When Jump Signs Make Treatment a Real Crack-Up
Recently I have had several patients who have produced new thinking and creativity regarding the blended use of treatment techniques.
23/yo female distance runner: While working with this patient with persistent R gluteal pain, particularly during long periods of sitting or sustained/intense up hill running, I noticed that while her trust in me as a clinician was high, she was almost impossible to palpate due to significant jump signs. Seeing, but not always treating, this patient roughly twice per week as she began to train for high level competition, PRT and PRRT were effective as treatments and held until significant aggravating factors were introduced. Yet each time I would begin palpation, throughout the hip, glute, thigh, and lumbopelvic region, significant jump signs would occur, even in the absence of any reported pain at the palpation site. As a random thought, I began to palpate areas largely unrelated to her chief complaint. Gastroc (JUMP)... upper trap (JUMP)... wrist extensors (JUMP)... It was here that a rather unremarkable light bulb flashed in my head and I decided to complete a PRRT "1 minute" nociceptive exam. Tender points abound, however jump signs accompanied almost every palpation. PRRT Primals were utilized and eliminated not only all of the nociceptive exam tender points, but the jump signs in both the nociceptive exam and in the local area being treated around the R hip and thigh including the adductor complex, sartorius, illiacus, and piriformis, allowing me to utilize PRT effectively. This sparked a thought process surrounding the use of PRRT Primals, TREs, and other downregulating techniques prior to treatment in sensitive patients.
17/yo male football player: At 6'7'' 260lb this young man presented as the worlds largest Tickle Me Elmo complete with a red beard. Imagine this soft spoken Sasquatch responding to Mulligan, for transient hip pain, sometimes bilateral, with an inability to provide treatment via PRRT or PRT due to jump signs and tickle responses. This particular patient would even respond to reflex testing at the patellar tendon with a giggling fit. Palpation of the first rib would result in the patient going into cervical extension, shrugging both shoulders, giggling, and wiggling to the furthest end of the table possible. While administering a PRRT "1 minute" nociceptive exam, the patient responded to palpation by, quite literally, crossing his feet and arms, and toughing through the giggle responses and jump sings. After performing PRRT Primals, not only was I able to reassess the PRRT "1 minute" nociceptive exam with no pain, jump signs, or guarding behavior on all previous sites, but was able to palpate the adductors and hip flexors without jump responses and treat with PRT accordingly.
14/yo female cross country runner: 'Thssssssss', we all know this sound, it is the sound made when tender point palpation sneaks up on the patient in a sensitive area or the patient of hypersensitive to palpation. This bilateral MTSS patient presented with the 'eyes wide open, tremor, and thsssssss sound' upon palpation in every area of her body I could concievable connect to MTSS. The same response was present during the PRRT "1minute" nociceptive exam. PRRT Primals and a bit of spot treating for upper T-Spine and plantar reflexes reduced all of her pain upon palpation and jump signs to zero saving those directly over the R posterior tibialis and an area of the R tibia that I would go on to evaluate further. The PRRT plantar reflex self release, or the 'crampy thing' was utilized to some effect, though the treatment was too uncomfortable for the patient to tolerate on an on going basis. Enter TREs. TREs, another global down regulating treatment, worked quite well with this patient, reducing her jump signs and allowing for some spot treatment throughout the hips with PRT. TREs were incorporated into her harder rehab/cross training days as a cool down, often only utilizing the last position, the bridge and butterfly. TREs have also proven to be an effective and highly desirable treatment for the 6'7'' football player as a way to cool down after his therapeutic exercise program or after football practice.
It seems that techniques which provide global ANS down regulation not only allow for further treatment in such cases by easing some of the apprehension involved with hands on treatment, but are desirable to this up regulated patient population as a treatment option. These cases highlight some of the ways I have blended techniques to help patients who are seemingly difficult to treat and assess due to an aversion to palpation. While I have not defeated the tickle monsters, but this round goes to me.