2. 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
3. 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
12. Veins
• V. Oksipitalis
• V. Postaurikularis
• V. Retro-
mandibular
• V. External Jugular
• V. Komunikans
• V. Jugularis
Interna
• V. Jugularis
Komunis
• V. Jugularis
Anterior
• V. Brakiosefalika
14. Superficial
• Platysma
• Trapezius
Anterior
• SCM
• Scalenes group
• Prevertebral
group
Posterior
• Erector spinae
group
• Splenius capitis
• Splenius
cervicis
• Suboccipital
group
Muscles of The Neck
22. 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
23. 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
25. 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
26. • 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
30. •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
31. 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.
32. 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
33. Patophysiology
External Trauma:
• The neck received external forces that cause
abnormal cervical vertebrae position or
movement that leading to injury and pain
34. 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
35. 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
36. 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
39. 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
41. 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)
42. Flynn TW, Cleland JA, Whitman JM. User’s Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008.
43. 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.
53. 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
55. 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
Prentice WE. Therapeutic Massage. In: Prentice WE. Therapeutic Modalities in Rehabilitation. 4th ed. 2002. McGraw-Hill. New York.
56. 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)
57. Effects on Pain
Release of β-
endorphins from
pituitary gland &
hipotalamus
effect in the
transmission of pain-
associated signal in
descending spinal
tracts
58. Effects on Pain
•Release of
enkephalin from
inhibitory
interneuron on
dorsal horn of
medulla spinalis
block the pain
signal
transmission
59. 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
60. 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
61. 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
Prentice WE. Therapeutic Massage. In: Prentice WE. Therapeutic Modalities in Rehabilitation. 4th ed. 2002. McGraw-Hill. New York.
Minasny, B., 2009. Understanding the process of facial unwinding. International journal of therapeutiv massage and bodywork 2 (3), 10-17.
62. 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
Prentice WE. Therapeutic Massage. In: Prentice WE. Therapeutic Modalities in Rehabilitation. 4th ed. 2002. McGraw-Hill. New York.
63. 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
Prentice WE. Therapeutic Massage. In: Prentice WE. Therapeutic Modalities in Rehabilitation. 4th ed. 2002. McGraw-Hill. New York.
64. 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
Prentice WE. Therapeutic Massage. In: Prentice WE. Therapeutic Modalities in Rehabilitation. 4th ed. 2002. McGraw-Hill. New York.
65. 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
66. 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
68. 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.
69. 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
70. 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
71. Petrissage
Kneading on the Hand, for Contracted Tendons
and Muscles. Kneading with Both Hands, Called Squeezing.
Petrissage- wringing
Rolling
72. 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
73. 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
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.
74. • 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
75. • 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
76. 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
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.
77. 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
78. 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
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.
86. 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
87. 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).
88. 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
89. Sherman KJ, et al. (2012)
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
• 1 x 30 min /week
• 2 x 60 min /week
• 2 x 30 min /week
• 3 x 60 min /week
• 3 x 30 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
90. 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.
91. 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.
92. 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.
93. 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.
94. Recommended Dose
•2 or 3 times per weekFrequency
•60-minuteDuration
•4 weeks of treatmentTotal Treatment
Time
The efficacy increase with increase dose
Sherman KJ, et al. (2012)
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).
95. 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
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).
Recommended Massage Protocol
96. 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
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).
97.
98. 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
99. 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)
100. 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
101. 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
102.
103.
104. • 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.
105.
106. • 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.
• Author information
• 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.
• PMID: 18923311 [PubMed - indexed for MEDLINE]
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.
110. • 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.
• Author information
• 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.
• PMID: 19748402 [PubMed - indexed for MEDLINE]
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.
120. • 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
121. Recommended Dose
Sherman KJ, et al. (2012)
• The recommended dose are:
–4 weeks of treatment
–2 or 3 times per week
–60-minute massages
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).
122. • 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
123. 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
Editor's Notes
Good morning all. Thank you for coming. Today I’ll present my first literature review about massage therapy for neck pain.
First I will review about the neck, which including
There are 7 cervical vertebral column
The 3rd - 6th vertebrae is a “typical” cervical vertebrae
The 1st, 2nd, and 7th are “atypical” cervical vertebrae
Typical cervical vertebrae has
rectangular bodies with articular uncinate processes on their lateral aspects
triangular vertebral foramina
bifid spinous processes
and transverse foramen
Normal movement of cervical area includes flexion, extension, rotation and lateral flexion
The total movement of cervical area is consist of combination movement from AOJ, AAJ, and 2nd to 7th cervical vertebral columns
There are 8 cervical spinal nerves come out from foramen intervertebralis, despite of 7 cervical vertebral columns
The 1st cervical spinal nerve comes out from above atlas/C1/1st cervical vertebral column
the 8th cervical spinal nerve comes out from foramen intervertebralis between C7-T1
Motoric component cervical spinal nerves innervate variuous muscle according to the level
Sensoric component cervical spinal nerves has segmental area of innervation known as dermatomes
There are two plexus that arise from cervical spinal nerves root
These are the ligaments in the cervical area
These are the veins in the neck region
The important superficial veins are External Jugular Vein that close to the SCM muscle
The lymphatic vessels from thead, face and neck will drain into the superficial & deep cervical lymph nodes
And then to the right and left jugular lymphatic trunk
The right jugular lymphatic trunk will drain directly into right venous angle
But the left jugular lymphatic trunk will drain into the left venous angle through the thoracic duct
Arahnya kemana
Pijatan
Otot origo insersio
And now the muscles of the neck divided into 3 parts
This is platysma muscle
This is the summary
The muscle involved
Jangan lebih dari 1 slide
(eg, disk bulging or degeneration, osteophytes, spondylolysis, congenital facet abnormalities)
Jadiin 2 slide
Postural cause of neck pain is frequently found and leading to disability
Normal cervical postur is defined by cervical lordosis that maintained to keep the head in line with gravity line, where the head is slightly anterior to the gravity line
Upper point of gravity line is on the outer ear cavity
Jadiin 2 slide
in shoulder, arm and hand, with the most frequent site in interscapula area with or without radiation to the occiput, shoulder or arm
fleksibilitas spina servikal, re-edukasi postur dan penguatan
partisipasi aktif pasien
This is the neck exercise, which include
The VAS is best at detecting change in patients who improve in pain.
The NDI, a neck-specific functional status questionnaire, 10 items including pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation.
the NDI has proofed to be a valid tool for functional assessment of neck disability.
& the most commonly used self-report measurefor neck pain
The NDI can be used to evaluate the patients status at present and to evaluate the evolution during the therapy
Manual therapy: a modality by using hands to affect the musculoskeletal, neuromuscular and circulatory systems
Includes: massage, joint mobilization, and traction, as well as proprioceptive neuromuscular facilitation techniques
The word massage is derived from two sources. One is the Arabic verb mass, to touch, and the other is the Greek word massein, to knead. However, history shows that this was not an art exclusive to the Greeks and Arabs. The general knowledge of massage was also known and practiced by the Egyptians, Romans, Japanese, Persians, and Chinese.
In Sweden in the early part of the nineteenth century, Peter H. Ling (1776-1839), the acknowledged founder of curative gymnastics, used massage as a branch of gymnastics. He appears to be the founder of modern-day massage techniques with some incorporation of French massage techniques into his system.15
Very light massage (effleurage) almost instantaneous reaction through transient dilation of lymphatics and small capillaries
Heavier pressure more lasting dilation increase blood volume and blood flow temperature in area being massaged
Lying down supine or prone or
sitting in a chair, facing the table while leaning forward and supported by pillows on the table
Forearms and hands are on the table for additional support (Fig. 17-8). The therapist can administer the massage while standing behind the patient (Fig. 17-8).
Result aja
Subjek
Evaluate the optimal dose of massage for individuals with chronic non-specific neck pain
The efficacy increase with dose
Massage therapy is a very subjective therapy
That must be tailored-made for each patient
The therapist must be able to assess patient condition to adjust the therapy according to the patient’s needs
Otot terkait terutama ekstensor leher
Massage has effects on the circulation, the lymphatic system, nervous system, muscles, myofascia, skin, scar tissue, psychologic responses, relaxation feelings, and pain
Reducing or eliminating pain.
Improving joint mobility.
Improving circulation.
Improving lymphatic drainage.
Reducing muscular tension.
can’t be given if there are open wound on the skin
to perform the right assessment and massage therapy for the patient and also to avoid complication
Slide
Therapeutic massage techniques must tailored with the patient's need and tolerance
The therapist must be able to assess and gain feedback from the patient
Massage therapy has been known since the ancient history and reflects the soothing hand as healer
Hoy DG gabung biar dikit
A Dosing Trial of Therapeutic Massage for Chronic Neck Pain
30-minute massages, either 2 or 3 times a week, failed to provide significant benefits compared with control
The beneficial effects of 60-minute massages increased with dose and were especially evident for those receiv ing massage 2 or 3 times per week.
Compared with their control counterparts, massage participants were 3 times more likely to have a clinically meaningful improvement in neck function if they received 60 minutes of massage twice a week and 5 times more likely if they received 60 minutes of massage 3 times a week.
More effective than fewer or shorter sessions for individuals with chronic non-specific neck pain