This Case of the Month was submitted to JMS by Richard Abisia, LMT, CMMP – the latest graduate of SOMI’s Medical Massage Certification Program.
When you read Richard’s case, please pay attention to his evaluation’s accuracy and careful patient’s guidance to correct homework. However, Richard’s ability to masterfully formulate and constantly adjust treatment strategy is even more impressive. It allowed him to move from session to session slowly but steadily building stable clinical response and decisively helping patients in very complex situations.
Dr. Ross Turchaninov, Editor in Chief
MEDICAL MASSAGE vs MIXED SOMATIC SYNDROMES
by Ricard Abisia, LMT, CMMP
A forty-two-year-old male came to our clinic with bilateral chronic right middle back pain, numbness, and tingling in the 1st-3rd fingers on the right hand. Also, he had bilateral chronic lower back pain more prominent on the right and the pain level was consistent around 5 to 6 (on a scale of 1-10 with 10 being severe).
The patient cannot walk distances over 100 feet with quickly escalating pain. The Cervical ROM and ROM in the shoulder joints are greatly reduced, and the patient cannot reach behind their back. The patient cannot sleep if his arms are flat on the bed and he must have both arms on a pillow for support to relieve shoulder and middle-back pain which is significantly worse in the morning.
The patient is obese and works as a food chief inspector. The patient recalls a previous injury to their middle/lower back approximately 15 years ago when they were hit from behind by a baseball bat.
This recent pain started several months ago, and the patient was first treated by a chiropractor without clinical success. Considering the presence of neurological symptoms in the form of Radial Nerve Neuralgia, the patient was treated with Radiofrequency Nerve Ablation followed by plasma injections. The goal of the treatment was to block the inflammation in the spinal nerves and relieve the patient’s chronic pain while helping the affected nerve to regenerate slowly. According to medical sources, the ablation is effective within 3 to 15 months. The patient improved significantly after six months however the pain soon returned. Repeat ablation was suggested but due to insurance conflicts, there was no further treatment.
I conducted a layer-by-layer soft tissue evaluation, and it revealed the following:
Applying Kibler’s Technique confirmed the presence of active Connective Tissue Reflex Zones in the first level (in the skin) and the second level (in the superficial fascia) bilaterally from C2 to T12.
Applying the Opposite Shift Technique indicated the presence of tension and adhesions formed in the third level of Connective Tissue Zones (in the deep fascia) within the same distribution.
During an evaluation of the cutaneous reflex zones using a Sensory Test (slow bilateral striking of the skin), the patient reported less sensation on the right side along the paravertebral line.
Examining the Reflex Zones in the Skeletal Muscles confirmed the presence of active trigger points in the mid-thoracic iliocostalis as well as trapezius and levator scapulae muscles bi-laterally.
Evaluation Of Peripheral Nerves:
A negative Spine Compression Test ruled out acute nerve compression by the degenerated disk. However, stressing the C5-C8 spinal nerves with the Nerve Compression Test paravertebrally triggered local and radiating pain patterns.
Wartenburg’s Test used to evaluate the presence of brachial plexus irritation from a tensed anterior scalene muscle was positive bilaterally.
Finally, a Compression Test by the upper Quadratus Lumborum fibers under the last rib was positive on the right indicating possible irritation of the upper lumbar spinal nerves there.
I saw my initial goal in blocking the pain analyzing system locally to decrease the intensity of chronic pain and give the sensory part of the patient’s brain time to rest and reset itself.
I started with drainage of the area performing effleurage starting from T12 to the axilla on the right (most affected). My next step was to decompress superficial fascia and use it as a tool to balance the autonomic nervous system. To do that, I used Connective Tissue Massage on the entire posterior thoracic region within the patient’s comfort zone, avoiding triggering autonomic reactions. I drained the tissues again.
The next step was applying the “Big Fold” Technique to decompress deep fascia and relax paravertebral muscles. I followed with effleurage again and concentrated on the posterior cervical spine, especially C5-C8 levels decompressing paravertebral tissues there. Finally, I applied different kneading techniques on each part of the trapezius muscles and finished with effleurage.
Homework: I taught the patient to stretch the posterior cervical muscles during long exhalations following morning showers and to use this stretching routine at least three times daily.
The patient reported that he could sleep with less discomfort and keep his arms on the bed without pillow support.
Local pain in the right mid-back intensified from soft tissue release during the previous session, which is an expected reaction. Testing of superficial and deep fascia indicated that they were no longer unrestricted, and the patient could capitalize on the fascia decompression results—the Nerve Compression Test on levels C5-C8 became negative.
During the evaluation, the patient exhibited a positive Wartenburg’s Test, which indicated an irritation of the brachial plexus by the anterior scalene muscle. Since this irritation was the likely cause of the middle back pain and hand numbness, I decided to address this potential trigger. I performed a Medical Massage protocol to decompress the anterior and middle scalene muscles and free the brachial plexus from chronic irritation.
Homework: I taught the patient how to do passive stretching of the scalene and levator scapulae muscles and asked them to add it to their stretching routine.
The patient reported ROM restoration in the right shoulder joint and approximately 40% flexion and abduction improvements before feeling pain. The patient shared that middle-back pain intensity decreased by 30%. A Wartenburg’s Test was now negative and a Nerve Compression Test on levels C5-C8 remained negative.
I started with cervical paravertebral muscles relaxation techniques. I then added friction to the lateral surfaces of the spinous processes concentrating on C5-C8, followed by effleurage. Next, I targeted the trapezius and rhomboid muscles using kneading before using Trigger Point Therapy on the iliocostalis, trapezius, and rhomboid muscles. I finished working the back by passively stretching the rhomboids. Next, I repeated the Anterior Scalene Muscle protocol, followed by an additional application of PNF stretch to scalene and levator scapulae muscles.
Homework: Added stretching for Rhomoboids muscles
The patient significantly improved and could grasp his hands behind the back and had no ROM restrictions in the right shoulder. Nerve Compression Tests were bilaterally negative with no more numbness/tingling in the right hand.
The pain now concentrated in the lower mid-back (around T10) and in the lumbar erectors which I now began to target. I started with drainage followed by Connective Tissue Massage in the lower back to decompress superficial and deep fascia. I was able to avoid autonomic reactions. I followed with drainage and incorporated parts of the Medical Massage protocol for Quadratus Lumborum Muscle Syndrome to decompress its upper part under the 12th rib.
Homework: Showed patient child’s pose/happy baby stretch and QL stretches.
The patient reported moderate pain in the right hip and general soreness in the soft tissues of the back but without any dysfunction. The patient is now able to walk longer distances without debilitating back pain and describes current pain at around level 2—full ROM without pain and discomfort.
The Reflex Zones in the deep fascia are still present at level L3. I applied steps of the Medical Massage protocol for Middle Back Pain and brought the patient’s discomfort level down to 1.
I concentrated on detailed work surrounding the left lower lumbar erectors, emphasizing their lateral edge, and used TPT on the lower lumbar erectors. To decrease muscle tone and reset resting muscle tone, I used Neuromuscular Reset Therapy (NRT) in the gluteal group and on the anterior hip muscles.
The patient felt tension when the left lower extremity relaxed after hip flexion. I used NRT as a tool for an indirect tension reset in the muscles of the left lower extremity through relaxation of the rectus abdominis muscle. At the end of the session, the patient could sit up without assistance and had zero pain or discomfort.
Homework: Continue to use stretching techniques to reinforce treatment.
The patient reports stable, pain-free long walks and has only residual pain and tightness on the right side of the paravertebral muscles at level T7. There is some tension in the intercostal muscles along the T7 intercostal space. Applying compression in the intercostal space triggers pain referral further down between the ribs.
I incorporated parts of the Medical Massage protocol for Intercostal Nerve Neuralgia to decrease tension in the intercostal muscles, decompress the intercostal nerve and prevent possible rib subluxation. I used friction along and across the intercostal muscles and their insertions into the upper and lower ribs periosteum, followed by drainage and passive stretching. I finished by applying Postisometric Muscular Relaxation with NRT on internal/external obliques.
Homework: Continue stretching and walking to engage the muscle pump.
Currently, the patient is on supportive therapy. The patient’s goal is to lose weight and slowly increase the intensity of the exercises.
Please Join SOMI for Medical Massage Seminar in Phoenix, AZ on February 18-20 2023 to open new professional possibilities for you and your patients. This exceptional 3 three days program (24 CEUs) takes therapists from MM theory and patient’s evaluation to the application of Medical Massage Techniques and Medical Massage Protocol for the successful management of Chronic Headaches:
About the Author
I grew up in Vallejo, CA, in the Bay Area, and after graduating High School, I joined the United States Air Force and faithfully served our country for ten years as an Aircraft Mechanic for the A-10 Warthog and the F-16 Fighting Falcon.
When I left the military and moved to Phoenix, AZ, I enrolled in the Arizona School of Massage Therapy. I graduated at the top of my class. Still, I was always a striver, and in 2016 I started my journey into learning Neural Reset Therapy developed by Lawrence Woods, which I became master certified in May of 2017. During this program, I became aware of Dr. RossTurchaninov’s program through the Science of Massage Institute, as Lawrence had references on resetting tissues based on the Glezer/DalichoZones to have a beneficial effect on the deeper organ structures. Due to COVID, I was able to start my journey into the Medical Massage field only in February of 2022.
Currently, with my colleague Angel Perea, LMT, we use Medical Massage, Neural Reset Therapy, Quantum Alignment, Muscle Testing, and Pulse Electromagnetic Frequency to deliver incredible clinical results.
Category: Case Studies
Tags: 2022 Issue #3