Post childbirth pain

[-xoxo-]

I sure hope someone can give me some more ideas on how to help this woman. She has had severe sciatic pain since she had her baby five months ago. Here's the story: this was her eighth baby, a long and hard labor, the midwife had her to squat to push. She does not remember feeling anything tear (but in that situation, it would be hard to separate the different pains!). The next day her right hip was hurting, and by the day after that, she could not get out of bed. It was over a week before she could walk at all. She had severe sciatic pain radiating down the outside of the right leg She went to her chiropractor who diagnosed stretched ligaments in the sacroiliac joint, and a tipped and twisted pelvis. Four treatments later, she could walk slowly with a walker. Then she called me. I found extremely tight muscles on the right side, pretty much all of the muscles from the ribs to the ischial tuberosities. The left side was almost as bad. Plus, her upper arms and shoulders were tight from using the walker. She has difficulty moving her hips to get on and off the table, and walking is done very slowly and with obvious pain. TFL and glute minor are sore to touch, as are the attatchment points all along the sacrum, coccix, illiac and femur. The thigh adductors are tight and tender, too.
I have done as deep of work as she could tolerate all through her hips, doing stripping, cross fiber friction, slow myofascial stretching, and some friction on the accessible areas of the ligaments. Piriformis is very stubborn, and it feels like the deeper muscles, gemellus and the others, are involved. (It's hard to access these, as she is rather heavy.) Today, I worked on her side-lying and really got some good release all around the hip joint and in TFL and glute minor.
Should I be working more on those sacral ligaments? Should I be trying to access Psoas? Any advice would be appreciated.

 

[Abbie]

Post childbirth pain

Stretched her SI ligaments? Good heavens, no wonder she's in pain!

Be very cautious about deep work. Her SI joint(s) are less stable now than before, and her muscles are probably tensing to stabilize the area. If you work too aggressively, you could aggravate either the muscle spasms or relax them enough to destabilize the joints further - leaving her more vulnerable to greater injury.

Painful work is not the answer. Her CNS is in protective mode, and you don't want to fight it. Instead, work with it. Gentle MFR and positional release may help reduce the bracing without destabilizing her pelvis further. Gentle AIS, PNF, or muscle energy technique may increase her ROM while strengthening the stabilizing muscles around her sacrum. Minimize the pain of the treatment and you will obtain better results.

Those are the extent of what a massage therapist should consider doing at this point. If she is still seeing her chiro, great - but she needs to spend some time working on stabilizing and strengthening the SI joint and surrounding tissues. For that, she needs to see a physical therapist for a proper assessment and to get initial guidance. With that in hand, she will improve more quickly and may graduate to doing some work with a knowledgeable personal trainer. (I have done this type of training - it can be tricky and takes a careful touch.)

At all phases of her recovery, your role is to be a supporting member of her treatment team, and that may mean taking a back seat to her other care providers from time to time. Get her to a PT ASAP, then see how things proceed from there.

 

[Chipmunk]

Post childbirth pain

I agree with Jason. My first thought on reading the OP is that this woman needs careful, nurturing, gentle work for now. recovery from childbirth itself can take months, when the birth is difficult it can take even longer. I remember that even 6 months after the birth of my daughter I felt like I was in shock...

 

[Ramin]

Post childbirth pain

Thanks for the feedback. I have not trained in AIS or PNF, whatever those stand for. The myofascial I was trained in is slow, specific stretching of individual muscle strands, and is not painful. Sometimes a little uncomfortable, but not painful. I'll have to go back to my books and refresh my memory of the Jin Shin Do points for that area and try some energy work.
This client is Amish, and will not go to a PT. They don't even see a doctor unless it is an emergency or other methods have failed. I don't have a clue what she could do to try to strengthen the area and increase range of motion. I would be reluctant to do any pulling/stretching for fear I would further injure something. I HURTS her to move her legs/hips.Range of motion movements is out of the question. I did read on this forum about problems with the pubic symphisis(sp?) that could be also involved. I plan to check that next session.

 

[Pompal 09.]

Post childbirth pain

Thanks for the feedback. I have not trained in AIS or PNF, whatever those stand for. The myofascial I was trained in is slow, specific stretching of individual muscle strands, and is not painful. Sometimes a little uncomfortable, but not painful. I'll have to go back to my books and refresh my memory of the Jin Shin Do points for that area and try some energy work.
This client is Amish, and will not go to a PT. They don't even see a doctor unless it is an emergency or other methods have failed. I don't have a clue what she could do to try to strengthen the area and increase range of motion. I would be reluctant to do any pulling/stretching for fear I would further injure something. I HURTS her to move her legs/hips.Range of motion movements is out of the question. I did read on this forum about problems with the pubic symphisis(sp?) that could be also involved. I plan to check that next session.

You have good intentions, but energy work and myofascial release aren't enough. Amish or not, her issues require a scope of practice beyond that which you have. She needs to be educated about the special challenges she is facing, because failure to address this properly now could result in a lifetime of needless pain and longterm disability.

Help her see the need for proper medical evaluation and treatment. This is the greatest service you can render her.

 

[Dilly]

Post childbirth pain

Jason is right, she needs more help than you'll be able to provide to her. Hopefully even with her Amish traditions she'll be able to find the appropriate person to help with the necessary healing & strengthening. Perhaps you can at least aide her in finding another massage practitioner with more extensive training, since she is unlikely to see a doctor for her condition. Consider someone who knows Structural Integration, Active Isolated Stretching and the like, who can also help give her the exercise routines she will be needing.

By the way here's a website link for PNF (Proprioceptive Neuromuscular Facilitation) for your information:
http://www.thestretchinghandbook.com/archives/pnf-stretching.php

Here's a list of AIS practitioners in Tennessee (taken from Aaron Mattes website: stretchingusa.com) Hope this list will get you started making some calls

Nashville Shannon Marlowe 615-356-5888

Nashville Tonya Dickie 615-460-0082

Nashville Cheryl Fugua cell: 615-414-3253
615-758-8978

Knoxville Connie Legate –Krusenklaus 865-951-2975
Email: tsmg2260@gmail.com

Knoxville Tennessee Sports Medicine Group 865-951-2975
Email: tsmg2260@gmail.com fax: 865-951-2972

Knoxville Kimberly Heinks 865-384-6055
competitedge@comcast.net MS.Heinks@hotmail.com

Brentwood Doug Harris 615-480-6003
Tennessee Stretch Therapy

Lexington Karol Lyster-Disher 731-968-9206
Email: disher777@yahoo.com

Norwood Robin Smallen 781-414-9334
Email: volswinbig@msn.com

Memphis Stephanie Corder 901-754-6008 or 901-652-3876
http://www.stephaniecorder.com

 

[Tyagi G]

Post childbirth pain

Oh wow. That is definitely not good.

The nerve in question is most likely the lateral femoral cutaneous nerve, which runs very near the hip joint. Chances are good that during the long, difficult labor, the ligaments stretched, allowing the right ilium to shift and stretch abnormally, which caused stress on the right hip joint, irritating the femoral cutaneous nerve, which would give her the electric sciatica-like pain on the outside of the thigh. Not fun at all!

The ligaments will eventually return to their normal position, as long as the pelvic bones are aligned properly. If her DC is helping her, wonderful. If not, (or if her progress plateaus), she needs to see a DC who does clinically-oriented applied kinesiology. I'm not talking the chicken-bone waving here I'm talking one who performs real muscle tests, makes their adjustment, and then re-tests to make SURE the adjustment was effective. This is especially important when you're talking the pelvis. OR, a DC certified in Activator technique - something gentle that the CNS won't balk at, that still gets the same job done (i.e. the joints adjusted) with a fraction of the force. Activator has a strict protocol to it that also involves testing, before and after. Any DC can put her on her side and lean into her, hear a cavitation (the "crack") and call it good, but that would be counterproductive. And to NOT see a DC right now is the last thing this lady needs.

I agree wholeheartedly with Jason - no deep pelvic work. Go ahead and give firm pressure to the upper traps and pecs and whatnot, but Jason's right - the ligament laxity is a major CNS decision to guard and stabilize. The brain knows her body's not stable so it's resorting to other measures, recruiting the muscles to work overtime.

If I were her, I would personally get a sacroiliac support belt. These are wide and durable, very comfortable, and they offer support to lax SI ligaments while they resolve, especially when walking or sitting or rising from a seated position. I've personally tried those and they ROCK. You just wear them right outside your clothes. What a difference they made with me!

I sure hope she feels better soon. As much as I don't usually recommend Standard Process, I used them during residency and had several patients on the Ligaplex II formula and they believed in it even more than I did - may be worth a try. They're nutritional supplements that come in capsule form and you take 2 caps at a time (I forget whether it was just once a day or 2-3x/day) and they should theoretically speed the stabilization of the ligaments. The patients responded incredibly well and they reviewed a big difference.

Hope that helps!
Hugs,
~Jyoti

PS: Has she had post-partum lumbopelvic x-rays? If she were my patient, she'd definitely be getting some

 

[Reyna08]

Post childbirth pain

Thanks for all the feedback. I did stop doing any deep work and just did Jin Shin Do and gentle MF. The day that her TFL let go saw big reduction in the pain when walking. I encourged her to see an MD for X-rays, but so far she hasn't done it. She has been seeing her chiro pretty regularly, and I worked on her every week for 4 weeks, then every other week, now once a month. She uses essential oils every day. I don't know which ones, it is a commercial blend similar to Young Living's PanAway. She is walking much better, much less pain, and can get on and off the massage table with no trouble. I researched some stretches and exercises out of one of my massage textbooks and printed them out for her, with the stipulation that it was entirely up to her if she used the information or not. She has done some of them and thinks it helps, some of them either hurt to try or didn't seem to do much. I do wish she would see a PT, but it's not like I can tell her she HAS to. I have hopes that given time she will be pain free if nothing happens to re-injure the area. Having had low back/sacrum issues myself in the past, I know it can take a looooog time for ligaments to heal, and it doesn't take much to re-injure the darn things. Again, thanks to all who answered this post. Makes me feel less like I'm all alone out here!

 

[Omar]

Post childbirth pain

Update: I had to have rotator cuff surgery and was off work for 5 months. Just got back to work, contacted all my clients to let them know, and found out that this lady is pregnant again already. She is walking better than back in September when last I saw her, but not back to normal, and I'm wondering how this new pregnancy will affect her injuries. I have'nt treated her yet, her appointment is in 2 weeks, so don't know what I'll find in the way of scar tissue, imbalance, etc. Any suggestions? I'm going to have to do some serious thinking about how to address her issues in side-lying position. I know I'll have to be sure she is well supported and not twisted while on the table. Wish I had one of those support systems with all the shaped bolsters, but I don't. ( And wouldn't that be fun, carrying all those cushions around in the car? I do house calls, 35 miles is a bit far for a buggy ride.) Is it at all possible that the relaxin (sp?) in the later seforum.xxxes of pregnancy could actually HELP resolve her issues, or is it more likely that the instability will make her worse? I know from my training that you must be very cautious when stretching pregnant ladies in the last trimester because the joints get really lax and easily injured... I've heard of a support belt-type thing for pregnancy, would that be a good or a bad suggestion? (I've never been pregnant, so am not familiar with a lot of stuff pertaining to such things.) Any ideas would be welcome.