Working with Whiplash, Part II (Myofascial Techniques)

myofascial techniquesBY TIL LUCHAU In a rear-end impact or a backward fall, the head and neck are thrown into hyperextension, which overstretches and injuries soft tissues of the anterior neck, such as the sternocleidomastoid. Image courtesy of Primal Pictures. Used with permission. 108 massage & bodywork may/june 2010 Working With Whiplash, part 2 Cold Whiplash In the previous article, I wrote that whiplash has metaphorically “hot” and “cold” phases, and described some approaches for working with hot patterns. Here, I will describe two techniques from Advanced-Trainings. com’s Advanced Myofascial Techniques seminars that are particularly effective for working with cold whiplash. I will also share some of our instructors’ advice and best practices for strategizing whiplash sessions. A brief review of our hot/cold distinction: hot whiplash is usually (but not always) more recent, generally less than six weeks since being injured. Hot whiplash is characterized by sympathetic nervous system (“fight or flight”) arousal, inflamed and hypersensitive tissues (anywhere in the body), and immobilization and guarding via muscular contraction and spasm. Once some time has passed, an older but still unresolved whiplash can show the “cold” pattern of hard, dense connective tissue restrictions (versus muscular spasm), especially deep around the joints, which also limits mobility. Hot whiplash needs to be worked very carefully to avoid increasing the tissue inflammation and further aggravating the client’s autonomic arousal. While cold whiplash can usually be approached more directly, we’re not out of the woods yet: cold whiplash can easily be reactivated into a hot pattern if worked too much, too deeply, or too fast. Go slowly until you learn how your client responds. The primary goals in working with hot whiplash are to calm the aggravated nervous system responses and to encourage whole-body motility (self-generated movement), which minimizes connective tissue scarring and adhesion. Only when a whiplash has progressed to the cold stage do we add the additional primary goal of restoring local mobility (the ability to move or be moved) by directly addressing movement and tissue restrictions.1 Cervical Core/Sleeve Technique: Gently use the backside of a soft, semi-open hand to ease the outer layers of the neck posteriorly. Do not put any pressure on the underlying structures of the throat and neck—the styloid process, lymph nodes, carotid artery, and vagus nerve are all in this region and merit special care. CerviCal Core/ Sleeve TeChnique As shown in Image 1, a sudden backward acceleration of the head, such as that caused by a rear-end impact or a backward fall, will violently overextend and injure the soft tissues of the anterior neck 2. Once the inflammation of the hot stage has diminished and the rest of the body has been prepared (see Strategizing Your Sessions, page 112), you can begin addressing the tissues of the anterior neck by working the neck’s outer “sleeve”—the superficial cervical fascia and the sternocleidomastoids (SCM). Since we’re beginning with superficial layers, the tool we’ll use is the soft fist, as the drier texture of the skin on the dorsum of the hand is better suited for superficial work than the palm. Rather than a hard, closed fist, the soft fist is open, easy, and relaxed, with both the fingers and thumb out and comfortable (Image 2). It is important to keep the wrist and metacarpals aligned with the forearm— this protects your wrist from strain and connect with your colleagues on massageprofessionals.com 109 Strategizing your Sessions: Whiplash Tips from the Advanced Myofascial Techniques Faculty Three of our lead instructors at Advanced-Trainings.com share some of their key considerations for strategizing whiplash sessions: Tip 1. Begin with light touch in the first session. The trauma of whiplash and its aftereffects can trigger hyperarousal of the nervous system, which can make working with whiplash clients challenging. The nervous system of an injured person is on overload, and needs to be approached with care. Work gently to gauge how the client will respond, especially in the first session. Remain patient, and avoid aggravating the tissues and nervous system. Trying to get too much done in any one session can be overwhelming for the client. If you work too deeply too quickly, it can create more guarding and trauma. —Ellyn Lindquist, CAMT CR Tip 2. Work from appendicular to axial. Imagine you are sitting at a stop sign looking in your rearview mirror and you see the car behind you isn’t slowing down and is about to hit you. You brace for impact by clutching the steering wheel and stomping both feet into the pedals and floor. This reaction is initiated to help protect the body from the impact that is about to occur. As a practitioner, if your client’s arms and shoulder girdle are still compressed from this response, you cannot effectively release the neck. The same goes for the feet, legs, and pelvic girdle. Release the shoulders, arms, feet, legs, pelvic girdle, and low back early in your whiplash work. Working here helps release the protective compression these parts exert on the axial spine. —Larry Koliha, CAMT CAR Tip 3. Be sure to integrate and close your work. After working with whiplash, it is important to finish your session judiciously, making sure that primary shock points where injury can accumulate are left free and adaptable. The atlanto-occipital junction is one of these places and the therapeutic effects that cascade throughout the body by releasing restrictions at this neural/myofascial crossroads are difficult to overestimate. The sacroiliac (SI) joint is another; decompression of the myofascial structures embedded here enables better adaptability and function at this critical structure. Working the SI joint complements and completes the circle of integration when having worked with the spine, neck, or upper body. —George Sullivan, CAMT CAR noTES 1. Til Luchau, “Preparing the Neck and Shoulders for Deep Work,” Massage & Bodywork (January/ February 2009, page 120), and “Working With the Cervical Core,” Massage & Bodywork (March/April 2009, page 122). compression, and allows you to work less, making your touch more sensitive. Using the proximal knuckles of your soft fist, gently catch the outer layers of the neck, just anterior and superficial to the SCM belly. We don’t use oil or lotion at this stage—we want the gentle friction of the soft fist to differentiate and free up the tissue layers we’re working. Using gentle posterior friction, take up any slack in the outer wrappings of the neck. There are delicate structures in the neck, so be sure you’re staying superficial. Think about just catching the outer collar of a turtleneck sweater, without putting any pressure on the deeper structures, or without pulling the “collar” too tightly across the front of the throat. Your client should be comfortable—if he or she feels that you’re pressing too deeply, or pulling too much on the front of the throat, readjust your pressure, layer, and/or direction until there is no discomfort. After carefully taking up the slack of the outer layers of the neck, ask your client to gently turn his or her head away from the side you’re working. Your working hand stays static, so any sliding is initiated by the client’s movement and tissue release. Make sure your client’s movement is slow and focused— “muscling through” the movement won’t help him or her learn an easier way of moving, and might even cause you both to miss the cues that keep your pressure safe. Optimally, your client’s head and neck should stay aligned, moving around the longitudinal axis of the spine, rather than rolling off to the side. In Image 2, my right hand is gently guiding my client’s head with this alignment in mind. You can repeat this anchoring and turning in two or three places between the base of the neck and the base of the skull, and at the slightly deeper layer of the SCM. Then, repeat on the opposite side. This technique can also serve as a great finishing move. Dr. Ida Rolf (the originator of Rolfing structural integration) often used a connect with your colleagues on massageprofessionals.com 111 myofascial techniques To assess cervical translation, cradle and move the head together with the vertebrae above the individual vertebrae being assessed. In this case, left translation of C4 is being assessed. Not visible from this angle are the finger pads isolating the translation movement at a single cervical vertebra (as in Image 6). It can help to imagine the vertebrae like a stack of coins; hold and move the whole stack above the individual “coin” that you want to assess. similar technique to make sure her client’s neck was adaptable, long, and free at the end of her sessions. The ligamentous structures surrounding a cervical vertebra. The purple arrow indicates placement and direction of gentle pressure for the release phase of the Translation technique (shown in Images 5 and 6). Source image courtesy of Primal Pictures. Used with permission. laTeral CerviCal TranSlaTion TeChnique The deepest soft-tissue structures of the neck, such as the zygapophyseal (or facet) joint capsules and ligaments, can be primary sources of pain and movement restriction long after a whiplash injury has occurred. Once the inflammation of the original injury has settled, restoring mobility to these deep structures can provide significant relief. Lateral translation refers to sideto-side movement of one vertebra in relation to another. In order to check for deep soft-tissue restrictions, we’ll feel for the freedom of this important movement at each vertebra, since the other movements of the neck—flexion/extension, rotation, and lateral bending—will be affected by the same connective tissues that restrict translation. Any of several deep structures can be involved: the facet joint capsules, the ligamentum flavum, as well as the small intertransverse ligaments and muscles (Images 4 and 112 massage & bodywork 7). These very deep structures are difficult to palpate directly, but using translation allows us to effectively assess and release any of the structures that are restricting free motion. To perform the technique, begin by gently feeling for the boniest lateral projections of the cervical vertebrae, at and just posterior to the lateral midline of the cervical spine. These projections are the small transverse processes, and the articular processes just behind them. Together, these lateral protrusions form a relatively wide platform for your touch (Image 4). Don’t worry about being too exact—simply feel for the most prominent bony lateral projection. Next, using the broad, soft pads of several fingers on these projections, feel for straight side-to-side movement of each cervical vertebra. Stay broad and soft; avoid poking. Although you’ll want to feel for isolated movement at each individual vertebra, do this by cradling and moving the head together with the entire cervical spine above (cephalad to) the vertebra you’re assessing (Image 4). Assess the entire length of the neck before trying to release individual restrictions; assess each vertebra in turn, for both left and right translation. I find it easier to be thorough by starting at the base of the neck and working upward. Typically, you’ll find that some vertebrae translate easier to one side than the other. If there’s been a whiplash injury, these left-right differences are often quite pronounced. Beginning with one of the most restricted vertebra, encourage easier translation in the restricted direction by sidebending the neck around the fulcrum of your touch (Images 5 may/june 2010 You CAn SEE ThESE TEChnIquES In Massage & Bodywork’s dIGITAL EdITIon, WhICh fEATuRES A vIdEo CLIp fRoM AdvAnCEd-TRAInInGS.CoM’S AdvAnCEd MYofASCIAL TEChnIquES dvd And SEMInAR SERIES. ThE LInK IS AvAILAbLE AT boTh WWW.MASSAGEAndbodYWoRK.CoM And WWW.AbMp.CoM. To release translation restrictions, gently sidebend the neck around the fulcrum of your fingers (arrow) and wait for the subtle softening of a ligamentous response. Pictured here is the direction of release for a vertebra that resists left translation. and 6). This is a direct approach—in other words, you’ll encourage the restricted vertebra to translate more in the direction it doesn’t easily go, by sidebending the neck around your firmyet-sensitive, broad-yet-specific touch. Since we’re asking for deep, ligamentous change, you’ll need to be patient and wait for the body to respond—for four to six breaths, at least—until you feel a gradual softening or easing of the hard restriction. Then, recheck. If you’ve been specific enough, gentle enough, and patient enough, you’ll feel more movement in the previously restricted direction. Repeat this procedure for each translation restriction you find.3 Whole Body students gave several well-reasoned answers—the sacrum, the jaw, the arms, the lower back. “Wrong,” she said, “you start working whiplash at the big toe.”5 The implications of this point of view have inspired several generations of Rolfers and other integrative practitioners to study the complex interconnections that make up a living body. As Larry Koliha and George Sullivan describe in the sidebar tips, all of us can learn from Rolf’s insight that whiplash is an entire-body phenomenon. As a result, untangling the effects of whiplash often means focusing less on the local injuries involved and more on the whole body—from the big toe up. Til Luchau (www.Facebook.advancedtrainings.com) is a member of the Advanced-Trainings.com faculty, which offers continuing education seminars throughout the United States and abroad. He is also a Certified Advanced Rolfer and a Rolf Institute faculty member. The ligamentous capsules of the facet joints (green) and the intertransverse muscles (orange) are two structures that can limit translation when shortened or restricted. The arrow indicates placement and direction of pressure for a vertebra that resists left translation. Source image courtesy of Primal Pictures. Used with permission. 2. In addition to anterior neck tissue injury, violent cervical hyperextension also causes posterior damage, such as the “nutcracker injury,” where the posterior arch of C1 is crushed between the extending occiput and the spinous process of C2. Deeper anterior structures, such as the pre-spinal complex of longus capitis and the anterior cervical fascias, can be injured as well. 3. Some variations of Lateral Cervical Translation Technique: 1. This procedure is described with the neck in a neutral position, that is, neither flexed nor extended. By passively flexing or extending the neck slightly during assessment and release, you’ ll sometimes find even more restrictions; 2. Occasionally, an indirect release is helpful with a particularly stubborn area. This involves sidebending the neck in the opposite direction to that described above—in other words, taking the restricted vertebra further into its easier direction, instead of into the barrier. We’ve found that patient and sensitive direct work is effective for the majority of restrictions, however. 4. Til Luchau, “Preparing the Neck and Shoulders for Deep Work,” Massage & Bodywork (January/ February 2009), and “Working With the Cervical Core,” Massage & Bodywork (March/April 2009). 5. This story was relayed to me by body therapist William “Dub” Leigh. While the techniques presented in these two articles will give you very effective tools for working with whiplash, it would be wrong to give the impression that this is all you’ll need to be expert in this complex injury pattern. Locally, the techniques for working the neck’s superficial fascia and the deep posterior compartment described in previous Myofascial Techniques articles4 will be helpful for addressing the local effects of cold whiplash. Most importantly, working with whiplash requires a big view of the body. Ida Rolf, reportedly asked one of her classes: “Where in the body do you start working with whiplash?” Her noTES 1. In both hot and cold whiplash, there are also secondary symptom-specific goals, such as gentle headache relief in the case of hot whiplash, or decompressing neurovascular pathways in the case of cold whiplash with upper limb numbness, etc. connect with your colleagues on massageprofessionals.com 113