Application of First Aid Soft Tissue Massage
ART Literature Review:
by Everett Johnson, DC, ART
Application of first aid soft tissue massage to prevent musculoskeletal disorders in the work place.
This case report describes the presentation of an employee experiencing lumbar spine discomfort to an on-site soft-tissue massage program at a manufacturing facility in the United States. The employee was found to have palpably tight and tender psoas major muscles, which contributed to her low back discomfort. Active Release Techniques soft-tissue management system was the only intervention used during the sessions. This report documents the use of Active Release Techniques as a first aid initiative in a manufacturing setting as an effective method for preventing a discomfort from becoming a costly musculoskeletal disorder of the lumbar spine.
Work-related musculoskeletal disorders are a leading cause of workplace injury in the United States. The Bureau of Labor Statistics estimates that musculoskeletal disorders were the cause for twenty-eight percent of all reported workplace injuries and illnesses in 2009. Employers are permitted, through OSHA regulations to provide massage, as a component of first aid care, to employees to prevent conditions from escalating to the level of an OSHA recordable injury.
This report documents a case of an employee seen at an on-site soft tissue massage program through Active Release Techniques Corporate Solutions as a wellness/first aid initiative. This program is currently being offered at over 175 facilities in the United States. The employee comes from their work area directly to the ART provider on-site. The session typically lasts fifteen minutes, and the employee returns to work, with no restrictions to duty. This is the first case report documenting the effectiveness of the program.
A 59 year old female production worker presented to the on-site soft-tissue management system with a complaint of moderate, bilateral low back discomfort and feelings of weakness of her right thigh. Her discomfort was brought on by a change in the production line that required her to lift heavier materials more often, along with increased hours of production for the new product. The employee’s low back discomfort was worse with forward flexion and she presented to the on-site soft-tissue session with a limp due to weakness of her right thigh muscles. The employee states that she has had back issues off and on for the last three years Visual analog pain scale revealed a pain at its worst as a 7/10 and pain at time of presentation as 5/10. The employee was asked to perform motions that aggravated her condition and to point to the locations which she felt the discomfort. She pointed to her lumbar area during forward flexion motions, and it was noted that upon rising to extension from the flexion position she had difficulty standing upright and her discomfort was also increased in the lumbar spine. Resisted hip flexion of the right was 4/5 compared to 5/5 left.
Palpation of the lumbar spine revealed tightness of the erector spinae bilaterally, with some local tenderness on the right, located at the L4-L5 area. This palpation did not recreate the discomfort she experienced when performing flexion or extension. Palpation of the right psoas muscle did however recreate the discomfort the employee described as she performed flexion and extension motions. Further palpation inferiorly at the junction of the iliacus and the psoas major at the approximate area of the femoral nerve caused the employee to describe an increase in discomfort. Active Release Techniques protocol for working the psoas major muscle was performed on the employee. The employee was side-lying with the right side up. The area of the right abdomen was massaged from lateral to medial to encourage movement of the underlying viscera to shift from the area of the psoas major muscle. The psoas muscle is then palpated for adhesions along its length. When an adhesion is located tension is applied with the fingers of the inferior hand and the employee was placed in position to start the procedure, with the hip in flexion, to shorten the psoas. The psoas was then lengthened through its range of motion while the tension remained over the area of the adhesion. The employee had difficulty in performing the first two passes, with the third pass being much easier to perform and she complained of less discomfort.
After the session the employee was asked to perform the same motions she had described as being uncomfortable, upon initial presentation. She performed flexion and extension range of motions several times reporting that it did not hurt anymore after each repetition. The total time for the session was approximately fifteen minutes, and the employee was sent back to work immediately after. During session two the following week, the employee reported she had mild discomfort (2/10 on VAS), and after repeating the procedures from the first session she reported no discomfort.
The employee came back for a third session a week later and said she had aggravated the condition by doing some heavy lifting and working increased hours at work. This time, however, the discomfort was on the left side, with no reports of any issues on the right side of her low back. She reported the discomfort as about a 4/10 on the VAS with most of the discomfort during flexion and return to neutral position during active ROM. The same procedures were performed on the left side psoas. After the procedure on the left psoas she reported some low back discomfort still but felt much improved overall. The area of her lumbar spine was palpated and the multifidii were addressed, using the ART protocols. She reported no discomfort in her low back (1/10 on VAS) after the massage of the multifidii was performed and she had no restrictions in active ROM.
She had previously sought out traditional Chiropractic care, outside of work, for the issue with short lived relief to her discomfort. She presented the following week for a follow-up session and she reported some minor twinges of discomfort through the week, and that were so slight that she said they were not noteworthy. The psoas was palpated with no aggravation to the employee and no recreation of previous discomfort. She did have some tightness of the multifidii in the lumbar spine, that did not give her discomfort during palpation or during the technique application. Follow-up with the employee two weeks later was negative for any low back discomfort
This case demonstrates the successful use of ART on-site at a manufacturing facility in the United States. No other protocols were used during the sessions and no outside treatment for the condition was performed during the time the employee was taking part in the ART program.
Typically, an employer without a soft-tissue first aid program would send such a case to an occupational medicine clinic for evaluation and care.
The ART protocols are based on discomfort patterns that are linked to specific anatomic sites to perform the massage. The specificity of the technique allows for relaxation of the muscle and release of adhesions that occur in the fascia, muscles and nerves. Tension is taken on the site of adhesion with either a thumb or fingers. Active and passive motions of the structures in the area are performed to allow passage of the tissue through the area of tension. Typically the tension is held on the structure for 3 seconds after the end range of motion is reached. The tension created combined with the movement of the structure allows for relaxation of the muscle through a stretch allowing adhesions to release in-between the tissues, thus restoring the relative motion between structures.
There are some limitations to this type of program. The program was designed to keep employees well at the workplace by providing massage on-site. In doing this, companies have benefitted through decrease in medical expenditure by being proactive in thinking towards musculoskeletal disorders Soft tissue massage done as a first aid initiative in the workplace is limited to only the massage, since most other forms of therapy performed are regarded as a medical procedure, which results in the session becoming a work injury and therefore an OSHA recorded event. Some of the limitations include: no prescribing of stretches for the employee’s condition, no imaging, and no diagnosis of the condition.
Objective measurements were not included in this case. Range of motion was observed and not measured. The charge of this program is a first aid and wellness initiative, and no diagnosis or medical evaluation is performed. Range of motion improvements are made by visual observations of the motion performed and noticing any discomfort for the employee. Subjective response of the employee is gauged as either positive or negative for outcome of the session and weighs heavily in the decision for effectiveness of the session. The employee is asked to grade their discomfort on a visual analog scale, which is also used as a determinant of effectiveness of the sessions.
Referral of the employee to an Occupational Medical Doctor is indicated if the employee does not respond or responds negatively to the sessions performed. Typically cases seen on-site are resolved in less than 4 sessions. Providers at on-site locations are trained to evaluate the employee’s condition and an immediate referral to an outside program is made if the provider determines the employee’s condition warrants it.
This report documents the use of Active Release Techniques as a first aid initiative in a manufacturing setting as an effective method for preventing a discomfort from becoming a costly musculoskeletal disorder of the lumbar spine. More reports of this nature would increase corporate knowledge and appreciation of these types of care programs, as a method of keeping employees well and decreasing medical expenditures by treating work-related musculoskeletal injuries on-site. Future studies could include collecting data from a large group of companies that currently use the ART Corporate Solutions’ program. A retrospective look at the types of cases seen, the number of sessions performed per case, employee response and the average cost per case would provide valuable data for companies looking to decrease costly medical expenses for musculoskeletal disorders.
1. http://www.osha.gov/pls/oshaweb/owadisp.show_document p_table=NEWS_RELEASES&p_id=19158