Cultures all over the world have used kneading or rubbing as a part of health care for thousands of years. The Yellow Emperor’s Classics of Internal Medicine, written in China about 1000 BC, mentions massage in the treatment of paralysis and reduced circulation as part of a three-year training program for doctors of massage. However, for the modern massage therapist, how the profession is defined often depends on where and when you were trained. Massage therapy is in a state of growth and change globally, and this is reflected in how massage therapists define themselves.
To generalize, in Canada the massage therapist enters the medical arena due to training that emphasizes working with the client to assess and treat dysfunctions. (I’m including relaxation and stress reduction as a treatment.) Many manual techniques and other modalities including hydrotherapy and stretching are used. A background in anatomy, physiology and pathology is also taught.
The legislated 2200-hour minimum training requirement in British Columbia, Newfoundland and Labrador and Ontario, which is being replaced by a competency standards-based curriculum, seems to be moving the rest of the country in this direction. Members of the Canadian Massage Therapist Alliance in provinces and territories without regulatory legislation are adhering to this standard. In the U.S., where 34 states have regulations governing required massage education, an average program requirement is 500 hours, though some states and many schools exceed this number (e.g., New York requires 1000 hours).
Generally, programs of this length include basic anatomy/physiology and a variety of manual techniques ranging from Western massage to Eastern energy work. Client assessment involves health, history taking and range of motion, however, it is uncommon for other orthopedic testing to be used.
Perhaps, because of training, the definition of massage therapy seems to be as an alternative hands-on therapy, somewhere outside the medical model, although there is a move in this direction in some states. In Australia, a new association has pushed for 1000 hour training as a minimum national standard. The definition of the profession also seems to be an alternative, hands-on therapy with some post-graduate courses in medical massage.
So, at a minimum, a massage therapist is a professional who uses assessment and a variety of manual
techniques and other modalities to work with the client in achieving optimum health, reduction of pain and stress and increased range of motion.
Description of Primary Modalities Used
Ask an average member of the public what techniques a massage therapist uses and you’ll likely hear about effleurage, petrissage and tapotement (though perhaps not in those technical terms). These manual techniques, plus stroking, vibrations, rocking, shaking and passive range of motion are commonly called Swedish massage.
There are many other modalities the massage therapist uses in addition to the classic techniques. Assessment
protocols, lymphatic drainage, various connective tissue or fascial techniques, diaphragmatic breathing, Cyriax’s cross-fibre frictions, trigger point techniques, joint play, hydrotherapy, stretching and active inhibition techniques such as post-isometric relaxation are commonly taught in Canadian massage schools. On the West Coast, more detailed spinal assessment, actinotherapy and osteopathic modalities such as craniosacral work is part of the undergraduate program, whereas these are post-graduate courses elsewhere. Eastern-derived modalities such as Shiatsu and Reflexology tend not to be included in Canadian massage therapy school curriculums.
Short-Term Goals for this client; including method of treatment utilized to reach those goals
A primary short-term goal is to perform and record a thorough assessment of the client. It’s important to do your own observation and testing so that you know what you’re working with, even if the client has been assessed by another health care professional.
A client may not present as an insurance claim in the first visit after an accident. By doing a thorough initial assessment and documentation with every client, you’ll have the appropriate information should it be needed
in later paperwork.
- I’d ask the client to fill out a questionnaire such as the Vernon-Mior Neck Pain and Disability Index, 1 which is one way to measure the initial symptoms in an accepted manner for both medical and insurance documentation.
- A postural assessment is indicated for two reasons. First, the client may adopt a posture to avoid pain; in the early stages of a whiplash, this often presents as a head-forward posture. (In a lateral view, the external auditory meatus is anterior to the plumb line and the sternocleidomastoid muscle is oriented almost vertically). Second, Mrs. Jones works as a data input clerk, which likely means she had a pre-existing imbalance of a head-forward posture and hyperkyphosis.
- I’d palpate for any heat, swelling or hypertonicity in the affected tissues.
- The client’s breathing patterns should also be checked, since the prognosis for apical breathers may be poorer. 2
- Active free and passive relaxed ranges of motion in the cervical and thoracic spine are a good starting place for testing.
- Cervical facet joints are tested for irritation since Mrs. Jones was looking to the right at the time of impact, which approximates and compresses these joints on the right side. Areas of hyper- or hypomobility in the thoracic and cervical spine are assessed with joint play; likewise, rib mobility should be checked.
- Since the injury is likely in the subacute stage, isometric strength testing (stopping when pain is noted) will help isolate specific muscles that may have been strained, such as sternocleidomastoids.
- A whiplash often involves more than the neck, so it’s important to make an assessment global, not regional. For example, while Mrs. Jones’ seatbelt undoubtedly prevented more severe injuries, it could also cause trauma to her anterior shoulder and thorax. The temporomandibular joints can be overstretched when the client’s head moves into hyperextension during the accident. Likewise, the impact could affect the lumbar spine, pelvis and legs.
- By definition, the classification of a whiplash-associated disorder WAD Grade 2 does not involve neurological symptoms, so in theory, testing for these would be fruitless. Clinically this may not be the case, so be prepared to do neurological testing if symptoms indicate this.
- Heat from inflammation would likely still be present, so a cold hydrotherapy application such as a gel pack is applied over these areas. This will also help decrease pain.
- Edema is reduced using lymphatic drainage techniques, which also remove fibrin from the initial lymphatic capillaries, reducing adhesion formation. If the client is unable to tolerate much specific massage to the neck in the early stage of whiplash, light lymphatic drainage may be the only work done directly on the neck.
- The pain-spasm cycle in her neck muscles can also be mediated by teaching Mrs. Jones slow, unforced diaphragmatic breathing. This also reduces sympathetic nervous system firing and tight muscles. Reduce the feelings of stress associated with the accident and her current symptoms by using diaphragmatic breathing as daily self-care.
- Spasm can be reduced by the client submaximally contracting the antagonist of the spasming muscle.
- If possible, trigger points are treated using less invasive techniques, such as muscle stripping. Trigger points that refer into the head – like sternocleidomastoid – may be causing Mrs. Jones’ headaches, especially if they occur toward the end of the work day.
- Another short-term goal is to treat compensatory structures. These may result from postural issues relating to work, or other injuries associated with the accident. Sometimes, due to the focus placed on the neck by other whiplash treatments, clients have said they feel divorced from the rest of their body. In the early treatments, I’d spend time working on her face, torso, back, arms and legs to “reconnect” Mrs. Jones to her body.
- I’d maintain range of motion using pain-free, mid-range passive relaxed range of motion of the neck.
- The last short-term goal is to educate the client. This includes self-care: cold hydrotherapy, diaphragmatic breathing and active free range of motion of the neck to the onset of pain only. It also involves telling the client that many cases of whiplash resolve in four to six weeks and that she should be as active as possible. 3, 4
The initial appointment is an hour and includes assessment, lymphatic drainage and hydrotherapy for the pain and edema, and teaching some self-care such as breathing and pain-free range of motion.
Shorter, more frequent treatments will address the inflammatory process in the early subacute stage, for example two or three half-hour treatments per week for three weeks. The client is then reassessed.
The treatment frequency is decreased as the client improves, to once a week for the late subacute stage.
Any mention of a treatment plan for whiplash has an additional component if it is an insurance claim. The Quebec Automobile Insurance Society/Societe d’assurance automobile du Quebec commissioned a report on the clinical, social and financial factors of “the whiplash problem.”
In 1995, The Quebec Task Force (QTF) on Whiplash Associated Disorders published the classification system defining the term Grade 2 WAD; it also published a guideline for patient care that includes reassuring the client, managing pain and returning to usual activities as soon as possible. If unresolved, after 12 weeks the patient is referred to a multi-disciplinary team.
- Interestingly, the QTF’s definition of unresolved is: Unable to resume normal activities. A patient who still has residual pain or limitation of range of motion, but who is able to resume work and other usual activities is considered to have resolved WAD.4 There have been several rebuttals of the QTF’s definitions and conclusions. Try the following websites for a sample: www.bcchiro.com/chiroandyou/news “BC Chiropractors Question Validity of Whiplash Research Generated By Insurance Companies.” www.chiroweb.com/archives/13/15/02.html “Quebec Task Force on Whiplash Associated Disorders: What Does it Mean for Practitioners?”
- In September 2003, the Financial Services Commission of Ontario – which regulates the insurance industry in that province – further crystallized a course of treatment for health care providers in the “Pre-Approved Framework Guideline for Whiplash Associated Disorders Grade II Injuries With or Without Complaint of Back Symptoms.”
- Despite the QTF’s conclusions that whiplash is a short-term, self-limited disorder, figures from the report show that persons with Grade 2 WAD reported neck pain (81 per cent), headache (37 per cent), paresthesia (29 per cent), and auditory (14 per cent) and visual (10 per cent) symptoms for six months to two years after the accident.
- Physical factors that can slow the client’s recovery include pre-existing degeneration, small vertebral canal size and a straight cervical curve. This information is obtained from X-ray findings; with written permission from the client, I could request a report from the appropriate health care provider, for example, Mrs. Jones’ Chiropractor.
Re-assess the client after six weeks using appropriate testing. I’d include a new copy of the pain questionnaire for the client to fill out; the two questionnaires can be compared to note how the client is progressing.
In this case the long-term goals are occurring in the late sub-acute stage when the healing tissue is less fragile and inflammation, pain, spasm and edema are diminishing. These symptoms are treated using the same techniques listed in the short-term goals. Hydrotherapy is modified to contrast applications of cold and warm to promote a flushing effect to the tissues; if inflammation recurs either due to activities of daily living or more vigorous, deeper techniques used in the late subacute stage, cold hydrotherapy is used again.
In the late sub-acute stage, the focus is on specific muscles in the neck, such as sternocleidomastoids and scalenes, and posterior neck and shoulder girdle muscles. Ischemic compression can be used to treat trigger points in these muscles; recall that trigger points reduce range of motion by shortening the muscle.
- The supra- and infrahyoid muscles, running over the front of the throat between the mandible, hyoid bone and sternum are frequently injured in a whiplash, and just as frequently overlooked during treatment. Clinically, trigger points in these muscles seem to refer into the throat. I’d treat these one side at a time, using my fingertips to stroke over these small muscles, moving from the lateral aspect to the midline. 5
- A spasm of longus colli, which covers the anterior aspect of the cervical vertebrae, can be reduced using isometric contraction of the multifidi on the posterior aspect of the vertebrae. If left untreated, a hypertonic longus colli can reduce the cervical lordotic curve.
- Tight suboccipitals can be addressed using long-axis traction, Golgi tendon organ release, or a passive stretch where the spinous process of C2 is stabilized with the fingertips of one hand, while the other hand grasps the occiput and slowly tractions the occiput into flexion.
Hypomobility of any of the vertebrae or ribs is treated using joint play techniques.
A long-term goal continues to be treating compensating structures. This could include fascial techniques and stretching for shortened pectoral muscles if Mrs. Jones had a head-forward posture, or a hyperkyphosis. The TMJ and muscles of mastication may also need to be addressed.
Another goal is to gradually increase the client’s range using passive range of motion to the onset of pain only. Self-care takes an increasing role in the recovery.
- Pain-free isometric strengthening for affected muscles is indicated. I could show Mrs. Jones how to strengthen the multifidi at the back of her neck. While seated, she places a rolled towel behind her neck at the level to be strengthened and holds the ends in both hands; she isometrically resists neck extension.
- Diaphragmatic breathing is still important for pain and stress control.
- Postural reeducation is important. I’d recommend frequent breaks from her habitual position at work and gentle stretches to the onset of pain for short neck muscles such as sternocleidomastoids and scalenes.
If a client is unresolved after 12 weeks, the Grade 2 WAD protocol indicates that the client is referred to a multi-disciplinary team. Clinical experience suggests that for many clients, a combination of complimentary therapies optimizes recovery. Some rewarding learning experiences have occurred for me working in a multi-disciplinary setting.
About Fiona Rattray. Fiona Rattray graduated from Sutherland-Chan School in Ontario in 1983. She was a practical examiner for what was then called the Board of Masseurs of Ontario before joining the treatments faculty of Sutherland-Chan in 1990, teaching about trauma and postural conditions and supervising student clinics. She was also Chief Examiner for the practical program. She left the school in 2001 to pursue writing and creating post-graduate workshops. Along with Linda Ludwig, RMT, she co-authored “Clinical Massage Therapy: Understanding, Assessing & Treating Over 70 Conditions” in 2000. For 13 years, she worked as a supervisor in the health care tent at an annual music festival. She learned a lot about acute trauma in a truly multi-disciplinary setting which embraced allopathic and alternative medicine, everything from oxygen masks to oat straw tea and massage. For many years her practice was in the east end of Toronto. At present, she lives in a rural setting, a maple sugar bush to be exact, and has a practice near Elora, Ontario.