avascular necrosis of hip

[stregapez]

I got a phone call from a fellow today who scheduled a massage with me tomorrow afternoon. He has avascular necrosis of the hip (post car-accident), has quite a bit of pain, and says he gets regular massages *to improve circulation to the area*. Thoughts? Can massage improve circulation to bone in a mechanical way. How about autonomically? Can avascular necrosis have an automonic aspect?
(by the way, I am about 1/4 of the way through the thread on autonomics, using online dictionaries :))

Dana

[stregapez]

So, were these questions too ignorant to warrant a reply, or were people just hesitant to give a definitive answer? or are you just not interested in massage :)

I saw the client Friday. I may possibly pass him on to someone else (and lose the opportunity to have a regular, 2 time a week client), although he likes me...and wants me to adapt my techniques for him. I normally use forearms, fists and palms a lot, and this guy doesn't much like it, and really wants me to use my thumbs and fingers a ton (which aggravates my hand condition)

In any case, I am curious about AVN now, and massage, or anything else that could help, or not

It turns out it is idiopathic, probably not from an accident. Guy is about 55.
His first orthopedist told him to start using a cane, and that he would have to have surgery in a month. He didn't use cane and docor got angry. Meanwhile he began acupuncture "to open to meridians" and homeopathy.....
Went to see second orthopedist (apparently someone widely respected in town) who , according to client, recommended against surgery, and suggested he get massage regulary "to aid circulation" Client started to do so at least twice a week for a few months, Upon last visit to the doctor, doctor told him he could see new tissue repair (I am assuming this means vascular repair, as everything I've read on the net says bone repair with AV can only be sclerotic)

In school we learn, on promtional material we see, we are told by mts, constantly, that "massaage improves circulation" While I'd like to believe that, and tend to somewhat, I've never been sure in what way it's true and, moreover, what significance that has.
My questions (some of them applying generally, not just to AV)
1) Does muscle (and skin maybe?) really get ischemic from tension ? and can this cause pain (seems to me like it could)
2) If massage really helps blood circulation to muscle and skin (and other soft tissue) mechanically wouldn't that last only during the massage, and is it thus significant? I'm guessing it could *help* break an ischemic pain cycle .
3)Importantly, in this case, if someone has avascular necrosis of bone (head of femur), can massage really help that via mechanical circulation ? And if it does only for the duration of the massage is that actually significant in heading off the disease process?
4)Ok, everything has an automonic and an emotional component, and if if massage helps the guy to get into a parasympathetic or happy/confident mental state that would be good (though, actually he was one of those rare clients who never seemed to relax mentally during the whole thing, which may have been due either to him not liking mt technique, or to his personality, who knows) I am wondering a wee little bit if sympathetic-prone people might be more likely to get ideopathic AV, but that is only a hunch, and I feel close to playing witch-doctor speculating about that...

I am also wondering why the 2nd ortho recommended against surgery, as everything I've read so far says surgery is usually highly recommended to offset further bone deterioration.

I'm also very curious about massage helping circulation in bed-ridden people (especially elderly) It seems to be true, from what I hear, and on "The ABCs of Geriatric Massage" video I now own, Dietrich Miesler swears he has twice saved a leg in an old person with massage (that was scheduled to be amputated !). I don't totally see how doing massage twice a week on a limb could have that great an affect, but I am probably missing something.

I asked the AVN and massage for circulation on orthopedic massage e-venue, and got only one not-so-sure (doubtful actually) answer. I could ask it on a regular massage forum, and I may, but I wanted to ask it here too. My friend who runs a massage clinic, and used to teach at a massage school assures me it can help with circulation to and form bone (including lymph)

Dana

[Jon Newman]

Dana,

I think seeing an accupuncturist for AVN will be about as helpful as seeing a massage therapist.

[stregapez]

I can see how both could help with pain and sense of well-being, and they do for him (though i haven't personally had much benefit when i've gotten accupuncture) But don't know about circulation to the bone (re massage, nevermind accupunure), and so am unclear an ortho told him this.

Other opinions?

Dana

[nari]

If an orthopod told him this, it sounds as though he does not want to take further action (ie surgery) at this point. The fellow is probably too young for a total hip arthroplasty, which should at least help him.
Sounds like the ortho is biding his time until things either get better or worse.

We really can't advise your course of action - too many unknowns. You can only be guided about how much the patient is willing to try massage as an only hope. As long as he understands that there are no certainties it will help.

Nari

[stregapez]

Thanks Nari ~ no thoughts on circulation and massage???

I'm not going to tell him "you're doctor is full of ****" on that (not anytime soon at least) but I'm curious about the rationale. I did tell him I had doubts re mechanical effects (but when you come down to it I actually have no frigging idea)

I would suggest he "get"/learn Simple Contact but I am doubting he'd want to replace massage with it, from what I see/am told by him, plus I don't actually know what it is :) and I don't know any practitioners in the area. I told him about Trager tonight (involves gently moving with no rubbing or stroking) and that I wouldn't mind becoimg a practitioner, and he said "but do you think most people would really like that? (basically) :)

I'm going to keep giving him massages for now ( saw him tonight; we compromised on the length of time, number of days per week, and technique) So I guess I'll see about talking to the doctor, since his former CMT was able to do that.

Can anyone possibly have actual healthy bone repair with AVN?

Dana

[nari]

It would seem highly unlikely...once the process has started, it doesn't seem likely that it would be reversed. I guess it might be possible for it to stagnate, but that is a guess. It behaves something like gangrene - a necrosis.

Nari

[aléa]

Right. I don't know how massage could help reverse necrosis anywhere, especially in the bone.
soft mobilisation would probably be more helpfull, to save function that is.

[Barrett Dorko]

It would be a mistake to speculate that Simple Contact and the consequent ideomotion would help him. I think it's important not to state or imagine that things will change with movement designed to do something else though, as we know, "hope springs eternal."

This is what keeps con men in business.

An OT last week wanted me to treat her at the end of class for her "balance issues." Makes you wonder where she'd been all day.

[stregapez]

Barrett,

I'm not yet totally informed as to exactly what Simple Contact is supposed to do or help with. Been meaning to frame some questions re that or exactly what I should read, but so far been occupied by other things. Were there a reason to mention it (such as I knew how to do it, or knew anyone else in town who did it) I wouldn't have tended to suggest it could help repair necrotic bone or even increase circulation. According to my understanding it can possibly help with pain, and discovering natural movement that helps with pain.

Ale'a, or anyone,

I dont even know what soft-mobilization is. The words seem to be used differently by different people, *i think* (example pts vs mts) If anyone feels like giving a short explanation that'd be great. I have no problem at all suggesting my clients see a PT in addition to or instead of massage. The problem is I'm relatively ignorant about what PTs do... I don't remember this guy mentioning seeing not seeing one way or the other, and haven't had the right opportunity to ask yet. He is quite "stubborn," for the record

He swears massage (of aductors especially) helps tremendously with acheiving painless range of motion, though I'm not sure for how long after a massage (will ask)

For good or bad, too, the fellow seems to be looking for friendship and someone to talk to as much as massage and he has decided I'm that person. We'll see how that goes (I had anxiety dreams about it last night, but usually i adapt to such things, lately)

Hopefully if he needs surgery and/or to see a pt he'll do that eventually.

Dana

[emad]

Dana ;

I am not following the main topic idea regarding necrosis ,but i catched your questioning about the difference between massage and soft tissue mobilisation ,in my own view, no great difference all are touch basically .I have a good article regarding soft tissue mobilisation was in the manual therapy Journal but not on my computer it is in papers .I will try to find something on the web for you .

Regards
Emad

[stregapez]

Thanks Emad.

Any suggestions of skin techniques for hip pain Diane? (in case he is open to some of that in place of deeper stuff?) Might be easier on my hands.

Or "myofascial" techniques, anyone ?(I have Sean Riehl's video as a guide :)) Yoo bad he doesn't appear to teach the classes anymore

Dana

[Jon Newman]

Dana, the following might help. Let us know what you find out. Thanks.

Non-traumatic avascular necrosis of the femoral head.
J Bone Joint Surg Am. 1995 Mar;77(3):459-74. Review. No abstract available.
PMID: 7890797

Nontraumatic osteonecrosis of the femoral head: ten years later.
J Bone Joint Surg Am. 2006 May;88(5):1117-32.
PMID: 16651589

[Diane]

Any suggestions of skin techniques for hip pain Diane? Well.. that depends.

First of all, is his "avascular necrosis" a real diagnosis, based on MRI or something, or just a medical assumption based on physical lack of range? Also, how long has he been like this? I can't answer with the info that's been presented so far, and I'm reluctant to base any conclusions/treatment ideas on such a dx if it is real.

If it is actual avascular necrosis, nothing you do or any manual treatment will do is going to really help anything. It's a surgical problem.

If it is merely a painful hip with limited abduction, try handling the obturator nerve, in prone. Not massage of the adductors (sounds painful).. rather just rest your arms on the back of the leg, let your hands wrap round the skin of the inside thight, wait for your fingerprints to stick to his skin, then pull it slowly and steadily, and not very far, upward, rolling the soft tissue around the femur into internal rotation. Then pause, and wait. Wait some more. Wait longer. In two or three minutes you should be able to feel a change, something will feel like it elongates, and the thigh will relax and feel like it can stretch further in the direction you're taking it. Wait again. Eventually you will have taken up all the slack the guy's nervous system can offer you, then let go slowly. That's it. Check for more abduction, and if he has more, then good. If not, then he doesn't; move on.

Massage is to manual therapy as beans are to vegetables; one type, certainly not the last word in soft tissue handling.

[stregapez]

Thanks Diane

He says he has had MRIs, and, as i said in the first post, the first orthopedist recommended surgery. According the to the client, the second orthopedist recommened against surgery, and also told him the last MRI showed improvement and some "repair". Go figure. Like i said, i don't know enough about AVN to know if that's possible or what it could mean. I really will try get in contact with the doctor in next week or so.

He does seem to have a lot of muscle tension in adductors. I am working adductors a lot because *he* INSISTS on it. I gave him a talk on how I don't think causing pain is a good thing before the first session. He assured me that what he likes done on his bad leg does cause some pain while it's happening but makes him feel better afterward (walking doesn't hurt etc) And like I said he is very , very hard-headed. It's possible that even though he has AVN, part of his pain is related to muscle spasm (in my opinion) secondary to the AVN, or maybe it's partly a psychological thing where he thinks the muscle work will make him feel better. He has resumed playing golf since he started getting massages

In either of those cases perhaps the skin streching could do the same thing. (I know the guy well enough though to assume he will insist on at least some massage of adductors. I'm not doing it real deep, but he isists on having it done for a prolonged period of time.)

Jon, thanks. Maybe will get a chance to make a trip to the library.

Dana