The Effectiveness of Myofascial Release, Joint Mobilizations and Trigger Point Therapy on
Chronic Whiplash Associated Disorder
Karissa Felix
2nd Year Massage Therapy Student at OVCMT
karissafelix@live.com
Abstract
The purpose of this case report was to determine the effectiveness of Myofascial Release, Joint
Mobilization and Trigger point therapy on individuals suffering from chronic whiplash
associated disorder (WAD). Whiplash is a neck injury due to forceful, rapid back-and-forth
movement of the neck. It most often occurs during a rear-end auto accident, but the injury can
also result from a sports accident, physical abuse or other trauma. This study hypothesizes that
using the massage therapy techniques mentioned previously are effective modalities in
increasing range of motion (ROM) and decreasing pain and headaches in patients with chronic
WAD.
This is a single subject case study done over the course of 7 weeks on a 1 hour a week basis. The
subject is a 24 year old female who has been suffering from chronic WAD for 6 years after being
involved in a motor vehicle accident. She complains of consistent, throbbing headaches and
decreased motion in her cervical spine.
Assessments were done every treatment and included AROM of the cervical spine, postural
scans and subjective information on pain and headaches. At the end of these treatments the
results showed an increase in pain free cervical spine AROM and a decrease in neck and
headache pain from 8/10 to 4/10. Headaches were also reported as having decreased in
reoccurrence as well from 5x/wk. to 3x/wk.
The study supports the hypothesis that the use of myofascial release, joint mobilization and
trigger point therapy are effective modalities in treating chronic WAD.
Keyword List
“Whiplash Associated Disorder” “Massage Therapy” “Post-Traumatic Headache Disorder”
“Neck Pain” “Myofascial release” “Joint Mobilizations” “Trigger point therapy”
Introduction
Whiplash is an injury to the cervical spine and surrounding tissues caused by a forceful, rapid
back-and-forth movement of the neck. It most often occurs during a rear-end auto accident, but it
can also be a result from sports accidents, physical abuse or other trauma (Mayo Clinic, 2015).
Common signs and symptoms in a patient suffering from whiplash include; neck pain, muscle
stiffness, decreased range of motion in the cervical spine and headaches or migraines (Rattray,
2000). Most people with whiplash recover within a few months after a course of pain
medication, exercise and manual therapies. Some people, though, experience chronic neck pain
and other ongoing complications for a much longer period of time.(Mayo Clinic, 2015) A
whiplash injury is classified as chronic if a patients’ symptoms extend beyond 6 months.(Norton
et al., 2013). In order to assess the severity of each individual whiplash case the Quebec Task
Force created a guideline in 2001 for classification of WAD into 4 different stages. These stages
range in severity from a patient experiencing no complaints of neck pain to experiencing neck
pain associated with vertebral fractures and dislocations (Rattray, 2000).
WAD injuries have the possibility of creating lesions in most of the structures within the neck
and in severe cases are assessed for the potential of fractures and dislocations in the cervical
spine. WAD injuries typically involve the most of the muscles, ligaments, joints and nervous
tissues of the neck,but can also extend into the shoulders and back due to the body’s response of
guarding and repairing the damaged structures.(Elesko, 2014) The muscles which often
experience the most damage include; the sternocleidomastoids, scalenes group, trapezius and
longus coli muscles. Muscular strain injuries may also be seen in the suboccipitals, intrinsic
spinal muscles, cervical erector spinae, levator scapulae, rectus capitis anterior, longus capitis,
platysma and the supra and infrahyoid muscles (Rattray , 2000.) The joints most commonly
affected by whiplash are the facet joints of the cervical spine and the intervertebral joints and
discs, possibly resulting in avulsion fractures. Damage may occur along the thoracic spine, or to
the shoulder girdle, and these are also common referral patterns for cervical spine lesions. It is
important to note that patients with chronic WAD may have multiple injuries stemming from one
common traumatic event (Elesko, 2014).
Due to the many differences each patient may present with treatment for whiplash is dependent
on the severity of the injury and can range from manual therapy to surgical intervention. In most
cases a doctor will prescribe pain medication, possibly a neck brace for a few days and referral of
the patient to a physiotherapist, chiropractor and/or registered massage therapist (RMT) may be
given.
When treating whiplash as an RMT the main focus is to restore a patients pain free ROM,
decrease matured adhesions in the soft tissue around the neck and maintain joint health in the
cervical, and possibly thoracic, spine (Rattray, 2000). Various technique such as; Swedish
Massage, Deep Tissue Massage, Trigger point therapy, Myofascial release, Joint mobilizations,
Therapeutic Exercise, Range of Motion and Neuromuscular Therapy among others have been
found to be effective in doing this (Sutton, 2014)
For this Case Report I have decided to focus on using Myofascial release, Trigger point therapy
and Joint mobilizations as my modalities. I have found these modalities to be effective in treating
various whiplash patients in the past and various papers and studies done by Elesko (2014),
Buckland (2013) Norton (2013) and Sutton (2014) support this concept. I’ve also chosen these
techniques, in part, because they are less invasive and less aggressive then techniques such as
Neuromuscular Therapy and Swedish Deep Tissue which I feel is important when treating
someone suffering from chronic pain. I hypothesize that these techniques; Myofascial release,
Trigger point therapy and Joint Mobilizations, will also be effective in treating chronic WAD by
decreasing the occurrences of headaches and increasing overall ROM.
Myofascial Release (MFR) is a hands-on technique that involves applying gentle sustained
pressure into the myofascial connective tissue in the direction of resistance. This technique is
used to break up adhesions and promote unrestricted blood and lymph flow in these tissues. The
definition of fascia includes all the tissues that are traditionally designated as ‘fascia’ in human
anatomy as well as tendons, ligaments and bursae (Myers, 2015). When the fascial system
sustains severe trauma, such as whiplash, fascia modifies the mesh of its fibers becoming more
rigid and plastic than fluid and elastic; the result being that it becomes denser and the collagen
fibers in its matrix align irregularly (Buckland, 2013). The use of MFR in this case study will aid
in returning the fascial fibers of the deep cervical fascia to their original flexibility and fluidity.
Once the fascial fibers have been realigned there should be an increase in the available ROM of
the cervical spine and a decrease in tension in the cervical muscles.
Trigger points are hyperirritable spots within a taut band of skeletal muscle or fascia. They are
tender to touch, exhibit predictable pain referral patterns and cause shortening of affected
muscles (Rattray, 2000.) They are a common disorder in even healthy individuals and can be
debilitating in nature, leading to secondary conditions such as tension headaches and visceral
discomfort due to their referral patterns. There are various way of treating trigger points from
deep muscle stripping and skin rolling to prolonged or alternating ischemic compressions, all of
which have shown to be equally effective (Rattray, 2000). The treatment of trigger points in this
case study will help to realign muscle fibers and restore muscle length. This will lead to a
decrease in pain and reoccurrence of headaches.
Joint mobilizations are skilled passive manual therapy techniques applied to joints and related
soft tissues at varying speeds and amplitudes. Speed and amplitude can range from small
amplitude force at a high velocity to large amplitude and low velocity. These techniques are
applied on a continuum in order to improve joint heath, increase ROM and decrease pain in a
joint.(Dixon, 2003) When a joint has a dysfunction the muscles and tissue surrounding the joint
work to create stability around the unstable area, this leads to hypertonicity, adhesion formation,
trigger points and pain in the region. By restoring proper joint alignment and function there will
be a decrease in tension in the surrounding muscles and an increase in ROM for the patient.
Hypothesis
Over the course of 7 weeks, on a 1 hour per week basis, I hypothesize that using
Myofascial Techniques combined with Joint Mobilizations and Trigger point therapy will help to
decrease the occurrences of headaches and increase the available pain free ROM in patients
suffering from chronic WAD.
Assessment
For assessments during this treatment I took ROM measurements of the cervical spine
pre and post each massage, in which all ranges were recorded. I did a full postural assessment
before each treatment to examine how various muscles and joints were adapting to the massages.
Subjective information regarding pain experienced pre and post massage, was recorded based
upon a pain scale from 1-10 that was established and explained to the patient at the first session
(1 representing a light touch and 10 representing the worst pain the patient has experienced). I
also did various special tests throughout the course of the treatments in order to help isolate areas
of irritation, hypertonic muscles and trigger points. The special tests I did that showed a positive
result were: Spurling’s compression test was positive for muscle spasm on the left while the head
was extended and rotated left, Hautant’s Test was positive for minor vertebral artery
compression on the left and muscle testing for upper trapezius and levator scapula muscles
showed positive results bilaterally for weakness and muscle spasm, indicating a presence of
trigger points in those muscles. Through palpation of various muscles I was able to discover the
presence of moderate to severe trigger points in both left and right levator scapula muscles at the
insertion on the superior angle of the scapula. I recorded all my findings, subjective and
objective, in order to compare any changes in the patient throughout the durations of the
treatments.
Subject Case History
The patient in this study is a 24 year old female, suffering from chronic WAD. She was in a
MVA in 2009 in which she was hit from the rear into oncoming traffic and then consecutively hit
from the front causing severe whiplash. She saw a physiotherapist for a few months postaccident but stopped her treatments due to financial reasons. The physiotherapist gave her
exercises for her shoulders and neck and she felt they only exacerbated her symptoms and thus
she stopped doing them shortly after her last visit to the physiotherapist. Currently she suffers
from frequent headaches which she explains as radiating from her occiput in a “headband style”
around the posterior, lateral and anterior portions of her head. When given a scale from 1-10 she
rated her headaches as between 7-10/10 on an almost consistent basis. Accompanying these
headaches are symptoms such as dizziness, nausea and decreased ROM. She is currently
working in the behavioral development program at OSNS. Her job entails work with special
needs children and involves varying amounts of stress and noise which can, and frequently do,
exacerbate her headaches. She is also a very active individual and trains at the gym 3-5x week,
depending on her condition, doing various weight training and cardio exercises in order to keep
herself physically healthy. She is hoping that these treatments will help her with decreasing her
headaches and increasing her ROM, as well as she hopes to learn ways to manage her headaches
and pain without the use of pharmaceuticals.
Treatment
The patient was initially treated with a 1 hour relaxation massage to assess her tissue and her
tolerance for massage. After this initial session we continued with 6 more consecutive treatments
on a one hour basis, one week apart. She complied with my request to not take any pain
medication within 4 hours of each treatment so assessment findings would not be affected. The
specific treatment goals during these massages were as follows; to increase the pain-free ROM of
the cervical spine in all ranges using passive ROM and joint mobilization techniques, to decrease
the patients headaches by way of releasing the trigger points in the sub occipital and levator
scapula muscles, and to educate the patient on natural pain management techniques to help her
with her headaches when she was out between treatments.
The techniques used during each treatment were myofascial release to start, progressing to
Trigger Point Therapy and then ending with Joint Mobilizations, the time used for each
technique varied depending on the patient’s signs and symptoms each session. The Myofascial
techniques used were limited to shaping, spreading, cutting and cross hands technique and were
used on the upper traps, levator scapula, scalenes and sternocleidomastoid bilaterally. Trigger
points were found in the levator scapula and sub occipital muscles and were dealt with in various
ways, depending on their presentation, with focus on prolonged ischemic compressions and
muscle stripping. At the end of each treatment a Gr 2 or 3 sustained cervical distraction was used
to maintain joint health and increase ROM. There were modifications made during one of the
treatments as the patient presented with a severe headache and so they were treated for such with
hydrotherapy (derivation technique with ice on occiput and heat placed on the feet) and light
swedish techniques, other than this the treatment protocol stayed the same as previously stated.
The patient was sent home with various homecare suggestions such as; stretches to bilateral
levator scapula muscles starting at 30 second increments 3 times per side, once per day and
slowly working our way to three times per day. Ice was given to the patient as homecare to be
used when she was experiencing the onset of a headache and was to be placed at the occiput for
no longer then 15mins. Heat was given as a twice daily home care for levator scapula to decrease
the pain referral from her trigger points. Pain free AROM of the cervical spine was also given to
the patient to do, all ranges were to be done at least once a day but up to as many as three times a
day at her discretion.
Outcomes
The following charts and tables show the changes in ROM, pain and headache occurrences
throughout the treatments (Tx).
Fig 1. And Fig 2. show a dramatic decrease in the subjective information the patient has provided
in regards to the pain they are experiencing with each headache at the beginning of the
treatments, as the treatments progressed and at the final treatment.
Though all the charts in Fig4. show some increase in AROM, Fig 4d. and 4e. show the most
improvement in Lateral Flexion ROM. On both sides from first treatment to final treatment there
was an increase of 30°.
Fig 1. Headaches on a Pain Scale Progression Pre-Tx vs PostTx (rated from 1-10)
10
9
8
6
5
4
3
2
1
Tx 1
Tx 2
Tx 3
Tx 4
Tx 5
Tx 6
Tx 7
Treatments
Pre Tx
Post Tx
Fig 2. Pain Scale as reported by patient from 1st Tx vs 7th Tx (Pre and Post)
1st Tx
7th Tx
Difference
Pre Tx
8
3
-5
Post Tx
6
2
-4
Fig 3. Duration (in days) patent reported having headaches
6
5
4
Days
Pain Scale
7
3
2
1
0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Weeks between treatments
Duration of each headache
Progression of headaches reported each week
Fig 4. Cervical Spine Range of Motion progression Pre Tx and Post Tx (1st, 4th and 7th Tx)
Fig 4a. Extension AROM
Degrees of movement
70
60
50
40
30
20
10
0
1st Tx
4th Tx
7th Tx
Treatments
Pre Tx
Fig 4b. Right Rotation AROM
70
50
30
10
-10
90
Degrees of movement
Degrees of movement
90
Post Tx
1st Tx
4th Tx
7th Tx
Fig 4c. Left Rotation AROM
70
50
30
10
-10
1st Tx
Treatments
60
Post Tx
Pre Tx
Fig 4d. Left Lateral Flexion
AROM
Degrees of movement
Degrees of movement
Pre Tx
50
40
30
20
10
0
1st Tx
4th Tx
Treatments
Pre Tx
Post Tx
4th Tx
7th Tx
Treatments
7th Tx
60
Post Tx
Fig 4e. Right Lateral Flexion
AROM
50
40
30
20
10
0
1st Tx
4th Tx
Treatments
Pre Tx
Post Tx
**Flexion was consistently full so it was not necessary to show a progression chart.
7th Tx
At the end of the treatment we were able to achieve the goals of the patient by increasing the
patients active pain-free ROM and decreasing the incidences of headaches throughout her week.
This was achieved because the patient was compliant with attending treatments every week and
doing her homecare when she was able to do it pain free. I think this treatment would be very
effective for a patient suffering from chronic WAD as long as the patient was homecare
compliant as to do this without the homecare aspect would have taken more treatments and
would not be as cost effective.
Discussion and Conclusion
At the end of this series of treatments the patient left with a decrease in pain from 8-10/10 to
4-5/10, around a 50% decrease in reported symptoms. Her headaches went from an almost daily
occurrence to ~2-3x per week and her pain free AROM increased in Lateral Flexion by ~30° on
both right and left sides. The increase in ROM and decrease in headache pain and headache
occurrence was what was expected to happen through the course of these treatments, these
outcomes are also supported by other studies done by Buckland, 2013 and Elesko, 2014. With
this evidence I feel this choice of modalities is effective in treating chronic WAD. The only
adverse reaction to these treatments was the patient’s consistent feeling of nausea and dizziness
post every session, though such side effects could also be due to nervous system damage from
her original accident, specifically of the vagus nerve. Recommendations to further improve this
study would be; proper assessment and record keeping on the patients use of medication
throughout the treatment period, further research on each individual modality used in this case
report could be done to determine which would be most effective for a patient suffering from
chronic WAD, as well as larger a larger scale version of this study on a sample population.
Citations
Anatomy Trains website: Fascia. Retrieved from: http://www.anatomytrains.com/fascia/
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chronic whiplash associated disorder. Retrieved from:
https://www.rmtbc.ca/sites/default/files/files/Utopia%202%20Diana%20Buckland1.pdf
Dixon, M. (2003) Joint Play the Right way (3rd ed.). Vancouver, British Columbia
Arthrokinetic publishing
Elesko, K. (April 2014) A multimodal approach for chronic whiplash associated disorder
pain. Retrieved from:
https://www.rmtbc.ca/sites/default/files/files/WCCMTVPT_KElesko2ndPlace.pdf
Mayo clinic staff (2015). Definition of Whiplash. Retrieved from:
http://www.mayoclinic.org/diseases-conditions/whiplash/basics/definition/con-20033090
Norton, H., Lowe, R., Van Horebeek, E., Bortels, S., & Kistmacher, S. (2013). Whiplash
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http://www.physio-pedia.com/Whiplash_Associated_Disorders#Chronic_Whiplash
Rattray, F. (2000) Clinical Massage Therapy (1st Ed.). Llora, Ontario: Talus Inc.
Sutton, D., Côté, P., Wong, J., Varatharajan, S., Randhawa, K., Yu, H., Southerst, D.,
Shearer, H., Van der Velde, G., Nordin, M., Carroll, L., Mior, S., Taylor-Vaisey, A., &
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Retrieved from:
http://www.thespinejournalonline.com/article/S1529-9430(14)00650-0/fulltext