Spinal adjustments in the hands of a skilled chiropractor represents one of the most effective methods of reducing spinal pain. But at times, just as in the treatment of extremity problems by way of the spine, the local painful tissue must be evaluated and treated.In a percentage of low back cases, patients may respond to adjustments and reach a plateau where they no longer progress. They may have increased range of motion, but still complain of an "ache or burning" that persists after prolonged sitting, standing or bending. Or they may complain of morning backache which lessens during the day until they posturally stress themselves again. Exercises may relieve them but does not solve their problem. Intersegmental spinal examination may be relatively normal and there is no longer spinal tenderness on deep palpation.
These types of spinal syndromes may respond to friction massage. These patients often, on deep palpation, complain of pain over the capsules of the facets, over the sacral base, over and superior to the posterior superior iliac spines, on the iliolumbar ligaments, interspinal ligaments, and the fascicles of the lumbar multifidus which arises from a common tendon from the caudal tip of the spinous processes attaching to the mamillary processes, the iliac crest and sacrum.1 Palastanga2 mentions the use of friction massage in the sulcus, just medial to the posterior superior iliac spine in the fascial origin of the erector spinae or superficially in the posterior sacroiliac ligament. He also mentions the ligaments connecting the sacrum and coccyx or the muscle attachments to the coccyx. Occipital insertions of the trapezius and splenius capitis are also frequently involved. A common area of tenderness lies along and on the inner border of the iliac crests.
Bogduk and Twomey1 decribe the insertions of the lumbar longissimus and iliocostalis and the thoracic longissimus and iliocostalis as inserting into the iliac crests, posterior superior iliac spines and sacrum as tendinous insertions. They state that contrary to most modern textbook descriptions, the lumbar longissimus and iliocostalis do not attach to the erector spinae aponeurosis but anchor the lumbar vertebrae directly to the ilium.
Just as soft tissue anywhere else in the body, the triad of overuse-inflammation-fibrosis can occur. It has been empirically proven since the early 1900s that friction massage across scar tissue in muscles, ligaments, and tendons increases the extensibility and, therefore, the function of chronic dystrophic tissue. Due to the layers of fascia and collagen over the muscular-tendinous tissue, friction in a circular direction or in several longitudinal directions on the same area can alleviate the chronic nature of some back conditions. Unfortunately, functional tests to prove the existence of lumbar "tendinitis" is not as easily elicited as in the extremities, so it is necessary to rely more on palpation for tenderness. Sometimes passive lumbar flexion or lateral bending may be an indicator of the fibrotic pain and the eventual alleviation of the pain after friction. As the patient progresses, the tenderness and the patient's complaints should decrease.
I use a rubber-tipped T-bar for the deep friction. Interestingly, friction anesthesia will occur as in the extremities and often causes anesthesia of adjoining previously sensitive tissue. Again, as with the extremities, ten minutes of friction is necessary.
- Bogduk, N.; Twomey, L.T. Clinical Anatomy of the Lumbar Spine. New York, Churchill Livingstone 1987; pp 72-91.
- Palastanga, N. "The use of transverse frictions for soft tissue lesions." In Grieve GP. Modern Manual Therapy of the Vertebral Column. New York, Churchill Livingstone 1986; pp 819-833.
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