Bowen Technique: Case Studies 7 – 12
Bowen Technique – A Dozen Case Studies – Part 2
The following text details the second half of a 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 – 2014. I am happy to discuss these cases if you are interested.
Case 7 – Neck pain and headaches associated with coccyx dysfunction:
Kim presented to the clinic complaining of chronic ongoing neck pain and stiffness that had been getting worse over a period of a few years. She reported that now she often woke with a headache and that she had found little relief from various forms of remedial therapy.
Assessment showed a short left leg (about 14mm) which did not change during the screening procedures. I performed the Lower Back and Upper Back Procedures and then used the Mid Back Procedure to assess the paraspinal muscles in the region over the kidney – there was no great difference.
I locked the left leg and made gentle contact with the lateral margin of the coccyx at its junction with the sacrum. The patient immediately complained that my gentle contact was quite painful. I explained why I wanted to conduct the coccyx procedure and she suggested I just go ahead and do what I needed to. I completed a gentle left-sided coccyx procedure and as I lowered her leg back to the table, she reported that the pain, which was quite strong initially, had transformed into a “tingling and warm feeling”. I left her to contemplate the response and when I returned five minutes later she said the feeling had passed. I noted the leg lengths were now perfectly equal.
I had the patient turn over and I completed the Neck Procedure. I noticed her neck was nowhere near as tight as I had expected it would be. I asked her to return in a week.
She returned one week later and reported that she felt significantly better. Again she demonstrated a short left leg (but only about 6mm). I repeated the coccyx procedure and she told me it was still a little painful. The leg length corrected immediately.
She returned for a follow up appointment a week later and her leg lengths were equal. She reported that she had not experienced any headaches or neck pain during the last week and that she felt minor stiffness was the only symptom still remaining.
She returned two weeks later (four weeks since her initial presentation) reporting no symptoms at all and she even declared her neck was “feeling normal”.
Comment: The filum terminale anchors the dura mater at the coccyx making it one of the most significant sites of dural attachment. Coccyx dysfunction can lead to migraines, headaches, pain and stiffness of the neck and occipital region. The Lovett brother paired structure for the coccyx is the sphenoid bone.
Case 8 – Right hip pain associated with left piriformis spasm:
John is a 38 year old farmer who presented to the clinic with pain in his right hip. History reveals the pain to be present for more than 18 months although it improves at times and aggravates at others. He finds it gets worse if he walks long distances.
Assessment reveals a short left leg (a visual difference in excess of 1 cm) which does not change when the head is turned from side to side. It does however, cross over and become the long leg when the knees are flexed – indicating dysfunction of the left Sacro-iliac joint.
After completing the Lower Back Procedure (Moves 1 & 2 revealed heightened tension on the left side) I performed the piriformis procedure (also on the left side) which the patient found to be quite uncomfortable. I noted the left leg immediately ‘dropped’ down to be symmetrical with the right. I repeated the procedure 5 minutes later and noted the move was still quite painful for the patient. A few minutes later I checked the leg lengths finding them to be equal. Furthermore, upon knee flexion there was no change to this state of symmetry.
I treated the patient three times over the next four weeks and the tenderness of the left piriformis muscle completely resolved. The patient report improvement with regard to the right hip pain at the first follow-up and he has continued to improve over time. He no longer experiences hip pain.
Comment: In clinic, I have noted a repeating pattern in which the hip or the knee, on the long leg side, suffers from inflammation. When I find the joint inflammation is on the long leg side I simply correct whatever issue is sustaining the short leg and this seems extremely effective in correcting the patient’s symptomatology.
Case 9 – Adductor spasm associated with knee pain and swelling:
Keira is 12 years old and has been suffering from recurrent idiopathic swelling and pain of the left knee which is worse following sport (she plays netball). This problem has been happening for two months and has not responded to physiotherapy.
Assessment revealed a short right leg – I was happy to see this since it was what I expected (see comment at the end of Case 8). Screening procedures were unremarkable. I treated her with the Lower back and Upper Back Procedures, Piriformis on the short leg side and the Psoas Procedure on the side opposite the short leg – none of these made any change to the asymmetry. I decided to check the coccyx but that too proved unremarkable. I had the patient turn over.
I checked her neck (no problem there) and I gently treated her knees. The right leg remained short. I explained to Keira (and her Dad who was also present) that I suspected her adductor could be the problem and asked if it was OK for me to use the Pelvic Procedure. The left adductor was fine but the right adductor was very tight and certainly very uncomfortable when I moved it. I noted the leg lengths had immediately corrected. I repeated the right adductor move once more about five minutes later and then asked her to come back in a week.
The next week she reported she was much better. We repeated the Lower Back, Upper Back and Pelvic Procedures and found the right adductor to be less uncomfortable than before.
She came in for another follow-up three weeks later and reported she had not experienced any further swelling or pain of her knee. Since she presented with no sign of asymmetry I told her she needn’t return until she gets a new problem.
Case 10 – Chronic sciatic pain associated with cervical and cranial dysfunction:
Jennie is a 72 year old lady who presented to the clinic on the 3rd February complaining of multiple issues associated with her lower back and legs. She complained of progressive bilateral leg pain which extended through both iliotibial bands and prevented her from walking up stairs. She also complained of left-sided sciatic pain which extended from the left sacro-iliac joint to the lower part of the left leg. This pain could vary over time from ‘quite mild’ to ‘severe’. She had been experiencing this sciatic pain for about 6 months.
Finally, Jennie described a condition of ‘restless legs’ which bothered her during the night and forced her to get up and move around.
She provided a report of a CT Scan that had been performed two weeks earlier which concluded: “There is marked disc degenerative change demonstrated at L4-5 and L5-S1. Also present is a small broad based left-sided posterio-lateral L4-5 disc bulge contacting the L5 nerve root”.
In addition, the CT report noted the presence of osteophytes as well as moderate osteoarthritis of the apophyseal joints through sections of the lumbar spine.
Assessment: I assessed Jennie and found that she demonstrated a ‘double cervical turn test’. That is to say, with her head turned one way, her right leg was short but when she turned her head to the other side, her left leg became short. I knew from this that her main issue was high up in her neck and cranial region.
As I conducted the treatment I could feel so much tension though out the paraspinal tissue at various levels. I performed the Lower Back and Upper Back Procedures and had her turn over. I explained that I thought her main issue was in her neck and I found she was polite enough to humour me. The right side of her neck was very tense and really difficult to move. I also completed the TMJ Procedure (the Textbook version) which addresses dysfunction associated with the sphenoid and cranial bones. I repeated the neck and TMJ work a few times over 10 – 15 minutes and then finished with the Pelvic Procedure, noting great tension through the right adductor.
Jennie returned the following week reporting no change at all. Assessment revealed the same situation as the week prior and I simply repeated the treatment. I noted the tension on the right side of her neck has reduced somewhat so I felt encouraged. I asked her to persist and give me a chance as I thought I really could help her.
When she returned the next week she reported she had not had any of the sciatic pain at all, and that the other symptoms might have improved a little. Assessment showed just a short left leg with no change upon screening. I ran through a basic treatment, checking her neck (which was a lot better) and releasing the right psoas. The release of the right psoas resulted in her legs returning to a state of symmetry.
The third week was also a good one and I repeated the treatment of the week before in accordance with a similar presentation. Her fifth visit marked the fourth week of our journey and it appeared the wheels had well and truly fallen off! She had felt so good she had decided to do some gardening and the following day she felt worse than she had in months. She not only had the sciatic nerve pain back (with interest) she also had a pain radiating from her neck into and down her right arm. Assessment showed a positive cervical turn test and I reassured her it would be easy to get her back on track.
I simply treated the Lower Back, Upper Back and Neck and then the TMJ. I noticed the neck spasm released quickly and she left feeling much improved.
She returned the next week saying she was ‘the best been in a very long time’. She had experienced immediate relief and had continued to improve throughout the week. The best bit was, her neck felt great to me…nice, soft, relaxed paraspinals, all happy to move anywhere I wanted!
Although she continued to return on a weekly basis for the next four weeks, the treatments were very minimal and simply encouraged the maintenance of the recovery process. It seemed the hard work was already done. I saw her yesterday (she is having fortnightly treatment now and will move to monthly soon) and noted it was ten weeks since she had initially presented for treatment. She feels terrific and stated that all the leg and lower back pains seem to have fully resolved – the only problem she has now is a very mild condition of restless legs at night.
Comment: This case is very similar to Case 1 except the symptomatology was more varied. If you haven’t read the comment following Case 1, please do so. I often find a patient aggravates and then makes a very nice recovery. In some ways, this seems to validate the old phrase, “you need to get worse before you get better”. I find that when a chronic condition responds well initially, any setbacks along the way usually respond well to treatment and these also seem to help in the overall recovery process.
Case 11 – Carpal tunnel syndrome with Neck and TMJ involvement:
Angela is 49 years old. She presented to the clinic seeking some relief to her chronic carpal tunnel syndrome. History detailed frequent numbness, weakness and pain in the right hand that occasionally extended to the forearm (both the flexors and the extensors). Assessment revealed a short right leg which corrected on cervical rotation.
I completed the Lower Back and Upper Back Procedures and turned the patient. I was keen to palpate the tissues in her neck and I did so using the Neck Procedure. The paraspinal tissue on the right side of her neck (at the level of Move 6) was very tense and it refused to be moved at all!
I told the patient that I didn’t think she had carpal tunnel syndrome. I thought her symptoms had their origin in her neck and that improvement would come but it would be slow since the spasm in her neck was both chronic and severe. She told me she ‘knew’ she had neck problems and that she was having an MRI Scan on her neck in the very near future. She had thought the Carpal Tunnel issue was a separate problem. She went quiet for a few minutes and then said, “When the ache in my hand spreads to the arm, sometimes it spreads up to the shoulder and then my neck feels even tighter… Do you think you can help?”
I asked her to try a few treatments and see. I added the TMJ Procedure and repeated both the Neck and TMJ Procedures a few times before completing the treatment with the Shoulder Procedure and a few moves over the forearm flexors and extensors.
Over the next few weeks I treated her weekly and she reported symptomatic improvement after each treatment. I was completely focussed on her neck and I was certainly making progress, albeit slow. On the forth visit she produced a report detailing the findings of the MRI. It read, “Note is made of C5-6 and C6-7 degenerative change and whilst there is foraminal encroachment, there is no convincing neural compression at the level of C5/6. There is encroachment of the right C7 nerve”.
After the fifth treatment I moved her to fortnightly visits and she continued to enjoy improvement. On her seventh visit I completed the neck procedure and laughed. I was so pleased with the change that I could feel in her neck and I told her she would soon be ‘symptom free’. She replied with the following comment: “I’m 99% symptom free now and I’m absolutely delighted”. She is no longer suffering any neck pain or stiffness and her hand and arm are fine. I continue to treat her on a monthly basis and so far, assessment shows tonal symmetry.
Comment: This case serves as another example of chronic dysfunction resolving slowly over multiple treatments over a period of time. On palpation, I can feel her neck has physically changed so much. The MRI showed right C7 nerve encroachment yet she is now symptom free. I can’t help wondering what another MRI would show if it was taken now…
Case 12 – Chronic tennis elbow:
Michael was referred to our centre by a case manager at a local rehab centre. The referral read, “Michael is a 57 year old gentleman who was involved in a truck accident four years ago and it has left him with persistent pain in his left elbow (epicondylitis). He is also reporting neck and shoulder involvement.”
I was informed that the rehab service provider would pay for five sessions if I thought we could help.
Michael sat in the chair prior to the first treatment and he seemed very depressed and quite pessimistic about our chances of helping him. When I asked why that was so, he told me that he had been treated by so many people for his tennis elbow and all that ever happened was that it got ‘much worse’ after any treatment (I bet a few of you can already see where this is going).
I asked him to lie on the table so I could assess him. Michael was a mess! His muscles were as tense as they could be and he flinched at every contact. With his head straight he showed a short left leg (12mm). When he turned to the left the leg length discrepancy remained unchanged but when he turned his head to the right, the right leg showed shorter (10mm). I made a note on the treatment record of a ‘double’ Cervical Turn Test and made a mental note to address the sphenoid dysfunction.
I moved gently through the Lower and Upper Back Procedures and released the left infraspinatus. As I was doing this, I informed Michael that I would NOT be touching his arm today as I didn’t want to cause him the ‘usual’ reaction. I told him he had serious dysfunction in his neck and that I would focus on that. He told me he had serious dysfunction EVERYWHERE so I could start anywhere I liked!
His Neck was in spasm and his pterygoid and temporalis were incredibly tender to move but I noted that his leg length did correct following the TMJ work.
The following week Michael returned and reported that although he had been very sore after the treatment, he had felt considerable improvement.
His neck certainly felt much looser and I was able to effect much better TMJ moves. I worked with Michael on a weekly basis for five weeks and through this time he experienced many headaches and much aggravation of the pain in his arm (although I never actually treated his arm). On the fifth visit he told me he felt lots better ‘overall’ and that he believed the treatments were helping him significantly. I had contacted his doctor and found that no MRI or CT scan had been performed following the accident, so I urged the doctor to investigate as I was certain there must be significant disc pathology associated with Michael’s elbow symptomatology.
Sometimes in practice, the lines can become a little blurry. The rehab provider was not prepared to fund further treatment for Michael and he had not been able to work for the last 4 years. He lived in a town that was 100km from my clinic and was trying to survive on a very small pension. I made a deal with him that, if he came fortnightly for the next three months, I would only charge him half price for the treatment – He was happy to comply. In the mean time, his doctor organised a CT Scan which revealed “moderate bilateral exit foramina stenosis of C5/6 and C6/7 along with moderate degenerative change of the mid to lower cervical spine”.
Over the next few months he continued to improve. He was also able to reduce the pain medications he was taking by 75% and enjoy a much better quality of life. I urged him to continue to invest in the treatments we were giving him as, so far, he had not seemed to show any plateau.
He continued with fortnightly treatments and is still doing so today, two years after he presented for the first time. Six months ago, a medical specialist he was seeing arranged an MRI scan which noted similar findings to the earlier CT Scan but with the addition of small osteophytes and a disc bulge pressing on the left C8 nerve root. Michael reports that his elbow, arm and neck pain have all been resolved for many months. He rarely gets headaches now and can happily cope with daily activities. His only remaining symptom is some mild numbness that is constantly in the fingertips of his left hand.
I treated him a week ago and I commented on how great his neck feels (to me). His leg lengths now reveal tonal symmetry… and he likes to fall asleep during the treatment.
Comment: Much could be said regarding this case. Chronic dysfunction can heal very slowly over a long period of time. The therapist needs to be able to measure dysfunction so that treatment can be targeted to the appropriate place. Being able to measure slow progress is also important. Michael had incurred many injuries in the truck crash and some had not been diagnosed or identified – Indeed, some had been misdiagnosed. It is also worth noting that the cervical spine and the cranial bones are important sites of dural attachment.