In every issue of our journal you will find Case of the Month which we will select among submitted ones. Everyone who is using MEDICAL MASSAGE PROTOCOLs in their practice may submit their cases for the review and we will share with our readers the best one in every new issue.
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This Case of the Month contribution submitted by Ed Liepert, RMT addresses the very important and frequently overlooked subject of scoliosis and its management.
We may split the somatic rehabilitation of patients with scoliosis into two major groups. The first group consists of children between ages 10 and 17. This range covers the ages when scoliosis is first detected until the patient matures into full grown adult and fear of the progression of deformation stops. For these patients, the combination of medical massage therapy and correct behavioral changes is critical to prevent further development of deformation, and in many cases, helps to reverse pathology to some degree.
The second group of patients, which this submission addresses, consists of adults who have lived with scoliosis sometimes for many years. Some patients suffer from pain all their lives while others feel the onset of pain later in life especially women during menopause when osteoporosis complicates the clinical picture. For this group of patients, somatic rehabilitation greatly improves quality of life by helping them feel less pain, muscle tension and restriction of movements.
Massage therapy is unable to change an already existing deformation of the spine but it can decompress curvature(s), a fact greatly appreciated by the patients. This article is an excellent illustration of the validity of massage therapy as a viable rehabilitation tool when other modalities fail. We also think that Ed demonstrates exceptional clinical skills in the evaluation and treatment of patients while paying critical attention to details.
MEDICAL MASSAGE vs SCOLIOSIS
Patient: Male, 55, Chief Executive Officer of a large company. The patient has a history of scoliosis since age 11. He has consulted with numerous medical and osteopathy doctors and physical therapists including spinal surgeons for the past 40+ years as well as several alternative practitioners such as chiropractors, massage therapists, etc.
The patient came into our office with severe pain while walking, standing, sitting, lying and driving. He could not travel in a car for more than 30 minutes and needed to change positions constantly when engaging in any activity.
During assessment a major protrusion of the posterior rib cage on the left as the ribs were pulled toward the spine. The distortion caused by the scoliosis could be readily seen from both the anterior and posterior views.
The patient had been seeing a surgeon every year to track his condition and evaluate if corrective surgery may be needed. Because of pain intensity, the patient was presented with surgery as an option, but the patient does not want to do it.
To assess the benefit of neuromuscular techniques with IBP Test results for a patient with severe scoliosis and determine alternatives to planned surgical intervention by implanting a Harrington Rod for the future stabilization of scoliosis.
We considered that the information gathered during the IBP Test would facilitate the design of a treatment protocol to address the patient’s needs. In such case, the planned intervention would reduce pain intensity and increase quality of life for this patient.
IBP TEST (Innominate Bone Position Test)
The adult pelvis consists of two ossa coxae or innominate bones and the sacrum. Each innominate bone is formed by the fusion of three bones: the illium, ischium and pubis. At birth, these three bones are separated by hyaline cartilage, which is slowly substituted by bone. By the late teens and early twenties, the complete fusion of all three bones occurs with formation of two innominate bones, which together with the sacrum form the adult pelvis. The sacrum and two innominate bones are held together by two sacroilliac joints (SIJ).
The Innominate Bone Position (IBP) Test maps the imbalance in the patient’s musculature as hip abduction progresses and presents an accurate picture of the biomechanical forces acting on the innominate bones.
The IBP test evaluates the position of the two prominent landmarks of each innominate bone: i.e., four point total while the hip abduction proceeds from a closed stance to full abduction at specific intervals during the abduction. The examiner looks at the position of the anterior superior illiac spine of the one innominate bone with regard to the position of the anterior illiac spine of the other innominate bone while the hip abducts to several stances to full abduction available for the person being tested. The same procedure is used to examine the position of both posterior superior illiac spines with regard to each other and finally the position of each anterior superior illiac spine with regard to the posterior illiac spine of the same side (both Right landmarks & both Left landmarks).
The degree of hip abduction is indicated by proceeding from a closed stance to several sequential or consequential positions of hip abduction directly lateral in the coronal plane to the maximum that the person being tested can obtain comfortably . The recommended foot width positions is from closed stance to 25 cm (10 inches), 50 cm (20 inches), 75 cm (30 Inches), 100 cm (40 inches) etc to the maximum obtainable for each patient while the practitioner measures or visually inspects the position of the illiac spines. ( Note: IN North America, floor tiles are 12 inches in width. The practitioner may chose to use the 12 inch width increment instead of the 25 cm or 10 inch increments in such a situation.)
I have found that the commonly used Standing SIJ test does not give accurate clinical information on the condition of the person being examined and frequently misleads the practitioner. The IAOM of Europe no longer teaches SIJ testing for this very reason. I have compared the results of the Standing SIJ Test to results of therapy and the IBP test and have found that the expected results often were not reached. One such tome was at a MFR seminar. I did the IBP test before and after the treatment conducted at the seminar. There was no difference in the positions of the illiac spine in the pre- to post- treatment measurement. The therapy being presented did not correct the innominate bone position of the person being treated. This has proved true when comparing several type of therapy protocols such as relaxation massage, Swedish massage, some deep tissue work, CS, bone manipulation and exercise therapies. It is suggested that the nervous system is simply tricked to accept the abnormal position and adjust to the abnormal position which thereby would have the nociceptors desensitize to the impulses being measured.
The assessment using the IBP Test indicated that my patient’s right innominate bone moved into anterior rotation as hip abduction progressed while the left innominate bone moved into posterior rotation. I called this result Type 1 APAS or Asymmetric Pelvic Angle Syndrome. In addition, in the supine position, there was significant difference of the right anterior superior illiac spine compared to the left one.
First Therapy Session
The treatment protocol suggested was to treat the left adductor magnus and adductor longus muscles, the right psoas and illiac muscles. The first treatment resulted in some relief. The position of both anterior superior illiac spines was neutral in the patient’s supine position after the therapy. However, while standing, both spines were not on the same level, meaning that the condition had not changed. However intensity of pain subsided.
The patient’s scoliosis was listed as 70 degrees and the twisting of the body was quite pronounced. Considering in this situation the patient experienced a decrease in pain, it was obvious that I was on the right track by improving the pelvic angles. Of course, at this point I did not expect the improvement of the scoliosis deformation.
Second Therapy Session
The patient noticed that traveling in a car felt better, and he was able to sit longer before pain started to bother him again. However, standing and walking were still painful. The rotation of the innominate bones had lessened after the first treatment and remained such. However, the difference in the position of innominate bones side to side had not.
I decided to concentrate on the elimination of innominate bone rotation and address other issues after. The innominate bones moved to a more neutral angle in the anterior-posterior plane, but did change their position in lateral plane. The first obvious reason for this is the difference in the length of the lower extremities. It is difficult to imagine but in his forty years of seeking therapy, no one measured or mentioned the necessity of compensating for one shorter leg. I placed various shims under his foot and, despite that the innominate bones did not level properly, the improvement was significant. The total difference between right and left lower extremities was about 8 mm.
Third Therapy Session
The pain was significantly reduced in all positions or activity, which did not require standing or walking. I suggested that the patient have the shoe for his shorter leg built up to 1/4 of an inch. After he did that, improvement was immediate especially while he was standing and walking.
After two more treatments, the patient stopped frequent use of pain medication, and after a year his pain was significantly reduced. The patient refused to have any surgery since he had little or no pain while in the sitting and lying positions. Now he can undertake an automobile ride up to two hours with little discomfort. Currently, the patient does not use any pain medication.
The patient’s next annual X-ray assessment showed a slowing of further increase in the scoliosis progression, and his condition is considered stable. His spinal surgeon was amazed by such improvements since he had not seen this before.
During that first year, I worked on the patient one to two times per week, but for the past year he has visited our clinic only periodically. Presently, the focus is to continue to treat the psoas and the lower back muscles to maintain less pressure within curvature and decompress vertebral segments.
Neuromuscular Therapy is highly effective in reducing pain and tension developed as a result of scoliosis especially if the IBP Test is used for the examination of patient and the formulation of MEDICAL MASSAGE PROTOCOL. In addition, compensating the shorter leg with some sort of orthopedic device is a very important component of successful somatic rehabilitation.
To reduce tension buildup in the soft tissues as a result of scoliosis, the practitioner must work on the shorten muscles and fibrotic tissue formed along concave side of curvature and the muscle and tissue inferior to the convex area on the side of the convex curvature. The best approach is deep friction applied from several angles. Pain relief comes only when the pelvic angles become level, and the innominate bones are in a balanced position with regard to each other as much as possible.
Liepert continually works on improving his professional knowledge by taking classes in Myofascial Release, Lymph Drainage, Fitness and Nutrition, Anatomical Dissection etc. He believes “a good knowledge of the mechanics of the body is necessary to understand the concepts of the way the therapy works.”
Category: Case Studies