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PPA ( Painful Palpatory Area )
I had a client today with a pain problem that I was able to take care of very easily... I started thinking that if I saw her 30 years ago I would not have been able to help... And indeed it would have been very intiimidating and scary.. But now, its easy... So I thought it might be helpful for new therapists to hear my thought process and how I approached her problem? I hope it does?
I'd seen her a couple of months ago when she came in with a migrain headache.. Fortunatally or luckily at that time I was able to rid her of her headache within a 50 minute session... It doen't always go that way with migrains... Anyway she came in today in obvious pain.. she moved carefully and held her right arm in a contracted position as if it was broken and in a sling. She told me that she didnt have a headache, but that she was feeling severe in her shoulder and arm. And could not figure out what caused it? Nothing that she could remember.. She went to the medical doctors in order to rule out anything really bad. The docs were unable to offer her an explanation as to the cause or the reason for her weird pain syndrome. They said it was probably a pinched nerve, and gave her pain meds and muscle relaxers. Remembering how I helped her with her headache she came into see me. I asked where she hurt the most.. She touched her right clavical chest area. But told me it also hurts all the way down her arm into her hand. She asked me if I can fix a pinched nerve. I said I doubt it its a pinched nerve, but that I could probably help her if I could find a a PPA (Painful Palpatory Area). I explained to her that usually within or near the area of pain she experiences, there should be one or two very painful spots.. And if thats the case there is a 90% chance that she will walk out of the spa pain free. She said Gawd Ihope so. Before she got on the table I palpated her entire shoulder area. Or most of it anyway. I palpated her infraspinauts, supraspintus, her pectoralis major and minor, deltoid and her entire arm finding any palpatory painful areas until I touched her upper trap-scalene area on the side of her neck. She winced in pain. A nocioceptive withdrawal response.. Or as Travell would call it..A Jump Sign or Flinch response. I told her that its my experience that if we are ale to eliminate those very painful spots, all her pain problems are over. I got her on the table and did a more extensive exam for tender areas(PPAs). I found a couple mild tender areas on the errector muscles on the effected side near her scapula at T8 and T4. I eliminated those tender ares as well as the very painful scalene area within a few minutes. My total time with her was about 30 minutes. She booked a 50 minute massage but only charged her for a 25 minute session.. So she could save the reast of the money for a follow up visit to make sure those tender areas dont come back... After she got up off the table she smiled its gone. I reminded her that she is not healed yet. That the cellular damage was still there. And the only reason she feels better is because the contracted muscles fibers have opened up now.. And that she is not to stretch or test the area. She needs to heal now..The biggest mistake therapists make is telling their clients to stretch after a succsssful massage.. If you get a cut. you clean the cut. Put a bandaid on it and let it heal.. You dont keep oening up the bandaid and poking the cut to see how its doing.. You leave it alone and let mother nature heal things.. I told her to increase her protien intake for a coupld of days because protien is the only thing that repairs damaged muscle tissue..and thats wht she has on a cellular level...Then I talked to her about her job..I asked her id she is on the phone a lot..She said that she is a pharmacy assistant and is constantly on the phone filling orders..She holds the phone between her neck and shoulder keeping her hands free for work.. I told her that is the action that caused her problem.. The perpetuating factor as Travell calls it. And that she has to stop doing that unless she wants to keep paying me in order to fix it. I will download and attach a picture of her problem and add it to this thread. We dont need to be working at ME for $15 an hour. We have within our license to dominate and be the go to guys for the ache and pain industry.. Its a Billion dollar industry..I only wish our education system would know that and teach that. Truth is ...IF THERE IS NO UNDERLYING PATHOLOGY, ITS SOFT TISSUE WORK ALL THE WAY. Unless our education system changes..TRUTH WILL REMAIN HIDDEN, LIKE A SHADOW IN THE DARKNES.
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Replies to This Discussion
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Permalink Reply by Gordon J. Wallis on
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Here is a picture of her problem. Its over now though. I re-read my thread.. Sorry for all the mispelled words, I'm not good at that.. But I think you can understand what Im saying?
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Permalink Reply by Tasha S. on
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Thank you for your post! As a newer therapist, I still find myself second-guessing my treatment protocol and wondering if my work is being effective, usually during a session...Afterwards, my client will say how wonderful they feel. I have to remind myself that this is a life-long learning process. At the very least, I'm confident that I can practice listening and responding to my clients, and over time my experience will add up to the answers I need.
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I basically, for the most part. Only have one treatment protocal. So there is no second guessing. And I usually know if my work is effective, because I have meserable objectives.
Tasha S. said:Thank you for your post! As a newer therapist, I still find myself second-guessing my treatment protocol and wondering if my work is being effective, usually during a session...Afterwards, my client will say how wonderful they feel. I have to remind myself that this is a life-long learning process. At the very least, I'm confident that I can practice listening and responding to my clients, and over time my experience will add up to the answers I need.
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Permalink Reply by Gary W Addis, LMT on
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Tasha, what Gordon has labeled PPAs are what others call trigger points. I like his label more. The book definition of trigger point conflicts often with what we find in the tissue; therefore, the books say, well, there's active (referring) TPs then there are passive and latent TPS (non-referring). They are all painful palpatory spots, they may or may not send pain somewhere else. They all respond to treatments. Doesn't have to be killer pressure--in fact, Gordon has helped me to learn that too much pressure is often counter-productive. But it does have to be deep enough to create at least some pain response: you can't treat it until you find it, and for that, client and/or tissue response to the pain is necessary.
Don't be intimidated. Find the pain, keep contact with it and think how best to make it go away. Hard ischemic compression is merely one way of many that if you keep an open mind, you will discover on your own one by one. Like Gordon taught me, it doesn't have to be complicated. The most important lesson I've learned is ignore the experts who tell you to stretch stretch stretch to relieve tight tissue-- for the most point, i think that advice is nonsense: the muscle tightened for a reason, so find and eliminate the reason, instruct the client to give it a chance to heal without interference and it will relax into its normal resting length all by itself.
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Well stretching is good. I stretch every day.. But if you have had a succesful massage session. Like the client comes in hurting in a specific area. And when he leaves not hurting. He should not go home and stretch that area. He needs to leave it alone, and let it heal. You are talking about damaged muscle tissue.. It maybe on a cellular level.. But thats what it is..
Gary W Addis, LMT said:Tasha, what Gordon has labeled PPAs are what others call trigger points. I like his label more. The book definition of trigger point conflicts often with what we find in the tissue; therefore, the books say, well, there's active (referring) TPs then there are passive and latent TPS (non-referring). They are all painful palpatory spots, they may or may not send pain somewhere else. They all respond to treatments. Doesn't have to be killer pressure--in fact, Gordon has helped me to learn that too much pressure is often counter-productive. But it does have to be deep enough to create at least some pain response: you can't treat it until you find it, and for that, client and/or tissue response to the pain is necessary.
Don't be intimidated. Find the pain, keep contact with it and think how best to make it go away. Hard ischemic compression is merely one way of many that if you keep an open mind, you will discover on your own one by one. Like Gordon taught me, it doesn't have to be complicated. The most important lesson I've learned is ignore the experts who tell you to stretch stretch stretch to relieve tight tissue-- for the most point, i think that advice is nonsense: the muscle tightened for a reason, so find and eliminate the reason, instruct the client to give it a chance to heal without interference and it will relax into its normal resting length all by itself.
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I don't stretch and know I should, actually I don't get in a workout very often anymore--and know I should. Too bad that so many people abuse a good thing ,though. They become fanatical about a sport, and injure and reinjure themselves. they go to a therapist who tells them to stretch that injured muscle. They enjoy ice cream, so eat a quart a day.
We can tell them but we can't force them to apply a little commonsense to their lives. I'm giving that advice to myself also-- I need to cut down on the sweets, and need to exercise more, and need to stretch afterward. But, sheesh, in today's world it is difficult as hell sometimes just crawling out of bed.
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Lol. Yea. Do as I say. Not as I do.
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Permalink Reply by Therese Schwartz on
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Wow, Gary, you are so right about how difficult it can be to crawl out of bed sometimes!! We are overwhelmed and bombarded on all sides by so much...and most of it really doesn't even matter!
I have started being much more clear with my clients about not overdoing it when the pain goes away. People want to get back to exercising, but doing too much right away is counterproductive. I tell them I'm giving them permission to be lazy! :)
I like the label PPA much better than trigger point - given that (as far as I know) there is no clear definition of what a trigger point is, maybe that's not the best term. But a PPA is easy to understand!
A few months ago I finally committed to doing yoga at least 5 nights a week; I only do about 15 minutes but I have about a 70% reduction in pain in the mornings by doing the yoga at night. That seems worth it! :)
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