Jim Moretz, PhD, LMBT

Client:

Female (48) has an intermittent problem with her left hip “feeling like it pops out of joint” when she is walking. The main complication is not pain (she rates it 3 out of 10), but loss of balance and the immediate need to shift her weight to the right hip. “If not, I feel like I am going to fall.” The client does not recall an originating injury or incident. She has not noticed any causative pattern or common aggravating factors. Per week, she works three (3) twelve (12) hour shifts as a Registered Nurse in a critical care hospital unit. Occupational activities include short bursts of walking, long periods of standing, and heavy lifting/turning of patients. Recreational activities include aerobic walking, gardening, strength training, and some yoga. Until 2013, she played softball yearly, in both co-ed and women’s leagues.

Initial Assessment:

Hip Range of Motion (ROM) testing:

Lateral ROM (normal 40° to 60°)

Right - 51°

Left - 51°

Medial ROM (normal 30° to 40°)

Right - 30° LOW

Left - 20° Deficit

Client is within the normal ROM for Right and Left lateral rotation. Right medial rotation is low normal ROM. Left medial rotation is a significant deficit.

Added to the presenting symptoms, these results suggest a rather common condition called “Snapping Hip.” The investigative question in this study is how to treat snapping hip with Neuromuscular Massage Therapy.

Presently, the conservative treatments for snapping hip are anti-inflammatories, stretching, and avoiding the aggravating activities. When one’s occupation is the aggravating activity, avoidance is impossible. The only treatment for recalcitrant cases is surgery to lengthen the iliopsoas or iliotibial band. Due to the difficulty of diagnosing the actual cause of snapping hip, surgery limited to these muscles cannot have a consistently positive outcome.

Application of Neuromuscular Therapy (NMT) Treatment

Day 1

90-minute Deep Tissue massage focused on the attachment sites for the Left Coxal Adductors, TFL, and Gluteus Medius. Post-session ROM showed a 23° Left Medial Rotation

Day 2

60-minute Passive Stretching on bilateral Coxal Rotators (30 minutes each side). Client reported sore hamstrings and sitting for over six hours that day while driving and teaching. Post-session ROM test showed Right and Left Medial Rotation of 15°.

Day 3 – Day 5

No NMT sessions due to client work schedule. Client reported noticing repeatable pain pattern in left hip when it was engaged to move a patient or object from a non-ideal starting position, but no “snapping” sensation.

Day 6

120-minute Deep Tissue, Trigger Point Release, and Active Release session focused on Left Coxal Adductors, TFL, and Gluteus Medius. Post-session ROM showed a 30° Left Medial Rotation

Day 7

No NMT session

Day 8

60-minute Passive Stretching on bilateral Coxal Rotators (30 minutes each side). No Post-session ROM test.

Day 9

120-minute bilateral Myofascial Release session focused on all Lower Extremity and Coxal muscles. No Post-session ROM test. 

Day 10 – Day 12

No NMT sessions due to client work schedule. Client reported no “snapping” sensation. However, a “new” pain pattern and weakness was detected in Left hip, slightly anterior to original site. Client reported a fall in which the right foot slipped out while walking down-hill. Client fell backwards and to the left, landing on left shoulder with left knee flexed and left hip abducted and laterally rotated.

Day 13

Final 120-minute Deep Tissue, Trigger Point Release, and Active Release MT session focused on Left Coxal Adductors, TFL, and Gluteus Medius.

Results:

Post-therapy Medial ROM:

Left - 33°

Right - 35°

1) Left medial rotation was normalized, although still in the low end of the range.

2) Right medial rotation was increased.

3) The proportional relationship between Left and Right medial rotation was 86% which indicates the client is now in the third stage of healing (Remodeling).

Recommendations

Further treatment to continue the NMT treatment schedule described above for an additional two weeks and consult a personal trainer to begin a strength training regimen. The progress trajectory suggests that the proportional relationship between Left and Right medial rotation could be 95% to 100% within 60 days.

Conclusions

This case study presents evidence that snapping hip resulting from a medial coxal rotation deficit combined with a significant disproportionate bilateral medial rotational relationship can be effectively resolved with alternating NMT sessions focused on 1) attachment and myofascial release, and 2) passive stretching. Attachment and Trigger Point release therapies should not be repeated within 48 hours (ideally 72 hours). Passive stretching between deep tissue modalities may be crucial to the client’s recovery and response to the more aggressive techniques. It remains unclear whether the decrease in ROM after the initial increase is to be expected, or, at least, not surprising. The initial 3° increase in the Left medial rotation is considered clinically significant.

Cyctic Fibrosis Definition

A genetic mutation of the cystic fibrosis transmembrane conductance regulator (CFTR) gene that affects the cells that produce mucus, sweat and digestive juices so that, instead of secreting lubricants that promote biological function, these cells, especially in the lungs and pancreas, secrete thick, sticky fluids that clog tubes, ducts and passageways.

Etiology[1]

The human genome contains two copies of the CFTR gene.

Signs/Symptoms[2]

Cystic fibrosis signs and symptoms vary, depending on the severity of the disease. Even in the same person, symptoms may worsen or improve as time passes. Some people may not experience symptoms until adolescence or adulthood.

People with cystic fibrosis have a higher than normal level of salt in their sweat. Parents often can taste the salt when they kiss their children. Most of the other signs and symptoms of cystic fibrosis affect the respiratory system and digestive system. However, adults diagnosed with cystic fibrosis are more likely to have atypical symptoms, such as recurring bouts of inflamed pancreas (pancreatitis), infertility and recurring pneumonia.

Respiratory signs and symptoms

• A persistent cough that produces thick mucus (sputum)

• Wheezing

• Breathlessness

• Exercise intolerance

• Repeated lung infections

• Inflamed nasal passages or a stuffy nose

Digestive signs and symptoms

• Foul-smelling, greasy stools

• Poor weight gain and growth

• Intestinal blockage, particularly in newborns (meconium ileus)

• Severe constipation

GI Manifestations[3]

• gastroesophageal reflux,

• small intestinal bacterial overgrowth

• intussusception

• meconium ileus

• distal intestinal obstruction syndrome

• appendicitis

• fibrosing colonopathy

• gastrointestinal cancer

Risk Factors[4]

• Family history

• Race:

  • Approximate US CFTR gene mutation carriers:

    • 1 in 29 Caucasian-Americans

    • 1 in 46 Hispanic-Americans

    • 1 in 65 African-Americans

    • 1 in 90 Asian-Americans

  • Approximate CF-Race correlation in the US:

    • 1 in 2,500-3,500 Caucasian-Americans

    • 1 in 4,000-10,000 Hispanic-Americans

    • 1 in 15,000-20,000 African-Americans

    • 1 in 100,000 Asian-Americans

Treatment

Because CF has so many pulmonary and gastrointestinal manifestations, treatment is always personalized and continually adjusted according to the disease progression.

Medications[5]

Besides medications necessary for treating the manifestations of CF, since 2012, some drugs known as CFTR modulators has been available to treat the root cause of CF. The three types of modulators are potentiators (e.g., ivacaftor), correctors (e.g., tezacaftor), and amplifiers (remain in R&D). The Cystic Fibrosis Foundation is encouraged by the potential of the next generation of CFTR modulators. However, until curative medication is developed, mucus thinners (e.g., dornase alfa, hypertonic saline) and anti-inflammatories (e.g., ibuprofen) remain therapeutically necessary and are the subject of further research and clinical trials.

Massage Therapy

Benefits

Research to date supports the use of Complementary and Alternative Medicine (CAM), including Massage Therapy (MT). However, the research also illustrates the need for additional research that meets rigorous standards of research practice.[6] For example, CF patients and their families who report CAM benefits are not likely to enlist professional CAM practitioners.[7] A common outcome that has surprised researchers is that family members of CF patients who receive MT also reported significant reduction of stress, anxiety, and musculoskeletal pain even though they did not receive MT themselves.

Risks

Although the base pathology of CF is not immunosuppressive, some patients are treated with induced immunosuppression.[8] Therefore, the main contraindication for MT in CF patients is the potential for the therapist to infect the client.

[1] https://www.cff.org/What-is-CF/Testing/Carrier-Testing-for-Cystic-Fibrosis/

[2] https://www.mayoclinic.org/diseases-conditions/cystic-fibrosis/symptoms-causes/syc-20353700

[3] Stephanie Demeyer, Kris De Boeck, Peter Witters, Katrien Cosaert, “Beyond pancreatic insufficiency and liver disease in cystic fibrosis,” Eur J Pediatr (2016) 175:881–894 (DOI 10.1007/s00431-016-2719-5)

[4] G.E. Palomaki, S.C. Fitzsimmons, J.E. Haddow, “Clinical sensitivity of prenatal screening for cystic fibrosis via CFTR carrier testing in a United States panethnic population,” Genet Med. (Sep-Oct 2004) 6.5:405-414.

[5] https://www.cff.org/Research/Developing-New-Treatments/CFTR-Modulator-Types/

[6] Myra Martz Huth, Kathleen A. Zink, Naomi R. Van Horn, “The Effects of Massage Therapy in Improving Outcomes for Youth with Cystic Fibrosis: An Evidence Review,” Ped Nursing (July-August 2005) 31.4:328-332

[7] Ana Tanase, MD and Robert Zanni, MD, “The Use of Complementary and Alternative Medicine Among Pediatric Cystic Fibrosis Patients,” J Alt & Comp Med. 2008 14 (10):1271-1273.

[8] Stephen Kirby, Brian Whitson, et al. “Survival benefit of induction immunosuppression in cystic fibrosis lung transplant recipients,” Jour Cystic Fibrosis 14 (2015) 104–110.

Signs and symptoms depend on which structures are compressed. Neurogenic thoracic outlet syndrome generally compresses and irritates the nerves of the brachial plexus, the complex of nerves that supply motor and sensory function to the arm and hand. Symptoms may include weakness or numbness of the hand, unilaterally decreased size of hand muscles, and pain, tingling, prickling, numbness and weakness of the neck, chest, and arms. Venous thoracic outlet syndrome is caused by damage to the major veins. This condition often develops suddenly after unusual and exhaustive use of the arms. Symptoms can include swelling of the hands, fingers and arms, as well as heaviness and weakness of the neck and arms. The veins of the chest wall may also appear engorged. Arterial thoracic outlet syndrome is the least common, but most dangerous. It originates from congenital bony abnormalities in the lower neck and upper chest. Symptoms typically include cold sensitivity in the hands and fingers; numbness, pain or sores of the fingers; and poor blood circulation to the arms, hands and fingers.

Treatment strategies depend on the type TOS. Neurogenic cases usually benefit from therapies aimed at increasing range of motion to the neck and shoulders, strengthening muscles and promoting better posture. Venous cases often require blood thinners to reduce the risk of clot formation that can occur when blood pools in areas of decreased flow. If blood thinners prove ineffective, surgery is necessary to relieve the compression. Arterial cases most often require surgical interventions that involve removing a rib or other offending structures. Blood thinners and thrombolytics may also be required.

The different types of TOS highlight the importance of taking a thorough intake history before performing massage on clients that report symptoms of TOS. On the one hand, venous and arterial TOS should be considered absolute contraindications for massage therapy due to the potential for embolisms. However, 95% of TOS cases are neurogenic, for which massage therapy should be the primary recommended intervention. Interestingly, the Mayo Clinic website makes no mention of massage therapy as a treatment option. Since many people use this very reputable site, massage therapists should advocate for their clients to have a thorough diagnostic process.

Currently, surgery is recommended if the vaguely termed “conservative therapy” is ineffective. Yet, research continues to illustrate massage therapy as an independent discipline which may not be “conservative.” The three most surprising facts uncovered in the research for this paper were: 1) Travell and Simons’ method for releasing an elevated first rib; 2) the extensive muscular and modal MT treatment recorded in a 2014 case study in New Zealand as part of a 3-year, 3600-hour, bachelors of health science degree program in massage therapy; 3) the conclusion from a 2006 study that persistent disorders require the compound effects of multiple MT sessions. These facts suggest that the terms “non-invasive” and “conservative” must not be confused or interchanged. A curative MT treatment may well be more progressive as practitioners creatively and inventively seek to avoid invasive surgeries.

References:

Cleveland Clinic On-line Health Library@ myclevelandclinic.org

Hamm, Michael. “Case Report: Impact of massage therapy in the treatment of linked pathologies: Scoliosis, costovertebral dysfunction, and thoracic outlet syndrome.” Journal of Bodywork and Movement Therapies 10 (2006): 12–20. Print.

Simons, David G., Lois S. Simons, and Janet G. Travell. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Vol. 1. 2 vols. Williams & Wilkins, 1999 (504-537).

Wakefield, Mary Lillias. “Case Report: The Effects of Massage Therapy on a Woman with Thoracic Outlet Syndrome.” International Journal of Therapeutic Massage & Bodywork 7.4 (2014): 7–14. Print.

The ANA projects that 500,000 RNs will retire by 2022, while the need for nurses in the US will rise by 1.1 million. Since the average cost of training a new grad is $50,000 and replacing a retired nurse costs between 75% and 125% of the retiree’s annual salary, nurse retention will be critical. Studies show that group cohesion is improved by good collective experiences. Therapeutic massage can accomplish two things that will dramatically improve your work environment.

First, it can relieve the common pains suffered by nurses: neck, shoulders, back, knees, and feet. This can extend your career in the long run and make it more enjoyable today.

Second, if the entire unit receives massage therapy, common bonds of pain relief and increased mobility will create a tighter team ethos that may well result in better patient outcomes. It may sound trite but it is quite possible that “Nurses who are healed together, heal others together.”