Melina Lake - Registered Massage Therapists` Association of British

Transcription

Massage Therapists’ Association of British Columbia
Clinical Case Report Competition
West Coast College of Massage Therapy
New Westminster
April 2014
Third Place Winner
Melina Lake
Will petrissage and golgi tendon organ release to
iliopsoas, quadratus lumborum, and lower trunk
musculature reduce symptoms of Crohn’s disease?
P: 604.873.4467
F: 604.873.6211
[email protected]
massagetherapy.bc.ca
MTABC 2014
Running Head: MUSCLE RELEASE FOR CROHN’S DISEASE
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Abstract
Despite the growing use of massage therapy among people suffering with Crohn’s
Disease (CD), there is little research regarding release of musculature bordering the colon
and its effect on CD symptoms. In this case study, a 31-year-old male with CD of 18
years underwent five 1-hour manual treatments of Petrissage and Golgi Tendon Organ
release over 2.5 weeks. Iliopsoas (IP) and Quadratus Lumborum (QL) were specifically
addressed with the primary goal to decrease pain and hypertonicity in the lower right
abdominal quadrant, right anterior hip, and the low back. The secondary treatment goal
was to lessen intestinal aggravation. The patient tracked frequency and rated intensity of
pain on a 0-5 scale over a 4.5-week period and monitored intestinal flare-ups. Results
show elimination of pain in patient’s lower right quadrant and right anterior hip with a
slight decrease in low back pain. The frequency of intestinal aggravation lessened;
however, cannot be credited to massage treatments since contributing lifestyle variables
were not controlled. These findings suggest massage therapy applied to IP, QL, and
neighboring musculature of the trunk help alleviate chronic pain felt in patients with CD,
particularly in the lower right abdominal quadrant. To better isolate the relationship
between the unhealthy colon and manual therapy to its adjoining muscles, a larger,
randomized sample size is needed with control of confounding variables.
Keywords: crohn’s disease, golgi tendon organ release, iliopsoas, massage,
petrissage, quadratus lumborum
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Acknowledgements
I thank my participant for his time, flexibility, and interest as well as my advisors Patricia
Ibbitt and Sean Cannon for providing direction.
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Table of Contents
Introduction
5
Symptomology
5
Medical Interventions
6
Hypothesis
7
Anatomy & Physiology
8
Supportive Research
9
Methods
Patient History
11
Assessment
12
Tables
13
Treatment Goals, Management Plan, Modalities
14-15
Results
16
Figures 1-9
17-19
Discussion
20
Conclusion
21
References
22
Appendix A
25
5
Introduction
Inflammatory Bowel Disease (IBD), including both Crohn’s Disease and
Ulcerative Colitis, is characterized by recurrent, intermittent inflammation of the
intestines with a chronic, unpredictable course of action. Crohn’s Disease (CD),
otherwise known as Regional Enteritis, is an autoimmune condition, which presents as
patchy areas of full thickness inflammation anywhere in the gastrointestinal tract. It most
commonly involves the terminal ileum of the small intestine and the cecum or proximal
large intestine (Venes, 2005). CD causes ulcerations into lymph areas within the mucosa,
resulting in interspersed granulomas leading to fibrosis of the muscularis and serosa. This
causes rigidity within the intestinal wall, eventually narrowing its lumen and possibly
forming fistulations (Damjanov, 2006).
The etiology of Crohn’s Disease and Ulcerative Colitis is unknown; however,
research suggests causes may be attributed to emotional stressors and genetics
(Damjanov, 2006). Canada has one of the highest incidence rates of IBD in the world
with over 200,000 Canadians currently diagnosed and 9,000 new patients diagnosed each
year (www.ccfc.ca).
Symptomology
The effects of CD include abdominal pain commonly in the lower right quadrant,
malabsorption, and diarrhea (Venes, 2005). As the disease progresses, symptoms worsen
to bleeding, constipation, vitamin insufficiency, and anemia (Damjanov, 2006). The
periumbilical or abdominal pain from pathology in the terminal ileum often refers pain to
the low back (Goodman & Fuller, 2009). There is much research to support the
involvement of spinal joints with IBD. A Case Report on a 27-year-old female with
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posterior buttock pain found after a Rheumatologist evaluation, the patient was diagnosed
with Spondyloarthritis (SpA) from a history of CD (Coronado, Sheets, Cook, &
Boissonnault, May 2010). In the journal of Digestive Diseases, M. De Vos (2009) affirms
IBD and Spondyloarthritis are tightly related. Clinical evidence links gut and joint
inflammation with HLA-B27, the Major Histocompatibility Complex (MHC) antigen
linked to immune-mediated inflammatory conditions. De Vos’ findings state, in all
various forms of SpA, gut inflammation was described in 60% of patients, categorizing
patients as high risk for developing CD (2009).
Medical Intervention
There is no known cure for CD. Typically, medical interventions include antiinflammatory drugs such as corticosteroids and patients often require nutritional support
(Venes, 2005). Surgical removal of the diseased bowel segments is necessary if cases are
resistant to medication (Damjanov, 2006). However, a study from St. Michaels’ Hospital
in Toronto, Ontario (2004) discovered gastroenterology patients are dissatisfied with
conventional medicine and have a growing desire to improve their health by improving
their quality of life. The study reports 63% of people with gastrointestinal problems in
Canada use Alternative Medicine (AM) to manage their symptoms; the most commonly
used being herbal medicine, chiropractics, and massage therapy (Ganguli, Cawdron, &
Irvine, 2004). When compared to subjects with other illnesses, participants with IBD
reported living with more severe side effects from prescribed medication plus more stress
and worry about their diseases. These patients use AM more frequently than those with
other medical conditions (Ganguli et al., 2004).
Furthermore, after surveying 90 people with IBD, the University of Manitoba’s
Inflammatory Bowel Disease Clinical and Research Centre found patients consider
physical therapies like massage and exercise to be safe because they avoid concerns
regarding surgical procedures or loss of control (Burgmann, Rawsthorne, & Bernstein,
2004). As these patients experience increased disease activity they increase use of
Alternative Medicine (AM) in an attempt to treat pain, cramps, diarrhea, gas/bloating,
decreased energy, stress, joint pain, and constipation. Patients stated exercise, diet, and
prayer, improved their symptoms 95% of the time while massage and other forms of
relaxation therapies helped 67% of the time (Burgmann et al., 2004).
Despite its growing popularity among patients with CD, there is little research
about the effects of massage therapy performed on adjoining musculature to the colon.
When cellular function is disrupted, tremendous strain is placed on the surrounding soft
tissue (Cubick, Quezada, Schumer, & Davis, 2011). Several studies show the close
relationship between the colon and Psoas Major since fistulizing CD is considered the
most frequent cause of Psoas abscesses (Tonolini, Campari, & Bianco, 2012). Goodman
and Fuller (2009) state obstruction from an inflammatory mass in the low right quadrant
may also cause buttock, hip, thigh, or knee pain (2009), yet no explanations for this
finding are included. Medical research does not tend to attribute musculoskeletal or
visceral pain to have a myofascial connection or basis (Muscolino, 2012). Therefore, the
purpose of this study is to evaluate whether massage therapy to musculature attaching to
and surrounding the colon will help recover the impact of Crohn’s Disease.
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Hypothesis
Will Petrissage and Golgi Tendon Organ Release to Iliopsoas, Quadratus
Lumborum, and lower trunk musculature reduce symptoms of Crohn’s Disease?
Anatomy & Physiology of Involved Structures
The colon or large intestine is 1.5 meters long beginning at the cecum and ending
in the sigmoid portion. An extension from the terminal ileum of the small intestine, it
passes upward from the lower right abdominal quadrant to the liver, then turns to run
transversely passing the stomach, then heads downward to extend into the rectum. It’s
connected to Psoas Major through peritoneum and Quadratus Lumborum and Transversal
muscles through loose areolar tissue. Its function is mixing, then dehydrating intestinal
contents by absorbing water, forming feces (Gray, 1977).
The Psoas Major is a long muscle located on the side of the lumbar spine and
pelvic margin. It arises from the transverse processes, the lateral bodies, and
intervertebral discs of all five lumbar vertebrae and runs inferiorly and gradually
diminishes in size to join the Iliacus muscle (Gray, 1977). The Iliacus is a flat, triangular
muscle lying within the whole iliac fossa of the ilium. It converges inferiorly and inserts
to the outer Psoas Major tendon. Together both muscles make the Iliopsoas (IP) and
terminate into the lesser trochanter of the femur. Anteriorly, Psoas Major is placed behind
the peritoneum with the iliac fascia, colon, kidney, Psoas Minor, renal vessels, and ureter.
Its posterior surface meets Quadratus Lumborum along with the lumbar vertebrae. Iliacus
is separated from the peritoneum by the iliac fascia and shares a border with the cecum
on the right and sigmoid flexure of the colon on the left. IP flexes the thigh when the
origins are fixed and bends the lumbar spine and pelvis anteriorly when the femur is
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fixed. IP also maintains an erect position by stabilizing the spine and pelvis upon the
femur and assists in raising the trunk from a recumbent position (Gray, 1977).
Quadratus Lumborum (QL) arises from the posterior iliac crest, aponeurotic fibres
of the ilio-lumbar ligament, the transverse processes of the upper four lumbar vertebrae,
inserting to the lower border of rib 12. This irregular quadrilateral muscle is related
anteriorly to the colon and Psoas muscle, as well as the kidney, and Diaphragm. QL’s
actions include drawing the 12th rib inferiorly and assisting in inspiration by fixing the
diaphragm. Unilaterally, it draws the pelvis superiorly and when working bilaterally, both
muscles flex the trunk (Gray, 1977).
Note: see Appendix A for images
Supportive Research
Travell & Simons (1993) describe QL as one of the most troublesome muscles
contributing to low back pain. In relation to the abdomen, QL may elicit pain along the
lower quadrants and anterior iliac crests. When Iliopsoas is taut, pain may refer vertically
along the ipsilateral lumbar spine to the sacroiliac region and proximal buttock (Travell
& Simons, 1993). IP shortening may lead to tension in the iliac fascia and peritoneum of
the lower abdominal quadrants. Moreover, QL may be shortened in patients with CD
from habitual trunk flexion or hunching due to chronic abdominal pain. Consequently
this puts more dependence on IP to maintain the trunk in an erect, upright position. Deep
stroking massage is considered “probably the most effective way to inactivate central
TrPs when using a direct manual approach” (Travell & Simons, 1993, p. 141).
In a Case Study on an adolescent male with severe anterior abdominal pain and a
history of CD, Muscolino’s (2012) findings support the connection between viscera and
musculoskeletal problems. The patient described the quality of pain as a dull pressure,
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never sharp that mildly radiated to his groin region. Pain was aggravated by forward
trunk flexion and sitting, as well as prolonged standing. A Gastroenterologist confirmed
CD did not directly cause his symptoms, despite the similarities. After further assessment
combined with the patient’s history of chronic abdominal pain and muscle engagement
from CD, the patient was diagnosed with Myofascial Pain Syndrome with trigger points
in his left Rectus Abdominus and Psoas Major muscles.
Treatment of these trigger points included stimulation of Golgi Tendon Organs to
decrease muscle tone and soft tissue manipulation such as sustained compression and
deep stroking to break adhesions and decrease hypertonicity. Deep moist heat was
provided post treatment as well as a stretch to Psoas Major. After four sessions over 2
weeks, the patient reported to feeling better (Muscolino, 2012).
Walach, Guthlin, & Konig (2003) found when ten 20 minute massage treatments
including effleurage, petrissage, vibration, friction, and tapotement were applied twice a
week to patients with chronic low back pain, pain ratings dropped from 5.8/9
pretreatment to 4.6/9 post treatment and to 3.8/9 at the 3 month follow up. Walach et al.
state the passive movements of massage plus mobilization and stretching enhance blood
flow and metabolism, reducing tension and enabling reduction of substances involved in
the generation and prolongation of pain. Another study on management of chronic low
back pain by the Touch Research Institute of the University of Miami found flat hand
stroking and kneading across back muscles and the abdomen led to less pain and
improved range of motion in trunk flexion post-treatment among participants
(Hernandez-Reif, Field, Krasnegor, & Theakston, 2001).
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In a Case Report documenting her personal experience with massage therapy and
CD, 30 year-old Orla Liddy (2007) describes when experiencing symptoms, her spine
and surrounding musculature act protective by tensing. After undergoing just one
rhythmical soft tissue massage, which included gentle lifting movements combined with
circling and sweeping to her back and abdomen, she reports feeling soothed with an
accelerated healing process to her CD flare-up. The Department of Physical Therapy at
Miami University found sustained direct myofascial release to the lower intestine,
thoracic and pelvic regions improved GI tract function after 6 treatments over a two-week
period. This improvement lasted 5 weeks following the treatment series (Cubick,
Quezada, Schumer, & Davis, 2011).
This evidence supports the efficacy of massage therapy techniques such as
Petrissage and Golgi Tendon Release to trunk musculature in relieving symptoms of CD.
Methods
Case History
Patient is a 31-year-old male diagnosed with Crohn’s Disease 18 years ago, in
1996. He suffers from intermittent intestinal flare-ups 2-3 times a week, which typically
cause diarrhea, lower right abdominal pain, and low back pain. Patient rates abdominal
pain as 6/10 and low back pain 5/10 at their worst and both zero at their best. Abdominal
pain is an ache with cramps, which sometimes refers to the right ilium region. Low back
pain is a tight, dull ache. Patient’s medications include Loperamide or Immodium when
experiencing diarrhea, a daily multivitamin, plus vitamin B12 and D for related
malabsorption. He sees a Gastroenterologist roughly once every 2 years and is currently
not receiving any treatment for low back or abdominal pain. Patient had 18 inches of his
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terminal ileum and cecum region surgically removed in 1996. In 1997 patient had surgery
to remove adhesions as a result of the first surgery. As a result of these incisions, in 2002,
2003, and 2010 the patient had three separate hernia repairs in his umbilical region for a
total of 5 surgeries in 14 years. He works as a casual Registered Nurse (RN) where he
mainly stands, walks, and lifts patients. Physical activities include biking and skiing. Due
to patient’s irregular work schedule, his sleep ranges from 2 to 12 hours in a 24-hour
period. He claims to manage a tension free lifestyle besides minimal stress while at work.
Observations
Structural Scoliosis, diagnosed at 3 months old, with a primary C-curve to the left
between T2 and T5, slight hyperkyphosis and moderate hypolordosis of the lumbar spine.
Posteriorly, left ilium is slightly inferior with the right superior. Anteriorly, the left sits
superior and the right inferior. Slight anterior rotation of shoulders bilaterally with the left
sitting superiorly compared to the right. A prominent right torsion of left anterior thorax
from Pectus Excavatum, diagnosed at 3 months old.
Palpation
Lower right abdominal quadrant was taut and firm, particularly around scar tissue
from previous surgeries. Bilateral Iliopsoas caused referred pain into anterior ilia and hips
and hypertonicity in bilateral iliac fossae with more pain on right. Hypertonicity and pain
in bilateral Erector Spinae, Gluteus Maximus, and Quadratus Lumborum, referring across
entire low back plus myofascial adhesions at bilateral Sacroiliac regions. Bilateral Lower
Trapeziuses were taut as was the Diaphragm.
Neurological
Patient had no neurological symptoms.
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Range of Motion
Lumbar Spine within normal limits with slight pain at end range of Left Lateral
Flexion and Extension. Diaphragm mobility low on inspiration and expiration, patient
presents as apical breather.
Special Tests
Orthopedic tests followed protocol seen in Magee’s Orthopedic Physical
Assessment (2006). Sphinx, Bilateral Straight Leg Raise, Thomas test, and Manual
Muscle test for Quadratus Lumborum were performed before and after each treatment to
assess pain and hypertonicity in the lower right abdomen and anterior hip (see Table 2),
and bilateral low back (see Table 3). Patient rated any pain from test performance on a
scale of 0-5 (see Table 1).
0
1
2
3
4
5
Table 1: Pain Scale
No pain
Mild
Mild - Moderate
Moderate
Moderate – Severe
Severe
Table 2: Right Anterior Low Quad & Ant Hip Pain, Pre & Post Treatment
Jan 14
Jan 18
Jan 23
Tx 1
Tx 2
Tx 3
Pre Tx
1.5
0P
1
Sphinx
Post Tx
0.5
0P
0P
Straight Leg Raise
Thomas test (all Neg.)
Jan 28
Tx 4
2
Jan 31
Tx 5
0P
0.5
0P
Pre Tx
60° “pinch” 1.5
0P
70° 1
0P
0P
Post Tx
0 P, 0 “pinch”
0P
0P
0P
0P
Pre Tx
R Hip Flex = 1.5 “pinch”
L Hip Flex = 0
R Hip Flex = 0.5 R
L Hip Flex = 0.5 R
0P
0P
0P
0P
0P
0P
0P
0P
Post Tx
Pre Tx
R = 0.5
R=0P
R=1
R=1
R = 0.5
L=0P
L=1
L=0
L=0
L=0
Post Tx
R=0P
R=0P
R=1
R=0
R=0
L=0P
L=0P
L=0
L=0
L=0
Legend: Tx = Treatment, BL = Bilateral, L = Left, R = Right, P = Pain, Flex = Flexion
Note: Thomas test had negative results each treatment, but pain was elicited
QL MMT: All graded 5 = Normal/100% “Complete range of motion against gravity with maximal resistance”
(Magee, 2006, p. 30)
QL MMT
(all grade 5 BL)
Table 3: Low Back Pain, Pre & Post Treatment Outcomes
Jan 14
Jan 18
Tx 1
Tx 2
Pre Tx
1.5 BL
1.5 L
Sphinx
Post Tx
0.5 BL
0.5 L
14
Jan 23
Tx 3
1R
Jan 28
Tx 4
2 R, 1 L
Jan 31
Tx 5
0.5 BL
0
0.5 R, 0 L
0 BL
Pre Tx
70° 2 BL
70° 2 L
70° 2 R
70° 2 R
70° 1 BL
Post Tx
Pre Tx
90° 0.5 BL
0P
80° 0.5 L
R Hip Flex = 2 L
L Hip Flex = 2 L
90° 1 BL
0P
90° 0.5 R
0P
90° 0.5 BL
0P
Post Tx
0P
Straight Leg Raise
Thomas test
(all Negative)
R Hip Flex = 0 P
0P
0P
0P
L Hip Flex = 0.5
Pre Tx
L=0
L=2
L=0
L=0
L=0
R = 0.5
R=0
R=1
R=1
R=0
QL MMT
(all grade 5 BL)
Post Tx
L=0
L=2
L=0
L=0
L=0
R=0
R=0
R=0
R=0
R=0
Legend: Tx = Treatment, BL = Bilateral, L = Left, R = Right, P = Pain, Flex = Flexion
Note: Thomas test had negative results each treatment, but pain was elicited
QL MMT: All graded 5 = Normal/100% “Complete range of motion against gravity with maximal resistance”
(Magee, 2006, p. 30)
Treatment Goals
Primary treatment goals were to decrease pain and hypertonicity in the lower right
abdomen, right anterior hips, and low back, specifically addressing Iliopsoas and
Quadratus Lumborum, using relaxing Swedish massage, deep stroking and point pressure
Petrissage, and Golgi Tendon Organ (GTO) release. The secondary goal was to decrease
patient’s intestinal aggravation from Crohn’s Disease.
Management Plan
The week prior to treatments, the patient tracked number of days and intensity of
low back pain, right abdominal and anterior hip pain, and intestinal aggravation. Intensity
was measured using the 6-point scale shown in Table 1. A total of 5 treatments were
performed after the initial assessment over the course of 2.5 weeks with patient tracking
pain and symptoms between treatments. Treatments entailed 1 hour of manual therapy
plus pre assessment and reassessment post treatment. Patient documented his symptoms
for a week following the last treatment. The same intern therapist performed all
treatments at the West Coast College of Massage Therapy Clinic in New Westminster.
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Hydrotherapy
Patient was instructed to apply a warm heat pad to his low back for 15 minutes
post treatment.
Therapeutic Exercise
Side bending stretch for QL and IP
Frequency: Three repetitions bilaterally, twice daily
Intensity: Tissue stretch felt without pain
Duration: Hold 30 seconds
Time: 2.5-week treatment period
Precautions
Therapist was careful to stay within patient’s pain tolerance, especially if patient
experienced recent exacerbations of symptoms. Hand placement was closely monitored
and direct pressure over the terminal ileum and cecum was always avoided.
Treatment
Treatment began in supine with a warm up to the abdomen including
diaphragmatic breathing and light, broad palmar stroking. The following Petrissage
routine was applied to both left and right sides of the abdomen, starting with the left:
picking up along sides of the abdomen, fingertip stroking, kneading, and point pressure
along the iliac crest and into iliac fossa with the Iliopsoas slackened by passive hip
flexion. Next patient was put in prone; the back was warmed up with diaphragmatic
breathing and longitudinal stroking, point pressure was applied to Psoas Majors, left side
first, by reaching across body and sinking fingertips into the muscle, using patient’s body
weight for pressure and depth. The same Petrissage routine was applied bilaterally to the
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low back and posterior iliac crests, starting with the less painful side. Deep point pressure
to the muscle belly of QL and GTO release at the transverse processes L1-4 while the
patient breathed deeply into abdomen. Treatment ended with clearing of long palmar
strokes compressing and lifting the low back muscles, then diaphragmatic breathing in
supine.
Results
Based on the collected data, the goal to decrease pain and hypertonicity of
Iliopsoas and the lower right abdominal quadrant were reached (see Figures 6-9). Upon
palpation over the 2.5 weeks, pain referral from the right Iliopsoas diminished and access
to the muscle within the iliac fossa became easier as treatments progressed. Prior to
treatment, pain was reported in the lower right quadrant 3 times per week and by the last
treatment and week to follow, pain was gone, regardless of an intestinal flare-up (see
Figure 1). The right low back pain proved to be the biggest challenge in improvement as
it dropped slightly with deep point pressure over the course of treatments, but remained
present throughout the following week. Left low back pain showed an increase at
treatment 2 because the patient fell two days prior while skiing. Yet, this left low back
pain was gone by treatment 4 and did not return in the week to follow (see Figures 1-5).
Patient’s intestinal aggravation was less frequent in the week post treatments (see Figure
1). Patient did not remember to do the provided stretch over the course of treatments.
Table 4: Days of Pain Report Pre, During, & Post Treatment
Low Back Pain
Right Ant. Abdominal & Hip Pain
# Days/7
# Days/7
Week Pre Tx
3
3
Tx Week 1
3
1
Tx Week 2
3
3
Tx Last 3 days
1
0
Week Post Tx
2
0
Legend: Tx = Treatment
Figure 1
Intestinal Aggravation
# Days/7
3
0
2
0
1
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Figure 2
Figure 2 Figure 2
Figure 4
Figure 3
Figure 5
18
Figure 6
Figure 7
Figure 8
Figure 9
19
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Discussion
Application of Swedish and Petrissage techniques plus GTO release decreased
hypertoned Iliopsoas, Quadratus Lumborum, and surrounding tissue tension, which
decreased pain from chronic postural compensations and myofascial adhesions. The
patient no longer felt pain in the lower right abdominal quadrant. This may have
influenced the patient’s reduction in intestinal aggravation the week following treatment;
however, this cannot be attributed as a result of massage therapy because lifestyle
variables were not controlled.
Although the patient’s low back pain, particularly on the right, decreased it
remained constant despite releasing surrounding musculature. This may be attributed to
structural scoliosis or possible arthritis or inflammation within the lumbar spine. The
constant pain felt at 70-90° with the Bilateral Straight Leg Raise indicates a lesion or
stress in the lumbar spine (Magee, 2006). Medical Imaging and MD diagnosis is needed
to determine these speculations. Re-observation of pelvic alignment following the last
treatment would have helped determine whether low back pain is a structural issue.
As for this study’s process, since it strongly focused on both IP and QL, Manual
Muscle Testing IP should have been included as an assessment tool. Directly addressing
the patient’s scar tissue through myofascial release or colon by visceral manipulation may
have specifically lessened patient’s intestinal flare-ups. Although the patient did not do
assigned homecare, solely stretching IP and QL may have provided relief and proper
realignment of loosened muscle fibres, but patient education and a designed routine to
improve posture and core strength would most likely provide more long-term
enhancement.
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Future studies should include a patient without diagnosed structural
misalignments to gain better specific results relating to involved musculature. Controlling
participant’s diet, sleep patterns, exercise, and activities would provide greater efficacy of
massage therapy treatments. Finally, a longer, more consistent treatment period would
most likely lead to better results.
Conclusion
Due to the unpredictable, intermittent attacks of Crohn’s Disease, effective
treatment and management of symptoms is difficult and varies among patients. Since
patients’ symptoms often result from emotional stressors (Damjanov, 2006), the growing
use of alternative relaxation treatments like massage therapy is a successful management
tool (Burgmann et al., 2004). The anatomically close relationship between the large
intestine and deep trunk muscles such as Iliopsoas and Quadratus Lumborum suggests
tension in one structure consequently causes tension in another, worsening the abdominal
and back pain associated with CD. This study shows that by decreasing muscle tension
around the colon, relieving chronic pain is possible, especially in the lower right
abdomen. Despite these findings, more research is needed to better isolate the
relationship between a diseased colon and manual therapy to adjacent trunk musculature.
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Walach, H., Guthlin, C., & Konig, M. (2003). Efficacy of Massage Therapy in Chronic
Pain: A Pragmatic Randomized Trial. The Journal of Alternative and
Complementary Medicine, 9(6), 837-846. Retrieved from:
24
Appendix A
Anterior view QL and IP
Posterior view QL
Retrieved from http://fitnesstrainingdownloads.com
(Gray, 1918). Retrieved from http://weeklymuscles.blogspot.ca/
Colon
(Gray, 1918). Retrieved from http://www.bartleby.com/107/180.html
25

Melina Lake - Registered Massage Therapists` Association of British

Transcription

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