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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) Version 1 – June 2006 2 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) Version 1 – June 2006 3 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 4 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) Version 1 – June 2006 5 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) Version 1 – June 2006 6 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 ©2006 MCPT Remedial Techniques 1 (Neck & Thoracic Spine) – Diploma (HLT50307) Version 1 – June 2006 7 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 8 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) Version 1 – June 2006 9 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) Version 1 – June 2006 10 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) Version 1 – June 2006 11 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) Version 1 – June 2006 12 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) Version 1 – June 2006 13 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) Version 1 – June 2006 14 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) Version 1 – June 2006 15 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) Version 1 – June 2006 16 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) Version 1 – June 2006 17 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 18 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 19 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) Version 1 – June 2006 20 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) Version 1 – June 2006 21