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November 11, 2011

Massage in the Context of Physical Therapy: Part 3

Last week I was assigned a patient who was being discharged home, who I had not worked with before. As a PT, the responsibility of initial evaluation, re-evaluation, and discharge documentation falls to us because it is beyond the scope of PTAs. This patient, again, was relatively young, and had a diagnosis of spinal stenosis. Spinal stenosis occurs when the space within the spinal canal or around the nerve roots becomes narrowed.

She was not having a good day. Maybe because it was the first day of rain following a particularly warm and dry spell. She had pain radiating through her gluteal region and down her thigh to her knee. She could not walk standing upright and walking aggravated her pain to 8/10. I felt terrible, we were sending her home in this condition. I advised her about sleeping positions that might settle her pain, a towel roll under her waist in sidelying, a bed pillow between her legs, knees to ankles, to maintain a neutral spine. This settled her pain to a 6/10, but it went right back up to an 8/10 when we walked again.

I taught her stretches and reviewed her core stabilization exercises, issuing her theraband so she could perform her exercises at home. Her pain improved to a 6/10 again, and again, it jumped up to 8/10 with walking. I was running out of ideas. And then the light bulb turned on: massage.

I positioned the patient side-lying, pillow between her legs and proceeded to work, explaining which muscles were where and what they were used for. The gluteus maximus, the big muscle we recognize as out bottom is the powerful muscle we use to propel the body forward during walking. Gluteus medius (and boy was it tight) was used for balance. Gluteus minimus, which sits higher and deeper into the bony crest is also used for balance. Tensor fascia lata hooks into the broad band of connective tissue on the outside of leg that goes to the knee (also tight and painful, full of trigger points. I explained the position of the sciatic nerve, sandwiched between tight muscles, it could get pinched and send pain down the leg to the big toe. Its typical presentation: pain in the middle of the butt cheek. "That's it, right there!" she said, and I used the broad tool of fist to soften the larger muscles rather than the smaller, pokey tool of my fingertips.

I couldn't leave the task without checking the joints above the region of pain. They said in PT school, "Always address the joints above and below the problem." I knew this already from my experience as a massage therapist. Quadratus lumborum was tight and full of trigger points. The QL is a tough muscle to work all the knots out; definitely impossible in one session given the woven configuration of its fibers, allowing for the twisting motion of the lumbar spine. (Anyone out there with tips for releasing QL humanely in one session?? I'm open to input.)

With my treatment time up, I knew I wasn't done, but it was the best I could do. The patient sat up. She felt freer and more flexible. Her pain was reduced. The proof in the effectiveness of the treatment: she was able to walk back to her room with her pain staying down to a 4/10.

Posted by linda at November 11, 2011 9:17 AM

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