Michael Durrett LMT, CMMP, Spring, TX
Several months ago a 60 year-old woman came to my office complaining of upper and lower back pain. She has multiple factors that contribute to these symptoms, including her profession as a Home Health Care Nurse, which requires long and frequent drives. Additionally, 12 years ago she was diagnosed with Fibromyalgia.
In seeking pain relief, she has gone through the complete spectrum of commonly accepted treatments such as medications (Lyrica, Gabapentin, opioids) as well as physical therapy and lifestyle changes. She has also received regular Swedish and Deep Tissue massages from one of the national corporate massage chains. The last option has provided her with only short-term pain relief.
As I went over the details of her intake form, I found that along with the driving for work, she spends a considerate amount of time working on a computer. Stretching and exercise seemed to always be scheduled for tomorrow. She indicated that the pain she felt was a burning sensation that wrapped around her neck and shoulders as well as her lower back and down her legs especially left one. She noted that most times activity did not affect the strength of the pain. I asked when the onset of her pain began, her response was, “This is all I can remember.”
The burning character of the pain she experienced immediately alarmed me. During the observation part of evaluation, I noted that the patient was walking with a left side limp due a tightened lower back. I asked her to try and touch her toes to examine posterior mobility. She was unable to perform the movement without significant pain in the lower back. The best she was able to do was collapse her neck and middle back. The visual portion of the observation was the most telling. Also, I noticed a high glossy sheen across the skin of her back with patches of dry skin and multiple stretch marks.
Palpatory evaluation indicated:
1. Positive Sensory Test and Red Dermographism reaction (sensory changes) along the C4-C7 dermatomes especially between her neck and deltoid area. In the same areas her skin exhibited presence of the patches of dry skin.
2. Positive Sensory Test and Excessive Red Dermographism reaction along the T12-S1 dermatomes. These changes were detected all way to her feet on both sides.
3. Examination of superficial and deep fascia. A wide area of reflex changes in fascia in the form of Connective Tissue Zones (CTZs) was detected in her lower back starting from the sacrum all the way to the middle back.
4. Examination of skeletal muscles indicated generalized tension in the posterior neck and shoulder muscles with active trigger points present in Trapezius and Levator Scapulae Muscles. In the lower body and her legs she exhibited generalized tension, but active trigger points were present in Lumbar Erectors and Quadratus Lumborum Muscles, especially on the left.
5. Examination of the periosteum showed the presence of moderate tension at the insertion of tensed muscles into the bones in the upper and lower back.
As we completed the evaluation, she articulated that all she wanted was for me to hurry up, give a deep tissue massage and asked me to use my elbows to relieve pain. I explained that was not the best idea and that there are better treatment options than using a lot of pressure. She declined my offer to implement Medical Massage and asked that we move forward with a deep tissue massage. Fifteen minutes into the session that she requested, she began to cry. She was not getting any relief. I gave her a tissue and I asked her if she wanted to stop. She told me, “No, remember no pain no gain.” Tears seemed to be a regular occurrence when she received massage in the past. At this point, I asked again if she would be willing to try Medical Massage therapy. She finally conceded.
Work With Client
Going along with the name of my business, Empowering Touch, I began to educate her how we would work with her problems. I told the client that I wanted her to understand what I was doing, what will happen in her body during and after the therapy, why things were going to feel the way they would, and just as important, why past treatments did not work for her.
For example, I explained her cause and location of active trigger points in her erectors and applied and hold gentle compressions below her pain threshold in the direction of entrance into the trigger point. These areas were the major sources of her discomfort. While holding pressure we both noticed that her muscles began to relax. It was no longer a session where she just laid there and received therapy, she was now learning something new about her body and her mindset about what massage is and how it can help her started to shift.
This is when things got interesting. I told her that we would not be able to address trigger points in her muscles during this session, not because of time, but because presence of very active CTZs all over her back. I explained to her what I had found during the evaluation and told her how I would address those changes. Then, in plain words I explained to her what CTZ is, its role and that it can be painful to treat CTZ in the beginning.
Medical Massage Therapy
Before I started with the first stroke of Connective Tissue Massage in her sacral area, according to Science Of Massage Institute’s charts, I asked her to report if she feels any cutting or burning sensations when I applied strokes. With the first stroke she immediately said: “Both!!!”. I immediately decreased the pressure and speed of the strokes.
She could not believe the intensity of sensation that was coming from such a light touch. I think she literally levitated off the table and she began swearing at me like only a woman from Chicago could. We finished the session with only completing the sacral/lumbar area of the Connective Tissue Massage Chart. I let her know of the possible side effects of this massage, such as, nausea, dizziness and lightheadedness, and then I quietly left the room.
It took a while for her to come to the door. I asked her how she was feeling, and she said that she felt a little dizzy, but she was amazed with the amount of freedom she felt in her body with such simple treatment. Immediately, she wanted to know how long she had to wait before coming back. I described her personalized treatment plan and selfcare homework she must do, and we scheduled the follow-up appointments.
Two days later when she came in for her second appointment, she indicated that the pain had come back. However, it wasn’t as intense. It dropped down from a constant 9 level of pain level to approximate level 7. Thankfully this was without any opioids for pain management, something she has not been able to accomplish in a long time.
Two days later, she came back for her 3rd appointment. When she arrived, she was talking about an upcoming work trip. She was very nervous, as it was an 8-10 hour round trip and prolonged sitting has historically been a trigger for her intense pains. Going into the 3rd session, her pain level was a 4-5. I saw her right after she got back from the road trip, and she was elated that she did not have any pain while she was gone.
It took five one-hour sessions of Medical Massage protocols I learned while receiving my SOMI Certification, over the span of two weeks to get her to a point of permanent normalcy. During those sessions I gradually introduced other modalities besides connective tissue massage: trigger point work, lots of Post Isometric Relaxation (PIR), addressing her skin, etc.
At this point I observed her long-term results continuously for 7 months. We see each other monthly for one supportive session and she doesn’t have any discomfort and fully enjoys her life and work.
I am sure that the key to this and my other clients’ treatment successes is to be patient and explain everything in smallest details. I could have easily continued with the style of massage she requested, repeating the same mistakes all of the therapists before me had made. I would have gotten paid and moved on to the next client. Instead, I took a moment to step back, wait, look at the bigger picture and educate her that we both need to start to work on her abnormalities.
A lot of times we can be so anxious in our evaluations that we pass over small clues that can lead us to the right assessment of what the patient’s body is telling us. I am grateful that I was taught to recognize and was able to palpate those CTZs, which led me to not only a successful treatment plan, but a happy, healthy and empowered client.
Michael Durrett, CMMP, LMT is our former student who successfully practices Medical Massage Therapy in Texas. This clinical case is great illustration of how therapists who practice clinical aspects of massage therapy should engage the patient’s body and mind during the treatment process. Only in such case can stable clinical results be achieved, even in complex cases of somatic abnormalities.
1. Correct evaluation of the client should consist of two equally important components: examination of soft tissues and active involvement of the client in the treatment process.
2. Evaluation of the soft tissues must be conducted on a layer by layer basis when all 4 types of the soft tissues (skin, fascia, skeletal muscles, periosteum) are examined separately.
3. When evaluation is conducted correctly, all data collected by the therapist fits together as pieces of the same puzzle. For example, sensory abnormalities Michael detected during palpatory examination of the skin matched exactly the location of structural changes in the skin due to the tension in CTZs. In such case the superficial fascia compressed and irritated the cutaneous nerves which innervated the skin in C4-C7 dermatomes.
4. CTZs when active may create a wide arrangement of symptoms in the soft tissues. They may even mimic or contribute to various visceral abnormalities since CTZs’ activity is under intimate control of the autonomic nervous system which governs all our body functions.
5. Treatment must be also arranged on a layer by layer basis so the therapist addresses abnormalities in each type of the soft tissues with matching treatment options.
Science of Massage Institute