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Hands-on experiential learning: Qualitative evaluation project--Interviewing people about what massage means to them

Submitted by RST on Sun, 05/06/2012 - 11:10
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Introduction

This exercise asks you to collect and record data about the personal and unique meanings that people take from massage.

The purpose is to give you the experience of conducting qualitative research on a very small scale, so that from it, you get a sense of how researchers design and carry out studies to investigate a particular research question.

We're going to use an ethnographic interview, which is a qualitative research method. It's a way of interviewing people, usually one-on-one, to find out basic facts about their lives, how they understand the world around them, and possibly such things as what meaning they derive from it.

 

Designing your project

The research design for this project is fairly straightforward:

Decide on 2 or 3 people whom you would like to interview to learn what they think about massage, and what their experience with massage is.

Decide on the setting where you would like to interview them--invite them to your place, drop by theirs, invite them out for coffee, or whatever other setting works well for you to ask questions and note down their answers.

Invite people to participate in your study. Two or three is enough for this, as it is really a demo more than it is an actual project.

Make sure that before you interview anyone, they have signed and given you a copy of the consent form later in this post.

Meet them for the interview, and record their answers to your questions.

Write up their answers to your questions, and--making sure you observe accepted practices of confidentiality--tell us in the comments below what you wanted to explore, what questions you asked in order to explore that, what their answers are, what you think their answers tell you about the meaning they take from massage, and anything else about the process that strikes you as worth mentioning.

 

Primum non nocere--First, do no harm.

 

Remember that, as a healthcare professional and as a researcher--even in an exercise as small-scale as this one--you have a responsibility and a duty above all to protect the identities of the people you interview.

Before you share information with the rest of us in the POEM community, make sure that you have removed or shielded any information that would help people to figure out the identity of the people you interview.

Perhaps the most obvious thing to do first is to make sure you don't use someone's real name. But by itself, that may not be enough to protect the identity of your participants.

Consider, for example, the following description:

"Mary", an MT originally from Alabama who now lives in the Seattle area, and who speaks Cambodian and works with refugee clients...

 

That description is specific enough for people who know me to figure out that "Mary" is really me; changing the name was not enough to hide that fact.

Consider changing the sex and age of your participants, as well as any other relevant demographic characteristics, that will protect their identity. In a context where it doesn't affect the meaning of the results, a 27-year-old man can become a 50-year-old woman, if necessary for the sake of protecting confidentiality in a research project.

Change details in the interviews that don't affect the meaning of the answers your participants provide. For example, with 1684 residents, Oshoto, WY is small enough that people from there might know each other well enough to recognize each other's stories. So if I interviewed someone who said something like "When I was growing up in Oshoto, ...", then I would either change the name of the town, or I would remove it altogether and just report the person said "When I was growing up, ...".

Although your sample size in this exercise is so small that this may not be practical here, for future projects you might combine two or more people into a composite character, whose identity can't be guessed because that single individual doesn't exist.

 

Does this changing of facts feel somehow deceptive--enough so that you're wondering about the ethics of it all? If you're new to qualitative research, and it does feel that way, then that's a good thing, because it means that you're integrating previous ethical principles with what you're learning now about research, and you're pushing at the boundaries of what you know.

You're right that integrity is at the core of research, and--although this can feel somewhat deceptive--this way of protecting your participants is squarely at the heart of research integrity.

First of all, you are doing it to protect your participants--they do not need to fear embarrassment, financial consequences, or worse, because they shared information with you. Your focus is on the information itself; nothing will happen to the participants as a result of giving you their answers to your questions.

Second, you will be faithful in the information you provide. You will not make up characters that do not exist at all, and you will not make up answers or information that someone did not share with you.

You are not changing the heart of the content of the answers. Changing someone's birthplace from Oshoto, WY to Pinson, AL, for example, or leaving it out entirely, is a detail that does not substantively change what massage means to that person, which is what this exercise is about.

On the other hand, to totally invent a person who you didn't really interview, and then to report an answer that you made up as being from that person--that would be a major ethical breach of integrity. But you're not doing anything like that here--in changing the details of real people who really exist, and who really gave you those answers you are reporting, you're nowhere near that ethical lapse.

 

Think about how you are going to invite your participants to talk to you. You want this to be about them, not about their trying to please you by telling you what they think you want to hear, so give some thought to your questions before you sit down with them for an interview.

Closed-ended questions, where the person being interviewed has a limited set of responses to choose from--"yes" or "no" questions, for example--tend not to be as good for this purpose as open-ended questions.

"Do you think massage benefits you?" does not encourage someone to open up to you as "Tell me about what you think massage does for people."

Decide on the questions you want to ask, and think about what you will do if the discussion goes in very different ways from what you expect. Think about what you will be reporting in future, and keep that in mind as you are deciding on the questions you will ask.

 

Carrying out your project

Informed consent

A core foundational principle of research is that the person you're interviewing should be participating willingly, and should understand why they are participating. If that willingness changes, they are free to stop participating at any time they want to.

This consent form is based on the one available at this link.

You can paste this consent form into a document, and print out two copies--one for your interview participant to keep for themselves, and one to sign and give to you to keep.

 

Participant's Agreement

I am aware that my participation in this interview is voluntary.

If, for any reason, at any time, I wish to stop the interview, I may do so without having to give an explanation.

I understand the intent and purpose of this research, and I understand that I will be asked about my understanding and experiences of massage.

I understand that I am free to expand on the topic or talk about related ideas.

I also understand that if there are any questions I would rather not answer or that I do not feel comfortable answering, then I have the choice of stopping the interview or moving on to the next question, whichever I prefer.

I understand that the information I provide will be used in a general way for a group online discussion of how people understand and experience massage, and that my identity will be kept confidential. Only the interviewer will know my identity; none of the other participants in the discussion of the answers to the interview questions will be aware of who I am.

I have been offered a copy of this consent form that I may keep for my own reference.

I have read the above form and, with the understanding that I can withdraw at any time and for whatever reason, I consent to participate in today's interview.



_________________________________                       ___________________
Participant's signature                                         Date
 

_________________________________
Interviewer's signature
 

 

 

 

Reporting on your project

In the comments to this story, please share your findings, and outline your evaluation of the interview.

Tell us how you approached the task, and what your key findings were.

In addition, think about the kinds of quantitative data you'd like to collect to boost your qualitative findings--what are your qualitative findings, what other processes do they point to, and how would you use quantative methods to investigate those processes?

 

Information sources on ethnographic interviewing

Design4Instruction: The Ethnographic Interview accessed 6 May 2012

Ethnomed: "Collecting Ethnographic Data: The Ethnographic Interview" accessed 6 May 2012

Johns Hopkins Bloomberg School of Public Health Center for Refugee and Disaster Response (CRDR) publication: Training in Qualitative Research Methods for Private Voluntary Organizations and Non-Governmental Organizations accessed 6 May 2012

Sakai Project article: "Ethnographic Interviews - Interviewing and Observing Users" accessed 6 May 2012

Wikipedia article "Ethnography" accessed 6 May 2012

 

 

 

Should you wait 24 hours after scuba diving before getting a massage?

Submitted by RST on Sat, 02/04/2012 - 08:58
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Summary

There are at least three issues involved in deciding how long to wait between massage and scuba diving, either massage before diving, or massage after diving.

  1. Does massage make DCS (decompression sickness, "the bends") more likely to happen, or does it make it worse if it does happen?
  2. Does massage cause a situation that makes false positives for DCS more likely, meaning that resources are used unnecessarily to diagnose and treat suspected cases that are not really DCS?
  3. Does massage cause a situation that makes false negatives for DCS more likely, meaning that real cases of a potentially life-threatening condition are ignored or missed?

There are theoretical scenarios for "yes" answers to all 3 of those questions that are all physiologically plausible, although there is no evidence yet to quantify what the real clinical risk from those theoretical risks are.

However, the safest way to practice is to wait 24 hours after getting a massage before scuba diving, and to wait 24 hours after scuba diving for getting a massage.

If the--admittedly very low--probability of DCS actually does turn into a case:

  1. The MT will never be able to prove that the massage did not cause, worsen, or mask the symptoms of DCS, and
  2. If the case turns adversarial and legal, there is information on record from Divers Alert Network DAN, the pre-eminent diving medicine research and education organization, where MDs and physiologists recommend waiting as the safest principle. A lawyer will be able to point to that recommendation, and argue that the MT violated standards of practice, such as they exist, by not waiting according to that recommendation.

For these reasons, POEM recommends spacing massage and scuba diving at least 24 hours apart in each direction as the safest course to follow.

 

Over at Massage Practice Builder's Wall on Facebook, an MT asks:

Years ago I recall reading somewhere that massage is contraindicated within 24 hours after scuba diving. In searching now, I'm finding contradictory information. Anyone have a reliable source re this? Thanks!

 

Divers Alert Network (DAN), the go-to site for medical information about diving, doesn't answer the question directly, but sketches out some of the issues involved.

A DAN physician recommends against deep-tissue massage before diving, but says nothing about it afterwards:

Massage & Diving

I've been told not get a deep tissue massage the same day as diving because it can cause DCS. Is this true?

You raise an interesting question about the possible association between massage and DCS risk.

 

* DCS = decompression sickness, colloquially called "the bends".

Wikipedia's article on DCS provides a very good summary:

Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurisation. DCS most commonly refers to a specific type of underwater diving hazard but may be experienced in other depressurisation events such as caisson working, flying in unpressurised aircraft, and extra-vehicular activity from spacecraft.

Since bubbles can form in or migrate to any part of the body, DCS can produce many symptoms, and its effects may vary from joint pain and rashes to paralysis and death. Individual susceptibility can vary from day to day, and different individuals under the same conditions may be affected differently or not at all.

 

Source: Inside the underwater caisson--building the Brooklyn Bridge, http://xroads.virginia.edu/~ma03/pricola/bridge/images/caisson2.jpg accessed 4 February 2012

 

DAN's article continues:

Some have cautioned against massage before diving. The clearest justification is to avoid muscle pain that might be attributed to DCS.

 

So he's not saying that massage makes a diver more likely to actually get the bends; he's saying that the massage may cause slight soreness afterward that can confuse the diver and the healthcare team into thinking it's a case of the bends: a false positive for DCS.

The other possibility, which the DAN physician doesn't address here, is that the diver could actually get the bends, but ignore the symptoms and fail to seek medical attention for a serious condition, thinking that the soreness comes just from the massage: a false negative for DCS. We'll discuss this more later on in this post.

A more speculative [theoretical, not yet backed up by evidence] concern is to minimize the development of micronuclei [micro-bubbles filled with gas, less than 10 µm in diameter: less than 1/8 the width of a human hair].

 

 

Source, first picture: http://www.d.umn.edu/news/2008/August/Human_hair.jpg, accessed 4 February 2012

Source, second picture: http://www.seas.ucla.edu/~pilon/Photos/1.jpg, accessed 4 February 2012

 

The nature and action of micronuclei has not been confirmed, but it is believed that they are the seeds from which bubbles form. There is a theoretical concern that tissue massage may induce [bring about] micronuclei formation and thus precipitate [promote] bubble formation. Tissue stimulation could also increase blood flow which may either positively enhance tissue gas elimination or precipitate problematic bubble formation.

 

See how things are interconnected? The claim that massage increases blood flow is problematic, but whatever the evidence that emerges for or against that claim, it can play a role one way or another in whether or not massage increases the risk of DCS.

 

As you can see, there is no clear sense of what massage might do and this effect would likely vary depending on dive profiles and intensity of the massage. We should note that massage has not been confidently associated with any of the cases of DCS that have come to us, and we are not aware of any study done to address this question. The clearest piece of advice is that deep tissue massage should probably be avoided, so that the potential of post-dive pain and diagnostic confusion are minimized.

Dr. Nick Bird MD.

 

A physiologist at the DAN site reiterates the precautionary principle:

Decompression safety, as with many things, is a matter of balancing strings of decisions so the net outcome is in your favor. My approach is to stack as many factors as feasible in my favor to compensate for the Murphy effect or chance that we see frequently in decompression sickness.

Neal W. Pollock, Ph.D.

 

 

What are some of the factors involved in decompression sickness?

In general, being at a healthy weight works in your favor, while being overweight is thought to slightly increase your risk of DCS. Exercise, especially forms that put strain on the joints, is discouraged right after diving, as it's considered a slight risk factor.

Dehydration is thought to raise the risk of DCS as well. so the tradition of encouraging people to drink plenty of water after a massage cannot hurt, and may provide a tiny bit of protection.

The prohibition against flying or mountain climbing within 24 hours after diving is a result of the way the gas laws work in physics.
 
The ideal gas law (the description of the way gases work) is:
 
PV = nRT
 
The (P)ressure times the (V)olume of the gas equals the (n)umber of molecules [amount] of the gas times a constant R times the (T)emperature.
 
(V)olume [the size of the nitrogen bubbles that migrate to the joints and cause the bends] is what we care about, so let's isolate that variable on one side of the equation.
 
So the behavior we care about is described by:
 
V = (nRT)/P
 
The (V)olume 
1. goes up as the amount of gas (n) goes up;
2. goes up as the (T)emperature goes up;
3. goes down as the (P)ressure goes up, and vice versa.
 
 
 
 
Since massage cannot add to the amount of nitrogen in the body, and in fact during the massage, the body will continue to shed excess nitrogen, I hypothesize that (1.) is not an issue.
 
Massage does raise skin temperature, so if you want to take a 100%-risk-avoidant path, you could say that the slight theoretical risk of that gain in temperature means that it's absolutely contraindicated. However, my experience in anatomy and physiology leads me to think that the distribution of the nitrogen bubbles throughout the entire circulatory system is not likely to be affected enough by local changes in skin temperature for that to be a significant risk. I hypothesize that the theoretical risk of (2.) is not going to make a real clinical difference.
 
(3.), in my opinion, is, of all the risk factors, the most likely to have an effect. I honestly don't know whether BP-lowering effects of massage could make the bubbles large enough to create a real increased risk. That would however, make an excellent study.
 
That was as far as I was able to take it with my basic physics; since I was rapidly getting in over my head (ha!), I put out the bat signal for someone with specialized knowledge on both sides of the question: physicist/MT Keith Eric Grant.
 
He was able to clarify the question more:
 
Like you, I can see the basis for diving and flying, but not for massage. Massage may change skin temperature, but I think that's mostly by dilating superficial capillaries; i.e. not an actual change in blood temperature. Nor would I expect that massage would create anymore of a change in pressure than moving around or sitting down.
 
The real issue here is solubility. Gas solubility does decrease with temperature, but your body is simply not going to let that change.
 
The pressure dependence of solubility isn't the ideal gas law per se but Henry's law.
 
That law states that the concentration of the dissolved gas will be proportional to the pressure. As I recall, commercial airlines pressurize to about 7000 ft.
 
I would think that the greater danger would be not from the massage but from not recognizing symptoms of the bends and doing a massage in their presence rather than referring to medical care. http://en.wikipedia.org/wiki/Decompression_sickness#Signs_and_symptoms
 
I remember Donald Schiff talking some years back about a pilot coming in for a massage and referring him to emergency care.
 
I agree with his point about the risk of not recognizing decompression sickness.

 

 

Dive Injury Case Report

 

Case 8 – A diver with back trouble developed pain and motor weakness in his back and legs after 11 dives over three days complicated by altitude exposure. He had partial resolution during a long series of recompressions.

A 63-year-old male divemaster had made 50 dives during the past year and more than 200 lifetime dives. He had a history of degenerative lumbar disc disease and hypothyroidism for which he took synthetic thyroid hormone. He was on a liveaboard vacation and had made 11 dives over a 3 day period with a maximum depth of 128 fsw [feet of salt water] (39 msw [meters of salt water]) and a last dive depth of 100 fsw (30 msw). All dives were uneventful and used 32% nitrox [nitrogen-oxygen combination] with dive times according to an air computer.

He performed five dives the first day, four the second, and two morning dives on the third day. He stated he was well hydrated, well rested and had not consumed any alcohol. While returning to the boat after the second morning dive, he developed pain in his lower back consistent with his pre-existing disc condition, but he was able to climb onto the boat without assistance. He did not make another dive but opted to rest, have a back massage, and eat lunch. Feeling better, he participated in a walking tour of a local island which took him to an altitude of about 2,000 ft (610 m). During the tour, the back pain returned, and he had difficulty walking due to numbness in his legs but was able to return to the vessel where a physician also on vacation was concerned that might have neurological DCS. They informed the boat captain who placed the diver on first aid oxygen while they traveled to a nearby island with a hyperbaric chamber [where the air pressure can be increased or decreased in a controlled way].

Upon evaluation, the hyperbaric [high-pressure] physician found the diver had abnormal skin sensations bilaterally from his navel down to his toes, exhibited profound difficulty walking, and unsteadiness while standing. The diver was recompressed on Table 6 ["tables" here are hyperbaric medicine compression/decompression protocols] with extensions but had minimal improvement of his symptoms. Another Table 6 administered the following morning provided only slightly greater relief. Given the history of disc problems, the hyperbaric physician arranged for transfer to a hospital with greater diagnostic capability than on the island. As weather delayed air evacuation until the third day, the diver was treated again on a Table 5.

He was taken by air ambulance pressurized to one atmosphere to a larger hospital, but further diagnostic tests were inconclusive, and it was decided to continue hyperbaric therapy. The day after arrival, the diver received two treatments at 33 fsw (10 msw) for two hours with no improvement and later that day, a Table 6. Over the next seven days, he received 1-2 wound-care hyperbaric treatments (33 ft/10 msw) for 2 hours during which he reached a clinical plateau with no further improvement. His symptoms decreased over the next few months but intermittent symptoms continued, perhaps because of the existing disc problem.

 

Massage doesn't appear to have made the DCS worse--but can you think of any other role it could have played in this case?

 
If you work with scuba divers, it's useful to know the symptoms of decompression sickness. If a diver client mentions any of these symptoms, referring them to seek medical attention is the appropriate thing to do.
 
Signs and symptoms of decompression sickness
 
DCS type Bubble location Signs & symptoms (clinical manifestations)
Musculoskeletal

Mostly large joints

(elbows, shoulders, hip, wrists, knees, ankles)
  • Localized deep pain, ranging from mild to excruciating. Sometimes a dull ache, but rarely a sharp pain.
  • Active and passive motion of the joint aggravates the pain.
  • The pain may be reduced by bending the joint to find a more comfortable position.
  • If caused by altitude, pain can occur immediately or up to many hours later.
Cutaneous Skin
  • Itching, usually around the ears, face, neck, arms, and upper torso
  • Sensation of tiny insects crawling over the skin (formication)
  • Mottled or marbled skin usually around the shoulders, upper chest and abdomen, with itching
  • Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting edema)
Neurologic Brain
  • Altered sensation, tingling or numbness paresthesia, increased sensitivity hyperesthesia
  • Confusion or memory loss (amnesia)
  • Visual abnormalities
  • Unexplained mood or behaviour changes
  • Seizures, unconsciousness
Neurologic Spinal cord
Constitutional Whole body
  • Headache
  • Unexplained fatigue
  • Generalised malaise, poorly localised aches
Audiovestibular Inner ear [10][note 1]
Pulmonary Lungs
 
 
 

I'll let Neal Pollock of Divers Alert Network have the last word, as I can't possibly improve on the way he said it.

 

I end with the discussion of the capriciousness of decompression sickness to remind you of the power of the old adage of an ounce of prevention being better than a pound of cure. You are ahead of the game by asking the question. You should now think about all the little things that can all work together to keep your risk at a comfortably low level.

Neal W. Pollock, Ph.D., Divers Alert Network

How the principles of massage and remedial exercise were used successfully for the rehabilitation of a fractured leg

Submitted by Lee Kalpin on Thu, 08/11/2011 - 22:52
Posted in
case study on a fracture of the left fibula

How the Principles of Massage and remedial exercise were used successfully for the rehabilitation of a fractured leg – Lee Kalpin RMT

On Saturday, January 31, 2005, I fractured the fibula of my left leg. I wish I could tell my readers that I was doing something exciting and daring, but in fact the accident occurred, as most accidents do, in my own home.

 

mechanism of injury

Most fractures of the fibula occur as a result of forced inversion or eversion of the ankle and it is usually the lateral maleolus that is broken.  In my case the action was very different and the shaft of the fibula was fractured just proximal to the maleolus.  The action was extreme flexion of the knee so that my heel was touching the buttock, and forced plantar-flexion of the ankle. I then slid down several steps with my full body weight on the shin.

 

hospital treatment

Fortunately, this was a simple fracture and did not require reduction or pins - just a cast. It was very interesting for me to note that absolutely no information was given at the hospital regarding elevation of the limb, use of hydrotherapy, or exercise.  I realized that I was on my own with this injury, and was determined to make a full recovery as quickly as possible.

 

definitions of disablement

In order to have a good understanding of goals and outcomes in remedial exercise, it is necessary to define some basic terms.

  1. Pathology – the illness or injury that causes the symptoms
  2. Impairment – the symptoms as they affect the body systems; the limitations in movement and/or function that are caused by the pathology
  3. Disability – the changes and limitations to daily life and function that result from the impairments
  4. Handicap – the barriers presented by the client’s environment

 

protocol for a pre-acute injury

  • Pressure
  • Ice
  • Elevate
  • Rest

 

The pre-acute stage is identified as that short time before inflammation begins.  Inflammation can be limited by prompt intervention.  Massage therapists do not usually have an opportunity to treat immediately after an injury unless they are working with athletes during training and competition.

Immediately after the accident, I hobbled to my bed, elevated my leg, wrapped it in a tensor bandage and applied ice. This strategy limited the inflammation, pain and bruising.

 

testing

I palpated the painful structures, which were the fibularis longus and soleus, as well as the flexor and extensor muscles of the big toe.  I discovered point tenderness on the lateral aspect of the fibula about two inches proximal to the lateral maleolus. Xrays at the emergency department confirmed a fracture of the fibula and a fiberglass cast was applied. The doctor advised that my leg would likely be in a cast for eight weeks.   I was provided with crutches and instructed on their use.  I was given a prescription for analgesic medication and sent home.  I did not fill the prescription since the prompt use of ice had limited the pain.  Also, I live alone and did not think I could manage on crutches if my balance was impaired by strong medication.

 

protocol for an injury in the acute or protection stage

  • Rest from function
  • Ice
  • Compression
  • Elevation

 

Mobilize joints of unaffected limb.  Stretch muscles of unaffected limb

Mobilize joints of affected limb proximal and distal to the injury.  Maintain movement to decrease risk of thrombus formation.

 

application of protocol

The leg was rested from function as no weight-bearing was permitted on the cast.

It is possible to ice a limb in a cast by wrapping the cast in plastic and applying ice packs for extended periods of time. However, this was not necessary as I did not have excessive swelling.  I did apply heat packs to the inguinal area to encourage venous and lymphatic return

Compression was not necessary because of the cast

I kept the leg well elevated for many hours per day, and slept with it elevated.

 

I performed mobility and stretching exercises for the unaffected (right) leg several times a day while lying supine.  The unaffected leg takes the full weight of the body when using crutches.  Quadriceps and hamstrings are overused when raising and lowering the body from chairs and cars, using only one leg .

 

I moved the toes of the affected leg frequently.  This is necessary to make sure that circulation and nerve supply are normal, and also provides a pumping action to prevent thrombus formation.  I also performed mobility and stretching exercises for the knee and hip to keep those joints moving.

 

I did experience “transitional swelling” in the foot of the left (affected) leg during the time the cast was on.  This occurred if the leg was lowered for any length of time.  The foot became very swollen and discoloured (purple).  When the limb was elevated, the swelling subsided.  

 

disablement

impairments were swelling, and lack of ability to weight-bear on the injured leg

disability included difficulty in performing household tasks, lack of ability to bathe or shower independently, inability to drive my car (which is a standard shift), inability to navigate stairs on crutches, difficulty in walking outside with crutches due to icy conditions, inability to shop for food.  It was necessary to obtain a wheelchair because performing household tasks while balancing on crutches was just too hazardous.

handicap – the stairs in my house, and my standard car provided barriers to normal functioning. Icy conditions provided an additional handicap.

 

protocol for an injury in sub-acute or limited motion stage

 

Elevate if swelling is present.

perform gentle mobility in all ranges except the direction of the injury

perform isometric strength exercises

maintain mobility of the unaffected limb

maintain mobility and strength of the joints proximal and distal to the injury

         

Hospital treatment

After two weeks the fiberglass cast was removed,  my leg was xrayed again, and I was given a boot cast (or walking cast).  The doctor advised that this cast must be worn constantly and removed only to shower, and that I could not weight-bear on the cast.

 

Homecare application of protocol

I continued to experience transitional swelling, and therefore elevated my leg whenever possible.

Received several massage therapy treatments, including lymph drainage, muscle work on both the affected and unaffected leg, and passive stretching of quads on the affected leg.

I observed that there was some muscle atrophy in gastrocnemius and soleus, as well as the quadriceps muscles in the affected leg.  There was a noticeable difference in size between my injured and uninjured leg.

At this time I started to perform isometric exercises with the injured ankle, moving it into plantar-flexion and dorsi-flexion, using the cast as resistance.  I also performed knee extensions from a seated position using the weight of the rather heavy boot-cast as resistance to build up the quadriceps muscles.

Flexibility exercises for the unaffected leg were continued.

In spite of doctor’s advice, I did start to weight-bear with the boot cast after about two weeks.

I found that I could not sleep with the boot-cast on.  The first night I woke in terrible pain, which seemed to be either ischemic or nerve related, and I had to remove the cast. After that time I removed the boot-cast whenever I was resting and elevated the leg, propped between pillows to limit movement.  When speaking to other people who had experienced fractures, they told me that they also removed the boot-cast to sleep. I wonder if orthopedic specialists know this?

 

Disablement:

Impairment – lack of ability to weight-bear and walk normally

Disability– walking with crutches on stairs or snow continued to be a challenge but became easier as I could weight-bear on the boot-cast.  I was able to trade cars with my brother and driving an automatic car increased my mobility and independence.

I was not able to perform massage treatments, but did continue teaching throughout this time, missing only one class session!

 

 

protocol for return to function stage

stretches to affected limb to return normal range of motion

strengthening exercises to affected limb

balance (proprioception) exercises when a lower limb is affected

conscious effect to normalize gait when a lower limb is affected

Hospital treatment

Six weeks from the date of the fracture, my leg was xrayed again and I was advised that the fracture was healed, and that I could discard the boot cast and walk in a shoe with goodsupport.  The doctor told me that my injured leg would be weaker and that swelling of the foot would continue for a year. With good remedial exercise, this prognosis is not accurate.

I was given only one exercise to perform; that was a proprioception exercise of standing on one foot and balancing. No muscle testing was performed.

 

home care application of protocol

Quadriceps had returned to normal size as a result of exercise during the sub-acute stage.

I immediately focused on normal gait, making an effort to “roll-through” from heel to toe when walking and to avoid limping.  I found it beneficial to walk barefoot to build muscle strength and balance.

 I increased stretching of the ankle to obtain normal range of motion.  Walking up and down stairs normally requires good range of motion of the ankle.  Within one week I was able to walk stairs properly without the one-step-at-a time “baby-step” motion.

Increased strengthening exercises for gastrocs and soleus with weight-bearing toe-raises.

Balancing on one foot proved to be challenging.  We do not realize how many muscles come into play when balancing.  It took about one week to achieve balance on the affected leg.

Two weeks after the cast was removed, I reclaimed my car and began using my injured leg to work the clutch.  This helped to build strength in the plantar-flexors.

Cycling has been my major exercise activity as it builds all the muscles of the leg, and encourages equal use of both legs, without excessive weight-bearing.  I cycle ten kilometers a day, when weather permits.

I performed my first massage therapy treatment on April 1st– two months after the injury and two weeks after cast removal.

Two months after cast removal I accompanied a grade eight trip to Ottawa, where we did a terrific amount of walking, some of it over rough ground in the La Fleche Park caves. This was my test for the recovery of function in my leg, and I was well able to keep up with all the activities.  And I had a lot of fun too!

 

 

disablement

pathology -  Post-fracture/ muscle strain injury.  Pre-existing osteoarthritis in the metatarsal-phalangeal joint of the big toe was exacerbated, particularly in the right (uninjured) foot.  This is a result of taking the entire body weight on the right foot for several weeks.  The injury to the muscles, andt he arthritis are more of a challenge than the fracture.

impairment -  All ranges of motion of the ankle are normal.  Pain is felt on forced plantar-flexion of the ankle when kneeling with the weight of the buttocks on the heel. Some pain in both feet after extensive walking due to arthritis.  There is palpable scarring in the plantar fascia and the tendon of the flexor muscles in the affected foot. I perform aggressive self-massage on these areas, including muscle stripping, trigger-point release, and frictions..

disability -  There is no functional disability.  I am able to perform all tasks and functions without pain.  I am working on improving my general conditioning.

 

conclusions

The principles of hydrotherapy, remedial exercise and massage are extremely effective in the return to function of a fracture injury.  Massage therapists can play an important role in rehabilitation.

 

I had believed that hospitals and medical staff provided adequate support and advice. My experience taught me that very little support is actually provided. There is a real concern that some clients, particularly those who are older, might never make a complete recovery from their injuries without proper care. There is a real need for massage therapists to provide treatment for clients with fractures by providing massage, in addition to advice on hydrotherapy and remedial exercise.  A progressive remedial exercise  program which begins in the early stages of healing is crucial to achieving a satisfactory outcome.

Exercise

Submitted by RST on Thu, 02/24/2011 - 07:08
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