Case Reports: Where’s your first draft?
Posted: February 27th, 2012 | Author: admin | Filed under: massage | Tags: education | No Comments »Here at the Foundation we’re very excited about case reports, and empowering folks to write and submit them. They are the number-one way (along with donating to the MTF!) for regular therapists to transform the research landscape of massage therapy.
What is a case report, anyway? It’s simple: a case report is a story from your clinical practice, translated into a common format (Intro/Methods/Results/Discussion), and then shared with your colleagues out in the world. The reasons to write a case report are many, but the biggest reason is this: it’s what you should do when you have something to share. It’s part of our responsibility as clinicians to occasionally open a window into our practice, so that others may benefit.
When I say clinician, I’m talking about you. The person reading these words. Someone who gets paid to help people feel better, function more fully, and awaken more fully into themselves. What happens in your practice? What do you wish could be seen by physicians or researchers? What is common but undocumented? What is vexing or mysterious? I want to know.
I can tell you one mystery that has thoroughly disappeared: “How does one even get started with a case report?” If you’ve done the work of becoming licensed in massage therapy, you have the necessary skills to begin. Getting done is a bigger challenge, but we’ve got your back there, too:
Want to know how case reports are put together? Check out the Massage Therapy Foundation’s case report contests for step-by-step guidelines, outside resources, and examples from past contest winners. Do you feel rusty with finding or understanding research articles? Enroll in our excellent new online course – Basics of Research Literacy. Are you looking for inspiration or indignation? Just type the words “massage therapy case report” into Pubmed.gov and click on the first thing that looks interesting.
The most important thing is begin the story. Everything else is grounded in that act. Your first draft doesn’t need to be fancy — just write as if you were speaking to a colleague.
Here, I’ll start:
Case Report. A 30 year-old male patient hands me a self-typed letter that carefully conveys his medical history: a rare form of leukemia that took him down fast but somehow decided not to kill him.
He was eighteen when the cancer announced itself and confined him for years to a hospital bed. It was surreal for him to be suddenly so infirm, but by that time he had already accrued a lifetime of random calamity: A freak car accident at age two. A wicked bike fall at twelve. Broken bones and open wounds. Avascular necroses in his hips and knees. Thyroid and pancreatic swings. His eyes meet me briefly and then return to some distant horizon. He speaks quietly, as if sharing a secret, not entirely believing his own presence in the room.
His reason for visiting me is symptoms relating to the most recent diagnosis: Graft-versus host disease (GVHD). It’s an auto-immune reaction instigated by some donated bone marrow. His immune system, stimulated by an intermittent sense of invasion, had proliferated its inflammations and fibroses in a variety of ways. GVHD is a trickster disease, able to mimic a number of other autoimmune disorders and then morph into new modes. In recent years, the condition had manifested like a patchy, regional scleroderma. The skin on his left ribcage, left shoulder, left neck and left arm contains a number of quarter-sized skin adhesions, where the superficial fascia had spontaneously scarred and grabbed hold of the overlying epidermis. Each adhesion is colored a little pale, depleted of its melanin, and his normally mobile skin is like stiff leather under my fingertips.
He says his left shoulder felt glued down, stuck, tight and sore. The drape of his t-shirt and the taut meat below conveys a sense that his left upper trapezius has been suffering under heavy downward opposition. His knees and shoulder sockets ache “occaisionally” but he said they feel “OK” today. His low back ached more or less all the time, and he described his neck as “stiff but not usually painful”. I asked about headaches, and he said “Not usually. Not for long, anyway.”
He says that he wants freedom in the left shoulder, some reduction in back pain, and maybe some better sleep. I have him remove the t-shirt, and I notice that several of his adhesions lie along the path of cutaneous nerve roots (C6 through T4 dorsal rami on the left side) and the radial and axillary nerves of the arm. The overall effect is one of strapping the scapula close to the upper ribs, and the trapezius, serratus anterior, levator scapulae, and rhomboid muscles all seem to struggle mightily during scapulo-humeral abduction. The arm feels to me like it wears a tight stocking, and every motion seems oppressed by this constrictive garmet. He works as a carpenter-contractor, is two years married, and had recently recovered enough to finish his GED.
I figure that some careful fascial release might be able to improve his shoulder mobility, and to the degree that cutaneous nerves were entrapped, it would be worth trying to free them. However, I’m concerned about inflaming the tissue, especially with a mysterious autoimmune process going on. I will have to cover ground slowly, and ask for communication as we do the work. And what about his pain perception, given the gnarly history of accidents and hospital care?
“I… don’t have a normal relationship to pain”, he says.
“In what way?”
“If a pain is really bad, I feel it for a second, and then I kind of turn it off.”
His leukemia treatment ten years prior had involved a thick stream of pain medications, but he didn’t like the mental haze or the digestive side effects. “I hated the painkillers, so I started not taking them. I just learned how to change what I’m feeling.” The doctors were dumbstruck, he says.
I could respond in any number of ways, but our intake time is already lengthy. “Can you feel this pressure?” I ask, pressing my thumb with medium force into his forearm.
“Ow, yes” he replies.
“That’s what I don’t want to exceed in our work. So let me know, ok?”
“OK.”
Fast forward three months. So far we’ve had 8 hour-long sessions. Our results have been mixed: In terms of shoulder mobility, we’ve had some good success. The first 3 sessions, especially, saw him go from severe limitation to only mild restriction (e.g. He went from a labored 70 degrees scapulo-humeral abduction to a comfortable 120.) “I’ve never gotten that kind of relief with massage” he reports with a sigh. The cutaneous adhesions have also reduced in size and number, although the skin remains discolored in the previously adhered spots.
His back pain has been fluctuant, but overall I don’t think it’s improved. There is still generalized ROM limitation, point tendernes, and muscular hypertonicity throughout his thoracic and lumbar spine. It has admittedly been a secondary focus. It’s also possible that a reduction in exercise is to blame: He’s been sitting in college classrooms recently, and running less.
His sleep disturbance had some early improvement, but then did not seem correlated with receiving massage. He tells me halfway through that his thyroid medication is “messed up” again, and that he’s waiting to adjust it with the doc. Two sessions later he says the sleep has normalized since reducing his thyroid medication.
Our current plan is to re-focus on the back pain, and leave the shoulder complex as a secondary focus. He seems quite grateful for the work, and seems less focused on his symptoms and more on the day-to-day frustrations of a carpenter and a 30-year-old college student. I take this as a good sign: perhaps he his comfortable enough most of the time to indulge in more pedestrian complaints.
I have to admit that as the sessions progressed, I became less focused on the tissue-level pathology, and more aware that his definition of “health” was expanding along with his range of motion. As I gained familiarity with his body, my clinical intent shifted to include not just fascial release, but kindness and embodiment.
My early tendencies as a massage therapist were to become so enthralled with dramatic conditions that they made opaque the person suffering in front of me. My role, I thought, was to understand, and in the absence of understanding, I could not really treat. My tools were few, but my curiosity was relentless, and this mostly worked well. The trigger points were found and muscles made loose. Scars were frictioned and ranges of motion increased. Except that this constant striving made me unable to arrive. Their healing would be a victory in my mind, their stasis a defeat, and I would sacrifice their sense of independence for my sense of accomplishment.
I wonder now if my early patients left feeling well-examined but never truly heard. It’s a constant balancing act when you’re asked to deploy a compassionate art within the constraints of a complex medical condition. The best sessions — from my perspective — seem to be those where love for the work and love for the patient seem to be one and the same.
I’m curious how other massage therapists have dealt with similar situations, and I’m looking forward to the day when we have better evidence around the efficacy and contraindications of massage for autoimmune conditions like GVHD.
The Massage Therapy Foundation offers two Case Report Contests each year: one contest is for Practitioners (submission deadline is October 1 annually), and another contest for Students (submission deadline is March 1 annually). Learn more by visiting the Case Report Contest section of our website.
Mike Hamm teaches anatomy, technique, and research literacy at Cortiva Institute Seattle, and maintains a full time bodywork practice focused on orthopedic injury and trauma recovery. He was the winner of the Massage Therapy Foundation’s 2005 Student Case Report Contest, and presently serves as a reviewer for the Foundation’s Professional Case Report Contest. He has published articles in various research journals and trade magazines on subjects including nerve entrapment and research literacy education. When not teaching or doing bodywork, Mike plays music in a Seattle band.
