By Dr. Ross Turchaninov
Phoenix, AZ

In this clinical case, we are going to illustrate one important notion: Medical Massage practice is an essential part of the MT profession and medicine in general, since it delivers stable clinical results even in very complex cases.

IS MEDICAL MASSAGE ESSENTIAL?

The patient is a 55-year-old female who works as a hairdresser. For years, she had experienced chronic lower back pain, in part due to her long working hours. Several years ago, a lower back MRI confirmed the presence of a posterior 5 mm L5 disk herniation with spinal canal stenosis.

During the last 5 years, she had periodically been seen in our clinic (1-2 times per year) with moderate and, rarely, acute lower back pain, which we were able to successfully control while she did her regular maintenance at home.

Her hair salon was closed due to the coronavirus pandemic. Just before Easter, she decided to clean her entire house, including the backyard, and she did it in one day. The next day, she woke up with screaming pain and a complete inability to move due to the pain and weakness in her right leg. The pain was radiating all the way down both legs, especially to her right foot, making it completely numb and putting her entire lower extremity on ‘fire’.

The patient’s husband called 911, and an ambulance took her to the nearest emergency room. An MRI was performed, which confirmed the presence of a central L4-L5 disk extrusion with severe central spinal canal stenosis and bilateral foraminal stenosis. In other words, the content of her disk leaked out posteriorly and dramatically decreased the space in the spinal canal and both foramina, which let the L5 spinal nerves out of the vertebral column. Fig. 1 illustrates the radiologist’s report.

Fig. 1. Patient’s radiology report from the emergency room

Due to the severe pain, an epidural injection was performed in the hospital, and she was released home with recommendations to see a neurologist and/or neurosurgeon. She was also given a prescription for pain medication, a muscle relaxant and gabapentin (to decrease spinal nerve inflammation).

The day after her epidural injection, she got some relief from the intensity of her symptoms. She waited three more days, but there wasn’t any further improvement. She consulted a neurologist, and he suggested she see a neurosurgeon. Considering that she had been successfully treated in our clinic, the patient made an appointment as soon as she was able to move independently.

The video below illustrates her walking to the therapy room in the corridor of our clinic. At the moment the video was taken, she had already had one epidural injection, and she was on heavy medications. That is how disk extrusion looks clinically.

EVALUATION

The patient was pale, breathing superficially and frequently (tachypnea), sweating profusely, her blood pressure was 160/90, and most of the time she felt nauseous. All of that indicated that the spinal nerve’s compression triggered a protective reaction in the form of acute lower back pain, which in turn greatly unbalanced her autonomic nervous system, initiating severe autonomic reactions from various systems and organs.

There was no way to examine anything, since the patient was still in screaming pain while getting on the table.

TREATMENT

The first two sessions were used to inhibit the pain-analyzing system and decrease protective muscle tension. We concentrated on the middle back, sacrum and finally the lumbar area. We used LDM in combination with an inhibitory regime of massage therapy, careful application of techniques to relax the paravertebral muscles, permanent electric vibration, activation of the H-reflex and gentle passive stretching. She was given supportive homework recommendations, and she had to do light exercise in the swimming pool.

By the third session, the patient was still in acute pain, but she was able to get around more easily and was standing straighter. She felt great pain relief while she was in the water, and the pain came back as soon as she got out of the pool.

At that time, it became possible to examine her soft tissues. As we predicted, her lumbodorsal fascia exhibited severe shortening, including its insertions into the SI joints, the periosteum of the sacrum and the lateral surfaces of the lumbar spinous processes. The Sensory Test indicated a sensory deficit along the L4-L5 dermatomes due to the cutaneous branches being compressed by the lumbodorsal fascia and lumbar erectors; abundant active TPs were detected in the lumbar erectors and quadratus lumborum muscles; and there were periosteal changes in the spinous processes of the lumbar vertebrae, the entire right side of the sacrum, the right SI joint and the iliac crest all the way to its middle point.

Thus, sessions 3-7 were dedicated to the use of soft tissue rehabilitation modalities to decompress the entire lower back and, finally, the L4-L5 segment specifically.

To do that we gradually added Connective Tissue Massage with elements of Myofascial Release, Trigger Point Therapy, Postisometric Muscular Relaxation and decompression of the periosteum using Cyriax’s friction and Periosteal Massage.

The video below illustrates our patient walking in the clinic corridor after the 10th session of the Medical Massage protocol for Lumbalgia. What separates the first and second videos are 10 every-other-day sessions of Medical Massage.

The patient was advised to restart using the inversion table and continue her home routine and water exercise. She is not on any medication anymore, and she experiences only morning stiffness in the lower back, which she is able to control. The patient is not unique in our clinic. We deal with similar patients on a daily basis. Thus, Medical Massage therapy IS an essential business for our patients and for the patients our students are working with.

LESSONS

  • The patient had a very severe clinical case. Even after the epidural injection in the emergency room, the only solution offered to her was spinal surgery. There is no doubt that the patient suffered from severe disk pathology, and disk extrusion is the most advanced deterioration. Her disk extruded into the spinal canal and pinched both spinal nerves. However, it’s always worth a try to decompress the soft tissue component of the affected vertebral segment by Medical Massage first. If Medical Massage fails, the option of surgery is always still available.
  • Why did such a relatively simple therapy, compared to the complexity of spinal surgery, eliminate the need for surgical intervention? The first clue that conservative therapy, in the form of Medical Massage, might work for this patient was the significant reduction of the symptoms’ intensity in the water. Secondly, layer-by-layer decompression of the soft tissues in the lower and middle back eventually decreased pressure within the spinal canal, created extra space for the L5 spinal nerves to function and eventually eliminated the clinical symptoms.
  • Were the results presented in the second video long-lasting? Yes, if the patient is committed to doing her homework regularly and comes to the clinic for supportive therapy every month, pain-free function is more likely to be sustained. Due to the natural process of aging, her disks are going to dry out, triggering so-called ‘natural fusion’, and she is supposed to be completely pain-free, while some ROM, of course, is going to be lost. However, it is a small price to pay compared to the 30% failure rate of spinal surgeries.
  • The recent pandemic has greatly affected the entire country, including the MT profession. In many states MT is considered a non-essential business and its practice is forbidden to prevent the spread of the virus. There are a number of educators and therapists who correctly supported shutting down clinics on the basis that these services are non-essential. There is no doubt that it is absolutely ridiculous and unprofessional to practice pregnancy massage, oncology massage or even stress-reducing massage while the therapist and client can be potentially exposed to the virus. In our clinic we also cancelled all supportive therapies.
  • However, let’s look at the situation our patient was in when she entered our clinic after her first epidural injection. She was still in an enormous amount of pain and dysfunction and her treatment options were greatly limited, since even spinal surgery was out of the question, as hospitals at that time had cancelled all surgical procedures except emergencies. Our point is that in emergency situations, similar to what we described, Medical Massage IS an essential medical procedure, and patients must have access to it the same way they have access to DC or PT offices. Of course, with all possible precautions. Our clinic deals weekly with patients who suffer from a clinical picture of similar intensity, and we are simply unable to say to them ‘NO’ and suggest waiting for another month or two.

Successful treatment of this and similarly complex cases was possible only because of the clinical power of Medical Massage. The science-based Medical Massage Theory is information of such importance that SOMI requires our students to take it twice during our Medical Massage Certification. While many practices are still restricted, we recommend to therapists two new online classes that cover the first day of lecture, “Introduction to Medical Massage from Theory to Application.”

Begin your journey into Medical Massage by slowly absorbing this valuable information at your own pace. Both online classes are approved by NCBTMB and accepted by SOMI as part of our Certified Medical Massage Practitioner Program. These classes have been developed by practitioners who were once SOMI students and who recognized the need to provide solid science-based data for you in an online format. We can assure therapists of the unprecedented quality of the information, and we like the friendly way this important data is presented. SOMI does not have a financial interest in these projects. Here are links to the two online classes:


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