This Case of the Month was contributed to JMS by SOMI’s former student, Carolyn Anderson, CMMP, LMT, from Bristol, TN. In the years since Carolyn finished SOMI’s Medical Massage Certification program, she has kept in touch with us, and it has been very gratifying to observe how the complexity of her questions and patients she was working with changed with time. Years of SOMI’s work have paid off in our former students, who can independently solve very complex clinical cases on a daily basis.
MEDICAL MASSAGE vs. MULTILAYERED LOWER BACK TENSION
Male client, 43 years old. Counselor to high school teens, married with two children.
MAIN COMPLAINTS
Low back pain across the belt line anywhere from 4 to 6 on the pain scale, especially when sitting and driving. Also, he reported aching pain and numbness down the lateral aspect of the right leg to the knee, rated 4-6.
In three weeks, the client was supposed to go to Colorado for a ten-day, 40-mile backcountry hiking trip with nine high school students. The trip also included summiting two 14,000-foot mountains in 4 days. Because of the pain, he was really concerned about the plane ride and driving the van, let alone backpacking 40 miles up two mountains.
PATIENT HISTORY AND CLINICAL EXAMINATION
The client has been athletic since elementary school. Basketball was his sport of choice. While making a play as a college freshman, he was trapped at the basket and fell on his sacrum, resulting in severe low back pain. At 26, he was riding a moped at 30 mph, lost control, and ran into a telephone pole. The ignition key laid his knee open, requiring surgery. I mention these two incidents because these traumatic situations may have contributed to the overall picture.
He said that he has always had tight muscles, especially the lower back and hamstring muscles. He had received several steroid injections which brought some relief. Also, the client liked to run until October 2019, when he felt a sharp pain in his low back and he could barely return to the house.
An MRI done at that time confirmed an L4-L5 disc rupture. Since then, he has had two disc surgeries one week apart caused by an incomplete surgical procedure the first time. After the operations, he did PT for four weeks, has had chiropractic adjustments, and started to practice yoga daily.
The Sensory Test confirmed a sensory deficit in the common peroneal nerve distribution. He did not have night pain and did feel rested in the morning. That indicated that pressure builds up within the L4-L5-S1 segments during the day and is relieved during the night. Also, the client mentioned that movement decreased the pain intensity. That was a sign that his symptoms came mostly from the soft tissue component of the spine rather than the operated disks. Thus, during the day, active engagement of the ‘muscle pump’ and restoration of muscle oxygenation brought him relief from the lower back pain. These were the first encouraging observations.
There was no sensation of spreading pain associated with Fibromyalgia, and he didn’t have autonomic reactions associated with his lower back pain (i.e., headache, nausea, sweating, etc.) or any abnormalities in the Dermographism Test. Their absence indicated a lack of significant imbalance in the functions of the autonomic nervous system.
With mild to moderate pressure along the erector spinae muscles, they exhibited abundant active trigger points all the way up to the middle back.
Examination of skin elasticity and mobility indicated a significant buildup of tension in the lumbodorsal fascia.
Examination of the quadratus lumborum muscles on both sides indicated the presence of active trigger points, which were more pronounced on the right. The Compression Test applied to the upper and lower QL muscle on the right triggered an increase in tingling and numbness in the lateral leg.
The Compression Test applied at the level of L4-L5 in front of the right sacroiliac joint triggered mild pain radiation to the right leg. The client showed moderate restriction in lumbar flexion.
Thus, evaluation of the client’s soft tissues in the lumbar area indicated significant restriction of the tissues’ elasticity and mobility, which most likely, in combination with scar tissue formation after two spinal surgeries, contributed to the moderate irritation of the L4-L5 spinal nerve and that was the cause of his lower back and right side sciatica pain.
TREATMENT
Right from the beginning, my client and I formed a very good therapist/client bond. I gained his trust by explaining what I was going to do and as I proceeded. He was reassured that at this point it was a mostly soft tissue problem and that we had the chance to decompress his affected vertebral segments. The client was relieved to know that his back tightness/pain most likely wouldn’t result in another surgery in the future. My plan was to keep him on a maintenance program at least once a month if Medical Massage solved his issues.
The importance of gaining the client’s trust can’t be overstated, as Dr. Ross has emphasized to us in the article, “Clinical Application of the Gate Control and Neuromatrix Theory of the Pain” published in the Journal of Massage Science. HOW MASSAGE HEALS THE BODY: CLINICAL APPLICATION OF GATE CONTROL AND NEUROMATRIX THEORIES OF PAIN
The healthy placebo effect is absolutely needed to gain compliance from the brain to allow resolution of the client’s issues.
I followed the Medical Massage Protocol for Lower Back Pain (Lumbalgia) due to Tension in the Quadratus Lumborum Muscles for three sessions (approximately 60 minutes each). I also used silicone vacuum jars to release tension in the superficial and deep fascia. It was especially effective in removing the thickness in the Lumbodorsal fascia and in the QL region on both the left and right sides.
I worked on the quadratus lumborum muscles first because he felt the most pain there and because the tingling and numbness in his lateral right leg were referred sensations due to very tight QLs.
In the next three sessions, by faithfully following the protocol layer by layer (i.e., skin, fascia, muscle, and bone), we were able to fully relax the bilateral QLs and then work more on the erector spinae group, including the Trigger Point Therapy with fixed vibration and Postisometric Muscular Relaxation (PIR). The erector tension was also resolved as soon as tension in the lumbodorsal fascia was normalized.
Muscles in his lower extremities were also short. I worked locally there as well, paying special attention to the hamstrings, IT bands, vastus medialis and lateralis, the iliopsoas attachments, as well as lower leg muscles.
Altogether, we had a total of six sessions, with him doing his “homework” faithfully every day, before he flew out.
OUTCOME
While this client is 6’4” and had many areas of muscle tension and soft tissue restrictions, with his faithful observation of hot showers/Epsom salt baths and proper execution of the stretching exercises correlated with exhalations throughout the day, he was able to easily fly, drive, and hike with the nine high schoolers this past July (2020), and he led the way!
FUTURE TREATMENTS
Since this client returned from his trip, we have had an additional six sessions over three and a half weeks. I have evaluated and treated other tense muscle groups, including the rectus abdominis, which could also be contributing to the low back tightness that the client occasionally feels. He believes that SOMI’s Medical Massage was the game changer that actually allowed him to be able to keep his travel commitment with his high schoolers and avoid an unnecessary third surgery.
We are going to keep meeting for a while till he feels his body has good balance and he can manage with self-therapy at home and occasional supportive medical massage sessions.
ABOUT THE AUTHOR
Carolyn Anderson, CMMP, LMT
I graduated from Reflections of Health School of Massage, Johnson City, TN, in December of 2013. I was looking for a direction to further my knowledge of massage therapy in order to help resolve people’s aches and pains.
I was so thankful to Dolores Champagne, CMMP, LMT, who told me about the Science of Massage Institute’s Medical Massage Program. I would like to purposefully mention with all my conviction that the Medical Massage Protocols presented to me can resolve a variety of complex problems, of course with the client’s active cooperation. I have been fortunate to be able to successfully treat my family and many people in my community of Bristol, VA/TN since I received my CMMP in October 2016. It was the beginning of my path to becoming a massage clinician.
I consistently study Medical Massage textbooks published by SOMI, watch the Video Library, attend more Medical Massage seminars, work with other therapists who already successfully practice Medical Massage, and actively use the numerous resources provided by SOMI to further build my knowledge base. By doing this, I am gaining confidence to help the medical community to seriously consider the benefits of Medical Massage. This, in turn, will be the answer to the needs of many patients who are seeking help for unresolved somatic disorders.
Category: Case Studies
Tags: JMS 2020 Issue #3
