Massage & Bodywork

May/June 2010

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table lessons BY DOUGLAS NELSON LEARNING THROUGH THE STRUGGLE Mr. C. came to my office at the request of his doctor and his physical therapist, both of whom I admire greatly. He presented with pain in the mid-thoracic area, at about T8-9, on the right side only. The pain started about four years ago, after long hours of sitting over a microscope. At first infrequent, it increased slowly in frequency and intensity. If he changed position, it would lessen. If he was recumbent or supine, the pain disappeared. When he awoke, he had about 30 minutes of no pain. Gravity seemed to be his enemy. I had him side-bend to the left, which created a pull on the right side. Right side-bending against resistance also elicited pain, but less so. Passive flexion to the right lessened the pain. I remember clearly Mr. C. responding to a perplexed look on my face when I finished taking him through these movements. He kindly asked if I had any idea what the problem was. (My facial expression sure wasn't giving him any confidence!) "This worries me," I confessed. "It seems way too obvious, way too easy. Every time that happens, it turns out to be enormously complicated. Your doctor and physical therapist are two of the best I know. If this was as simple as it seems, they would have solved it by now. Everything points to a muscular cause. If you had an intrajoint issue, side-bending you into the pain should have made it worse. Stretching and contracting the muscle elicits symptoms. Let's approach this in the simplest way first. I am going to carefully and thoroughly treat the muscles in that area. We'll know soon enough if that helps." The next morning, he touched base. There was marginal improvement; the onset of pain was delayed by about 15 minutes. In two days, I saw him for a short session again. His symptoms were essentially unchanged. Over the next two days his symptoms were right back to 30 minutes pain-free upon awakening, followed by a day of discomfort, unless he would lay down. I have now seen him several times; the results are completely underwhelming. I tried referring him back to his doctor and physical therapist, but they don't know what to do for him either. I sent them a report of possible sources and the strategies I used to treat him. What they sent back to me was a very complimentary letter about my reasoning and differential assessment capabilities and sent him back to me. I could easily walk you through all the different strategies I did and why I thought they might work, but there is a much more valuable lesson in this case—one I don't see talked about very much. I have taught seminars for many years and in those seminars, it often helps to share an example where the application of some treatment made a profound difference in someone's pain. The purpose is meant to give value to the information, to show the potential value of what is being presented. There is, however, a possible downside to these successful case stories, including the ones I share with you in Massage 80 massage & bodywork may/june 2010 & Bodywork. I often get the sense that students think every client visit is like a CSI episode—each case is solved in an hour after insightful assessment and skillful treatment. Keep dreaming. In real clinical life, there are very few silver bullet treatments, where one session does it all. Mostly, people come in with musculoskeletal discomfort that could have several possible causes; figuring out the ultimate source takes time. By the second (and most often the third session) the source is clearer. The lesson is that the struggle is everything. If a client presents with something you solve easily, you have learned nothing. Clients such as Mr. C. are the real teachers for therapists like you and me. We cannot know everything and they don't expect us to. What they do expect is that we will search for new strategies, comb the literature, ask more experienced colleagues, or refer them elsewhere. The searching exposes us to strategies that may help future clients. If you are that therapist who struggles, who sincerely wants to help the people who grace your door, but the process takes longer than you'd like, welcome to the real world. Learning is messy, but learning is everything. As for Mr. C., it's game on! instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit or email him at Douglas Nelson is the founder and principal

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