Bowen Technique: Case Studies 1 – 6
Bowen Technique – A Dozen Case Studies – Part 1
The following text details the first half dozen case studies that I hope will be of interest to therapists who are using the ‘textbook approach’ to Bowen Therapy. I have selected cases that illustrate the holistic nature of therapy and I have also tried to include cases where significant pathology has been identified. All cases relate to consultations at my clinic in 2013 through 2014. I am happy to discuss these cases if you are interested.
Case 1 – Chronic pain and numbness in the thigh, lower leg and foot associated with disc injury:
Four weeks ago I had a frail ‘elderly’ lady (78 y.o.) present with constant ‘sciatic pain’ in her left leg as well as large regions of numbness on her thigh, lower leg and foot. She’d had these symptoms for 3 months and had just been told by her GP that she needed to be referred to surgeon because a recent MRI had revealed multiple disc bulges that were clearly contacting the exiting nerve roots at L4 and L5. She had kept her appointment with me because she didn’t want to have surgery and she hoped I could help. She had brought the MRI report with her.
I was very reluctant to say that I could help but I did agree to give her two treatments a week apart to see if it would offer any relief. I explained the disc pathology outlined on the MRI report and why it was ‘very serious’ and suggested that I too thought she would most likely be having a chat with the surgeon in the near future…
Assessment revealed a very short left leg which almost corrected when she turned her head to the right. I was encouraged by that, because I could see there was an important correction to be made in her neck. I rushed through the lower and upper back procedures and released the piriformis on the right side and then asked her to turn over (this all took about three minutes because I didn’t bother with any ‘waits’ – I was keen to find her neck issue).
During the Neck Procedure I found significant tension on the right side of her neck, especially around C1-2 area. I waited 2 minutes and found it still tight, so I went to the right TMJ (lateral pterygoid muscle) and found it extremely tender. The left side was fine so I explained I wanted to get this area right and I would be focussing on her jaw for a while and that I was sorry it was so painful. She replied, “it’s been giving me some bother for a few months but I thought it was ‘from tension’, because I’m in so much pain with my leg”.
After a five minute wait I repeated it (the TMJ procedure) and found symmetry had returned (the leg lengths had become equal), so I told her to come back in a week. To her credit, she asked me “are you suggesting that treating my jaw will somehow help the discs in my lower back?” I smiled a cheeky smile and nodded. I said, “we’re not interested in the discs in your lower back because we can’t change them. I’m interested in the function of the nerve passing right next to it – and yes, I expect this work on your jaw just might help. We’ll see in a week!” I think she left with some understanding of what I was hoping for.
One week later she reported 50% improvement in the pain and some small improvement in the numbness – so I was very pleased. I repeated the treatment because the assessment was the same. The jaw was tender but nowhere near as tender as before. Again, I told her to come back in a week.
She returned the following week and reported further improvement, so I moved her to ‘fortnightly’. In the mean time, she had booked about ten people in for treatment! This morning I was treating her 82 y.o. husband and she was sitting in the room. She reported no pain at all, and only the smallest patches of numbness. She has been riding her bike all week and now wanted to ask me about whether she should cancel the appointment she had made with the surgeon. My cheeky reply was, “who told you that you needed to see a surgeon? Yes, I think you should cancel the appointment!” She asked if this meant her discs had healed. I said, “I bet if we did an MRI again today, those discs would look exactly like they did on the last one…”
Comment: I have been thinking about the 78 y.o. lady throughout the day and odd thoughts have been forming in my mind. The immediate temptation is to suggest that, since the patient’s symptoms were the result of nerve impingement resulting from ‘identified’ localised bulging discs, somehow the treatment I gave her affected the disc bulges such that they were reduced in size or changed in some way but I would tend to reject this notion.
If we consider the disc bulge to remain a fixed, ‘structural’ issue that hasn’t changed in response to the treatment (and perhaps we can debate this issue at another point in time) then we must look for another explanation of why the subject’s symptoms (of leg pain and numbness) resolved so completely following a release of the tension in the right lateral pterygoid muscle.
Obviously, we could reason that the disc bulge was incorrectly identified as being involved in the patient’s pathology, but the MRI evidence correlates with the symptom picture and this makes for a very strong argument. I accept her symptom presentation was absolutely associated with the pathological ‘contact’ made between the disc bulge and the exiting nerve root.
Odd thoughts…I have been wondering if the change in dural tone, created by the treatment, was enough to take the irritation out of the nerve (despite its location immediately contacting the bulging disc). I have been imagining a garden hose going around the corner of a house. If the hose was ‘pulled tight’, it would be pulled against the corner of the house and this might cause the flow in the hose to become impaired. Accordingly, if the hose was ‘loosened off’ it might still contact the corner but its flow would not be affected. We might try to loosen it off by ‘freeing it up’ back at the tap.
To me, this is an exciting analogy! (Maybe you have all been thinking this already and I’ve only just caught on! ). I am thinking of the disc bulge as ‘a corner’ of sorts and the irritation of the dura mater as the equivalent of ‘pulling the hose tight’.
Those who have read the TMJ Procedure Discussion in my book will be aware that this move is much different to the TMJ release that is taught by most Bowen schools. The lateral pterygoid muscle attaches to the sphenoid bone. The sphenoid is in contact with all other cranial bones and is perfectly positioned to affect the dura mater. This means the lateral pterygoid is a very important key to unlocking dural tension (Bowen was particularly interested in the sites of dural attachment).
I suggest the ‘release’ of the lateral pterygoid allowed the sphenoid to ‘correct’. Following this correction, the dura mater is no longer irritated and so the dural tension that was previously generated begins to dissipate. Over time, the irritation disappears completely (as with all good healing) so that the ‘wrapping’ (the dura) around the exiting nerve roots at L4-5 ‘loosens’.
As per the garden hose analogy, the nerve function at this point is restored and the patient’s symptoms abate, even though the disc bulge remains unaltered by these events (in much the same way as the corner of the house doesn’t change in the analogy above).
The significance here may be that the therapist really needs to locate the site where the dura mater (the hose) is being ‘pulled’ and not worry so much about the lack of flow (the pain and numbness) or the contact point at ‘the corner’ (the disc bulge). In this lady’s case, the SMS was the lateral pterygoid muscle on the right side of her face! Think how exciting this is!!! In so many cases the real problem is a long way from the apparent site of the problem. The spine is an integrated, interrelated, whole unit… It’s time we, as holistic therapists, started seeing it that way!
In conclusion, I think disc injury is one area where Bowen generally does not enjoy good levels of therapeutic effect….But I have had a good number of cases where it has helped heaps – I’m certain the key lies in finding the SMS and clearing it.
Case 2 – Pain and swelling of the knee:
Two weeks ago a 71 y.o. female patient presented to the clinic complaining of pain and swelling in her right knee mostly around the head of the right fibula. She had been experiencing significant pain for about 6 weeks though she could not recall any trauma associated with the onset. She reported that she had been seeing another therapist for a few weeks without relief.
Upon assessment I found her right leg appeared about an inch longer than the left. I also noted that these asymmetrical leg lengths actually corrected when she turned her head to the left side. I commenced the treatment with the ‘Lower Back’ and ‘Upper Back’ Procedures and observed lots of sensitivity to the moves performed on her right leg. She had high levels of tension in the muscles on her left side.
I explained to her that I would be able to help her if I could succeed in restoring function to an ‘issue’ that was affecting her neck. This seemed to confuse the patient as she twice reminded me that she was here for a KNEE problem.
When she turned over I began the Neck Procedure and noted the paraspinal tissue on the right side resembled ‘a steel rod’ from C1 – C6. When I tried to move it with Move 6 of the neck Procedure, it would hardly move at all! I just had to be satisfied with moving a few fibres on the lateral edge of the muscle. Not only was it difficult to get it to move, moving it was also quite uncomfortable for the patient. Immediately following the move in her neck however, I noticed her leg length symmetry improved significantly. I explained and justified again why I was treating her neck and reassured her that this was the way to correct the knee pain. To her credit she allowed me to move it again a few minutes later but again, it was uncomfortable. I concluded the treatment with a shortened version of the Knee Procedure.
Last week she returned for the follow up and complained her knee was worse. She was displeased and a little annoyed and asked me if I would work more on her knee this time! Upon assessment I found the same presentation as the previous week. I followed the same procedures and when I got to her neck I felt I had to ask her if it was OK for me to treat her neck again and I told her that if it didn’t help this time then I would refer her to someone else! On making Move 6 of the Neck Procedure, I found the tissue to be very tight but significantly better than the previous week. The steel rod seemed shorter – it only spanned C2 – C4 and was not as tense. It moved well, although it was still a little painful for her. The leg lengths corrected after that move and then I did a few moves on the knee to make her happy.
She returned today and reported a 95%+ improvement. The swelling had resolved and there had been no pain for the last 5 days. She was delighted! I followed the same protocol but when I assessed her, her leg lengths demonstrated pure symmetry. Everywhere I moved, it was soft and she experienced no discomfort at all. When I rechecked the right side of her neck it was like she had bought a new one!
Comment: An interesting case… Right-sided knee pain resolved following the correction of a sustaining muscle spasm in the neck. It is also interesting because the patient was not enthused about me following this approach because it wasn’t symptomatic enough. Fixing her was straight forward – managing her was hard!
Case 3 – Chronic lower back pain:
Another interesting case: A 54 yo woman presented to the clinic complaining of ongoing lower back pain (right side around L4 – S1). After prolonged discussion concerning her mattress I was able to convince her that it would be worth trying Bowen therapy.
I began with LB Moves 1 & 2 and noted the elevated tension in the paraspinal tissue on the right side. Upon initial assessment she demonstrated a short left leg and a positive Derifield sign. I completed the LBP and performed a left Piriformis release and reassessed – she now demonstrated a short right leg (obviously I was pleased to see the case conform to a regular dysfunction). I carried out a Cervical Turn Test and noted the asymmetry cleared when her head was turned to the left.
I explained that I had discovered she had a neck problem and I asked if she was aware of any issue in her neck – She was not! I completed the UBP noting significant tension on the left levator scapula and then had her turn over. Sure enough, the right leg was still short with her lying supine.
I tried to perform the neck moves but the left side was very tense and painful to move and the right side simply wouldn’t move. I left the room and returned and we joked about the fact that I was right and she now understood that she did have a significant neck problem. I repeated the moves but there was little change in the tension state. Naturally, I went to the pterygoid muscle. I did my version of the TMJ Procedure and I knew immediately she was ‘affected’ by the release and so I left the room again. When I returned three minutes later I found her crying profusely (actually sobbing).
I noted the correction of her leg length and asked her if she was OK? She replied, “You’ve fixed my jaw”.
She went on to explain that 8 months ago she had surgery to remove a tumour in her throat followed by a course of radiation and ever since then she had had constant stiffness and pain in her jaw and also in the left side of her tongue which she thought was scar tissue etc.
She said she had tried to open her mouth after I left the room and her jaw ‘moved’. She felt a big movement and a deep release in her throat and tongue. She left saying her tongue and jaw were pain free and ‘not stiff’ for the first time since her surgery. She returned a week later and reported significant improvement in her back pain.
Comment: There is much we could say about this case. The emotional release is worthy of comment but I will leave that for the contemplation of the reader. When I encounter recalcitrant neck spasm I nearly always find the TMJ work is sufficient to act as the catalyst for change. In clinic, I find the paraspinal tension in the area of C2 to be an excellent indicator of pterygoid spasm – the tight side is also the side of the tight pterygoid.
Case 4 – Acute hip pain referring down the right leg:
A 25 y.o. professional jockey presented to the clinic complaining of two weeks of pain in the right hip that was referring at times into the lateral aspect of his upper thigh. Assessment demonstrated a short right leg (about 12mm difference). Screening procedures were unremarkable (negative).
After running through the Lower and Upper Back Procedures I assessed the tension in the paraspinal muscles from the first to the third lumbar vertebra – those on the left were extremely tense and tender to touch compared to those on the right.
Using the Kidney Procedure I moved laterally and superiorly over the erector spinae on the left side, once at the level of L-2 and again at the level of L-1. The moves were a little uncomfortable for the patient but the leg lengths corrected immediately. After a five minute wait I repeated the procedure noting significant relaxation in the area where the moves were made.
The patient returned a week later and reported at least 60% improvement. On assessment, the right leg was about 5mm shorter than the left and I repeated the procedure from the previous week. Again, the left paraspinal area was tense and tender though not as much as the previous week. Assuming improvement was likely, the patient was asked to return in two weeks.
The patient returned two weeks later and reported that he had been symptom free for the last 10 days. Assessment revealed symmetry of leg length as well as paraspinal tension in the area around L-1 to L-3. I asked him to return when he felt the need.
Comment: A fairly straight-forward case. I consider the name ‘the Kidney Procedure’ is somewhat of a misnomer – it is really a psoas release but because the moves are made to the tissue over the kidney, Mr Bowen called it the Kidney Procedure (it’s as simple as that!). The ‘tight’ psoas is nearly always (95% of the time) on the side opposite the short leg.
Case 5 – Chronic pain associated with Scheuermann’s Disease and multi-level disc injury:
An interesting case involving multi level disc bulges as well as Scheuermann’s disease …
Peter is 50 y.o. dairy farmer who presented to the clinic seven weeks ago complaining of severe pain in his middle back. He has had the pain for 3 years and had been forced to sell his farm. He was unable to work and was on high dose anti-inflammatory medicines as well as analgesics. The pain was fairly constant, usually around 7 or 8 out of 10 in severity, and located along the spine and the right paraspinal muscles but it also referred laterally into his right rib cage. He brought along his recent MRI report which revealed Scheuermann’s disease of the mid to lower thoracic spine (the vertebral bodies have developed to be ‘wedge-like’ in shape).
The MRI also showed multiple disc bulges at the level of T6-7, T7-8, T8-9 and T9-10. Two of these disc bulges making contact with the spinal cord.
Needless to say he was very tender to touch, and his thoracic spine felt (to me) like it was fused together. There was one important part of the history that gave me great encouragement however – he told me that every four or five weeks he would have a day or two where his pain levels dropped to around 2 out of 10.
I did the LBP and the UBP as gently as I could because of the pain but in addition to the spasm and tension throughout the thoracic region, I noticed he was showing a considerably short left leg. There was no change to this in response to the screening procedures I use, so I suspected he might have a psoas issue (Dairy farmers are always bending over and leaning under the cows to reach up and put on the milking cups).
I challenged the right psoas muscle with a lateral move over the paraspinal muscles at the T11-12 area (some of you will know this as the Kidney Procedure) and then reassessed his leg length. The legs became ‘nearly equal’ following the challenge. I repeated the upper back work and then released the tender right psoas (for the record, the affected psoas is nearly always on the opposite side to the short leg). After the psoas release, he said he could feel everything getting looser and he walked out looking a lot more comfortable than when he’d arrived.
The following week he reported great improvement. He had experienced a pain level of 2 out of ten since he had left the clinic last time and noted the referred pain (into his rib cage) had cleared. I repeated the same treatment because the indications were similar. He felt lots looser to me and he commented on how little discomfort there was from the treatment this week compared to last.
On Thursday just gone, I gave him his fifth treatment (He had three a week apart and now we treat him fortnightly). He says he can’t believe how much better he feels. Between treatments his pain levels stay around 1 out of ten and his doctor has reduced his medications (according to the patient, his doctor is going to come and see me). Another surprising thing is that he has been undertaking lots more activity, including re-painting some of the rooms in his home. He told me he can’t believe it because the specialist medical opinion was that the presence of multiple level disc bulges meant he would always have to live with the pain.
Comment: At the outset, after reading the MRI report and taking the history, I must admit I wasn’t confident with regard to the potential for a great outcome in this case. It just goes to show, the right move in the right place can make a world of difference to somebody’s life.
Case 6 – Chronic shoulder pain associated with extensive pathology detailed by ultrasound:
An irritable 66 y.o. female patient presented 14 days ago complaining of severe pain around the insertion of the right deltoid. A few questions revealed she had been putting up with pain in the right shoulder region for nearly 12 months. The shoulder was severely restricted and it was not possible to move the elbow away from her body more than 10 cm.
Initial assessment revealed a short right leg which corrected when she turned her head to one side. I treated her with the Upper Back, Neck and TMJ Procedure. I commented on how tight the neck was on the right side and focussed the treatment upon these tissues. I was unable to do the shoulder procedure but I did release the right infraspinatus.
She came back a week later, quite annoyed that she had actually gotten worse on the day after the treatment. And she had been ‘worse’ for three or four days. I repeated the treatment and noted significant improvement. I asked if she was feeling better ‘in the last few days’ and she reluctantly conceded she was. She could raise her arm to the position which allowed me to do the shoulder procedure.
Today she returned, two weeks after the first treatment and reported she felt really good. She had had no more pain and range of movement was great and her neck and TMJ had become ‘normal’. She was holding a piece of paper which turned out to be an ultrasound report (Her doctor had organised the ultrasound just before she came to see me – the ultrasound was performed five days ago). She had been back to the GP prior to seeing me this morning and had just obtained a copy of the report.
The report states: A 10mm x 8mm partial-thickness tear is seen in the right subscapularis tendon about 9mm from the biceps tendon. In addition there is a 7mm calcific focus in the subscapularis tendon. There is also a full-thickness 12mm x 4mm tear in the supraspinatus tendon as well as additional calcific changes. The subacromial subdeltoid bursa is distended.
Comment: This case shows that Bowen therapy has restored function to her neck and shoulder whilst resolving the chronic pain and restriction that she was experiencing. The extensive pathology is still present and fully detailed yet it is no longer causing her any dysfunction. Remarkable!