By Ani Papazyan, CMMP, LMT
This is a case that you don’t see every day but it was fun working on this patient and she is extremely happy with the results.
The patient is female, 48, very athletic and works out 5 days a week, two hours a day. Several years ago she was operated on twice because of an inflamed appendix. The second surgery was conducted because of complications after the first one. Two surgeries awakened her anterior abdominal wall and in a year she developed a hernia on the same spot. After living with an abdominal hernia more than a year she ended up with intestinal gangrene in the area of the hernia and was rushed to an emergency surgery. To avoid a similar problem in the future and prevent another herniation, a mesh was placed over the hernia.
Since the last (4th) surgery, which was a little over 2 years ago, she’s been unable to activate her rectus abdominis muscle on the right side, unable to put equal pressure on the right leg. When exercising she feels that her body weight doesn’t distribute evenly and recently also she has restricted ROM in the right shoulder joint.
Her other complaint was extremely sharp almost electric shock pain she felt around the scar, especially if it was touched even by clothes.
Prior to her being referred to our office, she had seen a sports medicine specialist, a chiropractor and a PT without any success.
EVALUATION
I decided to examine and address the scar first since its sensitivity will definitely interfere with my future treatment plans. Any even gentle palpation of the scar was very uncomfortable for the patient. During palpation the scar itself felt like a piece of wire, under high tension and there wasn’t any explanation of this from her surgeon. He recommended one more exploratory surgery to see why it’s still sensitive, but the patient refused to do anything in this area since each new intervention brought her more misery.
By using Sensory Test, I detected borders of the area around the scar where my patient’s skin was still very sensitive. Skin in a distance of 5 inches from the scar was extremely sensitive even to the light touch. At this point it was obvious that I was dealing with a severe case of Hyperesthesia which she developed as a result of the cutaneous nerve being compressed by scar tissues formed from four surgeries.
My next step was to look for other players which may contribute to my patient’s clinical picture. Considering the location of the scar, I made a list of muscles which would be affected by four surgeries and examined their fascial cover as well as their possible tension.
1. Psoas muscle since it borders the peritoneal cavity
2. Internal and external oblique muscles through the rectus sheath
3. Diaphragm
4. Latissimus dorsi muscle (in case changes in the right shoulder are just a compensatory reaction)
Even short palpatory evaluation confirmed their involvement
TREATMENT
Sessions 1-2
As was suggested by MEDICAL MASSAGE PROTOCOL for scar management, I started by applying an electric massager in the fixed, permanent mode along and outside the borders of the sensitive area of the skin. Thus my application of vibration started far away from the scar but very gradually I moved the massager slightly closer to the scar, always keeping it in contact with skin. To the patient’s amazement we were able eventually keep the massager on the scar without her jumping from electric shock type of the pain. We did two 30 minute sessions of this therapy.
Sessions 3-4
After I was able to eliminate the condition of hyperirritability from sensory receptors in the affected area, I started to work first on the leg muscles, hip flexors and iliopsoas, incorporating different leg stretches and eventually PIR. I also addressed the right latissimus dorsi muscle. At the end I worked on her abdominal muscles and was able to work on the scar itself with all techniques recommended to restore elasticity of the tissue there and diminish adhesions. It restored scar mobility and freed the cutaneous nerve.
Sessions 5-6
To the previous protocol I added Diaphragm Release Techniques and after that applied Abdominal Massage, as well as arm/torso resistant stretches. At the end of the 6th session she was able to put full weight on her right leg without any discomfort. At the same time her ROM in the right shoulder increased.
Every day I’m amazed how Medical Massage improves the lives of people who otherwise would have to get surgeries or just learn to live with the pain. I am so grateful that I can contribute to their wellbeing.
LESSONS
By Dr. Ross Turchaninov
1. If the cutaneous nerve gets into the scar after any surgery it creates very uncomfortable sensations of pain like electric shock with any scar’s stimulation (Hyperesthesia). It is such a debilitating condition that even the brush of clothing sometimes triggers screaming pain. Nothing will work until the cutaneous nerve is free from the irritation by scar tissues which have caught the nerve. However, it needs to be done correctly without excessive activation of sensory receptors which are already greatly compromised. Ani correctly used a slow but methodical approach to the treatment of Hyperesthesia.
2. Notice how Ani conducted the evaluation. It demonstrated her clinical thinking process and how important evolution is for the actual treatment.
3. The description of the treatment strategy Ani used illustrates her transformation from massage therapist to massage clinician. Notice how carefully she started the treatment process working from unaffected areas and tissues, moving closer and closer, putting more clinical pressure on the system and eventually applying more and more sophisticated techniques without the body fighting with her therapy.
Thus, instead of fitting pathological changes into her system of belief, she read the body clues and constantly adjusted her therapy to the patient on a minute to minute basis. This is what we call a massage clinician level of expertise.
4. Finally, notice that ROM in the right shoulder was restored while she worked only on the latissimus dorsi muscle without full decompression of the shoulder itself. This is a great illustration of the simple clinical fact that any treatment modality based on kinesiology is not a first treatment option since elimination of the initial trigger frequently allows the body to restore function by itself.
Kinesiology based therapies are great tools to know and use, but not until later when the initial trigger is eliminated by more sophisticated modalities, for example Medical Massage.
Category: Blog