Download Diploma of Remedial Massage

M CPT
MelbourneCollegeofProfessionalTherapists
"Excellence in Education"
NECK & THORACIC SPINE
REMEDIAL TECHNIQUES 1
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
Version 1 – June 2006
1
M CPT
MelbourneCollegeofProfessionalTherapists
"Excellence in Education"
Suite 5 – Ground Floor
(Right path way entrance, next door to Lifestyle Gym)
Cnr: Ferntree Gully Rd & Jells Rd
Wheelers Hill (Vic) 3150
Postal: P.O Box 3171 Wheelers Hill (Vic) 3150
Facsimile: 9560 4523
 9562-2280
Some images from:
Spence, A P: Basic Human Anatomy, The Benjamin/Cummings Publishing Co, Redwood City 1990
Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual Volumes 1 and 2. Williams
and Wilkins, Baltimore 1992
These notes are © SDCA PTY LTD trading as Melbourne College of Professional Therapists - MCPT. All rights
reserved. No part of these notes may be reproduced, stored in a retrieval system, or transmitted, in any form or
by any means, electronic, mechanical, photocopying, recording or otherwise without the express written
permission of SDCA PTY LTD.
These notes are intended as a guide only, and do not take the place of attendance in scheduled classes.
Revised June 2006
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Contents
Reference Texts
4
Suggested general assessment procedure
5
Muscle Strain/Tear
6
Granter/King pain scale
6
Principles of Treatment
6
Soft tissue treatment for head and neck
Cervical lateral flexors
8
Cervical extensors
9
Suboccipitals
10
Cervical rotators
11
Additional techniques
14
Soft tissue treatment for thoracic spine and shoulder girdle
Thoracic paraspinals
15
16
Management of pain of soft tissue origin in thoracic region
Acute onset
18
Chronic pain and softness
18
Additional techniques
19
Management of postural factors
Excessive kyphosis/lordosis
20
Insufficient kyphosis/lordosis
20
Management of scapulo-thoracic dysfunction
21
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Reference texts.
Human Anatomy and
Physiology (5th Edition) Marieb
The Anatomy Colouring
Book (3rd edition) –
Kapit and Elson
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
Muscle chart
Version 1 – June 2006
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Suggested General Assessment by Remedial Massage Therapists
(Similar to First Aid Diagnostic Approach; T.O.T.A.P.S.)
T = TALK - find out history of injury, (what, when, where, how etc)
What are the symptoms described by the patient?
O = OBSERVE - for signs, abnormalities, deformities, swelling, bruising etc,
T = TOUCH - Feel for tenderness/pain, fluid, crepitus, swelling, heat etc.
Know landmarks and check for asymmetry.
Compare injured with uninjured side.
A = ACTIVE MOVEMENT - Check ROM
P = PASSIVE MOVEMENT - Check ROM before onset of pain.
S = SKILLS TEST - If the patient "passes" the above inhibiting "tests" check they are pain
free with full movement when performing their specific sporting skills
before advising a return to their sport. Note, however, that training
may continue with non injured parts during the recovery phases.
Check STABILITY of joints for ligamentous damage.
SPECIAL TESTS
REFERRED PAIN
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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MUSCLE STRAIN / TEAR
Grade 1
Small number of muscle fibres
Localised pain
No loss of strength
Grade 2
Tear of significant number of muscle fibres with associated
pain and swelling
Pain reproduced on muscle contraction
Strength is reduced and movement limited by pain
Grade 3
Complete tear of muscle
(common at muscular-tendinous junction)
GRANTER - KING SCALE FOR DEPTH OF APPLICATION
PAIN - TISSUE RESISTANCE
Depth
Pain
Resistance
Grade I
Description
of Depth
No pain perceived (Indicated in
post-acute treatment of
inflammatory conditions)
Grade II
Grade III
Grade IV
Onset of pain
Moderate level of pain
Severe level of pain
A
B
C
No tissue resistance
Onset of tissue resistance
Moderate level of tissue resistance
Principles of Treatment
Techniques
Relaxation
Reduce unnecessary muscular
contractile activity
Passive joint movement
Muscle group mobilisation
Digital ischaemic pressure (DIP)
Increase tissue fluid exchange
Aid the removal of inter-muscular
metabolites & inflammation by
improving circulation (blood & lymph)
to and from the region
Longitudinal gliding (deep effleurage)
Reduce Pain
De-activate trigger points
Desensitise symptomatic tissue
Increase tissue length
Reduce local inter-muscular regions of
hypertonicity
Reduce interfibrillary adhesions and
connective tissue thickening
DIP
Ice, stretch, Myofascial release (MFR)
DIP
Transverse gliding (T/G), friction
MFR
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Getting the structure right - Skeletal alignment
Formation and treatment of an active trigger point
Formation and treatment of Myofascial Dysfunction
Development & Treatment of Inter-muscular thickening
Posture & pain
Reducing neuromuscular holding patterns - mobilisation
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Soft Tissue Treatment for Head & Neck
Cervical Lateral Flexors
Trapezius
for upper fibres use MFR to increase ROM in lateral flexion
Seated.
Broad MFR with forearm or fist superior to inferior
whilst moving from shortened to lengthened position.
Seated.
Head in lateral flexion at comfortable end range. Specific
MFR. Check for specific areas of restriction. Block distal
part of affected tissue with thumb and move towards
cranium.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
Version 1 – June 2006
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Scalenes Medius & Clavicular Head of SCM
Passively laterally flex neck noting restrictions to movement.
To treat right SCM.
Patient supine. Practitioner's right hand supports patient's head in
20 degrees of right lateral flexion. Thumb of right hand blocks
SCM fibres superior to clavicle. Left hand passively moves neck
into left lateral flexion.
Treat Scalenes Medius in same way
Cervical Extensors
Seated
SMT with active cervical flexion moving superiorly from T1.
Repeat with passive cervical flexion and rotation away.
Seated
Engage upper cervical fascia below cranium with patient in
extension. Maintain contact while patient actively flexes upper
cervical region (nodding forward)
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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If pain occurs in upper thoracic spine on cervical flexion or resisted extension:
Prone
Palpate exact site of pain. DIP Grade I-II until pain ceases.
Repeat with increased flexion and rotation away. Reassess pain
free ROM. Address restriction to flexion with:


SMT
TG/LG prone in flexion.
Sub-Occipital group
Assess upper cervical quadrant (flexion, lateral flexion and rotation away)
Assess rotations (A-A joint)
Treatment.
Supine. To treat right side support extended head in left hand. Passively rotate
to left while engaging tissue in a lateral to medial movement with pad of 3rd digit.
Stretch (R. side) - Supine. Take head into flexion and lateral flexion to left to R1.
Patient upper cervical extend and right laterally flex ("return to centre") against
your resistance at no more than 20% maximum contraction. Gently take head to
new R1.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Cervical Rotators
Levator Scapulae Syndrome
Prone
Arm adducted, scapula retracted. To address distal MTJ (insertion
onto scapula). To treat right side, place right thumb on superior
angle of scapula. Search attachment and MTJ for areas of
hypersensitivity and tissue thickening.
Treatment options:
DIP Grade I-II until pain ceases
T/G Grade I-II with passive scapula movements (could be done on side)
Supine
To address proximal MTJ and mid-belly. To treat right side with
SMT, support head in left hand. Have right shoulder slightly
elevated. Engage Levator Scapulae posterior to S/C/M with pads
of digits of right hand. Maintain an anterior to posterior pressure
with passive rotation to the left.
Repeat with right shoulder depressed (right hand under right
glutes)
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Pain on rotation (Cervical Quadrant Test - combination of extension, rotation and lateral
flexion). If positive (reproduction of patient's pain) probably indicates facet joint
pathology which could either have joint or soft tissue origin.
To address extrinsic (biomechanical) causes, use MFR especially increasing lateral flexion
away from affected side.
To address intrinsic soft tissue causes use DIP Grade 1B - IIB (acute pain) or
Grade IIB - IIIC (chronic pain / stiffness)
Prone
Neck in 10° flexion to expose joints. Palpate in 3
dimensions attempting to reproduce pain. Apply DIP
Grade 1-11 to exact site (to palpable soft tissue
abnormalities). Reassess ROM; if improvement continues
treatment adding rotation toward painful side.
Supine
Progress to L/G & T/G to lamina gutter while
mobilising head and neck in rotation.
SCM (sternal head) Stretch by extending neck & rotating towards affected
side.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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NB. It is important to address tight anterior structures in protracted posture syndromes.
Supine
MFR. To treat right side, support head in 45° left lateral rotation in left
hand. Engage tissue just distal to mastoid process with right thumb.
Apply caudal pressure longitudinally down S/C/M while passively
rotating head to right. Engage tissue just superior to sternal attachment.
Apply cranial pressure while passively rotating to right
Supine.
T/G. To treat right side support head on pillow in 45° left lateral
rotation and 45° flexion. Both hands are free to scan tissue of both
sternal and clavicular heads with T/G. Progress to using opposing
pressure with L and R hands.
Supine.
Stretch. Starting position for right fibres is 20° extension and right
rotation. Block "return to centre". Move to new R1. Reassess ROM.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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ADDITIONAL TECHNIQUES WHICH COULD BE EMPLOYED
To address cervical joint pathologies resulting in ROM and possible pain use Muscle
Energy Technique. (Onsen Technique)
0-A joint (side bending and rotation to opposite sides)
A-A joint (C 1 - C2) (50-65% of all cervical rotation occurs here)
C3-C7 lateral flexion (check asymmetry)
Bowen Technique for:
Neck
Headaches
Cervical & Upper Thoracic flexion (MFR - sustained)
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Treatment Techniques for Thoracic Spine and Shoulder Girdle
Getting the Structure Right.
Check height of L&R ilium (standing & seated). If a height difference exists both standing and
seated it then implicates structures above the ilia (Quadratus Lumborum, External Obliques).
Because most asymmetries in the thoracic region are compensatory curves it makes sense to
correct the lower structures first.
Correct tight Q.L. by one or more of the following PNF approaches.

side (high side down)

side (high side up, pillow under patient's down side)

prone
Check for lateral flexion asymmetry. If still evidence of lateral flexion (side-bending) use Muscle
Energy Technique to help "straighten spine".
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Soft Tissue Treatment for Thoracic Paraspinals
Check ROM (lateral flexion / rotation) looking for quality of movement.
Prone.
To treat right side stand on left side. Engage right thoraco-lumbar
fascia using forearm, moving laterally at T12, T10 and T8.
Repeat, laterally flexing away from tight side.
Prone.
To treat the right side, stand on the right side. Engage right
thoraco-lumbar fascia using the forearm at the level of T12.
Move superiorly parallel with the spine. Repeat either with pillow
under patient's abdomen to induce thoracic flexion or in a side
lying position with patient in a semi-curled position.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Seated.
To treat right side stand behind patient. Engage right thoracolumbar fascia using left elbow, right hand supporting left anterior
shoulder. Apply sustained MFT to target site while laterally
flexing and/or rotating away from target tissue. Reassess ROM.
Assess seated rotation (L & R). Note ROM and restrictions.
Prone
To treat right side, stand on left side. Use thumbs to produce
broad T/G through extensor group to treat dysfunctional tissue.
Prone
To treat left side, stand on left side. Support left forearm with
right hand. L/G through extensors, right hand guiding
movement.
Prone
As above but T/G through extensors using your forearm on a
diagonal orientation along the line of the intercostals to target
costal attachments of ilio-costalis. (Don't flick over the extensors,
glide through them)
Stretching Technique A (side lying) restricted side down. Support weight of
leg by holding knee with hand. Rotate shoulder girdle away and gently lower
knee to R1. Patient contracts muscles by pushing thigh into your lower hand and
shoulder into your top hand (maximum 20% effort). Gently induce further
stretch after muscle relaxation. Repeat this PNF another 3 times or until no
further improvement in ROM.
Stretching Technique B (seated). Onsen approach incorporating both lateral
flexion and rotation where necessary.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Management of pain of soft tissue origin in thoracic region
Acute onset
Perform functional movement testing to determine severity, location and cause of pain.
(Extension, flexion, rotation (L & R), combined movements). Palpate exact site of pain in a 3
dimensional way to locate affected tissue.
Prone
DIP (Grade I-II) until pain ceases.
Progress by putting tissue under greater stretch.
Prone
MFR (thumbs) Apply pressure in opposing directions.
Very effective in Longissimus spasm, a common source of
thoracic and lumbar pain.
Side lying
L/G with ice.
Progress by putting tissue under greater stretch by increasing
rotation away from affected side.
Chronic pain & stiffness - lamina gutter (eg. Multifidus)
DIP
- right angles to spinous processes (semispinalis & multifidus)
- parallel to spine (rotators)
MFR - Progress from above by simultaneously rotating spine while releasing soft
tissue applying transverse or longitudinal friction.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
Version 1 – June 2006
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ADDITIONAL TECHNIQUES WHICH COULD BE EMPLOYED
To improve breathing (reduce muscular inhibitions to inspiration) Myofascial Release to:
Intercostals & diaphragm (prone & supine)
Bowen Technique for:
Shoulders
Chest.
Stretches for
Trapezius - upper, middle
Neck extensors
Sternocleidomastoid
Scalenes
Levator Scapulae
Rhomboids
Pectoralis Minor
Pectoralis Major
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
Version 1 – June 2006
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Management of Postural factors in the development of pain or stiffness in
the thoracic spine
Excessive kyphosis / lordosis postural type; (see below)
Characteristics include;
- Forward head, hyper extended neck, inwardly curved chest, increased thoracic curve.
-
To reduce cervical lordosis.
Release anterior structures (S/C/M * Scalenes)
Release upper cervical extensors
Chin tuck exercises (retraction)
-
To reduce thoracic kyphosis
Release anterior structures (Pec. Minor and Pec. Major)
Thoracic extension exercises
-
To reduce lumbar lordosis
Release anterior structures (Iliopsoas, Rectus Femoris, and TFL)
Strengthen abdominals to improve control of anterior pelvic tilt.
Insufficient kyphosis / lordosis postural type (flat back): (see below)
Characteristics include;
Posteriorly tilted pelvis, abdominals variable (sometimes weak,
sometimes tight, wasted buttocks, tight, short and usually weak
hamstrings, knees slightly flexed, tight calves, weak hip flexors.
Corrective exercises include thoracic and lumbar flexion, extension
& rotation exercises
Release taut myofascial restriction especially in flexed and
rotated positions
Using a lumbar roll while seated to increase lumbar lordosis
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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Management of Scapulo Thoracic Dysfunction
In the athletic population the scapular must; have full unimpeded ROM especially in upward rotation.
provide a stable platform which permits
controlled movements at the gleno-humeral joint.
In the non athletic population a mobile yet stable scapula is vital for adequate function of the
gleno-humeral joint.
Aim of treatment is to release tight tissues THEN strengthen weak tissues.
Key Elements.
In static assessment
Is scapular protracted? (Kyphosis &/or lordosis excessive.) If so must

 release Pectorals (Minor & Major)
 release soft tissue around cervico-thoracic junction and superior angle of scapular. (Levator Scapulae)
In functional assessment
 Is any soft tissue structure resisting full upward rotation? (Pec. Minor, Lower Traps)
It should be a goal in injury/prevention treatment, and in the treatment of
cervical, thoracic, shoulder girdle and shoulder joint injury to aim to
achieve an unrestricted / mobile scapular at the very least in the resting
position.
©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307)
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