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Treatment Tools

By Debbie Roberts, LMT

About the Columnist
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Treatment with No Clear Protocol

Recently, in one of my seminars, a relatively new therapist with two years of experience said, "I like to do therapy when there is an ABC treatment protocol. That way I know exactly what to do." And I thought to myself, you are absolutely correct. It would be a lot easier if there was an ABC or a 1-2-3 way of doing massage therapy. The trouble is how often is that the case and what happens when your ABC treatment doesn't necessarily fit this client.

Clients come in many shapes and sizes and present with neurological issues, biomechanical issues, emotional issues, disease processes, past surgical procedures, new acute injuries and there is a vast difference in the treatment protocol between an elderly client and a pregnant client. Is there really ever an ABC or 1-2-3 treatment protocol? Isn't that like saying one size fits all?

To accommodate the ever changing clientele, our treatment protocol needs to be flexible and adaptive. The only way to stay consistent is to have an ABC assessment protocol rather than an ABC treatment plan. I invite you to follow along as we explore the journey with one of my clients who had the diagnosis of lumbar spinal stenosis, a surgical procedure called the X-Stop and the direction to take when there is no clear ABC treatment protocol.

Real World Example

Four months ago. I had a client who presented to my office in acute lumbar back pain with radiation of pain into her tailbone and down her right leg. In taking her health history, she explained that she had under gone two surgeries in which the surgeon had inserted a device called an X-STOP spacer. Time to ask the question: Is there is an ABC treatment protocol for this patient? Well, yes and no so let's investigate further.

map - Copyright – Stock Photo / Register Mark Her doctor told her it was a minimally invasive surgery and it should relieve her leg pain which he believed based on her MRI was being caused by lumbar spinal stenosis. In her case, physical therapy had not helped. He explained she would need to have the X-Stop placed at three levels of her lumbar spine to be successful. Here's the catch; her insurance company would only pay for two levels at this time. Being pain driven and wanting relief, she chose to proceed with surgery on the two levels. Initially, she said her pain level was immediately better but gradually over time and in about one year, a similar pain returned.

Her surgeon felt it was because he needed to do the third level as he had originally planned. The insurance company approved the final level and she went back to surgery. Only this time after the surgery, she didn't experience the relief of pain. In fact, she was left with radiation of pain into her tailbone, across her back and down the right leg. The surgeon ordered an MRI, as far as the surgery went the X-Stop looked well positioned and he felt over time the pain should go away. But one year later, the pain hadn't changed if anything it had become more debilitating. The pain limited her walking, it limited her exercise, it limited her sleeping, it limited her riding in a car and it limited her life. Now, instead of having just a biomechanical issue, it was becoming also an emotional issue. During her last visit with the surgeon he had relayed to her that in the second surgery he had to tighten something down more that he wanted to but she couldn't tell me what. Again, I will ask the question: Is there a clear ABC treatment protocol for this client?

Since her original diagnosis was pain caused by lumbar spinal stenosis, let's take a refresher course in what happens and how many people are affected. According to the American Association of Neurosurgical Surgeons, it is estimated that about 400,000 Americans, most over the age of 60, may be suffering from the symptoms of lumbar spinal stenosis. Lumbar spinal stenosis is a narrowing of the spinal canal which can compress the nerves traveling through the lower back and into the legs. There are as many as 1.2 million Americans with back and leg pain related to some form of spinal stenosis. Since the X-STOP device was approved for use by the FDA in November 2005, more than 10,000 X-STOP procedures have been performed in the U.S. for the relief of lumbar spinal stenosis.

What is the X-STOP surgery supposed to do? In a healthy spine, spaces in the spinal structure allow nerves to branch out from the spinal column to the rest of the body. Gradual changes to the spine due to aging, plus wear and tear from daily activities can reduce the space around a nerve until it becomes pressed or pinched, causing back pain, leg pain, cramps in the buttocks, difficulty walking and other symptoms. Once this happens in the lower spine, it is labeled as lumbar spinal stenosis. Typically, bending forward like leaning on a shopping cart relieves the pain because it increases the space around the nerve. The X-STOP spacer uses the same principle. The device is inserted into the back of the spine to prevent a patient from bending to far backward at the narrowed segment, a position that for patients with spinal stenosis can cause leg pain or sciatica.

Let's look at how the surgery is performed. The surgical approach to the spine is from the back with the patient typically lying on his or her side or belly on the operating table. A 2 inch to 3 inch long incision in the skin of the lower back is made over the level of the spine diagnosed with lumbar stenosis. Using x-ray guidance, the X-STOP spacer is inserted between the spinous processes, under the ligament at the very back of spine and secured into position. With the understanding of spinal stenosis and how the X-STOP functions in the lumbar spine, what is the ABC treatment protocol? There isn't one; you can't pre-plan this person's treatment. You have to assess the spine, pelvic positioning, overall general functioning of the body as a whole, what kind of range of motion there is now above and below the surgery.

Assessment Strategy

First, like any client, we will need all of their reports and a detailed health history form as a valuable beginning. Have them fill out the paperwork in advance of the session and return it to you early. This way, you have time to research and do some homework on the procedure they have under gone. You will be better informed about how and what structures have been affected.

Second, know how to do an assessment of the pelvis and sacrum. You should check the iliac crests, the heights of the PSIS, the gluteal folds, which delineate the lower border of the gluteus maximus muscle and compare heights. Perform a standing flexion test, a single leg motion test and a static position of the ASIS and pubic tubercles. Perform a bilateral motion test of pelvic rocking, feeling for resistance to motion comparing the right to the left side. You will need to perform a FABER test to determine if there is any hip involvement. In a prone position, you should evaluate the depth of the sacral sulci. The bottom line is you are evaluating for the presence of asymmetrical positioning of the ASIS, PSIS, ischial tuberosities and pubic rami looking to see if there is any presence of some sort of pelvic dysfunction. Results of this client's tests were a positive FABER test on the right, a superior ASIS on the right making the right leg appear shorter, a locking of the right SI joint on a forward bend test, and a deeper right sacral sulci.

Third, evaluate over all function, look at the way a person has to sit down to a chair. In her case, she had to sit down to the left and couldn't sit on the right side when she got to the chair. This correlated with the pelvic motion testing. The other thing I looked at was her function of side bending. Asking the question, is there any pain from right to left and looking for any limitation of motion. The test showed she stopped short of the left knee joint by 4 inches and could almost touch the right knee joint without any pain to either side. Now the X-STOP is supposed to only inhibit backwards bending not side bending so this was a probable indication that the right quadratus lumborum was not allowing her full range of motion to the left.

Putting it Together

  1. She has been in pain and asymmetrical for over a year. This is important to point out to the client because you need more than a couple of sessions.
  2. You will need to relieve the shortness in the right QL and re-evaluate.
  3. You will need to restore the motion of the right SI joint with isometrics and soft tissue work and keep re-assessing function.
  4. From the last article in which I explained breath work and the core, you will need to help the client perform this to help re-set the core into the proper firing order and re-assess.
  5. Homework of pillow squeezes in the sitting and lying position with the knees at 90 degrees to help keep the function of the SI joint. 6. 6. Use isometrics of the hamstrings to help correct pelvic anterior or posterior rotation, you just have to keep checking that they are becoming symmetrical.

Where is she now? Happy that she can now walk again for two miles, sit, sleep and her pain level is a manageable 2 to 3. We re-evaluate all of the above each time she comes in for her maintenance massage, which is now every four to six weeks. She is also receiving chiropractic care as part of her maintenance.

What happens when the one technique you spent so much time, money and energy on learning doesn't work for this person's problem? Refer them out is one answer, but learning to assess is another answer. It is okay to specialize as long as you are willing to only see that particular type of client and there is enough of that kind of clientele to see.

If you want to broaden your base of clients, having as many assessment tools as you have techniques will be very important. It is estimated that there are 300,000 to 350,000 massage therapists and massage school students in the U.S. According to the Department of Labor in 2012, employment for massage therapist was expected to increase by 20 percent from 2010 to 2020, faster than average for all occupations. With that kind of growth, the need for a better skill set is critical for the health of the overall profession. I witness time and time again a massage therapist learning one technique and not branching out to understanding assessment.

If I have heard it once I have heard it a hundred times. It takes too much time, I don't understand assessment, I forget to do it, and then there is the most famous one: They are paying me for a massage not an assessment. Aren't they paying you to get relief for their pain situation? Would you go to a doctor who had that attitude? What about the self-employed therapist who ends up wondering where all the clients have gone. The clients are out there, but the skill set of a therapist has to be broad enough to capture a wide variety and range of clients seeking relief from massage therapy. "Assess, don't guess."

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