Issue link: https://www.massageandbodyworkdigital.com/i/1358392
L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 25 "That's not good. What in the world happened?" I asked as soon as I saw Mr. R. struggle to rise from the waiting room chair. "Not fun," he answered. "I had a battle with a stairway." "It looks like the stairs won," I said. "Big time," Mr. R. admitted. "I slipped, and as I was falling, I turned to the right to grab the banister and catch myself. I missed and slammed into the steps with the right side of my back. It was a pretty good jolt." "How long ago did this happen? Have you been to the doctor?" I inquired. "I fell about 10 days ago and, yes, I did have it checked out. I was afraid I broke a rib, but the X-rays were fine." "Any pain when taking a breath?" I asked. "Nope. It only hurts if I cough or sneeze, and luckily, I have only done that once." "What about any movement restrictions?" "Getting in and out of bed is terrible, and, as you saw, getting up from a chair is no picnic either. It seems like anything that involves rotation of my spine really hurts." "Well, the major muscles of rotation are located right where the impact from the stairs hit your ribs. Let's have a look," I said. Mr. R. carefully and painfully climbed onto my treatment table. Since the impact was on his right lower rib cage, I had him lie on his left side. Suspecting the area of the right internal oblique was the epicenter, I decided to begin there, but proceeded very cautiously. Surprisingly, not much was tender. "Anything here?" I asked, as I explored more of the area. "Not really," he answered. That seemed surprising. To confirm my palpation was correct, I asked Mr. R. to rotate his upper body to the right, engaging the internal oblique muscle. I stabilized him so the muscle engaged but no movement of the skeleton occurred. I clearly felt the muscle engage, but the contraction wasn't painful. best practices | TABLE LESSONS Trajectory of Treatment BY DOUG NELSON This was curious, given the impact and the presentation of his symptoms. Exploring a movement component, I passively rotated his upper body gently to the right and anticipated his protective response. None came. As I passively moved his thoracic spine into left rotation, he winced in pain. At that point, I attempted to passively create lateral flexion of his spine to the right. It was painful. And now the picture was getting clearer. "Could you rotate your upper body to the right, but elevate your right shoulder at the same time?" I asked. He had no pain in doing so. When I asked him to rotate to the right, but initiate the motion by elevating his right hip, it elicited a painful response. The likely reason for his pain was now clear—an inflammation of the mechanoreceptors in the lower thoracic facet joints due to the impact of the fall. My treatment approach was to alternate movements that open these facets with massage approaches that maximize fluid exchange in the area. As our session ended, I explained to Mr. R. what I thought was possibly the cause of his pain, how that fits with the mechanics of the fall, and why certain movements were painful. "What should I do at home?" Mr. R. asked. "Remember the position I put you in that was so comfortable? Do that as often as possible and also laterally flex to the left, which should only feel like a nice comfortable stretch. If I am correct about what is going on, you should notice a small decrease in pain over the next two days, with a noticeable change after the third day. If that isn't what happens, I'm probably off base and we will totally rethink the approach. Let's connect in four days." Mr. R. followed my suggestions, and the pain did indeed decrease markedly after the third day—so much so that an additional session wasn't needed as the pain continued to improve with each passing day. The lesson here? When clients present with a range of symptoms, we attempt to make sense of all the information they reveal with a model of understanding that makes the pieces fit together. If we are correct in our understanding and how our treatment approach interacts with the process, we should also have some idea about the trajectory of the client's posttreatment experience going forward. After all, the goal of treatment is to alter the natural course of events, meaning that massage should speed recovery far faster than time alone could do. In Mr. R.'s case, the outcome matched my expectations, confirming my assessment and approach was likely correct. In fact, Mr. R. explained what we had done and why during a follow-up consult with his doctor. When Mr. R. asked if that made sense, his doctor replied, "I think the results speak for themselves." Even better, I've since had two referrals from his physician! Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois, and past president of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit nmtmidwest.com, or email him at doug@nmtmidwest.com.•