Muscle Imbalance Evaluation and Treatment of the Neck, Upper Back and Shoulder Areas

1. Muscle Imbalance Evaluation and Treatment of the Neck, Upper Back and Shoulder Areas Jose S. Figueroa, D. O. Physical Medicine and Rehabilitation, NMM/OMM IOMA, Spring 2010

2. Objectives • Review some concepts of muscle imbalances and the evaluation and treatment of key muscles as contributors to chronic musculoskeletal dysfunction in the neck, upper back and shoulder areas. • Be introduced to the evaluation and treatment of muscle imbalances of the upper quarter: • Evaluate Proprioception • Evaluate for the presence of faulty muscle “firing” patterns • Diagnose and manually treat tight/short muscles • Diagnose weak or pseudo-paretic muscles • Teach a home exercise prescription to address the tight/short and weak or pseudoparetic muscles • Follow-up for re-evaluations and exercise adjustments • Teach patients how to self-treat certain common somatic dysfunctions

3. Most of the information in this lecture is derived from the works of • Phillip Greenman, D.O.(he is the one in the pictures) • Dr. Vladimir Janda, a specialist in rehabilitation medicine at the University of Charles, Prague, Czechoslovakia, deceased in 2006

4. Road Map • Common UE muscles and their reaction to injury • Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: • Evaluate Proprioception • Evaluate for the presence of faulty muscle “firing” patterns • Diagnose and manually treat tight/short muscles • Home exercise prescription (HEP) for the tight/short muscles • HEP for the weak or pseudopareticmuscles • Summary and Conclusions

5. Table 1. Common upper extremity muscles and their reaction to injury

8. Stand Up, Please

9. Please ½ of You Remain Still and look for: • Forward shoulders (“rounded shoulders”) • Head placed in a forward position • Arms internally rotated

10. Upper Crossed Syndrome • Forward head posture • Straightening of the cervical lordotic curve • Extension of the upper cervical spine • Increased kyphosis of the cervico-thoracic junction • Internal rotation of the shoulder girdles. http://medical-dictionary.thefreedictionary.com/syndrome

11. Road Map • Common UE muscles and their reaction to injury • Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: • Evaluate Proprioception • Evaluate for the presence of faulty muscle “firing” patterns • Diagnose and manually treat tight/short muscles • Home exercise prescription (HEP) for the tight/short muscles • HEP for the weak or pseudopareticmuscles • Summary and Conclusions

12. Diagnosis of Muscle Imbalances Three Specific Types of Clinical Testing • Evaluate Proprioception • Through balance testing • Evaluate the sequence of muscle contraction (muscle “firing” patterns) during specific movements to evaluate which muscles contract out of sequence, acting as if they were weak • Evaluate asymmetry in muscle lengths • Muscles are isolated as much as possible and then tested for symmetry in their lengths and compared with estimations of normal

13. Treatment of Muscle Imbalances General Principles: • Goal: restoration of proper muscle length, strength and control of muscle function • Start with OMM • May need a home exercise prescription (HEP) • HEP should address muscle control (i.e., proprioception re-training) • When treating muscle imbalances: Quality of movement is more important than quantity

14. General Treatment Sequence • Establishing a process of re-evaluations to monitor progress • Establish a level of patient commitment to follow through • Re-training proprioception • home exercises (single leg stance) • PT (more advanced intervention)

15. General Treatment Sequence • Stretching the tight muscles • manual stretches in the office (Dr. or PT) • home stretches (self-stretches) • Re-training or strengthening late contracting (pseudoparetic) or weak muscles • home “strengthening” exercises • Teaching the patient how to self-treat specific recurring somatic dysfunctions on their own

16. Hands-On session Diagnosis and Treatments of Common Muscle Imbalances of the Neck, Upper Back and Shoulder

17. Road Map • Common UE muscles and their reaction to injury • Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: • Evaluate Proprioception • Evaluate for the presence of faulty muscle “firing” patterns • Diagnose and manually treat tight/short muscles • Home exercise prescription (HEP) for the tight/short muscles • HEP for the weak or pseudopareticmuscles • Summary and Conclusions

18. Evaluate and Treat Impaired Proprioception • Goal: the capacity to symmetrically stand on one leg with arms crossed and eyes closed for 30 seconds (eyes open and eyes closed) • Do the best possible if unable to reach goal

19. Look to your feet, Please • Remove your shoes • See if you can shorten one of your feet now • Let’s test each other’s SINGLE LEG standing balance

20. Road Map • Common UE muscles and their reaction to injury • Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop: • Evaluate Proprioception • Evaluate for the presence of faulty muscle “firing” patterns • Diagnose and manually treat tight/short muscles • Home exercise prescription (HEP) for the tight/short muscles • HEP for the weak or pseudopareticmuscles • Summary and Conclusions

21. Evaluating Muscle Firing Patternsof Upper Quarter Muscles

22. Upper Quarter Firing Pattern Tests • Cervical Flexion Test Supine • Shoulder Abduction Test • Scapular Stabilization Test • Scapular Depression Test

23. Cervical Flexion Test Supine • Start position patient is supine • Cervical Test Normal: the neck curls as it flexes • Cervical Test Abnormal: the neck cannot curl and the head is thrust forward due to weak deep neck flexors and overactivity of the sternocleidomastoids (SCMs).

24. Shoulder Abduction • The muscle firing pattern (sequence of contractions) is evaluated. • Normal sequence for shoulder abduction while seated is: • Supraspinatus • Deltoid • Infraspinatus • Middle and lower trapezius • Contralateral quadratus lumborum

25. Shoulder Abduction • Most common substitution pattern is: • Shoulder elevation by the levator scapulaeand upper trapezius (can lead to and perpetuate impingement) • Early firing of the quadratus lumborum even on the ipsilateral side

26. Scapular Stabilization Test 1 • Position one: patient on hands and knees on the table • Position two: patient lifts one hand. The scapula on the side with the hand on the floor is evaluated for winging. 2

27. Scapular Stabilization Test • Excessive winging of the medial border of the scapula occurs because of weakness and lack of stabilization by the lower trapezius, serratus anterior, and rhomboid muscles

28. Road Map • Common UE muscles and their reaction to injury • Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop : • Evaluate Proprioception • Evaluate for the presence of faulty muscle “firing” patterns • Diagnose and manually treat tight/short muscles • Home exercise prescription (HEP) for the tight/short muscles • HEP for the weak or pseudopareticmuscles • Summary and Conclusions

29. Evaluating and Treating Muscle Length Asymmetry of Upper Quarter Muscles

30. Evaluate Asymmetry of Muscle Lengths • Isolate to one muscle as best possible • Find the tight muscles and treat them with manual stretching at the clinic. • “Supercharges” the patient’s home stretching routine • Sustained Stretch: 20-30 secs, 2 or 3 reps. • Muscle Energy: Post-isometric Relaxation and Stretch • Then give them home stretches

31. Upper Trapezius/SCM: Length Test and Manual Stretching

32. Upper Trapezius/SCM: Self Stretch

33. Levator Scapula: Length Test and Manual Stretching

34. Levator Scapula: Self Stretch

35. Scalenes: Length Test and Manual Stretching

36. Scalenes: Self Stretch

37. Pectorales Major: Length Test and Manual Stretching

38. Pectorales Major Test/Manual Stretch Supine

39. Pectorales Minor: Observe for Tightness • Patient supine • Operator observes for the relative anterior posterior position of the shoulders. • Tightness of the pectoralis minor is shown as one shoulder elevates off the table.

40. Pectorales Major: Self Stretching

41. Latissimus Dorsi: Length Test and Manual Stretching Manual Stretch

42. Latissimus Dorsi: Self Stretching

43. Re-Evaluate the Sequence of Muscle Contraction • In order to assess for weak muscles or pseudoparetic muscles • Prescribe strengthening (or re-training) exercises at home if needed • Again: Quality of motion is most important

44. Road Map • Common UE muscles and their reaction to injury • Overview of Diagnosis and Treatment of Muscle Imbalances Hands On Workshop : • Evaluate Proprioception • Evaluate for the presence of faulty muscle “firing” patterns • Diagnose and manually treat tight/short muscles • Home exercise prescription (HEP) for the tight/short muscles • HEP for the weak or pseudopareticmuscles • Summary and Conclusions

45. Strengthening / Retrainingof Upper Quarter Muscles

46. Cervical Flexors

47. Lower Trapezius

48. Serratus Anterior

49. Rhomboid and Lower Trapezius Lower Trapezius Strengthening Rhomboid Strengthening

50. HEAD AND SHOULDER POSTURE EXERCISE