Massage Therapy for Low Back Pain

In the early 20th century, sacroiliac joint syndrome was the most familiar medical diagnosis for low back pain, which resulted in that period being labeled the “Era of the SI Joint.” Any pain emanating from the low back, buttock or adjacent leg regularly was branded and treated as SI joint syndrome. Yet, this medical mindset came to a screeching halt in 1934, when Jason Mixter, MD, published an article on the intervertebral disc lesion in The New England Journal of Medicine.1 His landmark report changed the popular understanding of sciatica and helped establish surgery’s prominent role in the management of sciatica at the time. Over the next few decades, discectomy surgery increased in popularity, causing many to identify that period as the “Dynasty of the Disc.”

SI joint syndrome continued its fall from fashion due to the lack of trustworthy clinical studies confirming its very existence. Although many manual therapists quietly continued treating this disorder with some success, no one was able to put forward a convincing biomechanical theory explaining how the sacrum becomes stuck “crooked” between the two innominate bones. Physicians were cautious and reluctant to envision a joint with so little movement causing so much pain, while manual therapists countered that its limited motion is vital to proper lumbar spine functioning. So, the SI joint argument raged until the late 1970s, when renowned manipulative osteopath Fred Mitchell Sr. introduced an innovative and practical biomechanical model that clearly demonstrated normal and aberrant SI joint movement patterns occurring in most individuals.2 Using muscles as levers to correct lumbopelvic restrictions, Mitchell’s muscle energy technique spurred a renewed interest in the SI joint as a source of back pain.

Figure 1 and Figure 2 in the complete article demonstrate a modified muscle-energy assessment and correction routine for a painful left unilateral extended sacrum.

As most SI joints only move about 2 to 4 millimeters during weight bearing and forward bending, they are described as a gliding-type joint. This motion is quite diverse from the hinge-type articulation at the knee or the ball-and-socket motion of the hip. Considered a viscoelastic joint, the SI’s major change comes from ligamentous stretching. Therefore, its primary purpose within the pelvic girdle is to provide shock absorption for the spine by stretching in various directions. When sacroiliac joints work in perfect harmony with the third bony articulation of the pelvis (symphysis pubis), a marvelous self-locking mechanism develops that helps us walk. Aided by power generated by the hip abductors (gluteus medius/ minimus, TFL and piriformis), the pelvic joints brace the weight-bearing side during gait. This locking system, termed force closure, lets smooth transference of body mass from one leg to the other. Although no muscles directly connect down the three pelvic joints, when working synchronously with the SI ligaments they provide the pelvis ? “the great adapter” ? with a remarkable antigravity springing system that can absorb both ascending and descending forces.

During the aging stage, there is an increase in the grooves on the opposing surfaces of the sacrum and ilium, which reduces available motion of the SI joint. This is a perfect example of the body’s innate wisdom attempting to sacrifice
complexity of motion for stability. An interesting note is that the age with highest incidence of disabling back pain (25-45 years) is the same age at which the greatest amount of motion is available in the sacroiliac joints. It’s not uncommon for an SI joint to become firm and permanently lock as we age. This may be a good motive for massage therapists to begin incorporating specialized soft-tissue mobilization techniques on a regular basis, to maintain joint-play and prevent agonizing arthrosis and arthritis from developing. Due to the small amount of sacroiliac movement and the joint’s inborn biomechanical complexity, proper assessment can be tricky.

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http://erikdalton.com/media/published-articles/sacroiliac-joint-syndrome/