This clinical case was submitted by our current student Don Lozon, LMT, from Salt Lake City, Utah. We would like readers to pay attention to how perfectly Don examined the patient’s soft tissues using all necessary tests and evaluation techniques and detected all pathological changes layer by layer. It gave him all the needed information to formulate an individually designed treatment strategy that worked perfectly for the patient despite Don having very limited time to help this patient.
This case is a perfect example of why we at SOMI concentrate so much on therapists’ evaluation skills. Overall clinical success lies in the practitioner’s ability to ‘read’ tissues and to understand and correctly interpret the nature of symptoms. All these skills Don exhibited perfectly, and we are very proud to work with like-minded therapists to guide them towards hard clinical skills.
MEDICAL MASSAGE vs. SEVERE WHIPLASH AND LIMITED TIME
A 31-year-old male patient was referred from the Chiropractic Office for Medical Massage for Whiplash after a car accident which occurred a month prior. The patient was treated by a DC for three weeks, two times per week. Unfortunately, I had only four days to work on him before he moved out of state.
CLINICAL INTERVIEW
The patient’s car was hit on the passenger side in a T-Bone accident while he was in the driver’s seat. Immediately after the car accident, the patient felt bilateral neck pain. The pain quickly migrated to the back of the head, triggering a severe headache. Symptoms were more pronounced on the right side.
At the time of evaluation, pain and cervical muscle stiffness were especially acute in the mornings, and an acute occipital headache with pulsating pain appeared daily in the late afternoon. The patient also felt pain in the right anterior shoulder.
ASSESSMENT
Visual assessment showed local soft tissue inflammation in the suboccipital area with skin redness below the hairline, which explained the presence of pulsating pain in the upper neck. Tissues in the suboccipital area were very sensitive to the touch.
Cervical ROM was significantly restricted in all directions: flexion, extension, and rotation. Repetitive cervical movements triggered cervical and occipital pain, so the patient tried to keep his head still.
1. Examination of Cutaneous Reflex Zones (i.e., dermatomes):
The Sensory Test indicated the presence of sensory alarm points for the C4, T2, T6, and T7 dermatomes on the right.
2. Examination of Fascia and Connective Tissue Zones (CTZs)
Palpation and testing revealed fascial adhesions formed within the fascia as a reflex reaction to the original trauma. The main foci of tension were located at the 1st (dermis of the skin) and 2nd (superficial fascia) levels along the right upper trapezius muscle in the right upper back, and at the 3rd (deep fascia) level of CTZs along the lower part of the left trapezius muscle in the middle back.
3. Examination of Reflex Zones in the Skeletal Muscles (i.e., Myotomes):
Further palpatory examination showed that C2-C4 myotomes bilaterally were mostly affected. Active trigger points were detected in both trapezius muscles (right is worse) in all three divisions. The Trigger Point Test in the lower left trapezius muscle activated tension in the middle and upper parts of the same muscle.
Examination of the suboccipital area revealed the presence of a significant muscle spasm. Even mild pressure during palpatory examination of the suboccipital area triggered withdrawal and worsening of the headache. The splenius capitis and obliquus capitis superior muscles were most affected. Also, palpation detected significant tension in the right sternocleidomastoid (SCM) muscle just below the mastoid process.
4. Functional Muscle Tests
‘Shrug’ test for the trapezius muscle was positive on the left side. Trapezius resistance Test #1 was positive bilaterally. Trapezius Resistance Test #2 was positive with pain referral down the shoulder.
5. Examination of Reflex Zones in the Periosteum (i.e., Sclerotomes):
The patient exhibited active periosteal trigger points on the right clavicle (C4), on the lateral side of the C4 spinous process, and along the right sternum at the level of T3.
6. Evaluation of the Greater Occipital Nerve
The initial presence of an acute headache and its worsening during the palpation of the suboccipital area pointed to the possible irritation of the greater occipital nerve. Indeed, even the slightest application of the Compression Test on and just above the occipital ridge immediately triggered pain radiation to the top of the head and occipital headache. Both Gernstein’s points on the top of the head were active, which indicated scarification and shortening of the cranial aponeurosis. Thus, it was clear that the greater occipital nerve was compressed by soft tissues at its emergence under the scalp.
TREATMENT
My Objectives:
- Decrease pain and eliminate hyperirritability of nociceptors (i.e., pain receptors).
- Eliminate symptoms of reflex zones in all tissues within affected dermatomes, CTZs, myotomes, and sclerotomes.
- Decompress the greater occipital nerve.
- Restore function.
I followed the Medical Massage protocol for Cervicalgia from the Video Library of the Science of Massage Institute. As I learned during SOMI’s Medical Massage seminars, the key component of successful rehabilitation of soft tissues is their decompression on a layer-by-layer basis. Therefore, I started with preparation of soft tissues using massage therapy in the inhibitory regime.
Next, I addressed the cutaneous reflex zones within the affected dermatomes using skin kneading and local stretching; to eliminate tension in fascia, I used Connective Tissue Massage; to eliminate local vasoconstriction in the trigger points, I used Trigger Point Therapy; to reset muscle spindle receptors in the affected skeletal muscles, I used Postisometric Muscular Relaxation; and finally, I addressed periosteal trigger points with Sherbak’s friction and periosteum at the insertions with cross-fiber friction and later with Periosteal Massage. The patient was given detailed homework to support the results of each session.
Results of 1st session
Pain became less intense but spread to areas where the patient hadn’t felt discomfort before. That was the expected reaction to the first session.
Results of 2nd session
The patient felt a significant decrease in headache intensity, and he also reported an increase in cervical ROM.
Results of the 3rd session
Residual headache at the end of the day. Gernstein’s points were negative. He reported that significant pain was still localized in the right SCM. Skin and fascia mobility greatly improved. Active trigger points in the trapezius and posterior cervical muscles became latent.
Results of the 4th session
No headache. Almost normal cervical ROM. Some latent trigger points were registered in the posterior cervical muscles.
I suggested he continue his homework and find someone in his new state who could eliminate the residual symptoms.
ABOUT THE AUTHOR
Don Lozon, LMT
I was stuck in a dead-end job I did not love. One day I had a very real epiphany. I wanted to do something that could help people. After this epiphany, I immediately started my search.
A week later I was at work and rotated to throw away a piece of paper in the trash behind me. I went down with sharp, electrical pain from my lumbar spine through my thigh, leg, and foot. I was unable to walk, sit, or stand. I went to the chiropractic office for help, and the doctor diagnosed my condition as Sciatica. After my first treatment session, I was almost pain-free, and I realized that this was what I wanted to do!
I started looking into chiropractic schools. At that time, I lived with my wife and our son in Mesa, AZ. We started our search but couldn’t find a chiropractic school in Arizona. One day I saw a commercial for the Arizona School of Massage Therapy. I felt that that was my true calling! I couldn’t believe there was a school for massage therapy down the street from where I worked. I enrolled immediately!
During our business ethics course, our instructor told us that he was working his way to a Medical Massage Certification. As you can imagine, we were all on the edge of our seats asking questions. I found the Science of Massage Institute in 2012. I enrolled in my first seminar on Anterior Scalene Syndrome / Thoracic Outlet Syndrome. I was hooked from the first class! Now I was learning the true Science of Massage that I never learned in massage school.
I started utilizing Medical Massage immediately after the first class with great success. I worked in a physical medicine clinic with nurse practitioners, chiropractors, and physical therapists. I became a chiropractic assistant and did the examinations for the doctor. I was in a great position to learn more clinical skills and to enhance my Medical Massage Assessment skills. The doctors in the clinic were intrigued by the books, techniques, and assessments I learned from the Science of Massage Institute (SOMI).
The Medical Massage Concept has become the basis of my profession. Thanks to Dr. Ross Turchaninov and everyone at SOMI, including all the students who contribute to the Journal of Massage Science, I’ve seen many amazing cases throughout my career that have been solved with the Medical Massage Concept.
In 2020, I opened a Medical Massage Clinic in an amazing space in Salt Lake City. This was during COVID-19, but that didn’t stop the growth of my Medical Massage Practice, with special thanks to everyone who has helped me grow!
Category: Case Studies
Tags: JMS 2021 Issue #2
