Patient – Client is a 24 years old male student, currently working as a bar tender. Few months ago he decided to start looking after his overall health and posture more seriously which is why he started a course of Sports Massage treatments with us.
Initial Appointment – Client came to me the first time being concerned about his posture which has become increasingly rounded forward. At that time he did not have any considerable pain, although he has noticed increased tightness and discomfort in his upper back and neck with some tension headaches.
As a therapist, I understood that his main concern was that his posture will continue to decline especially as a kyphotic back is something that runs in his family and his future job would be sedentary.
Observation – I carried out my first static assessment of the client’s posture and I noticed the typical upper crossed syndrome with a kyphotic thoracic spine, a lordotic upper cervical spine, protracted head, protracted scapula and internally rotated arms. The lower back seemed fine with no issues present. Palpation of the pectoral muscles found a lot of tension, as well as subscapularis, latissimus dorsi and teres major muscles too.
Muscle testing of cervical flexor muscles, lower trapezius, rhomboids and serratus anterior highlighted weaknesses.
Treatment Plan – I recommended to start with, 60 mins of Sports Massage once every 2 weeks, and advised the client to notice how long the benefit of it was going to be last for him by making sure to implement other adjustments in terms of the exercises shown into his daily life.
1st Treatment: 60mins Sports Massage:
I asked the client to lay on his front and I adjusted the height of the bed so I could use my body as a leverage for applying more pressure if I needed to. I started by releasing tension on the back, neck and shoulders with some soft tissue techniques and assisted stretching.
By activating the client’s relaxation response, the level of stress decreased, the body became more receptive to the treatment and the parasympathetic nervous system relaxes too. I also implemented MET’s (muscle energy techniques).MET are manual therapy techniques used to lengthen, strengthen and improve the range of movement of muscles and they actively engage the client in the therapy. These techniques when used in combination with conventional physical therapy have shown some promising results in managing upper cross syndrome. I then asked the client to turn on his back and I stretched the pectorals muscles, first slowly to the point where he felt a mild discomfort, and then I held it firmly but comfortably in that position. There was a reasonable level of pain for the client at this point. I encouraged the client to breathe slowly and deeply through it, and after 10 secs the tissues began to ease off to be able to gently increase the stretch.
2nd Treatment 60mins Sports Massage:
2 weeks later seeing the client again means that I am able to make continual progresses with less regression between sessions. In the meantime, I was happy to hear that the client has been consistent in performing the exercise routine that I suggested to do in order to benefit from the treatments. Same treatment carried out.
Exercise Prescription:
Thoracic Extension – holding the position for 45 seconds, either standing or sitting retract and depress the shoulders while extending the thoracic spine. Do not bend in the lower back or crane the neck.
T-Bar – lie flat on your back with legs bent at the knees and raise them towards your chest. Lift the arm and spread them into a T shape. Make sure your back is flat on the ground and move your hips from side to side, while maintaining lower back on the floor as much as possible. Repeat 10 times.
3rd Treatment 60mins Sports Massage (3 weeks later):
This time by listening to the clients feedback after his last session, I decided to take a different approach and start by treating the front muscles first, the pectorals, as he reported he still feels tight in those areas due to his pectorals being concentrically overloaded. I started with the fascia spread, to engage the tissue, I anchored my hands on either side to apply a cross hand spread, just to separate the tissue, I engaged the fascia holding for about 90secs.Engaging the tissues, I took my patient into abduction and external rotation. I did this direct fascia technique 2 to 3 times and I also moved actively patient’s shoulder into more abduction and external rotation to assist this in the stretch.
I noticed already at this point some extensibility in the connective tissue and I did then few skin rolling which ca be sensitive.Joint irritation treatment on the right side, between C3 and C4, I used a joint mobilisation technique, starting by landmarking the spinous process coming down to C3 and laterally on the spinous process. The intent here is to decrease the pain and increase the synovial fluid in the cervical joint.Treatment of the Trigger points on the neck – Anterior aspect in the splenius capitis upper trapezius muscles and the sternocleidomastoid muscles (after I did the neuromuscular techniques to warm up the area) I did the stripping technique coming from the inferior to superior aspect of the cervical spine, looking for trigger points.
Once I found a trigger point, I applied direct compressions into it, always within my client’s pain tolerance, waiting for a release or a decrease in pain, this can take between 20secs to minute. Once I received a decrease in pain, I flushed the area and provided a stretch. For the upper trapezius muscles, I come more laterally towards the acromion process looking for a trigger point, holding, and waiting for a release.
Following the trigger points, I took my client’s head supporting the base of the occiput, taking him into a full flexion position, into an active stretch, by stretching the splenius capitis, and holding the stretch for 30secs, then for the stretching of the splenius muscles, capitis and cervical, taking client’s head into a bit of flexion and rotation to the opposite side. For the upper traps stretch, I took the neck laterally flexed to the opposite side and rotate it to the same side and again I took him into a flex position, anchoring one of my hand into the acromion to provide more stretch for the upper trapezius fibres. I then worked on the sternocleidomastoid muscle, looking for trigger points, again after applying neuromuscular techniques to warm up the area, I glide along the tissues looking for trigger points.
Summary – In the six weeks period receiving 3 treatments, client has made significant changes in static posture, he feels physically better and he is not as uncomfortable as he is used to be, he has less tension headaches and he is much more mobile. Client is now more conscious of his static posture and he is actively incorporating a “good posture” in his daylight activities like walking. Noticeably client’s head is sitting in a more neutral position and his thoracic back is less kyphotic.
Case Study by Alessia our Sports Massage Therapist
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