My back hurts but you want to massage my front!?

Many times you'll go to a massage therapist and say "my back hurts here" and get massaged right there.

If you see a therapist trained in clinical thinking, they will acknowledge that it hurts between your shoulder blades, but want to release your pecs; your low back hurts but they're going to massage your core muscles through your abdomen.

This annoys some clients who just want you to grind on that knot between their shoulder blades for an hour. Rightfully so, if the therapist has not engaged them in client education as to why they're massaging the opposite side. Just grinding on that knot may sound great, but it will be unlikely to address the actual problem.

Let's look at a few examples:

Pectoralis Minor attaches to the front of the scapula

The scapula (shoulder blade) is not actually held to your skeletal system as a joint - it's merely held in place by muscles & connective tissue. This makes it highly mobile but also the potential for being held in sub-optimal position by shortened muscles.

Our average daily lives tend to involve too much hunching forward: at computer desks, driving, sleeping... When a muscle is in a shortened position with regularity, the body adapts. Your body says that if you're going to hold me in this position all the time, I'm going to lay down collagen fibers to lock the muscle in place so we don't have to waste energy with constant muscular contraction. The body aims for efficiency.

You know that pesky pain between your shoulder blades? It's often the muscles back there being overstretched & abused. By doing nothing but grinding my elbow into that area, I am likely to irritate the tissue more (stretching an already stretched muscle). By freeing up the chest, it helps allow the scapulae to retract to a more neutral position and relieve stress on that area between the shoulder blades. There are other muscles that play a role in this that don't seem directly connected, but pec minor is a good example and an area that tends to go under the radar.

Iliopsoas, often called Psoas (so-az) for short

Iliopsoas is huge for lower back pain. It's the same basic concept: this muscle is frequently fixed in a shortened position for many, many people. It attached to the pelvis as well as lumbar spine, and when contracted puts the spine into an excessive curve (think of an arched lower back) and contributes to an anterior (forward) tilt of the pelvis. Both these postural positions stress the lower back muscles and potentially nerves as well, causing pain, dysfunction, and negatively affecting postural alignment.

Too often I have heard of sufferers of chronic lower back pain getting massages for years and years without much progress, only to find they've never had their Psoas addressed. This deepest of core muscles can give powerful relief when released, and it's not just for lower back pain. This muscle is huge and has several attachments along the spine and pelvis - this can affect a multitude of areas.

Figuring out the root cause of your pain is important for lasting relief in massage. It's not as simple as the "I hurt here so massage here" approach many people seek. There is benefit in addressing the direct area itself, no doubt, but you have to look at the bigger picture for effective relief.

It's all connected.

Soreness & Massage

I had a friend ask me a very good question and an issue I'm seeing a lot as a new therapist.

This person went in for a deep tissue massage & heat treatment after waking up unable to move her neck. This is rarely a good solution, as nice as it may sound. The next day she woke up with searing pain and could hardly move her shoulder.

With that, she asked a very good question that I'm glad she asked: do I go in for round two? Or let my body heal on its own? 

The answer is to let your body do its thing. The increased pain and immobility was caused by the massage treatment. When any part of your body is sore or stiff it is a small injury. Tissues are irritated and likely have micro-tears in them. Your body's immediate natural response to irritated or damaged tissue is inflammation - the area swells. This causes the pain and lack of function/mobility.

By having someone go in there and stretch the muscles with massage so soon after the healing process has begun, you are making it worse. A hot pack is also likely to make it worse. Not to say you can't take a hot shower in the morning when you wake up stiff, but prolonged & concentrated heat on the area will in some fashion increase inflammation.

The best option the day you wake up with a stiff neck or sore anything? Ice. The cold reduces the swelling. I find it's more effective when you can relax the targeted area while doing so (lie down).

If you're hellbent on getting a massage (it's not always a bad idea), I would recommend avoiding a lot of deep work where the injured area is being heavily manipulated. People tend to have an inclination to go to a massage therapist with a "it hurts here so massage here" mentality when it can sometimes not be the best choice. If your massage therapist knows how to do myofascial work, I find that to be a helpful and less invasive way to work on a sore area. Deeper work to areas adjacent to the injury site can be helpful as well, but just know you may end up more sore! One of the more difficult sides of injury treatment massage is making that call of 

Next time you wake up and your neck hurts, do what you can to reduce swelling and then make a note to checklist your sleeping setup. It's likely the pillows under your head are not supporting your head properly! You want your head as level as possible. Check out my previous posts on sleep posture for a better explanation!

Stretch for desk workers - Brugger relief position

When you sit for long periods, the spine tends to round forward, putting excess strain upon it. This affects everything in your body - musculature, tendons & ligaments, fascia (connective tissue), overall energy, even your breathing. By being too hunched forward, you are compressing your diaphragm. At that point, full breaths are either not happening, or using more energy than is necessary. When this becomes habitual, it encourages neck and chest breathing, when you want to be expanding your full abdominal cavity when breathing.

The muscles in your back and neck fight gravity and become irritated, the muscles of your front side become tight and locked down.

How can we manage this?

Posture is deep rooted in the subconscious and it is a constant battle to correct. Think of your neural pathways like a wheat field. The path most traveled - your usual posture - is flattened and the obvious default navigation choice. To create a new path you have to push your way through the tall grass again and again. It will take hundreds and hundreds (maybe thousands) of mindful treks through this new path before it gets flattened out, and for the old path to grow over.

Even if you're not interested or committed to improving your body's posture, consider the idea of micro-breaks when at work/the desk.

Micro-breaks.

These breaks should be taken before you are feeling stiff, sore, or ache-y. Ideally you should take a 20-30 second micro-break every 20-30 minutes. If you have an analog clock in view, try to associate each 20 minute mark with standing up and getting your body moving, if just for a short while. Roll your neck around slowly, stretch, walk to the water cooler or bathroom, jog in place for 10 seconds - whatever is reasonable. It's entirely likely your job does not allow this type of consistent frequency, but just do what you can.

Longer breaks of 1-5 minutes should also be taken every 2-3 hours or as you need them. Try setting phone or computer reminders.

One of the most effective micro-break exercises, as well as my personal favorite, is the Brugger Relief Position. Developed by a European neurologist, this can be done in as little as 10 seconds. If you can't find a 10-second break at work, I don't know what to tell you.

Studies show it will help to reduce tension, improve breathing and improve posture within just a few weeks of practice.

Brugger's Relief Position, sitting:

1. Sit or perch at the edge of your chair.  Sit on your "sit bones" just around where the top of your legs meet your butt cheeks. You don't have to feel like you're falling off the chair, though.
2. Hold your head up high.  Imagine a string fixed at the crown of your head pulling you toward the sky.
3. Spread your legs slightly apart to the sides, knees above your ankles. Turn your legs outward to a comfortable degree.
4. Rest your weight on your legs and feet and relax your abdominal muscles.
5. Tilt your pelvis forward and raise your breastbone up. Another way to think of this is to bring your shoulder blades together in the back without raising your shoulders up; an arch of the back to combat the rounded forward posture present with long periods of sitting.
6. Turn your arms palm-forward, with your arms rotated outward.
7. Breathe deeply into your abdomen.

Hold this for 5-20 seconds, then relax. Feel free to repeat after ~30 seconds of rest. As always, discontinue at any point if pain is present. If anything doesn't feel right, trust that. Adjustments can always be made.

Brugger's Relief Position, standing:

1. Stand tall, with your head held high. 

2. Spread legs to about shoulder width apart.

3. Turn feet outward to a comfortable degree.

4. Draw your belly in toward the spine.

5. Tilt your pelvis forward, and raise your breastbone up.

6. Turn arms out, palms up, arms slightly raised out to the side.

7. Breathe deeply into your abdomen.

Hold for 5-20 seconds, relax. Again, feel free to repeat after a short ~30 second break. Make adjustments as necessary, etc. You get the idea.

With that, I'm off to go walk around a little and stretch! I hope this finds you well, desk jockeys of the world!

Myofascial wrist/forearm stretch (video)

Check out this easy to do stretch exercise for those tired, overworked forearms!

Be careful not to overdo it your first time. It's likely you've never really stretched these muscles. Just making a few takes of this video has me feelin' it in my right arm... Woo.

Wrist stretches for the keyboard worker & carpal tunnel

Do you find yourself with issues in the hands, wrist, or arms during a long shift at the computer? As with any repetitive stress issues, taking breaks and stretching are important. How do we stretch, though? Some areas are less easy to figure out than others. Here we will focus on the wrist.

Again, I'd like to preface with the fact that I'm not an expert in this department, and to trust your body. When stretching any part of the body, take it very slow at first until you know your limits. 

Also note that bouncing stretches are not good. This is where you take it to the stretching end point and bounce back & forth ala cheesy 80s workout videos. This can cause tissue damage as you're forcefully pushing past your natural level of flexibility. You want to take it to where it feels like a good stretch without pain. Hold it here for 3-5 deep breaths, and back out from the stretch at any time. You may only last through a breath or two before it's too intense and that's okay. Many of these areas have not been stretched much and I cannot stress enough to take it slow and listen to the signals your body is giving you.

1. One-arm assisted wrist stretch:

• Note that the image above is a person with high flexibility. This one can be very intense - don't overdo it!
• Sit in a chair with your feet flat on the floor. Extend your right arm out in frong of your right shoulder with your palm facing up. Use your left hand to gently pull your fingers toward you.
• Slowly let go of your right hand and turn your hand so your palm faces down. Using your left hand, gently pull your fingers toward you and hold for five deep breaths. Then release and repeat these two stretches with the left arm.
• If it's feeling okay, repeat both stretches two times on each wrist, and then shake out your hands to release your wrists. Allow your wrist and arms to fully relax for a few moments and adjust.

2. Palm-to-palm wrist stretch

• If either of this cause you pain, back out until there isn't pain, or just plain stop. If the pain is in the wrist, you may have some cramped space in your carpal tunnel.
• Sit in a chair with your feet flat on the floor. Bring the backs of your hands together in front of your chest, so your thumbs are pointing in. Press them together, and lower your elbows slightly to increase the stretch. Hold for five deep breaths.
• Then turn your hands around so your palms are touching, with your thumbs pointing away from you. Press every fingertip and the base of your palms together firmly, again lowering your elbows slightly to increase the sensations. Stay for five deep breaths.
• Repeat these two stretches for a total of three times. Then shake out your hands to release your wrists.

3. Hand on the wall stretch

• Positioning of your hand relative to your body affects the stretch - if your hand is further behind you than your body it will create a more intense stretch that reaches up through your pecs.
• Place the palm flat against a wall with all five fingers spread. Fully extend the arm and take several deep breaths. Slowly turn your head towards the opposite side and take another deep breath. Hold the stretch and return your head forward.

If you're looking for relief for general computer posture including shoulders, neck, and back: look up brugger relief position. It's a great exercise that is easy to do.

Sitting posture: at the desk

There is so much that could be going wrong with sitting posture, it's hard to know where to start.

I would like to preface these posts with a reminder that I am no expert in this, and some of this information may not ring true for you and your body. Any posture that isn't your natural posture will feel odd, so keep that in mind but ultimately trust your body and the signals it's sending you. Just focus on one adjustment at a time.

Other things to keep in mind: variety! There is no one sitting posture that's going to be perfect and comfortable for an 8 hour shift in a chair. It's important to stay mobile, and to take breaks. So many people take breaks from work without getting out of their chair. It's easy to hop on facebook instead of giving your body a break. If possible, get out of your chair every hour even just for 20 or 30 seconds. Walk around, do some light stretching, jog in place, do whatever you can to get your body mobile. We are designed to be mobile.

Head & neck: I might even recommend having eye level closer to the middle of your monitor - especially if it doesn't tilt up. It's very common to have a monitor be much lower than eye level. Put something under your monitor so that your neck does not need to be constantly bent forward. Phone books, reams of printer paper, sturdy boxes or other books... Doesn't need to be fancy. If you have pain or issues with the back of your neck and upper shoulders, this minor adjustment could be huge.

If you find yourself leaning your head forward to see what's on the monitor, adjust something that allows the screen to be visible while keeping your head neutral. For each inch your head moves forward, it multiplies the weight of your head. I mean this quite literally: if your head is 3 inches forward, your head is 3x as heavy as far as your neck muscles are concerned. Your neck does not need this added stress! A good baseline is having the monitor at arm's reach, like your fingertips could barely touch the screen. If vision is a problem for this, try a larger resolution on your monitor.

Shoulders & Arms: It's important to have arm support. As picture above, you want your shoulders relaxed down and back. The keyword here is relaxed. I have spent much time trying to correct my posture via using muscular effort to pull my shoulders back. This doesn't really help, and just creates its own problems. It's likely your arms are not able to relax back to an ideal position, but that's where massage and especially structural work comes in to help.

You want your elbows bent, forearms fairly parallel to the ground. The arms should not be reaching out to meet the keyboard. Ideally the keyboard would be quite close to the core of your body, but it's not easy to find a desk that actually accomplishes this. If you suffer from pain in the shoulder blade/scapula area (do you get those knots between your shoulder blades and your spine?), raise your awareness of how often your arms are reaching out to type or use the mouse. Having your arms reaching out for long periods of time puts excess strain on the musculature here. Think about keeping your elbows close to your body.

Right side = front side of your body

Back & Spine: It's important to understand the natural curvature of the spine here. Take note that the person would be facing to the right in the above picture. There is a light hunchback-esque curve in the shoulder/upper back region. This curve is exaggerated by a vast majority of our seating choices. Your back shouldn't be a straight rod, but you also shouldn't be sitting in what's basically the fetal position. All that to say, don't overdo it when trying to keep your head above your shoulders - there is a bit of natural curve here. When your monitor is too low and you have to bend your neck forward, you're taking away from the cervical curve here.

Lastly, the lumbar curve. This is important. So many chairs, including the one I'm sitting in right now, don't have proper lumbar support. You want to have your back and butt against the back of your chair. Unfortunately, a lot of chairs aren't shaped properly and this is uncomfortable. Many times, the base of the chair is so long that you feet can't reach the ground, or the actual shape of the back of the chair just doesn't fit. Make up for the lack of lumbar support with a small folded pillow, or one like this. There are a lot of lumbar supports for chairs out there. Find one that works for you.

 If your legs can't comfortably reach the ground, use whatever you can as a foot rest - a bucket, more phone books, whatever!

Now lets address the concept of 'sitting up straight.' Many of us, myself included, imagine sitting at a perfect 90 degree angle as perfect posture. It's much healthier to be leaned back somewhat. We're talking 100-120 degree, just a slightly obtuse angle. Putting all your body weight directly through your spinal column puts too much weight on the vertebral discs. Sources say that a 135 degree angle produces the least strain on the discs. This may cause you to be sliding out of your seat or just downright uncomfortable though. There is no one sitting posture that will be perfect. We're not designed to sit in a chair for 8 hours in a row.

Here's an article on the leaning back idea: http://news.bbc.co.uk/2/hi/health/6187080.stm

Legs, Hips & Feet: Keep your feet flat on the floor. This one is hard, I know. I like to rest my feet under my chair (on the legs of the chair seems comfy right?). This can contribute to an anterior (forward) pelvic tilt. Low back pain a common issue for you? Tight quads? Raise your awareness of what you do with your legs at your desk - it may help! You want your feet close to being directly under your knees (90 degree angle) or a little further forward. Having your ankles at a bit of an obtuse angle should be alright. I've read that you should have your knees a little lower than your hips. I'm not entirely sure why. I could see why they shouldn't be above your hips though.

Don't cross your legs for long periods of time (again, variety is key!). I'm guilty of this one as well. It can affect circulation, and it can attribute to unilateral (one-sided) tilts or rotations of the pelvis. This can surface in so many different ways. When your pelvis isn't sitting right, any part of your spine can be affected. I tend to cross my legs at the ankles when sitting, and I suspect it attributes to my tight IT bands (outside of legs) and tight deep hip muscles.

Speaking of hips, another important thing is to not have your legs spread too widely either. This can affect the lumbar curve in the spine, as well as various leg muscles, namely the deep hip muscles. You're holding them in a shortened position and if you do this long enough, the body adjusts and figures you don't need as much length in there. Google some piriformis stretches if this is an issue for you. I try to stretch my hips every day (just take it slow and don't do a 'bounce' stretch, hold it still and controlled). It's quite helpful for me!

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Like all disciplines and practices, good posture takes time. The hardest part is the awareness. Try sticky notes on your monitor or in the car, try computer/phone reminders, whatever you can to keep reminding yourself. You're changing neural pathways and you're not going to do it in one day. Think about your brain like a wheat field - your habits are these pathways you've gone through hundreds and thousands of times. The path is quite tread, quite comfortable. It takes mindfulness, effort, and energy to trudge through the tall wheat grass that has not been traversed. Each time it will get incrementally easier. Eventually, if you force yourself down this path enough, it will become the new standard path and you will no longer have to think about it.

Here are some resources for ergonomics & ergonomic office furniture:

General:

http://www.ors.od.nih.gov/sr/dohs/HealthAndSafety/Ergonomics/ErgonomicEquipment/Pages/officeequip.aspx

Custom chairs:

http://www.ergo4me.com/index.php

Posture itself (book/podcast I intend to check out!):

http://stopchasingpain.podbean.com/2013/03/19/new-rules-of-posture-with-mary-bond/

It's hard to see if something will work for you ergonomically if you are buying it online. I recommend finding something you can try out in person.

Sleep posture: stomach sleeping

Stomach sleeping.  Widely regarded as the worst of all three sleeping positions. I'm inclined to agree, but I think there are ways you can make it much less harsh on your body. 

Major problem areas: neck, & hips/low back.

HIPS/LOW BACK

If you're like most of us, you sleep with one leg up like the picture above. This puts torque (a twist) on your hips, which may create problems for you after a while. It may surface as pain/tension in your hips & legs, or low back. Our low back is unsupported with the curve flattened in this position. One way to bolster your low back is to put a small pillow under your abdomen.

The iliopsoas comes into play here as well. Shown above, Iliacus + Psoas minor/major = Iliopsoas. Commonly referred to as psoas (pronounced "so-az"). This momumental deep hip flexor (also a very relevant low back muscle) is capable of causing a wide variety of dysfunction. If this muscle is stretched and stressed all night every night, it can contribute to rotation at the trunk, one hip being higher than the other, pain in a variety of areas. Being directly connected to the spine and pelvis, its influence is strong.

Other than mechanical stress, this muscle is prone to emotional holdings. The stomach is a highly emotionally charged area of the body, and whether you believe it or not, emotion gets held in the tissues of our body. Having bodywork done here can be unreal! If you seek it out, make sure you have somebody with whom you're comfortable and can communicate. It is an area you need to be careful in, and you need to trust your body and speak up if there's pain or if it feels like they are on top of something they shouldn't be on.

NECK

Since your neck has to be turned to one side for this position, that can create a multitude of issues in the neck and shoulder. All sorts of muscles get twisted and stretched out of alignment. Not much I can think of in terms of remedy, but try to reduce the overall degree of rotation you have. Also try to switch sides and roll over when you can. Variety is good.

If you have thick pillows, consider a thinner pillow to start. The more height the pillow is adding to your head, the more strain you're putting on your neck in this turned position.