Bowen Technique Case Studies 73 – 78

Case 73:  Treatment of sub-acute neck pain and restriction

Theresa (a 38-year-old theatre nurse) presented to the clinic complaining of neck pain. In addition to the pain, she had also noticed that her neck was becoming increasingly restricted in its movement. The onset of her condition was associated with a motor vehicle accident that had taken place one month earlier. Although she had been receiving physiotherapy and massage treatment since the accident, the pain and the stiffness were actually worsening rather than improving.

Physical assessment of her neck revealed severe restriction of motion with maximum rotation on both sides reduced to around 40°. Flexion and extension were also significantly restricted.

Tonal assessment showed a left-sided dural drag and the screening procedures showed a positive sacroiliac joint dysfunction (positive Derifield sign). I applied moves of the Lower and Upper Back Procedures prior to turning her supine so I could work on her neck.

The muscles of her neck were extremely tense and rigid on both sides and it was quite difficult to get the tissues to move. I repeated the moves of the Neck Procedure several times but I felt little response from the treated tissues. After doing my best to release the muscles of the neck, I had her turn prone again and saw the presentation had not changed at all (she still showed the left-sided dural drag and the screening still showed a sacroiliac dysfunction).

I tried a Reverse Coccyx Procedure (using the left leg as the lever) and observed an immediate restoration of symmetry. I asked Theresa to come back in a week for a follow-up treatment. Before she left, Theresa asked me if I thought I could help. She was very pessimistic regarding her condition and she was quite fearful of further deterioration. I told her I thought the problem in her neck was really a coccyx problem and that, although I was quite confident, it would become clear in a week or two whether her condition would respond to the treatment.

Six days later, Theresa reported that she was feeling significantly better. Rather than deteriorating further, her neck pain had reduced by more than half. The tonal assessment and screening were the same as they were at the initial presentation and the treatment was also the same. I did notice that the neck muscles were definitely less rigid than they had been the week prior and I told her I was now confident she would make a full recovery if we continued the treatment. I asked her to return the following week.

Theresa came for her third visit a week later and stated that she had improved significantly. The treatment was simply a repeat of the two previous treatments. Once again, I could palpate a significant loosening of the muscles in her neck and she even commented how much easier they moved during the treatment. The treatment concluded with the coccyx work which resulted in symmetry.

Yesterday I saw Theresa for the fourth time. Three weeks had passed since her third visit. She told me she felt no pain and no stiffness. I assessed the range of motion in her neck and found it had dramatically improved. Tonal assessment showed symmetry. When I palpated the muscles of the neck (using the moves of the Neck Procedure) I was impressed. I concluded the treatment without working on her coccyx and I told her she should check back in four to six weeks just to ensure it was all going well. She thanked me sincerely for my help and ensured me she would return. She then confessed that she was quite amazed that her tailbone could be the source of her neck pain.

Comment: This case study illustrates a common presentation seen regularly in the clinic. The principles at play here are much the same as those illustrated in Cases 7, 24, and 27. Once again, a solid grasp of underlying principles, supported by simple but effective holistic assessment, allows the therapist to provide a treatment that is unique, individually tailored, and effective.

Case 74:  Treatment of chronic lumbar and bilateral hip pain

Terry is a 39 year old self-employed plumber who presented to the clinic six weeks ago complaining of debilitating lower back pain that extended into both hips and groins. He walked into the consulting room with obvious difficulty and then proceeded to describe the history of his condition.

He told me he had been in pain for almost six months although he couldn’t recall any event that may have caused his symptoms. To lessen the pain, he was taking codeine (Panadeine Forte) and oxycodone (Endone) as well as amitriptyline (Endep) but at times he would still experience episodes of severe cramp-like pain that would shoot from his abdominal and pelvic regions into his groin. Terry had not been able to work for the last three months and he was feeling pessimistic and quite depressed. A recent MRI had shown he had L5/S1 Disc degeneration with a mild disc bulge and an annular tear. It also identified significant facet joint arthropathy and bilateral sacroiliac joint degeneration.

In addition to the medications he was taking, he had also been receiving extensive treatment from an osteopath and also from a physiotherapist. Despite all this, his condition just seemed to be worsening. A friend had advised him to come and speak with me to see if I could offer any help to his situation.

The initial assessment showed he had a left-sided dural drag and that the screening was unremarkable. I applied the Lower and Upper Back work before turning him and checking his neck. I released the pterygoid on the right side using the TMJ release and then had him turn prone again. He still showed a left-sided dural drag so I decided to address the coccyx. I applied a reverse coccyx correction using the left leg as the lever and let him rest for a few minutes. Following the coccyx correction, his right leg appeared considerably shorter than the left so, using the right leg as a lever, I released the left lumbar paraspinal bundle (posterior psoas release). A few moments later, Terry was in symmetry.

I warned Terry that he would most likely experience a significant aggravation over the next few days and that, if he did, it would actually be a good sign. I asked him to return in a week.

He returned a week later and told me he had experienced four really horrible days following the treatment but that he had actually felt significant improvement in the last two days. I assessed him in the prone position and noted that this time he showed a right-sided dural drag. After the basic moves, I performed a reverse coccyx correction using the right leg as the lever. A few moments later, he was showing a short left leg so, using the left leg as a lever, I released the right lumbar paraspinal bundle (posterior psoas release). I was mildly amused by the fact that this week’s treatment had been a mirror image of the previous week.

Terry came back a week later for his third treatment. He said he was feeling a lot better and had not experienced any more of the cramp-like pains that would shoot into his groins. He was particularly happy because he had been able to significantly reduce some of his pain medications. The third treatment showed the same assessment findings and followed exactly the same treatment protocol to the previous one.

Terry returned a week later for his fourth visit and he told me he had experienced further improvement. He had completely stopped all his medications and was experiencing very little pain. He was just afraid he would move the wrong way and all the spasms and pain would return. Assessment showed a left-sided dural drag on this occasion and this resolved with a coccyx correction (reverse coccyx using the left leg as the lever). Since symmetry was restored by the coccyx correction, I concluded the treatment and asked him to return in a week.

When Terry came for his fifth treatment (four weeks after his initial presentation) he was delighted. His improvement had continued and he was feeling great. He had no pain at all and he had even started working again. The assessment and treatment were exactly the same as the previous week.

Today, Terry came for his sixth visit and he still held the symmetry established two weeks prior. He has returned to work and he has now been completely pain-free for three weeks.

Comment: It is not unusual for the coccyx to “swing” from one side to the other (and back again) over a course of several treatments. I have always seen it as a kind of pendulum effect that illustrates the body’s adaptation and healing response. With each movement of the sacrococcygeal complex, the body seems to further progress the healing response. In this instance, several weeks of treatment was all that was required to resolve many months of dysfunction.

Case 75: Treatment of recalcitrant knee pain

Mandy is 46 years old and she came to the clinic complaining of recalcitrant swelling and pain in her left knee.  The swelling and pain began more than six months prior, after she commenced daily boot camp training activities.  She had already tried a number of physiotherapy and chiropractic treatment regimes, lots of medication, and several cortisone injections but these had all proved unsuccessful.  Her doctor had arranged an MRI which showed she had a tear in her meniscus and he had advised her to lose some weight and then consult an orthopaedic surgeon.

In the last month or so the pain had spread from the knee to involve her whole left leg.  She said her quad now felt like it was always in spasm.  She told me she was frustrated as she was gaining weight because the knee was preventing her from doing any exercise. In addition, she was not keen to undergo arthroscopic surgery – except as a last resort.

I asked her to lie prone for the initial assessment and it was immediately clear she had a very short right leg.  I had her turn her head to the left and as she did, her left leg became short (a positive double cervical turn test – classic variety.  This indicates the primary issue is either the coccyx or the sphenoid).

After running through the Lower and Upper Back moves I had her turn supine so I could work on her neck.  The paraspinal bundle on the right side of the neck was tense and rigid and quite difficult to move (move 6 of the neck procedure).  In my notes I wrote “R Neck Crowbar” and then I went on to check the Right Temporomandibular Joint.  The tissues of the right TMJ were rigid and tense and the move was no doubt uncomfortable.

After repeating the move a few minutes later, I then tried to apply some moves to her left knee.  Unfortunately, due to excess adipose tissue, I couldn’t really get to moves 5 & 6 of the knee procedure, so I gave up on the idea of applying local treatment. 

I had her turn prone again so I could reassess her.  She now showed symmetry.  I told her I was confident that I could fix her knee and that it didn’t matter how fat or thin she was!  I concluded the treatment and asked her to return for another session in a week.

At the second visit she reported no change.  The assessment was the same and the screening once again showed a positive double cervical turn test – classic variety.  The treatment was the same as the previous week focusing primarily on the tissues of the right TMJ. 

At the third visit (one week later) Mandy reported significant improvement.  She said the pain was much less than before and only affecting the knee itself.  I repeated the treatment but this time the asymmetry did not resolve following the TMJ work.  This time, I had to apply a reverse coccyx procedure as well.  As she was now improving, I asked her to come again in two weeks.

At the fourth visit, Mandy said she was heaps better.  She was no longer experiencing any pain and had resumed full-on boot camp activities.  I went through the BRMs and released the TMJ and concluded the treatment because she showed symmetry.

Today was Mandy’s fifth treatment – six weeks since her initial visit.  She presented with symmetry.  She says her knee is “really good” and has been for almost a month.  She was enjoying the boot camp training and she had even managed to lose a few kilos.  She feels her quad muscle has relaxed now and I could feel ‘normal’ healthy movement through the paraspinal bundles in her neck.  I told her she didn’t need any further treatment.

Case 76:  Treatment of  nightly episodes of thigh pain

Sally is a delightful 77-year-old woman who presented to the clinic complaining of an “icy” discomfort running through the front of her right thigh. The pain is not present during the day but it wakes her each night and she usually loses a few hours sleep because of it. Once she gets up and moves around (usually she gets up and gets a warm wheat pack to put over it) the pain gradually resolves and she is able to return to sleep. She has experienced this “icy” discomfort for as long as she can remember (for more than two decades) and now it has become part of her normal nightly routine. The pain extends through the anterior portion of the quadriceps, particularly through rectus femoris. She had had many scans, tests, and procedures and had seen numerous medical specialists but finally, she decided she would just have to live with it. Recently, however, she spoke to a friend who urged her to come and see me.

Initial assessment in the prone position showed a left-sided dural drag (a short left leg). I went through several screening procedures but they were all unremarkable. I applied the Lower and Upper Back Procedures before turning her supine. In the supine position, she now showed a short right leg. I checked her neck, using the moves of the Neck Procedure, but it seemed fine and it had no impact on the presenting asymmetry. I palpated the rectus abdominus on either side of her umbilicus and noted significant tension on the right side. Using the anterior psoas release, I pushed into deeper levels of the abdominal muscles and as I did so, I encountered a layer of severe tension and restriction. As I did this, I watched Sally’s expression change from cheerful and unconcerned to one of alarm and significant discomfort.

I asked Sally to bear with me and to breathe in and out as I held the anterior psoas release for four or five breaths, each time gaining a little more release from the target tissue. When I let the holding points go, Sally explained that it had felt horrible. She had felt pain radiating into her right thigh and up through her stomach and into her chest. She felt a little nauseous too but once I had let go, she immediately felt normal again. I told her I would let her rest and then repeat the whole procedure again – a suggestion she really wasn’t too excited about.

The second application of the procedure was significantly better. The tension and restriction had already dropped heaps and although Sally experienced a similar sensation, it was nowhere near as uncomfortable as the first time. Five minutes later I released it for the third and final time and once again it had significantly improved compared to the previous application of the procedure.

I turned Sally prone and noted she now had a right-sided dural drag in the prone position. Using her right leg as the lever, I applied a Reverse Coccyx Procedure which brought her to a lasting state of symmetry. Although the experience had been more traumatic than she expected, Sally agreed to return in a week.

Sally reported a week later, that she had had several nights where she wasn’t woken by the icy discomfort. This was the first time she had ever felt an improvement and she was very excited that the treatment might actually resolve the problem. I repeated the treatment from the previous week and the discomfort was a lot less than the first time. In truth, the pathology was exactly the same but to a much lesser degree.

Two weeks later, Sally returned and reported that she was sleeping like a baby. She no longer experienced the pain or the icy discomfort. She said she couldn’t really believe she was fixed. Over the next month, I treated her on two more occasions, each time noting further improvement in the target tissue. After the second treatment, further coccyx work was not required as she simply returned to symmetry after the anterior psoas release. By the final treatment, she presented with tonal symmetry and her abdomen was no longer painful to treat. Sally says she is eternally grateful.

Comment: This case is interesting for many reasons. It provides an excellent example of the psoas trigger point pain referral pattern. It illustrates the importance of tactile recognition as an essential component of assessment. It highlights the importance of reaching the appropriate depth needed to facilitate the necessary tissue change.

I use this procedure numerous times, every day, in my clinic and when it is indicated, it regularly delivers the most valuable therapeutic outcomes.

Case 77:  Treatment of chronic hip pain in an 84-year-old female.

Agnes, 84 years of age, came to the clinic complaining of chronic pain and restriction of movement in her left hip. 

Agnes had fallen and fractured the neck of her femur one year earlier.  Although she attended the local hospital following the fall, the fracture was undiagnosed.  She was told she just had some bruising and she was sent home to try to walk and function normally.  Over the next ten days the pain worsened to the point of being intolerable so she went back to the hospital for further investigations.  At that time the fracture was diagnosed and a decision was made to perform hip replacement surgery.  That surgery was performed twelve months ago but now she still suffered constant pain and significant restriction of movement.  Despite ongoing physiotherapy, she still struggled to raise her left leg and, when she walked, pain radiated from her hip into the side of her leg.  When she walked, she did so with an odd gait that looked something like a limp.

I assessed Agnes in the prone position and noted that her right leg appeared to be an inch shorter than her left.  This remained unchanged when she turned her head to the right side but when she turned her head to the left, her left leg appeared to become an inch shorter (a positive presentation of a classic “Double Cervical Turn Test”).  It was clear that the main issue affecting her nervous system was associated with either her sphenoid or her coccyx.

I applied moves of the Lower and Upper Back Procedures and then had her turn supine.  The moves of the Neck Procedure allowed me to palpate the paraspinal bundles of her neck where I found severe restriction and tension in the bundle on the right side.  I released the sphenoid using the TMJ Procedure and then let her rest for five minutes.  I then checked her neck and felt significant loosening in the right paraspinal bundle.  At this point, Agnes complained that I should be treating her hip, not her neck.  I told her I needed to treat both if we wanted a successful outcome.

After checking for tension, I performed a left-sided anterior psoas release and then repeated it again a few minutes later.  I then checked for any tension in the adductors but they seemed unremarkable.  I had her turn prone again to reassess and I was pleased to see she now demonstrated a state of symmetry – this confirmed the main issue had indeed been the sphenoid dysfunction.  I asked her to return in a week.

At the second visit, Agnes complained that she felt no better.  I assessed and found the same presentation and applied the same treatment interventions.  She made the same complaints about me treating her neck and jaw.

At the third visit, she again complained she was no better.  I pointed out that she was walking much better and that she seemed to be able to raise her leg further than before.  She said that was true but she was now experiencing pain and stiffness in her neck.  I asked her if the hip pain was still constant and still referring down the side of her leg.  She said there wasn’t much pain in the hip now and that it only presented if she walked a long distance.  After a six second stare, I told her I thought she was actually improving quite well.  She ignored my comment and reiterated her complaint about her neck pain and she told me she blamed me for causing it.  She told me she had no pain in her neck until I started poking around in there.

I told her the neck pain was a good sign and that I believed it would resolve after this treatment.  I told her I thought her hip pain was progressing very well and that she should feel one hundred percent within a couple of weeks.  She didn’t seem convinced but she let me treat her again.

She came for her fourth session two weeks later.  She seemed to be walking quite normally and she told me that “fortunately” the soreness and stiffness in her neck had now resolved.  I asked if she had any pain now, anywhere at all?  She shook her head and said she had none.  I assessed her and saw that she had symmetry.  When I checked her neck, it felt much looser and it all moved nicely.

I told her she should be fine now and that she didn’t need to come for any further treatment.  She left without thanking me and I heard her at the front desk making another appointment for a month’s time – “just for some maintenance”.

Comment:  This case illustrates the importance of assessment as well as some of the realities of clinical practice.  Some patients are just delightful and some don’t quite fit that descriptor. Patient management can become quite challenging at times.

Case 78: Treatment of chronic hip pain following hip replacement surgery

Martha (64 years old) presented to the clinic one month ago complaining of severe and chronic pain of the right hip. Six months ago, she underwent hip replacement surgery (right side) and since then she had been experiencing severe pain in, over, and around the area of her surgical scar.  In addition, since the surgery, she has also been experiencing chronic pain and swelling in her right knee.  She had been seeing several therapists including her orthopaedic surgeon, her physiotherapist, and her chiropractor but since she wasn’t progressing at all, a friend suggested she drive 90 minutes to seek my opinion.

Assessment in the prone position revealed a short left leg of at least 20mm.  I mentioned this to Martha and she told me she was well aware of that.  It had only been like that since the hip surgery and then she told me she was addressing the issue by placing a “half-inch heel lift” under her left heel.  At that moment, I was lost for words.

I carried out the screening procedure and noted that she showed a positive Double Cervical Turn Test (2CTT) of the “classic” variety.  At that point, I knew I was going to love this case.

I asked her if she had spoken with her surgeon about the short leg that prevailed following the surgery.  She told me she had and that he emphatically denied having made the legs different lengths.  “I assure you Mrs Brown, your leg is exactly the same length that it was prior to the hip replacement… ” but despite his assurances, she remained quite certain the leg-length difference was the result of the surgery.

I asked Martha where she got the heel lift and who prescribed it.  She told me she bought it at the local supermarket in the isle with the shoe polish and shoe laces and that her chiropractor had suggested she try the heel lift since the leg-length issue had definitely resulted from the surgery.  Again, I was speechless.

As I performed the neck moves, I could feel significant restriction on the right side of her neck (move 6 of the neck procedure).  I asked her to open and close her mouth so I could palpate the condyle of her mandible and as she did so, I felt a loud “clicking” of her jaw.  I commented on it and she told me it had been clicking like that for many years but it didn’t bother her.

I told her I believed I could fix her hip pain and her knee pain and it would only take a couple of weeks.  I released the pterygoid on the right side and then turned her prone again.  Her left leg was now around 6mm short so I performed a reverse coccyx procedure (which it turns out I might have learned from Romney) and this resulted in symmetry.  I told her she needed to throw the heel lift in the bin and come back to see me in a week.

Martha returned one week later and reported at least 85% improvement.  Assessment showed a short left leg but only about 4 mm.  This treatment was a replica of the first treatment except the tensions were all much more subtle.

I saw Martha again today, three weeks since the second treatment.  She presented with symmetry.  She reported that her pain was 100% resolved within a day or two after the last session.  She feels great and she has also noticed that her jaw is no longer clicking.