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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                         Volume 2 – Issue 2 – June 2019 

 
 

Clinician-Administered Versus Self-Administered Suboccipital Release 
on Superficial Backline Function  
Colin Wilhite, MS, ATC1, Kristin A. Paloncy, EdD, ATC2, Karen Rawkowski, PT, ATC1, Todd Daniel PhD, ATC3 

1 Mercy Sports Medicine, Springfield, MO; 2 North Central College, Naperville, IL; 3 RStats Institute, Springfield MO 
 

 
ABSTRACT 

The effectiveness of trigger point release in the suboccipital 
region to improve hamstring mobility has been established in 
the literature, but the research has not clarified whether self-
administered soft tissue techniques produce the same 
improvements to mobility as when the clinician delivers the 
manual trigger point release. The purpose of the study was 
to assess whether the same increase in hamstring mobility 
within the superficial backline function that is achieved with a 
clinician-administered suboccipital trigger point release can 
also be obtained through a patient/self-administered 
method. The study employed a randomized, descriptive 
laboratory design in which 60 participants reported for a 
single data collection session and were randomly assigned to 
either a clinician-administered or self-administered treatment 
group. There was a statistically significant main effect for the 
intervention (F(1,58) = 18.24, p < .001, eta = .239) 
indicating that both the clinician-administered and the self-
administered groups improved in their hamstring mobility 
from pretest to posttest; but there was not a statistically 
significant interaction of time and group (F(1,58) = 18.24, p 
= .360, eta = .014) indicating that the effectiveness of 
suboccipital trigger point release on hamstring mobility did 
not differ between groups. The significant finding in this study 
is that toe touch distance – indicating improved hamstring 
mobility – increased for all participants following a 
suboccipital trigger point release. The significant clinical 
implication from the study is that improvement in hamstring 
mobility was similar whether the suboccipital trigger point 
release was clinician-administered or self-administered. If a 
clinician properly instructs a patient on how to perform a 
trigger point release in the suboccipital region, the self-
administered intervention can be just as effective at 
improving hamstring mobility as when the clinician performs 
the release. This finding allows clinicians to extend the scope 
of their treatment by empowering patients to effectively 
treat their own myofascial trigger points. 
 
Key Phrases 
Clinician-rated outcome, manual techniques, myofascial 
release   
 
Correspondence 
Dr. Kristin Paloncy, 30 North Brainard, Stadium Room 308, 
Naperville, IL 60540 
630-637-5515 
E-mail: KAPaloncy@noctrl.edu 

 
Full Citation 
Wilhite C, Paloncy KA, Rakowski K, Daniel T. Clinician-
administered versus self-administered suboccipital release 
on superficial backline function Clin Pract Athl Train. 
2019;2(2):12-19. 
https://doi.org/10.31622/2019/0002.3.   

 
Submitted: February 8, 2019 Accepted: April 23, 2019 
 

INTRODUCTION 

Trigger points are hyperirritable, localized 

areas of tightness within a band of skeletal 
muscle that can cause referred pain.1 Referred 
pain is experienced in 1 area of the body, 
although the cause of the pain originates in a 
different area of the body. Trigger points arise 
from the degradation of proper body alignment 
which is typically the result of poor posture.2-4 In 
these cases, the body necessarily recruits other 
muscles to compensate for body misalignment in 
order to maintain static positions.2-4 These 
misaligned static positions leave muscles 
contracted and the compensatory muscular 
contraction frequently leads to hypersensitivity in 
the form of trigger points. 2-4  

Individuals who spend hours a day seated at a 
desk, hunched over a computer, or curled around 
a mobile device routinely engage a forward 
head posture. A forward head posture requires 
that posterior neck muscles be engaged to 
maintain static tension in order to keep the head 
upright.2-3 This compensatory action within the 
nervous system can manifest as active trigger 
points. Trigger points are thought to be formed 
when sarcomeres, which are considered the 

https://doi.org/10.31622/2019/0002.3


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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 - June 2019 
 

building blocks of muscles, become overactive.2-5 
When this overactivity occurs and these 
myofilaments stop sliding over one another 
naturally, the sarcomere continues to stay in a 
switched-on position. This state of contraction 
leads to muscle pain, hypertonia, and stiffness, 
which is called a trigger point.3-5 Evidence is 
clear that the restriction to tissue caused by 
trigger points negatively affects the mobility of 
other parts of the body by causing extra tension 
along the connecting fascial tissue.1-4  

Fascia comprises sheets of web-like tissue 
surrounding muscles and joints, connecting 
different sections of the body to one another, 
allowing the body to function as 1 unit.5-10 As 
illustrated in Figure 1, the superficial back line is 
a fascial tract consisting of 4 pieces connecting 
large sections of the body to one another. Two 
pieces attach at the supraorbital ridge, go over 
the top of the head, down both sides of the 
spine, and attach again on the lower leg. The 
second 2 pieces travel from the distal section of 
the femur, down the posterior aspect of the 
lower leg, and attach at the metatarsal heads of 
each foot.8 These structures consist of the 
epicranial fascia, cords of the erector spinae, the 
sacrotuberous ligament, the hamstrings, the 
triceps surae, and the plantar fascia. The 
primary function of the superficial backline is to 
create the extension and hyperextension needed 
for an individual to maintain an upright posture. 
Clinical theory describing myofascial chains such 
as the suboccipital back line originates from the 
assumption that the muscles of the human body 
do not function as independent units.10 Instead, 
muscles are interconnected in identified chains 
and linked through fascial structures creating a 
system of structural continuity.10 Following this 
philosophy, trigger points that disrupt this 
function by causing pain or negatively affecting 
the mobility of 1 area of the superficial back line 
– such as the suboccipital muscles – will affect 
mobility along this facial tissue of the superficial 

backline, affecting even the distal region of the 
hamstrings.8  

 

Figure 1: Illustration of Superficial Backline 
Fascia 

Because sections of the body are connected by 
different fascial tracts, activation of a trigger 
point within a given muscle can affect the motion 
of other joints within the same fascial tract.2-4 For 
example, a trigger point in the serratus anterior 
can cause referred pain in a patient’s medial 
elbow on the ipsilateral side.11 In the case of 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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improperly stabilized forward head posture, 
tension can develop along the entire superficial 
backline as additional muscles are recruited to 
maintain an upright posture. However, trigger 
point release in the suboccipital region can 
reduce neural tension and act as a reset button 
for the nervous system, allowing patients to 
properly stabilize their head and neck.4,8 This 
decrease in neural tension allows greater 
flexibility of movement and better function of the 
superficial backline.   

Manual trigger point release is one of the many 
myofascial release methods used by clinicians to 
reduce pain and increase tissue extensibility in 
muscles with identified trigger points.11-16 The 
particular manual trigger point release technique 
of interest to this study was in the suboccipital 
region.4 Trigger point release in the suboccipital 
region restores head and neck motion by 
applying light pressure to any trigger point in 
the occipital muscles while the patient lies supine 
on a treatment table. In most cases, clinicians 
apply pressure manually using their fingertips to 
any area of tissue in the suboccipital region that 
feels tight or elicits pain.11-14 Devices such as 
lacrosse balls or dowel rods can also be used to 
release trigger points, in place of the clinician’s 
fingertips.11-14 Studies have shown that, following 
a trigger point release treatment, overall 
function of the superficial back line (measured by 
hamstring flexibility) immediately increases.2,4  

Although the trigger point release technique in 
the suboccipital region is typically administered 
by a clinician, the technique can be readily 
employed by patients themselves. However, 
research into the effectiveness of trigger point 
release in the suboccipital region has not 
clarified whether self-administered soft tissue 
techniques produce the same improvements to 
mobility as the clinician delivering the trigger 
point release. The purpose of the study was to 
assess whether the same increase in hamstring 

mobility within the superficial backline function 
that is achieved with a clinician-administered 
suboccipital-region trigger point release can also 
be obtained through a patient-administered 
method. 

PATIENTS 

The study employed a randomized descriptive 
laboratory design in which participants reported 
for a single data collection session. Following 
institutional IRB approval, participants were 
recruited from a Division I university in the Midwest 
through verbal announcements. Participants 
included a convenience sample (N = 60) of 18-24 
year-olds who were randomly assigned to either 
a control group (n = 30) or an experimental group 
(n = 30). The sample comprised 31 males (51.7%) 
and 29 females (48.3%). All participants gave 
written consent and were subject to inclusion 
criteria of having no current pain or injuries to the 
neck or back; however, all participants were 
assessed for the presence of trigger points in their 
suboccipital muscles and all of them had trigger 
points, although none were painful enough to 
preclude their participation in this study. All of the 
original 60 participants (100%) were included in 
the study.  

INTERVENTION 

On the day of the study, all participants reported 
to a classroom laboratory at the university and 
signed in on an attendance sheet. Those who 
signed in on an odd-numbered line were assigned 
to the clinician-administered (control) group, and 
those who signed in on an even-numbered line on 
the attendance sheet were assigned to the self-
administered (experimental) group. Each 
participant (both control and experimental group) 
completed 3 baseline measurements using the 
slide ruler box and the researcher recorded the 
mean score as the pre-test score. A meta-analysis 
of the criterion-related validity of the slide ruler 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 - June 2019 
 

box sit-and-reach test presents evidence that this 
is an effective method for measuring hamstring 
extensibility (mobility), and that the clinician 
should use the average of 3 tests in their reported 
score.15 Following baseline measurements, the 
researcher worked individually with each 
participant.  

Participants in the clinician-administered group 
were asked to lie supine on a treatment table 
while the researcher performed a trigger point 
release technique in the suboccipital region on the 
participant for 2 minutes. The researcher was an 
athletic trainer with 2 years of practice, who had 
completed all coursework in a post-professional 
masters athletic training program that 
emphasized manual therapies and included 
training in myofascial release including trigger 
point release therapy. To perform the trigger 
point release technique in the suboccipital region, 
the researcher held their forearms in a supine 
position at the same level as the participant. Using 
the fingers of both hands, the researcher started 
in the thoracic spine area and gently massaged 
the soft tissue while moving fingers superiorly 
through the cervical spine stopping when the base 
of the occiput was reached. Once the occiput was 
reached, the researchers moved their fingers 
inferiorly about ½ - 1 inch (over the C1/C2 area) 
then while cradling the posterior cervical area, 
palpated with the fingers for areas of tightness 
which identified trigger points. The researcher 
confirmed these were trigger points by asking the 
participant if this pressure caused pain. While on 
the trigger point(s), the researcher then applied 
gentle pressure anteriorly for approximately 30 
seconds to 1 minute per trigger point until they felt 
the tissue start to release and soften.4,8,14  

The participants in the self-administered group 
were asked to lie supine on a treatment table. The 
researcher performed a trigger point release 
technique in the suboccipital region for 5 seconds 
using the same method of application as the 

control group. This was done so that the 
participant could identify the feeling they should 
replicate during the trigger point release. During 
this time, the participant was asked to take note 
in feeling what pressure over the trigger point felt 
like and how much pressure the clinician was 
applying. Each participant was then given a 1 inch 
diameter plastic dowel rod that they placed in the 
suboccipital region of their head. They were 
instructed to reproduce the same sensation as they 
had felt by the clinician for 2 minutes. Therefore, 
the actual trigger point release was performed 
utilizing the plastic dowel rod as a self-
administered technique, and the initial hands-on 
portion done by the researcher was just 
maintained long enough to teach the participant 
how to replicate this sensation on their own.  

Immediately following completion of the clinician-
administered or self-administered trigger point 
release intervention in the suboccipital region, all 
participants were again measured on standing 
forward flexion. Participants were measured 3 
times on their standing forward flexion distance 
score using the slide ruler box. The mean score 
was recorded as the post-test superficial backline 
function score. All participants were then thanked 
for their participation and dismissed. 

OUTCOMES MEASURES 

The researchers in this study utilized toe touch 
distance as the single measurement of hamstring 
mobility. Standing forward flexion distance was 
measured using a slide ruler box and served as 
the baseline (pre-test) measurement of the 
participants’ superficial backline function. To 
obtain this measurement participants were 
instructed to stand with their feet together and 
knees locked on top of a platform next to the slide 
ruler box. They were then instructed to bend 
forward from the hips, while keeping the distal 
extremity locked, and attempt to touch their toes 
and hold for a single breath cycle (eliminating 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 - June 2019 
 

bouncing movements) before returning to the start 
position. The participants’ extended fingers 
moved the slide on the scale to a final position and 
the measurement was recorded in centimeters. The 
participants repeated this task 3 times; both pre-
test and post-test following the intervention and 
the mean score was recorded as the final 
measurement of hamstring mobility. All 
measurements and subsequent intervention were 
conducted by a single trained evaluator to control 
for variability and bias. Kippers18 found toe touch 
to be a valid and reliable test to measure active 
trunk and hamstring range of motion across all 
body types. Further, another study concluded that 
toe touch distance could be used as the sole 
measurement of hamstring mobility to accurately 
assess for an increase of mobility following 
clinician-administered trigger point release in the 
suboccipital region.4  
 
RESULTS 
 
Before conducting hypothesis testing these data 
were examined for potential violations of the 
assumptions of the repeated-measures ANOVA. 
Data were assessed for outliers using boxplots; 
no outliers were found. A Shapiro-Wilk test 
showed that both the pretest (p = .46) and the 
posttest data (p = .10) were normally 
distributed. While conducting the mixed 
repeated measures ANOVA (pretest to posttest, 
control vs. experimental), Box’s Test of Equality 
of Covariance Matrices was non-significant (M = 
5.72, p = .138), indicating that the covariance 
matrices were equivalent, so all ANOVA 
interpretations were done using multivariate 
tests.  

There was a statistically significant main effect 
for the intervention (F(1,58) = 18.24, p < .001, 
eta = .239) indicating that both the clinician-
administered and the self-administered groups 
improved from pretest (M = 4.74, SD = 7.96) to 

posttest (M = 6.79, SD = 7.58). But there was 
not a statistically significant interaction of time 
and group (F(1,58) = 18.24, p = .360, eta = 
.014) indicating that neither group outperformed 
the other. These findings show that the 
intervention was successful at increasing mobility 
an average of 2 centimeters regardless of 
whether the intervention was conducted by a 
clinician or by the patient. The magnitude of the 
mobility increase is displayed in Figure 2.  

DISCUSSION 

This study supports existing research findings that 
hamstring mobility, as measured by toe touch 
distance, significantly increases following trigger 
point release in the suboccipital region.2,4 In a 
randomized clinical trial, Aparicio2 found the 
suboccipital trigger point release technique 
significantly improved hamstring function as 
measured by toe touch distance, straight leg 
raise, and popliteal angle. Further, studies 
showed that when a release was performed on a 
trigger point which was causing an area of 
restriction that was within a fascial tissue 
structure, such as the superficial back line, it had 

Figure 2: Increases in Superficial Backline Function 
Distances by Group (in) 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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a positive effect on other areas that connected to 
this line.16-18  

This study demonstrates that a properly taught, 
self-administered suboccipital trigger point 
release is equally effective as a clinician-
administered treatment. The finding that both 
clinician-administered and self-administered 
suboccipital trigger point release delivers 
immediate improvements in mobility has 
implications for treating back pain. In a similar 
study examining the effectiveness of reducing 
trigger point sensitivity in the neck and upper 
back, the investigators measured pain intensity 
following a prescribed home-based program of 
ischemic pressure and stretching.19 The authors 
concluded that when monitored periodically by a 
clinician, home-based programs using self-
administered therapy techniques are an effective 
method for reducing trigger point pain.19 
While this study has shown that this manual 
technique can improve the overall function of the 
superficial back line, it should be noted that the 
reason why is still unclear. One possible reason for 
this outcome could be that the released tension 
relaxes the tissue in a way that allows more 
movement throughout the entire fascial line. The 
chain itself has too much tension, and this tension 
should be relieved to gain more motion. 
The single-iteration methodology employed in this 
study demonstrates that immediate release is 
possible. However, this study does not show how 
long that relief will last, nor does it address the 
effects of multiple self-applications of the 
technique. Additional research should examine 
how long relief continues after a single 
application of the technique and should introduce 
a longitudinal component to study whether 
patients who trained to perform suboccipital 
trigger point release on themselves can use 
repeated applications of the technique to reduce 
back pain or other symptomology. Furthermore, 
this research opens the possibility of exploring 
other trigger point release techniques known to be 

effective when delivered by clinicians and 
exploring their amenability to self-administration 
by patients.  
 
CLINICAL APPLICATION 
 
This study demonstrates that a properly taught 
self-administered suboccipital trigger point 
release was equally effective as a clinician-
administered treatment. The current study adds to 
the existing findings in three ways. First, this study 
demonstrates that when trigger points in the 
suboccipital area are released, an increase in 
mobility observed immediately. Second, this study 
demonstrates that immediate increases in mobility 
can be attained when the trigger point release 
technique in the suboccipital region is employed 
by a properly trained patient in the absence of a 
clinician. Third, the amount of training needed to 
teach a patient to effectively perform the trigger 
point release technique in the suboccipital region 
requires less than a minute.  

In a clinical environment dominated by managed 
care clinicians in a therapy setting are limited in 
treatment times and number of clinic visits with 
their patients; therefore, it is of great benefit 
when a clinician can identify manual therapy 
techniques, such as the suboccipital trigger point 
release, that can be taught to their patients and 
successfully administered outside of the clinical 
setting. This allows the clinician time within the 
scheduled therapy session to focus their 
intervention on other clinical goals.  

The significant finding in this study is that, 
following a suboccipital trigger point release, toe 
touch distance increased for all participants. These 
findings indicate that if a clinician properly 
instructs a patient on how to perform a 
suboccipital trigger point release, the intervention 
is just as effective as when the clinician performs 
the suboccipital trigger point release. Future 
research should explore the long-term effects of 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 - June 2019 
 

suboccipital release on toe touch over time, as well 
as the reason behind these effects, as the current 
study only measured the immediate effects and 
not the direct cause of them. 

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