Thursday, May 24, 2012

Mrs. R. Case Study Treatments So Far

#1. We did a 20 minute interview regarding medical history, surgery, auto collisions, daily activity, short and long term health goals, and pain management. I was trying to determine how she got to where she is and how to get her to where she wants to go. After the interview, I did about 40 minutes of neck massage. The goal of that neck massage was more for assessment and ROM testing than therapy. Again, trying to find a starting place.

#2. This session was to do physical assessments to coincide with the verbal history Mrs. R had relayed to me. We went through the Erik Dalton Myoskeletal Alignment Level 1 techniques, which I outlined in an earlier post. We also did some ROM testing with stretching of the neck, legs, hips, and arms. Very little of this session was therapeutically minded either- mainly assessment due to very tight, guarded tissue in most areas.

#3. The treatment started with Myofascial release techniques on the back, focusing on scapulae, quadratus lumborum and erectors. The very slow, steady warming up lasted about an hour and had very little direct, focused, pokey pressure.

#4. We did all anterior work, compensating for imbalanced driving and desk work postures. This included neck, pectorals, arms, and hands, concentrating also on opening the tissues to alleviate numbness and tingling coming from the shoulders and neck into the hands and arms. Later we moved to the quadriceps, psoas, and adductors of the leg, doing very slow, subtle stretching of the upper legs to improve mobility.

#5. After watching half of Erik Dalton's MAT Level 1, DVD 3 of neck techniques, I did some neck palpation on Mrs. R to feel for "fibrotic" tissue indicating "cervical fibrosis." Most of the techniques in the DVD were performed side-lying on a shirtless male client. As Mrs. R. is very conservative, I need more time to explore proper draping techniques to coordinate with the new techniques. With her level of cervical dysfunction, I don't want to experiment with too many positions yet. Supine is comfortable, so I kept with that. I also did some back work, finding more Right side scapula (rhomboid, upper trapezius, and Latisimus Dorsi attachment tension) than Left. The Left Quadratus down into the Left hip were more sore and tense- less freely moving that the Right. In the lower back areas I did some of the MAT techniques mixed with MFR to spread denser fascial restrictions. The MAT direct facet joint release type manipulation is still much too tender to achieve any results. Finally I did some pectoral and anterior arm stretches while Mrs. R. was prone.

#6. This treatment was all about the neck. Mrs. R. came in presenting with a headache and neck pain. Both stress and poor sleep were to blame, along with the chronic imbalances. My goal was to decompress the neck, meaning making room for the cervical spine to move more freely. For this I did traction of the neck with gentle stretching by pulling the head upward from the neck by the occiput area. We also did stretching of the neck in rotation in both directions, forward flexion and lateral flexion in both directions. I did deep sustained trigger point work on the levator scapula attachments. I lifted and tried to spread the sterno-cleido-mastoids.

After an hour of this neck work, I asked where else Mrs. R. wanted to focus and she said nothing felt overworked (painful to the touch more than usual) and her back was relatively pain free today. We agreed, together, that her goal of working through the chronic neck tension and imbalance was the priority, and that I should continue. Over the 2nd hour, I spent quite a bit of time trying to peel away the upper traps and other superior muscle attachments from the occipital area- like the SCM behind the ear. These connections, in addition to the posterior scalene and levator attachments on the top ribs and superior medial border of the scapula, respectively, seem to be responsible for much of the limited mobility of Mrs. R's neck and shoulders.

Since I had done at least an hour of neck work on Mrs. R before, and have received more than an hour of neck work on myself several times, and have done it on several neck and headache sufferers in the past, I did not have much hesitation about doing so much at one time. Unfortunately, I should have been more conservative. Mrs. R reported later that after leaving that Monday, she took 1000mg of Ibuprofen and went to bed. A debilitating migraine woke her up and she had to vomit 4 times throughout the night.

#7. Mrs. R came to the clinic 2 days later, Wednesday, for an hour treatment. She told me about the migraine incident and stated that it is not uncommon for her to have such a profoundly intense migraine and that she certainly wanted to continue treatments. Overall her adhesions in the musculature of the neck were improving- feeling (to her) like they are "breaking up." She did not, however, want any more neck work so soon. We focused on the low back and scapula release for half the hour and then moved onto the hips and glutes- all while prone. She laid with her head to the side, on the table, to be most comfortable, stating that the face rest would not be comfortable.

Her piriformes was exquisitely tender along with most points I touched along the SI joint. I did a stretch of the low back and hip- while prone I bend the knee to 90 degrees and internally rotate the hip by guiding/arcing the foot medially. The same motion as the following video, but 1 leg at a time, and 100x slower with a sustained stretched at a comfortable end feel. I then anchor the contralateral QL or superior sacrum area to counterbalance and more carefully control the intensity and intent of the stretch. Did I mention SLOWER?




Having come from work (professional internship) to this 7th appointment, Mrs. R had come wearing 1.5 inch dress heels. When leaving she said she was feeling better in the back and that her heels were not causing any discomfort at the time.

Interestingly, Mrs. R says that she wants to go back to school, which she does next week, so that she will be distracted from her pain again. Not that she's in more pain since we did this barrage of massage, but she's more attuned to it because I'm exploring so much of it mentally and physically and she has the time and leftover brain cells to focus on what her body is doing.

Moving forward, I'm not sure how often I'll be able to see Mrs. R and I intend on being MUCH more conservative with treatment of the neck- The last thing I want to do is cause any more damage or pain to her cervical structures! I am also going to encourage her to see a chiropractor for assessment and am interested to hear what her medical doctor has to say when she goes back for a check up in a couple weeks, regarding her needs for pain meds. We have a loose appointment scheduled for next Thursday, May 31st, which may turn into weekly or every other week, shorter treatments.

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