The School of Natural Therapies
Training School for Massage & Holistic Therapies
ITEC Sports and Remedial Massage
ITEC Level 3
Submitted by: Khaleem Ash
Case Study 2
Client Information:
I have provided a treatment to another friend Dxxxx, a 30-year-old active woman, said to have pain in her shoulders and neck. She described the pain sensation at the anterior aspect of her left scapula when her neck was in a certain orientation. She also felt that her present condition may have been aggravated by an aerobics class she had attended two weeks earlier. Dxxxx also revealed, during the consultation, that she sometimes took St John’s Wort to counter periods of depression.
Contraindications
Although Dxxxxx had mentioned depression during the consultation, there was never any indication of this during the conversation or any signs. The observed tension around her neck and shoulders, during the initial examination, indicated stress and may have been a contributory factor to her condition.
The secondary effects of remedial massage therapy would assist in relaxation of the nervous system and encourage progress towards homeostatic balance.
I took a full consultation, recorded her medical history and confirmed that she had not sustained any fractures nor had any accidents and that she was not on any medication. She did not suffer from any condition which might have made me consider cautions or contra-indications to treatment.
With the medical history and my assessment there was unlikely to be any significant structural problems in the region of the cervical spine, and that remedial massage therapy to the soft tissues involved in the neck and shoulders would be a very worthwhile plan to follow.
General assessment
I carried out a visual examination on Dxxxxx’s posture and active mobility of her limbs and torso. I recorded that her left foot was slightly rotated, and her left shoulder elevated. I also noted some imbalances in her neck and shoulder muscles. I asked Dxxxxx to look up and down, side to side and to bring her ear towards her shoulder and compared sides. She found it painful to move her head to the right and the movement was also restricted. Looking up also caused some discomfort. I then assessed Dxxxxx’s shoulder movements comparing sides. Dxxxxx’s showed me how she could move to produce the pain over her shoulder blade.
Treatment Plan
We discussed the situation and decided on the following to treat neck and shoulder muscles with neuromuscular and myofascial-stripping techniques to release deep muscle tension and improve neck movement and then to search for any trigger points that may be causing the pain and making the condition be so resistant to treatment and then finally to use movements to help to balance muscles.
I gave her some information about benefits of Massage Therapy and how we concentrate on one area at a time. In view of her stating that she did suffer from depression, I considered a full body massage with relaxation techniques. However, our goal was to reduce neck pain, so I concentrated on, the major neck and shoulder muscles.
Shoulder Specific Assessment
I informed my client that if any of the active, passive or resisted movements caused her any pain then she should stop or ask me to stop, and I would.
Active Movements
The following notes show any important points that were noted, and this is what part of the treatment plan is based on:
- Hand on opposite shoulder and elevates arm
- Left arm did not raise nearly as much as right
- Apley’s scratch test – abduction and lateral rotation
- Tightness/pain in the right triceps
- Medial rotation and adduction
- Left side got only about 50% of what the right side could do. This caused pain in the lateral border of the left scapula and humerus (posterior deltoid area)
- Abduction and lateral rotation, hands behind head and push elbows out posteriorly
- This gave pain in the left deltoid region
- Painful arc was present on left glenohumeral (GH) joint abduction, however full movement was managed
- ‘Empty can’ test
- Produced pain in the pronator teres area on the left arm
- Rotator cuff tear test negative
Neck Assessment (All Active Movements)
My client said her neck felt generally stiff in all of the movements, however there were no noticeable differences in range of movement (ROM) when comparing each side. When passively testing the atlanto-axial (AA) joint (in the supine position) it was restricted to the right (i.e side bent left).
Elbow Joint
Active elbow extension produced pain in the right biceps, also 4th and 5th fingers went into flexion only on the right hand dupuytren’s-like symptoms). To palpate above the right medial epicondyle was more tender than the left.
Treatment
Treatment involved myofascial release (MFR) to the erector spinae muscles, trapezius, rhomboids, and rotator cuff muscles; infraspinatus on the left had a lot of trigger points which I released. Also, I released a lot of trigger points within the left teres major and teres minor muscles; I often find these muscles are prone to trigger points and releasing them can have some tremendous effects. I performed a right anterior humeral head correction; also, a first rib MET was done on the left. I performed MFR on the left biceps and triceps. Since there was a lot of restrictions/pain within the left deltoid, I performed MFR on it and also worked transversely across deltoids fibres.
For mobilizations on the left shoulder, I tractioned the left GH joint and also did some ‘mortar and pestle’ type movements on the joint. My client particularly enjoyed the mobilizations and felt like it was doing some good.
I advised my client to rest her arm as much as possible for a few days and also to drink some water. I also gave her some stretches to do, i.e. triceps, pectoral stretches.
At the end of the session, Dxxxxx felt very relaxed and confirmed that she has had no pain or discomfort with her neck or right shoulder. After care and plenty of water advise given.
Homecare advice: Dxxxx’s homecare advice was as above to try to go to bed early to maximise the increased wellbeing from the treatment. I advised her to concentrate on her diet and stress levels and to take more breaks when working on the computer. I also advised her to request a workstation assessment at work so her posture could be improved. I briefly explained the Alexander Technique for Dxxxx to research.
Conclusion
The treatment that Dxxxx received was soft tissue remedial massage therapy which includes deep massage and mobilisations. I believe also that the relaxation aspects of the treatment were also a critical contributor. The relief to her discomfort and consequential increased awareness have given her confidence in the use of her neck, has reduced her stress levels, thus helping to stay active and happy.
Self-Reflection:
My client’s left shoulder has had some excellent results, she feels like she has a fully working left shoulder. Full active range of movement has returned since the problem started about a year ago and generally the left shoulder is feeling better than the right.
Overall, I was pleased with how Dxxxx’s treatment went. I felt positive that I could bring some difference in her condition. Dxxxx does live a hectic lifestyle and she is aware changes need to be made which was positive as Dxxxx noticed the shoulder felt looser just from treating the trapezius with a combination of techniques to help blood flow, unbind the fibrous tissues. I felt her feedback was extremely positive.
