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October 20, 2011

Massage in the Context of Physical Therapy: Part 2

Sometimes patients present with challenges where massage therapy is just the thing they need. For example, I was working with a patient who had broken his foot and was having to learn how to walk without bearing any weight through the cast. Being relatively young (anyone under the age of 50 - funny how that number keeps changing), you would expect him to be given crutches and send him on his way. However, he broke his foot because he passed out from a previously undetected heart condition. So the doctors had put in a pacemaker just under the skin of the opposite shoulder (it is protocol for pacemakers to dwell in the left shoulder). He had finally been cleared to a weight-bearing-as-tolerated status in the left arm. Initially, he was non-weight bearing until enough scar tissue knitted around the appliance to hold it in place. Not only that, the incision site was quite painful, which discouraged any use of the left arm anyway.

As you can imagine, this scenario creates quite a dilemma for walking. Initially, I tried fitting him for a hemi-walker, but he was too unsteady. So we used a standard walker for stability, but it was too painful and required too much energy to pick up, after all, this patient was ambulating by hopping on one foot. Using a rolling walker was the solution to this problem. However, by this time, the patient was exhibiting learned non-use of the left arm, and fear avoidance behavior with the belief that pain meant damage was occurring.

For a week and a half I worked with this patient to strengthen both legs and increase reliance on the left arm during ambulation, and increase his walking distance. I had to find a balance between performing exercise without creating heart palpitations or extreme dips in blood sugar, as this patient was also diabetic, both conditions that could create syncope (passing out) and falls. And yet, the left shoulder pain persisted, relieved only by ice. It was time to whip out my secret weapon: massage.

What I found in shoulder was a great deal of tension in pectoralis major attachment toward the humerus - cross fiber friction combined with massage with the grain of the muscle to stretch and ease discomfort where appropriate. The patient also pointed out pain at the top of the shoulder, the first head of the trapezius. Working with the trapezius naturally led me into the neck where the scalenes were tight and splenius capitis and cervicis along with the other cervical intercostals were tight and painful. I mobilized the scapula (shoulder blade) which, of course has pectoralis minor attached to the corocoid process, and leads right down into the anterior chest to the location of the pacemaker. I had to avoid the pacemaker placement because scar tissue massage would run counter to the necessary healing process of its placement. However, the increased pain and sense of pulling the patient was feeling was due to an overgrowth of scar tissue and muscle splinting that was counterproductive to the patient's recovery.

Following massage, the patient noticed an immediate decrease in pain and an increase in range of motion. This improvement continued into the afternoon and was noted during his occupational therapy as a marked improvement in functional tasks such as donning a shirt. OT took advantage of this through stretching and strengthening into the new range which the patient had not been able to tolerate previously.

My reward for utilizing this skill: "Thank you for fixing my arm," and a box of chocolates.

In my next post is another example of how I incorporate massage therapy into my physical therapy treatment.

Posted by linda at October 20, 2011 9:15 AM