By Jill Bielawski and Jerry Weinert
Originally published in Massage & Bodywork magazine, February/March 2000.
The last installments of “Redesigning Movement” focused on gaining flexibility in specific regions of the body. We drew attention to the postural and biomechanical issues that most massage therapists and bodyworkers face. A full head-to-toe routine of active-isolated stretching was explained as a means to prevent repetitive stress injuries that are brought on by the nature of our work and through dysfunctional biomechanics.
This final article in the series addresses specific conditions commonly seen in our clients and often felt in our own bodies. You’ve learned effective prevention strategies in the previous articles. Now we’ll look at the rehabilitation and management of these common conditions. Besides suggesting which active-isolated stretches would be most suitable for each condition, we will describe defining characteristics and factors that aggravate these conditions.
Six of the most common and annoying physical problems experienced by bodyworkers and their clients are headaches, neck pain, thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome and low back pain. We have chosen these conditions, not through any scientific method, but through clinical experience. They are commonly felt by bodyworkers as a result of the postures we assume while working. We are convinced that the majority of massage therapists and bodyworkers would agree that many of their clients’ somatic complaints fall within the six categories we have chosen. A larger list of conditions, more in-depth discussion and appropriate self-health measures are part of our new book, Stretching for Health, to be published later this year.
Headaches are commonly categorized as tension, migraine or sinus in origin. They may also be caused by a pathological disease process that is far less common than the other three causes.
Tension headaches are typically caused by physical or emotional stress. This includes factors such as eyestrain, poor posture, a neck injury like whiplash, or even conditions such as temporomandibular joint dysfunction. Migraine headaches, while vascular in origin, are often triggered or exacerbated by hypertonic soft tissue in the cervical region. Sinus headaches arise from increased pressure in the sinus cavities around the nose and eyes. It is not uncommon to find myofascial trigger points in the suboccipital and posterior scalenes region that refer to the sinuses and either initiate or aggravate a sinus headache.
Tension headaches are the most common type of headaches. Quite simply, tightness in the neck and shoulder muscles seems to be the most direct cause. In our experience, myofascial trigger points in any of the muscles of the neck and shoulders can “trigger” pain in the head, whether it be behind the eyes, at the base of the skull, toward the back or side of the head or that “tight band” around the head. Deactivating these trigger points and relieving tension in the muscles through therapeutic massage can frequently decrease the frequency and intensity of tension headaches.
Aggravating factors include: Headaches can also be initiated by certain foods and food additives (chocolate, nitrates, aspartame, etc.), medication interactions, lack of adequate water intake, skipping meals, smoking and drinking alcohol.
Self-health Measures: The most obvious, yet the most difficult measure to decrease or eliminate headaches is to slow down and have regular periods of rest and relaxation. Quite simply, try to eliminate one of the elements in the stress-tension-pain cycle.
Tension headaches also can be decreased or eliminated through a number of methods:
• Implementing a regular and moderate exercise program.
• Utilizing meditation.
• Reducing caffeine intake.
• Eating more whole foods and fewer fast or processed foods.
• Sitting quietly to eat meals; avoid eating on the run .
• Increasing flexibility in the neck and shoulder muscles.
• Cessation of smoking and tobacco use.
• Improving workplace ergonomics.
• Establishing regular sleep and wake patterns.
• Making time for relaxation, hobbies and varied recreational activities.
• Receiving periodic therapeutic massage or bodywork.
• Developing a trusting, emotional support outlet with friends, family or a therapist.
Stretching Recommendations: Doing the neck and shoulder routines daily as described in Part 2 (Aug./Sept. 1999), can create considerable relaxation and flexibility in the neck muscles, thereby producing an improvement in frequency, duration and intensity of headaches.
A frequent complaint, neck pain can result from a variety of factors. It can be acute or chronic. The most predominant cause of pain is damage to the soft tissue of the neck and can occur because of overuse, or injuries such as whiplash. Pain can also be due to abnormalities such as birth defects, structural trauma (i.e. fractures), degenerative and inflammatory diseases, or prolonged wear and tear resulting in cervical disc degeneration or protrusion (herniated disc). With various postural stresses, the disc degenerates as we grow older (typically age 40 and up), creating less space between the bones and more friction. Less frequently, neck pain can be caused by tumors or infection. Emotional stress is also an important contributing factor. Neck pain often causes, or is a major contributor to headaches, shoulder, arm and back pain. The longer a person has pain, the more effort is needed to correct it.
Aggravating Factors: Inactivity is one of several aggravating factors for neck pain. As soft tissue becomes more stiff and inflexible through lack of activity, the circulation to the area is decreased. Dysfunctional biomechanics is another factor, with the prime contributor being the head-forward, rounded-shoulder posture. Fatigue directly affects our sense of well-being and is a contributor to pain. We are less prone to continuing our supportive postural habits and more inclined to slouch and have contracted posture when we’re tired. Further tightness in the soft tissues can be caused by emotional stress. Stress can also worsen existing neck tension. Environment is something many of us forget when assessing pain. Consider this — a cool draft on the neck can cause stiffness and discomfort, just as allergies, fumes or odors from smoke, paint or some household cleaning products can irritate the respiratory system and eyes, thereby causing surrounding soft tissue to tense as a defensive mechanism. Other elements, such as fibromyalgia and temporolmandibular dysfunction, can also be aggravating factors in neck pain.
Self-health Measures: Neck pain can be decreased or eliminated through a number of methods.
• If the pain does not subside or you experience tingling, numbness or sharp, shooting pain referrals to other areas of your body, then schedule an appointment to see a medical professional.
• Maintain supportive postural habits. Practice bringing your sternum up and contracting your lower abdominal muscles to bring your head and neck into better alignment while sitting or standing.
• If you wear eyeglasses, be sure your prescription is current or is adequate for your needs. If you spend large amounts of time at the computer, you may need special computer glasses.
• Computer monitors should be 18” to 24” away and the top line should be approximately at eye level.
• Strategically use pillows to adequately support your neck while sleeping.
• When reading, be sure to keep your light well-positioned to avoid undue neck rotation or strain.
• Keep your neck warm. In cooler weather this may mean wearing a turtleneck shirt, even to bed.
• Use of ice or heat or both to alleviate the pain and discomfort.
• Maintain gentle movements of the neck. Modify any stretching or other activities involving the neck to stay within your tolerance.
• Get some exercise, even if it is just a walk around the block. The increased circulation and endorphin level will help reduce the pain and bring much-needed nutrients and oxygen to the area. Consult with a qualified professional for appropriate strengthening exercises when you are ready.
• Find ways to manage stress. Mental and physical flexibility is a key factor here.
• If your pain is related to conditions such as arthritis or fibromyalgia, there are support groups which may have information and tips on how to manage your pain.
• And of course, massage therapy can greatly relieve soft tissue tension. If pain is due to disc degeneration or herniation, decreasing muscle tightness will help alleviate pain caused by the pain-spasm-pain cycle.
Stretching Recommendations: Daily practice of the neck and shoulder routines as described in Part 2 (Aug./Sept. 1999) will be helpful. Incorporate trunk and hip stretches from Part 2 and Part 3 (Oct./Nov. 1999, Dec./Jan. 2000) a few times a week.
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome (TOS) comprises a variety of symptoms caused by abnormal pressure on the neurovascular bundle between the neck and the lower end of the armpit – the thoracic outlet area. The neurovascular bundle refers to a group of nerves (the brachial plexus) and blood supply (subclavian artery and vein). This bundle supplies the fingers, hand, arm, shoulder girdle and some regions of the head and neck with circulation. Nerve compression is more frequently involved than restriction of the blood supply. The most common symptoms are swelling or puffiness of the hand and fingers, dull achiness in the neck and shoulder region (especially at night), sense of fatigue in the arm, pain in the hand (especially in the fourth and fifth fingers), muscle weakness with difficulty in gripping things and when doing fine motor activities and tingling and numbness in the neck, shoulder, arm and hand. Doing activities with the arm elevated, such as combing or blow-drying hair or driving a car, also causes the above symptoms. And finally, it is not common, but some people may be born with an extra rib above their first rib, creating compression in the area.
Aggravating Factors: TOS often results from poor or strenuous postures, trauma or static muscle tension in the shoulder area. Occupations affected most are those requiring repetitive movement and posture such as cashiers, assembly line workers, plasterers and electricians. It can also occur in people who stock shelves or do needle work. Athletes who play volleyball, swimmers, tennis players or baseball pitchers can all be affected. Musicians, particularly violinists, are also susceptible to this condition. Carrying heavy loads, children, briefcases, purses and daypacks over one shoulder can aggravate TOS as well.
Self-health Measures: It is important when someone experiences discomfort that suggests nerve involvement such as numbness, tingling, puffiness or other similar symptoms in the arms or legs, that he seek medical attention for an accurate diagnosis. With that said, treatment for TOS responds well to manual therapy such as massage or physical therapy and stretching exercises. It is also necessary for the person to look at his activities of daily life, occupation and athletics to determine which postures or biomechanics need to be modified in order to alleviate the symptoms and make a more permanent change.
Overall, TOS can be well managed by doing the following:
• Sitting erect with lumbar support. This keeps the shoulders back.
• Avoid sleeping on the affected side.
• Avoid folding or crossing your arms.
• Taking breaks every 15 to 30 minutes from repetitive work which has you bent slightly forward.
• Avoid lifting things above shoulder level.
Stretching Recommendations: Alternate daily between one or two of the trunk, neck, shoulder and arm (Aug./Sept. 1999) routines as described in earlier articles.
Tennis elbow is known as lateral epicondylitis or more simply, tendinitis. It is inflammation of the tendon attachment to the humerus. The pain involved usually begins at the outside of the elbow and can radiate down the arm and in severe cases, to the hand. Most commonly, pain and sometimes weakness is brought on by grasping things like the steering wheel while driving or even picking up a glass. Sometimes an achy discomfort is present at night or after activities. Because we continually use our hands and arms, consistent care must be given to correct the injury. A similar condition, medial epicondylitis, can occur on the medial part of the elbow. This is commonly known as golfer’s elbow.
Aggravating Factors: Factors negatively affecting tennis elbow include strong repetitive motion where the elbow is extended and overloaded, such as tennis, golf or swimming; activities subject to repetitive stress such as hammering, turning a screw driver, computer work, excessive hand shaking (politicians beware) or window washing; or an increase in activity, or when poor conditioning or poor technique is involved.
Self-health Measures: Reduce the pain and inflammation of tennis elbow through rest, ice, compression and elevation (for more severe cases). To rest the area simply means modifying or avoiding the activities that aggravate the condition. It may mean modifying the grips on the golf clubs or tennis racquet and building up the grip on a screwdriver. Maintaining some movement of the affected area is necessary to promote circulation and tissue healing. Regular application of ice to the area will help control pain and discomfort and subsequently help reduce inflammation. Ice for 10 minutes and repeat three to four times throughout the day. For compression, use a forearm/ elbow band to support the tendon attachment during activities. In more severe cases, wrap the area with an elastic bandage to aid in decreasing the swelling. Elevating the arm above the heart is indicated for severe swelling.
Soft tissue manipulation by a massage therapist or physical therapist will help. Certain heat-producing liniments, available from an acupuncturist or herbalist, may bring relief by improving circulation to the area. If these methods don’t bring the relief you’re looking for, several ultrasound treatments by a physical therapist often achieve a positive outcome.
Stretching Recommendations: Undertake the shoulder and arm routines daily as described in an earlier article (Aug./Sept. 1999, Oct./Nov. 1999).
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome (CTS) is the most common Repetitive Stress Injury (RSI) or Cumulative Trauma Disorder (CTD) seen by health professionals and is also one of the most preventable conditions. It presents as pain, burning, numbness or tingling in the wrist or hand, which becomes worse after using the hands for activities requiring wrist action. This pain develops as a result of compression of the median nerve that travels through a narrow “tunnel” where the wrist meets the palm. Nine tendons also pass through the carpal tunnel. When certain activities are performed which require sustained or repeated flexion, extension or twisting of the wrist, friction occurs among the tendons in the carpal tunnel which creates inflammation and swelling. This process of inflammation entraps the median nerve that supplies much of the palm, thumb, index, middle and ring fingers. Carpal tunnel syndrome can lead to muscle weakness and a general impairment of hand function. For many individuals, the wrist/hand pain is worse at night.
Another factor which contributes to a “narrowing” of the tunnel, besides inflammation, is overly-tight muscles of the forearm which can compress the bones of the wrist closer together, subsequently narrowing the carpal tunnel or increasing pressure on the wrist joint or finger joints. Couple this narrowing with friction among the tendons and you have a painful condition which develops more quickly.
It is important to note that myofascial trigger points in the forearm or shoulder girdle can also bring on the same warning signs and mimic carpal tunnel syndrome. Unfortunately, we have seen individuals who had wrist/hand pain, went to their doctors and surgery was immediately recommended. After their surgical recovery they still had pain, only to find that on further examination, the cause of their pain was from a trigger point that was easily treated through massage or physical therapy. CTS responds well to non-invasive soft tissue manipulation. We believe surgery should only be the last resort after less invasive means have not produced results.
Aggravating Factors: Repetitive motion of the hands, wrist or forearm certainly aggravates the symptoms of CTS. Gripping, grasping or lifting with the thumb and index finger can strain the wrist. Computer work, certain musical instruments, assembly line work (like twisting a screwdriver) and house work, such as scrubbing floors, sinks and tubs, all contribute to strain on the tendons passing through the tunnel. Sleeping positions that place the hand in extreme flexion or extension place considerable stress on the tendons of the carpal tunnel. Previous bone fractures or dislocations in or around the wrist may produce a narrowing of the carpal tunnel, and fluid retention can also create swelling in the carpal tunnel and subsequently entrap the median nerve.
Self-health Measures: The most effective treatment program for CTS is prevention. Many of the repetitive activities that contribute to CTS overuse the flexor muscles of the forearm.Counteracting the repetitive activity by stretching the forearm flexor muscles is of ultimate importance. This can be done any time or any place. It is also important to:
• Keep the wrist in a neutral or straight position. To assist this at night, a wrist splint is helpful.
• Avoid repetitive movements or holding an object in the same way for extended periods of time.
• Reducing the speed with which you do a forceful, repetitive movement gives your wrist time to recover from the effort.
• Rest your hands periodically.
• Alternate easy and hard tasks, switch hands or rotate work activities.
• Stretch, stretch, stretch.
The earlier you have a professional diagnosis and treatment, the more successful the outcome will be. Doing regular flexibility exercises can reverse this progression and eliminate, or at least better manage, symptoms of CTS. Soft tissue manipulation or therapeutic massage by a skilled practitioner can loosen the hypercontracted muscles and allow stretching to be more effective. All the above self-health measures will be enhanced if the originally offending activity is modified or eliminated.
Stretching Recommendations: Doing the arm/wrist and shoulder stretching routines daily as described in an earlier article are important for prevention and recovery. It’s a good idea to include the neck routine at least every other day.
Low Back Pain
Low back pain is among the five most common reasons for a physician visit in the United States. It is responsible for billions of dollars in health care costs and lost time at work each year. It is largely a preventable problem. Mostly a musculoskeletal condition of overuse and improper body mechanics, low back pain may also be due to a less common disease process such as a tumor or dysfunction of an organ in the low back region.
Trigger points and nerve entrapments from tight muscles are easily remedied through massage, stretching and some aerobic and strengthening activity. With persistent back pain, it is important to have a physician diagnose the extent of the problem. Oftentimes, however, medication, surgery and/or bed rest is prescribed. If the condition is related to a ruptured or protruding disc, then surgery may be necessary. Statistically, over 50% of all low back operations end up with similar pain problems. Surgery may relieve the pain by removing some or all of a disc, but once again it doesn’t address what brought it on in the first place. Medication is useful for reducing pain and inflammation, but it does not treat the cause of the problem either. The original cause is due to tight muscles from improper body mechanics or overuse. Conventional medical wisdom says that bed rest is necessary for low back pain. Gordon Waddell, M.D., author of a recent systematic review on bed rest as treatment for back pain says: “Traditional management of back pain by rest is now discredited...We no longer use bed rest to treat any other musculoskeletal condition.” In general, bed rest is not recommended for any length of time unless lying down is the only position that does not elicit pain. Activity that is pain-free or minimally uncomfortable is preferable and may result in a faster recovery.
Aggravating Factors: Inactivity or dysfunctional biomechanics are the main factors which aggravate or instigate low back pain. Improper movement and posture can be due to the way the body has compensated for old injuries or can be related to stress and emotional strain.
Any time the trunk and head are tilted forward, even just leaning forward to hear someone speak or to write at a desk, the erector spinae muscles are in a contracted state. This includes standing postures, too. Bending forward with straight knees to rinse your mouth after brushing your teeth locks up the back muscles. Lying flat on your back without support under your knees can aggravate a sore back. Those “comfortable” positions we choose to stand in, with all the weight on one leg and the other foot twisted out in some other direction, favor muscles which are already too tight and can aggravate the back. Fatigue and overwork can certainly worsen back problems, too.
Self-health Measures: There are many things one can do to help low back pain. Overall, the best way to manage a low back problem is to have a balance between enough strength to do the activities of your daily living, adequate flexibility, and to have a good oxygen supply to your muscles through aerobic fitness. The other primary factors to consider are erect standing and sitting postures and good spinal alignment when lying on your side.
The following are just a few tips for preventing or taking charge of your back pain:
• Use lumbar support when sitting in a chair or automobile seat.
• Sit all the way to the back of the chair with your feet flat on the floor.
• Adjust the car seat back so that it is in the fullest upright position.
• Move the car seat closer to the steering wheel so your legs don’t strain to reach the pedals.
• Place one foot up on the bumper when lifting something from the trunk.
• Bend your knees when lifting.
• Avoid bending your back while lifting.
• If lifting something heavy, either get assistance or squat close to the object, hold it near your belly and use your legs to bring your body to an upright position.
• Avoid twisting your body while lifting.
• Instead of leaning over a desk, use a clipboard to bring your work closer to you.
• Take frequent breaks from any position, every 30 minutes or so.
• Avoid leaning forward and reaching. When possible, position yourself so you are closer to your work.
• When sleeping on your back, place a pillow under your knees.
• When sleeping on your side, try to keep your spine straight. A “body pillow” may prevent you from twisting and torquing your spine.
• Avoid sleeping on your stomach.
• Emergency relief position: In the event of severe back pain where there is no position of relative comfort, lie on your back on the floor and rest your legs (calves and feet) up on a chair or couch.
Stretching Recommendation: Daily stretching with the hip/low back routines as described in an earlier article (Oct./Nov. 1999, Dec./Jan. 2000) is important for managing low back pain because of the pull these muscle groups have on the pelvis. Add the lower trunk stretching routine every other day.