I always mention to therapists who graduate from SOMI’s Medical Massage Certification Program: ‘Only now that our training has ended will you face professional ‘nightmare’ scenarios. You’ll see very complex clinical cases that nobody could have predicted and for which no Medical Massage protocol was written. You will be forced to develop your own treatment strategies based on the evaluation and clinical skills we’ve shared with you!’

          This clinical case submitted to JMS by our former student, Kimberly Merryman, LMT, CMMP, who recently graduated from SOMI’s Program, is an excellent illustration of that. Yes, in the majority of somatic pain and dysfunction cases, Medical Massage is the ultimate clinical solution. However, even correctly formulated MM protocol, like any other therapies, has limitations in dealing with genetic diseases.

          Kimberly was presented with a rare, debilitating congenital disease called Rett Syndrome. With a correct understanding of the MM evaluation and treatment strategies, Kimberly took the challenge. She developed a Medical Massage protocol, which improved the patient’s life and relieved the burden from her family members who, for years, desperately sought help.

We hope that you enjoy Kimberly’s work as we did.

Dr. Ross Turchaninov, editor-in-chief

 

 

Medical Massage Therapy vs. Rett Syndrome

By Kimberly Merryman, LMT, CMMP

Cypress, TX

 

Patient: 30-year-old female with Rett Syndrome  

 

Medical History

          The patient was diagnosed as a toddler with Rett Syndrome, a rare genetic neurodevelopmental disorder that primarily afflicts girls. It is characterized by normal early development followed by regression of motor and language skills somewhere between 8 and 18 months. Life expectancy, on average, is mid-40s; death is often related to seizures, aspiration pneumonia, malnutrition, and accidents. 

Rett Syndrome symptoms: 

  • Cognitive impairment due to slowed brain development
  • Delayed growth in cranial bones
  • Seizures
  • Slow physical development
  • Severe gait impairment
  • Uncontrollable hand movements
  • Disorders of the digestive and respiratory systems  

 

          This patient had all these symptoms plus severe scoliosis of 50+ degrees. As a teenager, she had corrective surgery, but over time, her spine shifted again, and scoliosis reoccurred. She had lost her ability to swallow food, so a feeding tube had been in place for several years. Due to the nature of this neurological disorder, there is uncontrollable resistance to all movements. 

           I have yet to find articles or medical massage protocols for Rett Syndrome. Therefore, I was forced to compose my own treatment plan based on information from several articles on PT for Rett Syndrome and the knowledge I obtained with training from SOMI by Dr. Ross Turchaninov.  

          Based on the evaluation of her tissues, I used components of various Medical Massage protocols for scar tissue management, muscle atrophy, joint dysfunction and tendinitis, lateral shift techniques to decompress superficial and deep fascia tendonitis, lymphatic drainage, etc.  

 

Clinical Presentation  

          I started seeing this patient in October of 2023 and am working on her twice weekly. She is wheelchair-bound and non-verbal. Since she could not communicate, I had to separately evaluate every muscle, examine each joint movement, and take cues from the noises she made and reactions that the evaluation triggered. 

           My first task was to decrease her protective muscle tension so that I could conduct an evaluation as efficiently as possible. I found that grounding her patiently using gentle touch while wearing grounding shoes seemed to stabilize her reactions in each area that I was trying to examine.  

          The circulation in her lower extremities was very poor, and soft tissues were consistently very cold to the touch. I decided to use a heating blanket, and it helped a lot. She has restricted ROM and significant muscle atrophy in every joint.  

          In her back, the patient had a sizeable postsurgical incision after scoliosis correction, with deep adhesions along the scar. These adhesions had fused layers of soft tissue together and prevented their normal functioning. My conclusion was that these spinal adhesions were never managed correctly and, in combination with her lack of mobility, were triggers for scoliosis to reappear years after the corrective surgery. There was no ROM in any segment of her vertebral column, and scoliosis tilted her pelvis.  

          A Dermographism Test showed a Lasting White Reaction along her back, which indicated that sympathetic override had triggered local vasoconstriction and decreased circulation throughout the soft tissues of her back.  

          Besides that, she had contractures formed in all joints. I could extend her hands and fingers while working on her wrist and hand joints with careful application.  

          The patient’s hip joints had some ROM in flexion and extension, while inner and outer rotations were very restricted. Both hips are in adduction contractures. Scoliosis, which caused her pelvic and hip joints to tilt, also triggered calcifications in the hip and sacroiliac joints, creating immense pain.  

          She exhibited severe hypertonicity in the quadriceps and hamstring muscles, which restricted ROM in the knee joints. Each patella had ascended above its normal anatomical position, and patellar instability greatly affected her knee joint functions. Unfortunately, tendinous, ligamental hyperelasticity and atrophy are common problems for patients with Rett Syndrome.  

          The patient’s feet were fixed in plantar flexion, and periodically, muscle spasms created a lateral or valgus deviation in the ankle joints. There was no ROM in the direction of dorsiflexion. However, she did have limited ROM in medial deviation in the ankle joints.  

          Due to the reduced ROM, muscle atrophy, and muscle hypertonicity, every joint presented with a visual deformity, and unfortunately, the patient had reached the late motor deterioration stage. Besides losing walking skills, mobility, and muscle strength, she had also lost her ability to communicate, even with the blinking she had been able to use before. Now she just stared.  

 

Clinical Goals

          First of all, I clearly understood that I would never be able to decisively heal this patient due to the devasting nature of Rett Syndrome. However, I saw my goals were to assist in the quality of her life, address various pains associated with the disease, and help with the burden of care for her family.  

My plan was:  

  • Address interstitial edema in the soft tissue
  • Decrease tension in the superficial fascia, working on her body in quadrants
  • Inhibit muscle hypertonicity
  • Improve tissue mobility and elasticity
  • Decrease the intensity of adhesions in her back that had formed along the scar
  • Restore correct patellar tracking and alignment
  • Improve range of motion (ROM), muscle balance, and joint stability in each quadrant

 

          To enhance local circulation and promote soft tissue function, I started each session with Vodder’s Lymphatic Drainage Massage Protocol applied to each body quadrant, as the Medical Massage Volume I textbook suggested.  

          Besides helping her with interstitial edema, I felt LDM would assist her immune system in functioning more efficiently. Looking back now, I can confirm the validity of this treatment because, before our regular sessions, she was regularly getting sick with various colds and flu and was almost regularly congested.  

          I addressed one quadrant at a time with proper LDM treatment, choosing the quadrant that needed the most attention from a pre-treatment evaluation. Based on my assessment, I concluded that her lower extremities needed the most attention, so I began with her lower right quadrant to improve soft tissue mobility and elasticity. This allowed her patella to descend into correct alignment while enhancing circulation and hyperlaxation of the ligaments.  

          As I mentioned above, her legs had the worst circulation, were cold, and had turned purplish. After lymph drainage, I began each therapy with slow inhibitory massage strokes from leg to thigh on the quads, hamstrings, and inner thigh, making sure to work around the greater trochanter. I also used Dr. Ross’ MM technique to support circulation, decrease superficial and deep fascia tension, and use passive stretching.  

          Next, I individually addressed the ligamental support of her knees to restore their stability. That made a big difference because repetitive therapies stimulate collagen deposits to decrease ligament laxation and improve stability. Then, I worked on the attachments of tendons from all muscle groups around their insertions into the femur, tibia, and fibula. The two pictures below illustrate the patient’s legs before and during my therapy.  

          Please notice the difference in the color of her legs and the positions of each patella with her knees flexed before and during the therapy. Also, her body’s initial reaction to the treatment was protective spasms due to hyperirritability. You can see adduction contractures in her hip joints and increased valgus in her ankle joints. However, the patient’s knee flexion significantly improved.

          The patient’s parents bought a Healix Infrared Pad with red light therapy and heat to enhance the results of my therapies. I also used my Solex bone conductor for sound frequency as additional reinforcement. I can honestly say the combination of Healix Pad and Solex bio-frequency therapies significantly reinforced the clinical outcomes because the obtained results now last longer, so I don’t feel like I’m just catching up for missed days when I can’t see her.  

          I used Solex to program SEFIdots with bio-frequency to assist her immune system, decrease soft tissue inflammation, improve circulation, etc. The application of specific sound frequencies helped balance her bioelectric field. I regularly use Solex bio-frequency on my patients and see its clinical benefits firsthand, so I strongly advocate this additional therapy. More detailed info about Solex bio-frequency is at the end of this article.  

          As I mentioned, her feet being fixed in the plantar flexion, with muscle atrophy, created a pathological valgus deformity in the ankle joints, pulling both feet laterally. I started to work on her legs and feet by addressing weaker ligaments on the top of her ankle joints (extensor side), including the superior and inferior extensor retinaculum.  

          I used the same techniques on her knees, including slow, gentle, circular movements and stretching in the ankle joints. By repetitively applying this approach, I could eliminate the valgus angle in her ankle joints and restore some dorsiflexion, her first time experiencing that in years. The two pictures below illustrate her knees, ankle joints, and feet before and after my therapies.  

          In the first picture, both patellae were displaced well above their anatomical positions, and severe quadriceps spasms prevented further flexion in the knee joints. Both feet are in severe dorsiflexion, which is periodically accompanied by valgus deviation. Severe vasoconstriction is present.

          In the second picture, both patellae are in the correct anatomical positions, and flexion/extension in the knees significantly improved. Only Medical Massage therapy could specifically target the hyperlaxation of her ligaments and tendons to stimulate collagen deposits in these connective tissue structures, and it allowed me to reposition both patellas, the first time I had done so in years.     

          Also, there is no valgus deviation in her hip and ankle joints; both feet are no longer in pathological plantar flexion and normal circulation in the soft tissues of the lower extremities has been restored. 

          The future part of my treatment plan is to address her back to aid her mobility, decompress adhesions formed after the spinal surgery, and improve local circulation there.  

 

          Dealing with such a complex abnormality as Rett Syndrome taught me that in challenging clinical cases, improvements can be achieved by these key guidelines:  

  • Fully understanding how all players, especially the patient’s nervous system, operate and interact with each other
  • Grounding techniques
  • Having much patience to build a clinical response
  • Using other modalities to reinforce each other 

 

          Only massive amounts of patience, knowledge of the neurological system, grounding techniques, and using Dr. Ross’ MM techniques helped tremendously improve this patient’s quality of life. 

          For anyone who would like to learn more about the clinical benefits of Solex bio-frequency, please visit the Solex AO Scan tab on my website: www.theiym.net 

 

ABOUT THE AUTHOR

           Kimberly is a dedicated Certified Medical Massage Practitioner, Licensed Massage Therapist, and accomplished Yoga Instructor. She seamlessly blends therapeutic touch and mindful movements. With a passion for promoting holistic well-being, Kimberly has become a trusted professional in the field, known for her expertise and compassionate approach.

          As a CMMP, Kimberly deeply understands the human body, its intricate systems, and their interactions. Her treatments are tailored to address patients’ specific symptoms and concerns, providing stable clinical results. In addition to her proficiency in massage therapy, Kimberly is a Certified Yoga instructor, guiding patients and clients on their journey of self-discovery and physical wellness.

          Kimberly’s commitment to continuous learning ensures that she stays abreast of the latest scientific data, techniques, and advancements in the field, offering her patients the most effective and personalized care. With a warm and empathic demeanor, Kimberly creates a welcoming space for her clients, patients, and students. Her holistic approach to treatment recognizes the interconnections of mind, body, and spirit, emphasizing the importance of balance for overall health.

Kimberly can be reached at merryman.iym@gmail.com or (346) 200-2565


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