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The Gaia Centre for Holistic Therapy,

17 Frederick Street, Loughborough,

Leicestershire, LE11 3BH

email: clinic@activerecovery.co.uk

Tel: 01509 556101

© Copyright 2012 - Active Recovery - All Rights Reserved.

Medical Benefits of Deep Tissue Massage

Case History One

Author Tanya Milne MDip DTM, Dip SRM, MISRM, MSMA

Despite much anecdotal evidence to the effectiveness of Sports Massage, or other forms of deep tissue manipulation, from the majority of sports performers, little empirical scientific evidence exists to support the claims for any benefit from such treatment. The clinical studies that do exist* remain equivocal, suggesting effects may be psychological or the result of a placebo effect.The medical consultant to the client in the following case was, and still is despite the evidence, of such an opinion. The statement made about the client’s condition before massage treatment was, “as good as it’s going to get…”  “massage treatment won’t do any harm, but I sincerely doubt it will have any benefit!” (Consulting surgeon’s words). The opinion was that the client’s condition would not improve past the point reached by conventional treatment i.e. no further range of movement (ROM) in the digits, constant pain, and no possibility of a return to the client’s occupation. This case study is therefore presented, not as empirical evidence, but as just one more piece in the experiential jigsaw.

CLIENT

Male - Age 47; Occupation - Fork Lift Truck Driver; Past Medical History - none relevant, client previously fit and active.

massage case studies

ORIGINATING CONDITION

Client suffered a crush injury to the left arm complicated by a fracture of the left proximal radius.

INITIAL MEDICAL TREATMENT

The client underwent surgery for Open Reduction and fitting of a metal plate. The operation was successful, following which he was sent to the Outpatients department at the local hospital for physiotherapy. At this time there was no sign of future problems. Two months after the operation the arm became painful and ROM was affected in the middle and ring fingers - extension to middle/ ring fingers was reduced, full motion ROM - left hand 50°, right hand 65°. The client was unable to move his wrist, to fully form a fist, or fully open his hand, which resulted in inability to carry out everyday tasks, such as cutting up food, washing up, driving etc. He was beginning to suffer from depression as a result of this problem.

SUBSEQUENT MEDICAL TREATMENT

The client attended the Occupational Therapy (OT) Department and was referred for a full physiotherapy assessment carried out by the Senior Physiotherapist. The main concern centred on the increasing loss of active and passive ROM in the left hand middle and ring fingers. The problems highlighted, and initial actions taken are given in Table 1. In addition the client ‘s consultant had new X-Rays carried out to confirm there were no problems with the arm plate, and carried out tests to ensure there was no nerve damage present. All tests came back clear; no obvious reason for the problem presented.

The client was provided with splints, remedial activities, gentle surface massage, and stretch exercises. The client attended the Occupational Therapy (OT) Department twice weekly, in combination with physiotherapy treatments, for two months and, as a result, had some improvement to his ROM (Table 2).

The client continued to attend OT three times a week for the following six months. Progress had been made initially in restoring ROM, but after several weeks little further improvement occurred (Figs 1 & 2; Table 2). At this stage a Remedial Sports Massage Practitioner was brought into the case at the request of Occupational Therapist in charge of case. The Occupational Therapist felt that deep tissue manipulation techniques, as used in Clinical/Remedial or Sports Massage, might be of more benefit.

CLINICAL MASSAGE TREATMENT

At the first session, working with the Occupational Therapist, the Massage Practitioner carried out an examination of the affected right arm noting that it was pale and cold compared to the left arm. All the flexor/extensor muscles and tendons appeared to be 'stuck' together, and there was a 'lump' on the wrist extensors. Not only was there loss of ROM to the middle and ring fingers, but also ROM in the wrist and the joints of the metacarpals and phalanges were also badly affected. (No treatment was carried out at this session). The practitioner believed that it might be possible to help, but required the exact location of plate and requested sight of the X-rays.

The second session took place one week later, once the X-rays were available. The exact location of the plate was ascertained. The X-rays indicated that one of the screws was proud of the plate, and might be a contributing factor to the formation of the 'lump' on the wrist extensors. Care would be needed when working deep tissues, to ensure that no further trauma to area was caused whilst treatment was given.

Deep Tissue Massage (DTM) Treatments took place every three weeks over the following six months (in conjunction with OT every week). Each session commenced with warming, stimulating moves (effleurage/petrissage) to the forearm, hand, and fingers, monitoring at all times the client’s tolerance for pain, as some massage techniques, especially in the early stages of treatment could be very painful. The techniques used were deep tissue work including soft tissue release, trigger point therapy, neuromuscular therapy, cross fibre frictions, and compressions.

CONTINUING TREATMENT

The client continued to get OT and further deep tissue massage treatment, once or twice a month or when required, for a further year, until it was certain that the improvement was maintained. The client had remaining concerns linked with the plate in his forearm, where he thought the screw ends were causing some soft tissue soreness. It is now two years since the cessation of regular treatment; the client is back in work and only occasionally requires massage to the affected area.

CONCLUSION

It is thought that this problem may have been the result of several factors combining - scar tissue formation after the original trauma and operation, one of the screws being proud on the plate, and a shortening of tendons during healing due to the cast on the arm only extending to the metacarpals.

* Apart from many studies carried out by the Touch Research Institute at the University of Miami, Florida, USA and the recent research at Leeds University concerning neck/shoulder massage and reductions in hypertension, the following are typical of the contradictory articles found in Scientific Sports Journals:

Case Study Two

Figs 1 & 2: Finger Extension and ROM after 8 months of Occupational Therapy

Figs 3 & 4: Finger Extension and ROM after a further six months of DTM


Action

Loss of ROM in left middle and ring fingers at MCP & PIP joints

Provided hand based night resting splint

Provided dynamic outrigger splint for middle and ring fingers

Provided finger extension splint for middle and ring fingers (to be worn in conjunction with dynamicsplint), for use during day - ROM and effectiveness of splints monitored on a regular basis

General massage and passive stretches to flexor tendons in middle and ring fingers

Some general massage over scar on anterior aspect forearm, to reduce likelihood of tethering

Active use of hand encouraged, and remedial activities introduced

Increased stress due to pain and loss of function

Support provided

Advised on progressive relaxation

Loss of work role & driving

These were reviewed and advice and assessment undertaken as appropriate

Table 1: Initial presenting problems and actions taken

Problem

Action

Loss of Range of Movement

Continued attending Occupational Therapy  twice weekly

Using night extension splint for middle and ring fingers

Regular massage and passive stretching to help increase flexion and extension in digits

Therapy programme including graded micro-computer exercises and woodwork, for work hardening

Reduced grip strength

Therapy programme to encourage increase in grip strength

Encouragement to carry out normal domestic tasks, including gardening

Increased stress due to pain and loss of function

Pain tolerance has improved - now mainly limited to occurring after functional activity

Referred for counselling and to Mental Health Team

Loss of work role, and driving

Actively looking at returning to work - discussions underway with employers

Liaison with Job Centre - now driving

Table 4: Continuing problems and actions after 6 months Deep Tissue Massage

Pain

Minimal discomfort experienced across proximal posterior region of forearm, on rest

Still gets pain across dorsum of middle/ring fingers, and in extensor compartment of forearm, during sustained power grip

Discomfort around volar aspect of MCP's while gripping tools

Temperature

Occasionally middle and ring fingers are hot to touch over dorsum of MCP'S, after functional activities

Swelling

None

Colour

Good - circulation much improved

Sensation

Slight numbness at scar site

Skin

Slightly dry on hands

Scars

Well healed

Table 3: Subjective assessment after 6 months Deep Tissue Massage


Assessment

Initial condition

After 1 month OT

After 6 months OT

After 6 months DTM

Index Finger

MCP

PIP

DIP

Fingertip touch palm

0/65

23/76

0/60

1½ cm from palm

0/75

0/70

0/67

Touching with full tuck

0/85

0/95

0/80

Touching with full tuck

0/90

0/100

0/80

Touching with full tuck







Middle Finger

MCP

PIP

DIP

Fingertip touch palm

51/92

60/81

20/55

Not measured

21/89

61/95 (3O° E Passive)

25/62

Not measured

13/95

61/95 (3O° E Passive)

12/65

Touching with full tuck

10/97

17/115 (with some compensatory flexion at MCP)

0/70

Touching with full tuck







Ring Finger

MCP

PIP

DIP

Fingertip touch palm

41/87

62/80

11/55

Touching with ¼ tuck

13/86

45/96 (25° E Passive)

10/55

Touching with full tuck

0/92

43/115 (18°E Passive)

0/61

Touching with full tuck

0/93

5/11

50/68

Touching with full tuck







Little Finger

MCP

PIP

DIP

Fingertip touch palm

21/85

13/50

13/57

1 cm off palm

0/84

15/60

11/59

Touching with full tuck

0/10

20/70

0/55

Touching with full tuck

0/10

20/97

0/70

Touching with full tuck







Grip Strength  [Measured with electronic Jaymar]


Power Grip

Pinch Grip

39.6 lbs average

5.7 lbs average


80.3 lbs average

21.2 lbs average

87.8 lbs average

23.5 lbs average







Key: MCP - Metacarpal Phalangeal joint; PIP - Proximal Interphalangeal joint; DIP - Distal Interphalangeal joint

Measurements in degrees of extension start/finish

Table 2: Left Hand ROM and grip strength assessment results