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myofascial techniques

By Til luchau

108 massage & bodywork march/april 2010


Working With Whiplash, part 1
hot Whiplash
The psychobiological impact of nerve tissues, typically in the neck,
For hands-on practitioners, whiplash has long been recognized, shoulders, and back. Harmonic
and significant numbers of whiplash forces in the body, bracing reactions,
there is good and bad news sufferers experience anxiety, depression, and fascial connections can cause
or symptoms similar to posttraumatic tissue injury and inflammation
about whiplash. The bad news stress.5 What’s more, whiplash in unexpected, nonlocal areas
patients can be involved in legal or anywhere in the body, such as
first: whiplash injuries puzzle insurance difficulties, which may the rib cage, limbs, or pelvis.
complicate and even hinder recovery.6 • Instability or weakness from tissue
and befuddle manual therapists. If this wasn’t enough bad news, damage, and from dissociation of the
manual practitioners observe that muscle spindle/Golgi postural reflex
Not only do we regularly hear
whiplash symptoms can worsen after relationships in the injured muscles,
this from practitioners coming to
bodywork—almost as if their hands-on resulting from overstretching.8
our Advanced Myofascial Techniques
work had opened a Pandora’s box of • Restricted motion as a result of
courses, but a 2004 Advanced-
pain, soreness, and spasm. The aim of either acute muscle spasticity
Trainings.com survey asked 100
this article is to help you prevent this. and splinting reflexes, or from
experienced bodyworkers which
The good news about whiplash? In chronically adhered and shortened
conditions they would most like to
spite of its complexity, hands-on body connective tissues, including the
learn more about. The topic most
therapy can help. Skilled practitioners tissues around articulations.
frequently mentioned? Whiplash.
are getting very good results by using • Pain, anywhere in the body.
More bad news: whiplash is
soft-tissue release together with Causes include direct tissue injury,
common. Although estimates vary,
neurologically based approaches. neurologically referred pain, or
several sources cite nearly 2 million
Gentle encouragement of motility, autonomically associated pain
new cases of whiplash per year in
such as that provided by sensitive (e.g., posttraumatic headaches).
the United States alone. That means
and competent manual therapy, in • Vertigo (dizziness) and balance
that for each massage therapist in
combination with moderate activity, impairment. Cervical instability
this country, there are up to eight
is one of the most widely agreed-on can result in splinting and fixing of
new cases of whiplash every year.1
conventional treatments for whiplash. the neck and head (especially by the
Whiplash is also complicated—
(Immobilization and cervical collars, suboccipital muscles), which reduces
sufferers experience a wide array
once the most common treatment, the adaptive capacity of the vestibular
of physical, neurological, and
are now rarely used, as they have been system. Posttraumatic vertigo is also
psychobiological symptoms, which
observed to produce more problems postulated to be related to sympathetic
may not appear until weeks or
than they resolve.7) An increasing nervous system imbalance.9
months after the original injury.
understanding of the effects of trauma • Sympathetic (fight or flight) activation
Symptoms can persist for months or
on the nervous system is expanding of the autonomic nervous system
years, and for a significant number
massage therapists’ ability to help (ANS) from the trauma of the
of sufferers, get worse over time.2
clients whose symptoms were previously incident itself; from direct injury
Although there have been hundreds
only aggravated by hands-on work. to sympathetic nerve fibers in the
of studies on whiplash, and more
neck (Image 2)10; or from ongoing
are conducted each year, there is
The effecTs of Whiplash sympathetic stimulation from
widespread disagreement on diagnosis,
The effects of whiplash range from mild vestibular and balance impairment.
treatment, and even terminology3;
to severe, can change over time, and Symptoms can include sleeplessness,
most interventions for whiplash injury
may include any or all of the following: headaches, anxiety, or depression.
are “medically unproven”4; and the
• Tissue damage at the sites of Some of the more severe effects of
reasons for whiplash’s intractability
injury, from local overstretching or whiplash, such as prolonged anxiety
are only beginning to be understood.
micro-tearing of fascia, muscle, or or depression, obviously necessitate

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myofascial techniques

a referral to a qualified specialist. In and cold whiplash can respond very Hot whiplash often becomes cold
particular, clients with vertigo, nausea, differently to the same interventions. (restricted) once initial tissue damage
or ocular discomfort that worsen with Hot whiplash is distinguished by has begun to heal; cold whiplash can
head movement should be referred to being sensitive, fragile, and reactive, become hot (reactivated) if worked
a physician for evaluation before any as the fight-or-flight responses of too quickly or aggressively. We’ll
manipulation is performed, as this can the autonomic nervous system are focus on hot whiplash in this article
indicate vascular, ligament, or spinal still aroused. The head and neck are and cold whiplash in the next.
cord issues. These examples aside, typically immobilized by muscular
the majority of whiplash effects are spasm or hypertonus since the postural Working WiTh hoT Whiplash
well within our power to ameliorate. reflexes recruit muscular tension When working with hot whiplash, our
to provide the inherent structural primary goal is to calm our client’s
hoT and cold Whiplash stability that has been compromised by autonomic activation before trying
Metaphorically, it can be helpful to the injury. Because of tissue damage, to work with any tissue restrictions.
think of whiplash as having either “hot” inflammation will be a factor in a recent To get a sense of this, imagine that
or “cold” qualities. A recent whiplash or unresolved whiplash. The tissue in you’re working on an unprotected
(less than 3–6 weeks) will tend to show injured areas will feel softer or puffy central nervous system. In a way,
more hot qualities, while cold whiplash to your gentle palpation (though not you are—after a traumatic event,
is typically older (although older always literally hot). Your client may our ability to filter out or tolerate
whiplash can also be hot, or can turn respond to direct touch with guarding, intense experience decreases, leaving
hot if reinjured or worked insensitively). uneasiness, or pain, which further us feeling bare and unshielded. How
The table below summarizes differences increases sympathetic activation. would you touch a client who was
between these two phases of the In contrast, cold whiplash is nothing but a bare brain and spinal
body’s response. Although you can see typically older, less autonomically cord? Hopefully, very delicately and
elements of both hot and cold whiplash reactive, and restricted at the carefully—this is the ideal way to
in the same client, it is important ligamentous or joint level (as approach a recent or hot whiplash.
to differentiate the way you work opposed to muscularly spasmed). It Pace your work: because
with each type of symptom, as hot is characterized by stubborn, dense, sympathetic reactivation can happen
hardened tissue deep around the joints. by working either too long, too fast,

hot cold

time Since injury Usually recent. More than 3-6 weeks since injury.

PreSenting Pain, immobility, inflexibility; restricted or stiff


Pain, instability, spasm; guarded or careful movement.
SymPtomS movement.

mobility Fascial hardening; ligamentous and articular


Muscular hyper-tonus (spasm).
reStriction restrictions.

Inflamed, puffy, slippery; sometimes soft, sometimes Hard, dense, rigid, especially at deep levels. Can be
tiSSue Quality
hyper-toned; touch is often painful. insensitive to light touch.

Calm or soothe any unresolved fight-or-flight


goalS activation; encourage subtle motility; broaden client’s Release tissue restrictions; restore lost gross mobility.
focus beyond injury.

Work primarily with nervous system; work within client’s


Work with myofascial restrictions and movement
Str ategy range of active motility; address myofascial restrictions
barriers to restore mobility, both locally and globally.
only away from injured areas.

Imagine working on a bare nervous system: use Imagine melting a glacier with the warmth, pressure,
metaPhor
delicate, slow, gentle touch. and patience of your touch.

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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 SerieS.
the link iS available at both www.maSSageandbodywork.com and www.abmP.com.

or too deeply, instead try shorter


sessions with small, supportive,
calming interventions. Watch to
see how your client responds to
your work, both within your session
and between sessions. Gradually
increase duration, scope, or depth as
your client is ready. You can always
work a little more next time, but it
is hard to take back your work, once
you’ve already done too much.
Work elsewhere in the body,
before and after approaching any
injured or painful areas. This
broadens your client’s awareness
beyond his or her places of injury and
pain. Use the metaphor of a tangle
of yarn or string: you wouldn’t go
right to the tightest part of a tangle
and start pulling. Instead, work at
the periphery, gently and patiently Dizziness and vertigo after whiplash can be exacerbated by loss of adaptability in the neck,
loosening the overall pattern. limiting the body’s ability to position the head and adapt to stimulus from the balance
Instead of mobilizing the neck, mechanisms of the inner ear. Image courtesy of Primal Pictures. Used with permission.
encourage motility. Use your client’s
gentle active motion (i.e., motility)
to restore subtle movement to awareness to the otherwise
spastic areas, instead of applying healthy regions that have been
passive manipulation, stretching, or eclipsed by the painful areas.
direct release techniques (which do Begin by asking your client to
mobilize, but could re-aggravate). take a normal breath, and look to see
Breath, active exploration of range of where the thorax moves the most with
motion, and even micromovements inhalation. Using a soft, receptive
will help restore disrupted reflexes touch, “sandwich” that place, front and
and prevent tissue adhesion. Direct back, between your two hands, as in
work with gross movement barriers Image 3. Whether breath starts in the
or tissue restrictions come later, once belly, diaphragm, or chest, ask your
muscular splinting has subsided and client to gently allow the space between
injured tissues are less inflamed. your hands to fill with a normal breath.
There are many ways to work Note that we didn’t say, “push the
that accomplish these goals; much breath between my hands,” or even
of what you probably already know “breathe here.” Those imperatives will
about relaxing and calming can be evoke a more efforted response than the
extremely effective when applied invitation simply to “allow” the breath It can be helpful when working with hot whiplash
with the above considerations in to fill between your hands. Our aims to imagine working on a bare nervous system.
mind. A specific technique that are to calm the autonomic responses, Hyperextension injury to the cervical portion of
incorporates these principles is induce gentle active movement in the sympathetic trunks of prevertebral ganglia
the Breath Motility Technique. places that have lost it, and increase (along the front of the spine in green) is thought
proprioception. Try it in your own to contribute to vertigo and other autonomic
BreaTh MoTiliTy Technique body—a forcibly inhaled breath doesn’t symptoms associated with whiplash. Image
Breath has the power to calm the accomplish those aims as well as a courtesy of Primal Pictures. Used with permission.
nervous system, to catalyze lost breath that you simply allow to come
motility, and to bring proprioceptive in on its own. You’ll be able to palpate

connect with your colleagues on massageprofessionals.com 113


myofascial techniques

AdditionAl
ReAding
Herman, Judith L. 1992.
Trauma and recovery. New
York: Harper Collins.

Levine, Peter and Ann Frederick.


1997. Waking the tiger. Berkeley,
California: North Atlantic Books.

2. A study published in the European Spine Journal


The Breath Motility Technique is used when initiating work with hot whiplash, in order to soothe the found that during the period of time between the
first and second years following a motor vehicle
nervous system, increase motility, and broaden the client’s proprioceptive awareness beyond painful areas.
accident, more than 20 percent had symptoms
worsen (H. Olivegren, N. Jerkvall, Y. Hagstrom,
and J. Carlsson, “The Long-Term Prognosis of
the difference in your client’s breath, this technique with your client seated,
Whiplash-Associated Disorders (WAD)”, European
too. Continue to coach and encourage rather than supine. Seated work in Spine Journal 8, no. 5 (1999): 366–70).
your client until the breath is effortless, general can be very helpful, if the act
3. The term whiplash was first used to describe
and it is tangibly clear to each of you of lying down is painful or difficult. cervical injuries in 1928 by orthopedic surgeon
that the breath is moving in between These ideas should help you Harold Crowe, and is subject to some controversy.
your hands, both front and back. avoid the Pandora’s-box effect of Physical medicine texts variously prefer the terms
Once you both feel the breath in making whiplash pain worse with acceleration-deceleration injury, hyperflexion-
hyperextension injury, or cervical strain-sprain injury.
one area, move to a new place nearby, inappropriately deep or direct
and repeat. Keep the pacing even, work. In Part 2, we’ll share tips for 4. “Quebec Task Force Rewrites Whiplash Protocols,”
Dynamic Chiropractic 13, no. 12 (June 5, 1995): 28.
and the breath normal. Deep or fast recognizing and working with the
breathing, especially high in the chest, chronic, stubborn patterns typical of 5. In 1961, physician Robert Munro wrote: “In its pure
form and when rightly diagnosed, the symptoms of
would increase sympathetic activity, cold whiplash, where deep and direct
‘whiplash’ injury are those of cervical muscular spasm
rather then calm it. Continue to get work can be just what is needed. often complicated by neurosis.” R. Munro, “Treatment
agreement about your client’s ability to of Fractures and Dislocations of the Cervical Spine,”
sense the breath in each new spot. Stay Til Luchau (info@advanced-trainings.com) New England Journal of Medicine 264, no. 573 (1961).
encouraging, interested, and focused. is a member of the Advanced-Trainings.com 6. Statistically, whiplash sufferers with workers’
If it’s difficult for your client to feel faculty, which offers continuing education compensation claims or lawsuits have significantly worse
the breath in a new place, or if you seminars throughout the United States and outcomes than those who do not. In fact, in scientific
studies designed to judge the efficacy of interventions,
don’t feel it with your hands, return abroad. He is a Certified Advanced Rolfer and
investigators must exclude such patients or report
to the last spot where it was clear, and a Rolf Institute faculty member. their results separately. (From Brian Grottkau, MD,
move out gradually from there. Repeat writing in the New England Journal of Medicine
this pattern with the entire thorax noteS (348, no. 14 (April 3, 2003): 1413–14) about Andrew
and abdomen, on both left and right 1. Whiplash/bodyworker ratios are based on an estimated Malleson’s Whiplash and Other Useful Illnesses.)
250,000 bodywork practitioners in the United
sides. Take at least 10 minutes for this 7. Use of immobilization and cervical collars after
States. Estimates of whiplash prevalence range from whiplash injury have been observed to produce
technique, although allowing even more a low of 120,000 new cases annually (“Prevalence temporomandibular dysfunction, joint adhesions,
time would be well spent. This simple and Incidence Statistics for Whiplash,” available at muscle atrophy, and myofascial trigger points.
technique could be the bulk of an entire www.wrongdiagnosis.com/w/whiplash/prevalence. Whitney Lowe, “Assess & Address: Whiplash,”
session, which would leave your client htm (accessed January 2010)), to a high estimate Massage Magazine 104 (July/August 2003).
of 1,990,000 new annual cases (Croft, Arthur
feeling more settled and relaxed. 8. Rene Cailliet, Neck and Arm Pain
C., “Facts Concerning Whiplash Injuries,” Spine
Incidentally, if you notice that Research Institute of San Diego. Available at www. (Philadelphia: F.A. Davis, 1991), 88.
your client’s movement is guarded thewestclinic.net/pdf/Facts%20Concerning%20 9. Ibid., 112.
or painful, you may want to perform Whiplash%20Injuries.pdf (accessed January 2010)).
10. Ibid.

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