to Arthritis Research UK, back pain affects around a third of the United Kingdom’s
adult population every year (Arthritis Research UK, 2017). Back
pain is usually associated with muscles, tendons or ligament with muscular pain
being very common, originating from strains, sprains or joint dysfunction.
Possible causes for this type of pain are fatigue, overloading, poor manual handling
technique and incorrect posture (Miller, 2017).
This case study involves an
individual presenting with upper back and neck pain with tension,
representative of the issues suffered by a significant percentage of the
population. It was of interest to see if soft tissue therapy techniques could
affect the outcome with treatments involving techniques that are recognized in
the area of manual therapy. Soft tissue therapy is defined as, “passive movements to muscles, tendons and
ligaments for the reduction of discomfort and restoration of tissue
extensibility” (English Institute of Sport, 2017). Although this study
doesn’t attempt to contribute to any research or existing literature, it endeavors
to improve the author’s understanding as to what has impacted a patient’s back
pain and whether the treatment given can assist or improve the issue.
male, presented with a complaint of a stiff neck and upper back pain. The pain
was located along the nape of the neck and bilaterally across the superior and
middle part of the trapezius. The patient stated he was feeling tension in the
back of his head and stiffness when he palpated the left side of his back. He
described the pain as a dull ache, felt that it was more a muscular problem than
skeletal and that he would commonly suffer with tension headaches. The patient
had been retired for approximately three years after a very long, arduous
career in the Royal Marines and Police Force. He had previously visited the gym
regularly but highlighted that since retiring he has reduced gym work
considerably but remains very active through gardening, do-it-yourself and
coastal walking. The patient had a sub acromial decompression to his right
shoulder ten years ago and was advised to have
the same procedure to the left shoulder but he declined.
patient was observed in a standing position. His overall posture was good with
only slight protraction of the shoulders noticed. His active and passive range
of movement in both shoulders highlighted no pain or discomfort and measured
normal range and end feel in all modes of movement. There were no abnormalities
in the patient’s scapula movement. The patient stated he felt there was a
severe limitation and stiffness in his ability to rotate his neck and this was
clear to observe, particularly rotation to the left. All other movements of the
neck were normal and without significant pain.
out any major musculoskeletal dysfunction in the subjective and objective
assessment from the first session, it was clear after palpation that the
patient had tension bilaterally through his upper trapezius. There were several
areas where tender trigger points were noted including the medial border of the
right scapula and along the left upper trapezius. On palpation, these points
were noted to be the prominent areas causing the patient’s pain. Pain was
measured using the visual analogue scale and at this stage the patient’s pain
was assessed as 4 out of 10.
of this case study are as follows:
– To reduce tension, stiffness and pain in the upper back and neck
that caused the patient problems in his day-to-day life.
– To see if soft tissue therapy can aid in reducing the headaches.
– To see if treatment would improve movement even if the range is
already at a good standard.
achieve these aims, treatment over three sessions was conducted using practices
in soft tissue massage, neuromuscular therapy and muscle energy techniques.
All treatment consultation forms
can be seen in Appendix A.
Soft Tissue Massage
There are several forms of manual
technique used on soft tissue with one that is commonly experienced within
rehabilitation being massage therapy. Even though this form of soft tissue
therapy is highly popular within the world of sport and therapy for its
potential benefits, there appears to be little research that shows any evidence
of these perceived benefits (Ward, 2015).
Over the three sessions, massage
was carried out on the patient, focusing on the upper region of the trapezius,
deltoid, sternocleidomastoid, levator scapulae and scalene muscles on both
sides of the patient’s body. It was clear during the initial assessment that
the patient had noticeable tension and adhesions, therefore the decision to
carry out techniques such as effleurage, petrissage and tapotement was made. There is a belief that these techniques
promote relaxation, separate tissue adhesions, encourage blood flow and assist
in mobility (Sports Therapy UK, 2017).
Several studies imply this type of treatment can
be beneficial. A study on shoulder pain proposed
that soft tissue massage improved range of motion, pain and function but
concluded that the reason behind these results remained unclear (Van den
Dolder and Roberts, 2003). In contrast, earlier work by Farr et
al. (2002) claim that soft tissue therapy helps with muscular pain but suggests that it does not help function or strength.
After the first session, the
patient reported that the tension along his neck and upper back had eased,
however this appeared to return after a few days. After the second session, however, the patient
reported a reduction in tension up the neck and left shoulder. This was
interesting as on palpation of the upper back and neck, several muscles
including left upper trapezius and the sternocleidomastoid bilaterally in
particular still felt tight.
After every session it was
observed that the patients soft tissue appeared flushed. This is understood to
be a side effect of increased blood flow to the region (Massage Therapy UK, 2017)
and would suggest that the patient was responding
well to the treatment. Mori et al. (2004) conducted a study on
the effect of massage on blood flow in which they found there to be some
evidence that massage had an effect on skin temperature and improvement of
blood flow. This research would support what is believed to have happened to
the case study patient. However another study
contradicts this theory explaining that massaging the quadriceps did not show
any significant elevation of blood flow (Tildus and Shoemaker, 1995). Another study goes further stating that it actually
impairs blood flow during the stroke of the massage and therefore could delay
recovery (Wiltshire et al., 2010).
Although there are differences of opinion within
studies as to the effect this treatment has on the body, in this case the
patient believed it to be beneficial. His upper back was feeling less under
tension, softer on palpation and he found his movements more free including
rotation. In particular he noticed he felt much better in his general mood.
During the initial assessment the patient noted that he could not remember a
time when he didn’t have tension in his upper back. He had previously put this
down to his job roles that spanned over thirty years and involved load carrying,
either a heavy bergan or stab vest and attached equipment. The experience of
suffering with this chronic issue for a long time had an impact on stress
levels and mood. A study that was conducted on the effect of massage on
intensive care nurses showed that occupational stress levels had reduced after
massage (Nazari et al., 2015). Although this patient had been recently
retired, this study could support how the patient claimed his mood had improved
and how he felt the tension had reduced in his shoulders and neck.
Several trigger points were noted on palpation
of the patient, which could potentially be a cause of the pain and discomfort
that he was observing. Another interesting point noted was his complaint of
having tension headaches to the back of his head. Trigger points in the upper
Trapezius can refer pain up the neck and cause headaches (National Association
of Myofascial Trigger Point Therapists, 2017). These key points in the
assessment encouraged the therapist to try neuromuscular techniques on the
patient in the first session. Chaitow and DeLany (2005) discuss a case study
regarding a headache in which they suggest treating trigger points as an option
for tension headaches that are deemed chronic.
The patient in this case study noted that a few
days after treatment, the areas where this technique was used were very sore so
it was not conducted during the second session. It was attempted again during
the third session but using less pressure to see if there was an improvement.
The patient did feel less pressure in the back of his head but still noted
occasional headaches. He noted that where the trigger points were along his
upper back, there was a significant improvement in pain.
There is evidence to suggest that muscular
energy techniques improve end range and flexibility. One study on the hamstring
muscle found that applying this technique increased the stretch of the muscle (Ballantyne
et al., 2003), Another articulated the effects of muscle energy techniques
on cervical range of motion and showed a significant increase in ranges and
supported the technique in cervical range of motion (Schenk et al.,
The decision was therefore made to incorporate
muscular energy techniques as part of the treatment with the aim of maintaining
range of movement and to encourage flexibility. Although the muscles around the
patient’s neck and upper back were under various degrees of tension, the
initial range of movement was good so there was no expectation for any
significant improvement to the patient’s ranges. The patient’s lack of rotation
did however show noteworthy improvement after treatment from this technique
over that of soft tissue massage alone.
The observed results from this case study
indicate that the aims were achieved. The patient noticed several good outcomes
after the three sessions. His mood had improved after every session; his
headaches had reduced both in frequency and in level of discomfort. The tension
and stiffness of his upper back region had declined and his overall pain and discomfort
had reduced from 4 to 2 on the visual analogue scale.
Inspection of his upper back after every session
showed a much more palpable area which led the therapist to initially believe that
treatment was loosening the muscles and adhesions. However this was
contradicted as at each pre-treatment assessment thereafter, the muscle
resorted back to feeling very tense and tough to palpate, even though the
patient claimed he felt there was improvement. It could be argued that three
sessions of simple massage, trigger pointing and muscle energy techniques are
not enough to show visible signs of improvement physically. However, with the
patient stating that his mood had improved after each session, it is possible
that his emotional development had an impact on his perception that there was a
physical change in the tone of his muscles.
The reduction in headaches could also be down to
the patient feeling a lot more relaxed after each session. Research has shown
that even after a week of experiencing massage therapy tension headaches
reduced (Quinn et al., 2002). The duration
of treatment in this study was over three weeks so it is possible that this is
true in this case. It is also clear that
a working life of stressful roles that involved significant and regular load
carrying could have caused the muscles to become very tense. It could be
possible that having massage and neuromuscular technique conducted on these
areas of tension has relaxed the muscles for a period of time, which has
allowed relief against the headaches.
The patient’s range of movement was already good
despite the presenting complaints. The therapist therefore did not expect to
see improvements in this area but it was evident that his movements were
smoother and lacked the previous pain from the tension that had built up.
During a post session assessment of the
treatment plan, it is felt that the techniques used were appropriate for the symptoms
presented. However unforeseen circumstances required an adjustment to the plan
after the first session, caused by the patient’s reaction to the use of
neuromuscular techniques. The patient felt incredibly sore around the trigger
point areas despite feeling less tense.
On reflection this could have been caused by
over-zealous application of the technique by the therapist namely the pressure applied
was too hard, and each area was worked too long. This technique was therefore removed
from the second session but was used in the third after reassessment and revision
of the procedure. It is not clear whether implementing it in all the sessions
would have produced a better response but the third session showed no repeat of
the soreness that the patient felt in the first, which is believed to be an improvement
If the opportunity arose to conduct this study
again, the main alteration that would be considered would be to have more than
the three sessions conducted with the patient this time. This could have
potentially produced a better result with respect to the muscle tension, but it
is believed the other positive outcomes that were reported by the patient would
have still been the same. This was the first time that the therapist had
conducted such a treatment and it is felt that with more confidence and
experience, the technique would improve which could promote improved results. This
case study was also limited to massage, neuromuscular technique and muscular
energy technique. It is believed that if other techniques and areas of therapy
were incorporated then the patient could have experienced longer lasting
results. Examples here might include taping, that could have been used to
improve the patient’s posture which in turn could have reduced the tension in
his muscles, or the provision of exercise and stretching routines that could
have helped to maintain suppleness and flexibility between each session.
The therapist did consider the sub acromial
decompression to the right shoulder being a contributing factor to the
patient’s upper back complaints. It was concluded that further treatment outside
the limitations of this case study would be beneficial and for the patient to
reconsider the surgeons advice on surgery to the left shoulder.
A review of previous research that has been
conducted in various aspects of manual therapy, indicates that the majority
supports the outcome experienced in this case study. Although it has been more
on what the patient has felt rather than what has been seen physically, there
has been a positive outcome.