TDR Massage: A Case Study of Facial Fasciculations

By Linda LePelley, RN, NMT
September 2, 2015

TDR Massage: A Case Study of Facial Fasciculations

By Linda LePelley, RN, NMT
September 2, 2015

My client, a 64-year-old white female, had been experiencing a facial twitch which had become distracting and irritating. When she realized it was occurring more frequently, she went to her physician. He said it was probably nothing serious and suggested she reduce her coffee intake, which she did. She returned to him a few weeks later when she found the condition was continuing to worsen. Determining the cause of facial twitches, tics, or spasms can be a daunting task. Schimp, (2012) states, "Facial symptoms may be generated by peripheral or central mechanisms that involve neuropathic, neurovascular, or musculoskeletal factors." Because it had been going on for more than three months, and seemed to be worsening, her doctor referred her to a neurologist. She asked for permission to have it massaged, which he granted. According to Leite, et al, (2014), "Fasciculations are visible, fine and fast, sometimes vermicular contractions of fine muscle fibers that occur spontaneously and intermittently." This description represents my client's presentation well.

She told me the twitching was aggravated by cold and it seemed to worsen when she was resting or relaxing. She could make it stop for a little while if she tightened the muscles in her chin, but it would return within a short period of time. When asked to describe the characteristics of the sensations, she said it sometimes tingled, and was most irritating when it felt like there was something crawling on her chin.

The twitch was located below her lower left lip, just over the mental foramen. Upon gentle palpation, I could feel an area of elevated tissue density (TD). It felt like a firm strand of thin yarn, less than 1/4cm in diameter had been inserted into the affected tissues, and ran a course from the mental foramen toward the marginal mandibular branch, which roughly follows the jawline, for approximately 4 1/2cm. At first, the client said she couldn't feel anything in that area, but once I had isolated the specific location of elevated TD and carefully raked my finger over it, the client stated that it was slightly tender when pressure was applied. She felt the area with her finger again, and was surprised to find that there was a palpable spot associated with the tenderness. She expressed hope that these findings were related to the facial twitch and that it could be relieved. Because we could palpate elevated TD at the location of the problem, the likelihood was that we were dealing with a musculoskeletal issue.

The Tissue Density Grading Scale (TDGS), when used before and after treatment, is an effective way to chart a client's initial condition and then determine the effectiveness of any treatment provided. To document an area as small as I was dealing with in this case, I drew a red line (indicates G3) the width and length of the actual problem spot. The density of the tissues around the line for about 1/4cm were also elevated, so I colored around the red line with blue (indicates G2) to complete my illustration of the affected area.

I used the same principles of TDR massage for this small area (less than 4cm) as I would for any other area of elevated TD, but for one. Using a massage cream with excellent glide, I warmed one hand with the use of a stone. I immediately transferred that heat to the affected tissues in very gentle, light circular movements. The difference in this case was that I did not increase the pressure and movement as I felt the locus of density become smoother, soften, and then dissolve away – the face is too tender an area for that type of pressure. After about 45 minutes, the G3 strand was no longer palpable, the entire area was soft and just slightly denser than a G1, which I attribute to the increased circulation in the area. The client stated that it felt very relaxed, and there was no tingling sensation or fasciculation present. I colored my post treatment TDGS diagram green with streaks of blue to indicate the slightly elevated TD. The client returned for a follow-up treatment the next week and reported that she had experienced no twitching or sensations related to the area since her TDR treatment. Palpation revealed that the density of the involved tissues had been restored to normal.

Almost six months later, the client reported that she felt a tingling sensation and suspected that the twitch was coming back. Palpation revealed a thinner and smaller strand of tightness at the same location. I repeated the treatment as described above and within 20 minutes, it was no longer palpable. My client massages her own face regularly, and has a bi-monthly maintenance treatment to the affected area. She has not had a relapse in two years.

References:

  1. Leite, M. A., Orsini, M., de Freitas, M. G., Pereira, J. S., Gobbi, F. P., Bastos, V. H., & Oliveira, A. B. (2014). Another Perspective on Fasciculations: When is it not Caused by the Classic form of Amyotrophic Lateral Sclerosis or Progressive Spinal Atrophy? Neurology International, 6(3), 5208. doi:10.4081/ni.2014.5208.
  2. LePelley, L., (2014, March). The Tissue Density Grading Scale: A Communication Tool. Massage Today, 14, (3).
  3. Schimp, D. J. (2012). The Symptomatic Face: An Algorithmic Approach to Diagnosis. Journal Of The American Chiropractic Association, 49(3), 11-24.