This clinical case is an excellent illustration of the clinical potential of Medical Massage and how far it may take therapists who decided to learn and practice this unique modality. However, cases like this one are also gratifying to all SOMI instructors. It is an unprecedented feeling to see our former students develop into exceptionally effective massage clinicians like Teresa. Their clinical successes greatly justify all our efforts.

 

Dr. Ross Turchaninov, Editor in Chief

 

 

MEDICAL MASSAGE IN CASES OF DYSPHAGIA

 

by Theresa M. Brumble, RT(R)(CT), CMMP, LMT, LLLT

 

          I have been successfully practicing Medical Massage since 2017 but after finishing SOMI’s Medical Massage program in 2019, my practice has been blooming. I am always excited by new and complex clinical cases, which stimulate me mentally and professionally. This clinical case is a great example of how MM opened a completely new door for me as a therapist and impacted my practice.

 

          In January 2021, a 26-year-old female called to schedule an appointment at my office. She was a charming young woman with a nine-to-five desk job and a talented singer and trumpet player in her spare time. Her chief complaints were difficulty swallowing, a feeling of something “stuck” in her throat, and bilateral lower jaw pain. These symptoms appeared for the first time in 2018 while attending a friend’s wedding. The second time she felt likewise was at a hockey game, and soon after, her symptoms became more frequent, severe and began to bother her at work. She also recently developed bilateral TMJ pain and tight posterior and anterior cervical neck muscles, including SCM.

          An Ear, Nose, and Throat surgeon from Jefferson University Hospital in Philadelphia diagnosed her with Cricopharyngeal Dysfunction – meaning her Cricopharyngeal Sphincter was misfunctioning. Cricopharyngeal Sphincter or upper esophageal sphincter is semi-circular muscle which separates throat from esophagus and prevents the reflux of food. To do that sphincter muscle always remains contracted and it relaxes only during the swallowing.

          Swallowing is complex event and requires coordination between numerous anatomical structures. While allowing a bolus of chewed food to pass into the esophagus, the larynx must be closed to prevent aspiration pneumonia.  

          The Cricopharyngeal Sphincter is located at the esophagus’ entrance just below the Adam’s apple. The parasympathetic nervous system, specifically the vagus nerve, controls the sphincter’s opening (important note for later). Two hundred milliseconds before swallowing a bolus of food, the Central Nervous System (CNS) temporarily inhibits the vagal activity, and the sphincter relaxes, allowing food to pass into the esophagus (Jacob, 1989). Failure of the Cricopharyngeal Sphincter to relax is a direct cause of Cricopharyngeal Dysfunction or Dysphagia (Parrish, 1968). The video below (Cook, 2006) illustrates a swallowing registered using dynamic X-ray.

I.J. Cook, (2006)

 

          My patient began testing in December 2018 with Esophageal Manometry, a test to identify swallowing problems. It confirmed that her Cricopharyngeal Sphincter did not fully open during swallowing. She underwent Endoscopic Esophageal Dilation, but it didn’t help; her symptoms persisted, while a Barium Swallow test in 2020 came back normal.

          Next, she then tried a series of Botox injections to ease the intensity of symptoms and began speech and vocal therapy once she was cleared to go into the office during the Covid-19 Pandemic. Each treatment she underwent either helped temporarily or not at all. Finally, in desperation, her speech therapist from Jefferson University recommended trying a “non-conventional treatment” like massage or chiropractic therapy, which brought her to my website.

          When I face complex cases, my go-to source is the Journal of Massage Science and their Video Library. Ironically, JMS had published a clinical case on Dysphagia treatment only a few months prior. Here is link to the SOMI’s original article:

Medical Massage Courses & Certification | Science of Massage Institute » MEDICAL MASSAGE VS SWALLOWING PROBLEM

         I immediately re-read Dr. Ross Turchaninov’s article, brushed up on my knowledge of muscles involved with the swallowing function, and I knew what to do. During my patient’s visit, I explained my proposed treatment plan and how it could help her. 

          My initial consultation and evaluation began with a Postural Analysis that exhibited an “Anterior Head Position,” i.e., shoulders rolled forward, and her left hip elevated. Postural changes like these meant that the patient’s brain altered her positioning to decrease any anterior neck and chest tension. It explained why her head had an anterior tilt and why both shoulders were rotated inward. She also shared that anxiety attacks increased the intensity of her dysphagia.

          An initial palpatory evaluation showed a negative Wartenberg’s Test, which meant no direct irritation or compression of the brachial plexus on the anterior neck. However, both anterior scalene muscles exhibited tension with moderately active trigger points.

          I then performed a hyoid bone mobility test by gently placing my fingers on either side of the hyoid bone and asking my patient to swallow. I immediately felt a restricted vertical displacement of the hyoid bone during swallowing, especially on the left side. My patient confirmed that she indeed felt a pulling to the left when she swallowed food. Disbalance in the function of supra- and infrahyoid muscle as a factor in Cricopharyngeal Dysfunction is clinically established fact (Lee et al, 2015; Rob et al., 2019)

          I also evaluated reflex changes in the soft tissues, which could have formed following the Dysphagia. With my patient on her stomach, I started to test her posterior neck.

          A Dermographism Test revealed an overactive parasympathetic system. Striking the skin with my nail even slightly triggered a flare-up skin reaction, a.k.a. Excessive Red Dermographism. As I mentioned above, the parasympathetic nervous system controls the tension in the Cricopharyngeal sphincter. Excessive Red Dermographism means that an overactive vagal tone would probably prevent the sphincter from relaxing.

          Her superficial fascia along the posterior neck showed decreased elasticity and, on the left, ‘Orange Peel’ skin was visible. ‘Orange Peel” is a symptom where the skin becomes thick and pitted with pressure applied with skin’s lateral shift. It is a clear indicator of significant tension build-up in the superficial fascia with its thickening and even scarification. Location of ‘Orange Peel’ skin matched my patient’s complaints of the more acute symptoms on the left side of her anterior neck. With the superficial fascia compromised, tension would inevitably form in the posterior cervical muscles. As it turned out, the Upper Trapezius and Rhomboideus Minor muscles both had active trigger points.

          The tension in the periosteal reflex zones formed periosteal trigger points detected on the lateral surface of the spinous process C5 and on the lateral surface of the spinous process C2-C5. My patient also exhibited a restricted cervical ROM rotation to the left and a lateral shift of C1 to the left.

 

TREATMENT

          Before our first treatment session, I asked her to avoid stressful or anxious situations and to listen to throat-chakra meditation music for relaxation.

          My treatment plan included a Medical Massage protocol, various passive stretching techniques, and deep tissue laser therapy. I decided the best course of action was to begin an inhibitory regime of massage therapy. I first addressed the posterior neck, followed by a gradual move to TMJs and anterior scalene areas. I employed laser therapy, added superficial and deep effleurage in the direction of drainage, worked with the fascia to decrease tension, and balanced the autonomic nervous system. I used kneading to relax the trapezius and rhomboids and gentle repetitive friction at the proper muscle insertions (the occipital ridge, spinous processes of the cervical vertebrae, and the upper scapula). Next, I turned the patient supine and continued to work on her trapezius, sternocleidomastoid, and scalene muscles. I finished with an inhibitory treatment to the temporalis, pterygoids, and masseter muscles.

          After the first session, her anterior cervical pain and tension in both sternocleidomastoid muscles fell to “zero.” Throughout our next two MM sessions, I slowly added two complete Medical Massage protocols for Anterior Scalene Muscle and for Temporomandibular Joint Syndrome.

          After three sessions, her swallowing started to improve, and her TMJ pain was completely gone. It was time to address her supra- and infrahyoid muscles to restore proper mobility of the hyoid bone and reset the coordination between those muscles. I started with light effleurage, circular friction along her digastric muscles, and her supra and infrahyoid muscles. I could feel the difference between the integrity of the muscle on the right versus the more affected left side.

          After seven sessions, her anterior cervical pain was almost gone and her ability to swallow improved, becoming ‘more centered and consistent.’ Her singing also improved, and she felt her voice was more open, clear, and had a longer range.

          Since soft tissues in the posterior and anterior neck were balanced and relaxed, it was time for cervical adjustment on the C1-C2 spinal levels. I referred her to a chiropractor and after proper therapy, she had normal cervical ROM. The chiropractor shared that part of the hypoglossal nerve, which controls speech and swallowing and originates at the C1 spinal nerve was compromised at the spinal level–this was consistent with her complaints.

          I continued her treatment plan two times a week and added the final component of therapy by adding counter resistance. I gently squeezed the lateral sides of the hyoid bone and asked the patient to swallow. While she swallowed, I slightly resisted the upward movement of the hyoid bone. Next, I gently moved her hyoid bone up and down during her prolonged exhalations. As a variant of Post-isometric Muscular Relaxation, this powerful technique allowed to balance and coordinate the action of the supra- and infrahyoid muscles. As a preventative measure, I taught her to repeat this exercise at home whenever she felt close to experiencing Dysphagia.

          At that time, her Botox injections were due. We decided to forego Botox and continue our treatment without interruption to see if Medical Massage would be effective. After her first week without Botox, her Dysphagia did not worsen.

          After ten MM sessions, she had increased her hyoid range of motion, had more consistent centered swallowing, and had no hard bolus feeling when swallowing.

          We then took a two-week break, and she continued with at-home stretching and resistance to forceful swallowing. When she returned, she no longer felt her hyoid bone pulling to the left and her swallowing became 90% smoother.

          To maintain consistency and reduce stress, we continued sessions once a week but some symptoms remained. At one point, my patients asked if I had ever come across the Longus Colli muscle of the Anterior Neck. I shared that this muscle was not associated with swallowing but could address it in next session. 

          On a subsequent visit, I explained my plan to palpate and work on the Longus Colli muscle and asked her to signal any discomfort. I positioned my hand perpendicularly to her neck and used the tips of my second and third fingers to move the anterior edge of the SCM laterally, approximately at the level of the middle point of the SCM muscle. After that, I detected the pulse of the carotid artery, and I moved my fingers away from it while gently submerging my fingers vertically in the direction of the cervical spine. I proceeded gently and carefully. When I used gentle circular effleurage and then friction across the muscle fibers, my patient suddenly had an emotional release and began to cry. Stopping, I asked if she was okay and if a specific thought had triggered her and if we should cease the session. She wanted to continue and shared that oddly, nothing in particular had come to her mind. I proceeded therapy until she had another emotional release which then repeated three to four more times. When we finished our session, I handed her a glass of water, and she was shocked that the remaining feeling of something “stuck” was completely gone. We continued our medical massage protocol, laser therapy, and home stretching, including the Longus Colli treatment. I extended her treatments to once every ten to fourteen days until her swallowing normalized.

          I now only see her for 30 minutes every four weeks for maintenance. My patient had been very in tune with her body, and I think this not only inspired me but helped me proceed with confidence.

 

ANALYSIS

          I learned from SOMI that each clinical test provides only partial data, and correct clinical decisions can only be made when all accumulated data is analyzed. Here is my analysis: 

  1. The patient was clinically diagnosed with Cricopharyngeal Dysfunction by an ENT doctor.
  2. There is clinical connection between overactive sympathetic system and Cricopharyngeal Dysfunction (Verdonschot, et al., 2019). As readers recall, my patient had her first episode of Dysphagia during a friend’s wedding, and each following episode was associated with stress, anxiety, or excitement: hockey game, work stress, etc.
  3. My patient’s posture showed forward leaning head and shoulder positioning with an elevated left hip. This indicated the brain’s protective response to tension in the anterior neck; a clinical phenomenon established by Dr. J. Travel who linked pelvis disbalance/lower back pain with pain and/or dysfunction in the face or neck (Travel and Simmons, 1983).
  4. An Excessive Red Dermographism skin reaction confirmed the presence of increased vagal tone, which prevented the Cricopharyngeal Sphincter from relaxing.
  5. Superficial fascia on the posterior neck displayed tension more expressive on the left (presence of the ‘Orange Peel’ sign), and posterior and anterior cervical muscles exhibited active trigger points.
  6. A palpatory examination of her hyoid bone indicated its restricted mobility during passive manual displacement (more so on the left).

          It is well-known that chronic stress and anxiety are the leading causes of Dysphagia if all neurological causes (stroke, amyotrophic lateral sclerosis, Parkinson’s Disease, Alzheimer’s, MS, Brain tumor etc.), if neck structural changes (neck trauma, side effects of neck surgery, cancer etc.), are ruled out. This was the case for my patient. Without the help of medical massage, she would have continued to suffer while forever seeking a treatment that works. At that point the Cricopharyngeal myotomy was only option left, but surgical cut of the cricopharyngeus muscle creates its own significant side effects.

         I am grateful for the opportunity to help her, save her from questionable surgery and to treat all my other patients with Medical Massage Therapy – a clinical and science-backed practice that patients and physicians clearly need more of. 

          Since that I had several patients with same pathology and clinical response and my current goal is to teach this treatment protocol to other therapists and speech therapists. This treatment would also benefit all voice coaches and professional singers.

 

The patient’s letter:

          After over two years of countless doctor appointments with my ENT, speech therapy sessions, and a handful of Botox injections into a possible problematic throat muscle, I was at a loss of my next step to treat Dysphagia/difficulty swallowing. My results were inconsistent with previous treatments, and to be truthful, my anxiety and fear of eating were increasing. Then, I came across Theresa and MORE Medical Massage. I took a chance to see if my problems were soft tissue related. My situation is a unique one, but Theresa did not back away from it. Instead, from the first time I walked in, she was excited to tackle it and welcomed me with open arms! I could write for hours, but all in all, if you’re questioning about taking a chance to find relief with medical massage, laser therapy run, don’t walk! This is one of the best decisions I have made in finding a solution to my problems, and I hope it will be for you too!

Heather Berchtold

 

REFERENCES

Cook, I.J. Clinical disorders of the upper esophageal sphincter. GI Motility online (2006) May.

Jacob P, Kahrilas P, Logemann J, Shah V, Ha T. Upper esophageal sphincter opening and modulation during swallowing. Gastroenterology 1989;97:1469–1478.

Lee, H.Y, Hong J.C., Lee K.C., Shin Y-K., Cho S-R.. Changes in Hyolaryngeal Movement and Swallowing Function After Neuromuscular Electrical Stimulation in Patients With Dysphagia. Ann Rehabil Med. 2015 Apr; 39(2): 199–209

Parrish R.M. Cricopharyngeus dysfunction and acute dysphagia. Can Med Assoc J. 1968 Dec 21; 99(24): 1167–1171.

Travell, J .G., Simons, D.G.: Myofascial Pain and Dysfunction. The Trigger Points Manual. “Williams & Wilkins, Baltimore, 1983.

Verdonschot R., Baijens L.W. J., Vanbelle S., Florie M., Dijkman R., Leeters I. P. M., Kremer B., Leue, C.  Medically Unexplained Oropharyngeal Dysphagia at the University Hospital ENT Outpatient Clinic for Dysphagia: A Cross-Sectional Cohort Study. Dysphagia. 2019; 34(1): 43–51.

 

 

Theresa M. Brumble, RT(R)(CT), CMMP, LMT, LLLT

          Theresa Brumble, a Licensed Massage Therapist from Northfiled, NJ. She worked previously as a CAT scan/ MRI technologist for 20 years. Finally, she realized that she can help patients more and she went to massage therapy school. She quickly realized that she wanted to be on the therapeutic or medical side of body work. 

 

          “I purchased a Class IV Deep tissue laser for pain over 5 years ago and that changed my practice, but I didn’t realize until I went to my first SOMI Medical Massage seminar that I could actually improve the quality of life for my patients! I now use Medical Massage Protocols combined with deep tissue laser to help people in pain! I have been able to rid people of decades of headaches. I have helped to rehabilitate shoulders, knees and other joints quicker after surgery.

          Medical Massage has even kept people from surgeries. I use Medical Massage Protocols to reverse clinical picture of herniated discs in the lumbar spine. I have worked with patients from 9 to 91years of age.

          Since Medical Massage Concept incorporates Lymphatic Drainage, Therapeutic Massage, Trigger Point Therapy, Cupping, Vibration and Stretching Techniques, etc., it rejuvenates each layer of soft tissue! The laser I use in conjunction reduces inflammation, increases blood flow and heals on a cellular level! The two combined are amazing for all sorts of somatic disorders! My office, ‘MORE Medical Massage and Laser’ is located in Somers Point”.

 


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