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Research With Massage Therapy Foundation

By Massage Therapy Foundation Contributor

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Generating Knowledge by Exploring Practice

Contributed by Beth Barberree BA, RMT; April Neufeld, BS, LMT; Jolie Haun, PhD EdS LMT

Many complex medical conditions such as traumatic brain injuries, have little or weak empirical evidence to describe what constitutes an appropriate approach to care. This month, the Massage Therapy Foundation explores a clinical case report titled, "Concussion Treatment using Massage Techniques: A Case Study." The case study was conducted by Sylvia Burns, MEd, LMP and was published in the International Journal of Therapeutic Massage and Bodywork in 2015.

There is growing concern about concussion-related symptoms, so much so that a plea for new interventions on how to treat post concussion symptoms was issued by the American Academy of Neurology. This article described the author's experience of successfully treating a patient's ongoing post concussion symptoms, particular to imbalance in the upper cervical spine, using advanced massage techniques.

Methods & Case Presentation

The patient was a male graduate student in his early 20's who sustained a head injury when he fell and hit his head on the back of a bench. Witnesses reported that he lost consciousness for 20 to 30 seconds. The impact on his right occipital area was treated with cold compresses at the time, and upon medical examination found there was no fracture or bleeding.

Generating Knowledge by Exploring Practice - Copyright – Stock Photo / Register Mark The patient reported headaches upon waking on the first day post injury. He reported to his primary care provider that his headache pain was in the 8 to 9 level range on a 10-point scale in which 10 is most severe. Bilateral soreness and stiffness suggested he had suffered cervical strain. He also stated that he was suffering motion sickness with car or boat travel, and nausea and difficulty concentrating accompanied his headaches. These symptoms interfered with his normal functioning and daily tasks. The primary care provider prescribed several medications for symptom resolution, as well as rest.

Three weeks later he was experiencing ongoing symptoms including headache, nausea with movement (such as leaning over to tie shoes), and difficulty concentrating on computer tasks. He had "fuzzy" thinking and poor concentration, and reported being unable to operate perform other usual daily tasks. The patient received no neuro-cognitive testing. At this point, the physician referred the patient for massage therapy treatment. There were no other modalities applied to the patient other than the prescribed massage therapy.

Assessment

The massage therapist reviewed the patient's medical chart, general health, history of the event, treatment since the trauma event. Self-reported pain levels were noted using the Visual Analogue Scale (VAS). Physical assessment involved postural observation to assess for any imbalances in the pelvic and shoulder girdles, and cervical region. Then standing balance was evaluated using the Balance Error Scoring System (BESS), which has moderate to good reliability to assess static balance. This test involves having the patient stand on two feet and then one foot with eyes closed using both a hard and soft standing surface. These actions include feedback functioning from visual, somatosensory and vestibular systems. Scoring is based on the number of times the person commits errors (such as opening of eyes, removing hands from hips, lifting heels or forefoot from surface, moving hips more than 30° of flexion or abduction, stepping, stumbling, or falling, or staying out of the testing position more than 5 seconds). A lower score indicates fewer errors were committed.

With the patient on the table, palpation of the pelvic, cervical, and shoulder region was performed to assess muscle hypertonicity and strength of muscles in these areas.

Treatment

The massage therapy care was provided by the author, who has 20 years of clinical experience and is familiar with concussion and trauma work. The goal of the treatments was to facilitate musculoskeletal balance, based on the concept that imbalance in the body or body part results in contraction of antagonist muscles in an effort to pull the body back to an anatomically preferred position. If the imbalance is removed, the muscles should revert to normal tonicity.

One month following the injury, the patient received two massage therapy sessions that occurred two days apart, each 45 minutes in length. The patient was observed and evaluated for postural balance, specific cervical symmetry, pain level, and symptoms at each session prior to applying treatment. One week after the second treatment, the patient returned for a follow-up appointment to only collect information, but no massage was applied. The patient was then discharged from care.

The therapeutic massage interventions began with patient laying clothed, in a prone position on a massage table. Treatments began with the pelvic girdle and moved up the body to address the shoulder girdle and cervical areas. The practitioner focused on release of myofascial tissues, reduction of hypertonicities in muscle groups with origins in the cervical area and insertions in the shoulder girdle (e.g. levator scapula, sternocleidomastoid, and scalenes).

Much of the treatment focus was on the cervical and cranial region while the patient laid supine. Specifically, the sub-occipital muscles and ligamental attachments were treated, and gentle caudal traction to the spine was applied. Details of the how the therapist approached the atlanto-occipital imbalance guided by experienced palpation, and atlanto-axial joint dysfunction are provided in the full article.

Results

Before treatment, the patient reported consistent headaches at 8 out of 10 on VAS and was taking medication daily for pain and nausea. Following treatment, his headache pain was zero and he was no longer taking any medication. His ability to concentrate had increased from about 15 minutes to at least 2 hours, and he was able to increase his activity level each day. His BESS scores dropped by almost half, and his muscle tonicity and strength, along with cervical range of motion were normalized.

Discussion

This case report demonstrates how massage therapy could be an effective intervention for treatment of post concussion symptoms. In particular, cases that involve atlanto-occipital joint dysfunction and associated muscular imbalance may be especially improved. The author clearly articulated that the specific massage approach used in this case was very specific, and requires advanced training in physical manipulation techniques and sensitive palpation skills. With such encouraging results, a larger scale study could be undertaken, perhaps specific to cases with obvious atlanto-occipital involvement.

This publication supports the field of massage therapy in both research and practice. Case reports provide an in-depth review of a single case to provide the breadth and depth of information to fully explore complex cases where the literature may lack in definitive evidence. Case reports are often used to generate knowledge of new and best practices, such as the use of massage therapy for post-concussive symptoms. Case reports are a valuable way for massage therapists to share their professional practice to support advancement in the field of massage.

Did you know the Massage Therapy Foundation is a big supporter of both practitioner and student case reports? The deadline to submit to the Practitioner Case Report Contest is October 3, 2016. Find out more information and who has won past case report competitions by visiting www.massagetherapyfoundation.org/student-practitioner-case-report-contests/.

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