Transcript Muscle Imbalance Evaluation and Treatment of the Neck
Muscle Imbalance Evaluation and Treatment of the Neck, Upper Back and Shoulder Areas
Jose S. Figueroa, D. O.
Physical Medicine and Rehabilitation, NMM/OMM IOMA, Spring 2010 1
Objectives
• • Review some concepts of muscle imbalances and the evaluation and treatment of key muscles as contributors to chronic musculoskeletal dysfunction in the neck, upper back and shoulder areas.
Be introduced to the evaluation and treatment of muscle imbalances of the upper quarter: – Evaluate Proprioception – – Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles – – Diagnose weak or pseudo-paretic muscles Teach a home exercise prescription to address the tight/short and weak or pseudoparetic muscles – Follow-up for re-evaluations and exercise adjustments – Teach patients how to self-treat certain common somatic dysfunctions 2
Most of the information in this lecture is derived from the works of
• • Phillip Greenman, D.O.(he is the one in the pictures) Dr. Vladimir Janda, a specialist in rehabilitation medicine at the University of Charles, Prague, Czechoslovakia, deceased in 2006 3
Road Map
• • • • • • • Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions 4
Table 1. Common upper extremity muscles and their reaction to injury
5
Body Region
Neck and Trunk
Function: Primarily Postural/Tonic (Short and Tight) Function: Primarily Phasic (Weak)
Erector Spinae Group -Lumbar Region -Cervical Region Quadratus Lumborum Scalenes Sternocleidomastoid Deep Cervical Spine Flexors Erector Spinae muscles -Mid-thoracic Rectus Abdominis External Obliques Internal Obliques Transversus Abdominis 6
Body Region Function: Primarily Postural/Tonic (Short and Tight) Function: Primarily Phasic (Weak)
Shoulder Girdle Levator Scapulae Upper Trapezius Pectoralis Major Latissimus Dorsi Flexors of UE Middle Trapezius Lower Trapezius Rhomboids Supraspinatus Infraspinatus Serratus Anterior Deltoid Extensors of UE 7
Stand Up, Please
8
Please ½ of You Remain Still and look for: • • • Forward shoulders (“rounded shoulders”) Head placed in a forward position Arms internally rotated 9
• • • • •
Upper Crossed Syndrome
Forward head posture Straightening of the cervical lordotic curve Extension of the upper cervical spine Increased kyphosis of the cervico-thoracic junction Internal rotation of the shoulder girdles.
Road Map
• • • • • • Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions 11
Diagnosis of Muscle Imbalances Three Specific Types of Clinical Testing • • • – Evaluate Proprioception Through balance testing Evaluate the sequence of muscle contraction (muscle “firing” patterns) during specific movements to evaluate which muscles contract out of sequence, acting as if they were weak – Evaluate asymmetry in muscle lengths Muscles are isolated as much as possible and then tested for symmetry in their lengths and compared with estimations of normal 12
Treatment of Muscle Imbalances
• • • • General Principles: Goal: restoration of proper muscle length, strength and control of muscle function Start with OMM May need a home exercise prescription (HEP) HEP should address muscle control (i.e., proprioception re-training) • When treating muscle imbalances: Quality of movement is
more important than quantity
13
General Treatment Sequence
1. Establishing a process of re-evaluations to monitor progress 2. Establish a level of patient commitment to follow through 3. Re-training proprioception – home exercises (single leg stance) – PT (more advanced intervention) 14
General Treatment Sequence
4. Stretching the tight muscles – manual stretches in the office (Dr. or PT) – home stretches (self-stretches) 5. Re-training or strengthening late contracting (pseudoparetic) or weak muscles – home “strengthening” exercises 6. Teaching the patient how to self-treat specific recurring somatic dysfunctions on their own 15
HANDS-ON SESSION DIAGNOSIS AND TREATMENTS OF COMMON MUSCLE IMBALANCES OF THE NECK, UPPER BACK AND SHOULDER
16
Road Map
• • • • • Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions 17
Evaluate and Treat Impaired Proprioception • Goal: the capacity to symmetrically stand on one leg with arms crossed and eyes closed for 30 seconds (eyes open and eyes closed) – Do the best possible if unable to reach goal 18
Look to your feet, Please
• • • Remove your shoes See if you can shorten one of your feet now Let’s test each other’s SINGLE LEG standing balance 19
Road Map
• • • • Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions 20
Evaluating Muscle Firing Patterns of Upper Quarter Muscles
21
Upper Quarter Firing Pattern Tests
• • • • Cervical Flexion Test Supine Shoulder Abduction Test Scapular Stabilization Test Scapular Depression Test
Cervical Flexion Test Supine
• • • Start position patient is supine Cervical Test Normal: the neck curls as it flexes Cervical Test Abnormal: the neck cannot curl and the head is thrust forward due to weak deep neck flexors and overactivity of the sternocleidomastoids (SCMs).
Shoulder Abduction
• • The muscle firing pattern (sequence of contractions) is evaluated.
Normal sequence for shoulder abduction while seated is: 1. Supraspinatus 2. Deltoid 3. Infraspinatus 4. Middle and lower trapezius 5. Contralateral quadratus lumborum
Shoulder Abduction
• Most common substitution pattern is: – Shoulder elevation by the levator scapulae and upper trapezius (can lead to and perpetuate impingement) – Early firing of the quadratus lumborum even on the ipsilateral side
Scapular Stabilization Test
1
• • Position one: patient on hands and knees on the table Position two: patient lifts one hand. The scapula on the side with the hand on the floor is evaluated for winging.
2
Scapular Stabilization Test
• Excessive winging of the medial border of the scapula occurs because of weakness and lack of stabilization by the lower trapezius, serratus anterior, and rhomboid muscles
Road Map
• • Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop : Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions 28
Evaluating and Treating Muscle Length Asymmetry of Upper Quarter Muscles
29
Evaluate Asymmetry of Muscle Lengths • • • Isolate to one muscle as best possible Find the tight muscles and treat them with manual stretching at the clinic.
– “Supercharges” the patient’s home stretching routine – Sustained Stretch: 20-30 secs, 2 or 3 reps.
– Muscle Energy: Post-isometric Relaxation and Stretch Then give them home stretches 30
Upper Trapezius/SCM: Length Test and Manual Stretching
Upper Trapezius/SCM: Self Stretch
Levator Scapula: Length Test and Manual Stretching
Levator Scapula: Self Stretch
Scalenes: Length Test and Manual Stretching
Scalenes: Self Stretch
Pectorales Major: Length Test and Manual Stretching
Pectorales Major Test/Manual Stretch Supine
Pectorales Minor: Observe for Tightness • • • Patient supine Operator observes for the relative anterior posterior position of the shoulders. Tightness of the pectoralis minor is shown as one shoulder elevates off the table.
Pectorales Major: Self Stretching
Latissimus Dorsi: Length Test and Manual Stretching Manual Stretch 41
Latissimus Dorsi: Self Stretching
42
Re-Evaluate the Sequence of Muscle
Contraction
• • • In order to assess for weak muscles or pseudoparetic muscles Prescribe strengthening (or re-training) exercises at home if needed Again: Quality of motion is most important
Road Map
• Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop : Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions 44
Strengthening / Retraining of Upper Quarter Muscles
45
Cervical Flexors
Lower Trapezius
Serratus Anterior
Rhomboid and Lower Trapezius
Rhomboid Strengthening Lower Trapezius Strengthening
HEAD AND SHOULDER POSTURE EXERCISE
Sit Up Straight, Please
• • • • • • Stand with feet four inches apart Arms at side, thumbs point forward Tighten buttocks Rotate thumbs, arms and shoulders out and back while inhaling, squeezing the shoulder blades together in the back Maintain this position while pulling the shoulders down and exhaling Hold while correcting the head posture: – Bring head back to bring ears in line with shoulders – Do not point nose up or down, do not open mouth 51
Re-training Exercises Usually Target
• • • • • • Deep Cervical Flexors Lower Trapezius Serratus Anterior Rhomboids External Rotators of the shoulder Core strengthening, especially in patients who are active in sports and / or manual labor
Road Map
Common UE muscles and their reaction to injury Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop : Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Summary and Conclusions 53
• • • • • • •
Summary: Designing and Sequencing the HEP
OMM Treatment first, if there are somatic dysfunctions present Get a Commitment to Exercise from the patient Evaluate balance and Tx if needed Evaluate the tight muscles, do manual stretches and prescribe stretches Evaluate for weak muscles if the stretches do not take care of the problem.
Prescribe re-training/strengthening exercises if needed Once muscles start to act more balanced, start a general bilateral aerobic & strength training program in line with the patient’s goals 54
If Not Progressing
• • Assess for Non Compliance If Compliant…Perpetuating Factors like: – Undiagnosed Pathology (ex: Myofascial pain, ligament laxity, etc.) – Ergonomic derangements at home or work – Poor sleep – Poor sports training (usually over-training) – Aerobic or Anaerobic Deconditioning, thus requiring cardio or resistance training – Other: vitamin deficiency, etc.
55
Conclusion
• • • Exercise: long history in the healing arts Numerous exercise equipment systems have been developed and are currently in the market But many health professionals have limited knowledge and understanding of how to prescribe exercises that are appropriate for their patients 56
Conclusion
• • • Generic programs can be helpful Each patient is an individual and may require an exercise program specific for his/her problem If you practice the preceding principles and procedures you will have the added skill to identify specific problems and prescribe appropriate exercises to restore proper muscle symmetry and control, and ultimately improve the function of your patients.
57
Questions
??????????????
58