Research Case Report
Bodywork Modality Supervisor: Jack Baker June 23, 2008
Objectives: The intent of this study was to explore the possible relationship between the use of Neuromuscular Therapy (NMT) to bring about structural changes in the body to improve postural alignment and the subsequent reduction in chronic hip, low back, and knee pain.
Methods: The subject reported twenty years of chronic hip pain with low back and knee pain developing within the past four years. Frequency and duration of pain were recorded in a daily journal for a baseline period of one month before treatment and during treatment. Pre- and post- treatment PSIS/ASIS discrepancy was recorded to track anterior pelvic tilt, and before and after pictures documented postural changes. NMT was administered for five sessions over four weeks. Each session led up to the anterior pelvic tilt correction.
Results: PSIS/ASIS discrepancy decreased over the length of treatment, and either decreased or stayed the same after each session. Significant changes in posture were visible after treatment. Pain experienced by the client was reduced over the course of treatment and after each session.
Conclusions: These findings suggest that NMT can effect structural changes and postural re- alignment which corresponded to a reduction in chronic hip, low back, and knee pain.
Key Words: Neuromuscular therapy, chronic pain, low back pain, anterior pelvic tilt, postural misalignment, clinical massage, trigger point therapy
The intent of this study was to explore the possible relationship between the use of Neuromuscular Therapy (NMT) to bring about structural changes in the body to improve postural alignment and the subsequent reduction in chronic hip, low back, and knee pain in one client.
Congress has declared 2000-2010 as the Decade of Pain Control and Research (American Pain Society [APS], 2008). In 2005, the National Pain Care Policy Act became the first proactive pain care legislation introduced to Congress (APS, 2008). This bill reflects a nationally recognized need to increase resources for people who suffer from pain.
Reflecting a need to expand resources for pain, there has been an increasing trend toward the use of therapeutic massage for pain relief. Massage for pain management is now recommended by health care providers, and is even provided by several hospitals (Gatlin & Schulmeister, 2007). As massage becomes more mainstream, people with low back pain commonly turn to massage therapy for relief (Melancon & Miller, 2005). In fact, more people seek alternative therapy for low back pain than any other condition (Cherkin, Sherman, Deyo, Shekelle, 2003).
A survey commissioned by the American Massage Therapy Association found that medication and therapeutic massage tied as the favored type of pain relief (AMTA, 2005). In this same study, 93% of the respondents were in accordance that massage therapy is an effective method to reduce pain (AMTA, 2005). It is worthwhile to examine existing studies and conduct further research to determine the validity of such a widespread belief.
NMT is a specific type of massage that is dedicated to pain management. It is defined by the Associated Bodywork & Massage Professionals as a, “comprehensive program of soft-tissue manipulation [that] balances the body’s central nervous system with the musculoskeletal system . . . the goal is to help relieve the pain and dysfunction by understanding and alleviating the underlying cause . . . to locate and release spasms and hypercontraction in the tissue, eliminate trigger points that cause referred pain . . . and restore postural alignment, proper biomechanics, and flexibility to the tissues” (ABMP, 2007). In America, NMT grew out of a collaboration of ideas from pioneers such as Travell & Simons, Raymond Nimmo, Paul St. John, and Judith DeLaney (DeLaney, 2008). Dr. Travell provided a strong foundation with her myofascial pain and trigger point (TP) research (Travell & Simons, 1983), which was further explored and developed by Raymond Nimmo from the 1950s to the 1980s (Cohen & Gibbons, 1998). While Travell primarily used injections to treat TPs, Nimmo developed a method he called Receptor- Tonus Technique to deactivate TPs using a mechanical technique of applying force (Cohen & Gibbons, 1998). Inspired by one of Nimmo’s seminars, Paul St. John attended massage school, brought the concepts of TPs and NMT into the massage world, and developed NMT St. John method (DeLaney, 2008). Judith DeLaney taught the St. John method and after five years branched off with her own style called NMT American version (DeLaney, 2008). Although the methods used in these different styles may vary, one of the common goals shared by all styles of NMT is to reduce pain by finding and deactivating TPs.
Trigger points are one of six principles NMT aims to address (Baker, 2003). According to Travell and Simons (1983) a myofascial trigger point is a, “hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena.” The source of referred pain is the TP, but the pain is actually felt somewhere else, often remotely, in the body (Travell & Simons, 1983). TPs commonly develop within ischemic tissue, another principle of NMT, which is an irritated area of constricted blood that prevents oxygen and nutrients from entering and metabolic waste products from exiting (Baker, 2003). The other four principles are lesions (tears in muscles or connective tissue), nerve compression and entrapment, postural distortion, and biomechanical dysfunction (Baker, 2003). The focus of this case study will be on NMT’s ability to bring about structural changes to correct postural distortions and to locate and deactivate any TPs that have developed in ischemic tissue, causing pain to the low back, knee and hips.
Postural distortion and biomechanical dysfunction are the “root causes of discomfort, pain and predisposition to injury,” from NMT’s perspective (Baker, 2003). According to Davis’ Law, muscles that are shortened become hypertonic and possibly stronger, and muscles that are longer lose tonus, become weak, and cause pain (Baker, 2003). If posture becomes distorted, a pattern of shortened and lengthened muscles develops in the body. Travell and Simons (1992) acknowledge that distortions in the lower girdle (structural imbalances) can also cause postural misalignments and pain in the upper body. Following this logic, one can see the link between structural imbalances in the pelvic girdle and postural misalignment, and their ability to cause a shortening of musculature in the low back extensors and hip flexors and the possibility of it leading to chronic pain in the low back, hip, and knee. The goal of NMT is therefore to induce structural changes in an area, reversing an anterior tilt to the pelvis for example, to bring about overall postural alignment and a reduction of pain.
A case study of a 15-year-old girl with asymmetrical hip rotation and pain in the right knee for eight months without injury, found a connection between pelvic asymmetry and patellofemoral pain (Cibulka & Threlkeld-Watkins, 2005). This study suggests the potential of a postural distortion in one area of the body to cause ischemia and TPs to develop in the tissue and radiate pain to other areas. In another study that examined 150 people with apparent leg-length difference, pelvic asymmetry, and lateral curvature of the spine (all postural distortions), 55 complained of lumbosacral pain, and almost half of them had pain radiating down the leg (Timgren & Soinila, 2006). In this same study, people with improved alignment had a statistically significant (P<.01) correlation with an improvement of condition, referring to a reduction of pain (Timgren & Soinila, 2006). It was also noted in Timgren and Soinila (2006) that, “none of the patients with relapsing asymmetry showed improved condition.” Although the treatment used in this study was not NMT, it would be interesting to see if massage in the form of NMT could effect these same structural and postural changes and reduction of pain.
The impact of proper body alignment and pain prevention is also indicated in a discussion of nonpharmacologic methods to alleviate pain for cancer patients that stressed the importance of patient positioning to maintain alignment and prevent pain (Gatlin & Schulmeister, 2007). Another study found that increased thoracic kyphosis (hunchback posture) is correlated with increased multi-segmental spinal loads from T2 to L5, which is connected to dysfunction and pain (Briggs, van Dieen, Wrigley, Greig, Phillips, Lo, et al., 2007). Although the aforementioned studies have found or suggested positive correlations between postural misalignments and pain, the possibility of using massage in the form of NMT to effect postural changes, thus reduce pain, has rarely been rigorously explored and documented. The studies that have been done are general in nature and focus on massage’s ability to reduce pain without making the connection to postural imbalances and NMT.
There is evidence to show that massage therapy in general reduces pain and is superior to some techniques such as relaxation therapy, acupuncture, placebo treatments, sham laser therapy, exercise, progressive muscle relaxation, and self-care educational materials (Cherkin et al., 2003; Hernandez-Reif, Field, Krasnegor, Theakston, 2001; Tsao, 2007). Other studies contradict the efficacy of massage in reducing pain and found that massage therapy was not any more effective than techniques such as corsets, exercise, spinal manipulation, and transcutaneous electrical nerve stimulation (TENS) (Tsao, 2007; Vernon, Humphreys, Hagino, 2007). In another study, evidence supporting the efficacy of massage was not convincing enough because it was not based on enough rigorous clinical trials (Melancon & Miller, 2005). Within one review, massage was found to be more effective for treating low back pain than relaxation therapy, acupuncture, sham laser, and self-education, and less effective than spinal manipulation and TENS (Chou & Huffman, 2007). None of the trials examined in Chou and Huffman described the types of massage used, and they only tracked results during or up to one month after treatment. These results therefore reflect short-term effects of massage. The inconsistency in results and data and a lack of long-term studies translates to the need for more rigorous research.
A systematic review on massage studies from 2007 only found one trial that directly compared different massage techniques (Chou & Huffman, 2007). In this trial, cited in two reviews, acupressure/pressure point massage was found to be superior to Swedish massage with regards to pain relief, which indicates that certain techniques or modalities may be more effective than others when it comes to relieving pain (Chou & Huffman, 2007; Tsao, 2007). Given the previous explanation of NMT as a therapy that addresses the underlying causes of chronic pain, there is a need to further examine its effects on the treatment of postural misalignment by bringing about structural changes, and long-term pain relief. Treating pain without taking underlying issues into account will not result in long-term healing.
TP therapy has shown significant results in the reduction of pain in the head, neck, and shoulders (DeLaney, Leong, Watkins, Brodie, 2002; Eisensmith, 2007). It seems logical to assume this type of therapy would be just as effective on other areas of the body, which this study sets out to examine. TP therapy has also been found to be safe and noninvasive (Delaney et al., 2002). In one study that used Swedish, Deep Tissue, and TP therapy to treat people with pain all over the body, unexpected positive side-effects such as improvement in mood, digestion, and respiration more than doubled negative side-effects such as bruising, headache, fatigue, and soreness (Cambron, Dexheimer, Coe, Swenson, 2007). In a study examining the effects of manual therapies on chronic mechanical neck pain, spinal manipulation or mobilization was found to be superior to massage (Vernon et al., 2007). It was specifically stated, however, that none of the trials in this study included TP therapy. It is valuable to observe the possibility that NMT and TP therapy could be more effective than other massage modalities in reducing pain. In a study that was previously discussed, acupuncture massage was found to be superior to Swedish/classical massage (Chou & Huffman, 2007; Tsao, 2007). Although the study fails to provide a description of acupuncture massage, the results suggest that different types of massage have different effects. Not many modalities besides Swedish have been evaluated and compared.
NMT is indicated for this study because structural and postural changes have been shown to be made in the body using NMT following repeated sessions (Hamm, 2006). This study examined the treatment of linked pathologies and found positive results in the reduction of pain, improved ROM, improved sleep, and changes in posture (Hamm, 2006). This study also concluded that more research is needed for, “massage’s potential for simultaneous beneficial influence on multiple systems and processes in the treatment of pain and dysfunction…” (Hamm, 2006). NMT was combined with other techniques in this study, so it is difficult to determine the efficacy of NMT alone in treating pain. Based on the statistical findings in the aforementioned research and overall lack of studies examining specific types of massage, the current study aims to demonstrate that NMT addresses the underlying causes of pain by effecting structural changes, which leads to postural re-alignment and long-term relief from chronic pain.
A 60 year old male business owner and father has been suffering from chronic hip pain for the past twenty years. He has also developed chronic low back and knee pain within the past four years. The low back starts out stiff every morning and the pain level is usually mild but occasionally severe. The pain lessens throughout the day unless aggravating activities cause it to persist. He experiences sporadic stabbing pains in his left hip that are severe and only last a few seconds, and moderate achy pains that radiate down the leg and can last for days. He experiences mild stiffness in the left knee that can last from hours to days and occurs a few times a month. The client also reports moderate to severe pain in his left shoulder that can last from hours to days that limits his mobility. One to two times a year, pain in the left shoulder is severe and the client cannot turn his head at all. Although the client occasionally uses ibuprofen for aches and pains, he is not currently taking any prescription drugs for pain management. He is currently taking Levoxyl for low thyroid, Advair for asthma, baby aspirin, glucosamine, and fish oil. He has never experienced any major health problems or surgeries that would contraindicate massage.
When the client was eight years old he was diagnosed with Legg-Calvé-Perthes Disease in his left hip. It is a degenerative disease of the hip joint where ischemia and osteonecrosis (bone death) of the femur cause the ball of the hip to collapse and become flat (National Osteonecrosis Foundation, 2000). The client spent three years on crutches and one year with lifts in his shoes. He has never received any physical therapy, chiropractic, or any other treatments to address structural and postural imbalances resulting from changing walking patterns to protect the affected joint. A side effect of this disease that often occurs later in life is osteoarthritis of the hip, along with knee and back pain (NONF, 2000). Other repetitive motions have also contributed to the client’s experience of pain in the low back, hip, and knee. For the past 35 years, work related repetitive activities have included driving for at least 6 hours a day, carrying a 20 pound tank around with the left arm, and crawling through attics. Massage in the form of NMT is indicated to address structural and postural imbalances that have most likely initially developed from Legg-Calvé-Perthes Disease and have been exacerbated over the years by the aforementioned repetitive activities.
Baseline Postural Assessment
A month before treatment began, an assessment of posture was conducted by examining the client from four different positions in front of a plumb line. Gait was examined and range of motion tests exposed several structural imbalances and postural misalignments in the client’s body. The client walks with both feet turned out (laterally rotated) and kicks the left hip out with every step. The head juts forward, and both shoulders have a slight medial rotation. The left shoulder is slightly elevated, causing the right arm to appear longer. There is an overall rotation of the torso to the left, accompanied by exaggerated kyphotic thoracic and lordotic lumbar curves. The left iliac crest appears to be slightly lower than the right. An anterior pelvic tilt is indicated by a discrepancy of 2 1⁄4 inches between the posterior superior iliac spine (PSIS) and the anterior superior iliac spine (ASIS). The right foot appears to have a higher arch and the left medial malleolus is slightly lower. When the client is laying supine, the left leg appears slightly longer.
A treatment plan consisting of five sessions over four weeks was designed to address the client’s areas of chronic pain. Two sessions were conducted in the first week, followed by a session every week for the duration of the treatment. The client did not expect to have his pain completely disappear after five bodywork sessions, and merely expressed a desire to experience a reduction in the frequency of pain.
A postural assessment revealed that an anterior pelvic tilt is the chief causative factor of postural misalignment in the body. The sessions were strategically designed to release the muscles holding the pelvis in an anterior tilt to facilitate the anterior correction at the end of each session. Chronically contracted and short muscles in this posture are hip flexors and low back extensors, and they must be treated and stretched. Following this logic, the deep lateral rotators, adductors and iliopsoas were addressed first. The distance between the PSIS and ASIS was measured immediately before and after each session to track any changes from the anterior pelvic correction. This study could be improved by using more exact methods to measure PSIS/ASIS discrepancy. In this study, the bony landmarks were palpated and marked with a dot. The distance between the dots was measured with a cloth tape measure. The measurements were somewhat accurate but could benefit from being more exact with specialized calibration tools.
The pelvic tilt was also measured by tracking the discrepancy between the left and right medial malleoli before and after each session. All of the treatment techniques and choices for session design were based on the NMT manual by Jack Baker, personal consultation with Jack Baker, and 1230 hours of combined classroom training and clinical experience with 120 hours of specialized training in NMT.
Session 1. Lateral hip, adductors sidelying, anterior correction
- Place client in sidelying position with top leg straight and bottom leg bent for cross-fiber
examination of gluteus medius & minimus from greater trochanter to iliac crest.
- Cross-fiber and with-fiber tensor fascial latae from iliac crest to greater trochanter.
- With both legs bent, deep tissue compress and follow down IT band from greater trochanter
- Use thumbs and fingertips to examine edges of IT band on the lateral knee and up at the
- Adjust client so bottom leg is straight and top leg is bent forward at the knee and supported
with a pillow. On the bottom leg, bone clean along ischium and ischiopubic ramus for origin
of adductor magnus.
- Cross-fiber adductor muscle bellies down length of the adductor compartment.
- Sink & melt on adductor tubercle insertion of adductor magnus on medial knee.
- Finish with gentle cross and with-fiber circulatory strokes along adductor compartment.
- Have client turn to other side and repeat steps 2-9 above.
- Client supine: pelvic rocking (client’s knees up and feet together, allows knees to open and rock on angle parallel with femurs, pushing with one hand on left ASIS and pulling with right hand around iliac crest and vice versa) until it gets easier and goes farther.
- SI Joint Decompression: Client sidelying: heel of hand on gluteus medius and TFL, press straight down and hold on wing of ilium. Repeat on other side.
- Hip Hiking: Client supine: With client’s knees up and feet flat, have client alternate hiking hips until it begins to feel easier for the client.
- Traction: With outside hand on top of foot and inside hand under the heel, gently “whip” leg so that knee and thigh bounce on table.
- Hip rotation: Drape client to prepare for passive movement. Keeping knee at a 90 degree angle, start with thigh across the body, pushing the foot away and directing the whole leg back to the lateral side. Direct leg back toward the midline, keeping the 90 degree angle at the knee and pulling the foot toward you.
- Anterior Rotation Correction: Check for alignment of medial malleoli, start and end with the leg that appears longer. Have client clasp hands behind the knee, pulling leg toward the face with both hands. Hook outside hand under ASIS, and with other hand on ischial tuberosity, lean onto client’s leg with shoulder and prompt them to push into your shoulder.
- Repeat step 15, alternating legs until balance is reached (L & R medial malleoli are aligned).
- Wrap up session with bone cleaning along occipital ridge from mastoid process to midline,
apply gentle traction to neck, bounce hooked into mastoid process and release.
Session 2: Adductors supine, iliacus, psoas, anterior correction
- Client supine: Touching in, prompting deep breathing, and gentle rocking to mobilize area.
- Client supine: Have client flex and laterally rotate hip, and support thigh with cushions.
Follow adductor longus down to attachment on pubic bone. Move laterally, bone cleaning along superior pubic ramus. Move down along bone for adductor longus, brevis, and gracilis.
- Use pincer palpation and cross-fiber examination for adductors brevis and longus on the upper third to upper half of adductor compartment.
- With cream, cross-fiber belly of adductor magnus down to adductor tubercle
- Finish work in adductor compartment with general circulatory strokes
- Repeat steps 2-6 on opposite leg.
- Iliacus: Enter at ASIS and sink and melt, sculpting downward inside the bowl toward the
pubic bone and then, secondly, back toward the sacroiliac joint.
- Psoas: Instruct client to flex knees and rotate to one side so the knees rest to that side of the
table. Enter half way between the belly button and ASIS, and do some gentle counter clockwise circles to encourage organs to move aside. Gradually sink medially to touch psoas (confirm contact by having client lift knee to feel it engage). Use cross and with-fiber strokes to treat psoas from level of ASIS down to inguinal ligament.
- Psoas: Contact edge of psoas at level of ASIS and cross and with-fiber up toward T12.
- Anchor into the psoas at level of ASIS and have client slowly extend the limb. Use cross-
fiber as the muscle lengthens beneath your touch, following muscle up toward T12.
- Flex the client’s knee and hip to place foot against the inside of the outside of the opposite
outstretched leg. Laterally rotate hip and rest knee against your abdomen. Palpate iliopsoas
tendon inferior to inguinal ligament. Sink and melt, treating attachment with cross-fiber.
- Repeat 7-11 on opposite leg.
13. Repeat steps 10-17 from session 1 for anterior correction and wrap up.
Session 3: Quads, knee, calf, ankle, anterior correction
- Client supine: Touching in, prompting deep breathing, and gentle rocking to mobilize area.
- Apply cream, examine medial, inferior, and lateral aspects of the ASIS for TPs.
- With heel of hand, press just inferior to ASIS, and rock lateral side of leg while compressed
inferior to ASIS.
- Use flat palpation inferior to AIIS and down length of rectus femoris, examining for TPs.
- Displace rectus femoris and palpate and examine vastus intermedius for TPs.
- Cross-fiber examination of muscle belly of vastus lateralis and lateral aspect of patella.
- Cross-fiber examination of vastus medialis & sartorius.
- Treat around the patella. Support patella with one hand and bone clean with the other hand.
Give special attention to the oblique fibers of vastus medialis near the knee.
- Cross-fiber tibialis anterior and peroneals with cream.
- With client’s knee bent, hook fingertips into middle of calf and pull away from each other,
cross-fibering gastrocnemius and soleus.
- Cradling heel in palm of one hand, mobilize the foot with the other hand, taking it through
flexion, extension, inversion, and eversion.
- Repeat steps 2-11 on opposite leg.
- Repeat steps 10-17 from session 1 for anterior correction and wrap up.
Session 4: Gluteus maximus, lateral rotators, hamstrings, anterior correction
- Client prone: Touching in, prompting deep breathing, and torso rock to mobilize area.
- Over sheet, compressions around iliac crest, sacral attachments, and into sacrotuberous
ligament, and gluteal tuberosity.
- Drape client to expose gluteus maximus. Examine gluteus maximus for TPs using cross-
fiber movements in an arc pattern from the iliac crest to the greater trochanter, with arcs
- Repeat the arc pattern working with the direction of the gluteus muscle fibers.
- Grasp the skin and muscle belly and roll the tissue in all directions.
- Compress through the gluteus maximus to cross-fiber piriformis.
- Continue to work piriformis but with a different vector. Face client’s feet and bone clean
attachment on superior aspect of the greater trochanter.
- Cross-fiber examination of lateral rotators inferior to piriformis, working from trochanter
medially toward ischium.
- Anchor into piriformis and lateral rotators and stretch the muscles by pulling leg toward you.
- Compression/bone cleaning on ischial tuberosity.
- Cross-fiber TP examination of hamstring muscle bellies.
- Flex the knee and bone clean proximal third of tibia.
- Bone clean around medial and lateral epicondyles of the femur.
- General broad cross-fiber circulatory strokes on hamstrings and fanning around the knee.
- Repeat steps 10-17 from session 1 for anterior correction and wrap up.
Session 5: Low Back, anterior correction
1. Client prone: Touching in, prompting deep breathing, and torso rock to mobilize area. 8
- Spread cream on back with effleurage strokes.
- Bone clean along spinous processes from T1-sacrum.
- General circulatory back work (broad cross-fiber) on erector spinae.
- Thumb press down lateral edge of erector spinae.
- Sculpt inferior aspect of 12th rib from medial to lateral. Continue bone cleaning and
examining for TPs between ribs 12, 11, 10, & 9.
- Repeat thumb press along lateral edge of erector spinae.
- Examine for TPs in quadratus lumborum by moving out into soft tissue below the 12th rib
and press into transverse processes.
- Sculpt iliac crest medial to lateral examining for TPs, then from lateral to medial and
compression into iliolumbar ligament.
- Sculpt lateral free edge of QL and examine for TPs.
- Thumb press down lateral edge of erector spinae and examine for TPs in the lumbar area.
- Deep with-fiber strokes down length of erector spinae, in the middle of the bundle, and back.
- Wring across lower back and repeat steps 3-12 on other side.
- Transverse friction on sacrum and area of SI joint.
- Compressions into: gluteal tuberosity, ischial tuberosity, sacrotuberous ligament, lateral
border of sacrum, and into gluteus medius on both sides.
- Repeat steps 10-17 from session 1 for anterior correction and wrap up.
Report of Clinical Visits
Session 1: No trigger points (TPs) were uncovered during the session, but the adductor attachments on the ischium and adductor tubercle were very tender. The gluteus medius was hypertonic.
Session 2: Client reported pain before the session that was concentrated in the middle of the low back and the left shoulder was stiff. Crawling in attics and carrying a tank the previous day aggravated the low back and shoulder. Several TPs were found in the right psoas and referred to the right costal area, and right and left thighs. TPs were found in the right adductor belly and referred to the medial/anterior portion of the same knee. A TP on the left side of the occipital ridge referred to the left knee and thigh. Several tender points presented in the psoas, adductors and knee on the left side. After the session, the client’s arms extended further over his head, and his legs were basically the same length.
Session 3: He was experiencing pain in his low back since the morning, achy pain in his left shoulder, and pain ranging from 0-4 from a pulled right adductor. Bone cleaning on the left patella caused his left foot to twitch and “stretchy” feelings were felt in his whole leg. There was no tenderness in his right patella. A lot of tenderness was present in his left calf, tibialis anterior, and peroneals. After the massage, the tender spots were less tender, his medial malleoli lined up evenly after the anterior correction, and there was a decrease in the PSIS/ASIS discrepancy.
Session 4: Client reported pain concentrated on the right side of the low back and stiff ankles. Low back pain was exacerbated by lifting heavy boxes earlier in the week. Before treatment, the malleoli were almost even. During treatment, the right hamstring was riddled with tender points and TPs in the left and right ischial tuberosities, left piriformis, left gluteus maximus, and right hamstring all referred to the right knee. The right knee started hurting toward the middle of the session. The left and right medial malleoli lined up and the PSIS/ASIS discrepancy decreased.
Session 5: The client stated that “nothing hurt” before the session. The left malleolus was just slightly lower before the session. During the session, the piriformis was a little tight, but tender points on the back were much less sensitive than usual. The medial malleoli lined up after the anterior pelvic correction and the tender points eased up as they were revisited. No TPs were uncovered.
Daily Log Book
Table 1: Client Post-Massage Feedback
A daily log book was kept by the client one month before treatment to provide a baseline for his experience of pain. In the baseline period, the client reported having a stiff back and legs every morning and sporadic problems with his left knee, left shoulder, and neck. He completed the Brief Pain Inventory form which described his average pain as a 2. He also completed the Oswestry Low Back Pain Scale and his score was 28%. After the five sessions, his average pain dropped to a 1 and his Oswestry score dropped to 2%. Overall, the client did not report a high intensity level of pain. It is probable that pain was under-reported because he is accustomed to living with pain on a daily basis.
The day after massage for the first three sessions, the client’s back was “not as stiff as usual” and he slept really well the night after the session. Throughout the week, he stated that his back was stiff “but not as bad as usual.” By the third session, the client reported that he “felt really good” the night of the session, his back “felt good” in the morning, and he also slept well the night after the session. After the fourth session, the client started to notice stiffness in his shoulders. Before the final session, no pain was felt by the client. After the final session, the client slept well, “felt good” and was not “stiff and sore” for three days in a row. Spending an entire day at Disneyland on the fourth day re-aggravated some of his pain. Even after Disneyland, the client reported being stiff sometimes but not everyday.
The correction of the anterior pelvic tilt was measured by the change in inches between the PSIS and ASIS. A smaller distance indicates a correction in the anterior tilt. During the baseline, the distance on both sides of the body was 2.25 inches, indicating approximately a 15 degree difference between the two points. For a male, the distance should be within 5 degrees. From baseline to session five, there was a general decline in the PSIS/ASIS discrepancy. More specifically, the distance either stayed the same or decreased after each session. The iliac crests also lined up from left to right after treatment.
Before treatment, the plumb line fell slightly to the right of the nose and to the left of the belly button. The left shoulder was elevated so the right arm appeared longer. After treatment, the line was lined up with the nose but still left of the belly button and the arms were about even.
In the before picture, the anterior pelvic tilt is quite apparent, accompanied by an exaggerated kyphotic thoracic and lumbar lordotic curve, with the head jutting forward. The plumb line is in alignment with the ankle, knee and hip, but falls in front of the elbow and shoulder and behind the ear. This suggests a slight rotation to the left in the upper torso. In the after picture, the client clearly exhibits a more erect posture. The line now falls slightly behind the knee and hip, but is in line with the shoulder and elbow. The anterior tilt has been corrected somewhat, but there is still a slight rotational component to the upper torso.
Before, the line falls slightly left of the midline, and a rotation of the upper torso to the left is apparent. A hunching forward of the head and shoulders is also noticeable. After, the head and shoulders are pulled back more, but the line falls slightly to the right of the head which indicates the presence of a slight rotation.
Before, the line falls behind every joint and behind the ear. The lordotic lumbar curve is quite pronounced. After, the plumb line is almost in perfect alignment with every joint and falls just slightly behind the ear. The lumbar curve is also less exaggerated.
The client’s range of motion has clearly improved, especially throughout the thoracic spine. In the after picture his hands are folded on the floor and there is more space in the lumbar region. This position caused a lot of pain before treatment, and after he could hold the position longer.
Right lateral flexion improved as a result of treatment. In the before picture his fingertips fell above his knee and they reached the bottom of his knee after treatment. The client’s ability to move his neck more independently is also more apparent in the after picture.
Left lateral flexion also improved. The fingertips fall to the middle of the knee compared to a few inches above the knee in the before picture. The neck also laterally flexes more.
It is interesting to note that when the client made post-session comments about specific parts of the body, he noticed how range of motion increased and muscle tension decreased in his shoulders, neck, and arms. These areas of the body, however, were never directly addressed during the five sessions, excluding less than five minutes of bone cleaning on the occipital ridge and neck traction during each session wrap up. These subjective comments and objective observations of increased range of motion and reduction of tender points highlight the interconnectedness of the body and support Travell & Simons’ acknowledgement that lower girdle distortions can cause pain in the upper body (1992). This study demonstrates that correcting lower girdle distortions can also provide pain relief in the upper body without working directly on those muscles.
Although the client felt considerable relief in his upper girdle, he also became more aware of pain in his shoulders after the fourth session. It is likely that the pain in the shoulders was always present, but it took a back seat to the hip flexors and extensor that were screaming out in pain and therefore went unnoticed. The iliopsoas (chronically shortened) and hamstrings (chronically lengthened) contained the most TPs out of all the muscles addressed during treatment. Once these muscles were released and TPs were deactivated, pain from other muscles probably became more apparent to the client. The muscles in the shoulders and neck have most likely accumulated TPs from being held in a contracted (shortened) or over-stretched (lengthened) state for so long. The short muscles need to be released and stretched, and the long muscles (the ones screaming out in pain) need to be relieved and strengthened. It is important to address TPs in these areas after addressing the underlying factor, in this case the anterior pelvic tilt. Correcting the anterior pelvic tilt releases tension and makes it possible for shortened and lengthened muscles to return to a balanced state. Treating muscles and deactivating TPs in the upper girdle and neck would most likely provide more long-term pain relief. Although substantial changes were made in just four weeks, it would be beneficial to extend treatment beyond five sessions. Future research to determine the length of pain reduction and maintenance of postural alignment after the cessation of treatment would be interesting to explore.
This is the first known study to examine the effects of NMT alone (without intervening factors such as nutritional advising, stretching, changing aggravating activities or other massage techniques) on bringing about structural changes in the body to address postural misalignment and reduce chronic hip, low back, and knee pain. The results of this study suggest a positive relationship between postural re-alignment effected by NMT and a reduction in chronic hip, low back, and knee pain. The structural and postural changes resulting from NMT correlated with a reduction in pain both immediately after the sessions and over the course of treatment. Postural re-alignment was clearly visible from the before and after pictures. These findings suggest that NMT can effect structural changes and postural re-alignment which corresponded to a reduction in pain in this case study. As expected based on existing literature, research, and previous experience with clients, NMT’s perspective that postural distortions and biomechanical dysfunction are “the root causes of discomfort [and] pain” holds true (Baker, 2003).
The author wishes to thank Jack Baker for generously contributing to the planning of the session design, providing the training for the treatment techniques, and for all of his editing brilliance.
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