Abstract
Objective: To assess the effect of Swedish massage and cervical vertebral lateral translations on a laterally misplaced C7 vertebrae presenting with limited ipsilateral flexion and rotation.
Background: The patient is an 18 year old male with daily pain in the lower neck and limited right flexion and right rotation of the cervical spine (C/s). Upon further assessment, it was found that the patient had a laterally deviated C7 to the right, considered a mild form of scoliosis.
Methods: The study consisted of 5 treatments, each using the same techniques. General Swedish massage (GSM) was applied around the patients posterior upper back and neck at the beginning and end of each treatment. Grade 3 joint mobilizations in the form of lateral translation of C7 were performed in between. The outcomes were measured with a pain scale called the Brief Pain Inventory Short Form (BPISF) that was filled out before each treatment. Range of motion (ROM) was also assessed in both Active (AROM) and Passive (PROM) by using a “cervical range of motion instrument”, or “CROM” and were measured before and after each treatment.
Results: There was an average of a 27.5% decrease in overall patient pain. The areas of pain that improved the most were walking ability and normal work. After the final treatment, the patient had gained 47.1% of their AROM right lateral flexion and 20% in PROM of the same movement. In right rotation, the patient gained 20% with AROM and 23.5% with PROM.
Discussion/Conclusion: With the patient’s overall outcomes, it is believed that grade 3 joint mobilizations on laterally shifted vertebrae can greatly improve the person’s ROM and the amount of pain they are experiencing through their activities of daily living (ADLs).
Keywords: Cervical vertebrae, Swedish massage, joint mobilizations, scoliosis, neck pain.
The Effects of Swedish Massage and Joint Mobilizations on a Lateral Deviated Cervical Vertebrae: A Case Study
Introduction
Scoliosis, as defined in many research articles, is an abnormal lateral deviation of a group of spinal segments. Scoliosis is known to come from a wide variety of causes, the most typical one being idiopathic and most commonly occuring during a person’s growth spurt around puberty. Idiopathic scoliosis affects about 2% of all adolescents (Romano and Negrini, 2008). Though it is commonly found in the T/s and L/s, it can still occur in the neck and C/s, however the most common cause of C/s scoliosis is due to compensation of a larger curve in lower spine. This compensation is usually caused by the “rightening reflex” that describes the fact that a person will try and keep their eyes in a horizontal plane to establish their center of gravity. With a curve to one side, the patient will subconsciously tilt their head and neck to the other side in order to keep their eyes in a horizontal plane. This resulting neck curve is the common form of C/s scoliosis.
The severity of the scoliosis can be measured by the degree of deviation in the specific spinal segments. As of Rattray, 2000, normal limits is anything from 0-10 of deviation. Mild scoliosis is classified as any deviation between 10-20 and is commonly asymptomatic (Herling and Kessler, 2006). Moderate is 20-50 of abnormality and severe is greater than 50. If found early and in the mild stage, scoliosis has a high chance of being fixed with simple stretching and strengthening techniques. Once the scoliosis has reached a moderate level, there is the beginning of bony changes to the vertebrae and it has to be treated with braces. Severe scoliosis can only be treated with surgery and is linked to reduced respiratory function and osteoarthritis that has the possibility of decreasing the patients life expectancy.
There are two major types of scoliosis, called structural and functional (or non-structural). Structural scoliosis is classified as fixed bony changes caused by unknown factors without signs of any other physical problem. Functional scoliosis is a change in the spinal curvature caused by a secondary, musculoskeletal condition such as postural asymmetires, muscular imbalances and leg length discrepancies. Both structural and functional scoliosis do not exclusively involve the spine as they almost always include abnormalities in the ribs and pelvis as well.
Common signs and symptoms caused by both structural and functional scoliosis may include muscle imbalances between the two sides of the vertebraes and decreased ROM on the convex side. There may be pain and postural imbalances and other conditions that have been caused by the scoliosis itself. The span of the scoliosis can range from a single ve
Through time, scoliosis has the ability to continue getting worse, to stay the same, or even get better on its own. Single curves progress and become worse more than double curves do (Robin, 1990). As stated above, the degree of scoliosis decides the type of treatment it needs. Braces and surgery are common for moderate and severe cases as well as Harrington rods which is an instrument that is inserted onto the vertebral lamina on each end of the curve. Any surgical methods used on the spine has their own disadvantages. For mild scoliosis, manual therapy is deemed best for the patient as it shows positive outcomes with less chance of negative side effects that more invasive techniques may have.
Common treatment methods for mild scoliosis is manual therapy. Manual therapy is described as “All the manipulative and generally passive techniques performed by an external operator. More specifically, it is osteopathic, chiropractic and massage techniques” (Romano and Negrini, 2008). Previous studies have used joint mobilizations to treat the signs and symptoms of mild scoliosis, one study used upper cerivual adjustments on a nine-year-old boy with mild scoliosus and after 13 treatments, the patient showed a balance in their leg length discrepancy, posture and other palpatory findings (Eriksen, 1996).
The treatment plan of applying GSM and lateral joint mobilizations to both sides of the patient’s C/s scoliosis is similar to the common treatment plans used in the past. The only difference is that most scoliosis involves multiple vertebraes, while this patient only has one severely displaced segment. This will help make the lateral joint mobilization mare effective, as it will only need to be placed on one vertebrae, however this makes the treatment special and excludes it from possibly having the same level of effectiveness on larger types of scoliosis. Ultimately, this case study is designed to look at the effectiveness of GSM combined with lateral vertebral joint mobilizations in cases with minor lateral shifts of only a few vertebral segments in the C/s.
Background
The patient was an 18 year old ectomorphic male presenting with pain in the lower neck, starting around C5 and moving all the way down to between the shoulder blades at about T5, then further down to the sacrum. The patient stated that the pain was a constant “tight” pain that gets worse with prolonged sitting or standing and is better with heat and working out. His workouts mostly consisted of swimming, weights and “free body exercises”. The pain was located in the middle back between the scapulas, however sometimes it did radiate to the lower back. The pain was slightly more on the posterior left when compared to the posterior right side. The patient stated on the first day that the worst that the pain had ever reached was about an 8/10.
The patient showed limited AROM and PROM to the right side in lateral flexion and rotation. The patient was not aware of when the ROM limitations had started, but stated that the pain had increased within the past year and a half or so.
Upon examination, it was noticed that he had moderate head forward posture with retracted shoulder BL. It was also noted that the patient had a laterally shifted spinous process (SP) and transverse process (TVP) of C7. With assessment of his limited ROM, it showed that most of the limitations were coming from C7 and the vertebrae directly above and below (C6 and T1). To assure that this curve in the C/s was not a compensatory curve resulting from further vertebral deviations in the T/s or L/s, the whole spine was examined for abnormalities and came back negative. All other vertebraes were in a neutral lateral position.
The patient is a student and works as a lifeguard full time, meaning he spends the most of his time with his neck flexed, either looking down at a pool or looking down at textbooks. For recreation, the patient spends a lot of time working out at the gym and swimming. He states that strengthening his back through workouts has helped decrease the pain in the past. He also was minimally stressed throughout the duration of the case study, however when he does have a lot of stress, he claims he holds it all in his shoulder and neck.
The patient’s previous treatments had consisted of irregular massages from a Registered Massage Therapist (RMT) that mainly treated symptomatic pain relief in the patients upper, middle and low back. The patient claims to have seen the RMT about once a month for the last 2 years. The patient also received 5 chiropractic treatments in the span of about 2 months that focused on treating pain and displacement of C1 and C2 as well as his lower C/s and upper T/s. These treatments happened about 5 months before this study occurred and had to stop due to the patient’s financial reasons.
Assessments1
Two different forms of assessments were used for this study to measure two different goals, to increase ROM (right lateral flexion and rotation) and to decrease symptomatic pain. The first, objective measurement was measured with the use of a CROM device to measure the patients AROM and PROM of the C/s. The second, subjective form of assessment was a pain scale, specifically the BPISF, which asked 15 questions, all about different ways the patient may feel pain.
Instruments.
In measuring the patients AROM and PROM of their C/s, it was deemed that a CROM would be the most accurate way to measure the degrees of their movements. As the steps explained in (Youdas, 1992), which were followed completely, the examiner began measuring each movement by placing the patients head into neutral so that all three dial meters were at zero. The patient was then instructed to move into each motion as far as they could without feeling pain and without moving other structures of the body. The examiner then adjusted the patients head so that the two dials that were not used in the specific motion were back at zero, then they noted the angle of the third dial. The movements were done, starting with all movements to the patients “normal” left side, then moving to their restricted right.
(Youdas, 1992) used the same CROM machine as this study, and per that paper, the average AROMs of the C/s were measured for males aged 11-19. Right lateral flexion showed the average AROM of this demography is mean (x̄) 44.8 and standard deviation (SD) 7.7 with a range of 30-66. Right rotation was x̄ 74.1 and SD 7.6 with a range of 56-92. These “average” means and SDs were compared to the patient’s degrees of motion in the pre-treatment assessment and the conclusion of the study.
AVERAGE PROM
For the subjective information, there were many pain scales to choose from including a range of reliable instruments and techniques that may be used for research to measure the changes of the patients perceived pain. Of the listed scales, the Brief Pain Inventory Short Form (BPISF) seemed ideal for this study since it focuses on two fields of pain: 1) the intensity of the pain and 2) how much the pain interferes with acts of daily living (ADLs), (Younger, 2009). It contains 15 questions that range from focusing on the location of pain, and the intensity of pain from a scale of 1-10. It was decided that the BPISF would be filled out by the patient in the pre-treatment assessment, then before each of the 5 treatments to analyze the effects of the study.
Pre-Treatment Findings.
In the pre-treatment assessment, when doing AROM and PROM, the patients left side was used as their “normal degrees of motion” to compare to the limited right side. While in the pre-treatment assessment all ROMs were assessed with the CROM, only right lateral flexion and rotation were followed up on further treatments, as these were the only movements that were restricted. Then in the final treatment all ROMs were reassessed to see if there were further affects to the other movements. When performing PROM, bilateral (BL) lateral flexion and rotation found a firm end feel and Extension was “hard”.
When comparing the study subject’s pre-treatment findings to the assumed averages [of Youdas, 1992], the patients right lateral flexion (at 18 x̄) was 26.8x̄ lower than the average and right rotation (at 48x̄) was 26.1x̄ lower than the average. However, when comparing the patient’s right movements with their own left movements, the difference is lower, with right flexion only being 8x̄ different and right rotation being 10x̄. This means that the patients normal range of motion is just lower than the average in the study, or the patients ROM in all degrees has been decreased, showing that the laterally displaced C7 is most likely not the only issue in the patient’s neck. The comparisons of these averages are documented in Figures 1, 2 and 3.
When looking at the BPISF the patient filled out in pre-treatment assessment, their pain at their “worst” in the last 24 hours was at 7/10 (0 being no pain and 10 being pain “as bad as you can imagine”). The pain at its least in the past 24 hours was 0/10 and their pain on average was 4/10. “Normal work” was affected most by the pain, measuring at a 7/10 on a scale of 0 being no interference and 10 “completely interfering”. Sleep measured at 6/10 and general activity 5/10, then enjoyment of life was 3/10 and walking ability 2/10. Mood and relations with other people we both unaffected by the pain. These pain measurements are recorded in Figures 4 and 5.
The following special tests were performed before the first treatment to rule out any other C/s pathologies. All special tests were performed according to the written procedures explained in Magee and their outcomes are listed below:
Apley’s Superior and Inferior (WNL)
Distraction (+)
Maximum Cervical Compression (-)
VAT (-)
Sitting Arm Lift Test (-)
Prone Arm Lift Test (-)
Some manual muscle tests (MMTs) were also used before the first treatment to try to find any weak or painful muscles: Splenius cervicis BL (both rated a 5/5) and middle and posterior scalene BL (also rated a 5/5). After completing these MMTs in the pre-treatment and finding them all at acceptable levels, it was decided not to use them further in the study and they were removed from all other assessments. It was also decided that due to a 5/5 rating, muscle stripping, lengthening or heat to these muscles would not be useful and were removed from the treatment plan.
Joint play to the C7 vertebra was performed in the motion of a lateral glide. Pushing it further into the deviated plane (to the right) caused radiating down the right arm to the elbow as well as showed hypomobility. Pushing it to the left did not produce any pain and the movement was easy to perform.
Treatment Planning
Creating a treatment plan involved reviewing the patient’s pre-treatment assessment outcomes, and knowing that the primary aim of managing and treating any vertebral deviation is to stop the curvature progression (Hans-Rudolf Weiss, 2006). Based off these two facts, a treatment plan was created to stop C7 from deviating any further and to best achieve the two treatment goals of increasing ROM and decreasing pain. A combination of Swedish massage and Joint mobilizations were used in the span of five treatment sessions, all consisting of about 45 minutes.
Swedish massage and joint mobilizations were used in conjunction to create an effective treatment for the patient, while still staying simple enough to measure the modality’s effects.
While researching whether Swedish massage would be an effective modality for this patient’s symptoms, two systemic reviews were found indicating that is was. One systemic review studied 270 randomized control trials (RCTs) and found that massage therapy (MT) modalities including Swedish massage (similar to the modality used before and after the joint mobilizations of this case study) had a higher effect on reducing pain and disability in subjects with neck pain when compared to patients receiving no treatment, receiving placebo treatment and patients only receiving exercise treatment (Furlan 2010). However, this study found no evidence that MT (Swedish) can increase neck range of motion.
Another systemic review looked at 38 RCTs about neck pain specifically and found “moderate evidence” that MT improved the level of pain experienced. These treatments were compared to results of patients receiving inactive therapies as well as patients receiving traditional Chinese medicine (Cheng, 2014). As with the other systemic review, this article did not conclude that massage therapy can improve dysfunction and stated that they believed adding other active therapies to the massage treatments may help fix this.
After assessing the RCT, it was decided that another technique was needed to be added to achieve the second treatment goal, increasing ROM. One study tested three different techniques, consisting of high velocity and low amplitude manipulations, grade III posterior-anterior mobilizations and sustained natural glides (Lopez-Lopez, 2015). The neck pain intensity and cervical ROM were assessed after the final treatment and there was overall increased pain relief with the joint mobilization techniques versus the others as well as an increase in the affected ROMs, showing that joint mobilizations were the most effective with not only increasing ROM, but relieving pain as well.
It was chosen to mobilize the shifted segment, C7, though it has been explained in some studies that there is little difference between mobilizing the patients affected vertebrae vs. mobilizing a random one (Aquino, 2009). Aquino, 2009 states that any joint mobilization techniques helped decrease pain after the treatment. This verifies that joint mobilizations, whether on the proper segment or not, are effective with pain reduction, therefore further supporting this study’s treatment goals.
To limit variations of the outcome, homecare and stretching were not given to the patient, and the patient was instructed to continue his daily life as usual. (Vermeire, 2001) showed that there is very little, if not no change at all to the result of patients experiencing neck/back pain when using the following techniques: 1. Manual therapy (e.g. spinal manipulation, spinal mobilization, stretching and massage), 2. Manual therapy without spinal manipulation and 3. Manual therapy without stretching. This article helps validate the choice of technique since this study is only using a joint mobilization and does not include stretching. It makes the point that improvement has the biggest advantage when manual therapy is used, and the extra stretching or other techniques minimally affects the results.
(Vermeire, 2001) also states that the percentage of poor compliance of homecare and prescribed exercises is anywhere from 30-50%. This reduced compliance is seen regardless of “disease, prognosis or setting”. Due to these findings, it verifies that joint mobilizations are possibly the best choice for treatment since assigning homecare (whether stretches or exercise) may have up to a 50% chance of the patient not complying and the results of the study ending up inaccurate. The patient was also instructed to continue his ADLs as he normally would, meaning he continued to exercise on a daily base and maintained his habitual posture.
Application
Treatments occurred twice a week for three weeks, with the first session being assessment and the next five being treatment. Each treatment followed the same protocol, starting with a series of Swedish techniques, then moving into the cervical joint mobilization, and finally finishing with the same Swedish techniques, in reverse order. It began with warming up the posterior neck and upper back with Swedish massage. Effleurage, various strokes (including palmer, knuckle and elbow), thumb kneading and picking up were all used to warm up the tissue.
After the tissue was effectively warmed up, 4 sets of vertebral lateral translations we applied to C7 in the left direction. They were applied for 30 seconds per set, with a 30 second break before the next one. The procedure started by placing the fingertips onto the articular process of C7 and pushing it into the restrictive barrier. Palms of the hand support the occiput and the fingertips of the other hand palpate the mobilization. These steps were taken from the explained procedure in (Dixon, 2006).
Once the 4 lateral translations were performed, the same Swedish techniques as explained above were performed again to release any tissues that may have been fired up during the joint mobilizations, as well as to cool down the tissues before finishing the treatment.
The treatments were ended with gentle effleurage and then the patient’s ROMs were re-assessed. The full treatment plan is documented in Figure 6.
Results
When reviewing the BPISFs that the patient had filled out throughout the study, there was a significant decrease in the pain they were experiencing after the second and third treatment, however it rose again after the fourth treatment. By adding up the total of numbers selected on the BPISF, pre-treatment was 39, treatment #1 was 41, treatment #2 was 46, treatment #3 was 16, treatment #4 was 15 and treatment #5 was 36. [Younger, 2009] stated that a clinically significant reduction of pain should be at least a 30% decrease. By adding up the total pain of each treatment and dividing the pre-treatment total with each other treatment, the percentage of increase or decrease of pain can be found. By dividing pre-treatment with treatment #2, there was an 18.0% increase in pain. Before treatment #3, there was a 59.0% decrease in pain, and before treatment #4 there was a 61.5% decrease in pain. Unfortunately, when looking at the BPISF of the final treatment and comparing it with the pre-treatment, there was only a 7.7% decrease of pain, which would not constitute a “clinically significant reduction of pain”, according to Younger, 2009.
When looking at the C/s AROM and PROMs of each treatment, both before and after, there was a gradual increase in right lateral flexion and rotation throughout the whole duration of the study without any major changes. From the pre-treatment assessment before treatment #1 to the post-treatment assessment of treatment #5, there was a 16 increase in the patients AROM of right lateral flexion. For PROM of the same motion, there was an 8 increase. For AROM of right rotation, there was a 12 increase and PROM had a 16 increase. These changes are significant to the patient’s improvement of ROM. Interestingly, when assessing the first treatment findings with the final findings, there was also a 43.5% increase in left lateral flexion for AROM, but only a 13% increase with PROM. This shows that even though the movements to the right were the target movements, this technique also positively influenced the left movements too. AROM and PROM of the patients neck flexion and extension were not greatly affected.
Conclusion: Lateral cervical glides applied to a laterally deviated cervical spinous process can greatly increase the amount of ipsilateral flexion and rotation as well as decrease the overall pain experienced by the patient.
Certain special tests were also re-done, including the distraction of the C/s which was positive in the pre-treatment, and had become negative after the 5th treatment. A lateral glide of C7 to the right was also preformed, which in the first assessment it created “radiating pain down the right arm to the elbow” and also had a feeling of hypomobility. In the post-study assessment, there was no pain and no radiating symptoms.
Before and after the study, the compression test of the C/s was negative, and a BL manual muscle test of splenius cervicis and middle and posterior scalenes all were rated as a 5. The patient’s RROM of every movement was always 5 and never had any pain.
Discussion/Conclusion
Some flaws to the study that may have caused inaccurate