Osteopathic Cranial Manipulation for a Patient With Whiplash-Associated Disorder: A Case Report

Abstract

Objective

The purpose of this case report is to describe the immediate effects of osteopathic cranial manipulation on pain and cervical motion in a patient with whiplash-associated disorder.

Clinical Features

A 74-year-old man reported daily cervicogenic headaches after a whiplash injury caused by a traffic accident 3 months prior. Physical examination and osteopathic assessment identified tissue texture alteration, positional asymmetry, limited range of motion, and tenderness. The resulting diagnosis was somatic dysfunction of the head and the cervical region.

Intervention and Outcome

Osteopathic manipulative treatment was administered to the occipital area. The patient reported an immediate improvement in pain. Accessory movement of the cervical spine was improved.

Conclusion

This patient responded favorable to osteopathic cranial manipulation with improved symptoms and ranges of motion.

Introduction

Neck pain is the fourth leading cause of time lost to disability.¹ One leading cause of neck pain is whiplash injuries, which are primarily due to motor vehicle collisions but can also occur in other settings such as work and sports.² The Québec Task Force on Whiplash-Associated Disorders defined whiplash as “an acceleration-deceleration mechanism of energy transferred to the neck that results in soft tissue injury that may lead to a variety of clinical manifestations including neck pain and its associated symptoms.”³ The task force also coined the term “whiplash-associated disorders” (WADs) to describe the clinical entities related to the injury and distinguish them from the injury mechanism.² It is likely that WAD results from cervical sprain or strain. The exact pathophysiology is not known, and there may or may not be damage to soft tissue, including the joints, ligaments, and muscles in the neck, posterior shoulder, and upper thoracic regions. The incidence of reported WAD in Western countries has increased over the past 30 years and is likely to be at least 300 per 100<&thinsp;>000 inhabitants.^2,3 The annual cost of neck injuries is estimated at 4.5 to 29 billion dollars in the United States and 5 to 10 billion euros in Europe.² The majority of adults with traffic injuries report pain in the neck and upper limbs. Other common symptoms of WAD include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.^3,4 In some cases, pain experienced after a whiplash injury could persist for several months due to a chronic syndrome with central nervous system sensitization.⁵

The clinical management of musculoskeletal disorders such as WAD can be complex and often involves combining multiple interventions (multimodal care) to address symptoms and consequences.⁶ Manual therapy (including spinal manipulation), medication, and home exercise with advice are commonly used multimodal treatments for recent-onset and persistent neck pain.^7,8

There is scant evidence in the scientific literature on WAD concerning osteopathic manipulative treatment (OMT) and osteopathic cranial manipulation (OCM). Only 2 articles report the effectiveness of OMT in people with whiplash injury.^9,10 To our knowledge, no studies have investigated the effects of OCM related to pain and cervical range of motion after whiplash injury. The purpose of this case report is to describe the immediate effects of OCM on pain and cervical range of motion in one patient with WAD.

Case Report

A 74-year-old retired firefighter presented with headaches to an osteopathic outpatient clinic 3 months after he was in a traffic accident with a lateral and posterior impact.

Before presenting to our clinic, at 10 days after his whiplash injury, he received a rehabilitation program that consisted of manual therapy of the upper cervical spine, transcutaneous electrical nerve stimulation, and ultrasound. His physical therapy intervention was twice a week for the first month and once a week for the following month. At the end of the intervention, the patient reported partial benefits. One month after the end of the rehabilitation program, he was referred to our osteopathic outpatient clinic to treat his persistent headache.

During the history, the patient reported a 6 out of 10 on a numeric pain scale. He experienced daily disabling headaches, strictly unilateral, with a cervical and occipital onset that extended to the frontal, temporal, or periorbital area. Radiographic imaging was negative for bone fractures, and magnetic resonance imaging showed cervical osteoarthrosis (normal with age) and a C5 disc bulge. The patient's pathological history was negative for disease or head trauma.

Osteopathic assessment was performed to detect somatic dysfunction, which is characterized by: tissue texture changes, asymmetry, range-of-motion abnormalities, and tenderness.¹¹,¹² The manual assessment follows 4 steps: (1) detect cervical spine positional asymmetry by (a) observing the position of the cervical spine in relation to the head and (b) palpating the head and spine to detect asymmetrical vertebral position; (2) palpate the head and the cervical tissues to identify areas of tissue texture abnormalities; (3) assess motion of C0-C1 and C1-C2 in all directions of each body plane to detect asymmetrical movements; and (4) manually examine the upper cervical spine to reproduce head pain stressing the C1 and C2-C3 segments.¹³ This was done by applying a sustained force with the thumb to medially compress the apophysis transverse of C1, C2, and C3. For this patient, restriction of tissues identified with the characteristics of somatic dysfunction (ie, altered tissue density, asymmetry, and tenderness) was detected in the occipital area: the atlanto-occipital junction showed an altered area of tissue texture and an asymmetrical motion in left rotation.

Active range of motion (aROM) of the cervical spine was assessed using a Nordic semiconductor with an accelerometer and a gyroscope (S9 Sensor, Sprintit, Noale, Italy). An accelerometer and gyroscope are widely used in clinical practice to assess 3-dimensional active motion.14, 15, 16, 17, 18, 19 Applied to a person's finger over the nose root (glabella), this tool reduces the risk of positioning and reliability errors. The S9 sensor is connected to an application that graphically records spine kinematics (in degrees) in flexion, extension, rotation, and side bending. The active range of motion of the cervical spine was measured with the patient seated and the dorsal spine resting on the back of the seat. Registration was captured during the third flexion-extension movement before and immediately after the treatment.

Based on these findings, our diagnosis was somatic dysfunction of the head and the cervical region. Based on the assessment and the patient's response to prior physical treatments, OMT to only the cranial region, especially the occipital area, was selected. The cranial techniques consisted of 2 steps.

Step 1: Bilateral Occipital Bone-Mastoid Process Fascial Release

For the right side, the therapist's left hand grabs the occipital bone with the fingers as close as possible to the occipitomastoid suture (Fig 1). The therapist's right hand grabs the zygomatic process of the temporal bone with the thumb and the second finger (second finger placed inside the acoustic meatus). The last 3 fingers grab the mastoid process as close as possible to the occipitomastoid suture. The therapist's left shoulder gently rests on the patient's frontal bone. The therapist applies cranial compression using the left shoulder; meanwhile, the therapist's hands release the occipitomastoid suture using a direct technique (according to Greenman, direct technique involves the application of forces against a resistance barrier to achieve a change in tissue behavior texture¹⁴). The therapist rhythmically and slowly repeats this technique until a release is noted.

Fig 1.

Bilateral occipital bone-mastoid process fascial release (on the right side).

Step 2: Left Frontal Bone Eminence Compression and Release

The therapist's left hand grabs the occipital bone with the second and third fingers on the right mastoid process (Fig 2). The palm of the right hand is placed on the left frontal eminence. The patient's head is rotated to the right until the force vector has a perpendicular direction with respect to the ground. The force direction is applied slowly and rhythmically through the mastoid process until a tissue release is appreciated.

Fig 2.

Left frontal bone eminence compression and release.

Outcomes were measured by range of motion and numeric pain scale before (6/10) and immediately after (1/10) the treatment. Before-and-after motion assessment can be seen in Fig 3, Fig 4 and 4. Motion assessment of the cervical spine before treatment showed abnormal movement during the active flexion-extension test (Table 1). Immediately after cranial manipulation, right rotation and left side bending improved. The patient provided consent to publish his health information.

Fig 3.

Cervical motion in flexion-extension test before cranial manipulation.

Fig 4.

Cervical motion in flexion-extension text after cranial manipulation.

Table 1.

Range-of-Motion Findings Before and After Treatment.

Spine Motion During Flexion/Extension Test	Before	After
Flexion	42°	36°
Extension	50°	69°
Left rotation	1.5°	5°
Right rotation	19°	4°
Left side bending	17°	4°
Right side bending	0°	5.5°

Discussion

The patient improved immediately after the cranial treatment. We hypothesize that OCM may affect pain and cervical spine aROM by the manual stimulation of mechanoreceptors contained inside the fascial system, leading to tonus changes in the motor unit that are mechanically linked to the tissue under the practitioner's hand.²⁰ We propose that cranial techniques could induce physiological movement of the spine and decreased pain, interacting with the central nervous system via the fascial tissue.²⁰

Cervicogenic headache following whiplash injury may be referred pain from the cervical spine.²¹ Physiologically, cervicogenic pain is analogous to shoulder, chest wall, buttock, or lower limb pain referred from spinal sources.²⁰ The hypothesized mechanism underlying the pain involves convergence between the cervical and trigeminal afferents in the trigeminocervical nucleus. In this nucleus, nociceptive afferents from C1-C2 and C3 spinal nerves converge onto second-order neurons that also receive afferents from adjacent cervical nerves and from the first division of the trigeminal nerve via the trigeminal nerve spinal tract.²¹

In this patient's case, sustained pressure applied to the upper cervical spine reproduced the patient's symptoms during history, consistent with findings in the literature to diagnose cervicogenic headache.¹³ Conservative management for WAD, including active mobilization exercises, manual techniques, physical agents, multimodal therapy, behavioral approaches, and education, are considered effective for reducing pain and improving cervical ROM.²² The patient's history of treatments included these multimodal approaches but did not completely resolve the cervicogenic headaches. We hypothesize that these initial therapies were not focused on restoring physiological tissue stiffness around the occ-C1 junction.

The cranium is commonly neglected in cervicogenic headaches, with the exception of masticatory muscles, which could hide trigger areas.²³ OCM is part of OMT and is a widespread technique used by osteopaths, but its effectiveness in treating different musculoskeletal disorders is controversial.²⁴ Some osteopathic physicians report good clinical results in patients after whiplash, but no published data from clinical trials are available in the scientific literature.⁹ Only 2 papers that we know of have reported the effectiveness of OMT applied after whiplash injury. The results of these studies suggest the use of OMT for patients with WAD, but rigorous randomized controlled studies are warranted.^9,10 To our knowledge, there are no studies investigating the effect of OCM in WAD and specifically related to cervical spine mobility.

The cranial techniques used in this case represent a manual approach that immediately decreased pain and restored physiological cervical spine aROM. Accessory nonphysiological movement of the cervical spine observed in this case during the flexion-extension task was consistent with literature findings.²⁵ Research about whiplash biomechanics explains that upper cervical segments are flexed, while lower segments extend around an abnormally located axis of rotation that may cause abnormal movement in the cervical spine.²⁵

In the past decade, research in osteopathy has emphasized the role of the fascial system in cranial osteopathy and OMT in general.²⁶ Studies have highlighted the biological effects of indirect and direct fascial release regulating proliferation of proinflammatory cytokines and wound healing responses.27, 28, 29 In perinatal care, the role of gentle touch has been emphasized, a specific approach of OMT that comprehends cranial techniques and activates autonomic arousal and thus positive effects for newborn and preterm infants.³⁰ In this case report, we hypothesized that specific effects of OCM on pain and cervical spine aROM could be determined by the manual stimulation of mechanoreceptors inside the fascial system that lead to tonus changes in the motor unit, which are mechanically linked to the tissue under the practitioner's hand.³¹ Therefore, the cranial techniques in this case report could induce physiological movement of the spine and decreased pain interacting with the central nervous system via the fascial tissue.³²

Understanding the biological mechanisms that underpin the clinical efficacy of osteopathic techniques could propel those techniques to the class of evidence-based, first-line therapies. To provide an evidence base to describe the clinical effectiveness of OMT, a goal should be to establish the characteristics (magnitude, duration, and direction) of osteopathic techniques, providing a more rigorous study design.³³

Limitations

Lack of follow-up observation and an uncontrolled environment report limit the applicability of our results. Results could also be determined by a spontaneous remission of symptoms, natural history of the disorder, and contextual factors. Furthermore, the reliability and repeatability of these cranial techniques are poor, and most existing OCM studies have a high risk of bias.³³

Conclusion

After OCM, this patient had an improvement in symptoms and function, as measured by reported pain and ranges of motion.

Funding Sources and Potential Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): G.P.

Design (planned the methods to generate the results): G.P.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): G.P.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): M.G.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): G.P.

Literature search (performed the literature search): G.P.

Writing (responsible for writing a substantive part of the manuscript): G.P.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): G.P.

Practical Applications.

• •Cranial manipulation could be effective in the treatment of headache and cervical pain.
• •In this case, it appeared that cranial manipulation modified cervical motion.
• •This patient responded favorably to osteopathic cranial manipulation.

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