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A fundamental aspect of bodywork treatment is the assessment of the presenting symptom(s) and aetiology. Understanding the indicators of disease and differentiating between the likely causes entails taking a thorough case history and carrying out a good physical examination.

This means assessing the particular region of the body, not only for malfunction, but also for contra-indications and signs and symptoms that can determine the treatment protocol. In this and the next column, I will be taking a look at some of the common findings in the region of the back, a frequent source of pain and discomfort.

The patient's overall structure can identify a number of musculoskeletal malfunctions. Spinal curvatures are an example; these are invariably linked to muscular imbalances. Lordosis in the lumbar area may be observed when the patient is standing or lying prone and can be related to transient or chronic tightness in the lumbar muscles. Congenital scoliosis is generally noticeable in both the upright and prone postures.

Complications include rotation of the spine and considerable changes in the corresponding muscles, some becoming fibrotic, whilst others are rendered flaccid. A scoliosis is referred to as being functional, rather than congenital, when it is not in a fixed position. It is frequently a result of some transient mechanical imbalance and, therefore, can be improved with bodywork and manual manipulation techniques. Kyphosis of the thoracic spine relates to an increased forward flexion of the vertebral column. It is invariably associated with rigidity of the spine and muscle tightness – both can be observed in active movements on standing and felt on palpation and articulation of the spine in the prone position.

Tonicity of Muscles

Muscle groups of the back may be in different states. For instance, those on one side of the spine may be hypertrophied, whilst the corresponding ones on the opposite side would be weak or atrophied.

Over-developed muscles can be intentional and acquired as a result of repetitive physical action, such as a sporting activity or they can be indicative of an 'overuse' condition related to structural imbalances.

Compensating contractions of the muscles can occur, for instance, if the body is attempting to correct discrepancies in the spinal mechanics. When observing the back, it is worth noting that a spine that is fixed in rotation with certain irregularities of the ribcage can create a false impression of hypertrophied muscles on one side of the spine. The exact cause of any form of hypertrophy needs to be established prior to any treatment with massage and bodywork techniques. Atrophy of a muscle or muscles can result from insufficient stimulation of the contractile tissue through reduced physical activity (lack of exercise or bed confinement, for example).

Nerve impairment affecting the peripheral or central nervous system can lead to inadequate motor impulses reaching the muscle(s) and will, consequently, have a similar weakening outcome. Atrophied muscles will not respond to techniques such as percussive strokes if there is underlying motor nerve impairment; they can however benefit from the improved circulation and stimulation of the proprioceptor with bodywork techniques.

Back Pain

Discomfort in the region can range from a dull ache to a sharp pain. It can be localized to one area, or can radiate to other regions, such as the groin or the leg. Movements can exacerbate the pain or, indeed, alleviate it. Lumbago is a non-specific dull ache across the loin area. At times, lumbago is persistent and with no apparent cause; however, the most likely factor is the formation of nodules and adhesions, which impinge on nearby nerves. Techniques such as massage can be used to increase the local circulation and relax the muscles. Deep effleurage and cross-friction techniques are of particular use for the reduction of nodules.

Muscle Tightness

Muscle tightness is often the primary cause of back pain – generally a 'dull ache', and invariably associated with restricted movement of the spine. The precipitating factors in this situation are most probably 'bad posture' and/or lack of exercise, leading to contracted (perhaps even fibrotic) muscles and fascia. These tissues will feel very unyielding on palpation, but will benefit from massage and passive stretching (cross fibre and longitudinal).

Muscle Fatigue

A feeling of stiffness and some tenderness on palpation can signify muscle fatigue and, therefore, a build up of metabolites. These are typically a result of extensive physical activity such as sports, gardening or decorating or may be due to circulatory congestion and postural fatigue after a long period of travelling. Allowing for such factors, there should still be a certain amount of `yield' when the muscles are palpated. Improving the circulation is essential to decongest these tissues and massage movements are most effective.

Muscle Tension

Muscles are sometimes 'held rigid' and under tension. This involuntary spasm can be a protective mechanism when there is tissue damage.

The sustained contractions create muscle fatigue and pain in the muscles; massage can increase the circulation and temporarily ease the discomfort. The most common form of muscle tension is related to stress or other emotional factors. Muscles affected by emotional tension are tender and 'jumpy' on palpation. Techniques that are slow, rhythmic and light are more suited and effective than deep and heavy strokes.

Muscle Strain

A strain of the lumbar muscles is a common occurrence, and results in acute and severe pain when the sufferer attempts to carry out certain movements like bending forward or rotating the trunk. If the strain is severe, the pain is elicited on palpation of the muscle and also as the patient attempts to move or turn over on the treatment table. A protective muscle spasm accompanies the strain, the rigidity of the muscle fibres serve to act like a splint, thereby limiting movements of the back. Massage to relax the muscles is, therefore, counterproductive in the initial acute stage (one or two days) as this would undo the protective mechanism. Cold packs can be applied on the area of injury to reduce the pain and oedema. The muscle can be treated after the acute stage to increase the circulation, and also to prevent adhesions and excessive scar tissue formation.

Adapted from Handbook of Massage Therapy by Mario-Paul Cassar DO ND, Butterworth Heinemann. 1999.