Clinical Application of Neuromuscular Techniques The Upper Body Volume 1

284 CLI N ICAL APPLICATI O N OF N EU RO M U S C U LAR TEC H N I Q U E S : TH E U PPER BODY Splenius capitis Splenius cervicis Lower TrP F i gu re 1 1 .41 The combined pa tterns of splen i i trigger poi nt target zones of referra l . D rawn after Simons et a l (1 999). Ind ications for treatment Headache ( to vertex of head) and neck pain as well as blurred vision can result from trigger point activity in sple­ • 'Stiff neck' nius capitis (Simons et al 1999). Headache with explosive • Pain p roduced by rotation pressure 'in the eye' is a frequent complaint, therefore glau­ • Pain in head, especially the eyes coma and other eye pathologies should be ruled out in • Blurred vision addition to addressing trigger points within these and other cervical and cranial muscles. Cold wind or drafts across the Special notes neck tend to activate trigger points in these two muscles. Cervical articulation d ysfunctions are often associated with The splenii are often distinguished in the second layer of the splenii, particularly C1 and C2. posterior cervical muscles as a diagonal band lying in the lam­ ina groove which runs from the lower mid-line of the cervical The splenii are implicated in spasmodic torticollis (TS), region to the upper cervical transverse processes and to the along with the contralateral SCM (Hasegawa et al 2001). mastoid process just under the posterior aspect of the stern­ Deuschl et al (1992) reported: ocleidomastoid attachment. They (capitis more easily than cervicis) can often be palpated during the gliding tech­ Rotating TS (72% of the patients) was due to dystonic niques described above, as the thumb glides caudally on the activity of the splenius muscle ipsilateral to and/or the ster­ second (sometimes third) row of the lamina since the two nocleidomastoid muscle contralateral to the side of chin muscles lie directly under the skin in this area and are not deviation. One-third ofthese patients had also dystonic acti­ obscured by other muscle fibers. vation of the contralateral splenius muscle and, rarely, the contralateral trapezius muscle. Ten patients had laterocollis The cranial attachment of splenius capitis crosses the due to dystonic activation of all recorded muscles on one suture between the temporal and the occipital bones just side of the neck. Nine patients had retrocollis due to activity posterior to the mastoid. As Upledger & Vredevoogd ( 1983) of both splenius muscles and rarely additional activity in point out, contraction of splenius capitis causes the squa­ both trapezius muscles. mous portion of the temporal bone to rotate posteriorly while producing internal rotation of the petrous portion. f NMT TECHNIQUES FOR SPLENII TENDONS Crowding of the occipitomastoid suture, they state, can contribute to a wide range of symptoms including head The mid-bellies of the splenii are addressed in the gliding tech­ pain, dyslexia, gastrointestinal symptoms and personality niques previously discussed. Their cranial attachments are problems. The cranial attachments are addressed with the treated with the suboccipital assessment. However, the spinal suboccipital region on pp. 292-297. attachments may be assessed here with a special procedure

11 The cervical region 285 A • As the left hand rotates the head, the right hand should rotate with the neck as if glued to the back of the neck. B • This rotating movement will 'open the pocket' by pas­ c sively shortening the upper trapezius fibers while angling the thumb toward the nipple of the contralateral Figure 1 1 .42 A-C: The thumb slides into a 'pocket' formed anterior breast and against the lateral surface of the spinous to the trapezius while remaining posterior to the transverse process processes. to directly palpate a portion of lower splenii. • The thumb pad should press toward the ceiling as the right thumb slides into the 'pocket' formed anterior to the trapezius. • If the area does not allow penetration, or if pressure of the thumb produces more than moderate discomfort, light sustained pressure is applied to the 'mouth' of the pocket until the tissues relax enough to slide in further (Fig. ll .42B,C). • Pressure is directed toward the ceiling, as the thumb is positioned j ust lateral to the spinous processes. • Appropriate pressure is applied continuously for 8-12 seconds, which will often provoke a referral pattern if active trigger points are encountered. Pressure can be maintained for up to 20 seconds. If the tissue is involved, it will likely be intolerant to friction. • The thumb will be pressing into the tendons of the sple­ nius capitis and splenius cervicis superficially. • The thumb should then sink more deeply into the pocket (caudally) as the pressure release technique is repeated. • When taut fibers stop the thumb's caudal movements, mild to moderate static pressure may produce more relaxation of the surrounding tissue and may allow the thumb to slide further down the spinal column. This step may also address a small portion of the rhomboid minor, serratus posterior superior, semispinalis capitis, cervicis and thoracis, spinalis cervicis, multifidi and rotatores, since these muscles attach within the lamina of this area. • If tender, repeat the entire process 3-4 times during a sin­ gle session. • This step will help restore cervical rotation as well as reduce tilting pull on the transverse processes of Cl-3. • Surrounding tissue may also be treated by adjusting the thumb position and its direction of pressure. that allows the thumb to be placed deep to the trapezius and SPI NALIS CAPITIS AND CERVICIS directly onto a portion of the spinal attachments. Dr Raymond Nimmo referred to this procedure as the 'corkscrew tech­ Attachments: Spinous processes of C7-T2 and lower portion nique' (Chaitow 1996a, Nimmo 2001). of ligamentum nuchae to the (cervicis) spinous process of C2-4 or (capitis) b lending with semispinalis capitis • No pressure should be applied until the hand is correctly positioned and the head is rotated. Innervation: Dorsal rami of spinal nerves (C2-TlO) Muscle type: Postural (type I), shortens when stressed • The fingers of the right hand cup across the back of the Function: Flexes the spine laterally to the sam. e side and base of the neck, like a shirt collar (C6-7 area). (bilaterally) extends the spine • The right thumb is placed anterior to the trapezius and Synergists: For lateral flexion: longissimus, semispinalis cer­ posterior to the lower cervical transverse processes, pointing caudally. vicis, splenius cervicis, iliocostalis cervicis For extension: posterior cervical group • The left hand is used to rotate the head ipsilaterally, i.e. Antagonists: For lateral flexion: contralateral fibers of the toward the side being treated (Fig. 1l .42A). same muscle and contralateral fibers of its synergists For extension: prevertebral group

286 C L I N ICAL APPLICATI O N OF N E U R O M USCU LAR TEC H N I Q U E S : THE U PPER BODY Indications for treatment LO NG ISSI M U S CAPITIS • Inability to fully flex the neck Attachments: Transverse processes of Tl-5 and the articular • Loss of sidebending range of motion processes of C4-7 and to the posterior mastoid process Specia l notes Innervation: Dorsal rami of spinal nerves Muscle type: Postural (type I), shortens when stressed The spinalis muscles represent the most centrally located Function: Rotates the head ipsilaterally, laterally flexes the fibers of the three muscular columns commonly referred to as the erector spinae group. Longissimus components lie head to the same side and ex tends the head when bila ter­ intermediately while iliocostalis has the most la teral influ­ ally active ence on the positioning of the torso and spinal column. Synergists: Semispinalis capitis, spinalis capitis, longis­ simus cervicis The spinalis cervicis muscle is often absent and the Antagonists: Fibers of its contralateral synergists spinalis capitis is only occasionally present and, if so, usu­ ally blends to some extent with semispinalis capi tis ( Gray's LONGISSIMUS CERVICIS Anatomy 2005). When these muscles are present, they add bulk to the mass of lamina muscle fibers j ust lateral to the Attachments: Transverse processes o f Tl-5 ascending to the spinous processes, which is addressed with the first row of transverse processes of C2-6 gliding strokes applied to the cervical lamina groove. Innervation: Dorsal rami of spinal nerves fNMT FOR SPINALIS MUSCLES Muscle type: Postural (type I), shortens when stressed Function: Laterally flexes and ipsilaterally rotates the neck; • Repeat the gliding steps for the lamina groove while increasing the pressure (if appropriate) to penetrate to bilaterally extends the neck the spinalis muscles, which lie deep to the semispinalis Synergists: Semispinalis capitis and cervicis, iliocostalis muscles. cervicis, longissimus capitis and cervicis, spinalis cervicis • When trigger point tenderness or contractures are Antagonists: Fibers of i ts contralateral synergists revealed, individual examination and appropriate releases may be applied, such as static compression, muscle energy Ind ications for treatment of long issi mus m uscles techniques and pOSitional release. • Loss of range of motion in flexion and rotation • Transverse, snapping friction may be applied to tissues • Pain behind, below or into the ear region, into the eye that have a more fibrotic quality as long as evidence of inflamma tion is not present. region and down the neck (trigger point referral pa ttern) • The fingertips of the contralateral hand (nails cut short) Specia l notes are used to apply the techniques. The longissimus muscles represent the intermediate verti­ • The hand lies across the back of the neck with the finger­ cal column of muscular tension tha t erects the torso and tips curled so that they lie in the lamina of the opposite head . The cranial attachment of longissimus capitis lies side. deep to both splenius capitis and sternocleidomastoid. It usually has a tendinous inscription transversing it so that i ts • While avoiding contact with the spinous processes, the upper and lower fibers would have separate endplate zones fingertips are transversely snapped across the fibers as if and, therefore, two locations for potential central trigger plucking a guitar string. point formation. • The snapping transverse friction is applied repea tedly to The fibers of the longissimus muscles are addressed with the most fibrotic fibers, which are then lengthened the gliding strokes and transverse friction techniques previ­ through stretching. ously mentioned within this section. The occipital attach­ ment is a ddressed with the suboccipital techniques on • Microtrauma of the tissues is an almost certain outcome p. 292. Hydrotherapy applications appropriate to the condi­ of such attention, requiring appropriate attention to avoid tion of the tissues as well as stretching techniques may be excessive posttreatment discomfort and the patient's used both in the treatment session and at home. commitment to stretch the tissues daily throughout the repair phase. I LI OCOSTALIS C E RV I C I S • Ice applications can be used both immediately following Attachments: The superior aspect o f the angles o f the treatment and a lso as home care, coupled with carefully 3rd-6th ribs to the posterior tubercles of the transverse employed active elongation of the involved muscles. processes of C4-6 • Active movement methods may follow immediately in Innervation: Dorsal rami of lower cervical nenres (C6-8) the treatment session and should also be added to the Muscle type: Postural (type I), shortens when stressed home care program to encourage parallel connective tis­ sue repair (see Chapter 1).

1 1 The cervical region 287 Function: Laterally flexes the spine and extends the spine M uscle type:.Postural (type I), shortens when stressed when bilaterally active Function: When these contract unilaterally they produce Synergists: For extension: splenius cervicis, semispinalis cer­ contralateral rotation; bilaterally, they ex tend the spine vicis, longissimus cervicis Synergists: Multifidi, semispinalis cervicis Antagonists: Matching contralateral fibers of rotatores as For lateralflexion: scalenii, longus capitis, longus colli Antagonists: Contralateral fibers of scalenii, longus capitis, well as contralateral multifidi and semispina lis cervicis longus colli and fibers of contralateral iliocostalis cervicis Ind ications for treatment Special notes • Pain and tenderness at associated vertebral segments • Tenderness to pressure or tapping applied to the spinous The iliocostalis muscles represent the most lateral vertical column of muscles of the back. They extend segmentally processes of associa ted vertebrae from the most caudal attachments of the erector spinae group at the sacrum, iliac crest and thoracolumbar fascia to Special notes the cervical vertebrae. While no ind ividual fibers span the entire length, these segments work dynamically to erect the Multifidi and rotatores muscles comprise the deepest layer spine. A l though iliocostalis does not a ttach to the cranium, of posterior cervical muscles and are responsible for fine it influences cranial posi tioning through its attachment to control of the rotation of vertebrae. They exist through the the cervical spine. entire length of the spinal column and the multifidi a lso broadly attach to the sacrum after becoming appreciably Fibers of iliocostalis cervicis are influenced in the most thicker in the lumbar region. lateral gliding strokes of the posterior cervical lamina as the thumb glides along the posterior aspect of the transverse These muscles are often associated with vertebral segments processes. Further applications of gliding as well as trans­ that are difficult to stabilize and should be addressed verse friction are used in a prone position, which is dis­ throughout the spine when scoliosis is presented. Discomfort cussed later in this section (p. 320). or pain provoked by pressure or tapping applied to the spin­ ous processes of associated vertebrae, a test used to identify M U LT I F I D I dysfunctional spinal articulations, also often indicates multi­ fidi and rotatores involvement. Attachments: From the articular processes o f C4-7 these muscles cross 2-4 vertebrae and attach to the spinous Trigger points in rotatores tend to produce rather localized processes of higher vertebrae referrals whereas the multifidi trigger points refer locally and to the suboccipital region, medial scapular border and top of Innervation: Dorsal rami of spinal nerves shoulder. These local (for both) and d istant (for multifidi) pat­ Muscle type: Postural (type I), shortens when stressed terns of referral continue to be expressed through the length Function: When these contract unilaterally they produce of the spinal column. In fact, the lower spinal levels of multi­ fidi may also refer to the anterior thorax or abdomen. ipsilateral flexion and contralateral rotation; bila terally, they extend the spine In addition to the deepest level of gliding techniques sug­ Synergists: For rotation: rota tores, semispinalis cervicis, gested above for the cervical lamina groove (when appro­ scalenii, longus capitis, longus colli priate), the fibers may be treated with sustained digital Antagonists: Ma tching contralateral fibers of multifid i as pressure, such as tha t used in trigger point pressure release. well as contralateral rotatores, semispinalis cervicis, Unless contraind icated, contrast hydrotherapy (alternating scalenii, longus capitis, longus colli heat and cold applications) may be applied several times for short intervals (10-15 seconds), which often profoundly Indications for treatment releases the overlying muscles so that these deeper tissues may be more easily palpated. • Chronic instability of associated vertebral segments • Reduced flexion of neck I NTERSPINALES • Restricted rotation (sometimes painfully) • Suboccipital pain (referral zone) Attachments: Connects the spinous processes o f contigu­ • Vertebral scapular border pain (referral zone) ous vertebrae, one on each side of the interspinous liga­ ment, in the cervical and lumbar regions ROTATO RES LO N G U S AN D B R EV I S Innervation: Dorsal rami of spinal nerves Attachments: From the transverse processes o f each verte­ Muscle type: Postural ( type I), shortens when stressed bra to the spinous processes of the second (longus) and Function: Extends the spine first (brevis) vertebra above (ending at C2) Synergists: All posterior muscles and especially multifidi, Innervation: Dorsal rami of spinal nerves rotatores and intertransversarii Antagonists: Flexors of the spine

288 CLIN ICAL A PPLICATI O N OF N EU RO M USCULA R TEC H N IQUES: THE UPPER BODY L New Zea land physiotherapist Brian Mul ligan ( 1 992) has described a Fig u re 1 1 .43 Mobi lization for cervical rotation restriction using series of extremely effective mobilization with movement techniques for the spinal joints. In this summary only those relating to the the SNAG method. cervical spine a re detailed, a lthough precisely the same principles a pply wherever they are used. M u l l igan high ly recommends that the • This contact, against the tip of the spinous process, acts as a work of Kaltenborn ( 1 989) relating to joint a rticulation be studied, 'cushion', as the other thumb is placed agai nst the lateral aspect especially that relating to end-feel (see Cha pter 1 3). of the 'cush ion' th umb, reinforci ng the contact. These mobilization methods carry the acronym SNAGs, which • The practitioner's hands rest over the lateral aspect of the stands for 'sustained natural a pophyseal glides'. They are used to neck. improve function if any restriction or pain is experienced on flexion, extension, sideflexion or rotation of the cervical spine, usually from • The practitioner gl ides the spinous process a long its a rticulation C3 and lower. (There are other more special ized variations of these plane (toward the eyes) until slack has been removed (a very techniques for the upper cervicals, not described in this text.) small a mount of translation, gl ide, will be noted). The 'force' used is a pplied by the superimposed thumb, not the one in contact In order to apply these methods to the spine, it is essential for the with the spinous process, which acts as a cushion to avoid dis­ practitioner to be aware of the facet ang les of those seg ments being comfort on the spinous process tip. treated. These are discussed in the structure portion of this chapter. It should be reca l led that the facet ang les of C3-7 lie on a plane • The sustained glide/translation is maintained as the patient turns which angles toward the eyes. Rotation of the lower five cervical the head and neck in the direction of restriction or pain. Th is vertebrae therefore follows the facet planes, rather than being should be pain free and have a greater range, if the correct spin­ horizontal (Kappler 1997, Lewit 1985). ous process is receiving the appropriate translation. Mulligan says: 'Remember to try more than one [seg mental] level if your Notes on SNAGs first choice is painfu l . There is a tendency to locate on the spin­ ous process below the appropriate one, or rather, this has often • Most appl ications of SNAGs com mence with the patient weight been so in my case: bearing, usually seated. • If pain is sti l l noted or the range is not painlessly increased, the • They are movements which are actively performed by the patient, practitioner should recheck and identify the correct segment and in the direction of restriction, while the practitioner passively repeat the process. holds a n area (in the cervical spine it is the segment i m m ediately cephalad to the restriction) in a translated direction. • As rotation is carried out by the patient, the practitioner's ha nds follow the movement so that the angle of translation is • In the cervical spine the direction of tra nslation is a l most always constant. anterior, a long the plane of the facet articulation, i.e. toward the eyes. • If a new range is achieved this should be held for several seconds before return ing to the start position and repeating the process • In none of the SNAGs appl ications should any pain be experi­ several times. enced, although some residual stiffn ess/soreness is to be a ntici­ pated on the fol lowing day, as with most mobilization box continues approaches. • In some instances, as well as actively movin g the head and neck toward the direction of restriction while the practitioner main­ tains the translation, the patient may usefu lly a pply 'overpressure' in which a hand is used to reinforce the movement toward the restriction barrier. • The patient is told that at no time should pain be experienced and that if it is, a l l active efforts should cease. • Reasons for pain being experienced could be: 1 . the facet plane may not have been correctly followed 2. the incorrect segment may have been selected for translation 3. the patient may be attempting movement toward the barrier excessively strongly. • If a painless movement through a previously restricted barrier i s achieved w h i l e t h e translation is held, t h e same procedure is per­ formed several times more. • There shou ld be an i nstant, and lasting, fu nctional im provement. • The use of these mobilization methods is enhanced by normaliza­ tion of soft tissue restrictions and shortened m uscu lature, using NMT, MFR, MET, etc. Treatment of l i mited cervical rotation or pain on rotation • The patient is seated with the practitioner standing behind. • The restricted segments will have been identified using normal palpation methods. • The practitioner places the medial aspect of the distal phalanx of one thumb agai nst the spinous process of the verte. bra, cephalad to the dysfu nctional vertebra.

1 1 The cervical region 289 Box 1 1 . 1 0 (coptin Lled) ... . ,� Identical mechanisms are used for treatment of sideflexion, flexion Self-treatment using SNAGs and extension restrictions. The anterior gl ide/translation is mainta ined as the restricted movement is actively introduced by the Mulligan suggests using a small hand-towel to engage the spinous patient, with a l l the cautions and recommendations as above. process, with the patient holding the ends of the towel to introduce an anterior pu l l and therefore a gl ide/translation of the engaged segment. It is i m portant to remember that as fu l l flexion is ach ieved, the At the same time, the restricted movement is slowly performed. direction of glide will be more or less horizontal (always toward the eyes) and during extension it will be more vertical. We have found that this is even more effectively achieved if the patient places the hands behind the neck, with one middle (or index) Mulligan reminds the reader to ensure that the end of range is finger on the appropriate spinous process (previously identified by maintained for severa l seconds before a return to neutra l and that the practitioner and shown to the patient). The other m iddle (or the g lide/tra nslation should be ma intai ned until neutral is resumed. index) finger is superi mposed on the initial contact and the patient g l ides the segment anteriorly, toward the eyes. This process w i l l have An additional caution relating to extension dysfunction a rises been explained by, and practiced with, the practitioner. because as extension is introduced, the approximation of the spinous processes makes localization of contact more difficult. Mul ligan The restricted movement is then carried out (sideflexion, rotation, states: 'This is especially true if the neck being treated is smal l and etc.), while the translation is maintained. After the end of range has your thumbs a re of a generous size. This is where \"self SNAGs\" are been achieved, the translation is susta ined until a neutra l neck m a rve l o u s : position is resumed. Ind icati ons for treatment Innervation: Dorsal and ventral rami of spinal nerves Muscle type: Not established • Tenderness between the spinous processes Function: Lateral flexion of the spine • Loss of cervical flexion Synergists: Interspinales, rotatores, multifidi Antagonists: Spinal flexors of the contralateral side Special notes Ind ications for treatment The interspinalis muscles are present in the cervical and lumbar regions and sometimes the extreme ends of the tho­ • Cervical segments restricted in lateral flexion racic segment. In the cervical region, they sometimes span two vertebrae (Gray's Anatomy 2005). Specia l notes �NMT FOR INTERSPINALES These short, laterally placed muscles most likely act as pos­ tural muscles that stabilize the adjoining vertebrae during The tip of an index finger is placed between the spinous movement of the spinal column as a whole. The pattern of processes of C2 and C3. Mild pressure is applied or gentle movement of intertransversarii is unknown, but thought to transverse friction used to examine the tissues that cormect be lateral flexion. Fibers may also extend the spine. the spinous processes of contiguous vertebrae. This process is gently applied to each interspinous muscle in the cervical These muscles are difficult to reach and attempts to pal­ region. The neck may be placed in passive flexion in order pate them may endanger cervical nerves which exit the to slightly separate the spinous processes and allow a little spine near the muscles. Additionally, the vertebral artery more room for palpation. courses between each unilateral pair; pressure on this is to be avoided. The cervical portion of the intertransversarii The tissues being examined include the supraspinous lig­ may be elongated by active contralateral flexion, especially ament, interspinous ligament and interspinalis muscles. In when combined w ith rotation, as when one attempts to the cervical region, the supraspinous ligament is altered to touch the chin to the contralateral shoulder. form the ligamentum nuchae. L EVATO R SCAPU LA (FI G . 1 1 .44) We suggest that the small beveled pressure bar is not appropriate as a treahnent tool in the cervical region due to Attachments: From the transverse processes of Cl and C2 the vulnerability of the vertebral artery in the suboccipital and the dorsal tubercles of C3 and C4 to the medial region and the highly mobile nature of cervical vertebrae in scapular border between the superior angle and the general. While the tool can readily be used in the thoracic medial end (root) of the spine of the scapula and lumbar region, the fingertips are safer and sufficient for addressing the cervical region. Innervation: C3-4 spinal nerves and the dorsal scapular nerve (C5) I N T E RTRAI\\l S V E R S A R I I Muscle type: Postural (type I), shortens when stressed Attachments: Anterior and posterior pairs of bilateral muscles Function: Elevation of the scapula, resists downward that join the transverse processes of contiguous vertebrae movement of the scapula when the arm or shoulder is

290 CLIN ICAL APPLICATION OF N EUROM USCULAR TEC H N IQUES: THE U PPER BODY be addressed at the same time as levator scapula with later­ ally directed (unidirectional) transverse friction or static pressure. Medial frictional strokes are contraindicated since they could bruise the tissue against the Wlderlying trans­ verse processes. Caution must be exercised to stabilize the treating fingers to avoid pressing the nerve roots against sharp foraminal gutters. The anterior surface of the superior angle, while often the source of deep ache, is usually neglected during treatment Wlless special accessing positions are used. These 'buried' fibers may be touched directly in the supine position as described below as well as the prone position as shown on p. 437 where levator scapula is discussed in detail with the shoulder. Figure 1 1 .44 The referral pattern of levator scapula is a common Assessment for shortness of levator scapula com p l a i n t that is often m ista ken as tra pezi us pain. Drawn a fter Simons et al ( 1 999). • The patient lies supine with the arm o f the side t o be tested stretched out with the supinated hand and lower weighted, rotates the scapula medially to face the glenoid arm tucked under the bu ttocks to help restrain move­ fossa downward, assists in rotation of the neck to the ment of the shoulder/scapula . same side, bila terally acts to assis t ex tension of the neck and perhaps lateral flexion to the same side (Warfel 1985) • The practitioner 's contralateral arm is passed across and Synergis ts: Elevation/medial rotation of the scapula: rhomboids under the neck to cup the shoulder of the side to be tes ted Neck stabilization: splenius cervicis, scalenus medius with the forearm supporting the neck. Antagonists: To elevation: serratus anterior, lower trapezius, latissimus dorsi • The practitioner's other hand supports the head. To rotation of scapula: serratus anterior, upper and lower trapezius • The forearm is used to lift the neck into full pain-freeflex­ To neck extension: longus colli, longus capitis, rectus capitis anterior, rectus capitis lateralis (Norkin & Levangie 1992) ion (aided by the other hand). The head is placed fully toward contralateral flexion and contralateral rotation. Ind ications fo r treatment • With the shoulder held caudally and the head / neck in the pOSition described (each at its resistance barrier), • Neck stiffness or loss of range of cervical rotation stretch is placed on levator from both ends. If dysfunc­ • Torticollis tion exists and / or levator scapula is short, there will be • Postural distortions including high shoulder and tilted discomfort reported at the attachment on the upper medial border of the scapula and/or pain reported near head the spinous process of C2. • Patient indicates upper angle area when complaining of • The hand on the shoulder can gently 'spring' it caudally. • If levator is short there will be a harsh, wooden feel to discomfort this action. If it is normal there will be a soft feel to the springing pressure. Special notes f N MT F O R LEVATO R SCAPU LA The levator scapula usually spirals as it descends the neck to attach to the superior medial angle of the scapula. It is The patient is supine with the arm lying on the table. The known to have a n umber of accessory attachments, includ­ practitioner sits or stands cephalad to the shoulder with one ing onto the mastoid process, occipital bone and upper two hand placed on the posterior aspect of the scap ula, grasping its inferior angle lightly and displacing it cranially. Proper ribs (Gray's Anatomy 2005, p . 836), and may split into two displacement is imperative. layers, one a ttaching to the posterior aspect of the superior The shoulder is passively shrugged and the scapula angle while the other merges its fibers anteriorly onto the moved toward the head until its upper angle is available for scapula and the fascial sheath of serratus an terior (Simons palpation by the fingers of the practitioner's treating hand. et al 1999). Between the two layers of the proximal attach­ The finger pads are placed onto the anterior aspect of the ment, a bu rsa is often found which may be the site of con­ superior medial angle while the stabilizing hand continues siderable tenderness. to gently traction the scapula cranially (Fig. 11 .45). The transverse process attachments include scalenus The trapezius usually displaces naturally toward the medius, splenius cervicis and intertransversa rjj, which may table but if its a ttachment on the clavicle is wide, it may overlie the upper angle of the scapula. The fingers should

11 The cervical region 2 9 1 Figure 1 1 .45 Di rect contact of the anterior aspect of the upper Figure 1 1 .46 M ET assessment a n d t reatment o f ri g h t levator angle of the sca pula where levator sca pula attaches. sca p u l a . wrap all the way around the most anterior fibers of the the ipsilateral shoulder, so that the practitioner's forearm trapezius to touch the upper anterior aspect of the scapula. supports the neck. Pressing through the trapezius will not achieve the same • The practitioner's other hand supports and directs the results and might irritate trigger points located in these head into subsequent movement (below). fibers. Palpation of the anterior surface of the upper angle • The practitioner's forearm lifts the neck into full flexion will assess fiber attachments of the levator scapula, serratus (aided by the other hand). The head is turned fully anterior and possibly a small portion of the subscapularis toward contralateral sidebending and rotation. muscles. In some cases, angling the fingers laterally may • With the shoulder held caudally by the practitioner's (rarely) contact the omohyoid attachment but it is doubtful hand and the head/neck in full flexion, sidebending and that the rhomboid minor will be contacted medially. If ten­ rotation (each at i ts resistance barrier), stretch is placed derness is encountered, static pressure or gentle massage on levator from both ends. If dysfunction exists and/ or i t may be used to address these vulnerable tissues. is short, there will be marked discomfort reported at the insertion on the upper medial border of the scapula Static pressure or laterally applied unidirectional friction and/or as pain near the spinous process of C2. can be used on the transverse process attachments of leva­ • The patient is asked to take the head back toward the tor scapula as well as other tissues attaching there as long as table and slightly to the side from which it was turned, contact w ith the vertebral artery is avoided . The most lat­ against the practitioner's unmoving resistance, while at eral glide of the previously discussed lamina groove treat­ the same time a slight (20% of available strength) shoul­ ment will also address fibers of levator scapula (p . 281). der shrug is also resisted. • Following the 7-10 second isometric contraction and ,� M ET T R EAT M E NT O F L EVATOR SCAPU LA complete relaxation, slack is taken out as the shoulder is '(FIG. 1 1 .46) depressed further caudally with the patient's assistance ('As you breathe out, stretch your hand toward your Treatment using MET for levator scapulae enhances the feet'), while the neck is taken to (acu te) or through lengthening of the extensor muscles attaching to the occiput (chronic) further flexion, sidebending and rotation. and upper cervical spine. The position described below is • The stretch is held for at least 20 seconds. used for treatment, either at the limit of easily reached range • Caution is required to avoid overstretching this sensitive of motion or well short of this, depending upon the degree area. of chronici ty, which will also determine the degree of effort called for (20-30%) and the duration of each contraction It POSITI O N AL R E LEASE O F LEVATO R SCA P U LA (7-10 seconds or up to 30 seconds). The more acute the con­ dition, the less resistance is offered . • The tender point for levator scapula lies in the belly of the muscle approximately at the level of C6. • The patient lies supine with the arm of the side to be tested stretched out alongside the trunk with the hand • The patient lies supine; the practitioner stands at the supinated. head of the table. • The practitioner, standing at the head of the table, passes the contralateral arm LU1der the patient's neck to rest on

292 CLI N I CAL A P P LI CATI O N OF N E U R O M U SCU LA R TECH N I Q U E S : T H E U PP E R B O DY • For positional release on the left, the practitioner's right scapula muscle on Cl, C2, C3, and C4 transverse hand supports the head and neck while the middle or processes, until the reported pain score drops to 7 or less. index finger compresses the tender point sufficiently for • Fine-tuning is achieved by gently rotating the neck and the patient to be able to use it as a monitor during reposi­ head toward the left, and possibly adding in sideHexion tioning. to the left, until the palpated tenderness is reported as 3 or less. • A value of '10' is ascribed to the tenderness which should • This should be held for not less than 30, and up to 90, sec­ be moderate but not severe. onds, before a slow return to neutral. • The practitioner's left hand slides beneath the left SUBOCCIPITAL REGION (FIG. 1 1 .48) scapula to contact the inferior angle and the scapula is d rawn cephalad toward the attachment of the levator Rectus capitis posterior minor (RCPMin) and major (RCPMa), obliquus capitis superior (OCS) and obliquus Figure 1 1 .47 Leva tor sca pula positional rel ease. Reprod uced with capitis inferior (OCI) (collectively called the suboccipital perm ission from Deig (2001 ) group) perform fine-tuning movements which are vital to the positioning of the head and counteractive to the com­ posite triple movements of the lower functional unit of the cervical region. The suboccipital group, because of their attachments, are often directly involved in cranial suture crowding and / or temporal bone dysfunction, with the potential to negatively influence cranial function. Unilateral contraction of the four muscles produces slight lateral Hexion of the head with associated ipsilateral head rotation accompanied by extension - the three com­ posite movements of the upper cervical unit (type II). Bilateral contraction of all four muscles produces extension of the cranium and translation of the cranium anteriorly on the atlas. However, when acting alone, each of these mus­ cles individually produces a fine control of stabilization or Semispinalis capitis --.-f+;.' Splenius capitis -___ - Obliquus capitis superior fi-r-rlf-t .�H-- Vertebral artery Rectus capitis posterior minor --:--+t ---f+ Posterior ramus of C1 Obliquus capitis inferior --.;--Ihr� -i'If--f+ Rectus capitis posterior major =--:�1f'+ Spinous process of C2 -+''<-',I .-. ..'r-'It-,'- .'. --- f--f- -- Semispinalis cervicis Semispinalis capitis --'-+ -1,.-.- -- Longissimus capitis Splenius capitis --:'-1-+; Figure 1 1 .48 The subocci pita l s, which a re often d iscussed as a g roup, each has i ts own u n ique fu nction in movements of the head. Reproduced with perm ission from Gray's Anatomy for Students (2005).

1 1 The cervical region 293 movement of the cranium on the atlas, the atlas on the axis eyes and ears in an approximately level position. When the or retraction of the d ural tube wi thin the spinal canal (see cranium is posteriorly rotated, the suboccipital group's role discussion of rectus capitis posterior minor on pp. 52, 252). in sustaining this position is substantial. A forward head Their functions can be more fully appreciated when they position involves a posteriorly rotated cranium that has are viewed from above as well as from the side since the then been brought to a position where the eyes and ears are normal posterior view does not fully expose their oblique level with the horizon. The suboccipital space is crowded angles and, therefore, their full influence as head position­ and the muscles significantly shortened, which often leads ers. Their roles are discussed individually below. to trigger point formation. The contractures associa ted with trigger pOints may then assist in mainta ining the shortened Three of the four suboccipital muscles (all except RCPMin) position wi thout excessive energy consumption. form the suboccipital triangle. The vertebral artery lies rela­ tively exposed in the lower aspect of this triangle and is to Pain patterns and dysfunctional biomechanical patterns be avoided when pressure or friction is applied to this area, associated with trigger points may lead to compensatory especially when the tissues are placed on stretch. The changes in the lower functional unit and more distant struc­ greater occipital nerve courses through the top of the trian­ tures. Until these m uscles are considered and treated, gle before penetrating the semispinalis capitis and trapezius a ttempts to restore the head to a balanced posture are muscles, then continues on to supply the posterior ex ternal unlikely to fully succeed. Similarly, addressing only these cranium. The nerve may also penetrate obliquus capitis suboccipital muscles for forward head posture, while ignor­ inferior. ing the role of other cervical tissues, pectoralis minor, the diaphragm, upper rectus abdominis and pelvic positioning, Ideally, flexion (1 0°) and extension (25°) of the head occur as well as more wide-ranging causes of postural imbalance, between the occiput and atlas, as well as translation of the will produce short-term results at best. head upon the atlas. The degree of rotation or lateral flexion is only slight since more would be undesirable at this par­ Pollard & Ward (1997) explored this concept from a dif­ ticular joint due to the risk of unwanted spinal encroach­ ferent perspective. Their study, conducted on 50 university ment of the odontoid process (the dens) on the spinal cord. students (18-35 years of age), was comprised of three groups: The vertebral artery, which l ies on the superior aspect of the one group stretched the hamstring m uscles, another stretched lateral masses of the a tlas, might also be crowded by exces­ the suboccipital muscles and a third was placebo. Straight sive movements of the a tlas. The transverse ligament leg raise for testing ROM of the hip joint showed that retains the dens in position while allowing the atlas to rotate stretching the hamstrings increased hip ROM by 9% while around it. The ligament articula tes with the posterior aspect stretching the suboccipital muscles resulted in a 13% increase of the dens while the atlas articulates with its anterior of hamstring length. These findings clarify tha t cervical surface. treatment should be included with the treatment of extraspinal, lower limb musculoskeletal conditions as well Faulty head/neck mechanics, such as forward head pos­ as in inj ury prevention for a thletes. ture, place high demand on the suboccipital m uscles to maintain the head's position, while simultaneously crowd­ The proprioceptive role of the muscles of the suboccipital ing the space in which they operate, often physiologically region is directly related to the number of spindles per gram shortening them in the process. People who wear bifocal or of muscle. There are an average of 36 spindles per gram in trifocal glasses while working at the computer are prone to RCPMin and 30.5 spindles/gram in RCPMa, as compared, chronic shortening of these muscles by placing the head in for example, with 7.6 spindles/ gram in splenius capitis and posterior rota tion so as to see out of the appropriate portion just 0.8 in gluteus maximus (Peck et aI 1984). McPartland & of the lens for the chosen depth of field. Brodeur (1999) suggest that 'The high density of muscle spindles found in the RCPM m uscles suggests a value . . . When suboccipital muscles house trigger points, these [which] . . . lies not in their motor function, but in their role as are usually accompanied by articular dysfunctions of the \"proprioceptive monitors\" of the cervical spine and head'. upper three cervical levels (Simons et a I 1 999) . All the sub­ occipital muscles apart from obliquus capitis inferior con­ Liu et al (2003) showed that, not only do the suboccipital nect the atlas or axis to the cranium, while the inferior muscles have distinct morphological features, but also that a ttaches the atlas to the axis. each muscle is unique in both fiber type composition and sensorimotor organization. This suggests functional spe­ While the motor function of these four muscles is prima­ cialization. rily to extend the head and to translate and rotate the head, their dysfunctions include involvement in the all-too­ Hallgren et al (1994) suggest that damage to RCPMin, common forward head position. A number of researchers such as occurs in whiplash, would reduce i ts proprioceptive have shown that dysfunction of these small muscles in gen­ input, while facilitating transmission of impulses from a eral, and RCPMin in particular (often resulting from wide range of nociceptors which could develop into a whiplash), leads to marked increase in pain perception as chronic pain syndrome (such as fibromyalgia) . well as reflex irritation of other cervical as well as j aw m us­ cles (Hack et a1 1 995, Hallgren et al 1994, Hu et aI 1995). An Forward head posture i s discussed further i n Volume 2 of ultimate aim of postural compensation is to maintain the this text, where the influences of the lower half of the body on total body mechanics are more fully explored.

294 C L I N ICAL APPLICATI O N OF N EU R O M USCU LA R TECH N I QU E S : TH E U PPER B O DY vertebral artery and the suboccipital nerve, which could further aggravate any hypertonus of the region. The researchers at the University of Maryland in Baltimore state: Suboccipitals Upper semispinalis In reviewing the literature, the subject offunctional rela­ capitis tions between voluntary muscles and dural membranes has been addressed by Becker ( Upledger & Vredevoogd 1 983) Figure 1 1 .49 The referral patterns of the subocci pita l m uscles and who suggests that the voluntary muscles might act upon the the u pper sem ispinalis ca pitis a re si m i lar. Dra w n after Simons et al dural membranes via fascial continuity, changing the ten­ (1 999). sion placed upon them, thus possibly influencing CSF pres­ sure. Our observation that simulated contraction of the R E CTUS CAPITIS POST E R I O R M I N O R ( F I G . 1 1 .49) RCPM [rectus capitis posterior minor] muscle flexed the PAO membrane-spinal dural complex and produced CSF Attachments: Medial part o f the inferior nuchal line on the movement supports Becker's hypothesis . . . During head occipital bone and between the nuchal line and the fora­ extension the spinal dura is subject to folding, with the men magnum to the tubercle on the posterior arch of the greatest amount occurring in the area of the atlantooccipital a tlas joint (Cailliet 1 991). One possible [motor] function of the RCPM muscle may be to modulate dural folding, thus Innervation: Suboccipital nerve (C1) assisting in the main tenance of the normal circulation ofthe Muscle type: Postural (type I), shortens when stressed CSF. Trauma resulting in atrophic changes to the RCPM Function: While most texts note that this muscle extends the muscle may interfere with this suggested mechanism (Hallgren et al 1 994). The observed transmission of tension head, recent research (Greenman 1997) has shown it to con­ created in the spinal dura to the cranial dura ofthe posterior tract during translation of the head and to tense a connec­ cranial fossa is consistent with the described discontinuity tive tissue attachment (fascial bridge) to the dura mater, between the spinal and intracranial parts of the dura mater which retracts the dural tube and prevents it from folding (Penfield & McNaughton 1 940). Not only has the dura lin­ onto the spinal cord. RCPMin may play a small part in head ing the posterior cranialfossa been described as being inner­ extension and translation but, as noted above, its main role vated by nerves that subserve pain (Kimmel 1 961) but also would seem to be proprioceptive rather than motor. it has been demonstrated that pressure applied to the dura of Synergists: In head extension: rectus capitis posterior major, the posterior cranialfossa in neurosurgical patients induces obliquus capitis superior, semispinalis capitis, longis­ pain in the region of the posterior base of the skull simus capitis (Northfield 1 938). Therefore, one may postulate that the Antagonists: Rectus capitis anterior, longus capitis dura of the posterior cranial fossa can be perturbed and become symptomatic if stressed to an unaccustomed extent by the RCPM muscle acting on the dura mater. McPartland & Brodeur (1999) hypothesize: Indications for treatment A disease cycle involving RCPMinor, initiated by injury or chronic somatic dysfunction . . . leads to RCPMinor atrophy • Loss of suboccipital space . . . [which] . . . may directly irritate the meninges via the • Deep-seated posterior neck pain posterior atlantooccipital membrane, and result in reduced • Headache wrapping around the side of the head to the proprioceptive output to higher centers. The lack ofproprio­ ceptive output causes a loss ofstanding balance and cervical eyes vertigo . . . chronic pain . . . reflexive cervical and jaw muscle • Trigger points in overlying muscles activity, directly affecting the biomechanics of the region. Special notes Hack & Hallgren (2004) implicate postsurgical myodural adhesions as a possible source of postoperative headache fol­ Recent research (Hack et al 1995) has demonstrated that a lowing excision of acoustic tumors. They integrate two types connective tissue extension links this muscle to the dura of myodural union (anatomic and pathologic) into a unified mater which provides it with potential for influencing the theory of headache production, and report on a single patient reciprocal tension membranes directly, with particular who experienced relief from chronic headache after surgical implications to cerebrospinal fluid fluctua tion because of its separation of the myodural bridge from the suboccipital site close to the posterior cranial fossa and the cisterna musculature. We can gain insight from their results, and magna. It could also influence normal functioning of the

11 The cervical region 295 hopefully prevent the need for resection, by careful applica­ OBLlOUUS CAPITIS SUPERIOR tion of manual techniques to treat these tissues. Attachments: Superior surface of the transverse process of R ECTUS CAP I T I S POSTE R I O R M AJ O R C1 to the occipital bone between the superior and infe­ rior nuchal lines Attachments: Lateral part of the inferior nuchal line on the occipital bone and the occipital bone immediately infe­ Innervation: Suboccipital nerve (C1) rior to the nuchal line to attach to the spinous process of Muscle type: Not established C2 (axis) Function: Extension of the head, minimal lateral flexion of Innervation: Suboccipital nerve (C1) the head Muscle type: Postural (type I), shortens when stressed Synergists: For extension: rectus capitis posterior minor Function: Ipsilateral head rotation, extension of the head Synergists: For rotation : splenius capitis, contralateral SCM (questionable) and major, semispinalis capitis, longis­ simus capitis For extension : rectus capitis posterior minor (questionable), For minimal lateralflexion: rectus capitis lateralis obliquus capitis superior, semispinalis capitis, longissimus A ntagonists: For extension: rectus capitis anterior, longus capitis capitis Antagonists: For rotation: contralateral mates of obliquus For sidebending: contralateral obliquus capitis superior and capitis inferior and rectus capitis posterior major contralateral rectus capitis lateralis For extension: rectus capitis anterior, longus capitis I nd icati ons for treatment Indications for treatment • Loss of suboccipital space • Loss of suboccipital space • Deep-seated posterior neck pain • Deep-seated posterior neck pain • Headache wrapping around the side of the head to the • Headache wrapping around the side of the head to the eyes • Trigger points in overlying muscles eyes • Unstable atlas, especially sidebend cranially Special notes O BLlOUUS CAPITIS I N FERIOR People who chronically place the neck in flexion or exten­ sion stress these 'check' muscles while encouraging the evo­ Attachments: Spinous process of C2 to the inferior aspect lution of hypertonicity and trigger point activity. Referred and dorsum of the transverse process of C1 pain from triggers has poor definition, radiating into the lat­ eral head from the occiput to the eye. Upledger & Innervation: Suboccipital nerve (C1 ) Vredevoogd ( 1983) indicate that bilateral hypertonicity of Muscle type: Not established rectus capitis posterior major and minor can retard occipital Function: Ipsilateral rotation of the a tlas (and therefore cra­ flexion while unilateral hypertonicity is said to be capable of producing torsion at the cranial base. nium) Synergists: For rotation: splenius capitis, contralateral SCM The possibility of such a torsion occurring at the cranial Antagonists: For rotation: contralateral mates of obliquus base in an adult skull is unlikely in the extreme once ossifi­ cation of the sphenobasilar synchondrosis had taken place. capitis inferior, RCPMa and splenius capitis and the ipsi­ It could, however, occur in the more malleable infant or lateral SCM young adult skull (Chaitow 1999). Indications for treatment McPartland et al (1997) suggest a relationship between chronic pain, somatic dysfunction, muscle a trophy and • Loss of rotation, such as looking over shoulder standing balance. They confirmed that, when compared • Deep-seated posterior neck pain with controls, chronic neck pain subjects presented with • Headache wrapping around the side of the head to the almost twice as many somatic dysfunctions, decrease in standing balance, and marked atrophy of the rectus capitis eyes posterior major and minor muscles, including fatty infiltra­ • Unstable atlas, especially sidebend inferiorly with rotation tion. They hypothesized 'a cycle initiated by chronic somatic dysfunction, which may result in muscle atrophy, which can Special notes be further expected to reduce proprioceptive output from atrophied muscles. The lack of proprioceptive inhibition of Gray's Anatomy (2005) suggests tha t the superior oblique nociceptors at the dorsal horn of the spinal cord would and the two recti muscles are probably postural rather than result in chronic pain and a loss of standing balance'. phasic muscles, which has implica tions regarding their response to 'stress' in that they are likely to shorten over time (Lewit 1992). These two oblique muscles (superior and inferior) trans­ mit tilting pull on the a tlas, creating an unstable base for the head to rest upon. They will often be dysfunctional together

296 CLI N I CAL APPLICATIO N O F N EU RO M USCULAR TECH N IQUES: THE U PPER BODY [ Box 1 1 . 1 1 Cranial base release contralaterally, i .e. the superior oblique on one side and the inferior on the opposite side will be shortened by a tilted, This technique releases the soft tissues where they attach to the rotated a tlas. Since compensation by the upper functional cranial base and may be used either before or fol lowing cervical unit can be associated with any distortions occur­ suboccipital NMT assessment. ring in the remainder of the spinal column, we recommend • The patient is supine and the practitioner is seated at the head examina tion of the suboccipital region (and the cervical spine) when any spinal distortions are found further down of the table with the arms resting on and supported by the table. the column. Likewise, when the upper unit is found to be • The dorsum of the practitioner's hand rests on the table with dysfunctional, a full spinal examination may reveal associ­ a ted distortions. fingertips pointing toward the ceil ing, acting as a fu lcrum on which the patient rests the occiput so that the back of the When tissues of the suboccipital region are too tender skul l is resting on the practitioner's palm. The distal fingertips to be frictioned or when cranial techniques are to be touch the suboccipital m uscles while the pa lmar su rfaces of applied, the static release techniques offered in Box 1 1 . 11 the tips (finger pads) touch the occiput itself. may be preferred over those appearing here. The cranial • The patient allows the head to lie heavily so that the pressure base release may also be used prior to the following steps or induces tissue release against the fingertips. following them and is recommended to accompany cran­ • As relaxation proceeds and the fingertips sink deeper into the iomandibular therapy, especially when fonvard head pos­ tissues, the a rch of the atlas may be palpated and it may be ture is noted. encouraged to disengage from the occiput by application of mild traction appl ied to the occiput, 'sepa rating' it from the ,� N MT F O R S U B O C C I PITAL G R O U P - S U PI N E atlas (ou nces of effort at most, applied cra n ia l ly by the middle \" (FIG. 1 1 .51 ) fingers). This would probably not be for some minutes after com mencement of the exercise. The practitioner is seated at the head of the table with the • The effect is to relax the attach ments in the area being pa tient lying supine. The palms of the practitioner 's hands treated with benefit to the whole muscle. This 'release' of deep cradle the posterior cranium and the fingers cup the occipi­ structures of the u pper neck enhances d rainage from the head tal bone with the finger pads resting on the inferior surface and circulation to it, while reducing intercranial congestion. of the bone. The first two fingers of the treating hand address one side at a time, as the person may be intolerant � of two sides being treated at once. A small space is usually palpable between the occipital ridge and the first vertebra ( (atlas). This area infl uences rocking and tilting of the head and, therefore, posterior rotation of the cranium. \\ The treating fingers are placed just lateral to the mid-line at F i g u re 1 1 .50 Hand positions for cra n i a l base release. the inferior aspect of the occipital bone and press into the trapezius muscle and its tendon. Static pressure for 8-12 sec­ onds may be followed by medial to lateral friction directly on the trapezius a ttachment. Deeper pressure, if appropriate, will treat semispinalis capitis and RCPMin. Since the minor's a ttachment to the dura may be fragile, static pressure is B Fig u re 1 1 .51 ARB: Friction may be a pp l i ed to the subocci pitals a n d overlyi ng m uscles from the m i d - l i n e to the m astoid process. However, CAUTIO N m ust be exerci sed to avoid deep friction to the rectus ca pitis posterior m i nor a n d to the vertebral a rtery, w h ich is located in the subocci pita l triangle (see Fig. 1 1 .48).

11 The cervical region 297 ] Figu re 1 1 .52 Lief's N MT 'map' for cervical a n d u p per thoracic • The patient is prone with the face in a cradle or face hole. areas. Reprod uced with perm ission from Chaitow (1 996a). • The practitioner stands at the head of the table, resting the tips of the fi ngers on the lower, lateral aspect of the neck, the thumb tips placed just lateral to the first dorsal -spin a l process. • A degree of downward (toward the floor) pressure is applied via the thumbs, which are then bilatera l ly drawn slowly cepha lad a longside the latera l margins of the cervical spinous processes. • This bilateral stroke culminates at the occiput where a latera l sea rching stretch i s introduced across t h e bunched fibers o f the muscles inserting into the base of the skull. • The cephalad stroke shou ld contain an element of pressure medially toward the spinous process so that the pad of the thumb is pressing downward (toward the floor) while the lateral thumb tip is directed medial ly/centrally, attempting to contact the bony contours of the spine, evaluating for tissue abnormal ities, all the time being drawn slowly cephalad so that the stroke terminates at the occiput. • This combination stroke is repeated two or three times. The fin­ gertips, which have been resting on the sternocleidomastoid, may a lso be employed at this stage to lift and stretch the m uscle pos­ teriorly and latera l ly. • The series of lateral strokes (bi lateral ly, performed sing ly, or simu ltaneously) across the occiput from its inferior margin to above the occipital protuberance a ttempt to evaluate the relative induration and contraction of the fibers attaching to the occiput. • The th umb tips apply pressure to remove a l l slack into the medial fibers of the paraoccipital m uscu lar bund les as a latera l ly directed manual stretch is instituted, using the leverage of the arms, as though attempting to 'open out' the occiput. • The thumbs are then drawn latera l ly across the fibers of muscular i nsertion into the skull, in a series of strokes cu lminating at the occipitoparietal junction. • The fingertips, which act as a fu lcrum to these movements, should by now rest on the mastoid area of the temporal bone. • Several very light but sea rching strokes are then performed by one thumb or the other running caudad directly over the spinous process from the base of the sku l l to the u pper dorsal a rea. Pressure should be l ight (2-3 ou nces at most) and very slow. • Wherever local ized tissue changes are perceived, and especia lly if these evoke a painful response, they should be careful ly palpated to ascertain whether they are active trigger points. preferred over the more aggressive frictional techniques styloid process is avoided anterior to the SCM tendon when the pressure intrudes this deeply. Longer durations of where the styloid is located j ust inierior and slightly ante­ static pressure can also be used. rior to the earlobe. The fingers are moved laterally I inch (2.5 cm) and static Cranial to caudal friction may also be used on the occipi­ pressure and frictional movements repeated to influence tal tendon attachments which will have m inor influence on the remainder of the trapezius, semispinalis capitis and suboccipital muscles but significant influence on the tissues RCPMa . The head may be rotated slightly away from the overlying them. side being treated to make these muscles more palpable. The fingers are now placed caudally approxima tely a fin­ CAUTION: Moderate to extreme head rotation is not ger width and the steps repeated between CI (a tlas) and C2 (axis) to treat the inferior half of RCPMa and to include recommended for prolonged periods of time as the verte­ obliquus capitis inferior. If the spinous process of C2 is located, the fingers examine the space cephalad and slightly bral artery may be occluded within the transverse process, lateral to the process. This area influences rotation of the head. The center of the s ubOCCipital triangle is avoided dur­ thereby reducing blood flow to the cranium (see Box 11.5 ing the frictional techniques due to the location of the verte­ bral artery. for tests for circulatory dysfunction). To influence and examine tissues caudal to the suboccip­ Static pressure and iriction are continued at I-inch (2.5 -cm) ital muscles, this process may be continued throughout the intervals along the remainder of the suboccipital ridge to treat SCM, splenius capitis, longissimus capitis and obliquus capitis superior. Contralateral rotation of the head may be used with the caution above kept in mind. Pressure on the

298 CLI N I CAL A PPLICATION OF N EU RO M USCULA R TEC H N IQUES: THE UPPER BODY ,. . .' . .:��- ...� �.;{;.- � \" , . \\ . ,.�� Figure 1 1 .53 SCS position for posterior cervica l dysfunction. • The head/neck is then carefully eased i nto l ight extension until a reduction is ach ieved in the reported sensitivity. • With the patient supine a n area of localized tenderness ('tender point') is identified on the posterolateral or posterior aspects of • The pressure on the tender point ca n be constant or intermittent, the neck. with the latter being preferable if sensitivity is great. • Compression is applied to the tender point, sufficient to elicit a • Once a position is found that reduces the pain 'score', fine-tuning degree of sensitivity or pain which the patient is told represents a maneuvers commence, with movement of the head/neck into score of ' 10'. rotation away from the side of palpated pain being the com mon­ est beneficial direction. • If this fails to reduce the pain score, variations should be attempted, slowly, one at a time, including sideflexion away from and toward the pain side, as well as rotation toward and/or translational movements. • Any fine-tuning movement that either increases the pain 'score' or creates pain elsewhere indicates that the movement or posi­ tion is not appropriate and alternative directions shou ld be explored. • Once a reduction in sensitivity of at least 70% is achieved, fu l l inha lation and exha lation are mon itored by the patient to see which phase of the breathing cycle reduces sensitivity more and this phase of the cycle is mai ntained for a comfortable period during which time the overall position of ease is maintained. • If intermittent pressure on the point is being used, it needs to be applied periodica l ly d u ring the holding period in order to ensure that the position of ease has been maintained (by virtue of a non-return of palpation-induced pain). • After 90 seconds, a very slow and deliberate return to neutral is performed and the patient is allowed to rest for several minutes. • The tender point should be repalpated for sensitivity, wh ich should have reduced ma rked ly, as shou ld the degree of hyper­ ton icity in the surrounding tissues. posterior cervical muscles and is always repeated to the opposite side. Fibrotic bands or tendinous attachments may be treated with crossfiber friction and static pressure, as appropriate. PLATYSMA ( F I G . 1 1 . 54) Figure 1 1 .54 The prick l i n g pain pattern of platysm a is d istinct from the pattern of the u nd erlying SCM (see Fig . 1 1 .57). Dra w n after Attachments: A broad sheet of muscular fibers arising from Simons et al (1 999). fascia of the upper chest which interlace medially with the contralateral muscle, below and behind the symph­ ysis menti; intermediate fibers attach to the lower border of the mandibular body while posterior fibers cross the mandible and the anterolateral part of the masseter and attach to subcutaneous tissue and skin of the lower face Innervation: Facial nerve (cranial nerve Vll) Muscle type: Not established Function: May assist in depressing the mandible or d raw the lower lip and corners of the mouth inferiorly, espe­ cially when the jaw is already open wide; produces skin ridges in the neck which may release pressure on under­ lying veins (Moore 1980) Synergists: To mandibular depression: lateral p terygoid, mylohyoid, digastric, geniohyoid, gravity Antagonists: Masseter, medial pterygoid, temporalis

11 The cervical reg ion 2 9 9 Indications for treatment • Prickling pain to the lower face and mandible or over the front of chest • Presence of sternocleidomastoid trigger points. Special notes F i g u re 1 1 .55 General cervica l stretch, supine, fo l lowing isometric contraction. While the platysma does not seem to have an important function, its referra l pattern and potential influence on mus­ �. G E I\\J E RAL ANTE R I O R N E C K M U SC L E STRETCH cles located in its target zone may lead to indirect influences \" UTI LIZING M ET and perpetuation of trigger points in those tissues. The muscles of mastication (masseter especially) might be thus = influenced. Since somatovisceral referrals are known to occur in other body areas (see p. 47), it would be logical that • For involvement of rectus capitis anterior, suprahyoids, tissues overlying the thyroid gland might have influence on infrahyoids, platysma, supra thyroids and infrathyroids glandular function. Platysma (as well as sternocleidomas­ the hvo procedures described immediately below are toid, infrahyoids and scalenii) should be examined when performed with the mouth closed. glandular dysfunctions are noted. • For involvement of longus colli and longus capitis, the Studies indicate activity during sudden deep inspiration, mouth is held slightly opened. vigorous contraction during sudden, violent effort and in expressions of horror and surprise (Gray's Anatomy 2005). Note: Sternocleidomastoid and scalenii stretches described elsewhere in this chapter will a utomatically produce CAUTION: While spray and stretch techniques for treat­ stretching of many of these anterior neck m uscles. ment of trigger points are excellent applications for the CAUTION: Avoid traction or sidebend, especially with anterior neck muscles, sustained hot or cold applications rotation of the neck if disc damage is suspected, or imme­ over the carotid artery and thyroid gland are not recom­ diately after an accident until extent of inj uries is known. mended. Clear warnings should be given to avoid standing Va riations under a hot shower with the neck stretched in extension 1. Supine • This is a general non-specific stretching proced ure i n order to allow a hot spray on the anterior neck, as the (Fig. 11 .55). It would not be used if anterior displacement patient may experience a rapid fluctuation in blood pres­ of the articular disc (TM j oint) is suspected as even m i ld mandibular condyle pressure into the articular fossa may sure accompanied by dizziness, which could result in loss create intense discomfort. • The use of an open or closed mouth to involve different of balance and injury. A loosely wrapped hydrocolator structures as explained above should be noted . • The p ractitioner places the forearm (left in this example) pack that focuses its heat primarily onto the posterior cer­ in a position which allows the mid-cervical spine to rest on it and with the right hand cups the pa tient's jaw vical and filters somewh a t onto the anterior neck can be (which should be relaxed throughout the p rocedure, whether open for longus colli and longus capitis, or applied with the patient recl ined or seated. Adequate closed for other anterior hyoid-related muscles). , time should be given after appl ication before the patient • The practitioner grasps his own right distal forearm with the left hand, so forming a stable contact. is asked to stand. • When the practitioner gently leans backwa rd a degree of mild traction is introduced into the patient's cervical It N M T FOR P LATYSMA spine, to remove slack. • The patient is asked to lightly move the head into flexion The skin o f the anterior neck i s fairly elastic and therefore against the resistance of the contact hand on the (relaxed) usually lifts eaSily to be rolled. To address the fibers of platysma, the skin of the anterior neck is gently and slowly rolled betvveen the thumb and fingers in an attempt to d is­ tinguish tender points or trigger points. When tender tissue is encountered, gentle static pressure can be applied to assess for referral pa tterns and taut fibers that feel as though they a re 'glued' to the internal surface of the skin. CAUTION: Aggressive techniques of tractioning the skin, tuggi ng it or stretching it away from the neck or continu­ ously rolling the tissues over and over should not be used, to avoid damaging its attachments to the underlying tis­ sues. The skin over the anterior neck tends to l oosen with aging. The elastic and collagen fibers are fragile and should be treated with special care to avoid inducing a 'saggy neck'.

300 CLI N I CA L A P P L I CATI O N OF N E U R O M U SC U LA R TEC H N I Q U E S : T H E U P PER B O DY jaw. This isometric contraction position is held for 7-1 0 lowered, one segment at a time, for subsequent isometric seconds. contractions and stretches. • Following release of the effort, a mild amount of exten­ • A slight movement (50) toward the neutral position sion (100) is introduced to effectively stretch the anterior should be produced before each contraction and subse­ muscles of the neck. quent stretch. • The practitioner gently leans backward so that a degree • Immediately discontinue stretching if any dizziness is of mild traction is introduced into the patient's cervical reported. spine. This traction is released extremely slowly. • To produce greater emphasis on stretching of one side or • The procedure is stopped if p ain or dizziness is reported. the other, a moderate degree of sidebend (about 20°) away from that side should be introduced prior to the 2. Seated. A general MET stretch involving most of the deep extension. and shallow muscles attaching to the anterior cervical spine, skull and hyoid bone is perfonned as follows (Fig. 11.56). STERN OCLEIDO MASTOI D (FIG. 1 1 .57) • The patient is seated and the practitioner stands at the Attachments: Sternal head: Anterior surface o f the sternwn side facing (in this example) the left side of the head. to the mastoid process and occipital bone (lateral half of • The practitioner's left hand wraps around the right side superior nuchal line) of the patient's head, palm of hand cupping the ear and Clavicular head: from the superior surface of the medial third mastoid, stabilizing the head finnly against the practi­ of the clavicle to blend with the tendon of the sternal head tioner's chest or upper abdominal region. and attach with it to the mastoid process and occipital bone • Female practitioners should introduce a shallow cusmon between the patient's head and their own torso, in order Innervation: Accessory nerve (cranial nerve XI) and to avoid inappropriate contact. branches of ventral rami of e2-4 cervical spinal nerves. • The use of an open or closed mouth to involve different May also include motor fibers from vagus nerve which structures as explained above should be noted. join at the jugular foramen (Simons et a1 1999) • The small finger of the practitioner's left hand is at the level of the p a tient's axis (e2) . Muscle type: Postural (type I), shortens when stressed • The practitioner's right hand stabilizes the posterior aspect Function: Unilaterally: rotates the head contralaterally (and of the neck in order to support it below the level of e3. • Traction is gently initiated as a slow movement is made tilts it upward) and sidebends the head and neck ipsilat­ into pure extension of the head and neck of about 10° at erally most. Bilaterally: flexes or extends the head, depending on the • The patient is asked to gently (20% of strength) take the position of the cervical vertebrae (see below), lifts the head and neck forward into flexion, as the practitioner head from the pillow when the patient is supine, may resists this effort, mainly with the left-hand contact. assist in forced inspiration (especially when the inter­ • The contraction is held for 7-10 seconds after which, with costals are paralyzed) traction still being maintained, a further 50 of extension is Synergists: For rotation: trapezius of the same side, con­ initiated and held for not less than 10 seconds. tralateral splenius capitis and cervicis, obliquus capitis • To introduce stretch into m uscles attaching more distal inferior and levator scapula than e3, the contact hand on the posterior neck can be For lateralflexion: scalenii, trapezius Forflexion of cervical column (see below): longus colli Fig u re 1 1 .56 Genera l cervica l stretch, seated, following isometric Sternocleidomastoid contraction. muscle Figure 1 1 .57 Composite referral patterns of SCM muscle. Drawn after Simons et al ( 1 999).

1 1 The cervical reg ion 301 Antagonists: For rotation: contralateral SCM and trapezius, (two vapocoolant dispensers, one of which may have been ipsilateral splenius capitis, splenius cervicis, levator used) the patient will [give] evidence [oJ] dysmetria by scapula and obliquus capitis inferior underestimating the weight of the object held in the hand on For lateral flexion: contralateral SCM, scalenii, trapezius the same side as the affected sternocleidomastoid muscle. Inactivation of the responsible sternocleidomastoid TrPs Ind ications for treatment promptly restores weight appreciation by this test. Apparently, the afferent discharges from these TrPs disturb • A diagnosis of atypical facial neuralgia, tension central processing of proprioceptive information from the headaches or cervicocephalangia upper limb muscles as well as vestibularfunction related to neck muscles. • Persistent dry cough or sore throat • Mimics trigeminal neuralgia and produces facial pain or Lymph nodes lie superficially a long the medial aspect of the SCM and may be palpated, especially when enlarged. These sca lp tenderness nodes may be indicative of chronic cranial infections stem­ • Blurred vision, perception of dimmed intensity of light ming from a throat infection, dental abscess, sinusitis or • Visual disturbances, eye pain, excessive lacrimation, tumor. Likewise, trigger points in SCM may be perpetuated by some of these conditions (Simons et aI 1999) . See Figure ptosis and difficulty raising the eyelid 11.18 for lymphatic system of the neck and Figure 12.39 for • Inflamed or congested sinuses lymphatic drainage pathways of head and neck. • Hearing loss and ear pain • Disturbances in orientation including postural dizziness, Lewit (1999) points out that tenderness noted at the medial end of the clavicle is often an indication of SCM vertigo, disequilibrium, ataxia, sudden falls and nausea hypertonicity. This will commonly accompany a forward head position and /or tendency to upper chest breathing Special notes and will almost inevitably be associated with hypertonici ty, shortening and trigger point evolu tion in associated muscu­ Sternocleidomastoid (SCM) is a prominent muscle of the lature, inclu ding scalenii, upper trapezius and levator anterior neck and is closely associated with the trapezius. scapula (see crossed syndrome notes on p. 82). SCM, along SCM often acts as postural compensator for head tilt associ­ with the splenii, have also been implica ted in spasmodic ated with postural distortions found elsewhere (spinal, torticollis (TS) (Hasegawa et al 2001, Deuschl et aI 1992). pelvic or lower extremity functional or structural inadequa­ cies, for instance) although it seldom causes restriction of f NMT FOR SCM neck movement. The patient i s supine and the practitioner is seated cephalad SCM is synergistic with anterior neck muscles for flexion to the head and positioned slightly away from mid-line on of the head and flexion of the cervical column on the tho­ the side to be trea ted . The pa tient's head is rotated approxi­ racic column, when the cervical column is already flattened mately 45° ipsilaterally and passively sidebent to shorten by the prevertebral muscles. However, when the head is the SCM so it may be lifted while also moved somewhat placed in extension and SCM contracts, it accentuates lor­ away from the carotid artery. There still remains an area dosis of the cervical column, flexes the cervical column on where the artery lies vertically deep to the now diagonally the thoracic column and a dds to extension of the head. In overlying SCM. Orienting the head and neck in this manner this way, SCM is both synergist and antagonist to the pre­ avoids positioning the SCM to overlie the entire length of vertebral muscles (Kapandji 1974). the artery and decreases the chance of disturbance of the artery. However, cau tion is exercised to avoid compression SCM trigger points are activated by forward head posi­ of the artery in all circumstances (Fig. 11.59). tioning, 'whiplash' injury; positioning of the head to look upward for extended periods of time and structural compen­ The SCM is compressed in a broad general release sations. The two heads of SCM each have their own patterns between the flattened fingers and opposing thumb of the of trigger point referral which include (among others) into same treating hand. The finger pads provide more effective the ear, top of the head, into the temporomandibular joint, compression against the opposing thumb pad than the fin­ over the brow, into the throat and those which cause propri­ ger joints do. As thickened bands or nodules are located in oceptive disturbances, disequilibrium, nausea and dizziness. the sternal head of SCM, the cranium may be placed in va ry­ Tenderness in SCM may be associated with trigger points in ing positions that stretch the fibers slightly while still allow­ the digastric muscle and digastric trigger points may be satel­ ing the muscle to be lifted and held in flat compression. The lites of SCM trigger points (Simons et al 1999). m uscle fibers may be rolled between the fingers and thumb gently to reveal more localized contractures. The bands are Simons et al (1999) report: examined through their entire length for thickenings associ­ ated with trigger point formation or for exquisitely tender When objects of equal weight are held in the hands, the patient with unilateral TrP involvement of the clavicular division [of SCM] may exhibit an abnormal weight test. When asked to judge which is heavier of two objects of the same weight that look alike but may not be the same weight

302 C L I N ICAL APPLICAT I O N OF N EU R O M USCU LAR TEC H N I Q U E S : T H E U PPER BODY Box 1 1 . 1 4 Balancing of the head on the cervical colamn External carotid artery Internal carotid artery Posterior belly of digastric muscle Figure 1 1 .58 T h e posterio r cervical m u scles counterbala nce Carotid triangle ---\\1'; the a nterio rly placed center of g ravity of the cra n i u m . Reproduced w i t h perm ission from Kapa n dj i (1 998). Superior belly of omohyoid muscle Common carotid artery --./- Sternocleidomastoid muscle ---_+t Figure 1 1 .59 The ca rotid a rtery cou rses deep to SCM. Hand is carefu l ly placed to avoid com p ression o r d isturbance of this i m po rta n t structu re. Reprodu ced with perm ission from Gray's Anatomy for Students (2005). The head is in eq uil ibrium when the eyes look horizontal ly. In this Figure 1 1 .60 The sternal head of SCM is examined with pi ncer position the plane of the bite, shown here by a piece of cardboard com pression a t t h u m b-width i n terva ls from the mastoid process to held tightly between the teeth, is also horizontal, as is the the sterna I a ttach ment. auriculo-nasal plane (AN), which passes through the nasa l spine and the superior border of the external auditory meatus. The head taken as a whole constitutes a lever system : • B is the plane of the bite • C is the cord subtending the a rc • P is the perpendicular • the fulcrum 0 lies at the level of the occipital condyles • the force G is produced by the weight of the head appl ied through its centre of g ravity lying near the sel la turcica • the force F is produced by the posterior neck muscles which constantly counterbalance the weight of the head, which tends to tilt it forwards. Th is anterior location of the centre of g ravity of the head explains the strength of the posterior neck muscles relative to the flexor muscles of the neck. In fact. the extensor muscles counteract gravity whereas the flexors a re helped by g ravity. This also explains the constant tone in these posterior neck muscles preventing the head from tilting forwards. When one sleeps while sitting the tone of these muscles is reduced and the head fa lls ... [toward) the chest. (Kapandji 1 974)

1 1 The cervical region 303 Figure 1 1 . 61 Sternal a n d clavic u l a r attachm ents of SCM a re g e n tly carotid artery is relatively exposed a few inches inferomedial to the attachment. Additionally, lubrication used for gliding frictioned. will need to be removed or a thin cloth or paper tissue laid over the tendon so that grasping fingers do not slip when the spots . When active loci are found, pressure is applied into subsequent compressions are applied. the suspected myofascial tissue to meet and match the ten­ sion of the contracture. The patient should report a mid­ The clavicular head of SCM can sometimes be distin­ range on the discomfort scale and may describe referral guished from the overlying sternal head if they are allowed to patterns for active (recognized pattern) or latent (unfamiliar gently (intentionally) slip between the grasping fingers. Once pattern) trigger points. The fingertips (rather than finger isolated, the full length of the clavicular head may sometimes pads) often provide a more precise compression against the be addressed in the same grasping, compressional manner thumb once bands have been identified. used for the sternal head. However, the deeper head is often difficult to grasp, even when the cranium is repositioned to Duplication of the patient's sy mptoms, particularly those shorten it . If it cannot be isolated for compression without which agree with known referral patterns for that muscle, intrusion into the underlying tissues, stretching techniques indicate a trigger point has been located and local twitch may be used to elongate its fibers and to soften them. They responses, when seen or felt, serve as confirmation. Trigger may eventually be distinguished, either at the end of the ses­ point pressure release is applied to any trigger pOints sion or at subsequent sessions. The clavicular attachment is found. The tissue can be gently taken into stretch as com­ often very tender when friction is applied. Static pressure may pression is applied, if appropriate. be substituted or ice applications used until central trigger points are deactivated and stress on the attachment is reduced. The compression techniques can be applied in thumb­ width intervals from the upper portion of the belly of the Longissimus capitis and splenius capitis attachments may sternomastoid head to the sternal attachment site. The treat­ sometimes be influenced on the mastoid process deep to the ing hand may need to be pronated as it nears the thorax to SCM attachment. The head lies on a bolster or wedge to bring better reposition the fingers for grasping near the attachment. it into supported flexion of around 45° which passively short­ The sternal attachment may be frictioned if not too tender but ens the SCM. The patient must completely relax the SCM and it is often the site of exquisite tenderness (Fig. 11 .61 ). can therefore offer no assistance in maintaining head position. The head is rotated contralaterally to access the posterior The occipitomastoid attachment of both heads of the SCM (medial) aspect of the occipital attachment of SCM. If the SCM can often be grasped between the thumb and first two fingers tendon has been softened, the practitioner's thumb or finger­ close to the cranial attachment. Sometimes separation of the tips may be able to displace the most posterior fibers and slide clavicular and sternal heads is distinct; however, often the tis­ slightly under the SCM's most posterior (medial) edge . This sue will feel thick, indistinct, fibrotic or otherwise undefined. step may also be applied with the head in ipsilateral rotation Short gliding strokes applied with the thumb (or fingers) (without elevation), which utilizes the weight of the cranium may be used to soften the tendons and uppermost portions of to create pressure on the attachment site. The fingers displace muscle fibers so that they may eventually be lifted and the most medial fibers while also applying pressure on as grasped. The gliding strokes must be kept short since the much of the cranial attachments as possible under the edge of the SCM. Static pressure or light friction may be used with either head position. ,. T R EAT M E N T O F S H O RT E N E D S C M U S I N G M ET , (FIG. 11 .62) The patient is supine with the head supported in a neutral position by one of the practitioner's hands. The shoulders rest on a cushion, so that when the head is placed on the table it will be in slight extension. The patient's contralat­ eral hand rests on the upper aspect of the sternum to act as a cushion when pressure is applied during the stretch phase of the operation. • The patient's head is fully but comfortably rotated con­ tralaterally. • The patient is asked to lift the fully rotated head a small degree toward the ceiling and to hold the breath. • When the head is raised there is no need for the practitioner to apply resistance as gravity effectively provides this.

304 CLI N I CAL A PPLICATIO N OF N EU RO M U SCU LAR TECH N I QUES: T H E U PPER BODY Fig u re 1 1 .62 M ET trea tment of sternocleidomastoid. Figure 1 1 .63 Sternocleidomastoid positional release. Reproduced with permission from Deig (2001 J. • After 7-10 seconds of isometric contraction with breath held, the patient is asked to slowly release the effort (and the tender point side while the patient reports on the the breath) and to allow the hea d / neck (still in rotation) level of pain/discomfort in the palpated point. to be placed on the table, so that a small degree of exten­ • When this reduces to 3 or less, it is held for 30-90 sec­ sion is allowed. onds, after which the head and neck are slowly returned to neutral. • The practitioner 's hand covers the patient's 'cushion' hand (which rests on the sternum) in order to apply S U PRAHYO I D M USCLES oblique pressure /stretch to the sternum to take it away from the head and toward the feet. The suprahyoid muscles attach the hyoid bone to the mandible (and to the cranium) while also positioning it in • The hand not involved in stretching the sternum caudally relationship to the cervical spine. The positioning of the should gently restrain the tendency the head will have to hyoid bone, trachea and larynx/pharynx is critical since the follow this stretch, but should not apply pressure under air passageway lies between the hyoid and the cervical any circumstances to stretch the head/neck while it is in spine (approxima tely C3-4) as well as between the trachea this vulnerable position of rotation and slight extension. and the lower cervical spine. • The degree of extension of the neck should be slight, The suprahyoid muscles should be treated with the 1 0-15° at most. infrahyoids in cases of reduced cervical lordosis as together they contribute to flexion of the neck, acting as the long arm • This stretch, which is applied as the patient exhales, is of a lever. When the mandible is fixed by the mandibular maintained for not less than 20 seconds to achieve elevators, the supra- and infrahyoid muscles flex the head release/ stretch of hypertonic and fibrotic structures. on the cervical column, as well as the cervical column on the thorax. Positioning in this way will also produce a flatten­ • The other side should then be treated in the same manner ing (reduction) of cervical curvature (Kapandji 1974). CAUTION: Care is required, especially with midd le-aged The suprahyoid muscles are discussed in detail in Chapter 12 together with the cranium and craniomandibu­ and elderly patients, in applying this useful stretching pro­ lar muscles due to their obvious role in hyoid and mandibu­ lar positioning as well as their physical contribution to the cedure. Appropriate tests should be carried out to evaluate floor of the mouth. The suprahyoid muscles are easily pal­ pable from an intraoral aspect, which especially addresses cerebral circulation problems (p. 257, Box 11.5) that, if pre­ the bellies of the muscles. If attachments along the inferior sent, suggest that this particular MET method be avoided. surface of the mandible are tender to palpation, the intrao­ ral trea tment described on p. 385 is suggested. �. P O S IT I O N A L R E L EASE O F ,STERNOCLEIDOMASTOI D I N FRAHYO I D M USCLES (FIG. 1 1 .64) • The main tender point for the sternocleidomastoid muscle The infrahyoid muscle group consists of the sternohyoid, is located on the superior surface of the clavicle, approxi­ sternothyroid, thyrohyoid and omohyoid muscles. This rna tely 1 inch (2.5 cm) lateral to the sternoclavicular joint. • The practitioner sits at the head of the supine patient and palpa tes the tender point with the ipsilateral hand with sufficient pressure for the patient to register discomfort that is ascribed a value of '10'. • The practi tioner's other hand eases the patient's neck into flexion, sideflexion toward, and rotation away from

1 1 The cervical reg ion 305 Hyoid bone ---_+! __----- tnternat jugular vein ..1. --- --- Thyrohyoid muscle Thyroid cartilage -----1..-. Omohyoid muscle ------#-�... --- Common carotid artery Cricoid cartilage -----H,- -l..� l---- Sternothyroid muscte Sternohyoid muscte ----W-I JfM+.____.'-fI:- H- Figure 1 1 .64 Su pra- and infra hyoid m uscles control posi tioning of the hyoid bone, w h ich, a mong other functions, assists in maintaining a n adeq uate a i r passageway. Reprod u ced w i th permission from Gray's Anatomy for Students (2005). group stabilizes and depresses the hyoid bone and, acting of the hyoid bone, its fibers merging with the contralat­ with the suprahyoid muscles, contributes to flexion of the eral sternohyoid near the mid-belly cervical column when the mouth is closed. Innervation: Ansa cervalis (Cl-3) Muscle type: Phasic ( type II), weakens when stressed Since somatovisceral referrals are known to occur in Function: Depresses the hyoid bone (especially from an ele- other body areas (see p . 47), it would be logical that tissues vated position during swallowing); functions with the overlying the thyroid gland might have influence on glan­ infrahyoid group to flex the cervical column with the dular function. Infrahyoid muscles, sternocleidomastoid mouth closed and scalenii should be examined when glandular dysfunc­ Synergists: For hyoid movement: sternothyroid / thyrohyoid tions are noted due to their proximity to the thyroid and unit, omohyoid parathyroid glands. For hyoid stabilization: suprahyoids and remaining infrahyoids STE R N O HYO I D For flexion of cervical column: longus colli, longus capitis, sternocleidomastoid, scalenii, rectus capitis anterior and Attachments: Posterior surface of the manubrium sternum, lateralis, suprahyoids and remaining infrahyoids the medial clavicle and the sternoclavicular ligament to Antagonists: To hyoid movement: suprahyoid muscles attach to the inferior border and inner surface of the body To flexion of cervical column: posterior cervical muscles

306 C L I N ICAL A P P L I CAT I O N OF N E U R O M USCU LA R TECH N I Q U E S : THE U P P E R B O DY Ind ications fo r treatment Function: Depresses the hyoid bone; eleva tes the larynx; functions with the infrahyoid group to flex the cervical • Dysfunction in hyoid bone movement during swallowing column with the mouth closed • Preparation for prevertebral treatment (longus colli, Synergists: For hyoid movell1ent: sternohyoid, sternothyroid, longus capitis) omohyoid • Difficulties in swallowing For hyoid stabilization: suprahyoids and remain.ing infrahyoids STERNOTHYR O I D Forflexion of cervical column: longus colli, longus capitis, sternocleidomastoid, scalenii, suprahyoids and rema in­ Attachments: Posterior surface o f the manubri um sternum ing infrahyoids and from the 1st rib cartilage to the thyroid cartilage Antagonists: To hyoid movement: suprahyoid muscles Innervation: Ansa cervalis (Cl-3) Toflexion ofcervical column: posterior cervical muscles Muscle type: Phasic (type II), weakens when stressed To elevation of the larynx: sternothyroid Function: Depression of larynx, depression of hyoid bone I nd i cations for treatment when acting as a unit with thyrohyoid; functions with the infrahyoid group to flex the cervical column with the • Dysfunction in hyoid bone movement during swallowing mouth closed • Preparation for prevertebral trea tment (longus colli, Synergists: For hyoid movemen t: sternohyoid, thyrohyoid, omohyoid longus capitis) For hyoid stabilization: suprahyoids and remaining • Changes in voice or voice range (la rynx positioning) infrahyoids Forflexion of cervical column: longus colli, longus capitis, O M O HYO I D sternocleidomastoid, scalenii, suprahyoids and remain­ ing infrahyoids Attachments: The inferior belly of this t\\ivo-bellied muscle Antagonists: To depression of larynx: thyrohyoid arises from the upper margin of the scapula near the To hyoid movement: suprahyoid muscles scapular notch and its superior belly from the lower bor­ Toflexion of cervical column: posterior cervical muscles der of the hyoid bone lateral to the insertion of sternohy­ oid. The two bellies are joined by a central tendon which is Ind i cations fo r treatment ensheathed by a fibrous loop which may extend to the deep cervical fascia and attaches to the clavicle and 1st rib • Dysfunction in hyoid bone movement d uring swallowing • Preparation for prevertebral treatment (longus colli, Innervation: Ansa cervicalis profunda (Cl-3) Muscle type: Phasic (type II), weakens when stressed longus capitis) Function: Depresses the hyoid bone; tenses deep cervical • Changes in voice range (larynx positioning) • Difficulties in swallowing fascia which reduces the possibility of soft tissue being sucked inwardly d uring respiration; dilates the internal Special notes j ugular vein; functions with the infrahyoid group to flex the cervical column with the mouth closed Sternothyroid draws the larynx downwards during swal­ Synergists: For hyoid movement: sternohyoid, sternothyroid, lowing and speech and during the singing of low notes, for thyrohyoid example. The linkage between the sternum and the hyoid For hyoid stabilization: suprahyoids and remaining allows this muscle to influence crania l mechanics. infrahyoids For flexion of cervical column: longus colli, longus capitis, The fibers of sternothyroid lie in direct contact with the sternocleidomastoid, scalenii, suprahyoids and remain­ anterolateral surface of the thyroid gland and should be ing infrahyoids exam ined and treated with all glandular dysfunctions. Antagonists: To hyoid movement: suprahyoid muscles However, ca u tion should be exercised to avoid frictioning Toflexion of cervical column: posterior cervical muscles directly over where the gland lies. Further studies are needed to assess the trigger point referral patterns of the I nd ications for treatment infrahyoid muscles and their possible role in neck, throat, thyroid, voice and TM] dysfunctions. • Dysfunction in hyoid bone movement during swallowing • Preparation for prevertebral treatment (longus colli, THYROHYO I D longus capitis) A ttachments: Anterior surface of thyroid cartilage to the lower portion of the greater horn and body of hyoid bone The extraordinary connections of this muscle, linking as it does the scapula, clavicle and hyoid bone (which via other Innervation: Hypoglossal nerve attachments links it indirectly to the mandible), give some idea Muscle type: Phasic (type II), weakens when stressed of the potential for cranial problems arising from numerous

1 1 The cervical region 307 influences on these structures, includ ing respiratory and pos­ \\� tural dysfunctions. Omohyoid may arise from the clavicle instead of the scapula and, if so, would be referred to as the cleidohyoid muscle. It N M T FOR I N FRAHYO I D M US C L E S \\� CAUTION: The treatment protocols of the superficial and Carotid deep anterior cervical muscles are some of the most deli­ artery cate and precise used in NMT. They are to be approached with extreme caution due to the proximity of the carotid B artery and the thyroid gland. Training (with hands-on supervision) is strongly recommended prior to practice of Fig u re 1 1 .65 The infra hyoid gro u p is exam ined a t fingertip i n terva ls any anterior neck techniques. from the hyoid bone (A) to the cricoid cartilage (8). Extreme The practitioner stands at shoulder or chest level of the CAUTION is exercised to avoid the carotid a rtery (immediately supine patient and faces the throat. The hyoid bone is stabi­ latera l to the edge of the hyoid bone and thyroid carti lage) and the lized with the index finger of the practitioner's most caudal thyroid gland (ca udal to the cricoid cartilage). See text for hand by reaching across the patient to the opposite greater CAUTIONS. horn of the hyoid bone and carefully placing the index fin­ ger on its outer surface. Cau tion must be exercised to stay in The anterior surface of the stabilized thyroid cartilage is contact with the hyoid bone and not allow the stabilizing treated in this compressional or frictional manner until the finger or i ts posteriorly oriented fingertip to venture off the cricoid cartilage (first cartilaginous ring of the trachea) is lateral edge of the hyoid bone where the carotid artery reached at approxima tely mid-way between the hyoid bone resides. Additionally, the hyoid bone must not be pressed and the sternal notch. Extreme care is used at the most lat­ posteriorly but only stabilized enough to discourage its eral aspects of the hyoid bone and the thyroid cartilage movement when frictional techniques are used. With the index finger of the practitioner's cephalad hand, gentle friction may be applied to the supra- and infrahyoid muscles on the superior, anterior and inferior aspect of the hyoid bone. Caution must be exercised to keep the trea ting finger in contact with the hyoid bone and not allow it to slide or be accidentally placed lateral to the edge of the hyoid bone or thyroid cartilage due to the location of the carotid artery (Fig. 11 .65A). The stabilizing finger is reloca ted to the thyroid cartilage on the contralateral side. The treating finger is placed on the uppermost medial aspect of the anterior surface of the thyroid cartilage and is used to press the overlying infrahyoid muscles onto the thyroid cartilage where sta tic pressure or gentle trans­ verse friction is used to assess their fibers. When the p roper pressure is used, the vertical fibers may be distinctly felt as they are caph.lred against the underlying cartilaginous surface or as the treating finger is slid across them in gentle frictional movements. If too little pressure is used, the skin will merely slide over the muscles and benefit of treatment will be sig­ nificantly reduced. Too much p ressure might press the entire stnlcture posteriorly into the esophagus, longus colli, longus capitis and the anterior surface of the cervical vertebrae. The right amount of pressure will meet and match the ten­ sion found in the tissues and elicit a mid-range response on the patient's discomfort scale if tension exists in the tissues. The treating finger is moved laterally one fingertip width and the frictional work repeated. It may be moved laterally once more in most cases, depending upon the size of the practitioner's hands and the width of the patient's cartilage (Fig. 11 .658).

308 CLI N I CA L A P P LI CATI O N OF N E U R O M U S C U LA R TEC H N I QU E S : THE U P P E R B O DY Thyroid cartilage Cricoid cartilage Figure 1 1 .67 Technique for opening the thyrocricoid visor. Reproduced with permission from the Journal ofBodywork and Movement Therapies 1 999 ; 3 (3) : 1 41 . Figure 1 1 .66 With the h ead passively e l evated and the patient Pitch control is primarily controlled by the thyrohyoid mus­ holding a deep breath, attachment of the sternohyoid and cles. To treat these muscles, the patient lies supine and the sternothyroid may be reached (on some patients) on the posterior [practitioner]fixes on the thyroid cartilage with theforefin­ aspect of the sternum. ger and thumb ofone hand whilst the other handfixes on the inferior border of the hyoid with a finger and thumb. The along their full length t o avoid allowing the treating finger cartilages are then held apartfor 20 seconds byfixing on one to go laterally beyond the edge of the cartilage (even mildly and moving the other. This stretch should be given in an during friction) as the carotid artery runs vertically the inferior, superior direction and a lateral direction. entire length of these structures. Friction applied near the lateral edge should be unidirectional toward the mid-line It is essential to treat the cricothyroid visor, if it is locked which adequately transverses the muscular fibers while in position due to a restricted cricothyroid muscleforfunc­ avoiding contact with the artery. tion of the vocal cords. These muscles are of particular importance as thetj affect the vocal folds directly. If the Caudal to the cricoid cartilage, the thyroid gland lies rel­ cricothyroid muscles are short and the visor mechanism atively exposed, covered only by the skin, cervical fascia locked they create an unhealthy stretching and elongation of and the thin infrahyoid muscles. Frictional or compres­ the vocalfolds. To open the visor, the thumb tip ofone hand sional techniques (either flat or pincer) are not used caudal is placed on the anterior surface of the cricoid, whilst the to (below) the cricoid cartilage since the thyroid gland other thumb tip is placed on the inferior aspect ofthe thyroid would most likely be intruded upon. These lower portions cartilage, gentle pressure is applied to both cartiLages to of the fibers are easily stretched (in most cases) by extension open the visor. of the head and neck with the mouth closed. Among the posttreatment effects, the patient might note a The patient's head is supported with a wedge or pillow in drop in pitch and increased resonance of voice, decrease in passive flexion at approximately 45° (chin toward chest). The pain and discomfort, decreased tenderness in musculature practitioner's treating fingertip is placed on the posterior sur­ and decreased hoarseness when these associated symptoms face of the sternal notch. As the patient takes in and holds a have been present. Spray and stretch applications for the deep breath, the sternum will lift away from the thorax and anterior neck, as discussed by Simons et al (1999), could (sometimes dramatically) allow the finger to penetrate fur­ also be isolated to these tissues and the myofascial release ther (Fig. 11 .66). The finger is swept first to one side and then described above used . the other while maintaining a firm contact onto the posterior surface of the sternum where the sternohyoid and sternothy­ � LONGUS COLLI (FIG. 1 1 .68) roid muscles attach. Static pressure may be used if the attach­ ments are too tender for frictional techniques. Attachments: Superior oblique portion: anterior tubercles of transverse processes of C3-6 to the anterior tubercle of '�S O FT T I SS U E T E C H N I QU E D E R I V E D F R O M the atlas \" OSTEO PATH I C M ET H O D O LOGY Inferior oblique portion: from the first three thoracic verte­ bral bodies to the anterior tubercles of transverse Simone Ross (1999), i n discussing osteopathic approaches processes of C4-7 (varies) to dysphonia, describes the following safe soft tissue treat­ Vertical portion: from the vertebral bodies of C5-T3 to the ment technique (Fig. 11 .67). vertebral bodies of C2-4

\" The cervical region 309 h-flF--\" Rectus capitis anterior muscle -.-.:,a Rectus capitis lateralis muscle �--i�t'r Longus capitis muscle ,.. .-. ---- Levator scapula muscle }.�f-iI.<-�\\r Longus colli muscle AnteriOr 'rI'I.-- Middle Scalene muscles Posterior .-.-d�'\" Phrenic nerve Figure 1 1 .68 Prevertebral a n d lateral vertebral muscles. Reproduce d w i t h permission from Gray's Anatomy for Students (2005). Innervation: Ventral rami (C2-6) Synergists: For lateral flexion and contralateral rotation: Muscle type: Not established scalenii, SCM, longus colii, levator scapula (Warfel 1985) Function: Unilaterally, sidebends and contralaterally For cervicalflexion: longus colli, suprahyoids, infrahyoids, rectus capitis anterior, SCM (when the neck is a lready rotates the neck; bilaterally, flexes the cervical spine flexed) Synergists: For lateralflexion and rotation: ipsilateral scalenii, Antagonists: To lateral flexion and rotation: contralateral scalenii, SCM, longus capitis, longus colli, contralateral SCM, longus capitis, levator scapula (Warfel 1985) levator scapula Forflexion: longus capitis, suprahyoids, infrahyoids, rectus To cervical flexion: posterior suboccipitals, posterior cervi­ capitis anterior, SCM (when the neck is already flexed) cal muscles, SCM (when the neck is already extended) Antagonists: To lateral flexion and rotation: contralateral scalenii, contralateral levator scapula, SCM, longus capi­ Indication for treatment of prevertebral tis, longus colli m u sc l e s To cervical flexion: posterior cervical muscles, SCM (when the neck is already extended) • Difficulty swallowing • Diagnosis of loss of cervical lordosis or 'mil itary neck' LONGUS CAPITIS • Unstable cervical column • Unstable atlas Attachments: Anterior tubercles o f the transverse processes • Chronic posterior cervical myofascial dysfunction of C3-6 to the basilar part of the occipital bone • Chronic dysfunctions elsewhere in the spinal colunm Innervation: Ven tral rami of Cl-3 (compensatory) Muscle type: Phasic (type II), weakens when stressed • Loss of vertical dimension of cervical discs Function: Unilaterally, rotates the neck contralaterally and • Posterior protrusion of cervical discs flexes the head to the same side; bilaterally, flexes the head and neck

CLI N I CAL A PPLI CAT I O N O F N E U RO M U S C U LA R TEC H N I QU E S : T H E U P P E R B O DY Vertebral artery -----------t-If---:-'i �\\ ,.- C6 vertebral body ---. �-- Esophagus __-_ - Trachea Inferior thyroid artery ---, Oeep cervical arte�ry ---, �,r-.-rT.'nI Ascending cervical artery Supreme intercostal artery ---. \\W\\'\\'-\\' <------- Anterior scalene muscle Costocervical trunk ---. �;iI-=;�. Transverse cervical artery Thyrocervical trunk -----A-:; ��-..I1=1 C�-� Suprascapular artery Right subclavian �-- Left subclavian artery ---: artery ,.'t-��- Internal thoracic Rib 1 --4.1- artery '--j� Left common carotid artery Figure 1 1 .69 Sca lenus a n terior, longus col l i a n d longus capitis are removed from the l eft side of this d ra w i ng to revea l attachment of sca lenus m edius deep to it Also visible is the cou rse of the vertebra l a rtery t h rough the transverse process of the cervical reg ion. Reproduced with perm ission from Gray's Anatomy for Students (2005). Special notes The deep anterior cervical muscles produce flexion of the head and neck and therefore reduce the cervical curva ture. Longus colli and longus capitis lie on the anterior surface of When shortened, they can increase anterior pressure on the the vertebral bodies of the cervical spine. Superficial to them discs and can contribute to posterior protrusion of the disc lie the hyoid bone, thyroid cartilage, larynx, pharynx, esopha­ into the spinal cord. Unilaterally, they also sidebend and gus and trachea. Irnur ediately lateral to these structures, the rotate the column and therefore may be involved in scoliotic carotid arteries run vertically as they pass through the cervical and other compensatory postural dysfunctions originating region to serve the cranium. All of these surrounding struc­ in other aspects of the spinal column or elsewhere in the tures require that extreme caution be exercised in the assess­ body. The number of muscle slips for each varies grea tly as ment and treatment of the prevertebral muscles. Fingernails do their individual attachmen ts. of the treating fingers should be cut short and filed smooth. The superficial muscles of the anterior neck should Hoppenfeld (1976) notes: 'Difficulty or pain upon swal­ always be treated before the longus colli and capitis to help lowing may be caused by cervical spine pathology such as release tension of the muscles covering the thyroid carti­ bony protuberances, bony osteophytes, or by soft tissue lage. The superficial structures must all be displaced in swelling due to hematomas, infection, or tumor in the ante­ order to reach the prevertebral muscles. Tension in the over­ rior portion of the cervical spine.' If the patient reports diffi­ lying 'strapping' muscles may prevent the structures from culty swallowing or if the practitioner encounters suspicious being moved sufficiently to allow room for manual treat­ tissue, it is important to rule out these (as well as esophageal) ment to be applied. pathologies prior to treatment of the deep cervica l muscles.

11 The cervical region 3 1 1 Inflammation and tendonitis of longus colli muscle has Figure 1 1 .70 Skin is first d isplaced towa rd the side to be treated to been implica ted as the primary cause of retropharyngeal create excess i n order to provide a more flexible su rface t h rough tendonitis, an acute inflamma tory condition that produces which to pal pate after the more superficial structu res a re d isplaced. gradually increasing neck pain, associated with throat pain See text for deta i l s and i m porta n t caution s. and difficulty swal lowing (Fahlgren 1988, Ring et al 1994). pressure receptor nerve endings (baroreceptors) associated This condition, though not common, is frequently over­ with blood pressure (Leonhardt 1986). Stedman 's Medical Dictionanj (2004) notes tha t disturbance looked (Fahlgren 1988). of the carotid sinus might ca use a slowing of the heart or an Specific referral patterns for most of the deep anterior cervi­ uncontrolled fall in blood pressure. Additionally, the carotid glomus, a small organ whose chemoreceptors are ca l muscles have not been established. Simons et al (1999) note sensitive to the partial pressure of oxygen in the blood, is a lso housed in the same location. that they can refer to the anterior neck, laryngeal region and mouth. The anterior neck region is in clear need of research If there is insufficient room between the artery and the dis­ regarding many areas of myofascial pain and dysfunction. placed thyroid cartilage for the trea ting finger to be placed, CAUTION: The treatment protocols of the deep anterior the structures are gently allowed to return to their original cervical muscles are among the most delicate and precise position. This displacement can be applied again to reevalu­ used in N MT. They are to be approached with extreme a te the conditions for treatment. When there is insufficient caution due to the proximity of the carotid artery, vocal room to trea t the tissues manua lly, positional release, muscle cords and the thyroid gland. Training (with hands-on energy techniques or other stretching methods may be sub­ supervision) is STRONGLY recommended prior to prac­ sti tuted. Under no circumstances should the treatment be tice of these techniques. applied if the arterial pulse has not been located or is found to be too close to the mid-line to allow safe application. It N MT FOR LO N G U S C O L L I AN D CA PITIS If the space between the arterial p ulse and the displaced The supine patient is facing toward the ceiling (head in neu­ thyroid cartilage is at least slightly wider than the treating tral position) and the practitioner is standing a t the level of finger, the finger may be placed onto the anterior surface of the upper chest and facing the cervical region. The thumb of the vertebral bodies as high as the overlying tissues will the practitioner's ca udal hand is used to displace the hyoid bone, thyroid cartilage, esophagus and trachea away from allow (Fig. 1 1 .71 ) . This p lacement is usually about the C3 or the side being treated. A l l movements of these structures should be performed slowly, gently and w i th extreme C4 level, which is approximately level with the hyoid bone. regard for the carotid arteries, as directed below. The finger is then gently pressed into the tissues (toward the treatment table), which captures the muscles gently I t may be necessary to create 'extra skin' to avoid stretch­ against the anterior su rface of the underlying vertebra . The ing the superficial tissues, which creates a taut, inflexible fibers of longus colli and longus capitis are usually palpable surface through which it is difficult to feel the underlying when taut and may a lso be moderately tender. Static pres­ tissues. To assure a softer skin surface, 'extra skin' is first sure or gentle, very na rrow transverse fric tion may be displaced toward the side being treated by starting with the applied while being extremely careful not to disturb the pad of the prac titioner 's caudal thumb past the mid-line of carotid artery l a teral ly. The palpa ting finger may discern the rounded surface of the discs between the vertebral bod­ the thyroid cartilage and hyoid bone (Fig. 1 1 .70) . The thumb ies or the hard protrusions of an terior calcific 'spurs'. Caution must be exercised to avoid excessive pressure onto is moved laterally along w i th the underlying skin toward the side being treated. Wi thout releasing the displaced skin, the underlying structures are then contacted by pressing through the skin and onto the ipsilateral edge of the thyroid cartilage. The cartilage is lifted slightly away from the underlying muscles (toward the ceiling) as all the superfi­ cial structures a re moved contra laterally so tha t their la teral edge lies just past the mid-line. All downward (toward the cervical vertebrae) pressure is avoided as this would cause the superficial structures to scrape across the muscles as they are being displaced. Once the structures are displaced to the mid-line or fur­ ther, the carotid a rtery must be precisely located to ensure that there is enough room for one finger to be placed on the anterior surface of the cervical column. An index finger is placed gently onto the carotid ar tery and the p u lse located. Extreme caution must be exercised not to friction the pal­ pa ting finger, nor to disturb the artery in any way. A t the bifurcation of the artery is the carotid sinus, which contains

3 1 2 C LI N I CA L A P PLI CAT I O N O F N E U R O M USCU LAR TEC H N I Q U E S : T H E U P P E R B O DY )\\ the table. The practitioner stands facing the left side of the head (which is clear of the end of the table) and firmly Figure 1 1 .71 After the trachea, hyo id bone and thyro id ca rti lage supports it. a re d isplaced, the carotid pu lse is ca refu l ly located to assess if • The practitioner's right hand grasps the right side of the adequate space is available for palpation of longus colli and longus patient's occiput while stabilizing the head against the capitis (shown here). Extreme CAUTION is exercised to avoid any practitioner's trunk with the head in a neutral position. contact w i th the ca rotid artery as gentle friction or static p ressure is • The practitioner's left forearm and hand lie across the applied. Th is technique is not recommended w i thout prior hands-on, pa tient's chest with the hand on the patient's right shoul­ s u p e rv i se d . der, pressing it onto the table. • Using this hold, the practitioner applies gentle cephalad the discs or onto the spurs to avoid damaging the tissues. traction in order to take out slack and then introduces The disc should never be pressed posteriorly in any attempt slight (100 maximum) ex tension, sidebending and rota­ to relocate it, as its anterior fibers may well be weak due to tion to the left (so stretching right-side longus capitis) by anterior protrusion and possible associated weakness of the means of the firm occipital hold and body movement. anterior longitudinal ligament. • When slack has been taken out the patient is asked to gently sideflex and turn the head back toward the right, The trea ting finger is placed one fingertip caudally and against resistance, for 5-7 seconds. static pressure or gentle friction applied again. This applica­ • When this effort ceases, the traction, extension, sidebend­ tion may be continued caudally as far as possible as long as ing and rotation are then increased slightly by the practi­ the displacement of the structures and the location of the tioner and held for 10 seconds. artery allow it. In the lower cervical region (approximately • This stretch effectively includes most of the anterior C5 or the level of the cricoid cartilage), the patient may feel throat musculature including the various hyoid-related the urge to cough or experience a 'choking' feeling, regard­ structures and pla tysma, as well as rectus capitis anterior. less of how gently the practitioner is working. At this point, • No force should be used and no pain produced by the the treatment is cUscontinued and the structures allowed to procedure and the treatment should be stopped if dizzi­ rest in normal position. ness is reported. • Repeat on the opposite side. The procedures are repeated to the other side and the entire protocol repeated after a short rest. These prevertebral mus­ RECTUS CAPITIS ANTERIOR cles usually respond guickly to manual treatment and very often one or two treatments produce a profound change in the Attachments: Anterior aspect of the lateral mass of the atlas tissue tension. Stretching technigues (as d irected below) may and the root of its transverse process to the inferior sur­ follow these steps and may be given as 'homework' unless face of the basilar portion of the occipital bone j ust ante­ contraindicated d ue to ligamentous or disc damage. rior to the occipital condyles It M ET STR ETCH O F L O N G U S CAPITIS Innervation: Ventral rami of Cl-2 or C3 Muscle type: Phasic (type II), weakens when stressed CAUTION: Stretching with the head in extension can be Function: Flexes the head on the atlas dangerous if circulation to the cranium is i n any way com­ Synergists: Longus capitis, sternocleidomastoid (when the promised (see p. 257). cervical spine is a l ready in flexion) • To treat the right longus capitis, the patient is supine and Antagonists: Rectus capitis posterior major and minor, positioned so that the head extends beyond the edge of splenius capitis, semispinalis capitis, trapezius, SCM (when the cervical spine is already in extension) I nd ications for treatment • Loss of ex tension of cranium Special notes This m uscle is sometimes called the rectus capitis anterior minor when the longus capitis is referred to as the rectus capitis anterior major. However, more current texts refer to them as rectus capitis anterior and longus capitis. Trigger point referral patterns from or to these deep anterior cervi­ cal tissues have yet to be established. According to Upledger & Vredevoogd (1983), bilateral hypertonicity of either longus capitis or rectus capitis anterior

1 1 The cervical region 3 1 3 inhibits occipital flexion and unilateral hypertonicity would be likely to produce torsional forces at the cranial base ( the sphenobasilar junction). The possibility of such a torsion occurring in an adult skull is remote once ossification has taken place. Longus capitis may be reached behind the posterior pha­ ryngeal wall through the open mouth (Simons et aI 1999). If rectus capitis anterior can be palpated, it would be in a sim­ ilar manner, through the longus capitis, deep to the upper­ most portion of its fibers. However, this is a difficult technique and requires Significant skill. It is doubtful whether it could be reached otherwise. Muscle energy teclmiques and active stretches involving flexion and extension of the (isolated) altlantooccipital joint will address rectus capitis anterior and lateralis, longus capi­ tis and the upper posterior suboccipitals. Extension stretches should be sparingly and carefully applied due to the location of the vertebral artery in the suboccipital triangle. R E CTUS CAP I T I S LAT E R A L I S Figu re 1 1 . 7 2 The styloid process i s first located a n d pressure o n i t avoided w hen attempting to locate the anterior aspect of the Attachments: Upper surface o f the transverse process o f the transverse process. atlas to the inferior surface of the j ugular process of the occipital bone as sharp. The fingernail of the treating finger should be cut short and filed smooth. Innervation: Ventral rami of Cl-2 Muscle type: Phasic (type II), weakens when stressed The external carotid artery and hypoglossal nerve course Function: Unilaterally, slight lateral flexion of the cranium near the styloid and transverse processes. Care must be taken not to occlude the neurovascular structures against to the same side; bilaterally, flexes the head on the a tlas the osseous elements. Synergists: For head flexion : suprahyoids and infrahyoids f N MT F O R R E CT U S CAP I T I S LATE R A LI S when the mouth is closed, rectus capitis anterior, SCM (when the neck is already flexed), longus capitis CAUTION: This NMT procedure shoul d be carried out For lateral flexion of the head: ipsilateral obliquus capitis superior, scalenus medius when it attaches to the atlas, w i th extreme care. longissimus capitis, levator scapula Antagonists: To cervical flexion : posterior cervical muscles The patient is supine with the head rotated contralaterally (especially suboccipital muscles), SCM (when the neck is approximately 45° away from the mid-line, which moves already extended) the s tyloid process slightly away from the transverse For lateral flexion of the head: contralateral rectus capitis process and opens the space slightly into which the treating lateralis, longissimus capitis, obliquus capitis superior, finger will be placed. The practitioner stands at the level of contralateral levator scapula the upper chest and facing the patient's head. I ndications for treatment To find the transverse process of the atlas (C1), the prac­ titioner's index finger of either hand is placed without any • Unstable atlas or one locked in sidebend pressure onto the anterior surface of the styloid process. • Tenderness or discomfort around the styloid process From this position, the finger is moved one fingertip width posteriorly, then one fingertip width inferiorly, then one fin­ region gertip width medially. If the practitioner has large hands and the patient's structure is more petite, half finger widths Special notes should be applied or the smallest finger used as the treating tool. The order of movement is important to avoid the liga­ The attachments on the styloid process should be addressed ments which course superficially to the mandible and to the before beginin ng this work. They are presented in this text hyoid bone, and to ultimately place the treating finger onto with the mandibular muscles on p. 338. Additionally, indis­ the anterior surface of the transverse process of the atlas. criminate or accidental pressure onto the styloid process should be avoided when addressing the rectus capitis later­ Gentle sta tic pressure is applied directly onto the anterior aliso The practitioner should be cautious with hand (finger) surface of the transverse process of the atlas (Fig. 11 .72). placement to avoid the styloid process, as it is fragile as well

3 1 4 CLIN ICAL APPLICATION O F N EU RO M USCU LAR TECH N I Q U ES : THE U PPER BODY While rectus capitis latera lis attaches to the upper surface of • Chest, back and arm pain (any or all of these) the transverse process and very likely will not be touched • Tingling and numbness in hand associated with entrap­ directly, connective tissue continuations may be influenced on the transverse process i tself. If not too tender and if neu­ ment syndrome rovascular struc tures are clear of the treatment finger, gen­ • Whiplash syndrome, particularly if lateral flexion action tle medial/ lateral friction may be applied as well. This area is often extremely tender and may require several applica­ was involved tions of ligh t pressure. The authors caution against the use • Cervical dysfunctions which are not responding to other of heavy, or even moderate, pressure on C1 when treating myofascial tissues. This upper cervical area is involved in modalities major proprioceptive input as well as conta ining important • Sedentary lifestyle, leading to quiet breathing patterns as and vulnerable neural structures and blood vessels and all manual approaches to it should be gentle. the norm • Evidence of dysfunctional breathing patterns in genera l SCA LE N I I (FI G . 1 1 . 7 3 ) • Loss of vertical dimension of cervical d iscs Attachments: Anterior: C3-6 anterior tubercles o f the trans­ Special notes verse processes to the superior aspect of the 1st rib ante­ rior to the subclavian artery The attachment sites of the scalenii muscles vary, as does Medius: C2-7 posterior tubercles of the transverse their presence. The scalenus posterior is sometimes absent processes to the superior su rface of the 1st ri b posterior to and sometimes blends with the fibers of medius. Scalenus the subclavian artery medius is noted to frequently attach to the atlas (Gray's Posterior: C4-6 posterior tubercles of the transverse Anatomy 2005) and sometimes extends to the 2nd rib (Simons processes to the 2nd rib et aI 1999). The scalenus minimus (pleuralis), which attaches Minimus: C7 (C6) anterior tubercle to the suprapleura l to the pleural dome, is present one-third (Pla tzer 1992) to membrane and 1st rib three-quarters (Simons et a1 1999) of the time on at least one side. When absent, is replaced by a transverse cupular liga­ Innervation: Ventral rami - anterior: C4-6; medius: C3-8; ment (Platzer 1992). posterior: C6-8; minim us: C8 The brachial plexus exits the cervical column between the Muscle type: Phasic ( type II), weakens when stressed, but scalenus anterior and medius. These two muscles, together modifies to type J (postural) if pattern of use demands with the 1st rib, form the scalene hia tus (also called the sca­ this, as in asthma tic or habitual hyperventi lation breath­ lene opening or scalene posticus aperture) (Platzer 1992). It is ing (Lin et a1 1994) through this opening that the brachial plexus and vascular structures for the upper extremity pass. When these muscle Function: Unilaterally, the scalenii group flexes the cervical fibers are taut, they may directly entrap the nerves (scalene spine laterally and rotates the spine contralateral ly. anticus syndrome) or may elevate the 1st rib against the over­ Bilaterally, they flex the neck and assist in elevation of the lying clavicle and indirectly entrap the vascular or neurolog­ 1st and 2nd ribs (which assists inspiration) ical structures (simul taneous compromise of both neural and vascular structures is rare) (Stedman's Medical Dictionan) Synergists: For lateral flexion: ipsilateral sternocleidomas­ 2004). Any of these conditions may be diagnosed as thoracic toid, prevertebral muscles, posterior cervical muscles outlet syndrome, which is 'a collective title for a number of For contralateral rotation: ipsila teral sternocleidomastoid, conditions attributed to compromise of blood vessels or contralateral splenius cervicis, levator scapula, rotatores, nerve fibers (brachial plexus) at any point between the base m u l ti fi d i of the neck and the axilla ' (Stedman 's Medical Dictionary 2004). Forflexion ofthe cervical spine: longus colli, longus capi tis, suprahyoids, infrahyoids, platysma During respiration, the scalenii assist by tractioning the upper two ribs and pleura cranial ly. This action increases Antagonists: For lateral flexion: contralateral scalenii, SCM, the diameter of the thoracic cavi ty, thereby supporting longus colli, posterior cervical muscles inspiration. When diaphragmatic function is reduced, For contralateral rotation: contralateral SCM, scalenii and scalenii may become overloaded, especially in quiet breath­ ipsilateral splenius cervicis, levator scapula ing (see Chapter 14 for more detail of the important role Forflexion of the cervical spine: posterior cervical muscles, these muscles play in respiration). SCM (when the neck is already extended) When longus colli holds the neck rigid and cervical lor­ Ind ications for treatment dosis is reduced, the bilateral scalenii flex the cervical col­ umn on the thoracic column (as in looking down at one's • A rterial obstruction to a rm own chest). However, when the cervical column is not held • Compression of brachial plexus rigid, bilateral contraction of the scalenii flexes the cervical • Diagnosis of thoracic outlet syndrome or carpal tunnel column on the thoracic column and accen tuates cervical lordo­ sis (as if looking up) which, when dysfunctional, may con­ syndrome tribu te considerably to forward head posture as the eyes and ears are brought to horizontal level.

1 1 The cervical region 3 1 5 \\ A � �. \\I Scalene mlnlmus B Figure 1 1 .73 ACtB : Sca l e n i i trigger points produce patterns of com m o n com p l a i n t that may come from any of the scal e n e m uscl es. Drawn after Simons et al (1 999).

3 1 6 CLI N I CAL APPLICATI O N O F N EU RO M U SC U LAR TECH N I QUES: THE U PPER BODY Box 1 1 . f 5 stdelying position repose It is frequently useful to place the patient in a sidelying position for Figure 1 1 .74 The l ower body is comfortably bolstered in a treatment of particu lar m uscles or when, due to the patient's physical condition (such as during pregnancy), she is unable to l ie sidelying position and the u pper a rm is su pported by the patient. supine or prone. If a sidelyi ng position is necessary for a particu lar treatment protocol but the person is unable to lie in that position, a This allows the practitioner to use both hands when applying supine or prone position can usu a l ly be substituted. techniques. When the patient is placed in a sidelying position, the head is m uch sti l l ness and restfu l ness as is consistent with the potential for supported on a pillow or bolster so that the cervical spine is instant action i n any direction: m a i ntained straight i n the m id-sagittal pla ne. The head should not remain unsupported during the session nor should the patient Pil lows and wedges are used to relieve inappropriate defensive attempt to su pport the head with a n a rm, as cervical and u pper muscular activity. Additionally, manual therapists may find Body extremity m usculature m ight become stressed and u n comfortable. Support Cushions\"\" to be a val uable tool in position ing the patient. This potentially stressfu l position could activate trigger points as Thei r design is i ntended to most ideally support the body in prone, wel l as produce exacerbation of the current condition or discomfort supine or sidelying positions. Both authors encourage the principles in additional areas. on which the design of this system is based, offering as it does most of its support via bony prominences, allowing the soft tissues to In a sidelying position, the lower leg (the one on the table) is release spontaneously during treatment. Additional ly, the space built kept fairly straight while the uppermost leg is flexed at the hip and i nto the mid-portion of the body su pport system al lows comfortable knee, which brings it forward, where it is laid on a bolster or thick prone lying, even in advanced pregnancy. su pport pil low to m a i ntai n the leg in a neutral sagittal plane. This positioning of the legs stabilizes the pelvis and discourages torsioning of the torso while a lso a l l ow i ng access to the medial aspect of the thigh of the lower leg. Likewise, the lateral torso, u ppermost lateral hip and upper extrem ity a re m ore accessible in a sidelying posture. This is the preferred position described in this text for treatment of these a reas. When the u pper extremity is addressed in the sidelying position, the patient's uppermost arm is often placed in a supported position (p. 454) so that the practitioner has both hands free. In the supported a rm position, the patient's lower arm (tableside) is flexed to 90· at both the shoulder and the elbow and internally rotated to grasp the u ppermost arm j ust a bove the elbow. The upper arm is also flexed to 90· with i nternal rotation and the forearm and hand passively hangs toward the floor (Fig. 1 1 .74). Chiropractor and certified Feldenkrais practitioner John Hannon (1 999) has described a number of useful, supported positions which ca n enha nce 'repose'. 'Repose embodies the state of qu iet readiness. This represents more than peace of mind or muscular relaxation, a lthough both may be featured pro m i nently. Repose indicates as .• Body Su pport Systems I n c. PO Box 337, Ashland OR 97520 (800) 448-2400 or (54 1 ) 488- 1 1 72. '\" N M T F O R SCALE N I I under the edge of the clavicular head of SCM (Fig. 1l .75A). It will feel similar to the clavicular SCM and will attach to The treatment of the scalenes can be performed in ei ther the first rib. The subclavian artery, which courses between supine or sidelying posture (Box 1 1 . 1 5) . Both positions are scalenus anterior and medius, is avoided by palpa ting its discussed here. pulse and locating the fingers in a position that does not compress it. The patient is supine with the head rotated contralaterally approximately 45°. The practitioner is seated cephalad to the The fingers apply unidirectional (laterally oriented) trans­ patient's head and locates the sternal and clavicular attach­ verse friction in a gentle snapping manner, begining near the ments of the sternocleidomastoid muscle. The pa tient may 1st rib and working up toward the tubercle attachments. need to lift the head slightly to make the SCM more obvious to Uncontrolled aggressive snapping techniques are avoided palpation. Contralateral head rotation will move the SCM and considerable caution must be exercised to avoid the medially and allow a slightly better access to the scalenus ante­ artery and also the brachial plexus, which exit the vertebrae rior, which often lies under SCM's lateral edge. Additionally, between the first two scalene muscles. Entrapment of the lateral flexion against resistance will assist the practitioner in nerves or irritation of them by the treati.ng fingers should be locating the muscle bellies. One side is treated at a time. avoided and the fingers reposi tioned if electric shock-like referrals are provoked. Additionally, extreme caution is used The practitioner uses the first two fingers of the treating to avoid pressing the nerves into the foraminal gutters, which hand to locate the scalenus anterior j ust lateral to or slightly

1 1 The cervical region 3 1 7 Figure 1 1 .75 When the sca lenii m uscles a re treated. CAUTION m ust be exercised to avoid the brachial plexus. wh ich courses between the scalenus a n terior a n d medius. A: Sca l e n u s anterior. B : Sca l e n u s medius. C: Sca l e n u s posterior. lie between the anterior and posterior tubercles. These gutters almost directly under the ear when the head is in neutral are sharp and could damage the nerves or myofascial tissues position and in proper coronal alignment (Fig. 11 .75C). This that attach nearby. muscle is often difficult to palpate. Transverse friction and static pressure techniques are again used to assess this short The treating fingers are moved posterolaterally and onto scalene muscle. Unidirectional finger movements oriented the scalenus medius (Fig. 11 .75B). This muscle is the longest anteriorly will usually identify this muscle when it is pres­ and usually the largest of the scalenii. The treating fingers ent, if it can be palpated. repeat the transverse frictional steps while avoiding the brachial plexus, which exits the spinal column between the The tubercle attachments may be treated by flexing the first two scalene muscles. When taut bands are located in fingers so that they arch around to the anterior aspect of the any of the scalene muscles, flat palpation against the under­ transverse processes and are placed directly onto the ante­ lying tubercles can be applied provided the nerves are not rior tubercles while taking care to avoid the nerves coursing compressed or irritated by the treating fingers. immediately posterior to the tubercles (Fig. 11 .76A). The posterior tubercles are found by sliding onto them from a The fingers are moved again posterolaterally and onto posterior direction. The transverse processes are located and the scalenus posterior, which attaches to the 2nd rib and lies

3 1 8 C L I N ICAL A P P L I CATI O N O F N E U R O M U SC U LA R TECH N I Q U E S : TH E U P P E R B O DY Figure 1 1 . 7 7 A sidelying position may be used to address the scalenii m uscles and their tubercle attachments. B the SCM and will feel similar to the SCM clavicular head. The entire length of the anterior, middle and posterior Figure 1 1 .76 The a n terior a n d posterior tubercles may be ca refully scalenes are each separately assessed and treated in a man­ palpated. CAUTION is exercised to avoid the sharp edges of the ner similar to the supine description above. General gliding fora m inal g u tters and the b rachial plexus. A: Anterior tubercles. B : techniques on the la teral neck are not recommended due to Posterior tubercles. the location of the brachial plexus and its close proximity to the sharp foraminal gu tters. the fingers slide around their lateral tips and onto the poste­ rior tubercles (Fig. 11 .76B). Mild, minute frictional move­ f T R EATM E NT O F S H O RT SCAL E N I ! BY M ET ments or light static pressure are used, while ensuring that the sharp foraminal gutters and cervical nerves are avoided. • The patient lies supine with a cushion or folded towel under the upper thoracic area so that, unless supported Variation in side/ying position. The scalenii may a lso be by the practitioner's contralateral hand, the head would treated with the patient in sidelying position and with the fall into extension. head rotated toward the table approximately 45° (Fig. 11.77). The practitioner stands posterior to the head. The patient • The head is rota ted contralaterally (away from the side to can simply begin to lift the head off the table with no resist­ be trea ted). ance needed to activate the scalenii for verification of their location. The scalenus anterior will be located j ust lateral to • There are three positions of rotation required: 1. full contralateral rota tion of the head /neck produces involvement of the more posterior fibers of the scalenii 2. a contralateral 45° rotation of the head /neck involves the middle fibers 3. a position of only slight contrala teral rotation involves the more anterior fibers. • The practitioner 's free hand is placed on the side of the patient's head to restrain the isometric contraction which will be used to release the scalenii. • With appropriate breathing cooperation (,Breathe in and hold your breath as you commence the effort, and exhale completely when ceasing the effort'), the patient is instructed to try to l ift the forehead a fraction and to a ttempt to turn the head toward the affected side while resistance is applied by the practitioner 's hand to pre­ vent both movements ('lift and turn'). • Both the effort and the counterpressure should be mod­ est and painless at all times.

1 1 The cervical region 3 1 9 J Figu re 1 1 .78 M ET treatment of sca lenus anterior. Fig u re 1 l .7 9 Scalene positional release. Reproduced w i th permission from Deig (2001). • After a 7-10 second contraction the head is allowed to toward the top of the head, this will enhance the stretch ease into extension. of the muscle. • This whole procedure should be performed bilaterally • The patient's contralateral hand is placed (palm down) several times in each of the three head positions. just inferior to the lateral end of the clavicle on the affected side. Scalenii stretches, with all their variable positi ons, clearly also influence many of the anterior neck structures. • The practitioner 's hand (which was acting to produce resistance to the isometric contraction) is now placed IPOSITIONAL RELEASE OF SCALENII onto the dorsum of the patient's hand. • The tender points rela ting to the scalene muscles lie on • As the patient slowly exhales, the contact hand, resting the transverse processes (sometimes on the very tips of on the patient's hand, which is itself resting on the 2nd these) of C2-6. rib and upper thorax, pushes obliquely away and toward the foot on that same side, stretching the attached mus­ • The patient lies supine and the practitioner sits at the head culature and fascia. of the table, palpating a tender point with sufficient pres­ sure to allow the discomfort to be ascribed a value of 10. • This s tretch is held for at least 20 seconds after each iso­ metric contraction. • For the scalenus anterior and medius, the head and neck are flexed and sideflexed toward the affected side (for • The process is then repeated at least once more. scalenus posterior slight extension or a neutral position • Thehead is rotated 45° contralaterally and the hand contact may be employed). which applies the stretch of the scalenus medius is placed • The head and neck may be supported on a small cushion just inferior to the middle aspect of the clavicle (practi­ or rolled towel, or by the palpating hand. tioner's hand on patient's hand which acts as a 'cushion') . • When the head is in neutral position for the scalenus • The other hand engages the 2nd and 3rd ribs close to the anterior stretch, the hand contact is on the upper sternum axilla and eases them cephalad until the reported dis­ i tself (again with the pa tient's contralateral hand as a com fort reduces to 3 or less. cushion) (Fig. 11.78). • In all other ways the methodology is as described for the • This is held for 30-90 seconds, a fter which a slow return first position above. to neutral is introduced . Note: It is important not to allow heroic degrees of neck CERVICAL LAM I N A - PRO N E extension during any phase of this trea tment. There should be some extension but it should be appropriate to the age The muscles of the posterior cervical region m ay also be and cond ition of the individual. addressed in a prone position. This body position often reveals taut fibers that were not distinct in the supine posi­ • A degree of eye movement can assist scalenii treatment. tion. The practitioner should listen carefully for communi­ • If the patient makes the eyes look caudally (toward the cations from the pa tient as the face cradle may obscure the voice in a prone position. Addi tionally, hand signals may be feet) and toward the affected side d uring the isometric needed for the pabent to quickly communicate if pressure is contraction, the degree of contraction in the muscles will too heavy or if trigger point referrals are experienced. be increased. • If during the resting phase when stretch is being intro­ duced, the patient looks away from the treated side,

320 CLI N I CAL APPLICATI O N OF N EU RO M USCULAR TECH N I QUES: THE U PPER BODY During the gliding strokes, osseous structures may be contraindicated d ue to inflammation. Detailed protocols for encountered in the lamina groove. These dense calcific pro­ assessing and treating the trapezius (pp . 429-435) and the tuberances may be bifid (split) spinous processes, a spinous levator scapula (p. 436) are also offered in the prone position. process of a dysfunctional (rotated) vertebra or the effects of enthesitis on the m ultitude of myofascial tissues attaching I N MT FOR POST E R I O R CRAN IAL ATTACH M ENTS in the lamina groove. When osseous tissue is found, the contralateral side is examined for similar structures. The The prone pa tient's chin is tucked slightly, in order to gen­ soft tissues of the area should be examined and treated and tly open the suboccipital space between the occiput and C1 osseous manipulations applied, if needed. However, the (atlas) . The practitioner remains at the level of the shoulder practitioner is strongly advised to practice within the scope or chest, facing the head to treat the ipsilateral side. of their professional license. Referral to the appropriate Excessive s tretching into flexion is not recommended for healthcare practi tioner for osseous assessment and manipu­ these procedures that treat the soft tissues of the posterior lation may be necessary if the segments do not respond to suboccipital region, due to the position of the vertebral soft tissue applica tions. artery in the lateral aspect of the suboccipital space between C 1 and the occiput. Caution is exercised to avoid the verte­ 16 N MT F O R POSTE R I O R C E RV I C A L LA M I N A - bral artery, which lies relatively exposed in the suboccipital , PRONE POSITION triangle. The prone patient's chin is tucked toward the chest. The The fingers provide stability and support for the move­ practitioner stands at the level of the shoulder or chest, fac­ ments of the thumbs. The thumbs are touching end to end ing the head, and treats one side at a time. One or both of and are placed just caudal to the inferior nuchal line where the practitioner 's thumbs begin at the level of C7 and glide the rectus capi tis posterior major and minor attach and superiorly from C7 to the occiput, while maintaining con­ between the inferior and superior nuchal lines where the tact against the lateral surface of the spinous processes and obliguus capitis superior attaches (Fig. 11.81). Transverse the lamina . The fingers provide stability for the thumbs as (medial/lateral) friction is applied to the cranial attach­ they repeat the gliding stroke 6-8 times (Fig. 11.80). ments of the posterior cervical muscles and mid-belly region of the suboccipital muscles. Static pressure may also The thumbs are moved laterally about 1 inch (2.5 cm) and be applied when trigger points are loca ted in the suboccipi­ the gliding strokes repeated 6-8 times. The gliding strokes tal muscles or posterior cervical muscles lying superficial to are continued in strips in the lamina through the posterolat­ them, or when tissues are too tender to be frictioned. The eral aspect of the transverse processes. The strokes are not attachments of trapezius, semispinalis capitis, splenius continued further anteriorly due to the position of the capitis, longissimus capitis and sternocleidomastoid may brachial plexus and the sharp edges of the foraminal gutters be included in this examination of posterior cranial attach­ on the anterolateral surface of the transverse processes. ments. Cranial-to-caudal friction may also be used as long as the vertebral artery is avoided (see Fig. 11 .48, p. 292). Unidirectional or bidirectional transverse friction may be applied to the attachments of the levator scapula, sple­ The frictional technigues are repeated between C1 (atlas) nius cervicis and other posterior cervical muscles unless and C2 (axis) to address the inferior half of rectus capitis posterior major and obliguus capitis inferior through the Figure 1 1 .80 The fingers h e l p to sta b i l ize the th u m bs w h e n gliding Figure 1 1 .81 M u ltiple attachments on the posterior cra n i u m may cra n i a l ly i n the l a m i n a g roove. be assessed as the thumbs contact the occipital bone.

1 1 The cervical reg ion 321 ] Figure 1 1 .83 The thin, flat occi pita lis m uscl e i s part o f t h e epicranius and refers strongly i n to the eye region. Figure 1 1 .82 The tra nsverse process of the a tlas is the a ttach ment which attaches to the skin over the craniwn and slides it over site of several m uscles that may be treated with ca refu l ly appl ied the bony surface of the craniwn as the brows are lifted. unidirectional (latera l) friction. Occipitalis' fibers are often not distinct and the practitioner overlying tissues. Lighter pressure may be needed and may must rely on anatomic knowledge rather than palpation only penetrate into the superficial tissues if they are too ten­ skills when locating it. When occipitalis' fibers are taut, they der to be pressed through. may be vaguely palpable but their tenderness and trigger point referrals will be apparent to the patient when they are The attachments on the transverse process of C1 of involved. Movement of this muscle may be palpable on some obliquus capitis superior and inferior, levator scapula and individuals when the eyebrows are raised repeatedly, since it splenius cervicis muscles are carefully examined. The SCM merges with the cranial aponeurosis and connects with the may need to be displaced anterolaterally in order to palpate frontalis muscle. However, with the patient prone, the face the muscles attaching to the transverse process of Cl. cradle may inhibit the movement of the cranial fascia and Caution is exercised to maintain contact with the posterolat­ prevent palpation of distinct movement of the occipitals. eral tip of the transverse process (Fig. 11 .82) and not allow the thumbs to intrude into the suboccipital triangle due to the Trigger point referrals from occipitalis often produce vertebral artery's location within the triangle (Fig. 1 1 .48). strong patterns of pain, pressure and headache into and around the orbit of the ipsilateral eye. The weight of the The thumbs are placed on the occipitalis muscle, which lies head on a solid foam pillow may irritate occipitalis trigger approximately 1-2 inches (2.5-S cm) lateral to the occipital points and cause the patient to awaken in the night with the protuberance (Fig. 11 .83). Transverse friction or static pressure headache (eyeache) pattern. See further discussion with the can be used to examine the occipitalis muscle. This thin, flat cranium in the following chapter. muscle attaches to the superior nuchal line of the occipital bone and to the galea aponeurotica (epicranial aponeurosis), Refe re n ce s Cassidy 1996 Quebec Task Force on Whiplash Associated Disorders. Journal of Musculoskeletal Pain 4(4):5-9 Alix M, Bates D 1999 A proposed etiology of cervicogenic headache: the neurophysiologic basis and anatomic relationship between Chaitow L 1991 Modified strain counterstrain. In: Soft tissue manip­ the dura mater and the rectus posterior capitis minor muscle. ulation. Healing Arts Press, Rochester, VT Journal of Manipulative and Physiological Therapeutics 22(8):534-539 Chaitow L 1996a Modern neuromuscular technlques. Churchill Livingstone, New York Allen M E (ed) 1996 The new whiplash. Musculoskeletal pain ema­ nating from the head and neck. Haworth Press, New York Chaitow L 1996b Muscle energy technlques. Churchill Livingstone, Edinburgh Banic B, Petersen-Felix S, Andersen 0 K et al 2004 Evidence for spinal cord hypersensitivity in chronic pain after whiplash Chaitow L 1999 Cranial manipulation: theory and practice. injury and in fibromyalgia. Pain 107:7-15 Churchill Livingstone, Edinburgh Buskila D, Neumann L 1997 Increased rates of fibromyalgia following Crowe H 1 928 Injuries to the cervical spine. Paper presented cervical spine injury. Arthritis and Rheumatism 40(3):446-452 at a meeting of the Western Orthopedic Association, San Francisco Cailliet R 1991 Neck and arm pain, 3rd edn. F A Davis, Philadelphia Calais-Germain B 1993 Anatomy of movement. Eastland Press, Crowe H 1964 A new diagnostic sign in neck injuries. California Medicine 100(1) : 1 2-13 Seattle

322 C L I N ICAL APPLI CATIO N OF N EU ROMUSC U LAR TECH N I QUES: THE U PPER BODY C u ratolo M, Petersen-Felix S, A rendt-Nielsen L et a l 2001 Central Hasegawa 0, Matsumoto S, Gondo G Iwasawa H 2001 Therapeutic hypersensi tiv i ty in chronic pain after whiplash injury. Clinical outcome of spasmodic torticollis [in Jilpanese]. No To Shinkei Journal o f Pain 17:306-315 [Brain and Nerve] 53(6):547-550 Curatolo M, Arend t-Nielsen L, Petersen-Felix S 2004 Evidence, Hendrickson T 1995 Manual of orthopedic massage. Privately pub­ mechanisms, and c l inical i mplications of central hypersens i t i v i ty lished, Oakland, CA in chronic pain after whiplash injury. C l inical Journal of Pain 2 0 : 469-476 Hoppenfeld S 1976 Physical examination of the spine and extremi­ ties. Appleton a n d Lange, Norwalk, CT Dan iels L, Worthingham C 1980 Muscle testing techniques, 4th ed n . W B Saunders, Philadelphia Hosono N 1991 Cineradiographic motion analysis of a t lantoaxial insta b i l i ty a t os odontoideum. Spine 16(Suppl 10):5480-482 Dean N, M i tchel l B 2002 A n a tomic relation between the nuch a l liga­ ment (ligamentum n uchae) and the spinal dura mater in the Hu J, Vernon H, Tantourian I 1995 Changes in neck EMG associa ted craniocervical region. Clinical A n a tomy 15(3):182-185 w i th meningeal noxious stim u lation. Journal of Manipulative and Physiological Therapeutics 18:577-581 Defeo G, Hicks L 1993 A description of the common compensatory pattern in relationship to the osteopathic postural exa m ination. H umphreys B, Shahar K, Bradley B H, Cramer G 2003 Investigation Dynamic Chiropractic 24:11 of connective tissue a ttachments to the cervical spinal dura mater. Cli n ical A n a tomy 16(2) : 1 52-159 Deig D 2001 Positional release technique: from a dynamic systems perspective. Bu tterworth-Heinem ann, Oxford Jacob B, McKenzie R 1996 Spinal therapeutics based on responses to loading. In: Liebenson C (ed) Reha b i l i ta tion of the spine. DeLa ny J 2006 Unique aspects of w hiplash syndrome. AMTA Williams and W i l k ins, Ba l timore National Convention prese n ta t ion, Atlan ta, G A Janda V 1988 Muscles and cervicogenic pain syndromes. In: Grant Deuschl G, Heinen F, Kleedorfer B et a l 1992 C l inical and polymyo­ R (ed) Physical therapy in the cervical and thoracic spine. graphic investigation of spasmodic torticollis. Journal of C h u rchill Livingstone, New York Neurology 239(1):9-15 Janda V 1996 Evaluation of muscular balance. In : Liebenson C (ed) Dommerholt J 2005 Persistent myalgia following whiplash. Cu rrent Rehabilita tion of the spine. Williams and Wi l k ins, Baltimore Pa i n and Headache Reports 9:326-330 Johnson G, Zhang M, Jones D G 2000 The fine connective Evjenth 0, Hamburg J 1984 Muscle stretching in manual therapy. tissue architectme of the human ligamentum nuchae. Spine A l fta Rehab, Alfta, Sweden 2 5 ( 1 ) :5-9 Fahlgren H 1988 Retropharyngeal tendinitis: three probable Johnston W 1985 Inter-rater rel ia bility. In: Burrger A, Greenman P cases w i th an lU1usu a l ly low epicenter. Cephalalgia (eds) Empirical approaches to the v a l idation of manipulative 8(2):105-110 therapy. Charles C Thomas, Springfield, n l inois Fernandez-de-Ias-Penas C, Alonso-Blanco C, Luz Cuadrado M Juhan D 1987 Job's body: a handbook for bodywork. Station Hill et a l 2006 Myofascial trigger p o i n ts in the suboccipital muscles P ress, Barrytown, NY in episodic tension-type headache. Man u a l Therapy 11 (3) :225-230 Kaltenborn F 1989 Mobil iza tion of the extremity joints, 4th edn. Olaf Norlis Bokhandel, Oslo Fryer G, Morris T, G ibbons P 2004 Relation between thoracic paraspinal tissues and pressure sensitivity measu red by digital Kapandji I A 1974 The physiology of the joints, vol. m, 2nd edn. algometer. J o u rnal of Osteopathic Medicine 7(2):64-69 Chu rchill Liv ingstone, Edinb urgh Gough P 1996 H u m a n occupant dynamics in low-speed rear-end Kapandji I A ]982 The physiology of the joints, vol. 1, 5th edn. collisions. In: Allen M (ed) The new whiplash. Musculoskeletal Churchill Livingstone, E d i n b u rgh pain emanating from the head and nec k. Haworth Press, New York Kapandji I A 1998 The physiol.ogy of the joi n ts, vol 3. The tru nk and the vertebral column. Churchi ll Livingstone, E d i n b u rgh Gray's anatomy 2005 (39th edn) Churchill Livingstone, Edinbmgh Gray's anatomy for students 2005 C h u rchi l l Livi ngstone, Kappler R 1997 Cervical spine. In: Ward R (ed) Foundations of osteopathic medicine. Williams and Wil kins, Baltimore Edinburgh G reenman P 1989 Principles of manual medicine. Williams and K immel D ] 961 Innervation of the spinal d u ra mater and the d u ra mater of the posterior cranial fossa. Neurology ] 0:800--809 Wi l kins, Bal timore Greenman P 1997 Personal communication Kuchera W, Kuchera M 1994 Osteopathic principles in practice. Hack G, Hallgren R 2004 Chronic headache relief after section of G reyden P ress, Columbus, OH suboccipi ta.1 m uscl e d u ra l connections: a case report. Headache Langemark M 1987 Pericranial tenderness in tension headaches. 44( 1 ) : 84-89 Cephalgia 7:249-255 Hack G, Kori tzer R, Robinson W ] 995 A natomic relation between the rectus capitis posterior m i n o r muscle and the dura mater. Leonhardt H ] 986 Color atlas and textbook of human ana tomy, Spine 20:2484-2486 vol 2, 3rd edn. Georg Thieme, Stuttgart Haldeman S, Dagenais S 2001 Cervicogenic headaches. The Spine Journa l 1 ( 1 ) :31-46 Lewit K 1985 Man ipulative therapy in rehabilitation of the locomo­ Hallgren R, G reenman P, Rechtien J ] 993 MRl of norma l and tor system. Bu tterworths, London a trophic muscles of the upper cervical spine. Journal of Clinical Engineering ] 8(5) :433-439 Lewit K ]992 Manipulative therapy in reha b i l i tation of the motor Ha l l gren R, Greenman P, Rechtien J 1994 Atrophy of subocci p i ta l system, 2nd edn. Butterworths, London muscles i n patients w i th chronic pain . Journal of t h e American Osteopa thic Associa tion 94( ] 2 ) : ] 032-1038 Lew i t K 1999 Manipulative therapy in rehabi l i ta ti o n of the motor Hannon J ] 999 Pillow ta l k : the use of p rops to encourage system, 3rd edn. Butterworths, London repose. Journal of Bodywork and Movement Therapies 3(1) :55-64 Lidbeck J 2002 Central hyperexcitability in chronic musculoskeletal Harakal J 1975 An osteopathica l ly i n tegrated approach to whiplash pain: a conceptual breakthrough w i th m u l tiple clinical impl ica­ complex. Journ a l of the American Osteopathic Association tions. Pain Research and Management 7:81-92 74:941-956 Liebenson C 1996 Rehabilitation of the spine. Williams and Wilkins, B a l t i mo r e Liem T 2004 Cranial osteopathy princi ples and practice Churchi l l Livingstone, Ed i n b u rgh, p 340-3- 42 Lin J-p, Brown J K, Walsh E G 1994 Physiological maturation of muscles in chi ldhood. Lancet 343:1 386-1389 Liu J-X, Thornell L-E, Pedrosa-Domellof F 2003 Muscle spindles in the deep muscles of the h u man neck: a morphological and

1 1 The cervical region 323 i mm unocytochemical study. Journal of Histochemistry and Peck D, Buxton D, Nitz A 1984 A comparison of spindle concentra­ Cytochemistry 51 (2): 175-186 tions in large and sma l l musc les acting in parallel combinations. Lundberg U, Kadefors R, Mel in B et a l 1994 Psychophysiological Journal of Morphology 180:243-252 stress and EMG activity of the trapezius muscle. Interna tional Journal of Behavioral Medicine 1(4) :354-70 Penfield W, McNaughton F 1940 Dural headache and the innerva­ tion of the d u ra mater. Archives of Neurology and Psychiatry Maroudas A, Stockwell R A, Nachemson A, Urban J ] 975 Factors 44:43-75 involved in the nutrition of the h u m a n l umbar intervertebral Pla tzer W 1992 Color atlas text of human anatomy: vol I, locomotor disc: cellularity and d i ffusion of gl ucose in v i tro. Journal of system, 4th edn. Georg Thieme, Stuttgart Anatomy 120:113-130 Mayer T, Brady S, Bovasso E et a l 1994 Noninvasive measurement Pollard H, Ward G 1997 A study of two stretching techniques for of cervical tri-planar motion in normal s u bjects. Spine i mprov ing hip flexion range of motion. Journal of M a n i p u lative 1 8 :219 1-2195 and Physiological Therapeutics 20:443-447 McAtee R, Charland J 1999 Facilitated stretching. Human Kinetics, Champaign, IL Pope R 2003 The common compensatory pattern: its origin and McKenzie R 1990 The cervical and thoracic spine: mechanical diag­ relationship to the postural model. A merican Academy of nosis and therapy. Spinal Publications, Waikanae, New Zealand Osteopathy Journal 13(4) : 1 9-40 McPartland J, Brodeur R 1 999 Rectus capitis posterior minor. Radanov B ]994 Relationship between early somatic, radiological, cognitive, psychological findings and o u tcome d u ring one-year Journal of Bodywork and Movement Therapies 3(1) :30-35 fol low-up in 117 whiplash patients. British Journal of McPartland J, Good ridge J 1997 Osteopathic examination of the cer­ Rheumatology 33:442-448 vica l spine. Journal of Bodywork and Movement Therapies Ring D, Vaccaro A, Scuderi G et a l 1994 Acute calcific retropharyn­ 1 (3): 173-178 geal tendonitis: clinical presentation and pathological characteri­ McPartland J, Brodeur R, Hal lgren R 1997 Chronic neck pain, stand­ zation. Journal of Bone and Joint Surgery 76(11 ) : 1636-] 642 ing balance, and suboccipital muscle atrophy - a pilot study. Journal of Manipulative and Physiological Therapeutics Robbie D 1977 Tensional forces in the h u m a n body. Orthopaedic 20( 1 ) : 24-29 Melzack R, Wa l l P 1989 Textbook of pain, 2nd edn. Church i l l Review VI ( 1 1 ) :46 Livi ngstone, London Mercer S, Bogd u k N 2003 Cl inica l anatomy of l igamentum nuchae. Ross S 1999 Dysphonia: osteopathic trea tment. Journal of Cl inical Anatomy 1 6(6) :484-493 Bodywork and Movement Therapies 3(3):133-142 MitcheH B 1998 A ttachments of ligamentum nuchae to cervical pos­ terior d u ra and lateral occipital bone. Journal of Manip ulation Schafer R 1987 Cl inical biomechanics. Will iams and Wi l kins, and Physiological Therapeutics 21(3): 145-148 BaItimore Mi tchell F, Moran P, Pruzzo N 1979 Evalua tion and treatment man­ ual of osteopa thic muscle energy techniques. MMP Associates, Seaman D, W i n terstein J 1998 Dea fferentation: a novel term to Valley Park, MO describe the neuropathophysiological effects of joint complex Moore K 1 980 Clinically orien ted anatomy. Will iams and Wil kins, dysfunction. A look at l ikely mechanisms of symptom genera­ B a l ti m o r e tion. Journal of Manipulative and Physiological Therapeutics Mosser S, Guyuron B, Janis J, Rohrich R 2004 The anatomy of 2 ] :267-280 the greater occipital nerve: implications for the etiology of migraine headaches. Plastic and Reconstructive Surgery Simons D, Travell J, Simons L 1999 Myofascial pain and dysfunc­ 113(2) :693--697 Mulligan B ]992 Manual therapy. Plane View Services, Wellington, tion: the trigger point manual, vol 1: upper h a l f of body, 2nd New Zealand edn. Williams and Wilkins, Baltimore Munglani R 2000 Neurobiological mechanisms underlying Sjaastad 0, Saunte C, Hovdahl H et a l 1983 'Cervicogenic' clu'oni c whiplash associated pai.n: the peripheral m a i n tenance headache. An hypothesis. Cephalalgia 3(4):249-256 of central sensitization. Journal of Musculoskeletal Pain Spitzer W, Skovrom M, Sa l m i L 1995 Scientific monograph of the 8 : 1 69-178 Quebec Task Force on Whiplash Associated Disorders. Spine 20:8S Myers T 1999 K i n esthetic d yston ia. Journal of Bodywork and Stedman's Electronic Medical Dictionary 2004 version 6.0. Movement Therapies 3(2) : 1 07-117 Lippincott Williams and Wilkins, Baltimore N i mmo R 2001 Techn ique for the i m med iate release of headache Steiner C ] 994 Osteopathic manip u l a tive treatment - what does it and neck pain, including w hiplash and the scalene an ticus syn­ really do? Louisa Burns Memorial Lecture October ] 2, 1993. Journal of the A merican Osteopathic Association 94( 1 ) : 85-87 d rome. In : Schneider M, Cohen J, Laws S (eds) The col lected Stiles E ] 984 Manipulation - a tool for your practice. Patient Care 45:699-704 writings of Nimmo & Vannerson: pioneers of c h i ropractic trigger Tay l o r J ]994 Pathology of neck sprain. I n ternational Journal of Pain point therapy. Privately published, Pi ttsburgh, p 111-127 [origi­ Therapy 4:91-99 nally published in 1986, The Receptor 2(3)] Norkin P, Levangie C 1992 Joint structure and function: a compre­ Taylor J, Taylor M 1996 Cervical spine inju ries. In: A llen M (ed) The hensive analysis, 2nd edn. F A Davis, Philadelphia Northfield D 1938 Some observations of headache. Brain new w hiplash. Musculoskeletal pain emanating from the head 6 1 : 1 33-162 and neck. Haworth Press, New York Olesen J 1990 Classification and d iagnOSiS c r i teria for headache dis­ Upledger J, Vredevoogd J 1983 Craniosacral therapy. Eastland orders, cra n.ial neu ralgias, and facial pain. International Press, Seattle Headache Society, Copenhagen Van Mamaren H 1992 Cervical spine motion in the sagitta l plane II. Spine 17(5) :467-474 Osch man J 1997 Gravity structure and emotions. Journal of Ward R (ed) ]997 Foundations of osteopathic medicine. Williams and Wilkins, Baltimore Bodywork and Movement Therapies 1 (5):297-304 Warfel J 1985 The extremities, 5th edn. Lea and Febiger, Pearce J 1995 Cerv icogenic headache: an early description. Journal Philadelphia Zink G, Lawson W 1979 An osteopathic structu ral exa mination and of Neurology, Neurosurgery and Psychiatry 58(6):698 functional i n terpretation of the soma. Osteopa th ic Annals 12(7) :433-440 Zumpano M, Hartwell S, Jagos C 2005 Soft tissue connection betvveen rectus capitus posterior minor and the posterior atlantooccipital membrane: a cadaveric study. C l inical Anatomy 19(6) :522-527

325 Chapter 12 The cranium CHAPTER CONTE NTS Massage/myofascial stretch treatment of masseter 368 Positional release for masseter 368 Cranial structure 326 NMT for lateral pterygoid 369 Occiput 328 NMT for medial pterygoid 369 Sphenoid 332 Stylohyoid 369 Ethmoid 335 External palpation and treatment of styloid and mastoid Vomer 336 Mandible 337 processes 371 Frontal 340 Intraoral palpation and treatment of craniomandibular Pa rietals 343 Temporals 344 muscles 372 Zygomae 347 Intraoral NMT applications 372 Maxillae 349 Temporalis 372 Palatines 350 NMT for intraoral temporalis tendon 373 Masseter 373 NMT treatment techniques for the cra n i u m 3 51 NMT for intraoral masseter 375 Muscles of expression 351 Lateral pterygoid 375 Mi metic muscles of the epicranium 352 NMT for intraoral lateral pterygoid 378 Occipitofrontalis 352 Med ial pterygoid 379 Temporoparietalis and auricular muscles 352 NMT for intraoral medial pterygoid 380 NMT for epicranium 354 Musculature of the soft palate 380 Positional release method for occipitofronta lis 355 N MT for soft palate 382 Mimetic muscles of the circumorbital and M uscles of the tongue 382 palpebral region 355 NMT for m uscles of the tongue 383 NMT for palpebral region 355 Suprahyoid muscles - the floor of the mouth 384 M i metic muscles of the nasa l region 356 NMT for intraoral floor of mouth 385 NMT for nasa l region 3 56 Cranial treatment and the i nfant 387 Mimetic m uscles of the buccolabial region 356 The craniocervical link 388 NMT for buccolabial region 357 Sleeping position and cranial deform ity 389 Muscles of mastication 358 What other reasons do medical authorities think Neck pain and TMD 359 External palpation and treatment of craniomandibular cause serious cranial d istortion in infants? 389 muscles 365 What are the long-term effects of deformational NMT for temporalis 366 NMT for masseter 367 plagiocephaly? 389 Different cranial approaches 390 Ear disease and cranial care 390 Summary 392

3 2 6 CL I N I CA L A P PL I CAT I O N OF N E U R O M USCULAR T EC H N I Q U ES : T H E U P PER BO DY The head is so central to human function that reemphasis of During cranial flexion (also known as the inhalatian phase), the its importance may seem unnecessary. However, aspects of paired bones of the skull rotate externally. This part of the cranial its role may usefully be restated. Most important hwnan cycle is associated with the followi ng. functions are expressed by, through, in and on the cranium, whether this involves thinking, neurological processing, • The occipital base is sa id to move anteriorly/superiorly. speaking, eating, seeing, listening, expressing or breathing. • The sacral base moves posteriorly/superiorly The craniwn not only houses four of the five senses and a vast array of glands, but is also a major element in a remark­ ('sacral flexion'). able balancing act that allows normal function of these (e.g. • The mid-line bones of the sku l l ' flex'. breathing, hearing, sight, speech) and also helps create a state • The paired bones of the skull externally rotate. of equilibrium in the face of major challenges imposed by • The effect of these movements is to flatten and widen the gravity and hwnan behavior. Where the head is held in space helps determine muscle tone and critically influences the effi­ skull (transverse diameter increases while anteroposterior ciency with which all bodily tasks are performed . diameter decreases, vertex becomes flattened). • The tentorium cerebelli flattens and the falx cerebri shortens Craniosacral and sacrooccipital concepts have emerged from front to back. which place dysfunction of the bones of the skull, its sutures • The spinal column straightens as a whole. and internal fascial structures (dura, reciprocal tension • The ventricles fill. membranes, etc.), as well as the circulation of blood, lymph and cerebrospinal fluid through it, at the center of many During cranial extension (also known as t h e exhalatian phase), health problems. In this chap ter we will examine aspects of the paired bones of the skull rotate internally as they return to this vast range of cranial activities, from the perspective of their neutral starting position. the influences that can be modified by neuromuscular and associated techniques. • All cranial motions in this phase involve a return to neutral. The majority of the text in this chapter relates to adults and the tissues of the adult cranium. There is a distinct dif­ • The occipital base is said to move posteroinferiorly. ference between the bony relationships of the skull in the • The sacral base moves anteroinferiorly (sacral 'extension'). adult and the infant, the most obvious being the immature • The mid-line bones 'extend' to their starting positions. articulations (sutures) in the young skull tha t allow direct • The paired bones interna l ly rotate to their starting positions. manipulation when required, in contrast to the treatment of • The effect of this is for the skull to become longer and the adult skull where indirect, disengagement (positional release) methods are more appropriate. narrower (transverse diameter decreases while anteroposterior diameter increases, vertex becomes more elevated). A section on cranial methods appropriate in the infant • The tentorium cerebelli domes and the fa lx cerebri is restored skull is found at the end of this chapter. to its normal position. • The spinal curves a re restored to normal. CRAN I AL STR UCTU RE • The ventricles empty. Before treating apparent cranial dysfunction, attention should the teachings of acknowledged cranjal experts to whom be given to soft tissue changes, muscle and fascia, which credit is offered in the text (Kingston 1996, Milne 1995, could, for example, be impacting upon cranial su ture mobil­ Wilson & Wa ugh 1996). In many of these exercises the ity. The descriptions that follow will use the following format. phrase 'wait for release' or 'when you sense a release' will be found. Box 12.2 explains what this phrase means. • Named bone and constituent parts • Bones with which it articulates and named j unctions Single (central) cranial bones: (sutures) (Gray's A natomy 2005). Thjs information will be • occiput provided either as text or as a detailed figure • sphenoid • Reciprocal tension membrane relationships w ith named • ethmoid bone (if any) • vomer • M uscular attachments (if any) • mandible • Range and direction of motion to be anticipated if normal • frontal. (using traditional cranial osteopathic and craniosacral terminology) (Box 12.1) Paired bones: • Other associations and influences • Dysfunctional patterns and consequences • parietals • Palpation exercises (for some key bones) • temporals • zygomae The palpation exercises that are included derive from • maxillae traditional cranial osteopa thic methods (Brookes 1981). • palatines. Additionally, some of the methods described are taken from Associated within the text but not discussed in detail: • lacrimals (paired) • inferior conchae (paired) • nasal (single) • sacral (single).

Holding tissues, sutures or joints in a position of relative comfort 1 2 The cra n i u m 327 J or ease or applying specific techniques may result in a 'release' of the dysfunctional pattern, either completely or partial ly. How is �-;:- the practitioner to recognize when this occurs? • The breathing pattern may alter and may become slow and deep There are certain guidelines based on the clinical experience or, in contrast, may become q u icker and be accompanied by rapid of many experts that can ind icate a loca l tissue release. eye movement and restlessness. • A sense of steady and strong pulsation, or of greater warmth, • Observation of the diaphragm region may provide useful informa­ enters the area. tion of such a change being imminent or current. • A very definite change (reduction) in palpated tone is noted. • Fasciculation may be observed, with trembling and twitching • A sense of the tissues 'lengthening' or 'freeing up' is perceived. intermittently or constantly. On a wider, whole-body level, such release phenomena may also • The patient may express a wish to vomit or cry or may sim ply involve deeper emotional release, sometimes ca l led 'emotional begi n crying or laughing. discharge'. This may be accompanied by a l l , or any, of the fol lowing. How should such changes be handled? If a local release is noted this can be held a nd gently released with nothing more being done to the • The patient becomes flushed and a change in skin color is particular area at that session apart from some soothing massage observed, from pale to ruddy perhaps. strokes. Alternatively, the holding pattern can continue at the new 'barrier' as the tissues are offered the opportunity to continue to • A light perspiration appears on the patient's u pper lip or brow. release, perhaps in the form of an u nwinding process. The skills appropriate for such techn ique a pplication need to be learned i n suitably detailed instructional forums. The 'emotional release' phenomenon is discussed in detai l in Chapter 4. Right parietal bone ---1 /-- Frontal bones Petrous portion of temporal bone --1+-\\-,- �--.,\\ Lef! temporal bone Occipital bone ---l't Temporal bone ---\"t:.'or\\ M�'-- Zygomatic process Zygomatic process ---'�:/<I! v,.'-- Left great wing of sphenoid Masloid process --./- �-\\-- Nasal bone Styloid process ---' \"-- Crista galli Great wing of sphenoid ---/ Pterygoid process ---' '--Ethmoid bone Zygomatic bone ---./ \"--Malar bone Lacrimal bone ---\" Maxilla ---' Pterygoid process Ramus of mandible ---' Antrum of Highmore Inferior turbinate Maxilla Vomer '--Coronoid process +-- Mandible Fig u re 12.1 Disarticu lated sku ll show i n g major bony components. Reprod uced w ith permission from Chaitow (2005).

3 2 8 C L I N I C A L A P P L I CAT I O N O F N E U R O M U S C U LA R TECH N I QU E S: T H E U P P E R B O DY See Box 12.3 for anatomical groupings of these bones. • The condyles, which form the lateral borders of the fora­ men magnum OCCIPUT Articu lations • The squama, the main body of the bone which forms the posterior border of the foramen magnum • With the atlas at the condyles. • With the sphenoid at the synchondrosis - this is potentially • The basiocciput, which forms the anterior border of the foramen magnum and which possesses a rostrum joining mobile up to about age 25 (Gray's Anatomy 2005, p. 464). it to the sphenoid at the synchondrosis • With the parietal bones at the lambdoidal suture. Box 1 2.3 Cranial bone groupings Bones of the ear • Incus Vault bones • Stapes • Two parieta l bones • Malleus • Occipital squama • Those portions of the temporal bone which develop from Unpaired (mid-line) bones • Occiput membrane • Sphenoid • Ethmoid Cranial base • Vomer • Body of sphenoid • Mandible • Petrous and mastoid portions of temporal bones • Basilar and condylar portions of the occiput (formed from carti­ Paired bones • Parietals lage) • Temporals • Frontals Facial bones • Zygomae • Malar • Maxillae • Lacrimal • Palatines • Pa latine • Lacrimals • Nasal • Inferior conchae • Turbinate • Nasal • Ethmoid • Incus • Maxillae • Stapes • Mandible • Malleus • Frontal • Vomer .-- Clivus Groove for inferior petrosal sinus --___ ._-_ Jugular lubercle Superior border of petrous Internal acoustic meatus part of temporal bone --__. __-_ -- Jugular foramen Groove for Sigmoid sinus �--\".:,.\". 1iiI1IIil�- Hypoglossal canal Groove for transverse sinus Foramen magnum Internal occipital crest Internal occipital protuberance Figure 1 2.2 I nterior aspect of occip ita l bone. Reprod uced with perm ission from Gray's Anatomy for Students (2005).

12 The cra nium 3 2 9 • With the temporal bones. The jugular notch of the Muscu l a r attachments (Fig. 12.3) occiput and the jugular fossa of the temporal bone meet to form an articulation. • Occipitofrontalis, which is rea lly two muscles that cross many sutures: • Posterior to this notch there is a beveled articulation which 1. occipitalis, which attaches to the occiput and temporal is partially internally (anterior aspect of articulation) and bones (via tendinous fibers to the mastoid), crossing partially externally (posterior aspect of articulation) the suture on the lateral aspects of the superior nuchal beveled, with a point of transition, known as the condy­ line losquamomastoid pivot, which allows an easily achieved 2. frontalis, which has no bony attachments but merges rocking potential in clinical evaluation and treatment. with the superficial fascia of the eyebrow area with some fibers continuous with fibers of corrugator • Anterior to the notch the basiocciput has a tongue-and­ supercilii and orbicularis oculi, attaching to the zygo­ groove articulation with the petrous portion of the tem­ matic process of the frontal bone and further linkage pora! bone. to the epicranial aponeurosis anterior to the coronal suture. Rec i procal tension m e m brane rel ationshi ps with the occi put • Trapezius (upper) attaches to the superior nuchal line and external occipital protuberance as well as the liga­ • Both the falx cerebri and tentorium cerebelli attach to the mentum nuchae. occiput (see Fig. 12.6). • Longus capitis attaches to the inferior surface of the • The bifurcated falx cerebri attachment is above the inter­ basiocciput. nal protuberance and houses the superior sagittal sinus. • Rectus capitis anterior attaches to the inferior basioc­ • Below the internal protuberance is the attachment of the cipuI, anterior to the condyle and to the lateral mass and falx cerebelli. root of the transverse process of C1 (atlas) . • Lateral to the internal protuberance are double ridges • Splenius capitis attaches to the superior nuchal line and formed by the bifurcated tentorium cerebelli attachments, mastoid process, crossing the suture, and the spinous with the transverse sinuses located within the bifurcations. Superior pharyngeal constrictor ---___ �-- Musculus uvulae Lateral pterygoid ------___ Masseter---� ,-- Tensor veli palatini Longus capitis ---., (palatine aponeurosis) Tensor tympani ---, �-- Medial pterygoid �-- Tensor veli palatini �--Temporalis a_-- Styloglossus Rectus capitis lateralis ---,. (.I.L--+ Stylohyoid n\"'\"l\"-' Stylopharyngeus Digastric; posterior belly --_-. --- Temporalis Rectus capitis anterior -------I.-tlf--+ M-\"t--'<'.... .------ Levator veli palatini Obliquus capitis superior ---� ,.-.It Longissimus capitis Rectus capitis posterior malor ---� '--Splenius capitis Semispinalis capitis ---�'\" '-- Sternocleidomastoid '-- Occipitalis Rectus capitis posterior minor --�- '--Trapezius Figure 1 2.3 Inferior view of skull, without mandible, showing muscular attachments. Reproduced with permission from Chaitow (2005).

330 CLI N I CA L A PPL I CAT I O N OF N EU R O MUSCULAR T E C H N I QU ES: T H E U P P E R BODY processes of the lower half of the cervical spine (Platzer • Blows to the occiput from behind can cause a crowding 2004, Simons et al 1999) to T3 and the lower part of the or distortion pattern of the occipital base with the sphe­ ligamentum nuchae. Gray's Anatomy (2005) notes that noid, prior to ossification. this muscle attaches to the ligamentum nuchae and spin­ ous processes of C7 through T3 and their supraspinous • Any injuries or strains affecting the temporal or parietal ligaments. bones w ill influence the occiput, and sutural restrictions • Semispina l is capitis and spinalis capitis attach to the relating to parietal or temporal articulations may then superior and inferior nucha l lines and the transverse evolve. processes of C7, T1-7 and the articular processes of C4-6. • Rectus capitis lateralis a ttaches to the jugular process • Muscular dysfunction in the suboccipital region can of the occiput as well as the transverse process of the directly influence dural status and thereby cerebrospina l a tl a s . fluid fluctuations (see notes on rectus capitis posterior • Rectus capitis posterior major is one of the suboccipital m inor above and in Chapters 3 and 11). m uscles (all of which lie deep) and it attaches to the lat­ eral aspect of the inferior nuchal line as well as to the • Internal drainage of the cranium can be directly influ­ spinous process of the ax-is. enced by changes affecting the reciprocal tension mem­ • Rectus capitis pos terior minor, another of the suboccipital branes that a ttach to the occiput and which house both muscles, attaches to the medial aspect of the nuchal line the superior sagittal and the lateral sinuses. and to the posterior arch of the atlas, commonly described as acting to bilaterally extend the head and maintain its Pa lpation exerci s es postural integrity. This unusual muscle has been shown to attach to the posterior atlantooccipital membrane via Palpation of sphenobasilar synchondrosis. This exercise dense connective tissue and to be fused to the dura by is performed using two different holds. numerous connective tissue elements (see more detailed notes on pp. 294-295) (Hack et aI 1995) . Vault hold (Fig. 12.4) . Patient is supine; the practitioner is • Obliquus capitis superior, also one of the suboccipital seated at the patient's head with forearms resting on the muscles, attaches between the inferior and superior nuchal table. Fingers are placed in a relaxed manner so that: lines as well as to the transverse process of the atlas. • small finger is on the squamous portion of the occiput Restrictions and hypertonicity in any of these muscles, uni­ • ring finger rests behind the ear near the asterion so that or bila terally, will strongly influence occipital function. the distal portion of finger is just on the mastoid Range a nd d i rection of moti on • middle finger is an terior to the ear to rest on the pterion The concept of any flexion potential in the adult occipi­ with the tip touching the zygomatic process tosphenoidal junction remains questionable. There is, how­ • index finger rests on the grea t wing of sphenoid ever, an undoubted degree of pliability at the occiput's sutural • thumbs rest, touching each other or crossed, without junctions with the parietals. A powerful pivot point also exists between the occiput and the temporal bone which touching the head if possible, allowing pressure between allows the temporals to 'externally rotate' when mobility them to form a base for the flexor muscles of the hand to is normal. operate. When palpating the occiput, the motion of this bone, eas­ The practitioner si ts quietly for at least 2 minutes or until ing anteriorly on inhalation and returning to its start posi­ cranial motion is noted (a sense of intermittent 'fullness' in tion on emala tion, raises the question as to what drives it. the palms of the hands may be all that is noted initially). Various hypotheses exist - respiratory influences; the recip­ rocal tension membrane responding to intrinsic forces (CSF, As the flexion phase (also known as the inhalation/ex ter­ for example); direct response to muscular influences, and nal rotation phase) of the cranial cycle commences (mani­ others. When palpating the bone, it is suggested that the fested by noting a sense of fu l lness, slight tingling, minute slight degree of motion that may be noted is assessed with pressure in palms of hands or in wrists / forearms, by pro­ no preconceptions as to what may be driving it (Chaitow prioceptors) the following might be noted: 2005) . • ring and middle fingers seem to be carried caudally and Dysfu nctiona l patterns laterally • Any injury affecting the atlantooccipital joint is l ikely to • index finger seems to be carried anteriorly and caudal ly. negatively influence occipital motion. These real or apparent motions are all passive with no effort on the part of the practitioner. As sphenobasilar extension commences (exhalation/ internal rotation phase) a sense might be noted of the pal­ pated bones returning toward their starting position (index finger moves cephalad and posteriorly, while ring and mid­ dle fingers move cephalad and medially). Frontooccipital hold (Fig. 12.5). Patient is supine and the practi tioner si ts to right or left near the head of the table.

12 The cranium 3 3 1 Figu re 12.4 Vault hold for cranial palpation. Reproduced with permission from Chaitow (2005). • The caudad hand rests on the table cradling the occipital Figu re 12.5 Frontooccipital hold for cranial palpation. Reproduced area so that the occipital squama closest to the practi­ with permission from Chaitow (2005). tioner rests on the hypothenar eminence, while the tips of the fingers support the opposite occipital angle. If these motions are sensed they may be encouraged, in order to assess any restriction, by using very light pressure • The practitioner 's cephalad hand (closest to the head) (grams only) in the appropriate directions to impede the rests over the frontal bone so that the thumb lies on one movement described. great wing of the sphenoid and the tips of the fingers on the other great wing, with as little contact as possible on During sphenobasilar extension (exhalation/internal rota­ the frontal bone. tion phase) a return to neutral may be noted, as the lower hand goes cephalad and the upper hand goes cephalad and • If the practitioner's hand is small, contacts are made on posteriorly. the lateral angles of the frontal bone. It may be some min­ utes before cranial motion is noted. These two palpation exercises offer an opportunity to assess the disputed mid-line motion functions, flexion and As sphenobasilar flexion (inhalation/external rotation phase) extension, of the cranial mechanism, that of the sphenobasi­ commences (sensation in the hands of fullness, tingling, etc.), lar synchondrosis and all that flows from it. the practitioner might feel: • Can these motions of the occiput and/or the sphenoid be • occipital movement which is caudad and anterior, while sensed? simultaneously • If movement is felt, what is actually moving? • the great wings seem to rotate anteriorly and caudally around their transverse axis.

332 CLI N I CA L A P P LICAT I O N O F N E U R O M US C U LA R TEC H N I Q U ES : T H E U PP E R B O DY • Does the movement continue when the patient holds the SPHENOID (FIG. 12.6) breath? • The body, situated at the center of the cranium - a hollow • Is the movement accentuated by deep inhalation and /or structure enclosing an air sinus exhalation? • Two great wings, the lateral surfaces of which form the There are no definitive answers at present as to what is only aspect palpable on the external cranium, the tem­ actually happening, with opinions varying from orthope­ ples, and the anterior surfaces of which form part of the dic to subtle energy hypotheses. Aspects of some of these eye socket concepts are included in this chapter - see, in partic­ ular, the 'liquid electric' hypothesis in descriptions of • Two lesser wings, the anterior surfaces of which form sphenoidal function, immediately below (Chaitow 2005, part of the eye socket Ettlinger & Gintis 1991, Greenman 1989, Upledger & Vredevoogd 1983). • Two pterygoid processes, which hang down from the great wings, and which are palpable intraorally postero­ medial to the upper 3rd molars Ethmoid spine--'-\" �--Sulcus chiasmatis Tuberculum sellae ---___ �--Middle clinoid process Superior orbital fissure ---�\\.) �\"\"-<Lesser wing Foramen rotundum ---t/. �;F;'\"-:= Greater wing Foramen ovale ------- ----.:.-; .-,. -r- Foramen spinosum ---\" tt-- Spine Emissary sphenoidal foramen ___.J Lingula Hypophysial fossa .J____ '-- Carotid sulcus '-- Posterior clinoid process A Dorsum sellae ____.J Posterior clinoid process Dosum sellae ---., Anterior clinoid process Lesser wing --{F-- Greater wing ��:..:J-fmSuperior orbital fissure ..-. s:§;: � �-- Occasional notch for abducent nerve �-- Foramen rotundum Spine Scaphoid fossa Pterygoid canal Pterygoid fossa '-- Lateral pterygoid plate B Pterygoid hamulus Rostrum Vaginal process Medial pterygoid plate Figure 12.6 Superior (A) and posterior (B) aspects of the sphenoid bone. Reproduced with permission from Chaitow (2005).

12 The cranium 333 • The pterygoid plates, which form part of the ptery­ Muscu l a r attachm ents goid processes and are important muscular attachment sites • The temporalis muscle attaches to the great wing and the frontaL parietal and temporal bones, crossing important • The sella turcica (,Turkish saddle'), which houses the sutures such as the coronal, squamous and the fron­ pituitary gland tosphenoidal. • The sphenobasilar junction with the occiput, a synchon­ • Specifically the attachments of temporalis are to the tem­ drosis that fuses in adult life (Gray's Anatomy 2005) poral bone and to the coronoid process and the anterior border of the ramus of the mandible. Articu l ati ons • Attaching to the internal pterygoid plate are buccinator • With the occiput at the synchondrosis. as well as a number of small palate-related muscles. • With the temporal bones at the petrous portion and pos- • Medial pterygoid attaches to the lateral pterygoid plate terolaterally with the squama. and palatine bones running to the medial ramus and • With the parietal bones at the pterion. angle of the mandible. • Anteriorly with the ethmoid. • Inferiorly with the palatine bones. • Lateral pterygoid attaches to the great wing of the sphe­ • Anteriorly both greater and lesser wings articulate with noid, the lateral pterygoid plate and the anterior neck of the mandible and its articular disc. the frontal bone bilaterally. • Inferiorly with the vomer. • Various small muscles relating to movement of the eye, • Anterolaterally with the zygomae. as well as levator palpebrae which help raise the eye­ brows, attach to those parts of the great wings of the sphenoid that form part of the eye socket. Reci proca l tension m e m bra ne rel ati onshi ps with R a nge a nd d i rection of motion the s pheno i d • In traditional osteopathic thinking the sphenoid rotates Both falx cerebri and tentorium cerebelli attach to the sphe­ anteriorly on flexion and returns to a neutral position noid (Fig. 12.7). during the extension phase of the cranial respiratory cycle (Fig. 12.8). Falx cerebri --- -___ �_+l,I.'mI._-! Sphenoid Siraighl sinuS--\\+-.lJ.-tft�����;;�;: �::<:: ::=:CJ Tentorium cerebelli -�<\\.--\"..,. Figure 1 2.7 The reciprocal tension membranes of the cranium. Reproduced with permission from Chaitow (200S).

334 CLINICAL APPLICATION OF NEUROMUSCULAR TECHNIQUES: THE UPPER BODY Axis of -1-+--- • The muscular links with the mandible create a connec­ tion between temporomandibular dysfunction and sphe­ ethmoid rotation -----, noidal dysfunction, with the influences being possible from either direction. Axis of sphenoid rotation --+ --�-'< •.• Dysfu nctiona l patterns Axis of Axis of • Because of the intimate linkage with neural structures, vomer rotation occipital rotation sphenoid dysfunction can be directly associated with optical, trigeminal and acoustic disturbances. SBS moves cephalad during flexion • Because of the proximity to the pituitary gland, endocrine disturbances may be an outcome of sphe­ Figure 1 2.8 Schematic representation of hypothesized cranial noidal dysfunction. motion features. SBS, sphenobasilar synchondrosis. Reproduced with permission from Chaitow (2005). • According to the structural!mechanical model, a range of possible 'lesion' patterns may exist between the sphe­ • In the adult skull, it is suggested that this motion is noid and any of its articulating neighbors, deriving from impossible (due to fusion of the sphenobasilar synchon­ trauma (possibly including forceps delivery or stressful drosis) but it remains a central part of the belief system of birth trauma) which can be evaluated and treated by a most craniosacral therapists. process of testing (see palpation exercises below). • Models other than the original osteopathic one exist for • If the 'energetic' or 'fluid' model is accepted, a different, explaining the influence of cranial function and dysfunc­ more intuitive, unstructured approach to palpation is tion, including what is termed the 'liquid electric model', suggested, as discussed in the exercise section below. which hypothesizes that cranial bones move in response to motion of the brain, which is itself responding to the Pa l pation exe rcises rhythmic pulls imparted by the spinal dura and a variety of muscular influences. General sphenoidal release (also known as 'sphenoid liff) (Fig. 72.9). Since, in the mechanical/structural model of • In this model the cranial bones 'float' and move in rela­ cranial therapy, it is considered that six possible dysfunc­ tion to a central focal point at the center of the brain. tion patterns can exist at the sphenobasilar junction, these There are in this concept no fixed axes or pivot points, are tested and treated while the occiput and sphenoid are with all movement responding to tissue changes else­ lightly palpated. where. Milne (1995) explains: 'Neurocranial bones float, as if they had neutral buoyancy and were suspended in • The patient's head is cradled in the hands so that the fin­ water, and are pushed or pulled by tidal electrical, mus­ gers enfold the occiput and the thumbs rest lightly on the cular, and osseous forces.' great wings of the sphenoid. • This model envisions a mechanism that is open to multi­ • By lightly (ounces at most) drawing the thumbs toward ple forces and avoids the physiological denial inherent in the hands, the sphenoid is 'crowded toward the occiput'. the 'bending joint' of the classic osteopathic modeL • This crowding is held for several seconds at which time Other a ssoci ati o ns a nd i nfl u e nces the thumbs alter their direction of push and are lightly drawn directly toward the ceiling, so (theoretically) • The first six cranial nerves have direct associations with decompressing the sphenobasilar junction and applying the sphenoid, with the 2nd (optic), 3rd (part of oculomo­ traction to the tentorium cerebelli as the weight of the tor), 4th (trochlear), 5th (nasociliary, frontal, lacrimal, cranium drags onto the practitioner's palms and fingers. mandibular and maxillary branches of trigeminus) and 6th (abducens) all passing through the bone into the eye • With the hold as described, the ease of movement of the socket (the 1st, the olfactory nerve, runs superior to the sphenoid is very lightly, individually assessed. These lesser wings). methods will not be described, as they require a degree of training for safe application. • The intimate relationship with the pituitary gland sug­ gests that endocrine function can be strongly influenced In order to evaluate this approach through other eyes, a via dysfunction of the sphenoid which creates circulatory quotation from Hugh Milne's (1995) insightful text The or other stresses on the gland. Heart of Listening will be usefuL Milne suggests 1/5 of an ounce contact pressure, which is approximately 5.5 grams, much the same as is recommended by Upledger & Vredevoogd (1983). To introduce decompression of the sphenobasilar joint, first take out all the skin slack under your thumbs so that you have a firm purchase over the wings themselves - not on the