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In the last column I covered dysfunctions of the muscles in the region of the back. Progressing with our assessment of the back we will now look at some dysfunctions of the skeletal structures, at the signs and symptoms associated with them, how to palpate for them and some basic massage and bodywork treatment. It is worth reiterating at this point that the purpose of the assessment is not only to help us evaluate the application of massage but also to be aware of any contraindications.

Dysfunctions of the Spinal Column

In some cases of back pain, two or more adjoining vertebrae may be misaligned or restricted in their movements i.e. fixed in one position. This structural malfunction may cause an irritation of the nerve root/s emerging in between the vertebral bodies; this would in turn lead to a radiating type of pain like sciatica. Another symptom may be referred pain in a related dermatome or myotome; for example diffused pain in the buttock or thigh. There may also be a degree of compensating muscle spasm in the back which in itself would give rise to considerable pain. A misalignment of the spinal column can be genetic and not easily reversible but more often it is episodic and results from bad posture, from functional scoliosis, bad lifting or strenuous activities.

Palpation of the spinous processes can be used to assess for misalignments and immobility of the spine. A gentle pressure applied to the lateral side of the spinous process is likely to elicit pain if that segment of the spinal column is misaligned or malfunctioning. The more severe the discomfort, the more acute the condition is likely to be. Massage is indicated to address any muscle hypertonicity and thereby reduce the pain to a degree. It can only be carried out, however, if the dysfunction is not too acute. In less significant dysfunctions, spontaneous corrections of the spinal alignments can indeed follow the muscle relaxation. The treatment is nevertheless contraindicated on areas of hypersensitivity: if there is considerable pain on palpation of the spinous processes or very severe radiating pain to other regions of the trunk or to the limbs. The symptoms of a disc herniation fall in the same category as the ones already mentioned, in some cases with greater severity, for which massage has a similar limited application.

Skeletal Pain

Two pathological conditions that can give rise to pain in the back are osteoporosis and arthritis. Osteoporosis refers to a loss of bone substance, leading to brittle and weakened bones. These changes can affect any bone, but the vertebral bodies are very susceptible and can undergo compression and collapse. In mild forms of osteoporosis the subject is able to move without discomfort whilst in the more advanced stages there is pain on movement and in severe cases the patient is unable to lie down due to pain and may have a very kyphotic thoracic spine. The spine is generally tender to palpation with a variable degree of hypomobility. Palpation of the spinous processes can bring on the pain; this may be difficult to differentiate from the pain associated with misalignments of the spine or that of nerve root problems. The aetiology is different in both cases and the muscle spasms that accompany these dysfunctions are not always present in osteoporosis. Whilst the muscles are not necessarily hypertonic in osteoporosis they are likely to have undergone fibrotic changes and will palpate as 'hard and cord-like'. Massage to the back can be applied in cases of mild osteoporosis where there isn't any severe pain in the spinal column. Pressure of the movements has to be adjusted very carefully however and heavy massage is restricted to those areas of fibrotic changes.

Rheumatism is a term that describes the degeneration and inflammation of a joint and its associated soft tissues. Osteoarthritis is similarly used to describe degeneration which is accompanied by osteophytosis (the formation of spurs) around the joints.

Osteoarthritis of the spine is a frequent cause of pain, with the lumbar and cervical areas being the worst affected segments. The complexity of the symptoms means that although pain is exacerbated with physical activity and abates with rest, the feeling of stiffness that is often experienced following bed rest is relieved with heat and movement. In most cases there is crepitus (crunching sound) and hypomobility in the affected joints when these are passively moved. Heat on palpation may be present if the inflammation of the joint is acute.

Spondylosis is defined as osseous hypertrophic spur formation at the vertebral endplates due to disc degeneration. This is a typical example of arthritic degeneration of the lower cervical, mid thoracic and the lumbar regions of the spine. It is often accompanied by intermittent periods of stiffness that is related to muscle guarding. Massage can be applied to help reduce the tightness and it can be followed by gentle mobilisation.

Spondylitis is synonymous with osteoarthritis of the apophyseal (facet) joints. It has a gradual onset and is found commonly in the over 60 age group. The pain of spondylitis does not abate completely but quiescent phases do occur. Inflammation and irritation of the joint surfaces is common with movement as well as with compression of the joints as in extension of the neck. Massage is used to improve circulation to the area. Passive movements should be limited to gentle traction (e.g. of the cervical spine), as rotational techniques may aggravate the roughened surfaces.

Rheumatoid arthritis is a systemic inflammatory condition affecting the joints and other tissues. The spine is not always affected at the onset of the condition. If there is involvement, however, palpation of the spinous processes will elicit pain. Massage to the back is contraindicated during periods of inflammation but of great benefit during remissions.

Ankylosing (rheumatoid) spondylitis is a progressive disease similar to rheumatoid arthritis. It affects mostly the costovertebral and sacroiliac joints, which are tender on palpation. Ankylosing (immobility and fixation) of the back gives rise to the `poker back', and sclerosis or fusing of the sacroiliac joints leads to immobility and low back pain. Muscle stiffness and shortening are likely to occur alongside the spinal column. Massage is indicated to improve the circulation, decongest the area and facilitate stretching. However, if the condition is chronic, massage may be ineffective and may even cause discomfort; in this case it is contraindicated.

Acknowledgement

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