"Maybe If You Just Press Harder"

Touch is a Form of Communication

By Douglas Nelson
[Table Lessons]

“My levator scapula is killing me,” she said. With that opening, it was clear that my client, Mrs. M., had some background in anatomy. The funny thing is, these self-assessments are seldom correct (including my own!).
“Tell me more about that,” I said.
“I’m a physical therapist, and at the hospital I am often pushing and pulling on patients from awkward positions. There often isn’t an ergonomic way to move them, and I’m sure that is what started this pain. For the last three weeks, the area of my scapula near the medial angle has been really angry. At first, it was intermittent; now, it is my constant companion.”
“May I check a few things first before we jump right into treatment?” I asked.
I had Mrs. M. sit in front of me while I passively moved her neck, checking her range of motion. Since the right side of her neck was the problem, I expected some limitation in left lateral flexion. To my surprise, I could not perceive any restriction or even a hint of hesitation on her part. I tested lateral flexion again, but this time to the right. Again, no hint of pain or limitation. Repeating left lateral flexion again, this time I put her neck in flexion to pre-stretch her levator scapula. There was still no limitation in left lateral flexion. As the final movement, I raised her right arm overhead, which rotates the scapula into upward rotation. Since the levator scapula helps create downward scapular rotation, this arm position (plus left lateral cervical flexion) creates maximal stretch on the levator scapula. Still, she felt nothing.
“I don’t feel much of a stretch, but it’s pretty tight back there, isn’t it?” Mrs. M. asked.
I smiled and nodded with no verbal response. To be honest, I find these questions quite awkward. Mrs. M. was looking for confirmation and validation, yet that isn’t what I found with my assessment. She knows what she feels, but the reason for her experience is probably not what she thinks it is. For me to say that so early in the session is quite risky; it could easily be interpreted as invalidating her perception and refuting her assessment of the source. That is not a good decision if I wish to create a therapeutic alliance with a client, so I went a different direction.
“Let’s explore this on the table. Could you lie face up please, and let’s see what we find in the tissue?” I asked.
With Mrs. M. in the supine position, I put the right scapula in a slightly elevated and protracted position, exposing the levator scapula attachment at the upper angle.  
Pressing quite firmly into the tissue, Mrs. M. gave no reaction.
“Is this tender?” I asked. “This is where the levator scapula attaches.”
“Maybe if you press harder,”
Mrs. M. said.
“Let me try something first,” I said.
Changing the angle of my wrist, I directed my pressure to the second and third rib, rather than the scapula. Mrs. M. winced in pain.
“Oh, my goodness, that is super tender,” Mrs. M. said. “I don’t think I can take that much pressure. Is that the levator scapula as well?”
“Actually, it’s a different muscle, and there is an important lesson here. May I show you something?”
Placing my finger on her forehead, I demonstrated the amount of pressure I was using on her rib.
“You’re kidding. That’s all the pressure you were using? It felt like three times that much,” she said incredulously.
“When I was on that first area, do you remember saying it might be tender if I just pushed harder? I was using almost three times the pressure at that point, and it still wasn’t tender. Isn’t that amazing?”
“Why would that be?” she asked.
“In my experience, when people ask me to press with an inordinate amount of pressure, I’m simply in the wrong place. Pressing harder won’t improve the situation. Touch is a form of communication, and the amount of pressure I am using is much like volume in verbal communication. If you don’t understand what I’m saying, I doubt that you would want me to say the same thing louder. You’d probably ask me to say it differently. Pressing really hard is analogous to yelling. If what you say is communicated clearly, you shouldn’t have to yell. That’s hard on everybody.”
 “I am assuming that the second place was a different muscle? What was that?” asked Mrs. M.
“Welcome to the serratus posterior superior,” I replied. “Nasty little guy, that one. Shall we continue?”
 What followed was very focused, gentle, and thorough work on her serratus posterior superior. I have seen her for one follow-up session, and her symptoms are 95 percent better. She is thrilled. And, best of all, no yelling!

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois, and president-elect of the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com, or email him at doug@nmtmidwest.com.