Written by: Judy Fasone RN, MSN-Ed, AHN-BC, HWNC-BC, SCTP
Columbus, Ohio
Abstract:
This case report illustrates how a person with a complex series of injuries and surgeries can regain a capacity of hope and healing utilizing the Trager® Approach. The client presents with a Foot Drop on the right side, severe chronic pain and hopelessness, and a desire and willingness to feel better. He survived a forty-foot fall from a tree, twenty years ago, and has lived with extensive repair to his spine. He has been living with pain from the limited mobility of spinal rods, vertebral fusions, and more recent hip replacements. Now, in an aging body, he seeks alternative care after being told, he “will just have to live with his pain”. After a series of sessions by a Senior Trager Practitioner, his mobility, functional status and sleep have improved; and his pain has decreased significantly.
Key Words: Foot Drop, Trager Approach, Self-care, Alternative therapy, Neuroplasticity
Introduction
Over a period of six months, sessions were given weekly to the subject of this case report, to reduce pain and address Foot Drop, which had been neglected. The Trager sessions gave the client relief as well as new information that allowed greater freedom in walking, better sleep and less hopelessness. At the end of each session, playful movement instructions for use at home were given. Milton Trager, M.D. (1908-1997), the originator of this approach felt repetitive movement such as rocking, enable the activation of positive neurological changes, which improve movement patterns (Fuchs, Fuchs, & Flügge, 2014). This somatic approach is known as psychophysical integration (Trager, 1987). Healing pathways are revealed through deep listening and a mutual trusting and respectful relationship. This case report includes personal testimony from the client and notes from a few of the sessions.
Presentation
On March 15, 2019, Eric, a 63-year-old male, 5’11”, 185 pounds, requested help from this Trager Practitioner for movement re-education, pain management and depression. His current problems include right Foot Drop, severe continual pain, poor sleep and hopeless feelings. Eric has an unsteady gait, lifting his right hip, leg and foot as he steps. His Foot Drop came on gradually after a hip replacement surgery (2015). The surgery was done to correct damage done by compensation patterns in his gait, after falling forty feet from a tree in 2001. At that time, the trauma included a broken hip, tail bone, ribs, shoulder and open book pelvic fracture; and resulted in surgery that included metal plates, two spinal rods and fusions. More recently in 2017, a third spinal fusion occurred. The right leg is muscle wasted and cold compared to left leg. An MRI and ultrasound were negative for structural damage of the leg. Foot brace and cane use is encouraged, although Eric prefers not to, as he is embarrassed by assistive devices.
Exacerbating factors include the physical stressors of heavy lifting while gardening, toting musical equipment to gigs and group music lessons with children, and sitting and standing for long periods of time. He can stand comfortably for three to four minutes. Emotional stressors include daily pain, wearing a visible brace in summer and falling in public. He voices feelings with appropriate affect and can share his needs and feelings in the moment. Eric sleeps poorly, waking every two to three hours a night due to feeling the hardware in his back. Pain is a constant eight out of nine on a pain scale of 1-10 and radiates from back to lower extremities but is poorly localized. Eric uses wine/beer, lidocaine patches, and CBD oil to assist with comfort and better sleep along with current prescribed medications: gabapentin, meloxicam, tramadol. Eric has received massage and acupuncture but has not experienced the Trager approach. Other alleviating factors are hot and cold baths (in summer).
Each session utilized the Trager Approach, which includes hands on while lying on a massage table and movement re-education called Mentastics® (mental gymnastics as defined by Milton Trager MD) which consisted of standing, sitting and lying. Self-initiated movements are guided by the practitioner. Eric was encouraged to find his own images and movement, and to gently explore his edges of comfort. During each session, the practitioner provided passive range of motion to initiate new, freer movement patterns in Eric’s body. Film footage was taken approximately every four weeks and shared with the client to allow him to visually see the improvement that was otherwise not noticeable to him. The following journal entries detail more personally his changes after four weeks into treatment:
Eric’s notes after the fourth session:
3-31-19 I have had chronic pain for many years, and by the new year (2019) I was barely sleeping 2.5 hours at a time. The “hardware” in my back was really bothering me. Good thing was, nerves were returning. That exposed the sensation of the two long rods and the six screws. It feels like sleeping on a small tablet or silverware. My muscles were very contracted and have been for some time. It is like when you brace yourself for an upcoming collision. I walked, stood and sat hunched. My Foot Drop added to my insecurity and self-consciousness of becoming handicapped. I slept all night after my first Trager session. Wow. That felt so good. I am reminded in my sessions to stand erect, up with the crown of my head, upward with my chest and have a bit of weight in my tailbone. Those instructional words follow me now daily. I hear them when I get out of my truck and walk into a store or when I’m walking out to the garden. It’s making a difference. Judy and I both know I won’t be taking these sessions forever, yet I can learn how to heal myself and benefit from Trager forever. The therapy continues to relax and lengthen my muscles. I am learning more about my recovery and my Foot Drop, too. I’m so encouraged by Judy and results of these sessions. I really am.
Practitioner notes:
3/23/19 Session #3 Eric hasn’t used a lidocaine patch since last session. Sleeping 7-8 hours a night with CBD and wine. Friends say he is walking better. Can now stand 10-12 mins with comfort. “I’m not as contracted with tight, sore muscles”. “I don’t feel like a broken person when I brush my teeth in the morning”. Toes are engaging more up and down.
4/18/19 Session #5 Dorsiflexion is better. Moves foot up and down 20 times and feels exhausted. Daily practice is helping. Using weight shifting as practiced in previous sessions. Added acupuncture sessions over the past 2 weeks.
4/24/19 Session #6 Practiced crawling to relearn cross crawl pattern. Rocking from heel to toe daily. Sleeping well continues. Easier to lie on back. Has no pain now, just weakness in back and leg.
5/2/19 Session #7 Toe lift improving. Extended knee, alignment improved. Balance still a problem. Standing for 12-15 mins without pain. No pain except occasionally at night when flat on his back too long. Shoulder improved after he stopped dragging the trash can from the truck to the end of the driveway. Both awareness of body and energy levels increasing.
5/23/19 Session #9 Gait improved, left shoulder engages in lift. Arms looser in stride. “this approach has helped me more than any other medical treatment I have tried”
7/31/19 Session #15 Returned from a 10-day camping trip to “forget about the aches and pains”. Feels better about using cane and foot brace when needed.
Eric came regularly for 6 months of weekly sessions. His movement, range of motion and comfort increased, and he expressed hope in the possibility of improvement. His sleep improved early on and continues to be adequate. He continues to garden and play music. He wears the foot brace when he is out and uses the cane when needed. His self-image and depression have improved. Eric does Mentastics regularly for his Foot Drop. These include rolling a ball around on the floor with the impaired foot, simple toe lifts and a self-care routine of gentle lengthening and reflex response that was taught during the sessions. Eric’s dedication to his self-care was impressive, and this has allowed him to continue the healing and strengthen new movement patterns between sessions. Eric’s gait distortion became less noticeable and jerky, and at this writing his pain now is controlled while lying down, but not totally when weight bearing. Eric also has a renewed hopefulness that one can improve function amidst a battery of assaults on a body.
One of Eric’s greatest challenges was the need to slow down while creating new movement patterns. Learning to move without pain and discomfort demands presence and patience. For instance, Eric’s shoulder pain remained unresolved until he realized he was reinjuring it every time he pulled the trash can alongside of the truck down the long driveway. Taking his time, he began to walk the cans out to the road, and his shoulder was relieved of the pain and limitations he had been experiencing. More evidence of the need to slow down were the frequent falls he reported. His hurry to get on stage without someone noticing he was limping, caused him to hurry, and he would fall, often in pubic. The humiliation of these experiences was difficult to bear and added greatly to his poor body image and low self-esteem, leading to depression. When he slowed down and became present with his body, he was able to control some of the incidents, and the negative feelings improved.
Discussion
The trained Trager® practitioner uses gentle touch and movement to initiate a series of repetitious movements such as rocking and passive range of motion which lengthens and integrates the entire body. This activity lulls the receiver into a para-sympathetic state, encouraging deep relaxation and rest. Conscious and unconscious tension are released and the client experiences calmness and pleasurable sensations, overriding painful or limiting ones. The practitioner guides both active (client initiated) and passive (practitioner initiated) range of motion on and off the table. Using Mentastics® (imagery suggestions and modeling), the practitioner encourages the client to engage in authentic, playful and spontaneous movement. Lengthy pauses of one-three minutes are introduced to allow the client to feel the effect of the movement. A typical session includes a variety of positions with the client: sitting, standing or lying on a massage table. Gentle, repetitious arcs, using swing and bounce, encourage positive, neurological, cellular and muscular changes and pleasurable sensations. The Trager Approach often gives clients with limited physical mobility a chance to regain efficiency and coordination that lead to effortless movement and peacefulness.
Dr. Trager felt this type of psychophysical integration was especially beneficial for those with neurological disorders such as Parkinson’s, post-polio syndrome or the after-effects of a stroke. In Eric’s case, the peroneal nerve damage resulting in Foot Drop most likely occurred after the right hip surgery. He remembered feeling something unusual in his gait at that time, but never had it addressed. Early treatment is recommended for any disease process affecting the central nervous system, including Foot Drop and stroke. Eric is a particularly creative person, and this process worked well for him. These techniques may not work well with someone who wants to be “treated” or “fixed”.
Much of the work during a session is happening in the minds of the practitioner and the client. The practitioner, in the process of internally asking for a certain tissue response, such as a feeling of lightness or freedom, must find the feeling within themselves to be able to transfer this feeling to the client. During the session, the client is engaged to give feedback by asking, “what are you noticing? How do your two sides, limbs, etc., feel different?” This type of questioning enables the client to increase body awareness and their vocabulary of feeling sensation. This sensation may be described as feeling heavier, lighter, effervescent, bubbly or other descriptive words. Awareness of sensation is often reported due to the increased circulation after a relaxation response. New neurological patterns replace damaged nerve endings, bypassing the blockages of sensation. Both the practitioner and the client are changed in the process. Neuroplasticity research helps us understand the connection and rewiring of the brain that occurs (3).
Having a motivated person to work with is a pleasure. A healing path is not a straight one. The client goes his own way, and the practitioner follows. There is an edge of sweetness, a mutual experience of freedom and expansion when the way is found together. Eric continues to teach music in elementary school programs, still using the brace and the cane. He is happier and more confident that he now has more choice about his life and his body, in terms of the greater awareness he has gained. He is a musical force in the community, hosting an open mic, and organizing fund raisers. After the eighteenth session he stated he was walking a half of a mile a day using the step counter. He is staying active and felt his balance was better. We agreed he had plateaued for now, and would return, when he needed a refresher.
Our bodies are like an old house…if you want to improve one area, underlying structures may need repair first. The “lynch pin” that holds an individual back from reaching their full potential lies in obscurity, but in time is revealed through deep listening and respectful relationship building. Self-care practices must be taught that can be done at home. These include strengthening weakened muscles, deep breathing, presence and loving the self. These practices could be helpful for many conditions and are sorely needed to make behavioral changes sustainable for our patients and clients. It is an honor to witness the deepest mysteries of life as healing occurs.
REFERENCES
1. Katirji B. Peroneal neuropathy. Neurol Clin. 1999;17:567–91
2. Aprile I, Caliandro P, LaTorre G, et al. Multicenter study of peroneal mononeuropathy: Clinical, neurophysiologic, and quality of life assessment. J Peripher Nerv Syst. 2005; 10:259–68.
3. Aprile I, Padua L, Padua R, et al. Peroneal mononeuropathy: Predisposing factors, and clinical and neurophysiological relationships. Neurol Sci. 2000;21:367–71.
5. https://www.tragerapproach.us/about-trager
6. Fuchs, E., Fuchs, E., & Flügge, G. (2014). Adult Neuroplasticity: More Than 40 Years of Research. Neural Plasticity, 2014, 541870-541870. Retrieved 5 1, 2020, from https://hindawi.com/journals/np/2014/541870
7. Trager, M. (1987). Movement as a Way to Agelessness. NY, NY: Station Hill Press.