Monday, June 17, 2019

Complex Conditions Does Not Mean Complex Treatment


As a student, I had the opportunity to complete a case study with a client who was living with Multiple Sclerosis.

Multiple Sclerosis (MS) is a chronic, inflammatory disease in which the immune system causes demyelination of nerves within the central nervous system. According to the World Health Organization and Statistics Canada, Canada has one of the highest rates of MS in the world: 2.9% of the population is affected. Fatigue, pain, weakness, spasticity, and paresthesia are common symptoms associated with MS.

This was really exciting for me, it was very difficult, in our student clinic or outreach settings, to have continuity of care with a client. To work with an individual every week, over three months, and observe the effect I was having, seemed like a great opportunity.

It also made me nervous.

I was only a student, not only that, I hadn’t received any advanced training at the time – no advanced techniques, remedial exercise, or homecare planning.  I asked my instructors to teach me some advanced techniques that would allow me to address the specific nature of the client’s diagnosis but was encouraged to proceed with what I considered to be a limited skill set. I lacked the confidence that I could make a difference.

I was not convinced but thought it was a good learning opportunity and, so, proceeded.

Help The Person, Improve A Condition

The client I worked with was in her 40’s, a mother of four. She had been diagnosed with MS 20 years prior but it had little effect on her life until the previous few years when she began to experience symptoms of drop foot. She started catching her toes on the stair lip and, by the time I saw her, she was using a walker. She had begun to make decisions that kept her from participating in her normal activities of daily living: driving, walking in winter, and trips with her kids.

At the outset, I had some challenges. I had only fundamental skills as a Massage Therapist and limited experience. The nature of a case study means it is limited in time and scope. Yet the condition itself is quite complex and can present many different symptoms. I took a very straightforward approach to tackle these challenges: listen, focus, and keep it simple.

I interviewed the client prior to starting the case study – partly to establish a baseline but mostly to understand what she wanted to address. Listening to her whole story provided context and direction for the treatment. It helped me understand what aspects of the condition were most affecting her life. Together, we identified what to ‘tackle’. 

It was important that was something measurable – not just because I was doing a case study but because the client wanted to understand the cause and effect of her efforts. Because of my limitations, keeping the protocol simple was necessary but it also turned out to be effective. The protocol used basic techniques like petrissage, tapotement, and stroking but it was applied consistently and regularly.

In retrospect, there were other aspects may have influenced the results. In choosing to participate, the client likely already felt hopeful and empowered, the regular break for self-care alone would be a change from her regular routine. Further, it provided an opportunity to get out of the house at a time when that was not easy for her. All of these aspects lie outside our treatment yet can have a significant impact on the outcomes.

Over the course of treatment, the results varied. The intervention used was a standardized massage therapy treatment approximately once a week for 12 treatments. The patient was assessed using the Multiple Sclerosis Quality of Life Inventory (MSQLI) (for the quality of life issues such as fatigue and pain) and measurement of dorsiflexion (as an indication of the degree of severity of drop foot).

The MSQLI is a comprehensive questionnaire that has been developed specifically for patients with MS and subdivided to include: health status, fatigue, pain, sexual satisfaction, bladder control, bowel control, visual impairment, perceived deficits, mental health, and social support. This self-administered survey takes approximately 45 minutes to complete. The raw scores of each section of the survey are scored, according to MSQLI instructions to determine the final representation of data. This case study, based on the patient interview, paid particular attention to Health Status, Modified Fatigue Impact Scale, and Perceived Deficits.

Most of the client’s symptoms improved steadily with a significant improvement in Perceived Deficits, meaning, the client felt she was developing the skills to cope with her symptoms. However, on three occasions, the ability to dorsiflex declined. 

Alarmingly, there were some new symptoms presenting at some points. Just past the halfway point of the treatment the client experienced the ‘worst spasticity of her life’. This was an extremely challenging point in the treatment.

Should I stop? Should I alter the protocol? Because of the random nature of Multiple Sclerosis, it was very difficult to determine how to proceed. On direction from the client, and with input from advisors, we continued. The overall result was positive, the client started with dorsiflexion of 2mm and, after 12 weeks, could dorsiflex 47mm. For her, it meant the difference between tripping and not tripping during her normal daily activities. Although she was not ready to return to driving, she had the confidence to attend a school trip to a museum with her children and successfully navigate the day with the use of a cane.

The important lesson for me was that a complex condition does not require a complex solution. Instead of employing advanced modalities or techniques, I listened, focused, and kept things simple by sticking to the basic principles of massage.

You can download the case study HERE if you’d like to learn more.


from Beauty Salon, Spa, Massage

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