34 march 2013 international journal of athletic therapy & training

Two common conditions affecting patients are neck pain and myofascial pain syn-drome. Troublesome neck pain has been reported to affect over 34% of the general population each year,1 and more than 23 million Americans are thought to suffer from

myofascial pain syn-drome.2 Acute cervical pain is more common in women, which is often episodic with common relapses.2,3 Predispos-ing factors for cervical pain are mental and physical stress,2 a his-tory of work-related neck injury,4 and pro-longed postures that stress the cervical spine (e.g., working at a com-puter).3

Poor posture or awkward sleeping posi-tions can create abnor-mal strain on cervical musculature, primarily

affecting the trapezius, levator scapulae, ster-nocleidomastoid, and suboccipital muscles. Strain on these muscles may cause pain, motion restriction, and secondary myo-fascial pain that can cause referred pain.5

Treatment of Acute Torticollis Using Positional Release Therapy: Part 1

MANUAL THERAPY

Russell T. Baker, MS, MS, ATC • California Baptist University; Alan Nasypany, EdD, ATC, LAT and Jeff G. Seegmiller, EdD, ATC, LAT • University of Idaho; Jayme G. Baker, DPT, ATC, PT • California Baptist University

Myofascial pain is often characterized by trigger points, which can be identified by palpation and general motor dysfunction.2 The development of cervical trigger points may result from muscle overload associated with support of the head during repetitive or sustained motions.2 Despite varying opinions about whether or not the terms trigger point and tender point are synonymous, there is agreement that they have many similar characteristics and predisposing factors (e.g., sympathetic upregulation, nutrition, proprio-ceptive dysregulation).6,7

Treatment of cervical pain usually begins with a comprehensive physical examination to exclude a structural lesion (e.g., fracture, stenosis) as the primary cause of symptoms and to determine whether the pain is attribut-able to mechanical, chemical, psychological, or combined factors.5 The treatment plan typically includes interventions that are expected to decrease pain, return motion, improve strength, and restore normal func-tion. Treatment options include patient edu-cation (e.g., sitting posture, sleeping posture), rest, use of a cervical collar, topical agents, oral medications, psychological support and counseling, and traditional physical therapy.5

Relatively little research evidence sup-ports the use of many interventions used to treat nontraumatic cervical pain. The use of

Cervical spine pain is a common condition affecting a wide variety of patient popula-tions.

Stress, a history of cervical pain, and poor posture are predisposing factors for cervical pathology.

A complete and accurate physical examina-tion is necessary to determine appropriate intervention strategies.

The use of an outcome measure and mini-mum clinically important difference (MCID) can guide a clinician to implement the most effective therapeutic strategies.

Key PointKey Point

© 2013 Human Kinetics - IJATT 18(2), pp. 34-37

international journal of athletic therapy & training march 2013 35

medication (e.g., NSAIDs, muscle relaxants), a soft cer-vical collar, and traditional physical therapy (e.g., ultra-sound, electrical stimulation, heat, traction, stretching with vapor coolant spray, massage) are primarily based on theoretical therapeutic benefits and previous clinical experiences.5 Research has demonstrated the existence of abnormal vascular function in patients who have myofascial pain that is associated with a palpable nodule within the affected muscle tissue.2 Furthermore, active trigger points appear to have elevated levels of inflammatory mediators, which sensitize nerve endings and produce persistent pain.2,8 A “latent” trigger point is believed to be a focal area of muscle dysfunction (i.e., weakness and localized pain) that is not active at rest but responds to mild to moderate palpation (i.e., sufficient pressure to blanch a nail bed).6,7

Trigger point sites in a muscle tend to have a symmetric active or latent site in the corresponding contralateral muscle. When a trigger point is present, it has a lower pain-pressure threshold (PPT), which does not appear to be correlated with the size of the trigger point.2 A low PPT is believed to be primarily related to localized inflammatory mediators and secondarily to mechanical factors.8 Localized ischemia and resultant hypoxia are probably responsible for the tenderness of the trigger point site.9 Palpation that identifies the exact location of a low PPT is an important component of the examination process.10

TorticollisTorticollis, commonly referred to as wryneck or acute neck stiffness, is defined as cervical muscle spasm that causes the head to be drawn to one side and rotated in the opposite direction.11 The term torticollis has been used to describe a wide range of cervical pathol-ogy, including acute neck pain and stiffness12 as well as atlantoaxial rotatory fixation/subluxation.13,14 The etiology of the pathology that produces torticollis is not completely understood.12-14

Typically, the patient reports waking from sleep with cervical pain, decreased motion, muscular spasm, and exhibits a rotated head position.12-14 Nontraumatic acute torticollis does not have a clearly established set of diagnostic criteria or a standardized treatment protocol. It may be caused by muscle spasm or soft tissue entrapment between vertebrae.13,14 If atlanto-axial rotatory fixation/subluxation is not present, acute

torticollis usually resolves with treatment (e.g., cervical immobilization, medication, rest) over the course of 1–3 weeks.13

A complete physical examination is necessary for a patient who presents with acute torticollis. Clinical guidelines have been developed to help distinguish muscular torticollis from atlantoaxial rotatory sub-luxation (AARS). Typically, the presentation of AARS involves some type of trauma, prior infection (e.g., upper respiratory tract infection), or recent surgery.13-15 Physical examination may reveal a palpable deviation of the spinous process of C2 in the same direction as the head rotation.15 Additionally, palpation of the ipsilateral sternocleidomastoid muscle (i.e., the muscle producing the head rotation) may reveal spasm. Sig-nificant spasm in the sternocleidomastoid muscle may produce a “cock-robin” position, with the head rotated to one side and the neck tilted laterally toward the opposite side.15,16 A patient with AARS should pres-ent altered range of motion. The condition is typically associated with the inability to actively rotate the head past the body midline in the direction opposite the abnormal head position.15,16 A patient without AARS should demonstrate an equal passive range of rota-tional motion on both sides.13

Positional Release TherapyPositional Release Therapy (PRT) is a term for a specific approach to detection, classification, and treatment of trigger/tender points.6,7,17 A position of comfort (POC) is established to relieve tension on the muscle-spindle mechanism in a relaxed and shortened state. The POC is held for a period (e.g., 90 seconds) to facilitate muscle relaxation.6,7,17 PRT is applied by treating the most severe tender point (TP), followed by the most proximal or medial TPs. Some TPs cause a “jump sign” (i.e., nociceptive withdrawal), which may be an indica-tion of clinical significance. 6

PRT has relatively few contraindications (i.e., open wounds, fracture, infection, pain during treatment positioning6,17) and offers a potentially effective treat-ment for a variety of injuries managed by athletic train-ers.17 Because some treatment positions may require a significant amount of cervical rotation, extension, and sidebending for a period of 90 seconds or more, normal vascular function must be confirmed (i.e., vertebral artery testing).6,7,17 The treatment should be

36 march 2013 international journal of athletic therapy & training

administered with the patient’s eyes open to permit the clinician to observe for nystagmus (i.e., involuntary oscillation of the eyes), which is sometimes associated with vertebral artery syndrome. Areas of tenderness to palpation have been designated by various terms (e.g., tender points, tender areas, trigger points, etc.) that are often used interchangeably.6,7 We define a TP as a tender region within muscle, tendon, ligament, fascia, or bone that is four times more sensitive than the surrounding tissue, or within the same tissue on the contralateral side.6

Research has confirmed that PRT can significantly reduce pain in patients with acute and chronic mus-cular dysfunction,18-21 and it can increase strength.20 Reduction of muscle spasm is the probable mecha-nism for restoration of normal pain-free motion and tissue flexibility. Restoration of normal local vascular perfusion may facilitate the removal of inflammatory mediators.21 PRT is a technique that is easy to learn, it presents few contraindications,6,17,21 and patients can be taught to self-administer the treatment for control of symptoms between clinic visits.22

Using Outcome Measures to Document Benefit

A useful method to document meaningful benefit from the administration of a treatment is the determination of minimum clinically important difference (MCID) for an outcome measure. Two examples of outcome measures are the Numerical Rating Scale (NRS) and the Disablement in the Physically Active (DPA) scale. The NRS is commonly used to measure pain intensity on a 0 (i.e., no pain) to10 (i.e., worst possible pain) rating scale.23,24 The DPA scale is a patient-centered outcome instrument designed for the physically active patient. The DPA includes measures of impairments, functional limitations, and disability and includes questions about health-related quality of life. The DPA scale has an MCID value of six points for patients with a persistent condition and an MCID of nine points for patients with an acute injury.25 For the NRS, a 30% change or a two-point reduction in the pretreatment rating is associated with a clinically important change.23,24

In part 2, we report the results of a study of the effectiveness of PRT to treat acute muscular torticollis in four patients who presented with cervical tender points.6,7,17

References 1. Bovim G, Schrader H, Sand T. Neck pain in the general population.

Spine. 1994;19(12):1307-1309.

2. Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S. Objec-tive sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med. 2011;30:1331-1340.

3. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783-792.

4. Nolet PS, Cote P, Cassidy JD, Carroll LJ. The association between a lifetime history of a work-related neck injury and future neck pain: a population based cohort study. J Manipulative Physiol Ther. 2011;34(6):348-355.

5. Dreyer SJ, Boden SD. Nonoperative treatment of neck and arm pain. Spine. 1998;23(24):2746-2754.

6. D’Ambrogio K, Roth G. Positional Release Therapy: Assessment and Treatment of Musculoskeletal Dysfunction. St. Louis, MO: Mosby;1997.

7. Chaitow L. Positional Release Techniques. 3rd ed. London, UK: Church-hill Livingstone Elsevier;2007.

8. Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, Gerber LH. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89(1):16-23.

9. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simon’s inte-grated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004;8(6):468-475.

10. Prushansky T, Handelzalts S, Pevzner E. Reproducibility of pressure pain threshold and visual analog scale findings in chronic whiplash patients. Clin J Pain. 2007;23(4):339-345.

11. Dirckx JH, ed. Stedman’s Concise Medical Dictionary for the Health Professions. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2001.

12. Gubin AV, Ulrich EV, Taschilkin AI, Yalfimov AN. Etiology of child acute stiff neck. Spine. 2009;34(18):1906:1909.

13. Hicazi A, Acaroglu E, Alanay A, Yazici M, Surat S. Atlantoaxial rotatory fixation – subluxation revisited. Spine. 2002;27(24):2771-2775.

14. Maigne JY, Mutschler C, Doursounian L. Acute torticollis in an adoles-cent. Spine. 2003;28(1):E13-E15.

15. Subach BR, McLaughlin MR, Leland AA, Pollack IF. Current man-agement of pediatric atlantoaxial rotatory subluxation. Spine. 1998;23(20):2174-2179.

16. Van Hosbeeck EMA, Mackay NNS. Diagnosis of acute atlanto-axial rotatory fixation. J Bone Joint Surg [Br]. 1989;71(1):90-91.

17. Speicher T, Draper DO. Top 10 positional-release therapy techniques to break the chain of pain, part 1. Athl Ther Today. 2006;11(5):60-62.

18. Alexander KM. Use of strain-counterstrain as an adjunct for treatment of chronic lower abdominal pain. Phys Ther Case Rep. 1999;2(5):205-208.

19. Lewis C, Flynn TW. The use of strain-counterstrain in the treatment of patients with low back pain. J Man Manipulative Ther. 2001;9(2):92-98.

20. Wong CK, Schauer-Alvarez C. Effect of strain counterstrain on pain and strength in hip musculature. J Man Manipulative Ther. 2004;12(4):215-223.

21. Kelencz CA, Tarini VAF, Amorim CF. Trapezius upper portion trigger points treatment purpose in positional release therapy with electro-myographic analysis. North Am J Med Sci. 2011;3:451-455.

22. Speicher T, Draper DO. Top 10 positional-release therapy techniques to break the chain of pain, part 2. Athl Ther Today. 2006;11(6):56-58.

23. Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole M. Clinical impor-tance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149-158.

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24. Pool JJ, Ostelo RW, Hoving JL, Bouter LM, de Vet HC. Minimal clinically important change of the neck disability index and the numerical rating scale for patients with neck pain. Spine. 2007;32(26):3047-3051.

25. Vela LI, Denegar C. The disablement in the physically active scale, part II: The psychometric properties of an outcomes scale for mus-culoskeletal injuries. JAT. 2010;45(6):630-641.

Russell Baker is an assistant professor in the Department of Kinesiol-ogy at California Baptist University. He is also a doctoral student at the University of Idaho in the Doctor of Athletic Training program.

Alan Nasypany is the Director of Athletic Training Education in the Department of Movement Sciences at the University of Idaho in Moscow, ID.

Jeff Seegmiller is an associate professor and Musculoskeletal Anatomy Chair in WWAMI Medical Education and the Department of Movement Sciences at the University of Idaho in Moscow.

Jayme Baker works at West Coast Spine Restoration Center and serves as an adjunct professor with the Department of Kinesiology at Cali-fornia Baptist University.

Trent Nessler, PT, DPT, MPT, Champion Sports medicine/ Physio-therapy Associates, is the report editor for this article.

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