During the course of attending massage school at A New Beginning School of Massage, students are given a number of assignments that requiring research and writing. Some of these assignments result in very insightful and well-thought-out information and decision-making outcomes. I am happy to share some of their assignments for you to enjoy.
My client is a 43-year-old female, and she presents with chronic tension headaches which are characterized by pain and pressure on the sides of the head, particularly on the left, and tenderness in the neck and shoulders. In addition to pain, her symptoms cause her stress, anxiety, insomnia, and mood disturbances. She also often resorts to pain medication, which causes rebound headaches when she tries to stop using them. She also presents with a kyphotic curve in the upper thoracic region with typical accompanying tightness and pain, severely reduced range of motion, and gait challenges, and neurological symptoms like spasticity.
I chose this client because her condition is severe and traumatic for her, and I want to use massage in addition to intervention with exercise and therapeutic movement that I use with her as a client in my practice.
ABOUT TENSION HEADACHES
The Mayo Clinic defines chronic tension headaches1 as headaches that last for more than 3 days or occur for more than 15 days per month, and include symptoms such as dull, aching head pain, pressure or tension in the forehead, sides, or back of the head, and tenderness in the neck, shoulders, and scalp. This client believes, and my experience supports, that her condition relates to both structural issues in the thoracic spine, cervical spine, and shoulder girdle due to postural distortion, as well as traumatic life events that contribute to certain muscle memory and "holding patterns" that keep her in what I would describe as "fetal" posture. She has also had breast and gluteal implants, which contribute to her structural issues.
MY TREATMENT PLAN
My plan included a combination of exercises, assisted stretching, and researched, targeted massage techniques that employ a gentle approach to "unwinding" her challenges. She has been relying exclusively on deep tissue work, and I want to test the gentler methods. My goal with this client was to decrease the severity, duration, and frequency of her headaches.
When researching headache treatments with massage, I found that many preferred a gentler approach. It seemed that light myofascial work and trigger point therapy2 were coming up as most effective. This was encouraging, as I was reticent to introduce even more trauma to the body. In a 2002 study3 of massage and chronic tension headaches, it was determined that two 30 minute massages per week that included trigger point and other therapeutic techniques to treat the upper trapezius, sternocleidomastoid, suboccipitals, splenius capitis, levator scapulae, and temporalis was effective in reducing the frequency and duration of tension headaches. While the intensity was seemingly unchanged, the results looked promising for causing some improvement, so I decided to follow their protocol. (see below)
After the first treatment, she reported a migraine headache, which she felt was triggered by the "limited attention" that her muscles were given, and the lack of deep tissue work. I was a little discouraged but hopeful that we would achieve some results with time. She allowed me to continue, and after week 2 she reported not only one day totally headache free, but also that she was able to get a good night's sleep without the use of medication.
Week 3 was interrupted by her work travel, and then when she returned she received botox injections throughout the head and neck to treat the headaches. She had received these injections a little over three months ago and was pleased with the results for the first two months. The headaches resumed in month three, and she was desperate for more significant relief.
While I was disappointed that the case study was interrupted by the intervention, I am glad that she is feeling better and that I got to see the promising results of the effect of these targeted therapies on chronic tension headaches. I will continue using the protocol with her, as she has come to enjoy it, and the new test will be to see if we can get her through the third month post botox treatment.
CHRONIC TENSION HEADACHE MASSAGE TREATMENT
Phase 1--preparatory tissue warm-up
(3 minutes) included bilateral pressure moving from the lower cervical region to the occiput. This procedure was repeated, with completion of 3 passes bilaterally.
Phase 2--myofascial release
(5 minutes) included 3 palmar glide passes each over the deltopectoral, deltoid, and posterior deltoid regions bilaterally. Additionally, 3 passes with a soft fist contact were made from the occiput to the lateral shoulder along the upper trapezius bilaterally.
Phase 3--axial cervical traction
(2 minutes) included application of manual axial traction with 1 hand under the head and neck and the other hand on the forehead. Gentle traction was applied with the head first slightly flexed, then with slight right lateral flexion, and finally with the head in slight left lateral flexion. Traction was held for 15 seconds in each position.
Phase 4--trigger point therapy procedure
(15 minutes) consisted of scanning palpation of the upper trapezius, sternocleidomastoid, suboccipital, splenius capitis, levator scapulae, and temporalis muscles to locate and manually treat trigger points. When located, active trigger points were treated by pincer or flat palpation with just enough pressure to elicit referred pain or autonomic referral phenomena. That pressure was maintained on the trigger point until the client reported that the referral pain had dissipated or for a maximum of 2 minutes. Pressure on the active trigger point was then slowly eased to elicit a vascular flushing. This procedure was repeated 3 to 5 times on each trigger point. Typically, 6 active trigger points were treated in the time allotted.
Phase 5--facilitated stretching techniques
(5 minutes) consisted of muscle energy techniques, which included therapist-assisted lengthening and stretching of the cervical paravertebral musculature. The stretching procedure invoked relaxation through reciprocal innervation mechanisms. The antagonist musculature was isometrically contracted; this was followed by passive stretching of the agonist musculature.
Phase 6--session closure
(3-5 minutes) included relaxing effleurage and petrissage strokes and application of passive motion to the cervical region to end the session
1 Mayo Clinic Website. http://www.mayoclinic.org/diseases-conditions/tension-headache/
2 AMTA website Article, May 2017, Tackling Migraines Head-On https://www.amtamassage.org/articles/3/MTJ/detail/3704/tackling-mgraines-head-on
3 Am J Public Health. 2002 October; 92(10);1657-1661. Massage Therapy and Frequency of Chronic Tension Headaches