studies were limited. Both pain and disability in a cohort of nearly 300 people found by the fourth day the heat-wrap had greater benefits as it did on day one. When a heat wrap is used for 3 consecutive days plus “education” (minimizing catastrophe/victimization potential) and teaching sensible “lifestyle accommodation” tactics, significant reductions in disability and improvements in pain relief were noted on the first day and the fourth. A Harvard study suggested dramatic improvement vs “other” interventions in the first 5 days with the use of heat-wraps. When compared with McKenzie protocols there were no significant differences in pain relief or function noted.

We have promoted this simple, cost effective treatment for nearly 10 years and continue to be impressed on how they seem to allow relief and ADL tolerance often better than ice or pills (ice is difficult to apply throughout a day if no freezer is available as well as the difficulty with skin irritation). However we all recognize that nothing is 100% and there are non-heat responders and conditions which simply will require some “ice time”. It’s important to note that in LBP IF the muscles are a source heat makes sense…IF the disc or joints are it also makes sense since “inflammation” of these structures is unlikely increased via skin surface heat.    

A several year systematic review on ankle sprains also recently suggested aggressive ice therapy promoted more recurrences and disability.

McKenzie classification of mechanical spinal pain: profile of directional preference Man ther Feb;13(1) 2006

Several reviews have been published regarding the typical findings using a movement classification analysis. This 2006 study presents these findings in a useful way i.e. IF you find that 75% of your patients have a “flexion” directional preference you have probably misinterpreted the examination (or have the most unusual patients in America!). Their findings show an average (from a cohort of 187 patients) 140/187 were “reducible derangements” (a disc that can likely reduce or be positively affected with sequential movements); 11/187 were “irreducible”. In a general sense this suggests that less than 10% of back patients have conditions which can’t improve with treatment, 75% will. 24/187 were classified as “other”…suggesting inflammation, postural or adherence etc.

98/140 (70%) were EXTENSION, (5%) FLEXION and (25%) LATERAL (or rotation or side-glide). Other studies also suggest a 3% or less prevalence of nerve adherence syndromes. These studies support the premise that mechanical evaluation of spinal patients using some sort of directional-preference is warranted. In our decompression classification we utilize these tests; however in the 10% of patients NOT demonstrating a DP axial traction therapy is usually the most sensible treatment. By fostering directional-preference findings we have found that traction-therapy works better and quicker.