Tp 1 astri - final

Massage Therapy
for
Neck Pain
Supervised by:
DR. dr. Tirza Z. Tamin, SpKFR-K
Presented by:
Setia Wati Astri Arifin
Tinjauan Pustaka-1

Neck pain is pain
felt on the neck,
indicating that there
are malfunction of
joints, muscles or
other structural part
of the neck
Neck pain is a very common
problemwith prevalence in the
community is about 40%
Introduction

There are various
treatment for neck
pain, such as rest,
medication, physical
modalities and exercise
Medication and referral
to physiotherapist is the
most common treatment
given in primary
healthcare setting
In US, massage therapy is
one of the most frequent
therapy used for neck pain,
as a single therapy or in
combination with other
therapies & become the 2nd
most frequent reason to
visit physiotherapist
Massage therapy also
become more popular
lately as many studies
conducted to investigate
effectiveness of massage
therapy for neck pain

NECK
Cervical
Vertebral
Column
Spinal
Nerves
Ligaments
Muscles
Blood
Vascular
Lymphatic
System
Range of
Motion

Cervical ROM
Movement
Degree (°)
Total AOJ AAJ C2-C7
Flexion 60 10 5 45
Extension 80 25 10 45
Rotation (each side) 75 - 45 30
Lateral flexion (each side) 45 5 10 30

Cervical Plexus
• C1 – C5
Brachial Plexus
• C4 – T1

Ligaments
• Ligamentum flavum
• Ligamentum
supraspinatum
• Ligamentum
interspinatum
• Ligamentum
intertransversum
• Ligamentum
longitudinal anterior
• Ligamentum
longitudinal
posterior
• Ligamentum nuchae

Arteries
•A. Temporalis
Superficialis
•A. Aurikularis Posterior
•A. Oksipitalis
•A. Vertebralis
•A. Fasialis
•A. Lingualis
•A. Tiroid Superior
•Trunkus Tiroservikalis
•A. Jugularis Interna
•A. Jugularis Eksterna
•A. Jugularis Komunis
•A. Brakiosefalika

Veins
• V. Oksipitalis
• V. Postaurikularis
• V. Retro-
mandibular
• V. External Jugular
• V. Komunikans
• V. Jugularis
Interna
• V. Jugularis
Komunis
• V. Jugularis
Anterior
• V. Brakiosefalika

Deep Cervical
Lymph Nodes
Jugular Trunk
Retroauricular
Nodes
Superficial
Cervical Lymph
Nodes

Superficial
• Platysma
• Trapezius
Anterior
• SCM
• Scalenes group
• Prevertebral
group
Posterior
• Erector spinae
group
• Splenius capitis
• Splenius
cervicis
• Suboccipital
group
Muscles of The Neck

http://www.slideshare.net/ananthatiger/muscles-of-the-neck-1
Superficial

Muscles Flexion Extension
Lateral
Flexion
Axial
Rotation
Sternocleidomastoideus XXX X (upper) XXX XXX (CL)
Scalenus anterior XX - XXX X (CL)
Scalenus medius X - XXX -
Scalenus posterior - - XX -
Longus colli XX - XX -
Longus capitis XX - XX -
Rectus capitis anterior XX (AOJ) - X (AOJ) -
Rectus capitis lateralis - - XX (AOJ) -
Splenius capitis - XXX XX XXX (IL)
Splenius cervicis - XXX XX XXX (IL)
Rectus capitis posterior mayor - XXX (AOJ & AAJ) XX (AOJ) XX (IL) (AAJ)
Rectus capitis posterior minor - XX (AOJ) X (AOJ) -
Oblikus capitis inferior - XX (AAJ) - XXX (IL) (AAJ)
Oblikus capitis superior - XXX (AOJ) XXX (AOJ) -
Keterangan:
AOJ : atlanto-oksipital joint
AA J : atlanto-aksial joint
CL : contralateral
IL : ipsilateral

Flexion
• SCM
• Scalenus
Anterior
• Longus Colli
• Longus Capitis
• Rectus Capitis
Anterior
• Scalenus
Medius
Extension
• Splenius
Capitis
• Splenius
Cervicis
• Rektus Capitis
Posterior
Mayor
• Oblikus Capitis
Superior
• Oblikus Capitis
Inferior
• Rektus Capitis
Posterior
Minor
• Upper SCM
Lateral
Flexion
• SCM
• Skalenus Anterior
• Skalenus Medius
• Oblikus Capitis
Superior
• Skalenus
Posterior
• Longus Colli
• Longus Capitis
• Splenius Kapitis
• Splenius Cervicis
• Rectus Capitis
Lateralis
• Rectus Capitis
Mayor
• Rectus Capitis
Minor
• Rectus Capitis
Inferior
Axial
Rotation
• Ipsilateral:
• Splenius
Kapitis
• Splenius
Cervicis
• Contralateral:
• Sternokleidom
astoideus

Definition
The International Association for the Study of
Pain (IASP)
• In its classification of chronic pain, defines cervical spinal
pain as pain perceived anywhere in the posterior region of
the cervical spine, from the superior nuchal line to the first
thoracic spinous process
The Bone and Joint Decade 2000-2010 Task
Force on Neck Pain and Its Associated Disorders
• Describes neck pain as pain located in the anatomical region
of the neck with or without radiation to the head, trunk,
and upper limbs

• Neck pain is common in the adult general population, with
prevalence estimates from 30% to 50%
• Among children and adolescents, prevalence estimates
range from 21% to 42%.
The Burden and Determinants of Neck Pain in
the General Population
(Results of the Bone and Joint Decade 2000 –2010 Task Force on Neck
Pain and Its Associated Disorders)
Epidemiology

Etiology
Mechanical
Traumatic
Nontraumatic
Nonmechanical
Rheumatologic/
Inflammatory
Neoplastic
Neurologic
Infections
Miscellaneous

Nontraumatic
• Neck Strain
• Postural
• Tension
• Torticollis (acquired)
• Spondylosis*
(degenerative arthritis)
• Myelopathy*
• Cervical Fracture* (see
neoplasm)
Traumatic
• Whiplash Syndromes*
• Disc Herniation*
• Neck Sprain
• Sports*
Mechanical

Rheumatologic/
Inflammatory
• Rheumatoïd Arthritis
• Ankylosing Spondylitis
• Fibromyalgie
• Polymyalgia Rheumatic
• Reiter's Syndrome
• Psoriatic Arthritis
Neoplastic
• Osteoblastoma
• Osteochondroma
• Giant Cell Tumor
• Metastases
• Hemangioma
• Multiple Myeloma
• Chondrosarcoma
• Glioma
• Syringomyelia
• Neurofibroma
Neurologic
• Peripheral Entrapment
• Brachial Plexitis
• Neuropathies
• Reflex Sympathetic
Dystrophy
Referred
• Thoracic Outlet
Syndrome
• Pancoast Tumor
• Esophagitis
• Angina
• Vascular Dissection
• Carotidynia
Infections
• Osteomyelitis
• Discitis
• Meningitis
• Herpes Zoster
• Lyme Disease
Miscellaneous
• Sarcoidosis
• Paget Disease

•The most common neck pain is non-
specific mechanical neck pain caused by
muscle strain, ligament sprain, spasm, or
a combination
•No specific lesions, or findings
•Usually caused by daily activities
Etiology
Philip D. Sloan, Essentials of the family medicine , Chapter 37 Introduction , Wolters Kluwer , 6th edition

Patophysiology
Irritation or
inflammation
on cervical
tissue can
produce pain
The nociceptive sites on cervical
area are:
1. Anterior & Posterior
Longitudinal Ligament
2. Outer Annulus Fibrosus
3. Duramater
4. Spinal Nerve Root
5. Facet Joint Capsule
6. Muscles
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

Patophysiology
• Two major mechanisms of neck pain are
trauma and arthritis
Trauma:
1.External trauma
2.Postural trauma
3.Tension trauma
Arthritis:
1. Degenerative
arthritis
2. Sequelae of acute
inflammation
arthritis

Patophysiology
External Trauma:
• The neck received external forces that cause
abnormal cervical vertebrae position or
movement that leading to injury and pain

Patophysiology
Postural Trauma:
• Wrong posture can
cause various trauma
to the
musculoskeletal
system, especially
the vertebral column:
1.Forward head
posture
2.Dropping shoulder
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991. Image Source: Quora.com

Patophysiology
Tension Trauma:
• Emotional factor  hypothalamic limbic
system  physiologic & neuromuscular system
• Tension within the neuromuscular system
manifest as a sustained isometric muscular
contraction  No period of relaxation
•  blood flow  Ischemic pain
•  lymphatic flow
•  nutrient & O2
•  metabolic waste, lactic acis

Acute Neck
Pain
Lasts less than
7 days
Subacute
Neck Pain
Lasts more than
7 days but less
than 3 months
Chronic Neck
Pain
Lasts more
than 3
months
Classification by Onset

Clinical Manifestation
• Pain on neck or pain from
neck, with or without
radiation to the head, back,
shoulder and upper
extremity
• Fatigue
• Sleep disturbance
• Headache
• Pain with movement
• Limited ROM
• Palpated trigger point
• Radicular pain:
• Sharp or dull, burning
sensation or shocking
pain depend on
ventral or dorsal nerve
root involvement
• Distributes according
to the dermatomal or
myotomal area
• Neurologic symptoms
such as tingling
sensation, paresthesia,
numb or weakness

X-
Ray
CT
Scan
MRI
EMG
Diagnosis
History
Physical
Examination
Additional
Tests

1. Trunk or lower extremity
neurologic symptoms, especially
long-tract signs.
2. Bilateral upper extremity pain.
3. Remote symptoms with neck
movements (lower extremity).
4. Signs of sphincter dysfunction,
bowel or bladder dysfunction or
incontinence.
5. Fever, unrelenting nocturnal
pain, weight loss, chronic fatigue.
6. Recent infection or surgery.
7. Polyarthralgia.
8. Dysphagia.
9. Nuchal flexion or extension
rigidity, especially in the absence
of trauma.
10. Cranial neurologic deficit or
central nervous system symptoms.
11. Cervical pain related to general
exertion (i.e., after climbing stairs).
12. Symptoms unchanged or
progressive, despite previous
functional management.
13. Onset of cervical pain associated
with direct head trauma, loss of
consciousness.
14. Sudden onset of cervical pain
without trauma or incident.
15. Neck or occipital pain with a
sharp quality and severe intensity,
or severe and persistent headache,
which is sudden and unlike any
previously experienced pain or
headache
Precautions
Symptoms that Should Raise Suspicion That The
Presenting Cervical Pain Is Not Of Mechanical Origin
(McMillin)

Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008.

The Scientiﬁc Evidence
Strongly Supports the Use of:
• Screening
protocols in
emergency care
in low risk patient
with blunt
trauma to the
neck
• CT-scanning in
emergency care
for high-risk
patients with
blunt trauma to
the neck
For non-emergency neck pain:
– Manual provocation tests in patients
with neck pain and suspected
radiculopathy
– The combination of history, physical
examination, modern imaging
techniques, and needle EMG to
diagnose the cause and site of
cervical radiculopathy
– Self-reported patient assessment to
evaluate perceived pain, function,
disability, and psychosocial status
Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of Neck Pain and Its Associated Disorders. Eur Spine J. 2008 Feb
29;17(1):101–22.

Treatment
Pharmacologic
Acetaminophen
NSAID
Muscle relaxant
Non-
Pharmacologic
Education
Heat Therapy
TENS
Traction
Orthosis
Massage
Manipulation
Stabilisation
Flexibility
Posture
Exercise

Evaluation
• Physical Examination:
– Palpation of trigger point & tenderness
– Cervical Range of Movement (CROM)
– Manual Muscle Testing (MMT)
• Pain Perception:
– Visual Analog Scale (VAS)
• Functional Assessment:
– Neck Disability Index (NDI)46,47

Cervical ROM
Examination
Image Source: http://www.slideshare.net/ssuser33ed1c/neck-trunk-rom-measurement

Image Source: annals.org
Image Source: womenhealth.us

Vernon H, Mior S. The neck disability index: a
study of reliability and validity. J Manip Physiol
Ther 1991; 14:407-415.

Massage Therapy
• Massage Therapy  a group of procedures,
which are usually done with the hands, and
include friction, kneading, rolling, and
percussion of the external tissues of the body
in a variety of ways, either with a curative,
palliative, or hygienic purpose
Prentice WE. Therapeutic Massage. In: Prentice WE. Therapeutic Modalities in Rehabilitation. 4th ed. 2002. McGraw-Hill. New York.
Braddom RL, ed. Physical medicine and rehabilitation 4th ed. Philadelphia : Saunders Elsevier 2011; 439-44
Delisa, Joel A, ed. Physical medicine and Rehabilitation : principle and practice, 5th ed. Lippincott, 2010; 1725-30

Purpose of Massage Therapy
•  pain
•  Flexibility
•  pain threshold
•  blood circulation
•  lymphatic drainage
•  lactic acid
•  muscle spasm
•  muscle tension

Reflexive
• Slow, gentle, rhythmical,
and superficial stroke 
relieve tension & relax
muscles
• Local effect on sensory
and motor nerves
• CNS response 
sedation
Mechanical
• Superficial direct force
 Produce mechanical
or histologic changes in
myofascial structures
Physiologic Effect of Massage

Effects on Pain
Gate control theory
• Massage  non-
nociceptive
cutaneous
stimulation of large
diameter afferent
nerve fibers (Aβ) 
block transmission
of pain carried in
smaller diameter
nerve fibers (Aδ &
C)

Effects on Pain
Release of β-
endorphins from
pituitary gland &
hipotalamus 
effect in the
transmission of pain-
associated signal in
descending spinal
tracts

Effects on Pain
•Release of
enkephalin from
inhibitory
interneuron on
dorsal horn of
medulla spinalis
 block the pain
signal
transmission

Effects on Circulation
•  Blood circulation
•  lymphatic flow
•  removal of
edema & metabolit
wastes
•  temperature
Effects on Metabolism
•  circulation  
dispersion of waste
products and 
supply of fresh
blood and O2
• Mechanical
movement  
removal and
hastens resynthesis
of lactic acid

Effects on Muscle
•Mechanical
stretching of
intramuscular
connective tissue
•Relieve pain and
discomfort
• Blood flow to
skeletal muscle
• venous return
• ROM
Effects on Skin
•  skin temperature
•  sweating
• Remove dead cells
• Stretches and breaks
down the fibrous
tissue on scar tissue

Psychologic Effect of Massage
• The “hands-on” effect  a feeling of being
helped
• Lower psychoemotional and somatic
arousal (e.g. tension and anxiety)
• General sedative effect
• Minasny (2009)  touching, stretching &
massage will induce relaxation through the
parasympathetic system & activate CNS
Minasny, B., 2009. Understanding the process of facial unwinding. International journal of therapeutiv massage and bodywork 2 (3), 10-17.

Patient Preparation
• Patient should be in relaxed
comfortable position  lying
down is most beneficial to
assist in venous flow
• Part being involved in
treament must be
adequately supported 
elevated (depending on
pathology)
• The body areas not being
treated should be covered to
prevent from chilling

General Consideration
• Comfortable and relax position
• Begin and end with effleurage,
increase maneuver progressively
• Sufficient lubricant
• Start superficial stroking at joint/just below the
joint  finish above the joint
• Pressure in line with venous flow  return stroke
without pressure, in centripetal direction

General Consideration
• Avoid bony prominences and painful joints
• Pressure regulation, determined by type and
amount of tissue present
• Steady and even rhythm
• If swelling present  treatment begin from
proximal part
• Massage should never be painful
• Forces applied in the direction of muscle fibers

Indication of Massage
• Musculoskeletal disorders
• Muscle spasm, sprain, and
postural strain of the back
• Arthralgias and various
arthrities
• Fibromyalgia
• Lymphedema
• Anxiety, stress and sleep
disorders
• Sports-related injuries
• As an adjunct treatment
for:
• Burn care
• Chronic pain
• Exercise-induced injury
• Headaches
• Cancer care
• HIV and AIDS
Braddom RL. Physical Medicine and Rehabilitation. 4th ed. 2011

Contraindication of Massage
Absolute
• Malignancy
• Thrombus
• Atherosclerotic plaques
• Infected tissue
• Areas of trauma/recent bleeding
• Open wound
• Severe varicose veins
• Acute phlebitis
• Cellulitis
Relative
• Scar tissue that is
not fully healed
• Receiving
anticoagulant
• Calcified soft tissues
• Skin grafts
• Atrophic skin
• Acute inflammatory
conditions
Braddom RL. Physical Medicine and Rehabilitation. 4th ed. 2011

Techniques
• Effleurage
• Petrissage
• Tapotement
• Vibration
• Friction Massage
• Manual Lymphatic
Drainage (MLD)
• Transverse Friction
Massage
• Myofascial Release
• Trigger Point
Massage
• Strain/Counterstrain

Effleurage (Stroking) Massage
• The focus of pressure is
moved by the hands
gliding over the skin
• To gain initial relaxation,
diagnose regions of
spasm and tightness
• Lubricants is used to
reduce the friction
between hands and skin
Brault, et al. Manipulation, traction and massage. In: Braddom RL. Physical Medicine and Rehabilitation: Expert Consult-Online and Print, 4th Edition. 4th edition.
Philadelphia, PA: Saunders; 2010. p439-444.

Superficial Stroke Massage
• Compressive force is
relatively light
• energizes cutaneus
receptor  acts by
neuroreflexive or
vascular reflexive
mechanism
•  Increase blood
flow
• Can be any direction
Brault, JS, Kappler, RE, Grogg, BE. Manipulation, Traction and Massage. In: Braddom RL, ed. Physical medicine and rehabilitation 4th ed. Philadelphia:
Saunders Elsevier 2011; 439-44
Wieting, JM, et al. Manipulation, Massage, and Traction. In: Delisa, Joel A, ed. Physical medicine and Rehabilitation: principle and practice, 5th ed.
Philadelphia: Lippincott Williams & Wilkins,
Deep Stroke Massage
• Compressive force is relatively
heavy
• Mechanically mobilizing fluid in
the tissue beneath the area
•  Lymphatic drainage, relieve
sprain, strain and bruising,
vascular congestion
• Should be in the direction of
venous or lymphatic flow
Effleurage (Stroking) Massage

Wieting, JM, et al. Manipulation, Massage, and Traction. In : Delisa, Joel A, ed. Physical medicine and Rehabilitation : principle and practice, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2010; 1725-30
Petrissage (Kneading) Massage
• Compression of the
underlying skin and muscle
between the fingers and
thumb or between the two
hands of the practitioner.
• Main mechanical effect is
compression &
subsequent release of soft
tissue, reactive blood flow
& neuroreflexive response
to that flow

Petrissage
Kneading on the Hand, for Contracted Tendons
and Muscles. Kneading with Both Hands, Called Squeezing.
Petrissage- wringing
Rolling

Superficial Technique
• Promote relaxation
Brault, JS, Kappler, RE, Grogg, BE. Manipulation, Traction and Massage. In: Braddom RL, ed. Physical medicine and rehabilitation 4th ed. Philadelphia: Saunders Elsevier 2011; 439-44
Wieting, JM, et al. Manipulation, Massage, and Traction. In: Delisa, Joel A, ed. Physical medicine and Rehabilitation: principle and practice, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
Deeper Technique
• Increase blood flow
• Mobilize fluid and
tissue deposits
• Decrease adhesions
and increase tissue
pliability
Petrissage (Kneading) Massage

Tapotement (Percussion)
• Applying rapid & rhythmic
alternating contact of
varying pressure between
the hands and the body’s
soft tissue
• The frequency about
3x/second
• The effect of tapotement is
thought to be stimulatory

• Using the ulnar aspect of the
hands to alternately strike the
body tissue
Hacking
• Using a clenched fist to repetitively
pummel the tissueBeating
• Using the finger pads, typically of
the index and middle fingers, to
strike the underlying tissue in rapid
succession  usually done over
sinuses
Tapping

• Uses the volar surface of all the fingers
Slapping
• The thumb and index finger do a light pinch
on contact
Pincement
• Involves the use of a cupped palm, which is
percussed against the chest wall 
frequently used to loosen bronchial
secretions
Cupping

Vibration
• Fine tremulous
movement, made by
the hand or fingers
placed firmly against a
part, this causes the
part to vibrate
• Commonly used for
patients who require
postural drainage, such
as individuals with
cystic fibrosis

Friction Massage
• Circular, longitudinal or
transverse pressure applied
by the fingers, thumb or
hypothenar region of the
hand to the small area
• Fingers is moved with
constant pressure in small
circular motions for several
cycles
• Goal : to breakdown
adhesions in scar tissue,
loosen ligaments and disable
trigger points
Wieting, JM, et al. Manipulation, Massage, and Traction. In : Delisa, Joel A, ed. Physical medicine and Rehabilitation : principle and practice, 5th ed. Philadelphia: Lippincott
Williams & Wilkins, 2010; 1725-30

Manual Lymphatic Drainage (MLD)
• Gentle & superficially focused
massage where lymph is moved
from areas of lymphatic vessel
damage to watershed regions
• Massage of the proximal region
of the extremity to be treated to
dilate the watershed lymph
vessels & allows them to accept
fluid from distal areas
• Then a more rythmic massage is
performed from a distal to a
proximal part of extremity

Ottawa Panel Evidence-Based Clinical Practice
Guidelines on Therapeutic Massage for Neck Pain
Systematic Review by Brosseau L, et al. (2012):
• Therapeutic massage can decrease pain, tenderness and
improve ROM for sub-acute and chronic neck pain
• Effective for relieving immediate post-treatment pain
symptoms
Cochrane Database Systematic Review by Patel, et
al. (2012)
• As a stand-alone treatment, massage for MND was
found to provide an immediate or short-term
effectiveness or both in pain and tenderness

Topolska M, et al. (2011)
Evaluation of the Effectiveness of Therapeutic Massage in
Patients with Neck Pain
• Therapeutic massage  CROM
• The effectiveness of therapeutic massage is comparable
to the effectiveness of rehabilitation physical therapy
Sherman KJ, et al. (2014)
RCT of Therapeutic Massage for Chronic Neck Pain
• Massage is safe and may have clinical benefits for
treating chronic neck pain
Topolska M, Chrzan S, Sapuła R, Kowerski M, Soboń M, Marczewski K. Evaluation of the effectiveness of therapeutic massage in patients with neck pain. Ortop
Traumatol Rehabil. 2012 Apr 3;14(2):115–24.
Sherman, K. J. et al. Five-week outcomes from a dosing trial of therapeutic massage for chronic neck pain. Ann. Fam. Med. 12, 112–120 (2014).

Topolska M, et al. (2011)
Evaluation of the Effectiveness of Therapeutic Massage in Patients
with Neck Pain
Objective
• To evaluate
the
effectiveness
and impact
of
therapeutic
massage on
the range of
motion in
patients with
neck pain
Subject
• 60 patients
• Aged 37-82
years
• Treated for
neck pain at
the
Rehabilitation
Department of
Zamość
University of
Management
and
Administration.
Method
• 2 groups:
• Kinesiotherapy +
physiotherapy
(n=30)
• Kinesiotherapy +
physiotherapy +
therapeutic
massage (n=30)
• Outcome
assessment:
• Saunders digital
inclinometer
• Neck Disability
Index (NDI)
• Visual Analogue
Scale (VAS)
Result
• Therapeutic
massage 
CROM
• The
effectiveness
of therapeutic
massage is
comparable to
the
effectiveness
of
rehabilitation
based only on
physical
therapy &
kinesiotherapy

A Dosing Trial of Therapeutic Massage for Chronic Neck Pain
Objective
• To evaluate
the optimal
dose of
massage for
individuals
with
chronic
non-
specific
neck pain
Subjects
• 228 persons
• Aged 20 to 64
• Chronic non-
specific neck
pain
• Lasting at least
3 months
• Primary health
care clinics in
Seattle
• From June
2010 through
August 2011
Method
• Randomized into
6 groups :
• a wait list control
group for 4 weeks
• 1 x 60 min /week
Result
• After 4
weeks of
treatment
• Multiple 60-
minute
massages
/week more
effective
than fewer
or shorter
sessions for
individuals
with chronic
non-specific
neck pain

Sarrafzadeh J, et al. (2012)
• The pressure release (PR) massage, phonophoresis of hydrocortisone
(PhH) 1%, and ultrasound therapy (UT) were effective for treating
patients with an upper trapezius latent myofascial trigger point (MTP)
Aguilera FJ, et al. (2009)
• The ischemic compression (IC) massage and ultrasound (US) were shown
to have an immediate effect on latent myofascial trigger points (MTrPs) in
the trapezius muscle.
• The use of IC show a short-term positive effects among C-A-ROM, Basal
Electrical Activity of the trapezius muscle, and MTrP sensitivity of the
trapezius muscle
Sarrafzadeh J, Ahmadi A, Yassin M. The effects of pressure release, phonophoresis of hydrocortisone, and ultrasound on upper trapezius latent myofascial trigger point. Arch
Phys Med Rehabil. 2012 Jan;93(1):72–7.
Aguilera FJM, Martín DP, Masanet RA, Botella AC, Soler LB, Morell FB. Immediate effect of ultrasound and ischemic compression techniques for the treatment of trapezius
latent myofascial trigger points in healthy subjects: a randomized controlled study. J Manipulative Physiol Ther. 2009 Sep;32(7):515–20.

Ruiz-Molinero C, et al. (2014)
• Ultrasound (US) is effective in reducing pain and mobility
limitation in the treatment of traumatic cervical sprain
• High-active ultrasound treatment is more effective than
placebo in reducing pain.
Walker MJ, et al. (2008)
• An impairment-based manual physical therapy and exercise
(MTE) program resulted in clinically and statistically
significant short- and long-term improvements in pain,
disability, and patient-perceived recovery in patients with
mechanical neck pain when compared to a program
comprising advice, a mobility exercise, and ultrasound
Ruiz-Molinero C, Jimenez-Rejano JJ, Chillon-Martinez R, Suarez-Serrano C, Rebollo-Roldan J, Perez-Cabezas V. Efficacy of therapeutic ultrasound in pain and joint mobility in
whiplash traumatic acute and subacute phases. Ultrasound Med Biol. 2014 Sep;40(9):2089–95.
Walker MJ, Boyles RE, Young BA, Strunce JB, Garber MB, Whitman JM, et al. The effectiveness of manual physical therapy and exercise for mechanical neck pain: a
randomized clinical trial. Spine. 2008 Oct 15;33(22):2371–8.

Ay S, et al. (2011)
• Compare the effect of phonophoresis, ultrasound and placebo
ultrasound therapies in the treatment of myofascial pain syndrome
(MPS).
• After treatment, there were statistically significant improvements in pain
severity, NTP, pressure pain threshold (PPT), ROM and NPDI scores both
in phonophoresis and in ultrasound therapy groups (P < 0.05).
• Statistically significant increase in cervical lateral flexion and rotation was
observed in the placebo US group.
• No statistically significant improvement in the cervical flexion-extension
joint movement, pain levels, number of trigger points and NPDI score,
pressure pain threshold (P > 0.05), also there were no significant
differences in all parameters between group 1 and 2 (P = 0.05).
• Both diclofenac phonophoresis and ultrasound therapy were effective in
the treatment of patients with MPS.
• Phonophoresis was not found to be superior over ultrasound therapy.
Ay S, Doğan SK, Evcik D, Başer OC. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatol Int. 2011 Sep;31(9):1203–8.

Bokarius, et al. (2010), Bronfort et al. (2010)
• Therapeutic massage more effective when
combined with exercise or other interventions
Rocio Llamas-Ramos, et al. (2014)
• 2 sessions of TrP-dry needling and TrP massage
therapy resulted in similar outcomes in terms of
pain, disability and CROM for chronic mechanical
neck pain
Bokarius, A.V., Bokarius, V., 2010. Evidence-based review of manual therapy efficacy in treatment of chronic musculoskeletal pain. World Institute of Pain 10 (5), 79-
89
Bronfort, G., Evans, R., Nelson, B., Aker, P.D., Goldsmith, C.H., Vernon, H., 2001. A randomized clinical trial of exercise and spinal manipulation for patient with
chronic neck pain. Spine 26(7), 788-799.
Rocio Llamas-Ramos DP-M. Comparison of the Short-Term Outcomes Between Trigger Point Dry Needling Versus Trigger Point Manual Therapy for the Management
of Chronic Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2014;44(11):1–34.

Recommended Dose
•2 or 3 times per weekFrequency
•60-minuteDuration
•4 weeks of treatmentTotal Treatment
Time
The efficacy increase with increase dose

1) CROM
Assessment
(A/P/R-ROM)
2)Hands-on
Check-in & tissue
warming
3) Lymphatic
Drainage
4) Neck work
(Part 1)
5) Addressing
compensatory
patterns
6) Neck Work
(Part 2)
7) Integration 8) Completion
60
Minutes
Recommended Massage Protocol

The Recommended
Strokes of Neck Work
e. Deeper longitudinal stripping
techniques running parallel to
muscle fibers to encourage
muscle lengthening
f. Treatment of scar tissue
wherever found (friction or
myofascial techniques)
g. Effleurage or petrissage of the
trapezius, paraspinals
(splenius cervicis & capitis),
levator scapula and SCM
muscles
h. Stretching to finish and
enhance soft tissue
manipulation
a. Friction on base of skull
b. Long slow repetitive
strokes down the lamina
from base of skull with
thumb to both sides of
spine
c. Slow friction of the
anterior neck muscles
d. Slow friction & other
strokes to scalenes group

Complication
• Very rarely associated with any serious complications,
most common mild complications:
– Discomfort or pain during massage treatments
– Increased soreness after treatment
– Dizziness
– Nausea
• Started less than 12 hours after the massage
• Lasted for 36 hours or less
• Massage appears relatively safe when provided by
appropriately trained therapists, but can be associated
with transient increases in pain
1..Paanalahti K, Holm LW, Nordin M, Asker M, Lyander J, Skillgate E. Adverse events after manual therapy among patients seeking care for neck and/or back pain: a
randomized controlled trial. BMC Musculoskelet Disord. 2014 Mar 12;15:77–77.
2. Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized Trial of Therapeutic Massage for Chronic Neck Pain. Clin J Pain. 2009;25(3):233–8.
3. Cambron et al, 2007, J Altern Complement Med [Internet]. PainScience.com. [cited 2015 May 19]. Available from:
https://www.painscience.com/bibliography.php?cam4

Advantages
• Effective for neck pain (chronic, non-specific, mechanical)
• Has multiple physiologic & psychologic effect
• Relatively mild and rare complication
• Suitable for patient who has contraindication for other
therapeutic modality (eg. patient with pacemaker, metal
implant)
• Don’t need sophisticated device
• Good cost-effectiveness
• Feasible schedule and place of therapy
– Schedule can be adjusted to meet patient’s & therapist’s schedule
– Can be performed not only at healthcare center but also in patient’s
house (as home program)

Disadvantages
• Skill-dependent  a registered skilled therapist
• Not suitable for person hypersensitive to touch
• Not suitable for acute phase
• Mild complication : transient  in pain during/after
massage therapy

Conclusion
Further study needed
to investigate long term
effect of massage
therapy,Massage therapy is an effective
therapy for neck pain with various
benefit & minimal risk
Recommended dose: duration of
60 minutes, frequency of 2-3
times per week, for 4 weeks

• Rheumatol Int. 2011 Sep;31(9):1203-8. doi: 10.1007/s00296-010-1419-0. Epub 2010 Mar 31.
• Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome.
• Ay S1, Doğan SK, Evcik D, Başer OC.
• Author information
• Abstract
• The aim of this study is to compare the effect of phonophoresis, ultrasound and placebo ultrasound therapies in the
treatment of myofascial pain syndrome (MPS). This is a randomized, double-blind placebo controlled study. Sixty
patients (48 women, 12 men, mean age 37.9 ± 12.2 years) with MPS were included in this study. Patients were
allocated into three groups. Group 1(n = 20) was received diclofenac phonophoresis, group 2(n = 20) was received
ultrasound and group 3(n = 20) was received placebo ultrasound therapies over trigger points, 10 min a day for 15
session during 3 weeks (1 MHz-1,5 watt/cm²). Additionally, all patients were given neck exercise program including
isotonic, isometric and stretching. Patients were assessed by means of pain, range of motion (ROM) of neck, number of
trigger points (NTP), algometric measurement and disability. Pain severity was measured by visual analog scale (VAS)
and Likert scale. The neck pain disability index (NPDI) was used for assessing disability. Measurements were taken
before and after treatment. After treatment, there were statistically significant improvements in pain severity, NTP,
pressure pain threshold (PPT), ROM and NPDI scores both in phonophoresis and in ultrasound therapy groups (P <
0.05). Statistically significant increase in cervical lateral flexion and rotation was observed in the placebo US group.
While there was no statistically significant improvement in the cervical flexion-extension joint movement, pain levels,
number of trigger points and NPDI score, pressure pain threshold (P > 0.05), also there were no significant differences
in all parameters between group 1 and 2 (P = 0.05). Both diclofenac phonophoresis and ultrasound therapy were
effective in the treatment of patients with MPS. Phonophoresis was not found to be superior over ultrasound therapy.
• PMID: 20354859 [PubMed - indexed for MEDLINE]
Ay S, Doğan SK, Evcik D, Başer OC. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatol Int. 2011 Sep;31(9):1203–8.

• Spine (Phila Pa 1976). 2008 Oct 15;33(22):2371-8. doi: 10.1097/BRS.0b013e318183391e.
• The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial.
• Walker MJ1, Boyles RE, Young BA, Strunce JB, Garber MB, Whitman JM, Deyle G, Wainner RS.
• Abstract
• STUDY DESIGN:
• Randomized clinical trial.
• OBJECTIVE:
• To assess the effectiveness of manual physical therapy and exercise (MTE) for mechanical neck pain with or without unilateral upper
extremity (UE) symptoms, as compared to a minimal intervention (MIN) approach.
• SUMMARY OF BACKGROUND DATA:
• Mounting evidence supports the use of manual therapy and exercise for mechanical neck pain, but no studies have directly assessed its
effectiveness for UE symptoms.
• METHODS:
• A total of 94 patients referred to 3 physical therapy clinics with a primary complaint of mechanical neck pain, with or without unilateral UE
symptoms, were randomized to receive MTE or a MIN approach of advice, motion exercise, and subtherapeutic ultrasound. Primary
outcomes were the neck disability index, cervical and UE pain visual analog scales (VAS), and patient-perceived global rating of change
assessed at 3-, 6-, and 52-weeks. Secondary measures included treatment success rates and post-treatment healthcare utilization.
• RESULTS:
• The MTE group demonstrated significantly larger reductions in short- and long-term neck disability index scores (mean 1-year difference -
5.1, 95% confidence intervals (CI) -8.1 to -2.1; P = 0.001) and short-term cervical VAS scores (mean 6-week difference -14.2, 95% CI -22.7 to
-5.6; P = 0.001) as compared to the MIN group. The MTE group also demonstrated significant within group reductions in short- and long-
term UE VAS scores at all time periods (mean 1-year difference -16.3, 95% CI -23.1 to -9.5; P = 0.000). At 1-year, patient perceived
treatment success was reported by 62% (29 of 47) of the MTE group and 32% (15 of 47) of the MIN group (P = 0.004).
• CONCLUSION:
• An impairment-based MTE program resulted in clinically and statistically significant short- and long-term improvements in pain, disability,
and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise,
and subtherapeutic ultrasound.
Walker MJ, Boyles RE, Young BA, Strunce JB, Garber MB, Whitman JM, et al. The effectiveness of manual physical therapy and exercise for mechanical neck pain: a
randomized clinical trial. Spine. 2008 Oct 15;33(22):2371–8.

• Arch Phys Med Rehabil. 2012 Jan;93(1):72-7. doi: 10.1016/j.apmr.2011.08.001. Epub 2011 Oct 7.
• The effects of pressure release, phonophoresis of hydrocortisone, and ultrasound on upper trapezius latent myofascial trigger point.
• Sarrafzadeh J1, Ahmadi A, Yassin M.
• Abstract
• OBJECTIVE:
• To compare the effects of pressure release (PR), phonophoresis of hydrocortisone (PhH) 1%, and ultrasonic therapy (UT) in patients with an
upper trapezius latent myofascial trigger point (MTP).
• DESIGN:
• Repeated-measure design.
• SETTING:
• A pain control medical clinic.
• PARTICIPANTS:
• Subjects (N=60; mean±SD age, 21.78±1.76y) with a diagnosis of upper trapezius MTP participated in this study. Subjects were randomly
divided into 4 groups: PR, PhH, UT, and control (15 in each group). All patients had a latent MTP in the upper trapezius muscle.
• INTERVENTIONS:
• PR, PhH, UT.
• MAIN OUTCOME MEASURES:
• Subjective pain intensity, pain pressure threshold (PPT), and active cervical lateral flexion range of motion were assessed in 6 sessions.
• RESULTS:
• All 3 treatment groups showed decreases in pain and PPT and an increase in cervical lateral flexion range of motion (P<.001) compared
with the control group. Both PhH and PR techniques showed more significant therapeutic effects than UT (P<.001).
• CONCLUSIONS:
• Our results indicate that all 3 treatments used in this study were effective for treating MTP. According to this study, PhH is suggested as a
new method effective for the treatment of MTP.
• Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Sarrafzadeh J, Ahmadi A, Yassin M. The effects of pressure release, phonophoresis of hydrocortisone, and ultrasound on upper trapezius latent myofascial trigger point. Arch
Phys Med Rehabil. 2012 Jan;93(1):72–7.

• J Manipulative Physiol Ther. 2009 Sep;32(7):515-20. doi: 10.1016/j.jmpt.2009.08.001.
• Immediate effect of ultrasound and ischemic compression techniques for the treatment of trapezius latent myofascial
trigger points in healthy subjects: a randomized controlled study.
• Aguilera FJ1, Martín DP, Masanet RA, Botella AC, Soler LB, Morell FB.
• Abstract
• OBJECTIVE:
• The purpose of this study was to determine immediate effects of ischemic compression (IC) and ultrasound (US) for the
treatment of myofascial trigger points (MTrPs) in the trapezius muscle.
• METHODS:
• Sixty-six volunteers, all CEU-Cardenal Herrera University, Valencia, Spain, personnel, participated in this study. Subjects
were healthy individuals, diagnosed with latent MTrPs in the trapezius muscle. Subjects were randomly placed into 3
groups: G1, which received IC treatment for MTrPs; G2, which received US; and G3 (control), which received sham US.
The following data were recorded before and after each treatment: active range of motion (AROM) of cervical rachis
measured with a cervical range of motion instrument, basal electrical activity (BEA) of muscle trapezius measured with
surface electromyography, and pressure tolerance of MTrP measured with visual analogue scale assessing local pain
evoked by the application of 2.5 kg/cm(2) of pressure using a pressure analog algometer.
• RESULTS:
• The results showed an immediate decrease in BEA of the trapezius muscle and a reduction of MTrP sensitivity after
treatment with both therapeutic modalities. In the case of IC, an improvement of AROM of cervical rachis was also
been obtained.
• CONCLUSION:
• In this group of participants, both treatments were shown to have an immediate effect on latent MTrPs. The results
show a relation among AROM of cervical rachis, BEA of the trapezius muscle, and MTrP sensitivity of the trapezius
muscle gaining short-term positive effects with use of IC.
Aguilera FJM, Martín DP, Masanet RA, Botella AC, Soler LB, Morell FB. Immediate effect of ultrasound and ischemic compression techniques for the treatment of trapezius
latent myofascial trigger points in healthy subjects: a randomized controlled study. J Manipulative Physiol Ther. 2009 Sep;32(7):515–20.

• J Bodyw Mov Ther. 2011 Jul;15(3):348-54. doi: 10.1016/j.jbmt.2010.04.003. Epub 2010 May 13.
• Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points: a double blind randomised placebo-
controlled trial.
• Gemmell H1, Hilland A.
• Abstract
• OBJECTIVE:
• The purpose of this study was to investigate the immediate effect of electric point stimulation in treating latent upper trapezius trigger
points compared to placebo.
• DESIGN:
• Double blind randomised placebo-controlled trial.
• SETTING:
• Anglo-European College of Chiropractic.
• PARTICIPANTS:
• Sixty participants with latent upper trapezius trigger points.
• INTERVENTIONS:
• Electric point stimulator type of TENS, or detuned (inactive) electric point stimulator type of TENS.
• The three outcome measures were pressure pain threshold at the trigger point, a numerical rating scale for pain elicited over the trigger
point, and lateral cervical flexion to the side opposite the trigger point.
• RESULTS:
• On the outcome of pressure pain threshold the electric point stimulator group had a mean change of 0.49 (0.99) kg/cm(2), while the
placebo group had a mean change of 0.45 (0.98) kg/cm(2) (t = 0.16, df = 58, p = 0.88). For change in pain over the trigger point, the electric
point stimulator group had a mean decrease of 0.93 (0.87) points, while the placebo group had a mean decrease of 0.23 (0.97) points
(t = 0.70, df = 58, p = 0.005). On the outcome of change in lateral cervical flexion the electric point stimulator group had a mean increase of
2.87 (4.55) degrees, while the placebo group had a mean increase of 1.99 (2.49) degrees (t = 0.92, df = 58, p = 0.36).
• CONCLUSION:
• Electric point stimulator type of TENS is superior to placebo only in reduction of pain for treating latent upper trapezius trigger points.
• Copyright © 2010 Elsevier Ltd. All rights reserved.
Gemmell H, Hilland A. Immediate effect of electric point stimulation (TENS) in treating latent upper trapezius trigger points: a double blind randomised placebo-controlled
trial. J Bodyw Mov Ther. 2011 Jul;15(3):348–54.

• Ultrasound Med Biol. 2014 Sep;40(9):2089-95. doi: 10.1016/j.ultrasmedbio.2014.04.016. Epub 2014 Jul
9.
• Efficacy of therapeutic ultrasound in pain and joint mobility in whiplash traumatic acute and subacute
phases.
• Ruiz-Molinero C1, Jimenez-Rejano JJ2, Chillon-Martinez R2, Suarez-Serrano C2, Rebollo-Roldan J2, Perez-
Cabezas V3.
• Abstract
• To determine if ultrasound (US) is effective in reducing pain and mobility limitation in the treatment of
traumatic cervical sprain, we performed an experimental study. The sample comprised 54 diagnosed
subjects with a mean age of 36.54 y (standard deviation = 12.245), assigned by simple random selection
to an experimental group with ultrasound treatment and a control group with placebo ultrasound.
Treatment consisted of 10 sessions of an ultrasound treatment protocol, followed by 15 sessions of a
protocol identical for both groups without ultrasound. The variables assessed were pain and joint
mobility. There was no significant difference (p > 0.05) between groups in the first 10 sessions of
treatment. However, there was a statistically significant difference (p < 0.05) between groups on the
pain variable, 20 days after completion of the US. High-active ultrasound treatment is more effective
than placebo in reducing pain.
• Copyright © 2014 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All
rights reserved.
• KEYWORDS:
• Mobility limitation; Pain; Ultrasonic therapy; Whiplash injuries
Ruiz-Molinero C, Jimenez-Rejano JJ, Chillon-Martinez R, Suarez-Serrano C, Rebollo-Roldan J, Perez-Cabezas V. Efficacy of therapeutic ultrasound in pain and joint mobility in
whiplash traumatic acute and subacute phases. Ultrasound Med Biol. 2014 Sep;40(9):2089–95.

• J Manipulative Physiol Ther. 2013 Jun;36(5):300-9. doi: 10.1016/j.jmpt.2013.04.008. Epub 2013 Jun 12.
• Short- and medium-term effects of manual therapy on cervical active range of motion and pressure pain sensitivity in latent myofascial
pain of the upper trapezius muscle: a randomized controlled trial.
• Oliveira-Campelo NM1, de Melo CA, Alburquerque-Sendín F, Machado JP.
• 1Department of Physical Therapy, Escola Superior de Tecnologia de Saúde, VN Gaia, Portugal. Ncampelo.estsp.ipp@gmail.com
• Abstract
• OBJECTIVE:
• The purpose of this study was to investigate effects of different manual techniques on cervical ranges of motion and pressure pain
sensitivity in subjects with latent trigger point of the upper trapezius muscle.
• METHODS:
• One hundred seventeen volunteers, with a unilateral latent trigger point on upper trapezius due to computer work, were randomly divided
into 5 groups: ischemic compression (IC) group (n=24); passive stretching group (n=23); muscle energy technique group (n=23); and 2
control groups, wait-and-see group (n=25) and placebo group (n=22). Cervical spine range of movement was measured using a cervical
range of motion instrument as well as pressure pain sensitivity by means of an algometer and a visual analog scale. Outcomes were
assessed pretreatment, immediately, and 24 hours after the intervention and 1 week later by a blind researcher. A 4×5 mixed repeated-
measures analysis of variance was used to examine the effects of the intervention and Cohen d coefficient was used.
• RESULTS:
• A group-by-time interaction was detected in all variables (P<.01), except contralateral rotation. The immediate effect sizes of the
contralateral flexion, ipsilateral rotation, and pressure pain threshold were large for 3 experimental groups. Nevertheless, after 24 hours
and 1 week, only IC group maintained the effect size.
• CONCLUSIONS:
• Manual techniques on upper trapezius with latent trigger point seemed to improve the cervical range of motion and the pressure pain
sensitivity. These effects persist after 1 week in the IC group.
• Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.
• KEYWORDS:
• Articular; Pain Perception; Pain Threshold; Physical Therapy Modalities; Range of Motion; Trigger Points
Oliveira-Campelo NM, de Melo CA, Alburquerque-Sendín F, Machado JP. Short- and medium-term effects of manual therapy on cervical active range of motion and pressure
pain sensitivity in latent myofascial pain of the upper trapezius muscle: a randomized controlled trial. J Manipulative Physiol Ther. 2013 Jun;36(5):300–9.

• Arch Phys Med Rehabil. 2011 Sep;92(9):1353-8. doi: 10.1016/j.apmr.2011.04.010.
• Effects of burst-type transcutaneous electrical nerve stimulation on cervical range of motion and latent myofascial trigger point pain sensitivity.
• Rodríguez-Fernández AL1, Garrido-Santofimia V, Güeita-Rodríguez J, Fernández-de-Las-Peñas C.
• Abstract
• OBJECTIVE:
• To assess the effects of a burst application of transcutaneous electrical nerve stimulation (TENS) on cervical range of motion and pressure point
sensitivity of latent myofascial trigger points (MTrPs).
• DESIGN:
• A single-session, single-blind randomized trial.
• SETTING:
• General community rehabilitation clinic.
• PARTICIPANTS:
• Individuals (N = 76; 45 men, 31 women) aged 18 to 41 years (mean ± SD, 23 ± 4y) with latent MTrPs in 1 upper trapezius muscle.
• INTERVENTIONS:
• Subjects were randomly divided into 2 groups: a TENS group that received a burst-type TENS (pulse width, 200 μs; frequency, 100 Hz; burst frequency,
2 Hz) stimulation over the upper trapezius for 10 minutes, and a placebo group that received a sham-TENS application over the upper trapezius also for
10 minutes.
• Referred pressure pain threshold (RPPT) over the MTrP and cervical range of motion in rotation were assessed before, and 1 and 5 minutes after the
intervention by an assessor blinded to subjects' treatment.
• RESULTS:
• The analysis of covariance revealed a significant group × time interaction (P < .001) for RPPT: the TENS group exhibited a greater increase compared
with the control group; however, between-group differences were small at 1 minute (0.3 kg/cm²; 95% confidence interval [CI], 0.1-0.4) and at 5
minutes (0.6 kg/cm²; 95% CI, 0.3-0.8) after treatment. A significant group × time interaction (P=.01) was also found for cervical rotation in favor of the
TENS group. Between-group differences were also small at 1 minute (2.0°; 95% CI, 1.0-2.8) and at 5 minutes (2.7°; 95% CI, 1.7-3.8) after treatment.
• CONCLUSIONS:
• A 10-minute application of burst-type TENS increases in a small but statistically significant manner the RPPT over upper trapezius latent MTrPs and the
ipsilateral cervical range of motion.
• Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Rodríguez-Fernández AL, Garrido-Santofimia V, Güeita-Rodríguez J, Fernández-de-Las-Peñas C. Effects of burst-type transcutaneous electrical nerve stimulation on cervical
range of motion and latent myofascial trigger point pain sensitivity. Arch Phys Med Rehabil. 2011 Sep;92(9):1353–8.

1) Cervical ROM
Assessment (A/P/R-
ROM)
2)Hands-on Check-
in/tissue warming
3) Lymph Drainage
4) Neck work
5) Address
compensatory
patterns
6) Integration
7) Completion
30
Minutes
Massage
Protocol

• Neck pain is one of the most common and painful musculoskeletal
conditions with point prevalence ranges from 6% to 22% and up to 38%
of the elderly population, while lifetime prevalence ranges from 14,2%
to 71%
Fejer, et al. (2006)
• The estimated 1 year incidence of neck pain from available studies
ranges between 10.4% and 21.3% with a higher incidence noted in
office and computer workers
• Between 33% and 65% of people have recovered from an episode of
neck pain at 1 year, most cases run an episodic course over a person's
lifetime and, thus, relapses are common
• The overall prevalence of neck pain in the general population ranges
between 0.4% and 86.8% (mean: 23.1%); point prevalence ranges from
0.4% to 41.5% (mean: 14.4%); and 1 year prevalence ranges from 4.8%
to 79.5% (mean: 25.8%)
• Higher incidence of neck pain among women and an increased risk of
developing neck pain until the 35-49-year age group, after which the
risk begins to decline
Hoy DG, et al. (2010)
Epidemiology

Recommended Dose
• The recommended dose are:
–4 weeks of treatment
–2 or 3 times per week
–60-minute massages

• Massage is mechanical stimulation of tissue by means
of rhythmically applied pressure and stretching
• It allows the therapist, to assist a patient to overcome
pain and to relax through the application of the
therapeutic massage techniques
• Massage has effects on the circulation, the lymphatic
system, nervous system, muscles, myofascia, skin,
scar tissue, psychologic responses, relaxation feelings,
and pain

Effectiveness of Massage Therapy for
Neck Pain
• 4 SR assessed the effect of massage on pain
and function (Haraldsson et al. 2006; Ezzo et
al. 2007; Gross et al. 2007; Vernon et al. 2007)
• All reviews identified major methodological
weaknesses of the individual studies, e.g.
often a lack of uniform definition of the
technique, dosage, the mode of performance
and indication for the management

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