Osteopathic Manipulative Treatment: Suboccipital Release

Anatomy and Physiology

The suboccipital region consists of 4 major muscles: the rectus capitis posterior major, obliquus capitis superior, rectus capitis posterior minor, and obliquus capitis inferior.[10] These muscles help support the head and allow for movement of the neck. The rectus capitis posterior major and obliquus capitis inferior muscles attach at the spinous process of C2. The Rectus capitis posterior minor and obliquus capitis superior attach at C1. Based on the attachments, these muscles allow for neck extension and rotation of the head. Within this muscle group is the suboccipital triangle, consisting of rectus capitis posterior major, rectus capitis posterior minor, and obliquus capitis superior. This critical landmark contains both the vertebral artery and the suboccipital nerve. The suboccipital nerve is what innervates these muscles. The larger muscles supporting the head and neck are superficial to the suboccipital triangle. These muscles include the sternocleidomastoid and trapezius. The posterior portion of the sternocleidomastoid attaches to the lateral mastoid process and superior nuchal line.[11] The trapezius muscle originates from the base of the occiput and nuchal ligament and extends to the spinous process of T12.[12] Compressing these muscles can cause compression of both the suboccipital nerve and the vertebral artery, causing decreased blood flow to that region. Subsequently, this can cause neck pain, headaches, and other symptoms. It has been noted that the "myodural bridge" connecting these muscles and the dura is a cause of cervicogenic headaches.[13] 

Indications

Indications for suboccipital release include:

• Tension headache
• Migraine headache
• Cervical muscle strain
• Nausea
• Anxiety

Contraindications

Tension Headaches, Migraine Headaches

• Acute cervical fractures
• Concern for neurovascular compromise
• Focal neurologic deficit

Neck Pain

• Acute cervical fractures
• Concern for neurovascular compromise [2]

Equipment

Equipment needed to perform the suboccipital release technique include:

• Pillow for comfort 
• OMT table in the outpatient setting

Personnel

A physician who has been trained and certified in osteopathic manipulative medicine.

Preparation

Before performing a suboccipital release, the patient should have a neurologic and musculoskeletal exam of the neck and upper extremities. It is vital to ensure that the patient does not have contraindications like those listed above. Once it is determined that the patient does not have a contraindication for the procedure, have the patient lay supine, and the provider should sit on a stool at the head of the bed. The table should align so that the patient's head is around the level of the provider's umbilicus. This allows for roughly a 90° angle of the provider's arms to perform this technique with appropriate ergonomics. 

Technique or Treatment

To perform a suboccipital release, start with positioning the patient. The patient needs to be supine and flat. A pillow can be placed under the patient's head for comfort until starting the procedure. See Video. Suboccipital Release Procedure. Once the patient is comfortable and correctly positioned, the provider sits at the head of the bed and places both hands underneath the patient's head in the occipital region. The provider should then feel for the occipital ridge along the scalp and move the hands slightly caudad until the muscle is felt. The provider then flexes the fingers upward against the suboccipital muscles and holds this position for 3 to 5 minutes or until significant muscle tension is released. After the treatment, it is important to re-assess the patient's symptoms. See Image. Suboccipital Release Hand Positioning. It is not uncommon to have some transient fatigue and persistent symptoms. However, most patients see an improvement in symptoms after undergoing this procedure. 

Complications

The suboccipital release is generally an easy and safe technique to perform. The most common adverse reactions include headache, fatigue, and nausea. Less commonly, there are risks of worsening pain and nerve compression.[2] The most feared complication of cervical manipulation is vertebral artery dissection. Symptoms of this include dizziness, headache, and neck pain. Vertebral artery dissection may also present with an insidious onset of symptoms and neurologic deficits on the physical exam.[3] 

Clinical Significance

Headaches, neck pain, and other musculoskeletal complaints are among the most common reasons for ED and office visits. First-line treatment typically includes NSAIDs, heat, ice, muscle relaxants, and other non-invasive procedures such as massage therapy and physical therapy. Knowledge of OMT techniques, especially suboccipital release, gives providers another option for patients who need or want more than just medications for their ailments. This short and simple technique can help with patient comfort, treatment compliance, and overall quality of life for acute and chronic musculoskeletal pain patients. 

Enhancing Healthcare Team Outcomes

Most physicians have heard of OMT or work alongside many osteopathic physicians. However, many physicians do not know the utility of these treatments and the wide range of techniques available to trained providers. Understanding this technique can show other providers the breadth of non-invasive treatment options for musculoskeletal complaints. In addition, in an outpatient setting, physicians and other providers are able to help improve patients' quality of life and pain within a few minutes. In an inpatient setting, understanding OMT gives the healthcare team more options for improving the patient's pain and discomfort and hopefully decreasing the length of hospital stay. With the information on OMT expanding in the medical community, many providers should have opportunities to learn these techniques and their underlying principles.