Clinical Application of Neuromuscular Techniques The Upper Body Volume 1

1 2 The cranium 385 Parotid duct --/'-f.-!'l\"1, f-!-+l:;,a Accessory pall of parolid gland F+..-. - Parotid gland Masseter Mucous membrane Body of mandible --it-l(cut edge) with subtinguat ducts Lingual nerve ---f'l/v\\ Sternocleidomastoid Digaslric - poslerior belly ---�\\iSublinguat gtand Submandibular gland (superficial part) Hyoglossus --.-/ Digastric - anterior belt\"--.-/ Mylohyoid �-\\-- Stylohyoid (turned down) Platysma (cut edge)--./- '-- Submandibular gland (deep part) Submandibular duct Fig u re 1 2.65 Com p ression of the sa l ivary g la nds is avoided w h e n a d d ressin g the su prahyo id m uscles i n the floor of the m o u th. Reprod u ced w ith permission from Gray's Anatomy (2005). Submandibular salivary gland infections may incite dys­ Figure 1 2.66 The e n t i re floor of the m o u th m ay be treated with function in surrounding muscular tissue which may, in one finger placed i n traorally a n d opposi ng dig its provi d i n g pressu re turn, create dysfunctional movement patterns of the externa l ly. mandible, including la teral excursion d uring opening (pro­ ducing a zigzag pattern of tracking) and occlusal interfer­ treatment of the anterior belly of digastric, as well as the ences. Glandular infections and s tones within the salivary mylohyoid and geniohyoid, is described here. glands should be considered and ruled out, especially when the suprahyoid muscles are unilaterally tender to palpa tion � N MT FOR IN TRAORAL F L OOR OF MOUTH (Fig. 12.65). These muscles may be treated either ipsilaterally or con­ Upledger & Vredevoogd (1983) point out that the mylo­ tralaterally depending upon the comfort of the practitioner hyoid can interfere with cranial mechanics because of i ts and the angle of the jaw. While using no pressure to position action in opening the mouth, when the hyoid is stabilized by the finger for treatment, the index finger of the practitioner's the infrahyoid, an action which would be counteracted by muscles attaching to the maxillae and the zygomatic bones. The complex of stabilization and counterpressures can, they suggest, 'interfere with the function of the craniosacral sys­ tem and contribute to temporomandibular dysfunction'. Trigger points in the posterior belly of digastriC can refer pain to the upper part of the sternocleidomastoid muscle as well as neck and head pain while triggers in the anterior belly refer to the lower incisors. If a trigger in digastric is referring into the lower incisors then a rapid tensing of the anterior neck muscles by the patient ('pull the corners of your mouth down vigorously') will activate the trigger and reproduce the pain. The digastric trigger point target zone includes the area of the stylohyoid muscle, whose pain pat­ tern is not yet clearly established but is presumed to be sim­ ilar (Simons et aI 1999). The posterior attachment of digastriC as well as the stylo­ hyoid has been previously discussed together with the mastoid and styloid processes (pp. 369-371). The intraoral

3 8 6 CLI N I CA L A P P LI CAT I O N O F N E U R O M U S C U LA R TEC H N I Q U E S : T H E U PP ER B O DY Helmut Leonhardt ( 1 986) has sum m a rized the processes of • The latter protrudes like a torus due to superior pharyngea l con­ deglutition as follows. strictor contraction (Passavant's ring torus), separating food pas­ sage from the upper airways. Voluntary inception of swallowing • The m uscles of the floor of the mouth contract a nd the tongue, • If the palatal muscles a re paralyzed, e.g. after diphtheria, food will enter the nose during deglutition. together with the bolus (of food), is pressed against the soft p a l a te . • Mylohyoid, d igastric and thyrohyoid m uscles l ift the floor of the • Subsequent movements are due to stimulation of the receptors in mouth and assist in visible and pa l pable elevation of the hyoid the mucosa of the palate. bone and the larynx, while the entrance to the larynx and the entrance to the epiglottis a pproximate. Safeg uarding the airway by reflex action • The palate is tensed a n d raised by the tensor and levator vel i pala­ • The root of the tongue lowers the epig lottis with the help of the a ryepiglottic muscles and the entrance to the larynx is (incom­ tini m uscles to press against the posterior wall of the pharynx. pletely) closed. Lateral pterygoid plate, partly excised ---, Maxillary artery ------r.'---, �,a.__-_ ---''<-.L-+_----- Tuberosity of maxilla Tensor veli palatini ---',. �--1t Maxilla Mandibular nerve Middle meningeal artery r.\\--H' Buccinator Spine of sphenoid r+--+ Parotid duct -0\\-+- Pterygomandibular raphe Levator veli palatini Pterygoid hamulus ---' Superior pharyngeal constri(:tor---.: Stylopharyngeus ---' Glossopharyngeal nerve ______ --..B.\", \\--- ---:�- Mandible Styloglossus ---­ [10£------ Hyoglossus Middle pharyngeal constrictor --- -=-- Mylohyoid Stylohyoid ligamenl --- Geniohyoid Greater cornu of hyoid bone --- --- Lesser cornu of hyoid bone 1<--- ------- Internal laryngeal nerve Lateral thyrohyoid ligamenl --- --- Thyrohyoid membrane Thyropharyngeus --- k-------- Superior laryngeal vessels --,IFI --------- Thyroid cartilage Inferior pharyngeal conslrictor Cricopharyngeus --;-�p+o :.�W.h\\'l_- Cricothyroid ligament f-- Cricothyroid '--- -------- Trachea Recurrent laryngeal nerve --- Esophagus ---.:E Fig u re 1 2.67 B uccinator a n d muscles of the phar:ynx. Reproduced with permission from Gray's Anatomy (2005). box continues

12 The cranium 387 Box t and hyoglossus muscles and pushes the bolus over the fauces into the pharynx. The bolus slides mainly through the piriform recesses prima­ • Simu lta neously, breath ing stops as the rima glottidis is closed. rily and partly over the epiglottis. • Thus, food passage is completely prevented from entering the Pharyngeal constrictors ca n then push the bolus through the d i lated lower airways. esophagus 'right down to the cardia'. Transport of the bolus through the pharynx and Leonhardt concludes: 'The bolus ca n a lso be propelled i nto the esophagus stomach by continuous waves of contraction of circu lar m uscle Leonhardt explains further that: (peristalsis). even against gravity, if the subject adopts an appropriate posture: The slit of the pharynx unfolds upward and forward when the larynx ascends. Then the tongue is pulled like a piston by the styloglossus A Condyle of mandible ---, The treating finger is pressed toward the external finger, capturing a portion of the suprahyoid muscula ture between the two digits. The tissue may be compressed or frictioned between the two digits at fingertip intervals until the entire floor of the mouth has been treated. The submandibular salivary glands should be avoided but the tissue surround­ ing them should be thoroughly examined. The external finger may also be used as the treating fin­ ger with the internal finger offering stability. This reversal of roles particularly addresses the anterior belly of digastric. Hyoglossus muscle Hyoid bone Genioglossus CRAN IAL TREATMEN T AND THE I N FAN T process B Styloglossus muscle This text has deliberately concentrated attention o n the adult skull. The skull of the infant, and more so in the neonate by Middle necessity, is immensely malleable, with the pliability of a constrictor milk carton. As a mainly cartilaginous structure at birth the infant skull is ultraresponsive to direct molding pressures. Hyoglossus The cranial bones are unconnected by sutures at birth Fig u re 1 2.68 Hyog l ossus a n d associated m uscles. A: Posterior view. and some of the cranial bones, known as composite bones B: Latera l vi ew. Reprod uced with perm ission from Gray's Anatomy (e.g. occiput, sphenoid, temporal) comprise several parts, for Studen ts (2005). allowing scope for the rapid growth of the brain (Carreiro 2003) (Fig. 12.69). The neonate cranium is remarkably soft treating hand (usually the most caudal hand) is placed onto and unstructured, allowing folding of the cranium as it one side of the floor of the mouth and slid posterior as far as passes through the birth canal. possible. A finger of the external hand opposes the internal finger to provide a supporting surface against which to Cranial distortion can be created by prebirth influences, press the muscles (Fig. 12.66). via trauma (seat-belt compression during an automobile accident, for example) or if the womb is crowded (perhaps by a twin), or if chemical influences distort development (drugs, toxins and/ or nutritional deficits). Far more likely to produce damage, however, are the influences of the dan­ gerous potentials of the powerful forces acting upon the supple skull during the birth process. Among the factors that can produce cranial damage dur­ ing birth are (Biedermann 2001, 2005): • too rapid a transit through the birth canal that precludes the opportunities for 'normal' molding to occur • too ex tended a period in the birth canal with excessive compression forces operating on the delicate mem­ branes, sometimes for many hours (Byrne et al 1993, Magoun 1976)

3 8 8 CLI N I CAL A P PL I CAT I O N O F N E U R O M U SC U LA R TECH N I Q U E S : T H E U PP E R B O DY • anomalous prenatal positioning and / or crowding (as in twins or triplets) • the application of mechanical force to extract the infan t ­ via inappropriate use of forceps or the stress of vacuum suction delivery (Noret 1993). As Milne (1995) explains: A newborn baby has no sutural interlocking or interdigita­ tion between adjacent cranial bones. The bony plates of the cranial vault arefree to float like icebergs in an elastic sea of membranous dura. The mechanism of thefontanelles, pliant cartilage, tender membrane, open sutures, cerebrospinalfluid and falx and tentorium has evolved so that what is, evolu­ tionarily, a huge head can pass through a small birth canal intact. This is achieved by progressive and controlled cranial implosio n . F i g u re 1 2.69 Anterosu perior view of a neonatal specim e n . The THE CRANIOCERVICAL LINK external peri oste u m has been removed from the rig h t frontal bones; it is sti l l in place on the left. The sutures from t h e right frontal bone Biedermann (2001 ) suggests that the common denominator can b e see n a s thicke n i n gs of connective tissue. Reproduced w i th in all of these negative influences is undue mechanical perm ission from Carrero (2003). stress impinging on vulnerable cerebral tissues and the craniocervical area. The result may include asymmetrical F i g u re 1 2.70 Schematic d i a g ra m d e picting t h e typical cone-sha ped posture, morphology or movement pa tterns, as well as rotational stra i n seen at the site of vacu u m place m e n t. The depth inappropriate responses to ex ternal stimuli. and exte nsion i nto deeper tissues a ppears to b e d ependent upon the d u ration and i ntensity of the a p p l ication of the device. Reprod uced Under normal conditions any minor distortions imposed w ith perm ission from Carrero (2003). during birth will resolve as a result of the influences of the reciprocal tension membranes within a matter of days, greatly assisted by the forces involved in suckling and crying (Frymann 1966). In many instances, however, such a recov­ ery is not achieved due to the degree of distortion created with - sometimes disastrous - consequences in health terms (Arbuckle 1948, Frymann 1976) . Dis tortions and deformities are often easily noted and may be the reason the parent(s) seeks assistance. Behavioral problems such as incessant crying, feeding difficulties, 'head banging' or frank illness might cause parents to attempt to find appropriate professional help. Clearly, if the healthcare provider consulted is ignorant of the influence of cranial function on health, whatever is offered will be less than sat­ isfac tory. After birth the pliability of the infant cranium continues to allow damage to occur more easily than once ossification has taken place. Falls and blows are obvious pOSSibilities, and indeed probabilities during the early years of life. If severe enough these may produce problems similar to those that can occur during childbirth. Biedermann (2001 ) describes what he terms 'KlSS' children in whom the main clinical feature is torticollis, often com­ bined w ith an asymmetrical cranium, postural asymmetry and a range of dysfunctional symptoms. KISS is an acronym for kinematic imbalances due to suboccipital strain. Biedermann notes: '[KlSS imbalances] can be regarded as one of the main reasons for asymmetry in posture and con­ sequently asymmetry of the osseous structures of the cra­ nium and the spine.'

1 2 The cranium 3 8 9 Figu re 1 2.71 Cra nia-facial treatment i nvolvi ng the correlates closely with the acceptance of recommended zygoma -temporal region on an i n fa nt. Re produced with perm issio n changes in sleeping position to supine or side positioning for from Von Pieka rtz Et Bryden (200 1 ) . infants because of the fear of SIDS. They report that older infants were treated with continuous positioning by the par­ Among the many symptoms reported by Biedermann in ent, keeping the infant off the involved side, while younger KISS children are: torticollis, reduced range of motion of the infants and those with poor head control were treated with head/neck, cervical hypersensitivity, opisthotonos, restless­ a soft-shell helmet. Only 3 of 51 patients have required sur­ ness, inability to control head movement and one upper gical intervention, and other patients demonstrated sponta­ limb underused (based on statistical records of 263 babies neous improvement of all measured parameters. treated in one calendar year up to June 1995). The researchers report: Biedermann (2001) is convinced that the most effective treatment for such infants is removal of suboccipital strain We beLieve that most occipitaL pLagiocephaLy deformities are by manual treatment, and not direct treatment of crania l deformations rather than true craniosynostoses. Despite asymmetry as this is consid ered to be a symptom of the varying amoun ts of suture abnormality evidenced on com­ underlying problem (most commonly suboccipital strain). puted tomographic scans, most deformities can be corrected Following appropriate treatment to reestablish full range of without surgery. In cases where progression of the craniaL upper cervical motion, functional improvement is reported deformity occurs, despite conservative therapy, surgicaL to be common within 2-3 weeks, although normalization of intervention shouLd be undertaken at approximateLy 1 year cranial asymmetry takes many months. How much treat­ ofage. (Argen ta et al 1 996) ment is required? According to Biedermann, of the 263 babies trea ted, 213 required only one treatment, 41 were WHAT OTHER FACTOR S D O MEDICAL treated twice and the remainder more often, with just 2 AUTHOR I TIES THIN K CAUSE SERIOUS CRANIAL requiring 4 or 5 treatment sessions. DISTORTI ON IN IN FANTS? SLEEPING POSI T I ON AND CRANIAL DEFORMITY It is reported (Miller & Clarren 2001) that deformational plagiocephaly (cranial distortion, or 'crooked head shape') One of the reasons for KISS-like problems seems to relate to can result from three different etiological processes: infant sleeping position. A research study by plastic and reconstructive surgeons has concluded that the almost uni­ • Abnormalities in brain shape and subsequent aberrant versal acceptance of positioning neonates on their backs to directions in brain growth avoid sudden infant death syndrome (SIDS) may well increase the incidence of abnormalities of the occipital cra­ • Premature fusion of a single coronal or lambdoidal suture nial sutures, causing significant posterior cranial asymme­ • Prenatal or postnatal external constraint. try, malposition of the ears, distortion of the cranial base and deformation of the forehead and facial structures (Argenta WHAT ARE THE L ON G - TER M E F FECTS OF et aI 1996). DE FORMATIONAL PLAGIOCEPHALY? The study reported that there had been a dramatic increase A study was conducted to determine whether there was an in the incidence of deformation of the occipital structures, increased rate of later developmental delay in school-aged although the patient referral base has not changed appre­ children who presented as infants with deformational pla­ ciably. Argenta et al note that the timing of this increase giocephaly without obvious signs of delay at the time of ini­ tial evaluation (Miller & Clarren 2001). A total of 181 families from the medical record review could be notified about the study and 63 families agreed to participate in a telephone interview. The sample of partici­ pants for the telephone interview was random to, and rep­ resentative of, the group as a whole. The families reported that 25 of the 63 children (39.7%) with persistent deforma­ tional plagiocephaly had required special help in primary schooL including special education assistance, physical therapy, occupational therapy and speech therapy, gener­ ally through an Individual Education Plan. Only 7 of 91 sib­ lings (7.7%), serving as con trols, required similar services. One useful finding was that affected males whose defor­ mity was due to uterine constraint were at the highest risk for subsequent school problems. It was also noted that the use of helmet therapy to correct the distortion (a standard medical approach) did not seem

390 C L I N ICAL APPLICAT I O N O F N E U R O M USCU LAR TECH N I Q U E S : THE U PP E R B O DY to affect the rate of developmental delay, almost half of the movements of the craniofacial region over the past 6 years, delayed patients having worn helmets (Miller & Clarren forty-nine children were treated successfully and 11 200 1 ) . showed no change.' D I F FERE N T CRA N IAL APPROACHES These children had been referred by general physicians in cases where standard treatments, such as insertion of This text is not an appropriate place in which to offer pre­ grommets, paracentesis, surgery and /or antibiotic usage, cise details of infant cranial care, as the methods required had failed. Spermon-Marijnen & Spermon (2001) suggest for application on such delicate structures need to be learned that 'passive movement of the cranium can restore the cir­ in closely supervised clinical and classroom settings. Suffice culation and motion by which drainage of the middle ear is to say that the method of application of cranial manipula­ stimulated' . tion in infants is usually direct rather than indirect - i .e. the barriers of resistance are engaged and molding is applied in These clinicians commence the process of trea tment by an attempt to normalize distortions, utilizing very gentle observation, palpation and motion palpation: and sensitive holding patterns. Look at symmetry or deformity, paying special attention to Biedermann applies a direct approach in cervical treat­ asymmetry, the orbital line, the level of ears related to the ment of KISS children, using what is described as 'minimal level of eyes, and the mastoids. Palpate the vault and posi­ imp ulse manipulation', commonly in a la teral direction, but tion of the sutures, noting swelling, overlap and mobility. with a rotational component in some cases. Test the condylar parts ofthe occiput and examine the occip­ ito-atlantal mobility. We measured theforce used in treatment ofbabies and adults [and found] the force used for treating babies is 15-20% of Palpation and motion palpation merge readily into treat­ that used in adults. In most cases the direction ofthe impulse men t: is determined by radiologicalfindings (85%) . . , The manip­ �tlation itselfconsists ofa short thrust with minimalforce of The techniques ofpassive motion testing are, in our opinion the proximal phalanx of the medial edge of the secondfinger. also effective as therapeutic movements, with the applica­ tion ofadditional or sustained pressure. The amount of force involved, tested with a calibrated pres­ sure gauge, required no more effort than would be needed The following list is a summary of the methods described to 'push a bell-button energetically'. by Spermon-Marijnen & Spermon (2001) as relevant tech­ niques used for children with chronic ear conditions. Clinical researchers and authors such as Viola Frymann ( 1976) and John Upledger (Upledger & Vredevoogd 1983) 1. Transverse movement of the sphenoid: Sitting at the head of record many instances of success in trea ting dysfunctional the supine patient, one index finger and middle finger on children, some with severe learning and behavioral prob­ the sphenoid, and the other index and middle finger on lems, as well as with a host of physical complain ts, utilizing the contralateral zygoma and frontal bone, very light cranial techniques (Upledger 1978). pressure is used to gently shunt the sphenoid into a translation. Hand positions then reverse and translation Should cranial distortion occur in infancy and childhood, to the other side is introduced. In this same way rotation when plasticity allows for a degree of movement not avail­ of the sphenoid may also be achieved. able in the adult skull, particularly in relation to the sphe­ nobasilar synchondrosis, the resulting distortion pa tterns, 2. Longitudinal movements of the nasofrontal region: Standing with their associated soft tissue imbalances of the reciprocaJ to the side of the supine pa tient, one hand over the crown tension membranes in particular, will become 'set' and will of the head, index finger contacts and stabilizes the supra­ be largely impervious to 'corrective' trea tment in adult life. orbital region on one side, while the other hand uses a Some modification of the associated stress patterns can stiU pincer contact on the superior aspect of the nose, to intro­ be initiated via cranial and other therapeutic measures, even duce a distraction force. This may be sustained, or can be in adult life, but restoration of structural 'normality' and used to rhythmically 'pump' the area. One side is treated, symmetry becomes a virtual impossibility after childhood. then the other, to 'influence the frontal and maxillary sinuses'. While not identical to the 'nasal release' method Moving away from cranial distortion to far more com­ described earlier in this chapter, it should achieve similar mon patterns of ill-health affecting infants leads inevitably results. to the topic of chronic ear infection. 3. Transverse movement of the zygoma-temporal and zygoma­ EAR D I SEASE AND CRAN IAL CARE maxilla region: The patient is supine and the practitioner is seated at the head . One side is trea ted at a time. Spermon-Marijnen & Spermon (2001) have treated many • Using finger and thumb contacts of each hand, one children with chronic middle ear disease, \\Ising cranial contact closer to the zygomatic-maxillary junction and techniques. They report that: '60 children [with otitis media the other closer to the zygomatic-temporal j unction, a with effusion] were inspected and treatment with passive gentle distraction/ separation is introduced as the pa tient's head is rotated contralaterally.

1 2 The cranium 391 j Figure 1 2.72 Distraction of zygoma and maxilla. Reprod uced w i t h permission from Von Pieka rtz Et Bryden (200 1 ). • The thumb and index finger of one hand are placed on A the zygoma and the same contacts of the other hand are placed on the maxilla, al lowing distraction tha t eases B the zygoma laterally and cephalad, and the maxilla medially and caudad. The d istraction is applied and Figu re 1 2.73 A: Cranio-facial treatment. B: Cranio-facia l distortion. released, synchronous with the brea thing of the pa tient, Reproduced with permission from Von Pieka rtz Et Bryden (200 1 ). several times. Spermon-Ma rijnen & Spermon suggest with the pa tient being asked to (a) swallow after each stretch, (b) swallow during the stretch or (c) perform a that these methods influence the maxillary and frontal Va lsalva maneuver during the stretch ( i .e. inhale, and sinuses, encouraging func tionality and drainage (Figs hold the nose and a ttempt to exhale through the nose, crea ting increased pressure in the nasopha rynx, in an 12.72, 12.73). attempt to open the Eustachian tubes). See the notes ear­ 4. Longitudinal movement of the petrous bone (mastoid lift): lier in this chapter on bitemporal rolling method tha t can have a direct effect on the a u d i tory canals tha t pass Patient is supine and practi tioner sea ted at the hea d . through the temporal bones. With finger contact on the petrous portion o f the mastoid bone, rhythmic repetitive longitudinal traction is applied cephalad, synchronous with brea thing. This decompres­ sion approach is thought to influence the craniocervical region. See also temporal rolling exercises described ear­ lier in this chapter for rhythmic approaches utilizing leverage of the mastoid processes. 5. Rotation of the forehead on hindhead: The frontal bone is held with one hand, while the other cradles the occipital region to act as a s tabilizing force. The frontal bone is gently rotated clockwise then anticlockwise several times to int1uence sinus drainage. This method could usefu lly be coupled w ith the frontal lift described earlier in this chap ter. 6. Distractions of relevant sutures: A gapping pressure is applied a t right angles across su tures. See also descrip­ tion of the parietal lift method ou tlined earlier in this chap ter, which offers a d i fferent way of releasing this suture and enhancing venous sinus drainage. 7. Opening external auditory meatus: The pa tient is sidelying, head on a firm p i llow. The practitioner pla ces two fingers of one hand on the mastoid process and two fingers of the other hand anterior and superior to the external audi­ tory meatus. A rhythmiC separation stretch is introduced,

392 CLI N I CA L APPLICATI O N OF N E U R O M U SCULAR TECH N I QUES: THE U PPER BODY SUMMARY hand might be used in these miniature mouths, and even then, it may be crowded. Delicate touch is mandatory and Cranial treatment of infants differs from the methodology short applications of very light touch are usually sufficient applied to adults in that it usually involves direct approaches. to achieve results. Pressures used are even lighter for infants than the gentle methods suggested for adults. Whether problems are devel­ CAUTION: It is essential that appropriate training is under­ opmental, distortional or are aimed at improving drainage taken before infants are treated using cranial or NMT (as in otitis or sinusitis), there appear to be a range of effective methods. trea tment methods, examples of which have been described in this chapter. The cranium, on which we have focused in this chapter, houses the organizing functions of the body, receiving and Most of the NMT treatments described i n this chapter integrating information before coordinating activity in those can also be applied cautiously to infants. However, it is sug­ parts of the human organism through which we actively gested that the practitioner has first mastered the tech­ (functionally) express ourselves. A number of glands (includ­ niques on adults before applying them to children of any ing pineal, pituitary, lacrimal and salivary) reside there and age. Additionally, the techniques would be used only when all of the senses except the sense of touch are confined to the absolutely needed, such as when the infant is having diffi­ cranium. Among the organs that are housed and protected culty opening the mouth to eat. Most adult index fingers, by the cranium are the eyes, which not only provide us with and most certainly the thumbs, will be too large to apply to vision, but are also intricately related to balance and head children or infants. The smallest finger of a small adult position (Box 12.12) . Through this central. command center the rest of the body is compelled into action. That the results ofthe present method of treating defects ofvision are Periorbita Fascial Superior far from satisfactory is something that no one would attempt to deny. sheath rectus muscle Dr William Bates' insig htfu l q uote in 1 9 1 9 remains true today i n many respects. Although genera l u nderstanding of eye health, dysfunctions and pathologies has considerably expanded since Dr Bates developed his infamous 'Bates method' of eye exercises ( 1 920), a g l a nce around us at the num ber of people who requ i re prog ressive support for visu a l cla rity (glasses, contact lenses, eye surgeries, etc.) reflects the i nherent deficiency in ophtha lmic medicine to prevent visual deterioration and to use natura l means to improve vision. M uscu lar anatomy of the eye Suspensory ligament The movements of the eye a re control led by six extrinsic m uscles: superior rectus, inferior rectus, medial rectus, lateral rectus, superior Inferior oblique Inferior rectus oblique and inferior obliq ue. Additional ly, levator pal pebrae superioris elevates the u pper eyelid, orbicularis ocul i closes the muscle muscle eye while corrugator su percilii draws the eyebrow medially and inferiorly to offer shade to the eye. The latter two of these are Figu re 1 2.74 Fascial sheath of the eyeba l l . Reproduced with discussed within the main body of the text. The intrinsic m uscles of the eye include the cil iary m uscle, w hich manipulates the lens, permission from Gray's Anatomy for Students (2005). and the sphincter and dilator pupillae, which control the size of the pupil. point of attachment. Part of this fascial sheath becomes the supporting suspensory liga ment at the inferior aspect, where it The anatomy and physiology of the eye itself, and the i ntricate benefits from contributions from the medial, lateral and two inferior deta i ls of eyesight in general, is q u ite complex and fu l ly discussed ocu l a r m uscles. Additiona l ly the medial and latera l check ligaments within most a natomy texts. This discussion is, therefore, primarily a re expansions of the investing fasci a that covers the medial and directed toward the extrinsic m u sculature and to steps that the lateral recti, respectively. patient ca n take to gain better health of the m uscles of the eyes. Since the extrinsic muscles su rround the eye, which is itself a fl uid It is easy to become confused when considering the attachments fi l led bal loon-l i ke structure, it i s reasonable to consider that and functions of the extri nsic ocu lar muscles (see Table 1 2. 1 ). reduced tension in the m uscles could i nfluence the shape of the eye, might alter eye hea lth and perhaps have some bearing on box continues eyesig h t. The bu lbar (fascial) sheath almost completely encloses the eyebal l (Fig. 1 2.74). The investing fascia of each m uscle blends with the bulbar sheath a s the m uscle passes through it to continue to its

1 2 The cranium 393 Box 1 2. 1 2 (continued) A Elevation Superior oblique Trochlea Inferior oblique Superior rectus Abduction .\"'.I.If Lateral \\ is_+-:. Mediat ...\"... Adduction rectus rectus Superior oblique Inferior rectus Superior recIIUS---ilWrI\\+f, Depression Lateral Medial B Superior rectus Look laterally and upward Inferior rectus Look laterally A Lateral rectus Medial rectus and downward Levator palpebrae superioris Superior rectus Lateral rectus Look laterally Superior oblique --f-=.:-r<;� Look medially Inferior oblique Look medially and upward Superior oblique Look medially B Inferior oblique Medial rectus Inferior rectus and downward Figure 1 2. 7 5 Actions of the m uscles of the eyebal ls. A : Action of F i g u re 1 2.76 M uscles of t h e eyeba l l. A : Superior view. B: La teral individual m uscles (anatomica l action). B : Movement of eye when view. Reproduced with permission from Gray's Anatomy for testing specific muscle (cl i nical testing). Reproduced with Students (2005). permission from Gray's Anato m y for Students (2005). takes the effort of the lateral rectus assisted by superior and However, it becomes clearer when one u nderstands that each inferior oblique, and requ i res that the right eye turn in a med i a l eyeba l l is directed anteriorly, while the axis of its orbit is directed d i re c t i o n . slig htly laterally (from back to front) (see Fig. 1 2.76). Gray's Anatomy forStudents (2005) points out that 'the pull of some of the Dysfu nctions of this coordinated system can lead to a variety of muscles has m u ltiple effects on the movement of the eyeba l l , while visual chal lenges as included in the fol lowing partial list ( Barrow that of others has single effects'. Additional ly, they work in 2005). coordination, not in isolation, to simultaneously position both pupils as needed. For i nstance, for the left eye to look laterally, it • Strabismus (crossed eyes) - inability to create para l lelism of the visual axes of the eyes (Stedman'S Medical Dictionary 2004). Eye box continues

394 C L I N I CA L A P P L I C AT I O N O F N E U R O M U S C U LA R T EC H N I Q U E S : T H E U PP E R B O DY turn can be consta nt or i ntermittent, ca n alternate from eye to Today much of mai nstream medicine stil l rejects the a pplication eye, or ca n a ppear when the person has read a lot or is very tired. of the Bates method exercises for the mature eye, a lthough these are • Esotropia - the eye turns in. commonly used to improve certa in eye cond itions in ch ildren. Bates • Exotropia - the eye turns out. suggested that eye movements - left and right, up and down, and in • Hypertropia - the eye turns up. l a rge circu l a r patterns - a re i ntended to elongate shortened m uscles, • Hypotropia - the eye turns down. thereby decreasing pressure on the eye that changes its shape and • Amblyopia - one eye is ignored, resu lting i n a lazy eye. a l ters the focal plane of the l ens. A n umber of other steps, such as acqu iring proper rest (for the body as well as the eyes), a lternating Although adu lts may develop strabismus, it most often develops in the foca l pla ne, palming, sun n i ng and swinging were also suggested. infants and young children. As t h e c h i l d g rows t h e condition does not More deta ils and descriptions ca n be found at the website for The usua l ly improve without intervention. Causes include i nadequate Bates Association for Vision Education development of eye coordi nation, excessive farsightedness (http://www.seeing.org/index.html). (hyperopia), and variation between the vision in each eye or problems with the eye muscles that control eye movement. Head trauma, There a re no harmful side effects from the exercises if performed stroke or other general health problems may also be the cause. appropriately (be ca utious with 'su nni ng') and they might prove Treatment plans may include eyeg lasses, vision therapy or eye muscle h e l pfu l for some people who have the determination to 'stick with surgery. Cranial osteopathic or craniosacral treatment may useful ly the program'. As is true for much of complementary and alternative accompany ophthalmic care i n such cases, especially in children. medicine, Bates' theories remain u n p roven and fi nding a qual ified practitioner can be challenging. Behavioral optometrists or vision The Bates m ethod therapists generally teach natura l vision i mprovement techniques Dr Bates expressed ideas that were outside of mainstream such as these, while also incorporating othe r visual therapy methods. ophtha l mo l ogy. He contended that faulty eyesight could be i m proved However, the reader is ca utioned that a ppropriate medical treatment and ocular d isorders reversed by incorporating natural visual habits is sti l l recommended, particu la rly for cond itions such as glaucoma, and reducing mental stra i n . He first described the Bates method in cataracts and other serious eye pathologies. Perfect Sight Without Glasses ( 1 920. a lso titled within the cover as The cure ofimperfect sight by treatment without glasses), theorizing One simple eye exercise, d iscussed by Leviton (1 992), can be easily that menta l strain played a ro le i n refractive error (presbyopia, fashioned from a 1 0-foot string or thin rope and 1 5 brightly colored astigmatism, hyperopia and myopia), as well as other eye cond itions beads (varying colors a re best). The beads a re tied onto the string at such as strabismus, am blyopia, cataracts and g laucoma. Due to the 8-inch intervals and the end of the string is tied to a doorknob or fact that copyrig ht has expired on this over 85-year-old version, a distan t object. The patient sits comfortably in a chai r at a d istance copy of the original text is now available as a PDF file at so as to pull the string taut. The string is held near the tip of the h ttp ://www.iblind ness.org/books/bates/ nose so that the eyes gaze across its length. While breathing deeply, attention is placed on the first bead nea rest the nose for a few seconds and a n attempt is made to visua l ly focus on it. The focus Table 1 2. 1 Extrinsic (extra-ocu lar) muscles M uscl e Origin I nsert i o n I nnervation Function Oculomotor nerve [111)- Elevation of upper eyelid Levator palpebrae Lesser wing of sphenoid Anterior su rface of tarsal superior branch plate; a few fibers to skin and Elevation, adduction, m edial superioris a n terior to optic canal superior conjunctiva l fornix Oculomotor nerve [1 1 1] - rotation of eyeba l l superior branch Depression, adduction, Superior rectus Superior part of common Anterior half of eyeball Oculomotor nerve [111]- lateral rotation of eyeball tendinous ring superiorly inferior branch Adduction of eyeball Oculomotor nerve [111)- Inferior rectus Inferior part of common Anterior half of eyeball inferior branch Abduction of eyeball tendinous ring i n feriroly Abducent nerve[VI] Depression, abduction, Medial rectus Medial part of common Anterior half of eyeball Trochlear nerve[IV] medial rotation of eyeball tendinous ring medially Elevation, abduction, lateral Oculomotor nerve [111]- rotation of eyeba ll Lateral rectus Lateral part of common Anterior half of eyeball inferior branch tendinous ring latera l ly Superior oblique Body of sphenoid, superi or Outer posterior q uadrant of and medial to optic ca nal eyeba l l Inferior oblique Medial floor of orbit Outer posterior q uadrant of posterior to rim ; maxilla eyebal l lateral to nasolacrimal groove Reproduced with permission from Gray's Anatomy for Students (2005). box continues

1 2 The cranium 395 Box 1 2.1 2 (continued) while elevating it as far overhead and lowering it toward the thigh while a lso fol lowing it visual ly. These movements are performed then moves to the next bead and so forth until a l l have been several times then the entire set of movements is repeated on the practiced. This ca n be repeated, moving from the distant end toward l eft while using the left arm to perform the exercise. It is not the face until all have been add ressed. Add itional ly, it is suggested uncommon for the eyes to feel fatigued or to ache for a brief that exercises be included that jump from a close bead to the time after the session d u e to the 'exercising' nature of the fa rthest distant bead, back to the second, then the farthest again, movements. then the third and so forth, u p and down the string, pausing on each to attempt to focus. For further d iscussion, i ncluding m uscle function tests, midl ine shift syndrome test and Ruddy's eye exercises, see Clinical Benefit may also be gained from exercises that stretch the recti Application ofNeuromuscular Techniques: Practical Case Study m uscles. It is best to perform the exercises while seated in case the Exercises, Case Study 6 (Chaitow Et Delany 2005). movements resu lt in l ightheadedness or vertigo. The right arm is pronated and placed in horizontal adduction to outstretch in Suggested websites front of the person. The wrist is extended and the fingers and • The Bates Association for Vision Education - thumb curled toward the pal m except for the extended index finger, which is pointing toward the ceiling to produce a single d igit on http ://www.seei ng.org/i ndex.htm I which to focus. Focus is p laced on the tip of the index finger as the • Vision Improvement Site - arm is moved slowly in abduction as far latera l ly as the eye can follow it without moving the head. Then it is slowly returned to the http ://www.vision i m provementsite.com/bates.htm I original position while also fol lowing it visua l ly. This is repeated • Imagination Blindness - http://www.iblindness.org/books/bates/ The upper extremity epitomizes functionality, whether performing manual therapy or surgery - or simply scra tch­ this involves throwing or lifting, writing, p a inting, playing ing an itch. It is to this remarkable assembly of structures music, comforting a baby's distress, lifting food to the mouth, that we turn our atten tion next - the upper extremity. Refe re n ce s relaxation or strain/counterstrain. Journal of Bodywork and Movement Therapies 10(3):197-205 Abe M, Murakami G, Noguchi M et al 2004 Variations in the Brookes D 1981 Lectures on cranial osteopathy. Thorsons, tensor veli palatini muscle with special reference to its origin Wellingborough and insertion. The Cleft Palate-Craniofacial Journal Byrne M, Keane D, Boylan P et al 1993 Intrauterine pressure and the 41(5) 474-484 active management of labor. Journal of Obstetrics and Gynecology 13:453-456 Abe S, Ouchi Y, Ide y, Yonezu H 1997 Perspectives on the role of the Cailliet R 1992 Head and face pai.n syndromes. F A Davis, lateral pterygoid muscle and the sphenomandibular ligament in Philadelphia temporomandibular joint function. Cranio: The Journal of Craniomandibular Practice 15(3):203-207 Carrero J 2003 An osteopathic approach to children. Churchill Livingstone, Edinburgh Arbuckle B 1948 Cranial aspect of emergencies of the newborn. Journal of the American Osteopathic Association 47(5):507-511 Chaitow L 1 999 Cranial manipulation: theory and practice. Argenta L, David L, Wilson J, Bell W 1996 An increase in infant cra­ Churchill Livingstone, Edinburgh Chaitow L 2005 Cranial manipulation: theory and practice, 2nd nial deformity with supine sleeping position. Journal of Craniofacial Surgery 7(1):5-11 edn. Churchill Livingstone, Edinburgh Barrow D 2005 Lazy or misdirected eye; crossed eyes. In: Chaitow L, DeLany J (eds) Clinical application of neuromuscular tech­ Chaitow L, DeLany J (eds) 2005 application of neuromuscular niques: practical case study exercises. Churchill Livingstone, Edinburgh techniques: practical case study exercises. Churchill Livingstone, Bates W 1919 A house built on sand. Better Eyesight 1 (2). Edinburgh Reprinted in: Quackenbush T (ed) 2001 Better eyesight: the complete magazines of William H. Bates. North Atlantic Books, Chatellier G, Degoulet E, Devries C et a1 1982 Symptom prevalence Berkeley in hypertensive patients. European Heart Journal Supplement Bates W H 1 920 The cure of imperfect sight by treatment without C:45-52 glasses. Central Fixation Publishing, New York Beder E, Ozgursoy 0 B, Ozgursoy S K 2005 Current diagnosis and Ciancaglini R, Testa M, Radaelli G 1999 Association of neck pain transoral surgical treatment of Eagle's syndrome. Journal of Oral with symptoms of temporomandibular dysfunction in the gen­ and Maxillofacial Surgery 63(12):1 742-1745 eral adult population. Scandinavian Journal of Rehabilitation Biedermann H 2001 Primary and secondary cranial asymmetry in Medicine 31 ( 1 ) : 1 7-22 KISS children. In: von Piekartz H, Bryden L (eds) Craniofacial dysfunction and pain. Butterworth-Heinemann, Oxford Clemente C 1987 Anatomy: a regional atlas of the human body, 3rd Biedermann H 2005 Manual therapy in children: proposals for an edn. Urban and Schwarzenberg, Ba ltimore etiologic model. Journal of Manipulative and Physiological Therapeutics 28(3):e1-€15 Costen J B 1934 A syndrome of ear and sinus symptoms dependent Blanco C. de las Penas C. Xumet J et al 2006 Changes in active upon disturbed functions of TMJ. Annals of Otolaryngology mouth opening following a single treatment of latent myofascial trigger points in the masseter muscle involving post-isometric 43(1): 1-15 De Laat A, Meuleman H, Stevens A, Verbeke G 1998 Correlation between cervical spine and temporomandibular disorders. C l inical Oral Investigations 2(2):54-57 DeLany J 1997 Temporomandibular dysfunction. Journal of Bodywork and Movement Therapies 1 (4):198-202

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399 Chapter 13 Shoulder, arm and hand C H A PT E R CONTENTS Assessment for shortness of rhomboids 439 N MT for rhomboids 439 Shoulder 401 MET for rhomboids 440 Structure 401 Deltoid 441 NMT for deltoid 443 Key joints affecting the shoulder 401 Supraspinatus 443 Pivota l soft tissue structures and the shoulder 404 Assessment for supraspinatus dysfunction 446 Assessment 407 Assessment for supraspinatus weakness 446 Repetitions are important 408 NMT treatment of supraspinatus 446 Janda's perspective 410 MET treatment of supraspinatus 446 Observation 410 MFR for supraspinatus 447 Pa lpation of superficial soft tissues 411 Infraspinatus 447 Range of motion of shoulder structures 411 Assessment for i nfraspinatus shortness/dysfunction 447 Active and passive tests for shoulder gi rd le motion (sta nding Assessment for infraspinatus weakness 448 NMT for i nfraspinatus 448 or seated) 412 MET treatment of short infraspinatus (and teres minor) 448 Strength tests for shoulder movements 413 MFR treatment of short i nfraspinatus 449 Muscula r relationships 413 PRT treatment of infraspinatus (most suitable for acute Spinal and scapular effects of excessive tone 415 Shoulder pain and associated structures 415 problems) 449 Thera peutic choices 416 Triceps and a nconeus 449 Specific shoulder dysfunctions 417 Assessment for triceps weakness 452 Specific muscle evaluations 420 NMT for triceps 452 Infraspinatus 420 MET treatment of triceps (to enha nce shoulder flexion with Levator scapula 420 Latissimus dorsi 420 elbow flexed) 452 Pectora lis major and m i nor 421 NMT for a nconeus 453 Supraspinatus 421 Teres minor 453 Subscapularis 421 Assessment for teres minor weakness 453 Upper trapezius 421 NMT for teres minor 454 Is the patient's pain a soft tissue or a joint problem? 422 PRT for teres m inor (most suitable for acute problems) 455 The Spencer sequence 422 Teres major 456 Treatment 429 NMT for teres major 457 Trapezius 429 PRT for teres major (most suitable for acute problems) 457 Assessment of upper trapezius for shortness 431 Latissimus dorsi 458 NMT for upper trapezius 432 Assessment for latissimus dorsi shortness/dysfunction 458 NMT for m iddle trapezius 433 NMT for latissimus dorsi 459 NMT for lower trapezius 433 M ET treatment of latissimus dorsi 460 NMT for trapezius attachments 434 PRT for latissimus dorsi (most suitable for acute Liefs NMT for upper trapezius a rea 434 MET treatment of upper trapezius 435 problems) 460 Myofascial release of upper trapezius 435 Subsca pularis 460 Levator sca pula 435 Assessment of subscapularis dysfunction/shortness 462 Assessment for shortness of l evator scapula 436 Observation of subscapularis dysfunction/shortness 462 NMT for l evator scapula 436 Assessment of weakness in subscapularis 463 MET treatment of levator sca pula 438 NMT for subscapularis 463 Rhomboid minor and major 438 M ET for subscapularis 463 Assessment for weakness of rhomboids 439 PRT for subsca pularis (most suitable for acute problems) 464 contents lists con tinues

400 CLI N I CA L A P PLICAT I O N OF N EU R O M USCU LA R T EC H N I Q U E S : T H E U PP E R B O DY Serratus anterior 464 MET for supinator shortness 496 Assessment for weakness of serratus a nterior 465 MFR for supinator 496 NMT for serratus a nterior 465 Pronator teres 496 Assessment for strength of pronator teres 497 Facil itation of tone in serratus a nterior using pulsed MET 466 N MT for pronator teres 497 Pectora l i s major 467 Assessment for shortness in pectora l i s major 470 MFR for pronator teres 498 Assessment for strength of pectoralis major 470 PRT for pronator teres 498 NMT for pectoralis major 471 Pronator quadratus 498 MET for pectoralis major 472 NMT for pronator quadratus 498 Forearm, wrist and hand 498 Alternative MET for pectoralis major 473 Forearm 499 MFR for pectoralis major 474 Wrist and hand 499 Pectoralis m inor 474 Capsule and ligaments of the wrist 501 NMT for pectoralis minor 476 Ligaments of the hand 502 Direct (bi lateral) myofascial stretch of shortened pectoralis Key (osteopathic) principles for care of elbow, forearm and minor 477 wrist dysfunction 503 Subclaviu s 477 MFR for subclavius 477 Active and passive tests for wrist motion 503 Sternalis 479 Reflex a nd strength tests 506 Ganglion 506 Coracobrachialis 479 Carpal tunnel syndrome 507 Assessment for strength of coracobrachialis 479 Phala nges 508 Carpometacarpal ligaments (2nd, 3rd, 4th, 5th) 509 N MT for coracobrachialis 481 Metacarpophalangeal ligaments 510 MFR for coracobrachialis 481 PRT for coracobrach ialis 48 1 Range of motion 510 Biceps brachii 482 Thumb 5 1 1 Assessment for strength of biceps brachii 483 Thumb ligaments 511 Range o f motion a t t h e joi nts o f t h e t h u m b 511 Assessment for shortness and MET treatment of biceps Testing thumb movement 51 1 brachii 483 Dysfunction and eva luation 511 NMT for biceps brachii 483 Preparing for treatment 5 1 1 Termi nology 5 1 2 MET for painful biceps brachii tendon (long head) 484 Neural entra pment 51 3 PRT for biceps brachii 485 Distant influences 51 3 Elbow 485 Introd u ction to elbow treatment 485 A nterior forearm treatment 5 1 3 Structure and function 485 Pa l maris longus 51 3 Humeroulnar joint 486 Humeroradial jOint 486 Flexor carpi radialis 51 5 Radioulnar joint 486 Flexor carpi ulnaris 51 5 Assessment of bony alignment of the epicondyles 486 Flexor digitorum superficialis 51 5 Flexor digitorum profu ndus 516 The lig a ments of the elbow 486 Assessment for l igamentous stabil ity 487 Flexor pollicis longus 516 NMT for anterior forearm 518 Evaluation 487 Assessment and MET treatment of shortness in the forearm Biceps reflex 487 flexors 519 Brach i oradialis reflex 487 Triceps reflex 488 MET for shortness in extensors o f t h e wrist and h a n d 521 PRT for wrist dysfunction (including carpal tunnel Ranges of motion of the elbow 488 Range of motion and strength tests 488 syndrome) 521 MFR for a reas of fibrosis or hypertonicity 521 EI bow stress tests 488 Strains or sprains 489 Posterior forearm treatment 522 Indications for treatment (Dysfunctions/Syndromes) 489 Superficial layer 522 Median nerve entrapment 489 Extensor carpi radialis longus 523 Ca rpal tunnel syndrome 489 Ulnar nerve entrapment 489 Extensor carpi radialis brevis 523 Radial nerve entrapment 492 Extensor carpi ulnaris 524 Extensor digitorum 524 Tenosynovitis ('tennis el bow' a nd/or 'golfer's elbow') 492 Extensor digiti minimi 525 Assessments for tenosynovitis and epicondylitis 492 NMT for superficial posterior forearm 525 Elbow surgery and manual techniques 492 Deep layer 527 Treatment 493 Abductor pollicis longus 527 Brachialis 493 Extensor pollicis brevis 528 NMT for brach ial is 493 Extensor poll icis longus 528 Extensor indicis 528 Triceps and anconeus 493 N MT for triceps (alternative supine position) 494 NMT for deep posterior forearm 528 NMT for anconeus 494 Intrinsic hand m u scle treatment 529 Brachioradialis 494 Thenar m u scles and adductor pol l icis 530 Assessment for strength of brachioradialis 494 Hypothenar eminence 532 NMT for brachioradialis 495 Metacarpal muscles 532 MFR for brachioradialis 495 Supinator 495 NMT for palmar and dorsal hand 533 Assessment for strength of supinator 496 NMT for supinator 496

1 3 Shoulder, arm and hand 40 1 ] SHOULDER in asymptomqtic individuals that they may not be clinically significant when seen in symptomatic pa tients.' STRU CTU RE In a second edition of the same text (2006), Liebenson fur­ The shoulder is an immensely complicated structure and it thers this discussion: is easy to become confused by its complexity and the wide range of assessment protocols that are used during clinical The clinical picture correlates mainly with changes infunc­ evaluation. Evidence from tests involving range of motion, tion, much less with structural pathology. Very frequently neurological reflex evaluation, muscle strength and weak­ pathological changes do not manifest themselves so long as ness assessment, postural analysis, and palpation relating function is not impaired. However, changes in function by to al tered tissue tone, pain patterns and myofascial trigger themselves may cause clinical changes in the absence ofany points may all be usefully ga thered and collated . A host (structural) pathologtJ For the same reasons, even clearly of other 'functional pa thologies' may also be discovered, diagnosed pathology can be clinically irrelevant (disc herni­ not to mention actual pathology, including inflammatory ations at CT, spondylolisthesis), whereas dysfunction that processes, arthritic changes and other degenerative can usually be diagnosed only by clinical means can be of possibilities decisive importance. It is easy to see how, as a result of the availability of all Liebenson's insightful sta tements lead us to question these data, 'information overload' might occur, with no clear how it may be possible to find a way through the maze of indication of where to begin therapeutic intervention. informa tion and to identify and extract the key elements Liebenson (1996) states the clinical conundrum as follows: in each particular case. This is most certainly not a recom­ 'So many structural and functional pa thologies are present mendation for skimping on assessment; however, it does offer the opportunity for meaningful evaluation of functional patterns, which can often highlight what have been termed 'key stereotypic movement patterns' (Jull & Janda 1987, Lewit 1991). How is the area working? Is i t behaving normally? Are firing patterns sequential and within normal parameters? Is the range of movement op ti­ mal? Functional assessment protocols are described (see pp. 408-410) which may be used to highlight particular struc­ tures tha t may then receive primary attention. These con­ cepts should be kept in mind as we work our way through the many essential aspects of shoulder function and dys­ function, the joints and soft tissue components and the tests associated with these. Figure 1 3.1 Anteroposterior radiograph of a n 1 8-year-old female KEY J O I NTS A F F ECTI N G TH E S H O U L D ER showing 1. head of h umerus, 2. acromion, 3. acromiocl avic u l a r joint, When considering shoulder movements, seven j oints must be functional for ease and integrity of shoulder use. It is use­ 4. clavicle, 5. coracoid process, 6. glenoid a rtic u l a r su rface. fu l to think of the shoulder girdle as being made up of these Reproduced with permission from Gray's Anatomy ( 1 999). seven separate joints, each interdependent on the integrity and function of the others. In summary form, these seven joints are (more detailed discussion follows): • glenohumeral (scapulohumeral) joint is a true joint in tha t it has two bones directly articulating (the head of the humerus with the glenoid fossa), is lined with hyaline cartilage, has a j oint capsule and is filled with synOVial fluid. The humeral head may glide up or down the fossa, anteriorly, posteriorly and with inversion or eversion • suprahumeral (subdeltoid) joint is a false joint in tha t it does not have a direct apposition of two bones nor does it have an articulating surface; instead it is comprised of a bone (humeral head) moving in respect to ano ther bone (acromioclavicular joint) and the overhanging cora­ coacromial ligament

402 C L I N ICAL A P P L I CATI O N O F N E U R O M USCU LAR TEC H N I Q U ES : T H E U P P E R BODY c AB Figure 1 3.2 The th ree deg rees of freed o m of movement of the shoul der join t. A: Flexion-extension. B : Abduction -adduction. C: Medial-lateral rotation . Reproduced w ith perm ission from Gray's Anatomy (2005). • scapulothoracic (scapulocostal) joint is a false joint com­ The rotator cuff muscles (supraspinatus, infraspinatus, posed of the scapula and its gliding movements on the teres minor and subscapularis - SITS) blend their fibers thoracic wall (thoracoscapular articula tion) with the joint capsule and offer muscular support. The SITS tendons are so closely approximated to the joint capsule • acromioclavicular joint is a true joint articulation of the tha t they are especially vulnerable to injury. acromial process of the scapula to the lateral end of the clavicle. lhis articulation forms an overhanging ledge that, The head of the humerus is capable of many combina­ while offering protection, also can impinge on movement tions of swing and spin, producing a highly mobile joint as of the h umeral head beneath the ledge. The only bony well as a relatively unstable one. However, it has basically attachment of the scapula to the entire thorax is the three planes of movement (abduction/adduction, flex­ acromioclavicular joint. All other attachments are muscular ion/ extension and medial/lateral rotation) which are most apparent when the scapula is fixed. • sternoclavicular joint is a true joint whose movement is often overlooked as part of the shoulder girdle. Since the Accessorymovements, such as translation of the humeral distal end of the clavicle must elevate and rotate with the head in all directions on the glenoid face (joint play), should acromion during elevation of the arm, its sternal articula­ also be manually possible. Osseous, ligamentous and mus­ tion and movement are also vital cular dysfunctions can limit joint play, as well as ranges of motion, and should be corrected when joint play has • sternocostal joint - true joint been lost. • costovertebral joint - true joint. Glenohumera l joint Supra h umeral jo int The glenohumeral joint is arguably the most important joint Located directly cephalad to the humeral head are the over­ of the shoulder girdle. With healthy movements of this joint, hanging acromioclavicular joint and the coracoacromial lig­ even though the others may be dysfunctional, the arm may ament. Even though their relationship does not constitute a be functional to some degree. When the glenohumeral joint true joint, the humeral head moves in relation to overhang­ is restricted, even if the other joints are free, there will be lit­ ing structures and therefore is vulnerable to the develop­ tle or no use of the arm. When all tissues associa ted with the ment of several pathological conditions affecting the joint are functioning normally, this joint has a greater degree acromion. The supraspinatus tendon, the humeral head of movement than any other joint in the body. itself, the inferior surface of the acromioclavicular joint or the coracoacromial ligament may be damaged (repetitively) The proximal end of the humerus is a convex ovoid that when the suprahumeral joint space is compromised. significantly exceeds the surface area of the glenoid fossa, with which it articulates. Therefore, only a small part of the The suprahumeral joint space may be compromised: surface of the humeral head articulates with the glenoid a t any given time. Additional surface area is provided b y the • when tissue normally residing there becomes enlarged glenoid labrum, a fibrocartilaginous rim that extends the through overuse or inflammation glenoid into a modified 'socket', which is further supported by the joint capsule. • by loss of normal position of the acromioclavicular joint due to muscular imbalance or dysfunction

�-------------------------------------------------------------------------- 3- --Sh- o- u l- - - , - - :::-l 1 de m • by repositioning of the acromioclavicular joint due to During the first 60° of abduction, movement should take postural compensations or habits of use, such as carrying place mainly at the glenohumeral joint, therefore the gener­ a bag that is strapped over the shoulder alized 2:1 ratio may not pertain a t every degree of abduction (Cailliet 1991), even in the unloaded shoulder at normal • by the existence of a subacromial osteoarthritic deposit. speed. In clinical possibility that one or more of the muscles of the region When the joint space has been reduced and the humeral could be dysfunctional and have bearing on the movements head is abducted beyond 90°, the supraspinatus tendon and ratios. This is the basic value of the scapulohumeral may be entrapped between the structures and damaged. rhythm test (described on p. 91) which demonstrates Excessive abrasion of the tendon will lead to inflammation whether there is undue scapula movement before 60° of and eventually deposition of calcium into the tendon. This abduction. For instance, with weakness of the lower fixators calcific deposit may then become a mechanical block to (e.g. lower trapezius, serra tus), there will be excessive abduction and overhead elevation of the arm. Additionally, scapula movement during the first 60° of abduction due to the subdeltoid bursa, which is located between the tendon poor stabilization by the lower fixators and excessive tone and acromioclavicular joint, may become inflamed or infil­ in the upper fixators (levator scapula and upper trapezius). trated by calcium, resulting in adhesions and 'frozen shoul­ It is therefore the coordinated movement of the arm with der' syndrome (or adhesive capsulitis). the scapula, coupled with proportional rota tion of the humerus and the overall health of the myofascial tissues, To avoid impaction aga.inst the overhanging structures, which results in physiological arm motion (Cailliet 1991). the humeral head has one distinct advantage - its ability to rotate laterally. When the arm is elevated beyond 90° of The space between the scapula and the thorax is filled by abduction, lateral rotation will move the greater tuberosity two muscles (serratus an terior and subscapularis) and areo­ and its attached supraspinatus tendon posteriorly, thereby lar tissue, which makes direct bony articula tion impossible avoiding the bony protuberances above. This rotation, cou­ but nevertheless allows movement. This is why this joint is pled with adequate elevation of the acromioclavicular joint termed a 'false joint', because the scapula moves in relation (achieved by upper and middle trapezius) and scapular rota­ to, rather than articulates with, the thorax. tion, will help ensure correct movement (see p. 402, Fig. 13.2). Contractures and hypertonicity of serratus anterior Scapu lothoracic joi nt and/or subscapularis may direc tly influence the scapula's ability to rotate. Scapular function may also be impaired With movements of the scapulothoracic joint, the concave due to adhesion of these muscles to each other. Scapular surface of the scapula translates and rotates in relation to mobilization techniques, such as that discussed on p. 440, the convex surface of the thorax. The scapula may be may be necessary to restore rotation and transla tion of the abducted (protracted), adducted (retracted), elevated, scapula. depressed and rotated both laterally (so the glenoid faces superiorly) and medially (glenoid fossa faces inferiorly). Acromioclavicular joint Movements of the scapulothoracic (scapulocostal) joint are The acromion's articulation with the lateral end of the clavi­ not only critical to movement of the humerus but are also pre­ cle, forming the acromioclavicular joint, a true joint, is impor­ cisely coordinated with it. During humeral abduction, there is tant not only because of the potential for impaction (as a proportionate movement of both the humerus and scapula, discussed above) but also because it is itself required to move called the scapulohumeral rhythm, which has generally been in order for functional elevation of the upper extremity to thought to be at an approximate 2:1 ratio. That is, it was gen­ occur. Movement of the clavicle against the acromion occurs erally agreed that when the humerus has been elevated to 90°, in all directions and axial rotation of the clavicle allows fur­ the scapula has rotated 30° while the humerus has moved 60°, ther movement augmented by its crankshaft design. making the total movement 90° with a similar concept also being applied to full elevation (180° - scapula 60°, humerus An articular disc often exists between the surfaces of the 120°). While it is useful and practical to consider these figures clavicle and the acromion, having developed into a menis­ in general, recent evidence has shown that the ratio may be coid from a fibrocartilaginous bridge at 2-3 years of age. significantly altered with light or heavy load (McQuade & Degenerative changes may occur in response to repetitious Smidt 1998) or with changes in velocity of motion (Sugamoto and/or rotatory traction forces imposed upon i t. et aI2002). McQuade & Smidt insightfully point out: Instability of this joint can occur if any of its supporting The results suggest that the historical assumption ofa sim­ ligaments are damaged. Loss of joint integrity can then ple linear 2:1 scapulohumeral rhythm ratio may be overly impede movement of the humeral head upon the glenoid simplistic and may not accurately describe the scapulo­ fossa. Additionally, chronic inflammation caused by repeti­ humeral rhythm under varying dynamic conditions. Thera­ tive impactions against the acromioclavicular joint's inferior pists need to understand the normal changing relationships surface may lead to formation of a subacromial osteoarthritic of the scapulohumeral rhythm under different conditionsfor deposit. While such calcification of the joint may offer stabil­ accurate interpretation ofclinical observations. ity and structural support, mobility will be impaired.

404 CLI N I CAL A PP L I CAT I O N O F N E U RO M U S C U LAR TEC H N I Q U E S : T H E U PPER B O DY Clavicle Acromioclavicular joinl/ligament Acromioo Sternoclavicular Glenohumeral Labrum joinUligament joinUtigament Scapula Sternum +-+-Humerus -lI-+-- Scapulothoracic articulatioo OOint) Anterior view Anterolateral view Figu r e 1 3.3 The seven sepa rate joints that com prise the shou lder g i rdle. Sternoclavicular joi nt Costovertebral joint The sternoclavicular joint is a tnte joint whose movement is A s the rib translates structurally to the vertebral column, the often overlooked as part of the shoulder girdle. Since the costovertebral joint asswnes the stress. The costovertebral distal end of the clavicle must rise with the acromion d uring joints throughout the thorax should be mobile and pain free. elevation of the arm, its sternal articulation and movement However, the health and pOSition of the first two ribs are par­ are vital. Serving as the two ends of a crankshaft engineered ticularly important due to the attachments of the scalene mus­ for twisting, the sternoclavicular joint and the acromioclav­ cles. The scalenes' influences on shoulder pain are numerous, icular joint are similarly designed. The sternal end of the including trigger point referral patterns and nerve entrap­ clavicle articulates with the sternum through an articular ment possibilities. Their influence on upper rib fixation may disc and also directly with the first costal cartilage. therefore indirectly impact on shoulder function. Compared with the acromioclavicular joint, few degen­ P IVOTAL S O FT T I SS U E STR U CTURES A N D T H E erative changes occur in the sternoclavicular joint. Its strength relies on its ligamentous support and its weakness SHOU LDER is to fracture rather than disloca te, although its mobility can be restricted because of dysfunctional attaching muscula­ Myers (2007) points out tha t: ture (subclavius, for example). The shoulder couples three joints into its movement - the ster­ Sternocostal joint noclavicular, the acromioclavicular and theglenohumeral, and three muscles acts as a pivot pointfor each ofthe three respec­ Since the clavicle articulates with the sternocostal cartilage tive joints - subclavius, pectoralis minor, and the teres minor. of the first rib, the health of the sternocostal joint is impor­ Generous and integrated movement for the shoulder depends tant. In extreme overhead pOSitions, weight might be on available movement at these three points. distributed onto the costal cartilage from the clavicle and transmitted onto the sternum. The first sternocostal These muscles, among the 10 or so that attach the shoul­ joint is therefore considered to be part of the shoulder girdle der to the axial skeleton, are pivotal in setting the position, and its mobility and integrity are important to shoulder while allowing subtle relative movement of the bones, so care. Its integrity can be compromised by excessive force that the overlying trapezius, latissimus dorsi, pectoralis imposed by the scalenes, according to Lewit (1991), who major and deltoideus can work properly. If these inner mus­ states: 'Tension in pectoralis and pain points at the ster­ cles are chronically contracted, fasciaLly shortened or nocostal j unction of the upper ribs seem to be connected (rareLy,for these muscles) too lax, the overlying muscles will with tension in the scalenes.' He continues: 'Blockage of the be required to strain to do their jobs, inevitably resulting in first rib goes hand in hand with reflex spasm of the scalenus trigger points in these large surface muscles. on the same side, which is abolished by treatment of the first rib.' Myers makes a further useful observation: It is worth noting that when any muscle is referred to by name this should be understood to be shorthandfor the muscle and

1 3 Shoulder, arm and hand 405 Most joints of the appendicular skeleton (apart from the pubis and is because the long head of triceps does not have as close a the tibiofibular junction) are synovial. Synovial joints comprise a relationship with the capsule, as do the previously mentioned thick capsule which protects the joint and somewhat restricts muscles, due to the presence of neural structures and blood excessive movement while a l lowing it a g reat degree of mobility. vessels. • Further sta bil ization of the capsule derives from the three The fibrous outer layer of the capsule merges with the periosteum glenohumeral ligaments (superior, midd le and inferior bands). of the bones which form the joint. • These all attach at their scapular end to the superior aspect of the medial margin of the g lenoid cavity, merg i ng with the glenoid I n the case of the shoulder the following characteristics apply to labrum (a fibroca rtilaginous rim attaching to the margin of the the fibrous capsule and associated ligaments. glenoid cavity). • The superior band ofthe glenohumeral ligament runs a long the • The capsule attaches medially to the circumference of the glenoid medial aspect of the biceps tendon before attaching above the covity beyond the glenoid labrum. lesser tubercle of the humerus. • The middle band of the glenohumeral ligament attaches to the • Superiorly it attaches to the root of the coracoid process, inferior aspect of the lesser tubercle. enveloping the origin of the long head of the biceps. • The inferior band of the glenohumeral ligament attaches to the lower aspect of the a natomical neck of the humerus. • Latera lly the capsule attaches to the neck of the humerus close to • The tendons of pectora lis major and teres major further the articular margin, apart from the medial aspect where the strengthen the anterior aspect of the capsule (and therefore the attachment is approximately 1 cm lower on the bone. The capsule joint as a whole). is sufficiently lax to a llow the rem arkable degree of mobility at the joint. Additional ligamentous features of the shoulder joint include the fol lowing. • The joi nt's stabil ity depends to a large extent on the muscles and the supporting ligaments (glenohumeral ligaments) that merge • The acromioclavicular ligament which covers the superior aspect with and surround the capsule. and fibrous capsule of this joint before merg i ng with the fibers of the aponeurosis of trapezius and the deltoid. • The capsule is reinforced by muscles: 1. superiorly by supraspinatus • The corococlavicular ligament attaches the clavicle to the 2. inferiorly by the long head of triceps coracoid process of the scapula, efficiently maintaining the clavi­ 3. posteriorly by the tendons of infraspinatus and teres minor cle's contact with the acromion. If the acromioclavicular joint 4. anteriorly by subscapularis. • The tendons of subscapularis, supraspinatus, infraspinatus and teres minor all blend with the capsule, creating a cuff. • The inferior aspect of the capsule (and joint), which during abduction has g reat strai n imposed on it, is the least stable. This Subtendinous bursa Coracohumeral Superior glenohumeral ligament ligament Middle glenohumeral ligament Long head of biceps brachii tendon --.- Transverse humeral Fibrous membrane ligament of joint caPSUIE�---1 ���_�... Synovial sheath Synovial sheath --;-.- Synovial membrane ------\\-\\---'\"..f-t..f. £11.4 Long head of biceps brachii tendon ---' Inferior glenohumeral ligament Ai Redundant synovial membrane in adduction Aii Redundant capsule Fig u re 1 3.4 A-C: Va rious l i g a me nts of the shou lder g i rd le. Reproduced with perm ission from Gray'sAna tomy for S tudents (2005). box continues

406 CLI N I CAL APPLICATI O N OF N EU R O M U SCU LAR TECH N I QU ES: T H E U PPER BODY Box 1 3.1 (�nti n ued) I n some instances pectora lis minor attaches into the shoulder dislocates, this ligament may tear which allows the scapula to capsule (rather than the usual attachment at the coracoid drop away from the clavicle. This l igament has two parts, the process), its tendon passing beneath the coracoacromial ligament. trapezoid and the conoid portions. • The coracohumeral ligament is a broad structure wh ich strength­ 1 . The trapezoid ligament ru ns almost horizontally, attaching ens the superior aspect of the capsule (its lower and posterior inferiorly to the upper surface of the coracoid process and borders merge with the capsule). The ligament attaches to the superiorly to the inferior surface of the clavicle. base of the coracoid process and travels obliquely inferiorly and 2. The narrow end of the conoid ligament attaches i nferiorly to the posteromedial edge of the root of the coracoid process latera lly to the a n terior aspect of the greater tubercle of the and su periorly, at its broader end, to the conoid tubercle on humerus where it blends with the supraspinatus tendon. the inferior surface of the clavicle. • The transverse humeral ligament runs from the lesser to the • The coracoacromial ligament comprises a strong tria ngular band g reater tubercle of the humerus, forming a canal for the retinac­ that li nks the coracoid process of the sca pula with the acrom ion. ulum of the long head of the biceps. Subacromial bursa (subdeltoid) Long head of biceps brachii tendon Acromion Supraspinatus ---IH -':'�\"-r;':� Coracoacromial ligament Fibrous membrane ---'/H W;-7.+'_�:; Coracoid process Glenoid cavity ------..�+_#fHl--+f-*- Synovial membrane ---Kilf!+�1 ;-,�-__:-r Subscapular bursae Infraspinatus ---If+_ .._. __ - --------- Pectoralis major - - Glenoid labrum -------,,.,.�-\\-.. Teres minor ---,.I!T' -:+!d'--Shl�rt head of biceps brachii Subscapularis ------__..--+.;-f-� and coracobrachialis Teres major --- Latissimus dorsi --- Long head of triceps brachii --- 8 F i g u re 1 3 .4 A-C: (Contin ued). box continues

13 Shoulder, arm and hand 407 Box 1 3. 1 (continued) • This articulation is, as in the case of the shoulder i tself, sur­ At the sternal end of the clavicle additional ligamentous structures rounded by a fibrous capsule. occur. • The anterior sternoclavicular ligoment covers the anterior su rface • At the sternoclavicu lar joint the su rface of the sternal a rticula­ of the joint attaching superiorly to the clavicle and attaching tion is smaller than that of the surface of the clavicle, which is covered with a saddle-shaped fibrocarti lage, and separated from inferomedially to the anterior aspect of the manubrium sternum the sternal notch by an articular disc. and the first costal cartilage. Articular disc Clavicular notch r-- Anterior • The posterior sternoclavicular ligament l ies on the posterior (capsule and ligaments sternoclavicular removed anteriorly Interclavicular ligament aspect of the joint, attaching superiorly to the clavicle and i nferi­ to expose joint) orly to the posterior aspect of the manubrium. ligament • The interclovicular ligament merges with the deep cervical fascia su periorly and connects the superior aspects of the sternal ends of the clavicles. Some fibers also attach to the manubrium. I n approximately 7% of the population small, ossified structures are present in the l igament, the suprasternal ossicles. These usually pyra mid-sha ped structures a re origi na lly cartilaginous, ossifying in adolescence. They may be fused to, or articulate with , the m a n u b ri u m . • The costoclavicular ligament attaches i nferiorly to the first rib and its adjacent cartilage and superiorly to the clavicle. Costoclavicular --,-j�. Manubrium of ligament sternum First costal ».;:-\"._, Attachment site for rib 2 cartilage '--rI Sternal angle c Figure 1 3.4 A-C: (Continued). I Table 1 3.1 Imaging studies of the shoulder Imaging moda l i ty Advantages Disadvantages Often identifies an a pparent 'abnormality' in an MRI 95% sensitivity and specificity in detecting complete asymptomatic patient rotator cuff tears, cuff degeneration, chronic tendonitis and partial cuff tears Invasive No ionizing radiation Relatively poor at d iagnosing a partial rotator cuff tear Arthrography Good at identifyi ng complete rotator cuff tear or Less useful in identifying partial cuff tears adhesive capsu litis (frozen shoulder) Operator-dependent interpretation Invasive U l trasonography Accurately diagnoses complete rotator cuff tears Ionizing radiation MRI arthrography Reliably identifies fu ll-th ickness rotator cuff tears CT scanning and labra l tears May be useful in diagnosis of subtle d islocation CT, computed tomographic; MRI, magnetic resonance imaging. Reproduced with permission from Woodward Et Best (2000). all the fasciae associated with it. Shortness, contracture, ASSESSM ENT or adhesion may occur anywhere within the myofascia itself, or in the surrounding connective tissues adhering to nearby Manual treatment is far more likely to be successful if its muscles, joints, or bones. Sensitive and exploratoryfingers are application is based on identifiable dysfunctional features. required to tease out the particulars ofeach situation. The practitioner needs a 'story' to work with, whether this is a possible connection between the patient's symptoms and Specific palpation, assessment and treatment methods for a palpable feature (something that is tense, tight, restricted, each of these muscles are described in this chapter. etc.), a demonstrable abnormality (restricted range, weakness,

408 CLI N I CA L A PPLI CATI O N OF N EU RO M USCU LAR TECHNIQUES: T H E U PPER BODY Table 1 3,2 Tests used in shoulder evaluation and significance of positive findings Test M a neuver Diagnosis suggested by positive result Apley scratch test Patien t touches superior a nd i nferior aspects of Loss of range of motion: rotator cuff opposite scapula problem Neer's sign Arm in full flexion Subacromial i mpingement Hawkins' test Forward flexion of the shoulder to 90· and Supraspinatus tendon i mpingement internal rotation Drop-arm test Arm lowered slowly to waist Rotator cuff tear Cross-arm test Forward elevation to 90· and active adduction Acromioclavicular joint arthritis Spurling's test Spine extended with head rotated to affected Cervical nerve root disorder shoulder while axially loaded Apprehension test Anterior pressure on the humerus with external Anterior glenohumeral i nstabil ity rotation Relocation test Posterior force on humerus while externa lly Anterior glenohu meral i nstability rotating the a rm Sulcus sign Pulling downward on elbow or wrist Inferior glenohumera l instability Yergason's test Elbow flexed to 90· with forearm pronated Biceps tendon i nstability or tendonitis Speed's maneuver Elbow flexed 20-30· and forearm supinated Biceps tendon i nstability or tendonitis 'Clunk' sign Rotation of loaded shoulder from extension to Labral disorder forward flexion Note: Not all of the above tests are fully described within this text. Reproduced with permission from Woodward Et Best (2000). etc.) or symptoms which can be modified manually (increase • Has this happened before? or decrease of pain as evaluation is performed, for example). • And, if so, what helped it last time? In order for the 'story' to be clinically useful it needs to It is very important to identify what eases symptoms as connect the patien t's presenting symptoms with something well as what worsens them, as this may reveal patterns that is identified by palpation an d / or assessment as in which 'load' and 'unload' the biomechanical features out of some way causing, contributing to or maintaining the w hich the symptoms emerge. The patient's own viewpoint symptoms. Appropriate treatment choices flow naturally as to what helps and what worsens symptoms, as well as from such a sequence. the practitioner 's evaluation as to where restrictions and abnormal tissue states exist and how dysfunction manifests History + symptoms + 'dysfunctional features' d uring standard testing and palpation, should together = a 'story' which helps to determine treatment choices form the basis, with the history, for making a tentative ini­ tial assessment. In taking a history of a patient and the presenting condition, important questions that we should ask include the following. R E PETITI O N S A R E I M PO RTA N T • How long have you had the symptoms? In performing assessments ( testing a shoulder for internal • Are the symptoms constant? rotation, for example), if performing the action once pro­ • Are the symptoms intermittent and, if so, is there any d uces no symptom, it may be useful to have the movement performed a number of times. As Jacob & McKenzie (1996) pattern? explain: • What is the location of the symptoms? • Do they vary at all? Standard range of motion examinations and orthopedic • If so, what do you think contributes to this? tests do not adequately explore how the particular patient's • What, if anything, starts, aggravates and / or relieves the spinal [or other area of the body] mechanics and symptoms are affected by specific movements and/or positioning. symptoms? Perhaps the greatest limitation of these examinations and • Do any of the following movements improve or worsen tests is the supposition that each test movement needs to be the symptoms - for example, turning the head one way or the other; looking up or down; bending forward; standing, walking, sitting down or getting up again; lying down, turning over and getting up again; stretch­ ing out the arm, and so on?

13 Shou l der, a rm a nd hand 409 J Throughout the treatment portion of this text. tests and Genera l com ments diagnostic criteria are offered for those i ndividuals l icensed to diagnose pathological conditions. While all practitioners may • The commonest limi ting factors relating to loss of range benefit from knowledge a nd u ndersta nding of these tests, of motion of the shoulder involve spasm, contracture, practicing within the scope of the practitioner's l icense is fracture and dislocation. strongly endorsed by the authors of this text. It is the responsibil ity of the i ndivid u a l to determ ine their scope of • Restrictions that have a hard end-feel during passive practice. Referral to a suitably qualified practitioner is range of motion assessment are usually joint related. suggested when evidence arises that a pathological con d i tion exists if the practitioner's license and training do not a l l ow • Restrictions that have a less hard end-feel, with slight appropriate investigation. springiness still available at the end of range, are usually due to extraarticular soft tissue dysfunction. performed only once tofathom how the patient's complaint responds. The effects of repetitive movements or positions • Refer to the notes on 'tightness / looseness' in Chapter 8 maintained for prolonged periods of time are not explored, (p. 1 63), which describe the concept of the 'tethering' of even though sllch loading strategies might better approxi­ tissues, as well as their end-feel. Awareness of these fea­ mate what occurs in the 'real world'. tures (end-feel, tight/ loose, ease/ bind) is important in making therapeutic decisions based on what is being pal­ • Assessments should evaluate symptoms in relation to pa ted d uring examination (Ward 1997) . posture and position, as well as to function or movement. • If the cause of arm pain lies in the upper extremity then • Function needs to be evaluated in relation to quality, as there is usually associated restriction of full range of well as symmetnj and range of movement involved. motion. • Any assessment needs to take account of the gender, age, • However, when pain is referred from elsewhere - viscera, body type and health status of the individual being perhaps, or from the cervical spine but not from trigger assessed, as these factors can all influence a comparison points - passive motion is seldom restricted (Simons et al with the 'norm' . 1999) and pain will usually be diffuse rather than local­ ized and will commonly be worse at night. In such cases, Attention should b e paid to the effect o f movement on other symptoms may offer a clue to the origin (digestive symptoms (does it hurt more or less when a particular problem, neck pain, cough, etc.). movement is performed?), as well as to the degree of func­ tional normality revealed by the movement. In the case of a • Atrophy in a muscle is usually due to: shoulder, for example, abduction of the arm may be 1 . disuse (immobiliza tion, disuse due to injury, handed­ achieved to its full range, with minimal symptoms, b ut: ness) 2. nerve or muscle disease (reflexes will be increased and • is this being achieved by the appropriate sequence of paralysis may be obvious in upper motor neuron dis­ movements of the scapula, with hinging occurring at the ease) acromion and the prime movers performing their actions 3. spinal dysfunction efficiently? 4. trauma which denervates the structure, in which case there will be no muscle strength or tendon reflex and a • or is the arm hinging from the base of the neck with inap­ marked reduction in size as fatty tissue replaces mus­ propriate muscular input from the synergists (muscle cle (see evidence regarding rectus capitis posterior substitution)? minor in Chapter 3) 5. nerve entrapment by soft tissue structures at various The quality of a movement, combined with its range and sites along the nerve's path (such as scalenes, pec­ effect on symptoms, all need to be evaluated . Janda's func­ toralis minor, triceps or supinator entrapment of radial tional tests are useful in achieving this (see pp. 88-92). nerve) (see Neurological impingement and the upper extremity, pp. 489-492). In this section aspects of shoulder assessment will be detailed with descriptions of examination methods for dis­ In discussing shoulder-arm syndrome, Lewit (1991) states: covery of: Experience has shown that any type of pain originating in • range of motion the cervical spine, even in its upper part as far down as the • strength upper thoracic and upper ribs - and even the viscera, the • reflex information heart, lungs, liver, gall bladder and stomach - may be • specific condition tests. the origin ofpain referred to the dermatome C4. CAUTION: AVOID TESTING (active or passive) for range Lewit notes that British and American charts usually show the of motion if there is a possibility of dislocation, fracture, shoulder region covered by the C5 dermatome. He disagrees: advanced pathology or profound tissue damage (tear). The phrenic nerve, originating from the C4 segment, pro­ vides a much more credible explanation of this widespread irradiation than does the dermatome CS. This explains the somewhat vague term 'shoulder-arm' syndrome.

4 1 0 C L I N ICAL A P P L I CATION O F N E U R O M USCULA R TECH N I QU E S : T H E U P P E R BODY JAN DA'S PERSPECTIVE The method of the scapulohumeral rhythm test, which has direct implications for neck and shoulder dysfunction, is as In Chapter 5 details were given of the resea rch work of follows. Czech researcher Vladimir Janda MD (1982, 1983). He has described the upper crossed syndrome in which the follow­ • The patient is seated and the practitioner stands behind, ing postural muscles shorten and tighten (see p. 34): observing. • pectoralis major and minor • The patient is asked to let the arm on the tested side hang • upper trapezius down and to flex the elbow to 90°, thumb upwards. • levator scapula • sternocleidomastoid • The patient is asked to slowly abduct the arm toward the horizon tal . while at the same time: • A normal abduction will include elevation of the shoul­ • lower and middle trapezius der with rotation or superior movement of the scapula • serratus anterior and rhomboids commencing only after 60° of abduction. are inhibi ted and weaken. • Abnormal performance of this test occurs if elevation of As these changes take place the relative positions of the the shoulder or rotation, superior movement or winging of the scapula occurs within the first 60° of shoulder head, neck and shoulders modify, so that cervical stress abduction. develops while, more specifically, there is a change in shoul­ der biomechanics. • This would indicate levator scapula and / or upper trapezius as being overactive and therefore shortened, • The scapula abducts and rotates due to increased tone in with lower and middle trapezius and serratus anterior upper trapezius and levator scapula, inhibiting serratus inhibited and weak. anterior and the lower trapezius. • Objectively, the area abou t a third of the way between the • This produces an altered direction of the axis of the glenoid angle of the neck and the lateral edge of the shoulder will fossa so that the humerus demands additional levator 'mound' during this test if levator scapula is excessively scapula, upper trapezius and supraspinatus stabilization, overactive. further stressing these already compromised muscles. • Another way of viewing the test is to judge whether the • A part of the ou tcome of such changes will be the evolu­ 'hinge' of arm abduction is occurring at the acromioclav­ tion of trigger points in the stressed structures and icular joint or at the base of the neck. referred pain to the chest, shoulders and arms. Variation • Pain mimicking angina may be noted plus a decline in respiratory efficiency. • The patient is seated or standing with the practitioner standing behind, a fingertip resting on the upper trapez­ Janda stresses the need to identify shortened structures ius muscle of the side to be tested. and to stretch and relax them, after which proprioceptive reeducation is indicated. Whatever local treatment these • The patient is asked to take the arm being tested into trigger points receive, reeducation of posture and use is an extension. essential aspect of rehabilitation. • If, at the very outset of this movement of the arm, there is Janda's scapulohumera l rhythm test discernible firing of upper trapezius, it is overactive and by implication shortened. In order to obtain a rapid overview of the function of the postural muscles associated with shoulder and scapula • By implication, this overactivity suggests that lower fixa­ behavior, Janda has devised a series of 'functional tests' . tors are weak with the same sort of imbalance noted in The reasoning is that if a normal action can be demon­ the initial findings of the test described above. stra ted to involve excessive activity of key postural (type I, see Chapter 5) muscles, this implies that: It is always useful to confirm a functional test such as this with evidence of actual shortening. Tests to establish this 1. the postural muscle(s) so identified will be overactive, evidence will be described later in this section. therefore by definition short O B S E RVAT I O N 2. the phasic antagonists will therefore be inhibi ted and not performing their roles as prime movers, so that Observe the person's shoulders simul taneously. 3. synergists will probably become overactive in • Is there evidence of asymmetry (one shoulder high or compensation deviation of the neck in a scoliotic curve, for example)? 4. as a result most of these muscles will develop localized • Is one or are both of the shoulders rounded? (postural areas of distress and trigger points will evolve. placement) • Is the upper crossed syndrome apparent? • VVhat, if any, are the influences of spinal curves (for example, is there increased thoracic kyphosis?)

1 3 Shoulder, arm and hand 4 1 1 • Is there al tered skin color (blanching indicating ischemia that might be involved. What is 'normal' will likely remain or increased hyperemia suggesting inflammation, for controversial at least until latent trigger points (which example)? restrict range of motion without pain symptoms) are assessed and deactivated in the 'normal' patients used in • What evidence is there of muscle hypertrophy (accentu­ the studies of ranges of motion. ated development of upper trapezius, for example) or atrophy (extreme laxity and weakness of lower scapula Flexion (anteversion) 0-1 800 fixators, for example)? 0-60° at glenohumeral joint - anterior fibers of deltoid, cora­ • Are there any tremors, suggesting neurological cobrachialis, clavicular fibers of pectoraliS major, biceps dysfunction? brachii, supraspinatus (possibly); 60-120° involves scapular rotation - the above plus trapezius, serratus anterior; PA LPAT I O N O F S U P E R F I C I A L S O FT T I S S U E S 120-180° involves the spinal column - all the above plus lum­ bar muscles which extend the trunk and stabilize the torso. • Assess skin and muscle tone and size. • Test brachial and radial pulses (brachial is medial to Extension (retroversion) 0-500 biceps tendon, radial is on ventrolateral aspect of wrist) Teres major /minor, posterior fibers of deltoid, latissimus as well as assessment of general reflexes and range of dorsi, long head of triceps, rhomboids, middle trapezius. motion. If there exists asymmetry of rate, rhythm, strength or wave form in the arterial pulses, circulatory Adduction 0-450 dysfunction is probable. Pectoralis major, latissimus dorsi, teres major/ minor, tri­ RAN G E O F M OTI O N O F S H O U L D E R STR U CTU R E S ceps long head, clavicular and spinal fibers of deltoid, cora­ cobrachialis (to neutral), biceps short head. Controversy exists regarding the normal range o f motion of the shoulder and which muscles are involved in particular Abd u ction 0-900 movements. The following list will give some reference for the practitioner as to which muscles are synergistic in par­ Deltoid, supraspinatus, infraspinatus, teres minor, biceps ticular movements. By referring to the antagonistic move­ long head. ments, the practitioner might also discern which muscles might be restricting range of motion. Elevation 90- 1 800 The list is not intended to add to the controversy but Deltoid, supraspinatus, infraspinatus, teres minor, biceps instead to be an aid in a thorough examination of tissues long head, trapezius, serratus anterior (at 1 20°, these plus contralateral lumbar muscles which laterally flex the trunk Box 1 3.3 Reflex tests (al ways compare both sides) to the opposite side). (Sc�W 1 987) Latera l (external) rotation 0-800 • Biceps reflex test. Practitioner and patient are seated facing each other. Tested arm (say right side) rests (completely Infraspina tus, teres minor, posterior deltoid, supraspinatus relaxed) on practitioner's left forearm ; practitioner's l eft (possibly) . thumb rests in cubital fossa on biceps tendon. That thumbnail is tapped with a neurological hammer and if the reflex is nor­ Medial (i nternal) rotation 0-1 000 mal the biceps should produce a slight jerk close to the tendon which will be both palpable and visi ble. This eva luates neuro­ Subscapularis, pectoralis major, l a tissimus dorsi, teres logical integrity at CS. major, anterior deltoid. • Brachioradialis reflex test. Same position as for previous test H orizonta l flexion 0- 1 400 but this time the neurological tap is to the brachioradialis ten­ don at the dista l end of the radius. There should be a slight Deltoid, subscapularis, pectoralis major/ minor, serratus 'jum p' of the brachioradial is, i ndicating normal CG integrity. anterior, biceps short head, coracobrachialis. • Triceps reflex test. Sa me position but this time the ta p is to the Horizonta l extension 0-400 triceps tendon as it crosses the olecranon fossa. A 'ju mp' of the triceps close to the tendon i ndicates normal C7 integ rity. Deltoid, supraspinatus, infraspinatus, teres major/ minor, rhomboids, trapezius, latissimus dorsi. Note: These spinal levels are im portant to shoulder function since the main nerve supply to the key muscles of this reg ion derive from C4-7. Box 1 3.4 What is nDlm.1 r�nge of arms? .. The normal ra nge of movement of the arms is a matter of dispute. (Cyriax 1982)

4 1 2 CLI N ICAL APPLICATI O N O F N EU R O M USCULAR TECH N I QU ES: T H E UPPER BODY Circu md uction • Bilateral abduction - abduct arms horizontally to 90° with elbows straight, palms upwards. Continue abduction Combines the movements about the three cardinal axes: (elevation) until hands meet in the center. • Sagittal plane - flexion and extension Impingement syndrome test • Frontal plane - adduction and abduction • Horizontal plane - horizontal flexion and extension. Patient is supine with arms at side. Scapular elevation • The elbow on the side to be tested is flexed to 90° and internally rotated so that the forearm rests on the patient's Upper trapezius, levator scapula, rhomboids major and abdomen. minor. • The practitioner places one hand to cup the shoulder in Scapular depression order to stabilize this, while the other hand cups the flexed elbow. Lower trapezius (indirectly latissimus dorsi and pectoralis major through their humeral attachments). Lower fibers of • A firm compressive force is applied through the long axis serratus anterior are questionable for this function. of the humerus, forcing the h umerus against the inferior aspect of the acromion process and glenohumeral fossa . Sca p u l a r adduction • If symptoms are reproduced or if pain is noted, supra­ Trapezius, rhomboids major and minor. spinatus and/or bicipital tendon dysfunction is indi­ cated (see false-positive information below). Sca p u l a r abduction False-positive compression test (see also Serratus anterior, pectoralis minor. impingement syndrome test a bove) ACTIVE A N D PASSIVE TESTS FOR SHOU LDER An associa tion has frequently been shown between thoracic G I R D L E M OT I O N (STA N D I N G OR S EATE D ) outlet syndrome and first rib restriction (Nichols 1996, Tucker 1994) . However, a connection between 2nd rib Both active and passive range o f motion tests may b e used restriction and shoulder pain has not been recorded in the to assess: literature until recently. • limits of movement of the glenohumeral joint Boyle (1999) reports on two case histories in which symp­ • scapular motion toms were present which resembled, in all respects (diag­ • soft tissue involvement. nostic criteria, etc.), shoulder impingement syndrome or rotator cuff partial tear which responded rapidly to mobi­ Bilateral comparison is possible by both sides performing lization of the 2nd rib. The patients both had positive tests the action simul taneously. If active testing shows normal for shoulder impingement, implicating supraspinatus range without pain or discomfort, passive tests are usually and /or bicipital tendon dysfunction (see impingement test not necessary. However, remember McKenzie's suggestion description above). (above) tha t repetition of an active movement a number of times, simulating 'real-life' behavior, offers a more accurate Boyle (1 999) describes evidence to support the way(s) in assessment than single movements. which 2nd rib restrictions (in particular) might produce false-positive test results and shoulder symptoms. These initial active tests offer a view of normal move­ ment and symmetry. • The dorsal ramus of the 2nd thoracic nerve continues lat­ erally to the acromion, providing a cutaneous distribu tion • Elevation (la teral rotation of scapula) and depression in the region of the posterolateral shoulder (Maigne 1991.). (medial rotation of the scapula) - hunch (shrug) shoul­ ders and return to normal. • Rotational restrictions involving the cervicothoracic region have been shown to produce a variety of neck and • External rotation and abduction - reach up and over shoul­ shoulder symptoms. Since the 2nd rib articulates with der to touch the superior medial angle of contralateral the transverse process of Tl (costotransverse joint) and scapula with one hand and then the other. the superior border of T2 (costovertebral joint), rota tional restriction of these vertebrae could produce rib dysfunc­ • External rotation and abduction tested bilaterally - place both tion (Jirout 1969). hands behind neck (fingers interlocked) and move elbows laterally and posteriorly in an arc. • Habitual overactivity involving scalenus posterior can produce 'chronic subluxation of the 2nd rib at its verte­ • Internal rotation and adduction - reach across the chest bral articulation' (Boyle 1999). This could result in a with elbow close to chest and touch opposite shoulder superior glide of the tubercle of the 2nd rib at the costo­ tip; or reach behind at waist level and touch inferior transverse j unction. angle of opposite scapul a . • Boyle reports that 'true' impingement syndrome is often related to overactivi ty of the rhomboids which would

1 3 Shoulder, arm and hand 41 3 'downwardly rotate the scapula', impeding elevation of • the practitioner ensures tha t the point of m uscle origin is the humerus at the glenohumeral jOint. efficiently stabilized • He suggests that rhomboid overactivity might also impact on the upper thoracic region as a whole (Tl-4), • care is taken to avoid use by the patient of ' tricks' in locking these segments into an extension posture. If this which synergists are recrui ted. situation were accompanied by overactivity of the poste­ rior scalene, the 2nd rib might 'subluxate superiorly on M U S C U LAR R E LATI O N S H I PS (Janda 1 983) the fixed thoracic segment', leading to pain and dysfunc­ tion mimicking shoulder impingement syndrome. • The prime mover in any action (agonist) performs the • Boyle hypothesizes tha t mechanical interference might greater part of the movement. occur involving ' the dorsal cutaneous branch of the sec­ ond thoracic nerve . . . in its passage through the tunnel • The assisting muscles (synergists) assist the prime mover adjacent to the costotransverse joint'. This nerve might be but do not carry out the actual movement unless the ago­ 'drawn taut, due to the superior anterior subluxation of nist is severely damaged or paralyzed. the second rib' leading to pain and associa ted restricted movement symptoms. • Movement in the opposite direction is performed by the • The reason for a false-positive impingement test, Boyle antagonist(s), which are passively elongated during nor­ suggests, relates to the internal rotation component mal movement initiated by the agonist. Therefore, if which adds to the mechanical stress of the dysfunctional there is shortening of the antagonist(s), movement range rib area. This could also, through pain inhibition, result will be l imited. in rotator cuff muscles testing as weak, suggesting incor­ rectly that a partial tear had occurred. • Muscles that stabilize parts of the body during movement • The possibility of a 2nd rib involvement should not dis­ of an area are stabilizers. These do not perform the move­ guise the possibili ty that this coexists wi th a true ment but if they are inefficient in producing stabilization, impingement lesion. it becomes more difficult for the agonist to perform its function and strength evaluations may be meaningless. STR E N GTH TESTS FOR S H O U L D E R M OVE M E N TS • Some muscles act as neutralizers. Based on its anatomical In the absence of atrophy, weakness of a muscle may be position each muscle operates in at least two directions. If a due to: muscle can both flex and supinate (biceps for example) and if an action of pure flexion is required, a muscle (or group of • compensatory hypotonicity relative to increased tone in muscles) that acts as a pronator (pronator teres in this exam­ antagonist muscles ple) has to neutralize the supination potential of biceps. • palpable trigger points in affected (weak) muscle, Jand a (1983) states: notably those close to the attachments As a rule when testing a two-joint muscle good fixation is • trigger point in remote muscles for which the tested mus­ essential. The same applies to all muscles in children and in cle lies in the target referral zone. adults whose cooperation is poor and whose movements are incoordinated and weak. The better the extremity is stead­ Muscle strength is most usually graded as follows. ied, the less the stabilizers are activated and the better and more accurate are the results of the musclefunction test. • Grade 5 is normal, demonstrating a complete (100%) range of movement against gravity, with firm resistance The authors highly recommend Janda's text and the other offered by the practitioner. referenced texts mentioned in this chapter for further explo­ ration of the art of assessment. • Grade 4 is 75% efficiency in achieving range of motion against gravity with slight resistance. Shoulder flexion strength (Fig. 1 3 . 5A) • Grade 3 is 50(},0 efficiency in achieving range of motion Anterior deltoid and coracobrachialis with assistance from pec­ against gravity without resistance. toralis major, clavicular head and biceps: Practitioner stands behind pa tient whose elbow is locked in flexion at 90°. • Grade 2 is 25% efficiency in achieving range of motion Stabilizing hand is on shoulder (placed so tha t it can also with gravity eliminated. palpate anterior deltoid d uring the test). The other hand holds anterior aspect of lower arm and patient is asked to • Grade 1 shows slight contractility without joint motion. • Grade 0 shows no evidence of contractility. �� :'.�\" ;:'»'�\"'.'-��l .....,'-, :' ,.: ,'\"... \"\" .• .... - ,\" \" _.-: �. • � ... , .':\"O.� '. _ For efficient muscle strength testing it is necessary to ensure tha t: Neutra l izers a re of g reat i m portance in daily l ife, but in muscle • the patient builds force slowly after engaging the barrier function testing they are a nu isance. Their action is greatly of resistance offered by the practi tioner diminished by correct positioning of the extremities to a l low accurate resistance and good fixation. (Janda 1983) • the pa tient uses maximum controlled effort to move in the prescribed direction

41 4 CLI N ICAL A P P L I CATI O N O F N EU R O M USCULA R TECH N I QU E S : T H E U PP E R B O DY AD BE cF Figure 1 3. 5 Strength tests of various a r m m o v e m e n.ts . A: Flexion ( t w o -j o i n t test). B: Extension ( t w o -j o i n t test). C: Abduction. D: Add uction. E : Internal rotation. F : External rotation.

1 3 Shoulder, a r m a n d hand 4 1 5 flex shoulder. Strength is graded and compared with other Elevation of the scapula side. If weakness is noted consider the nerve supply from C4 to C8, as well as trigger point input to the active muscles. Trapezius, levator scapulae assisted In) rhomboids major and minor: Practitioner behind patient evaluates relative strength as the Extension strength [Fig. 1 3.5B) patient's attempt to sluug is resisted - this assesses spinal accessory nerve integrity. Strength should be recorded as Latissimus dorsi, teres major, posterior deltoid with assistance suggested above. If weakness is noted consider the nerve from teres minor and long head of triceps: Stabilizing hand on supply from C2 to C8, as well as trigger point input to the shoulder palpating posterior deltoid, other hand holds pos­ active muscles. terior aspect of flexed lower arm (as in previous test) as patient is asked to extend shoulder. Strength should be Depression of the scapula record ed as suggested above. If weakness is noted consider the nerve supply from C4 to C8, as well as trigger point Rhomboid major and minor, assisted by trapezius: Practitioner input to the active muscles. stands in front and places hands so that fingers cover shoul­ ders over the upper deltoids and thumbs rest anteriorly below Abduction strength [Fig. 1 3.5C) the clavicles. Patient is asked to take shoulders back and down as practitioner resists and assesses strength. Since CS is the Middle deltoid, supraspinatus with assistancefrom serratus ante­ sole innervation of the primary muscles involved (although rior plus anterior and posterior deltoid: Stabilizing hand is on trapezius is innervated from C2) weakness may relate to its shoulder palpating middle deltoid; increasing resistance is integrity. Strength should be recorded as suggested above. If offered above flexed elbow as abduction is introduced. weakness is noted consider the nerve supply from C2 to C8, as Strength should be recorded as suggested above. If weak­ well as trigger point input to the active muscles. ness is noted consider the nerve supply from C4 to C8, as well as trigger point input to the active muscles. Protraction of the scapula Adduction [Fig. 1 3.5D) Serratus anterior: Examiner i s behind, patient flexes arm so that it is parallel to the floor with elbow flexed and forearm Pectoralis major, latissimus dorsi assisted by teres major, anterior at 90° to upper arm facing medially. Stabilization is offered deltoid and possibly posterior deltoid: Stabilizing hand is on by the practitioner in the mid-scapular region to prevent shoulder tip, patient's flexed arm is abducted and resistance spinal movement while the other hand cups the flexed is offered from a position medial to and above the elbow as elbow, offering resistance, as the patient attempts to push the patient attempts to adduct. Strength should be recorded the arm forwards, away from the body. If winging occurs as suggested above. If weakness is noted consider the nerve during this, it implies weakness of lower fixators of the supply from C4 to C8, as well as trigger point input to the shoulder. If there is weakness in any of the movements active muscles. described, but particularly scapular depreSSion, CS may be implicated (or C4 - see Lewit's views above). Strength Internal rotation [Fig. 1 3.5E) should be recorded as suggested above. If weakness is noted consider the nerve supply from C4 to C8, as well as Subscapularis, pectoralis major, latissimus dorsi, teres minor trigger point input to the active muscles. assisted by anterior deltoid: Arm at side, elbow flexed to 90° and with the elbow supported. Patient attempts to take the SPI NAL A N D SCAPU LAR E F FECTS O F forearm medially across the trunk while resistance is offered. Strength should be recorded as suggested above. If EXCESSIVE TO N E weakness is noted consider the nerve supply from C4 to C8, as well as trigger point input to the active muscles. • Trapezius - pulls shoulder girdle medially, occiput pos­ teroinferiorly, associated spinous processes laterally, ele­ External rotation [Fig. 1 3.5F) vates shoulder, rotates scapula laterally. Infraspinatus, teres minor assisted by posterior deltoid: Flexed • Levator scapula - pulls scapula medially and superiorly, elbow rests in stabilizing hand (elbow remains at the side rotates scapula medially and associated transverse throughout) with practitioner 's thumb at the elbow crease. processes (Cl-4) inferiorly and posteriorly. The other hand holds the wrist and applies increasing resistance as the patient attempts to externally rotate the • Rhomboid major and minor - pulls scapula medially and shoulder by moving the forearm laterally. Strength should superiorly and associated spinous processes laterally and be recorded as suggested above. If weakness is noted con­ inferiorly, rotates scapula medially (makes glenoid fossa sider the nerve supply from C4 to C8, as well as trigger face downward). point input to the active muscles. S H O U L D E R PAI N A N D ASSO C I AT E D STR U CTU R E S Lewit summarizes some o f the most common sources of shoulder dysfunction and pain and states that if shoulder

41 6 CLI N ICAL A P P L I CATI O N O F N E U R O M U S C U LA R TECH N I QU ES : T H E U P P E R B ODY pain exists, the following structures and their functions described by Lewit (199 1 ) and Janda (1982, 1983). In this require evaluation and palpation. pattern of dysfunction, imbalances occur between: 1. short tight pectorals and weak (inhibited) interscapu­ • Cervical spine and craniocervical junction • Cervicothoracic j unction, upper ribs lar muscles • Scapulohumeral (glenohumeral) joint (including joint 2. short tight upper shoulder fixa tors (upper trapezius, play with arm horizontal) levator scapula and pOSSibly the scalenes) and weak­ • Clavicular joints ened, inhibited, lower fixators (lower trapezius, serra­ • Abduction arc tus anterior) • All available muscle insertions 3. short tight neck ex tensors (cervical erector spinae, • Potential trigger point sites upper trapezius) and weak, inhibited deep neck flexors • Epicondyles (longus cervicis, longus capitis, omo- and thyrohyoid) • Carpal bone joint play leading to an unbalanced situation which has, as key features, Note: Not all Lewit's suggested evaluations are described in exaggerated cervical lordosis and consequent 'chin poking', this section (shoulder) of the book. dorsal kyphosis and a generally rounded shoulder posture, with winged scapulae which drift laterally, leading inevitably Lewit (199 1 ) also describes chain reactions that are rele­ to excessive strain on the rotator cuff muscles as they struggle vant to shoulder dysfunction. to maintain normal position and function of the humerus, which now meets the glenoid fossae in the wrong plane. • Craniocervical j unction restriction is often associated with upper rib restriction (most often the 3rd rib) and THERAPEUTIC CHOICES vice versa. If shoulder pain i s accompanied b y muscular imbalances (as • A tlantooccipital restriction is often associa ted with sub­ described by Lewit and Janda in the upper crossed syn­ occipital extensor dysfunction ('spasm'). drome), the following elements are called for. • If C 1 or C2 is restricted the lateral aspect of the spinous • Assessment of j oint restrictions, shortened muscles and process of C2 is usually painful and trigger point activity local myofascial trigger points. is likely in sternocleidomastoid inferior to the mastoid process. • Elimination of active myofascial trigger points (NMT). • Restoration of balance between hypertonic and inhibited • If postural stress is evident (forward drawn head or per­ sistent head extension during work) or if shoulder upper muscles (MET). fixators are excessively tight, C2 tenderness (spinous • Mobilization of restricted joints (articulation and possi­ process) can be anticipated, along with cervical restric­ tions in this region. Levator scapula attachment on the bly manipulation). scapula and the clavicular a ttachment of SCM are likely • Rehabilitation tactics, postural and, possibly, breathing to house active trigger points at their attachment sites. reed ucation. • A chain of interconnected dysfunction may exist between the subclavicular pectoralis and SCM. This may be asso­ If shoulder pain radiates from spinal structures the symptoms cia ted with upper chest breathing patterns, which would will be aggrava ted by head or neck movement and some also involve the scalenes and the masseter muscles (with degree of joint blockage (restriction) will be noted. This resultant trigger point activity likely in all or any of these requires normalization and among the choices available are: muscles). • identification and treatment of active trigger points • Epicondylar pain may be linked with mid-cervical • normaliza tion of associated muscle and soft tissues (see restriction, which is likely to rela te to craniocervical junc­ tion dysfunction. More locally, 'Pain at the styloid process Lewit's discussion of chain reactions above) of the radius . . . may be the only sign of blocking of the • use of MET to encourage normal joint function (p. 219) elbow (radioulnar) j oint'. • use of Ruddy's pulsed MET to encourage normal joint • Pain in the epicondyles, which usually involves over­ function (p. 201) strained forearm muscles, is likely to be related to • use of positional release methods to encourage normal increased muscle tension in the shoulder girdle, all of which require individual assessment. joint function (p. 225) • high-velocity thrust techniques (if licensed to perform • Carpal twmel syndrome is commonly related to thoracic outlet dysfwKtion, involving the cervicothoracic junction, these) . upper ribs, scalenes and probably a dysfunctional breath­ ing pattern. An epicondyle connection is also probable. If shoulder pain originates in the upper ribs, treatment may include: • Disturbed muscle function. It is important when consid­ ering neck, shoulder and arm dysfunctions to recall ear­ • use of MET, PRT and/or NMT (especially to the inter­ lier discussion of the upper crossed syndrome, as costal musculature and all attaching muscles) • positional release and MET methods for restoring normal function to elevated and depressed ribs, discussed on p. 554.

1 3 Shou lder, arm and hand 4 1 7 Note: Some of the signs of rib involvement with shoulder 1. pain severe and worsening with some restriction pain may include the following. 2. pain lessens but restriction remains 3. pain and restriction slowly vanish, with the whole • If the first rib is dysfunctional, shoulder pain is likely, with marked tenderness anteriorly when its attachment process lasting around a year. to the manubrium sternum is palpated. Capsulitis may follow bursitis or tendinitis or it may relate • Scapula pain is noted, along with shoulder pain, in dys­ to chronic pulmonary disease, myocardial infarction or dia­ function involving ribs 2, 3 and 4, with marked tender­ betes mellitus. When these more serious (potentially life­ ness on palpation of the medial scapula border. threa tening) visceral conditions exist as the underlying cause of the shoulder pain, and therapy reduces the pain to SPECI F I C S H O U L D E R DYS F U N CT I O N S a manageable level without addressing the cause, the vis­ ceral condition(s) may progress unnoticed. A differential A number of upper extremity dysfunctions and pathologies diagnosiS from a physician is therefore essential. may develop from biomechanical, biochemical and psychoso­ cial issues. Sorting through the numerous potential causes can The condition may relate to overuse or to a subluxation be challenging since many may be obscure. For instance, the which has reduced spontaneously or via treatment. If adhe­ effects of stress on postural muscles have been discussed, sions form within the joint capsule, the head of the humerus with specific consequences on shoulder mechanics. Therefore may bond to the glenoid surface (adhesive capsulitis). The dysfunctional patterns of brea thing as well as habits of use condi tion is most common in women between the ages of 45 should be considered. Bodor & Montalvo (2007) hypothesize and 65. that vaccine injected into the subdeltoid bursa can cause a periarticular inflamam tory response, subacromial bursitis, Pain is usually pronounced at the deltoid tendon attach­ biCipital tendonitis and adhesive capsulitis. They suggest that ment as well as in subscapularis. The deltoid, infra- and the upper third of the deltoid is avoided with vaccine injec­ supraspinatus muscles may atrophy in severe cases and cir­ tions, and 'the diagnosis of vaccina tion-related shoulder dys­ culatory changes may be noted (involving cyanosis and / or function should be considered in patients presenting with edema). Methods of treatment are called for which do not shoulder pain following a vaccination'. irritate the inflammatory processes but which attempt to normalize associated jOint and muscle dysfunction. In evaluating shoulder dysfunction, there are a number of screening tests that can be used to guide the treatment Lewit sta tes, 'The usual mobilization and manipulation plan or to suggest referra l for further assessment. The tests techniques are useless in dealing with the shoulder joint and evaluations described below are mainly derived from itself'. This highlights the critical importance of soft tissue the following sources. evaluation and treatment in this joint in particular and in most joints of the body, in our opinion. • Janda V 1983 Muscle function testing. Butterworths, London Supraspinatus tendinitis • Lewit K 1999 Manipulative therapy in rehabilitation of This may be associated with subdeltoid or acromial bursitis the locomotor system, 3rd edn. Butterworths, London or rotator cuff dysfunction (such as a sequel to supraspina­ tus strain). Symptoms include: • Liebenson C 2006 Rehabilitation of the spine, 2nd edn. Williams and Wilkins, Baltimore • ache at rest, especia lly when lying on affected side • increased discomfort on abduction • Lowe W 2006 Orthopedic assessment in massage ther­ • pain may refer toward deltoid insertion apy. Oaviau-Scott, Sisters, OR • pain on activity is restricted to a pain ful arc (see tests • Petty N 2006 Neuromusculoskeletal examination and below) due to effect of acromion process on tendon dur­ assessment. Churchill Livingstone, Edinburgh ing excursion of arm • localized tenderness on palpation will be noted over the • Schafer R 1987 Clinical biomechanics. Williams and inflamed tissues. Wilkins, Baltimore Ap/ey 'scratch' test • Ward R (ed) 1997 Founda tions of osteopathic medicine. Williams and Wilkins, Baltimore • Seated or standing patient raises arm overhead (abduc­ tion and lateral rotation) and flexes elbow, placing fin­ Ca psu l itis (aka scapulohu meral dysfu nction, gers as far down contrala teral scapula as possible. 'frozen shou l der') • The arm is then taken back to the side and the patient Generalized rather than localized pain in the shoulder may a ttempts to place the arm behind the back to reach as far suggest capsulitis or contracture of the joint capsule. Pain is up the contralateral scapula as possible (adduction with usually apparent on active as well as passive movement. medial rotation). Pain is felt more at night and when the arm is hanging down, moving or when carrying. Cyriax (1982) suggests that • If pain is noted on either movement, one of the rotator there are three stages, each lasting 3-4 months. These are: cuff tendons is probably inflamed, with supraspinatus the most likely.

4 1 8 CLI N I CA L APP L I CATI O N OF N E U RO M U S C U LA R TECH N I Q U E S : TH E U P P E R B O DY • If there is limitation but no pain, soft tissue restriction • Resistance is offered to the forearm proximal to the wrist or osteoarthritis is probable, without active inflam­ as the patient attempts to supinate the forearm. mation. • Pain localized to the proximal tendon attachment area • Variation: One arm performs the overhead movement indicates possible inflammation and instability (or dis­ while the other arm performs the test behind the back. placement) of the long head of the tendon. The patient can be asked to attempt to touch the hands and the distance between the fingers noted. This is Note: Pain localized at the elbow with this test may impli­ repeated while reversing the position of each arm and cate supinator muscle. the two results can be easily compared. Yergason's (tendon stability) test (Fig. 1 3. 7) 'Drop-arm' test. The patient fully abducts the arm (qual­ ity of movement should be observed) and starts to slowly • The pa tient fully flexes the elbow with the forearm lower it toward the side of the body. If the patient is unable pronated while the practitioner grasps proximal to the to lift the arm or unable to sustain the arm when lifted and wrist. the arm drops to the side from around 90° of abduction, rotator cuff damage is likely with supraspinatus most prob­ • The patient is asked to resist the attempt by the practi­ ably involved. If the patient is able to sustain the posi tion, tioner to supinate and extend the forearm. the practitioner can place a slight resistance load to deter­ mine if this causes the arm to drop. It is best to be prepared • An unstable tendon will displace and pain will be noted to catch the falling arm in case of abrupt d rop to avoid at the bicipital groove. unnecessary pain and potential trauma. Speed's test Bicipital tendinitis • Patient flexes the shoulder to 60° and fully extends the • There will be palpable tenderness over the inflamed por­ supinated forearm. Practitioner applies downward pres­ tion of the tendon. The two bicipital tendons should be sure to the forearm while the patient resists. differentiated from the subscapularis tendon, which can be palpated between them. • If pain or symptom d uplication is noted a partial rupture of the biceps is suggested. • Symptoms are similar to supraspinatus tendinitis but dif­ fer in location as referral is to biceps insertion. • If pain increases in the area of the bicipital groove ten­ dinitis is suggested. • If bicipital rupture (long head) or subluxation of the ten­ don from the groove has occurred there will be pain Note: Flexion and ex tension strength will be limited by noted on abduction and extension. bicipital tendinitis. • SpecifiC tests (below) help to localize the dysfunction. Subdeltoid bursitis (Fi g . 1 3.8) Lippman's test (Fig. 1 3.6) • Inflammation produces severe, deep-seated, localized pain with general weakness but especially on abduction. • Patient is seated with elbow passively flexed and relaxed on lap. • Movements in rotation, flexion and extension may be limited. • The tendon of the long head of the biceps is palpa ted (approximately 8 cm below the glenohumeral joint on the • Palpation of the bursa and region around the tendon will lateral surface of the shoulder). reveal edema which greatly restricts the humeral tuberosity in its movement into abduction. • Pressure is applied in an attempt to displace the tendon medially or laterally. • Tendons which pass through the bursa will be affected (bicipital, rotator and subscapularis). • If this can be achieved or if symptom pain is reproduced then an assessment of an unstable tendon and possible • When chronic, the condition moves from localized pain to tenosynovitis is confirmed. one of severe limitation of movement (particularly abduc­ tion and external rotation) as capsular adhesions form. • Variation: Have the patient lift a 2 kg weight overhead and slowly lower it to the lateral horizontal position. If • The condition commonly follows degenerative changes in symptoms are reproduced by this action (whether or not the rotator cuff at the base of the subdeltoid bursa, which there is displacement of the tendon from the groove), a result in calcification and associated inflammation. positive test result is noted . Subacromial bursitis (Fig. 1 3.9) Resistive supination test • Abduction of the arm which is painful or limited may • Seated patient's arm is flexed at the elbow, palm suggest subacromial bursitis. down. • Schafer (1987) reports: 'A painful, faltering abduction arc is characteristic of subacromial bursitis. To differentiate, the coracoid process is palpa ted under pectoralis major. It is found by circumducting the humerus which is nor­ mally tender. Once the process is found, the finger is slid slightly laterally and superiorly until it reaches a portion

1 3 Shoulder, arm and hand 41 9 Fig u re 1 3.6 Bicipital tendinitis. Figure 1 3.7 Yergason's test. Figure 1 3.8 Subdeltoid bursitis. Figure 1 3.9 Subacromial bursitis. of the subacromial bursa. If the same palpation pressure might result from the practitioner losing good digital here causes greater tenderness than at the process it is a contact on the b ursa as the deltoid tissue bunches. positive sign of subacromial bursitis.' • If pain induced by pressure remains the same, or • During this procedure care must be taken to avoid apply­ increases, during abduction, bursitis is not likely. ing pressure onto the neurovascular bundle coursing through this region. Su praspi natus calcification • The practitioner stands behind the patient and applies pressure to the subacromial b ursa area (just below the The tendon of supraspinatus inserts on the superior facet of coracoid process), producing some pain. the greater tuberosity, at which site calcification may occur. • The patient's arm just proximal to the wrist is grasped Symptoms are as follows. and is gently taken into abduction to approximately 1 000. • Digital pressure is maintained to patient tolerance and if • Severe pain (but not as severe as supraspinatus tendini­ bursitis is present, pain should lessen significantly as tis), which is made worse by most shoulder movements, abduction proceeds. Particular attention is required to is localized to the region superficial to i ts insertion at the maintain constant palpation pressure as pain reduction greater tuberosity of the humerus.

420 CLI N ICAL APPLICATION OF N EU RO M USCU LAR TECH N IQUES: THE U PPER BODY • Pain may be no ted on abduction, especially in the early s tages of arm abduction. • Bursitis may also be present. • X-ray evidence of calcification may be noted above the outer head of the humerus. • Spontaneous reabsorption may occur, particularly when mechanical interference is removed. Triceps b rachii calcification Fig u re 1 3. 1 0 Test a n d M ET treatment position for i nfraspinatus shortness. • Throwing injuries may aggravate and inflame posterior capsule structures leading to osteotendinous calcification • Infraspinatus in the infraglenoid area close to the attachment of the • Levator scapula long head of triceps brachii. • Latissimus dorsi • Pectoralis major and minor • Throwing action, especially the follow-through, will be • Supraspinatus limited and painful. • Subscapularis • Upper trapezius S PECI F I C M USCLE EVA LUAT I O N S I N FRAS P I N AT U S General tests for muscle weakness have been outlined ear­ lier in this chapter. Excellent resources are easily available The patient is asked t o reach backwards and across the back describing more specific testing procedures (see recom­ to touch the medial border of the opposite scapula (internal mended book list on p. 417). There are also a number of rotation of the humeral head). Pain is indicative of infra­ assessment methods that can identify dysfunctional states spinatus and/ or teres minor dysfunction /shortness. of postural muscles. Some offer clear evidence of shortness, while others suggest a tendency toward that state by virtue An additional assessment involves the patient lying of the inappropriate activity of the muscle. In order to clar­ supine with upper arm abducted to 90° and elbow flexed to ify the last statement it is worth repeating that when 90°, forearm pointing caudad, palm downwards (internal 'stressed' (overused, abused, misused, disused), muscles rotation of the humeral head). The forearm should be able which have a greater stabilizing role (postural - type I) will to lie parallel to the floor without the shoulder lifting from shorten over time whereas those with a more movement­ the table surface. If the forearm is elevated, infraspinatus is oriented task (phasic - type II) will weaken (see Chapter 2). short (Fig. 13.10). If inappropriate activity can be identified, as in the func­ LEVATOR SCA P U LA tional evaluation described earlier in this chap ter (scapulo­ humeral rhythm test, p. 410), relating to the upper crossed The practitioner stands at the head of the table, supporting syndrome in general and upper trapezius activity in partic­ the supine patient's neck, which is taken into full flexion ular, shortness can be assumed. If a muscle fires out of and sidebend, away from the side to be tested. Rotation of sequence and it is also a postural ( type I ) muscle, i t is short the head is then introduced, also away from the side to be or is going to become short. tested. The head and neck are stabilized in this pOSition with one of the practitioner's hands, while the other hand A simple extension of that knowledge tells us that the contacts the top of the shoulder (tested side) to assess the muscles that are antagonists to the overactive, hypertonic ease with which it can be depressed (moved distally). There postural muscles are going to become inhibited (weak). The should be an easy springing sensation as the shoulder is overactive muscle that is shortening may test as weak but it is pushed toward the feet with a soft end-feel to the move­ certain that its antagonist will be weaker than it ought to be. ment. If there is a harsh, sudden end-feel, levator scapula is short (Fig. 13.11). Trigger points can and do evolve in stressed soft tissues and whenever muscles are in a shortened sta te, there is a LATI SSI M U S DORSI strong likelihood tha t they will house active trigger points. Weakened antagonists may also harbor trigger points, The patient lies supine with head 18 inches (45 cm) from the which leads to the conclusion that all muscles need to be top end of the table and is asked to rest arms fully extended searched for triggers which could be contributing to, or be (elbows straight) above the head so that they lie on the treat­ the result of, dysfunctional muscular activity. The protocols ment surface, palms upwards. The arms should be able to written in this chapter are developed specifically toward easily reach the horizontal while being directly above the that end, as a 'routine' that is thorough and specific in the palpation of each muscle of the region. Tests for shortness of the following postural (type 1) mus­ cles, which have a direct connection with shoulder function, are described below.

1 3 Shoulder, arm and hand 42 1 Figure 1 3. 1 1 M ET treatment position for shortness of levator sca p u l a . Figure 1 3 . 1 3 Assessment and M ET treatment position for shortness of su praspi natus. positions of the arm may be introduced - for example, to eval­ uate the costal portion of the muscle, abduction together with approximately 45° of elevation above shoulder level is intro­ duced . The arm can then be allowed to hang loosely off the table. At this time the practitioner should apply light pres­ sure to the anterior surface of the shoulder joint, toward the table, and a 'soft barrier' should be noted. If the costal portion of pectoralis major is short, a firm, hard barrier will be noted. Figure 1 3. 1 2 Test posi tion for latissi m u s dorsi. S U P RAS P I N ATUS shoulders, in contact with the surface for almost all of the The practitioner stands behi.nd the seated pa tient, with one length of the upper arms, with no arching of the back or hand stabilizing the shoulder on the side to be assessed twisting of the thorax. If an arm does not lie parallel to the while the other hand reaches in front of the patient to sup­ other above the shoulder but is held laterally, elbow flexed port the forearm (elbow flexed). The patient's upper arm is and pulled outwards, then latissimus dorsi is probably adducted until an easy barrier is sensed (i.e. not forced) and short on that side (Fig. 13.12). the patient attempts to abduct the arm. If pain is noted in the posterior shoulder region this is diagnostic of supraspinatus dysfunction (Fig. 13.13). PECTORALIS MAJ O R AN D M I N O R SU BSCAPULARIS Using the same starting position as latissimus above, i f an Pa tient i s supine with upper arm abducted to 90° and elbow arm cannot rest with the dorsum of the upper arm in con­ flexed to 90°, forearm pointing cephalad, palm upward tact with the table surface without effort, then pectoralis (external rotation of humeral head). The forearm should be major or minor fibers are almost certainly short. able to lie parallel to the floor without the shoulder lifting from the table surface. If the forearm is elevated, subscapu­ Another way of evaluating pectoralis major is to have the laris or pectoralis minor is short (Fig. 13.14). patient lying supine close to the edge of the table on the side to be tested . It is important that the trunk be maintained in a U PPER TRAPEZIUS stable position without any twisting (knees may be flexed to assist in this). The arm on the tested side is taken into abduc­ To assess the posterior fibers of upper trapezius the patient tion and should easily reach a horizontal level, and prefer­ is supine with the neck fully rotated contralateraUy and ably much further. Any degree of elevation or non-elastic sidebent away from the side to be tested. At this point the end-feel at horizontal level indicates shortness. Other

422 C L I N ICAL A P P L I CATI O N O F N E U R O M USCU LAR TEC H N I QU ES : T H E U P P E R B O DY / IS T H E PATI E N T ' S PA I N A S O FT T I S S U E OR A l JOINT PROBLEM? ___ In Chapter 7 several simple screening tests devised by Professor Freddy Kaltenborn (1980) were listed. He sug­ B gested that we ask: Figu re 1 3. 1 4 Assessment position for shortness of su bsca pula ris o r 1. Does passive stretching (traction) of the painful area pectoralis minor. A : Normal. B : Short. increase the level of pain? If so, it indicates extraarticular soft tissue involvement. 2. Does compression of the painful area increase the pain? If so, it indicates intraarticular dysfunction. 3. Is active movement (controlled by the patient) restricted or does it produce pain in one direction of movement, while passive movement (controlled by the practitioner) in precisely the opposite direction also produce pain (and/ or is restricted)? If so, the contractile tissues of the area (muscle, ligament, etc.) are implicated. This can be confirmed by resisted tests. 4. Do active movement and passive movement in the same direction produce pain (and /or restriction)? If so, joint dysfunction is probable. This can be confirmed by use of traction, compression and gliding of the joint. Resisted tests are used to assess both strength and painful responses to muscle contraction, either from the muscle or its tendinous attachment. These tests involve producing a maximal contraction of the suspected muscle while the jOint is kept immobile somewhere near the middle of range posi­ tion. No joint motion should be allowed to occur during such an assessment. Resisted tests may usefully be performed after test 3 (above) to confirm a soft tissue dysfunction ra ther than a joint involvement. Kaltenborn suggests that before per­ forming the resisted test, it is wise to perform the compres­ sion test (2 above) to clear any suspicion of jOint involvement. These thoughts should also be kept in mind when the Spencer sequence, described in Box 13.6, is ca rried out. Fig u re 1 3. 1 5 Hand positions for assessment a n d M ET treatment of THE SPENCER SEQUENCE upper trapezius. A traditional osteopathic assessment sequence is described practitioner, standing or seated at the head of the table, uses in Box 13.6. This sequence is highly recommended as an a contact on the shoulder (tested side) to assess the ease with addition to neuromuscular therapy since it offers precise which it can be depressed (moved distally) . There should be evaluation of even minor restrictions in shoulder range and an easy springing sensation as the shoulder is pushed quality of motion, with the added advantage of allowing toward the feet, with a soft end-feel to the movement. If trea tment from the test position (see p. 423). there is a harsh, sudden end-feel, the posterior fibers of upper trapezius are probably short. Rotation of the head Clinical research (KnebI 2002) has validated application of toward the side being tested can be introduced to evaluate the Spencer sequence in a study involving elderly patients. anterior fiber shortness in a similar manner (Fig. 13.15). • In this study, 29 elderly pa tients with preexisting shoul­ der problems were randomly assigned to a treatment (Spencer sequence osteopathic treatment) or a control group. • The histories of those in the two groups were virtually identical: :± 76% had a history of arthritis, 21 % bursitis, 21 % neurological disorders, 10% healed fractures. • 63% had reduced shoulder ROM as their chief complaint, and 33% pain (4% had both reduced ROM and pain) .

1 3 Shoulder, arm and hand 423 Box 1 3. 6 Spencer's assessment sequence (Patri q u i n 1 992. Spencer 1 9 1 6) The Spencer sequence, wh ich derives from osteopath ic medicine in intent. Both muscle energy (MET) and positional release (PRT) the early years of the 20th centu ry, is ta ught a t a l l osteopathic treatment possibilities cou ld be incl uded and will be outl ined in the coll eges i n the USA. As the shoulder is put throu g h its va rious ranges shoulder treatment section (Box 1 3.9). of motion, close attention is paid to any signs of restriction and When this assessment sequence is being emp loyed for assessment these are noted. From what is pal pated and observed in th is and treatment. the scapula should be held fixed firmly to the sequence, clear indications can be derived as to which structures thoracic wal l to isolate i nvolvement of the g lenohu meral joi nt. The may be involved in creating any particular restriction. patient remains in a sidelyi ng position throughout, with the side to be assessed uppermost. The practitioner stands in front facing the For example, if restriction is noted i n shoulder flexion, it is patient at shoulder level. reasonable to assume that one or various soft tissues i nvolved in shoulder extension a re involved i n whatever is restricting that 1 Assessment of shou l der extension restriction movement. These soft tissue dysfu nctions may be secondary to (Fig. 1 3. 1 6A) actual osseous dysfunction or soft tissue changes m ight be (indeed • The practitioner's cephalad hand cups the shoulder, firmly usua l ly are) the main cause of restrictions in range of motion. The qual ity of end-feel helps to indicate whether restrictions a re compressing the scapula and clavicle to the thorax while the primarily the result of osseous or soft tissues. patient's flexed elbow is held by the practitioner's caudad hand as the arm is taken into extension toward the Over the years the sequence of assessment has been modified to optimal 90°. i nclude treatment elements other than the orig inal mobil ization { \\ ---'\" \\ \\� A B � --- -- ��-� 11�7, / )1\"( ( j,� � � /' /� ( \\�\\ --- --- /' f' � --- --- D --- --- Fig u re 1 3. 1 6 Spencer sequence positions. A : Shoulder extension. B: Shoulder flexion. C: Circumduction with compression. D : Circumduction with traction. E : Abduction w ith externa l rotation of shou lder. box continues

424 CLI N I CA L A P PLICAT I O N OF N E U R O M U S C U LA R TEC H N I Q U E S : T H E U P PER B O DY Fig u re 1 3. 1 6 (Contin ued) 3b Assessment of circu md uction capabi l ity with traction (Fig. 1 3.1 6D) • Be aware of any restriction in range of motion, ceasing • The patient is sidelying with arm straight. movement at the first indication of resistance to movement. If • The practitioner's cephalad hand cups the shoulder firmly, com­ the movement is less than 90·, restriction may be a result of shou lder flexor shortness (possibly involvi ng anterior deltoid, pressing the scapula and clavicle to the thorax, while the caudad coracobrachialis or the clavicular head of pectoralis major). hand g rasps immediately proximal to the wrist and i ntroduces slight traction, before taking the arm through slow clockwise cir­ 2 Assessment of shoulder flexion restriction cumduction. (Fig. 13.1 6B} • This is assessing range of motion in circumduction, as well as the • The patient has same starting position as previous test. status of the capsule of the glenohumeral joint. • The practitioner stands at chest level, half facing cephalad. • The same process is repeated counterclockwise. • The non-tableside hand g rasps patient's forearm while tableside • Any restriction is noted. Note: If restriction or pai n is noted in either of the circumduction hand holds the clavicle and scapula firmly to the chest wa ll. sequences (utilizing compression or traction), it is possible to • The practitioner slowly i ntroduces shoul der flexion in a plane eval uate wh ich m uscles wou ld be active if precisely the opposite movement were undertaken and it is these which wou ld be offering which is parallel to the floor as ra nge of motion to 1 80· is soft tissue restriction to the movement. assessed, by which time the elbow will be in extension. Obviously there are l i kely to be a rticular or capsular reasons for • The position of very first indication of restriction in movement these restrictions and, if this is the case, soft tissue involvement into shoulder flexion is noted and if this is less than 1 80·, would be seconda ry. dysfunction is assumed. • If a ny restriction toward flexion is noted the soft tissues 4 Assessment of shou lder abduction restriction impl icated in mainta i n ing this dysfu nction would be the shoulder (Fig. 1 3.1 6E) extensors (posterior deltoid. teres major, latissimus dorsi, and • Patient is sidelying and the practitioner cups the shoulder and possibly infraspinatus, teres m i nor and long head of triceps). compresses the scapula and clavicle to the thorax with the 3a Assessment of circumduction ca pabi l ity with cephalad hand while cupping the flexed elbow with the caudad compression hand. • The patient is sidelying with elbow flexed (Fig. 1 3. 1 6C). • The patient's hand is supported on the practitioner's cephalad • The practitioner's cephalad hand cups the shoulder while firmly forearm/wrist to stabil ize the arm. • The elbow is abducted toward the patient's head as range of compressing the sca pula and clavicle to the thorax. motion is assessed. • The practitioner's caudad hand grasps the elbow and takes • Some degree of external rotation is a lso involved in this abduc­ tion. the shoulder through a slow passive clockwise circumduction • Pain-free easy abduction should be close to 1 80·. while adding compression through the long axis of the • If there is a restriction towa rd abduction the soft tissues impli­ humerus. cated in maintaining this dysfunction would be the shoulder • This is repeated several times in order to assess range, freedom adductors (pectoralis major, teres major, l atissimus dorsi and pos­ and comfort of the circu mducting motion, as the: h u meral head sibly the long head of triceps, coracobrachialis, short head of moves on the surface of the g lenoid fossa. biceps brachii). • Any discomfort or restriction is noted. • As with all Spencer movements this is a passive activity. 5 Assessment of shoulder adduction restriction (not i l l u strated) • With the patient sidelying, the practitioner cups the shoulder and compresses the scapula and clavicle to the thorax with the cephalad hand while cupping the elbow with the caudad hand. • The patient's hand is supported on the practitioner's proximal forearm/wrist to stabil ize the a rm. • The elbow is taken in a n a rc forward of the chest so that the elbow moves both cephalad and medially as the shoulder adducts and externally rotates. • The action is performed slowly and a ny signs of resistance are noted. • The deg ree of adduction that may be regarded as normal in this movement would be one that allowed the movement to progress, unrestricted, until the flexed elbow approached the mid-line of the thorax. • If there is a restriction toward add uction, the soft tissues impli­ cated in maintaining this dysfunction would be the shoulder abductors (deltoid and supraspinatus). • Since external rotation is a lso involved, other muscles implicated in restriction or pa in may include internal rotators (subscapula ris, pectoralis major, latissimus dorsi and teres major).

1 3 Shoulder, arm and hand 42 5 Box 1 3 7 Cla¥lcular as-.sment {Greenman 1 989j Fig u re 1 3. 1 7 Assessment for restriction i n horizontal flexion a t the sternoclavicular joint. Note: In the authors' experience these clavicu lar restrictions ca n usua l ly be normal ized using soft issue approaches. Appropriate • Each side is then tested separately. treatment methods will be outlined in the text. • To test the right AC joi nt, the practitioner is behind the patient 1 Assessment and treatment of restricted abduction with the left hand fingers pa lpating over the joint. The right hand sternoclavicular joint holds the patient's right elbow. The arm is lifted in a plane, 45' As the clavicle is abducted it rotates posteriorly. from the sagittal and frontal planes. • As the arm a pproaches 90' elevation, the AC joint should be care­ • The patient lies supine (or is seated) with a rms at side. fu lly palpated for hinge movement between the acromion and the • The practitioner places index fingers on superior aspect of medial clavicle. • In normal movement, with no restriction, the palpating fingers clavicle. shou ld m ove slightly caudad, as the arm is a bducted beyond 90'. • The patient is asked to shrug the shoulders while movement of • If the AC is restricted, the palpating digit w i l l move cephalad and little or no action will be noted at the joint itself, as the arm goes the clavicle is pa l pated. beyond 90'. • Each clavicle should move slightly caudad (toward the feet). • If either fa ils to do so, there is a restriction of the associated joint. 2 Assessment of restricted horizonta l flexion of the u pper arm (Fig. 1 3. 1 7) • The patient lies supine while the practitioner is at the side, at wa ist level facing cephalad, w i th index fingers lying on the anteromedial aspect of each clavicle. • The patient is asked to bring the arms together in front of the face, arms extended, so that the hands are in a 'prayer' position poi nting toward the ceil i ng, while clavicular movement is moni­ tored as the patient pushes the hands toward the ceiling. • If the joint is functioning norma l ly there will be a 'dropping' of the clavicular head toward the floor (a posterior movement) on that side. • If one or both clavicular heads fail to drop but remain static or actually rise (toward the ceil ing), there is restriction. 3 Assessment for restricted acromioclavicu lar (AC) joint Stiles ( 1 984) suggests this initial eval uation of AC dysfu nction at the scapula, the mechanics of w h ich closely relate to AC function. • The patient sits erect and the practitioner, who is standing behind the patient, palpates the spines of both scapulae. • The ha nds a re moved medially until the medial borders of the scapulae are identified at the level of the spine of the scapula. • Using the palpating fingers as landmarks, the levels a re checked to see whether they a re the same. Inequality suggests AC dys­ function. • The side of dysfu nction remains to be assessed (i.e. the scapula might be superior or inferior on the side of dysfunction, so that w h i le i nequality of scapula height suggests dysfu nction, it is the specific assessment (below) that identifies which side is dysfu n c t i o n a l ) . • Treatment of the control (placebo) group involved the assessments were conducted during al ternate weeks, as patients being placed in the same seven positions (see well as 5 weeks after the end of treatment. descriptions and Figs 13. 16-13. 19) as those receiving the • Over the course of the study both groups demonstrated active treatment; however, the one element that was not significantly increased ROM and a decrease in perceived used in the control group was MET (described as the pain. However, after treatment: 'Those subjects who had 'corrective force') as part of the protocol. Home exercises received osteopathic manipulative treatment [i.e. muscle were also prescribed. energy-enhanced Spencer sequence] demonstrated continued improvement in ROM, while the ROM of the • Over the course of 14 weeks there were a total of eight placebo group decreased.' 30-minute treatment sessions. Functional, pain and ROM

426 CLI N I CAL A P P L I CAT I O N OF N E U R O M USCULAR TECH N I Q U E S : T H E U P P E R B O DY The test for AC restriction is to be found in clavicular assessment on • The process is repeated u ntil free movement of the medial clavi­ p. 425. cle is achieved. M ET for restriction of AC joint The test for horizontal flexion restriction of the sternoclavicu lar joint • Muscle energy technique is e mployed with the arm held at the is to be found in Box 1 3.7. restriction barrier, as for testing as described in Box 1 3.7, i.e. at ,16 M ET treatment of restricted horizontal flexion of the point just prior to a cephalad rise of the clavicle as the a rm is the upper arm (sternoclavicular restriction) e l evated. • If the scapula on the side of dysfunction (fa i l u re of AC joint to (Fig. 1 3. 1 8) h i nge appropriately) had been shown to be more proximal than that on the normal side, then before arm elevation commences • The patient l ies supine and the practitioner stands on the side the humerus is placed in external rotation, which takes the sca pula caudad against the barrier. contralateral to that being treated. • If, however, the scapula on the side of the AC dysfunction was more distal than the scapula on the normal side, then before arm • The practitioner's non-tableside thenar emi nence is placed over elevation commences the arm is interna l ly rotated, taking the scapula cephalad against the barrier before the isometric con­ the m edial end of the clavicle, holding it toward the floor. traction com mences. • The left hand (in this exercise we assume this to be a right-sided • The tableside hand is placed, palm upward, u nder the patient's problem) stabilizes the lateral aspect of the clavicle, with light but firm caudad pressure being applied by the left thumb, which ipsilateral shoulder so that it is in broad contact with the dorsal rests on its superior surface. • The arm, supported at the elbow by the practitioner (and inter­ aspect of the scapula. nally or externally rotated at the shoulder, depending on ind ica­ tions gained from scapulae imbalance), is raised until the first • The patient is asked to stretch out the arm on the side to be sign of inappropriate movement at the AC joint is sensed (a feel ­ ing of 'bind'). identifying the barrier. treated so that the hand can rest behind the practitioner's neck • It is important at this stage to ensure that all slack has been removed from the internal or the external rotation of the upper a rm. or tableside shoulder. • An u nyielding counterpressure is offered at the point of the patient's elbow by the right hand and the patient is asked to try • The practitioner leans back slightly to take out a l l the slack from to take that elbow toward the floor with less than fu l l strength. • After 7-10 seconds, the patient and practitioner relax, g reater the patient's extended a rm and shoulder, while at the sa me time internal or external rotation is introduced to take out any slack now available and the arm is elevated towards the ba rrier until l ifting the scapula slightly from the table. 'bind' is sensed. • Firm but not forcefu l pressure is sustained on the clavicle in a • The patient is then asked to attempt to pull the practitioner caudad d i rection as the slack is being removed from the tissues. • A further mild isometric contraction is asked for and the proce­ toward herself. dure repeated several times, until no further i mprovement is noted in terms of range of motion or until it is sensed that the • Firm resistance is offered for 7-10 seconds. clavicle has resumed normal fu nction. • Fol lowing complete release of a l l the patient's efforts, the down­ The test for abduction restriction of the sternoclavicular joint is found in Box 1 3.7. ward thenar emi nence pressure - to the floor - is maintained (painlessly) and more slack is taken out (practitioner leans back a little more). • The process is repeated once or twice more or until the 'prayer' test proves negative. • No pain should be noted during this procedure. ,16 M ET treatment of restricted a bd uction at the sternoclavicular (SC) joint • The practitioner sta nds behind the seated patient with the thenar eminence on the superior margin of the medial end of the clavicle to be treated. • To ach ieve this, the practitioner's a rm needs to be passed a nterior to the patient's throat and care needs to be taken to avoid any pressure on this. • The other hand cups the patient's flexed elbow and holds this at 90·, with the u pper arm externa l ly rotated and abducted. • The patient is asked to adduct the upper a rm for 5-7 seconds agai nst resistance using about 20010 of available strength. • Fol lowing the effort and complete relaxation, the arm is abducted further a nd externa lly rotated further, until a new barrier is sensed ('bind' is sensed at the SC joint by the practitioner). Fig u re 1 3. 1 8 M ET treatment for restriction in horizontal flexion at the sternoclavicu l a r joint. • As this is done, a firm ca udad pressure is mai ntained on the medial end of the clavicle.

1 3 Shou l der, a r m a n d h a n d 42 7 Box 1 3 . 9 Spencer's assessment sequence including M ET and PRT treatment The Spencer sequence, wh ich derives from osteopathic medicine in • At the position of very first indication of restriction i n movement, the early years of the 20th century, is ta u g h t a t all osteopathic the patient is i nstructed to pull the elbow toward the feet or pos­ colleges in the USA. Over the years i t h a s been modified to include teriorly, or to push further toward the d i rection of flexion, u t i l iz­ treatment elements other than the original a rticulation i ntent. The i n g n o more than 20% of ava i lable strength, building u p force sequences ca n be transformed from an assessment/articulatory slow ly. tech n ique into a muscle energy a pproach o r into positional release. • The patient's effort is firmly resisted and after 7 - 1 0 seconds the When used for assessment and treatment, the scapula is fixed firmly patient is i n structed to slowly cease the effort s i m u ltaneously to the thoracic wa l l to focus on involvement of the g lenohu meral with the practitioner. joint. In all Spencer assessment and treatment sequences, the patient • After the patient com pletely relaxes a n d upon exhalation, the is sidelying, with the side to be assessed uppermost, arm lying at the el bow i s moved to ta ke the shoulder further i nto flexion to the side with the e l bow (usually) flexed, with the practitioner facing next restriction barrier, where the M ET procedure i s repeated. slig htly cephalad, at chest level (Patriquin 1 992, Spencer 1 9 1 6). • A degree of active patient participation in the movement toward the new barrier is usually hel pful as it will create an inhibitory �. 1 a Assessment and M ET treatment of shoulder response in the tissue being stretched. , extension restriction (Fig. 1 3 . 1 6A) � 2 b Alternatively - PRT • The practitioner's cephalad h a nd cups the shoulder, firmly compressing the scapula and clavicle to the t h o rax w h i l e the • If there is a restriction toward flexion the soft tissues i m p l icated patient's flexed e l bow is h e ld by the practitioner's ca udad hand, in m a i n ta i n i n g this dysfu nction would be the shoulder extensors as the arm is taken i nto passive extension toward the optimal 90·. - posterior deltoid, teres major, l atissi mus dorsi and possibly infraspinatus, teres mi nor and long head of triceps. • Any restriction in ra nge of motion i s noted, ceasing movement at the first i n d i cation of resistance. • Palpation of these should reveal areas of m arked tendern ess. • The most painful tender point (painfu l to dig ita l pressu re) e l icited • At that ba rrier the patient is i nstructed to push the e l bow toward the feet or anteriorly, or to push further toward the d i rection of by pa l pation should be used as a mon itoring point, as the arm i s extension, utilizing no more than 20% of a va i lable strength, moved into a position which w i l l reduce that pain by not less b u i l d i n g up force slowly. than 70%. • This position of ease w i l l probably involve some degree of • This effort is fi rmly resisted and after 7 - 1 0 seconds the patient is extension and fine-tu ning to slacken the muscle housing the instructed to slowly cease the effort. (The d i rection in wh ich the tender point. patient is asked to push i s arbitra ry, to investigate the benefit in • Th is ease state should be held for anyt h i n g from 30 to 90 seconds terms of subsequent i ncreased freedom of movement.) before a slow return to neutral and a subsequent reevaluation of ra n g e o f motion. • After completely relaxing and upon exhalation, the e l bow is moved to take the shoulder further i n to extension, to the next restriction barrier, and the MET proced u re i s repeated (Liebenson 1 990, Mitch ell et al 1 979). �. 3a Articulation and assessment of circumduction • A degree of active patient participation in the movement toward , ca pabil ity with compression (Fig. 1 3. 1 6C) the new barrier is usu a l ly hel pful as it w i l l create a n i n h ibi tory • The patient is sidelying with e l bow flexed w h i l e the practitioner's response in the tissue being stretched (Chaitow 2002). cepha lad hand cups the shoulder fi rm ly, compressing the scapula �. 1 b Alternatively - PRT (Good hea rt 1 9 84, and clavicle to the thorax. , Jones 1 985) • The practitioner's ca udad hand g rasps the e l bow a n d takes the • If restriction is noted du ring movement towards extension the shoulder t h rough a slow clockwise circ u m d u ction, w h i l e a d d i n g soft tissues i m p l icated in m a inta i n i n g this dysfu nction would be compression throug h the long a x i s of the h u m e rus. the shoulder flexors - anterior deltoid, coracobrach ialis and the • This i s repeated several times i n o rd e r to articu late the j o i n t a n d clavicu lar head of pectoralis major. assess range, freedom a n d comfort o f the c i rcumd uction motion as the h u meral head moves on the su rface of the g l enoid fossa. • Palpation of these should reveal a reas of m arked tenderness. • The sam e procedure is then performed an ticlockwise. If any • The most painfu l tender point (painfu l to d i g ita l pressure) e l i cited restriction is noted Ruddy's 'pu lsed M ET' can be i ntroduced, in which the patient attem pts to execute a series of m i n ute by palpation is used as a monitoring point as the a rm is moved contractions toward the restriction barrier (20 times in a period into a position wh ich w i l l reduce that pain by not less than 700/0. of 10 seconds) at which t i m e the articulation i s con tinued (Ruddy • This position of ease usua l ly involves some degree of flexion and 1 962). fine-tuning to slacken the muscle housing the tender point. • This ease state should be held for anyth i n g from 30 to 90 seconds before a slow return to neutral and a subsequent reeva l uation of �. 3b Articulation and assessment of circu mduction the range of motion. , capabil ity with traction (Fig. 1 3. 1 6D) �. 2 a Assessment and M ET treatment of shoulder flexion • The patient i s sidelying with arm strai g h t w h i l e t h e practitioner's , restriction (Fig. 1 3.1 6B) ceph a l a d hand cups the shoulder fi r m l y, compressing sca pula a n d • Pa tient and practitioner have the same sta rting position as in the clavicle to the thorax. previous test. • The practitioner's caudad hand grasps the patient's arm above the • The practitioner's non-tableside hand grasps the patient's forearm elbow and i n troduces s l i g h t traction, before taking the a rm while the tableside hand holds the clavicle and sca pula fi rmly to t h rough slow clockwise circumduction. the chest wall. • This process articu lates the joint while assessi ng range of motion • The practitioner slowly introduces passive shoulder flexion in the in circumd uction as well as the status of the capsu l e of the horizontal plane, a s ra n g e of m o t i o n to 1 80· i s assessed, b y w h i ch glenohumeral joint. time the elbow is fu l ly extended. • The sa me process is repeated anticlockwise. - -------------------------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - box continues

428 C L I N ICAL A P PL I CAT I O N OF N EU RO M U S C U LA R TEC H N I Q U E S : T H E U PP E R B O DY Box 1 3.8 '(£OI1tinued) • If any restriction is noted, Ruddy's 'pu lsed M ET' ca n be introduced • The most painfu l tender point (painful to digital pressu re) el icited in w h ich the patient attempts to execute a series of m in ute con­ by this pal pation should be used as a monitoring point, as the tractions toward the restriction barrier (20 times in a period of 10 arm is moved a nd fine-tuned i nto a position which reduces that seconds) before a rticulation is continued. pain by not less than 70%. \" 3c PRT for circu mduction pain or restriction • Th is position of ease w i l l probably involve some degree of • If restriction or pain is noted in either of the circumduction adduction a nd external rotation to slacken the muscle h ousing sequences (utilizing compression or traction), eva luate which the tender point. muscles would be active if precisely the opposite movement were • This ease state should be held for anyth ing from 30 to 90 seconds u ndertaken. before a slow return to neutral and a subsequent reeval uation of • For exam ple, if on compression and clockwise rotation, a range of motion. particular part of the circumduction ra nge involves either restriction or discomfort/pain, cease the movement and eva luate \"�. 5a Assessment and M ET treatment of shou lder which muscles would be required to contract in order to produce add uction restrictio n (Not illustrated) an active reversal of that movement (Chaitow 2003, Goodheart 1 9 84, Jones 1 985). • The patient is sidelying and the practitioner cups the shoulder • In these antagonist muscles, palpate for the most 'tender' point and compresses the sca pula and clavicle to the thorax with the and use this as a mon itoring point as the structures a re taken to a position of ease which reduces the perceived pain by at least cephalad hand while cupping the elbow with the caudad hand. 700/0. • The patient's hand i s supported on the practitioner's cephalad • This is held for 30-90 seconds before a slow return to neutral and retesting. forearm/wrist to stabil ize the arm. • The elbow is taken i n a n arc forward of the chest so that the elbow moves both cephalad and medially as the shoulder adducts and externally rotates. • The action is performed slowly and a ny signs of resista nce are noted. \"�. 4a Assessment and M ET treatment of s h o ulder • At the position of the very first indication ofresistance to abduction restriction (Fig. 1 3. 1 6E) movement, the patient is instructed to pull the elbow toward the • The patient is sidelying as the practitioner cups the shoulder and ceiling or to push further toward the direction of adduction, compresses the scapula and clavicle to the thorax with the utilizing no more than 20% of available strength, building up cephalad hand while cupping the flexed elbow with the caudad force slowly. hand. • This effort is firmly resisted and after 7-10 seconds the patient is • The patient's hand is supported on the practitioner's cephalad instructed to slowly cease the effort. forearm/wrist to stabilize the arm. • After completely relaxing and upon exhalation, the elbow is • The el bow is abducted toward the patient's head as range of moved to take the shoulder further into adduction, to the next motion is assessed. restriction barrier, where the MET procedure is repeated if restric­ • Some degree of external rotation is also involved in this tion remains. abduction. • A deg ree of active patient pa rticipation in the movement toward • Pai n-free easy abd uction should be close to 1 80°. the new barrier is usually helpful. • Note a ny restriction in range of motion. � 5b Alternatively - PRT • At the position of very first indication ofresistance to movement, the patient is instructed to pull the elbow toward the waist or to • If there is a restriction toward adduction the soft tissues push further toward the di rection of a bd uction, utilizing n o more implicated in maintaining this dysfu nction would be the shoulder than 20010 of available strength, building u p force slowly. abductors - deltoid, supraspinatus. • This effort is firmly resisted and after 7-10 seconds the patient is • Since external rotation is a lso involved, other muscles implicated i nstructed to slowly cease the effort simulta neously with the in restriction or pain may i nclude i n ternal rotators such as practitioner. subsca pularis, pectoralis major, latissimus dorsi and teres major. • After completely relaxing and u pon exha lation, the elbow is • Pal pation of these should reveal a reas of marked tenderness. moved to take the shoulder further into abduction, to the next • The most painful tender point (painful to digita l pressure) elicited restriction barrier, where the MET proced u re is repeated if by palpation should be used as a monitoring point as the arm is necessary (Le. if there is stil l restriction). moved into a position which will reduce that pa in by not less • A degree of active patient participation in the movement toward than 70%. • This position of ease w i l l probably i nvolve some degree of the new barrier is usually hel pfu l. \" 4b Alternatively - PRT abduction together with fine-tuning involving internal rotation, • If there is a restriction toward abduction the soft tissues impli­ to slacken the muscle housing the tender point. cated in mainta i n ing this dysfunction would be the shoulder adductors - pectoralis major, teres major, latissimus dorsi and • This ease state should be held for a nything from 30 to 90 seconds possibly the long head of triceps, coracobrachialis and short head before a slow return to neutral and a subsequent reeval uation of of biceps brachiL • Si nce external rotation is a lso occurring i n this movement there range of motion. might be involvement of internal rotators in a ny restriction or pain. \"�. 6a Assessment and M ET treatment of internal rotation • Pa l pation of these muscles should reveal a reas of marked restriction (Fig. 1 3. 1 9) t e n d e r n ess. • The patient is sidelying and the flexed arm is placed behind the back to evaluate whether the dorsum of the hand can be pain lessly placed against the dorsal surface of the i psilateral lumbar area. box continues

1 3 Shou lder, arm and h a n d 42 9 rotation, to the next restriction barrier, where the MET procedure is repeated. f 6b Alternatively - PRT • If there is a restriction toward internal rotation the soft tissues implicated in mainta i n i ng this dysfu nction would be the shoulder external rotators - i nfraspinatus and teres m inor, w ith posterior deltoid also possibly b�ing involved. • Pal pation of these should reveal areas of ma rked tenderness. • The most painful tender poi nt (pai nfu l to dig ital pressure) elicited by pa lpation should be used as a monitoring point as the a rm is moved into a position which will reduce that pain by not less than 70%. • This position of ease w i l l probably involve some degree of external rotation to slacken the muscle housing the tender point. • This ease state should be held for a nything from 30 to 90 seconds before a slow return to neutral a nd a subseq uent reeva l uation of ra nge of motion. Fig u re 1 3 . 1 9 I n ternal rotation of shoulder. ,�. 7 Spencer's general soft tissue release (and lymphatic pump) • This arm position is maintained throughout the procedure. • The practitioner cups the shoulder and com presses the scapula • The patient is sidelying w ith the practitioner half facing cephalad and clavicle to the thorax with the cephalad hand while cupping at chest level. the flexed elbow with the caudad hand. • The patient's elbow is slowly brought (ventrally) toward the • The patient's hand (elbow extended) rests on the practitioner's practitioner's body while observing for a ny sign of restriction as this movement, which increases internal rotation, proceeds. tableside shoulder. Both of the practitioner's h a nds enfold the • At the position of very first indication ofresistance to movement, the patient is instructed to pull the elbow away from the patient's u pper humerus. practitioner, either posteriorly or medially or both simultaneously, utilizing no more than 20010 of ava ilable strength, building up • Traction is applied to the humerus, taking out the slack in force slowly. • This effort is firmly resisted and after 7-10 seconds the patient is periarticular soft tissues. instructed to slowly cease the effort simultaneously with the practition er. • The traction is slowly released. • After completely relaxing and u pon exhalation, the elbow is moved to take the shoulder further into abduction and internal • Compression is a pplied to the glenoid fossa by gently forcing the humerus into it. The cycle of compression and traction is rhythmica l ly a lternated until a sense of freedom is achieved. • In addition, tra nslatory motions can be i ntroduced, for example a n terior/posterior or cephalad/caudad, in combination with the alternating traction and compression. Note: All Spencer movements are performed passively (apart from the M ET isometric contraction element) in a control led, slow and repetitive manner. Knebl concluded: 'Clinicians may wish to consider OMT Middle fibers: spinous processes and interspinous liga­ [i .e. muscle energy technique combined with Spencer ments of C6-T3 to the acromion and spine of the scapula sequence] as a modali ty for elderly patients with restricted Lower fibers: spinous processes and interspinous liga­ ROM in the shoulder.' ments of T3-12 to the medial end of the spine of the scapula See Box 13.6 for detailed assessment of shoulder restric­ Innervation: Accessory nerve (cranial nerve XI) supplies tions using this sequence, and Box 13.9 for descriptions of primarily motor while C2-4 supply mostly sensory muscle energy technique and positional release technique Muscle type: Upper trapezius: postural ( type I) shortens for whatever restrictions are identified. when stressed Middle and lower trapezius: phasic (type II) weakens when T REAT M E N T stressed (Janda 1996) Function: En tire muscle: assists extension of the cervical and TRAPEZI US thoracic spine when contracting bilaterally Upperfibers: unilaterally extend and laterally flex the head Attachments: Upperfibers: mid-third of nuchal line and lig­ and neck to the same side, aid in contralateral extreme amentum nuchae to the lateral third of the clavicle head rotation, elevation of the scapula via rotation of the

430 CLIN ICAL APPLICATION OF N EU R O M U SCULAR TECH N I QUES: THE U PPER BODY clavicle, assist in carrying the weighted upper limb, help Synergists: The trapezius pair are synergistic with each to rotate the glenoid fossa upward other for head, neck or thoracic extension Middle fibers: assist in adduction of the scapula and in Upper fibers: SCM (head motions); supraspinatus, serra­ upwardly rotating the scapula after rotation has been tus anterior (Levangie & Norkin 2001) and deltoid (rota­ initiated tion of scapula during abduction) Lower fibers: a dduct the scapula, depress the scapula. Middle fibers: rhomboids (adduct scapula); deltoid, Rotation of the scapula remains a controversial ftmction of the lower fibers (Simons et aI 1999); however, they may supraspinatus and long head of biceps brachii (eleva tion stabilize the scapula while other muscles rotate it of the arm at the shoulder joint) (Johnson et a1 1994) Lowerfibers: serratus anterior (upward rotation of the gle­ noid fossa); pectoralis minor (Levangie & Norkin 2001) and latissimus dorsi (Kendall et a1 1993) (depression) Antagonists: Upper fibers: levator scapula (scapular rota­ tion) and lower fibers of trapezius M iddle fibers: pectoralis major, pectoralis minor (Kendall et a1 1993) Lowerfibers: upper fibers of trapezius, levator scapula Fig u re 1 3.20 Lym p h nodes of the upper l i m b. Reproduced w i th I n dications for treatment permission from Gray's Anatomy (2005). Upper fibers • Headache over or into the eye or into the temporal area • Pain in the angle of the jaw, neck pain • Stiff neck • Pain with pressure of clothing, purse or luggage strapped across upper shoulder area Middle fibers • Burning interscapular pain • Acromial pain • Gooseflesh on the lateral upper arm Lower fibers • Neck, acromial, suprascapular or interscapular pain Fig u re 1 3.2 1 The com bi ned patterns of com m on tra pezius trigger points (see a lso Fig. 1 1 .31 , p. 276). D rawn after Si mons et a l ( 1 999).

1 3 Shoulder. arm and hand 43 1 ] Special notes chair set too I.ow for the desk or compu ter terminal, eleva­ tion of the arm for painting, drawing, playing a musical • In assessing and treating the trapezius, the muscle is instrument and computer processing, particularly for divided into upper, middle and lower fibers in regards to extended periods of time, can all shorten trapezius fibers. nomenclature as well as function. The upper, middle and Overloading of fibers may activate or perpetuate trigger lower portions of the muscle often function independ­ point activity or may make tissue more vulnerable to acti­ ently (Gray's Anatomy 2005). vation even when a minor trauma occurs, such as a simple fall, minor motor vehicle accident or when reaching (espe­ • When the shoulder is fixed, trapezius extends and cially quickly) to catch something out of reach. sidebends the head and neck. Trigger points in the upper trapezius (see pp. 276 and • With shortening of the muscle, the occiput will be pulled 430) are some of the most prevalent and potent trigger inferolaterally via very powerful fibers. The potential points found in the body and are relatively easy to locate. nega tive influence of trapezius dysfunction is directly to They are also easily activated by day-to-day habits and occipital, parietal and temporal function in cranial therapy. abuses, such as repetitive use, sudden trauma, falls and acceleration/deceleration injuries ('whiplash'). They are • In some people upper trapezius fibers merge with stern­ often predisposed to activa tion by postural asymmetries, ocleidomastoid, offering other possible areas of influence including pelvic tilt and torsion, which require postural when dysfunctional (Gray's Anatomy 2005). compensations by these and other muscles. • The motor innervation of trapezius is from the spinal The upper trapezius helps maintain the head's position portion of the Xl cranial (spinal accessory) nerve. Arising and serves as a 'postural corrector ' for deviations originat­ within the spinal canal from ventral roots of the first five ing further down the body (in the spine, pelvis or feet). cervical segments (usually), it rises through the foramen Therefore, fibers of the upper trapezius may be working magnum, exiting via the jugular foramen, where it when the patient is Sitting or standing to make adaptive supplies and sometimes penetrates sternocleidomastoid corrections for structural distortions or strained positions. before reaching a plexus below trapezius (Gray's Anatomy Additional treatment of the cervical portion and occipital 2005). a ttachment of upper trapezius is discussed with the cervical region on p. 277. • Upledger & Vredevoogd (1983) point out that hyper­ tonicity of trapezius can produce dysfunction at the j ugular The instructions given below, for a prone pOSition, are foramen with implications for accessory nerve function, usually the easiest for learning these palpa tion techniques. so increasing and perpetuating trapezius hypertonici ty. However, a sidelying position is also effective for examin­ ing the trapezius and in some cases advantageous. When • Lundberg et al ( 1994) assessed the effects of mental stress the pa tient is sidelying with the upper arm lying on the and of physical load (both separa tely and in combination) (uppermost) lateral surface of the body, the upper, middle on perceived stress, physiological stress responses and and lower trapezius may be easily palpa ted and lifted from on muscular tension by measuring the activity of the the underlying tissues. Additionally, the fibers of each may trapezius muscle. They concluded tha t 'psychological be shortened or elonga ted simply by posi tioning the shoul­ stress plays a role in musculoskeletal disorders by increas­ der with the weight of the arm supported on the patient's ing muscular tension both in low-load work situations body. A prone or sidelying pOSition has an advantage over a and in the absence of physical load. It is also indica ted seated assessment since the trapezius would not be sup­ that the stress-induced increase in muscular tension is porting the shoulder girdle or the head during the examina­ accentuated on top of a physical load'. tion (as it would be with an upright posture). A supine position is discussed with the cervical region on p. 277. Fibers of upper trapezius initiate the rotation of the clavicle to prepare for elevation of the shoulder girdle. The middle ASSESSMENT OF UPPER TRAPEZIUS FOR fibers then join to lift the acromioclavicular joint off the humeral head and to elevate the entire shoulder. Since the S H O RTN ESS overhanging ledge created by the acromioclavicular joint can occlude the supraspinatus tendon and the subacromial 1. See Janda's scapulohumeral rhythm test ( p . 9 1 ) which bursa and can impact the humeral head, the inability to helps identify excessive activity or inappropriate tone in fully lift it off the underlying struch.ITes is significant. levator scapula and upper trapezius, which, because Additionally, this action is often used to support a phone to they are postural muscles, indica tes shortness. the ear, to carry articles strapped across the shoulder (lug­ gage, purses, backpacks, which, incidentally, compress the 2. Patient is seated and practitioner stands behind with one working fibers) and when carrying weight in the dependent hand resting on the shoulder of the side to be tested. The hand (bucket of water, baggage). other hand is placed on the side of the head which is being tested and the head /neck is taken into sidebending Any pOSition which strains or places the trapezius in a away from that side without force while the shoulder is shortened state for periods of time without rest may shorten stabilized. The same procedure is performed on the other the fibers and lead to the activa tion of trigger points. Lengthy telephone conversations, particularly when the shoulder is elevated to hold the phone, working from a

432 C LI N I CA L APPLI CAT I O N OF N E U RO M USCU LAR TECH N I QU E S : T H E U P P E R B O DY side with the opposite shoulder stabilized. A comparison Figure 1 3.22 The fi ngers curl around the forward 'l i p' of the is made as to which sidebending maneuver produced the a n terior fibers of tra pezi us. greater range and whether the neck can easily reach a 4So angle from the vertical, which i t should. If neither side practitioner's non-treating hand can rest gently on the can achieve this degree of sidebend then both trapezius patient's back for 'comforting support'. muscles may be short. The relative shortness of one, com­ pared with the o ther, is evaluated. Since this test might Flat compression near the center of the muscle belly a lso implica te scalene muscles or other cervical muscles, (fibers held between thumb and several fingers - flattened a ttention is paid to the tissue under the hand that is pal­ like a clothes pin) will provide a general release and can be pa ting the shoulder for a sense of tension or pulling in applied in 1-2 inch (2.S-S cm) segments along the upper the trapezius tissues as the test is conducted. fibers to examine their full length. Pincer compression (fin­ 3. The patient is seated and the practitioner stands behind gers and thumb held like a C-clamp) can then be used to with a hand resting over the muscle on the side to be more precisely examine and treat the remaining taut fibers. assessed. The patient is asked to extend the shoulder joint, bringing the flexed a rm/elbow backwards. If the The fibers of the outermost portion of the trapeZius can upper trapezius is stressed /short on tha t side it will be uncoiled by dragging two or three fingers on the anterior inappropria tely activa te during this movement. Since i t surface of the fibers while the thumb presses through the is a postural muscle, shortness in i t c a n then b e assumed. fibers (from the posterior aspect) and against the uncoiling 4. The patient is supine with the neck fully (but not force­ fingers (Fig. 13.22). As the fingers uncoil directly across the fully) sidebent away from the side being assessed. The hidden deep fibers, palpable bands, trigger point nodules practitioner, standing or seated a t the head of the table, and twitch responses may be felt. The wrist is kept low to stabilizes the head with one hand and uses a cupped sec­ avoid flipping over the most anterior fibers as snapping ond hand contact on the shoulder (tested side) to assess across them often produces extreme discomfort for the the ease with which it can be depressed (moved distally). patient and elicits referred pain. While controlled and spe­ There should be an easy 'springing' sensation as the cific snapping techniques can be developed and used as a shoulder is pushed toward the feet, with a soft end-feel treatment modality or to elicit twitch responses for trigger to the movement. If depression of the shoulder is difficult point verification, they should not be accidentally applied or if there is a more wooden feel at the end-point, upper to these vulnerable fibers. Static pincer compression should trapezius on that side is probably short. be applied to taut bands, trigger points or nodules found in the upper fibers of trapezius. Toothpick size strands of the f NMT FOR U PPER TRAPEZIUS outermost fibers of upper trapezius often have noxious referrals into the face and eyes and local twitch responses Cervical portion. The most superficial layer of the poste­ are readily felt in these easily palpable, often taut fibers. rior cervical region is the upper trapezius. Its fibers lie directly beside the spinous processes and orient vertically at The pa tient's arm is allowed to rest on the treatment table the higher levels and tum laterally near the base of the neck. a longside the body to place the glenohumeral joint and the With the patient supine, prone or sidelying, these fibers scapula in fairly neutral positions. The practitioner's thumb may be grasped between the thumbs and fingers and com­ can be used to glide from the middle of the upper trapezius pressed (one side at a time or both sides simultaneously) against each other. The occipital a ttachment may be exam­ ined with light friction and should be differentia ted from the thicker semispinalis capitus, which lies deep to it. Upper trapezius. The patient is prone with the arm hang­ ing off the side of the table to reduce tension in the upper fibers of trapezius. This arm position will allow some slack in the muscle, which makes it easier to grasp the fibers as they coil anteriorly in a slight spiral to their clavicular attachments. If appropriate and needed, the fibers may be slightly stretched by placing the patient's arm alongside the body on the massage table. This additional elongation may make the taut fibers more palpable and precise compression possible; however, it may also stretch ta u t · fibers so much that they are difficult to palpate or it may aggravate trigger points due to the tension increased by the stretch. The

1 3 Shoulder, arm and hand 433 laterally to the acromioclavicular joint. The thumb is then returned to the middle of the muscle belly and used again (or the opposite thumb can be used) to glide medially toward C7 or Tl . These alternating gliding techniques are repeated to spread the sarcomeres and ta ut bands from the muscle's center toward its attachment sites (see p. 277). A double thumb glide applied by spreading the fibers from the center simultaneously toward the two ends will traction the shortened central sarcomeres and may produce a pro­ found release (see Fig. 9.6). Full-length glides may reveal remaining thickness within the tissue, which needs to be readdressed with compression or other techniques. Myofascial release may also be used to soften and elongate the upper fibers. Central trigger points in these upper fibers refer strongly into the cranium and particularly into the eye. Attachment trigger points and tenderness may be associated with ten­ sion from central trigger points and may not respond well until central trigger points have been abolished. f NMT FOR MIDDLE TRAPEZIUS Figure 1 3.23 The m iddle tra pezius fibers may be l i fted a way from u nderlying tissue, ro lled between the thumb and fingers or This portion of the trapezius may be outlined b y drawing compressed to rel ease trigger poi nts. When fibers a re d ifficult to l i ft, parallel lines from each end of the spine of the scapula the overlying skin may be tractioned in a similar manner to provide toward the vertebral column. The fibers lying between myofascia l rel ease. these two lines represent the middle trapezius. The central portion of most of these fibers lifts readily if the practitioner's hands are positioned correctly. If needed, the humeral head may be elevated 3--4 inches (7.5-12 cm) by a rolled-up toweL wedge, etc. to further approximate the fibers of both middle and lower trapezius which often allows them to be grasped and lifted. While seated cephalad to the patient's shoulder, the prac­ titioner grasps the middle fibers of the trapezius with both , hands (Fig. 13.23) . Compression may then be applied to the mid-belly region of the upper half of middle trapezius, where its central trigger points are usually found. These tis­ sues may also be manipulated by rolling them between the fingers and thumb. The lower fibers of the middle trapezius normally lie flat to the torso and are not easily lifted by the fingers. Those fibers are addressed with gliding strokes after the lower trapezius has been treated. I NMT FOR LOWER TRAPEZIUS Figure 1 3.24 Th e lower trapezius fibers a re treated in the same way as m iddle tra pezius. The diagonal fibers o f lower trapezius traverse the mid-back from Tl2 to the inferior aspect of the medial third of the spine spine of the scapula to the spinous process of T12. The prac­ of the scapula. Although it usually benefits from it, occasion­ titioner should grasp and lift the outer (diagonal) edge of ally the lower trapezius fibers will be more accessible with­ the lower trapezius (Fig. 13.24). If appropriate, compression out the towel (or wedge) elevation mentioned above. and manipulation as described above may be applied to the fibers to reveal taut bands and trigger points. Trigger point The practitioner is repositioned to stand near the pressure on or gentle mid-belly (double-thumb) traction of patient's waist and faces toward the opposite shoulder. The the contractures will usually release trigger points found in outer fibers of lower trapezius can be most easily located these fibers. when a diagonal line is envisioned from the root of the

434 C L I N ICAL A P P LICAT I O N OF N EU RO M USCULAR T EC H N I Q U E S : T H E U P PER BODY When muscle fibers of the lower trapezius will not lift, The beveled pressure bar is angled posteriorly against fla t palpa tion may be used against the ribs and underlying the superior aspect of the spine of the scapula and trans­ muscles. (The grasp may be tested by lifting the fibers and verse friction is applied at tip-width intervals to the supe­ allowing them to gently slip through the compressed fingers rior aspect of the spine of the scapula to trea t trapezius to be assured of holding more than j ust skin.) Additionally, attachments. Additionally, the inferior aspect of the spine of the lower trapezius may be freed from fascial restrictions the scapula may be addressed in the same manner. when the skin overlying its outer fibers is lifted toward the ceiling and held for 1-2 minutes. The skin should be stretched Lubricated gliding strokes in all directions may be used to its elastic barrier and then held, allowing the fascia to on all portions of the trapezius to soothe the tissues and soften and elonga teo As the skin becomes more mobile, the increase blood flow. This is particularly important when muscular fibers deep to i t will demonstrate greater freedom more aggressive techniques, such as manipulation and of movement in relation to surrounding tissues. pressure bar work, have been used. Gliding strokes along attachment sites may also reveal areas of enthesitis (inflam­ � N MT FO R TRAP EZI U S ATTACH M E NTS ma tion of muscular or tendinous a ttachment to bone) and periosteal tension which may respond favorably to applica­ The humeral head is lowered and the arm allowed to rest com­ tions of ice rather than heat. Gliding is particularly applied fortably. Lubricated gliding strokes may be applied to the lam­ to any aspects of the trapezius that have not been addressed ina groove beside the spinous processes from C7 to L1 and on during the previous steps. the scapula and acromion. Thumb glides applied to the lam­ ina groove in progressively deeper strokes may release layers If central trigger points are located, pincer compression of tendinous tension and reveal locations of a ttachment trig­ may be used if the tissue can be lifted or fla t compression ger points and enthesitis in any of the layers a ttaching into the against underlying structures may be applied. Additional ly, spinous and transverse processes (which form the 'walJs' of gliding strokes may be applied from the center of the fibers the groove). Additionally, a beveled pressure bar (beveled rub­ (where most central trigger points will be found) toward ber tip) may be used in the lamina groove (see pp. 565-566) to the a ttachment sites. These techniques are intended to man­ assess and treat the numerous tendons that attach there. ually traction the actin and myosin elements and spread the tense central sarcomeres toward the periosteal tension a t Static pressure or friction applied with the finger, thumb the attachment sites. If inflammation is suspected at the or the beveled pressure bar can be used directly medial to a ttachments, stripping should defini tely be toward the and against the acromioclavicular joint for the upper fiber attachments so as to avoid placing further tension on these attachment of trapezius. already dis tressed connective tissues. CAUTION: Friction or use of the pressure bar is con­ traindicated when moderate to extreme tenderness is ,� LI E F ' S N MT F O R U PP E R TRAPEZ I U S A R EA present or when other symptoms indicate inflammation. , (see pp. 2 2 2 and 274) Whether using the beveled pressure bar or digital friction, the pressure may be angled an teriorly against the trapezius • In Lief's NMT the practi tioner begins by standing haJf­ attachment on the clavicle (see pp. 277-278) where static facing the head of the table on the left of the prone patient pressure or transverse friction may be lightly applied, with with the hips level with the mid-thoracic area. the pressure increasing only if appropriate. Extreme caution should be exercised when examining more than one or two • The first contact to the left side of the patient's head is a fingertip widths medial to the acromioclavicular joint on the gliding, light-pressured movement of the medial tip of clavicle. Medial to this point (exact pOSition varies based on the right thumb, from the mastoid process along the width of trapezius a ttachment on the clavicle) lies the la teral nuchal line to the external occipital protuberance. This edge of the supraclavicular fossa, an area in which the same stroke, or glide, is then repeated with deeper pres­ brachial plexus lies relatively exposed. Intrusion might dam­ sure. The practitioner 's left hand rests on the upper tho­ age the nerves and accompanying blood vessels in this area. racic or shoulder area as a stabilizing contact. The beveled pressure bar or fingertip should be placed • The trea ting/ assessing hand should be relaxed, molding immediately medial to the acromioclavicular joint and itself to the contours of tissues. The fingertips offer bal­ pressed straight in (caudally, through the trapezius) to trea t ance to the hand. the tendon of supraspinatus and (possibly) the tendon of biceps (long head). • After the first two strokes of the right thumb - one shal­ CAUTION: This step is contraindicated if a supraspinatus low and diagnostic, the second deeper, imparting thera­ tear, subacromial burs i tis or bicipital tendinitis is sus­ peutic effort - the next stroke is half a thumb width pected as surrounding tissues may be inflamed (see caudal to the firs t. A degree of overlap occurs as these assessments on p. 412 and impingement syndrome test, strokes, starting on the belly of the sternocleidomastoid, p. 418). glide across and through the trapezius, splenius capitis and posterior cervical muscles. • A progressive series of strokes is applied in this way until the level of the cervicodorsal j unction is reached. Unless

1 3 Shou lder. arm and hand 435 serious underlying dysfunction is found, it is seldom shoulder toward the ear (a shrug movement) and the ear necessary to repeat the two superimposed strokes a t each toward the shoulder. The double movement (or effort level of the cervical region. If underlying fibrotic tissue toward movement) is important in order to introduce a appears unyielding, a third or fourth slow, deeper glide contraction of the muscle from both ends. The degree of may be necessary. effort should be mild and no pain should be felt. • The practitioner now moves to the head of the table. The • After the 10 seconds (or so) of contraction and complete left thumb is placed on the right lateral aspect of the first relaxation of effort, the practitioner gently eases the dorsal vertebra and a series of strokes are performed cau­ patient's head/ neck into an increased degree of sidebend­ dally and laterally as well as diagonally toward the scapula. ing, before stretching the shoulder away from the ear • A series of thumb strokes, shallow and then deep, is while stabilizing the head, through the barrier of per­ applied caudally from T1 to about T4 or 5 and laterally ceived resistance if chronic, as appropriate. toward the scapula and along and across all the upper • The patient can usefully assist in the treatment by initiat­ trapezius fibers and the rhomboids. The left hand treats ing, on instruction, the stretch of the muscle (,As you the right side and vice versa with the non-operative hand brea the out, please slide your hand toward your feet'). stabilizing the neck or head. No stretch is introduced from the head end of the m uscle • By repositioning to one side, it is possible for the practi­ as this could stress the neck unduly. tioner to more easily apply a series of sensitively search­ ing contacts into the area of the thoracic outlet. Thumb L. MYO FAS C I A L R E LEASE O F U P P E R T R A P EZ I U S strokes that start in this triangular depression move , (see p. 2 2 1 ) toward the trapezius fibers and through them toward the upper margins of the scapula. • Patient i s seated erect, feet separated to shoulder width • Several light palpating strokes should also be applied and flat on the floor below the knees, arms hanging freely. directly over the spinous processes, caudally, toward the mid-dorsal area. Trigger points sometimes lie on the • The practitioner stands to the side and behind the patient attachments to the spinous processes or between them. with the proximal aspect of the forearm closest to the • Any trigger points located should be treated according to patient resting on the lateral aspect of the muscle to be the protocol of integrated neuromuscular inhibition tech­ treated. The forearm is allowed to glide slowly medially nique (INIT) - p. 197. toward the scapula / base of the neck, all the while main­ taining a firm but acceptable pressure toward the floor f M ET TREATM ENT O F U PPER TRAPEZIUS (Fig. 11 .36, p. 280). • The patient lies supine, head/ neck sidebent away from • By the time the contact arm is close to the medial aspect the side to be treated j ust short of the restriction barrier, of the superior border of the scapula, the practitioner's with the practitioner stabilizing the shoulder with one treatment contact should be with the elbow itself. hand and cupping the ear / mastoid area of the same side of the head with the other. • As this slow glide is taking place, the patient should equally deliberately be turning the head away from the • In order to treat all the fibers of the muscle, MET needs to side being treated, having been made aware of the need be applied sequentially. The neck should be placed into to maintain an erect sitting posture. The pressure being different positions of rotation, coupled with the applied should be transferred through the upright spine sidebending as described for different fibers. to the ischial tuberosities and ultimately the feet. No slump should be allowed to occur. • With the neck sidebent and fully rotated, the posterior fibers of upper trapezius are involved in any contraction • If areas of extreme tension are encountered by the moving and stretch (as are levator scapulae fibers). arm, it is useful to maintain firm pressure to the restricted area, during which time the patient can be asked to slowly • With the neck fully sidebent and half rotated, the middle return the head to the neutral position and to make several fibers are involved. slow rotations of the neck away from the treated side, altering the degree of neck flexion as appropriate to ensure • With the neck fully sidebent and slightly turned toward maximal tolerable stretching of the compressed tissues. the side from which it is sideflexed, the anterior fibers are being treated. • Separately or concurrently, the patient can be asked to stretch the fingertip of the open hand on the side being • This maneuver can be performed with the practitioner 's treated toward the floor, so adding to the fascial 'drag' arms crossed, hands stabilizing the mastoid area and which ultimately achieves a degree of lengthening and shoulder, or not crossed as comfort dictates, and with release. practitioner standing at the head or the side, also as com­ fort dictates (see Fig. 13.15). L EVATO R SCA P U LA (see Fig. 1 3.28) • The patient should be asked to introduce a light resisted Attachments: From the transverse processes of C1 and C2 effort (20% of available strength) to take the stabilized and the dorsal tubercles of C3 and C4 to the medial