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neck pain and scapular stabilization exercises ??

 
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neck pain and scapular stabilization exercises ?? - November 27, 2004 8:54:00 PM   
jbeneciuk

 

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Hello All

I am currently in the process of submitting a research proposal to my company IRB. Possibly some of your thaughts can assist me regarding a common occurence that I commonly see among PTs.

When treating pts with atraumatic neck pain (lets leave whiplash pts out of this conversation)..lets even clarify more and think of the pt we see that reports neck pain of greater than 8 weeks...atraumatic and presenting with no radicular signs or sx upon examination.

We may or may not find subcranial, mid-cervical, or upper-thoracic joint restrictions...again if we find restrictions we treat them...understandable ..

My question is why do most therapists that I have worked with incorporate scapular stabilization exercises into their treatment ???

***Now I just want everyone to know that although this sounds like an easy question, and an even easier answer may be on the tip of your tongue...I pose this topic because I would like some feedback and questions I will most likely have to defend upon IRB approval..

I may seem to play devils advocate with some responses , however it is only because in the end, I would like to present my theory and see how everyone feels..
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Re: neck pain and scapular stabilization exercises ?? - November 28, 2004 8:38:00 AM   
PTupdate.com


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Most of us probably do it to some extent, and we may have various reasons, many of which are not supported by research but work for us nonetheless.

One theory is that "slouched" posture leads to abnormal cervical mechanics. Strengthening the postural musculature can restore a more balanced mechanical strucutre. Try it yourself: Sit slightly slouched, and see how far your cervical rotation/sidebending/extension are, along with shoulder elevation. Now sit up "straight" and see the improvement in motion and elimination of impingement pain.

Trigger points and muscle tone are often found in cervical patients...usually in the levator, interscapular groups, and upper trapezius. Exercising these groups in a structured manner seems to reduce the complaints.

John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

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Re: neck pain and scapular stabilization exercises ?? - November 28, 2004 9:27:00 AM   
FLAOrthoPT

 

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i second that....a strong thoracic postural region will properly set up an aligned and efficient cervical region. Since most people tend to have weak periscapulars and scap stabilizers and if they work out usually tend to have overdeveloped anterior bias, then it would make sense that a lot of cerv. patients to scap exercises. I strongly encourage therapists to be right there to hold them in proper posture if necessary, repeating scap retracts in a forward head or slouched position only adds to the problem, less can be more i.e. quality of exercise over quantity.

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Re: neck pain and scapular stabilization exercises ?? - November 28, 2004 3:19:00 PM   
eam

 

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I cannot agree more. I just started treating a dermatologist who has had cervical/upper thoracic pain since February. She stands in a forward flexed, protracted position performing multiple procedures for 12 hrs a day. At the end of the week, she feels that even wearing a coat is too much for her. She feels like it is too heavy. I performed the various mobs to correct what is restricted, but more often than not, the postural imbalances that occur, if not corrected will result in the patient returning to the office without much improvement over the long haul. I usually stick to my guns when it comes to strengthening the posterior thorax and in her case, streching out the pecs which as you can imagine are tight. As an example, she lies prone on the table and performs a typical prone horiz. abduction and can barely make it through 10 reps. without weight. As FLAOrthoPT pointed out, it is important to do these exercises with patient. I often find that most patients who come into the clinic and perform them on their own are doing them wrong.
Erica

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Re: neck pain and scapular stabilization exercises ?? - November 29, 2004 8:24:00 AM   
jbeneciuk

 

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So as I mentioned before, I will play devils advocate...and ask the questions:
1) does every cervical patient (in this scenario), have weak scapular stabilizers or poor posture for that matter ?

2) I know that many of the scapular stabilizer MMTs are not very valid, however that is all we have to go by currently

3) does anyone believe there to be a direct correlation regarding the anatomical relationship of the levator, rhomboids, and upper trapezius with the cervical spine (via attachment sites)...may this anatomical relationship possibly be a reason the scapular stabilizers are important for cervical patients ??

4) I agree with the lack of research, however because it is so common and interests me to a great deal...I enjoy your feedback

5) what do you think of the anatomical link ??

6) Remember, not every cervical pt presents with poor thoracic posture or poor scapular strength (read stability) correct ??

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Re: neck pain and scapular stabilization exercises ?? - November 29, 2004 9:09:00 AM   
FLAOrthoPT

 

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I think we were saying why we would perform these exercises with the appropriate patients. Sure, you could have a person with great thoracic stability who has a scoliotic curve with compensator changes over the past 30 years which is causing neck pain, you can have vascularization of the end palte or disc causing a chronic pain type issue which may have nothing to do with scap strength. I think though, 80-90% of the non traumatic onset of neck pain is from either postural stress or from some sort of joint dysfunction. All of the postural stress patients would do well with the posterior strengthening, and some of the joint dysfunction patients would as well. It is also possible that altered joint functioning can cause "facilitated" segment or hypertonicity or hypotonicity in a segment causing muscualr dysfunction there as well. I am talking in circles now..

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Re: neck pain and scapular stabilization exercises ?? - November 29, 2004 12:18:00 PM   
jbeneciuk

 

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no you aren't talking in circles....I totally agree with all of your responses...I really do and thank you for your responses...how do you feel about teaching a patient how to perform these scapular stabilization exercises in a more manual based approach (say PNF manual resisted) before progressing them to the exercises we see every day in the clinic ?? Do you think there would be a difference in the control of these muscles...Remember we aren't just talking about strength, however as is mostly the case with this group, it is often a question of motor control, which i feel needs the ability to manually adjust ( via operator) the amount of resistance and assure the proper patterns are being used during a given exercise...I am very much interested in the benefits of manually administered exercises for this region..i feel that this method of training may have more benefits in the long run....any thaughts ??
**Thank you for your responses, so far everyone

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Re: neck pain and scapular stabilization exercises ?? - November 29, 2004 2:38:00 PM   
tf8560

 

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Hi Jben,
My two cents are these:
I like to use scapular PNF and use it alot with my manual scapular work. I also feel that these muscles lack endurance that is why I like to use a taping technique that I learned from Vicki Saliba Johnson at their Back Education and Training course (Institute of Physical Art). I take the micropore skin tape and tape essentially from the dorsal corner of the scapula to the insertion region of the lower trapezius as well as a second strip across the mid/upper scapular region more as a way of biofeedback so that when they slouch, they feel the pull of the tape and it reminds them to "straighten up". It seems to help. I've also heard that taking fishing line and placing hooks at the top of the head and the sacrum can also be excellent behavior modification techniques to promote better posture in people who slouch :)

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Re: neck pain and scapular stabilization exercises ?? - November 29, 2004 3:34:00 PM   
Shill

 

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I cant speak for most therapists, but I can speak for what I do, and what I used to do.
I used to give these exercises for the reasons stated above, primarily the "move the painful muscle, contracting and relaxing it rhythmically, and this seems to help with pain".
However, I no longer routinely do this, as I find it unnecessary. As EAM pointed out, all people with neck pain have some element of forward head, as well as extension loss. Staying out of forward head, retracting the NECK repeatedly during the daily routine, and improving extension usually gives excellent results, in the absence of keeping patients occupied with scapular retraction. Sure, it doesnt hurt, but I already ask enough of my patients to consistently, and frequently change the seated posture that leads to pain. Often, when they do sit with less forward head, there is some scapular retractor activation that occurs automatically.

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Re: neck pain and scapular stabilization exercises ?? - November 29, 2004 11:56:00 PM   
coloradojulie

 

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I look at origin insertion relationships normal or reversed and their impact on the neck. Levator is a prime example of a muscle that can reverse easily and cause problems, especially with overhead workers.

Length tension relationships change when the scapular position changes, either protracted or retracted, upward or downwardly rotated. Often levator tightness is more a matter of the change in length due to the movement of the scapula.

Scapular position is also related to thoracic position, as is cervical posture. The more kyphotic the greater the length tension problem, the more forward the scapulae are, the greater length tension issues in the cervical musculature.

I don't know if treating the neck in isolation can produce long lasting results, if thoracic posture is not addressed. Perhaps addressing this solely can improve the scapular position, without ever having done any low trap work? Chicken or egg?

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Re: neck pain and scapular stabilization exercises ?? - November 30, 2004 10:15:00 PM   
eam

 

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I routinely use scapula PNF on alot of patients. I find that you can identify a glaring weakness, incoordination, lack of endurance, decreased motor control, whatever we want to call it, with this manual technique. At the same time, you can simultaneously mobilize scap-thoracic joint. Alot of this is, as Shill mentioned, is keeping patients out of the FHP position and making them AWARE of this bad habit. Once people are cued into this, it makes a big difference. I still will give postural exercises b/c that just reinforces the above. Just my thoughts.
Erica

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Re: neck pain and scapular stabilization exercises ?? - November 30, 2004 10:53:00 PM   
jbeneciuk

 

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I am very greatful for all of the responses.
I feel this form of scapular exercise is very beneficial, especially in the earl stages of the rehab process. As "eam" mentioned, you can find specific ranges through motion where there is a deficit or if the impairment is an eccentric or concentric one.

i also think that because some of these muscles are postural muscles, the endurance they lack may be a contributing factor to the onset of atraumatic neck pain.

does anyone disagree that it is not a matter of weakness, yet insufficient endurance to maintain an "energy efficient" posture...one that does not place undue stresses on surrounding regions ??

The reason for the initial question I posed was because all too often I see that pts are started out with a scapular stabilization program with free weights, t-band, or other exercises and do not really ever develop the proper training for these involved muscles. I was concerned with the cervical region, not to mention the impact these muscles play on the shoulder complex.

thanks for the responses...I would like any feedback on my last comments.

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Re: neck pain and scapular stabilization exercises ?? - December 2, 2004 8:51:00 AM   
eam

 

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I do agree that depending on the person, muscular endurance is a factor. Look at my dermatologist, she can make it to about 2 pm doing all her procedures and then she starts to get neck and upper back pain. I am trying to train these muscles in a more functional way-for her, like in a typical work pattern. Not sure how to go about that one-but will give it a shot. She had PT somewhere else and did alot of free weights in prone etc and either she was doing them wrong or it was the wrong exercise for her but apparantly it did not really work for her. But they are definitely weak and need to be addressed in some form. She also had decreased thoracic mobility which you find alot with these patients, which need mobilization. Just my thoughts.
Erica

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Re: neck pain and scapular stabilization exercises ?? - December 2, 2004 12:32:00 PM   
Shill

 

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Erica,
What happens to your dermatologist on days when she does not work? Id be willing to bet that she feels rather well, and that at 2 PM, she doesnt hurt. She isnt bending over patients and protruding her neck repeatedly on her days off, and therefore no strain on the lower c spine to create referred perscapular pain. For the sake of symptom control, ask her to start retracting her neck in sitting, 3 sets of 10, or more, every two hours during the work day, AND, to make a concerted effort to spend less time cramming her head and neck forward during patient evaluations. With this simple idea, see if she can now make it to 3 pm, or 4 pm without symptoms. IF she does, you have an anecdotal answer that scapular endurance might have nothing to do with her pain. Also, she then sees that she can control the pain.

My view is that you can strengthen the periscapular muscles until the cows come home,(yes, I am from Wisconsin) but if she doesnt change the spinal position that brings on the worsening, you will have nothing but strong muscles. Its nice, but she wants to hurt less too.

Give it a try if it doesnt sound too far fetched.
You might be delighted with the results.

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Re: neck pain and scapular stabilization exercises ?? - December 2, 2004 10:04:00 PM   
certMDT

 

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I agree fully with Shill. I used to spend a lot of time working on scapular stabilizer exercises, without seeing any real functional carryover. In the patient mentioned, I would not go beyond addressing the sustained and repeated forces applied to the neck until I was sure that this was no longer the primary causative factor. I honestly can't remember the last time I advised a patient to perform scapular stabilization exercises for upper back pain, although I do plenty for shoulder pain. For this patient I would focus on cervical retraction as stated, followed by upper thoracic extension exercises and scapular mobilization exercises as needed.

DiVeta J, Walker ML, Skibinski B. Relationship between performance of selected scapular muscles and scapular abduction in standing subjects. Phys Ther. 1990 Aug;70(8):470-6; discussion 476-9.

A quote from the abstract:
The results indicate that no relationship exists between the position of the scapula in standing subjects and the muscular force produced by the middle trapezius and pectoralis minor muscles.

Charlie

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Re: neck pain and scapular stabilization exercises ?? - December 4, 2004 8:28:00 PM   
eam

 

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Shill and Charlie,
On weekends and days off, my dermatologist doesn't feel great either-it is starting to get cold here and she tells me that wearing a heavy overcoat actually bothers her. Admittedly she feels better not working. But one would think she would feel pretty good on off days but I don't get that sense from her. I do agree that neck retraction will help, could probably be the missing link here. If she is strengthening her scapular muscles in a sub-optimal spinal position she will be doing nothing that is useful, agreed. Elevating her awareness of her poor positioning is probably a lofty obstacle to overcome but I told her she has to do this. She says that when is aware of this she feels better. It is a matter of conditioning. I have been performing upper thoracic extension and scap. mobs and her mobiility has improved. I will add the neck retraction and post back. Thanks for the suggestions and the reference.
Erica

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Re: neck pain and scapular stabilization exercises ?? - December 5, 2004 2:59:00 AM   
coloradojulie

 

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As for the study mentioned...just curious...do most of our patients have pain when they are just standing...or doing something functional? Perhaps the dynamic role of these muscles throughout the ROM cannot be ignored?

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Re: neck pain and scapular stabilization exercises ?? - December 5, 2004 1:32:00 PM   
cneup

 

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Just to add a quick two cents to this discussion thread (specifically in reference to postural dysfunction) . . .
I agree with all that has been said above - however, no one has yet mentioned the importance of flexibility. It is very difficult to maintain correct alignment and achieve appropriate posterior chain activation sequencing if the pecs, lats, and subclavius etc. are hypertonic. I tend to push flexibility and thoracocervical mobility early - then progress into strengthening with manual faciliation in whichever way will activate the postural stabilizers appropriately. I then tend to sequence their HEP for strength followed by strength-endurance then endurance.
Courtney

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Re: neck pain and scapular stabilization exercises ?? - December 5, 2004 6:18:00 PM   
certMDT

 

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colorodojulie -

That's an excellent point, and if I remember correctly (I don't have the article right in front of me) it's pretty much exactly the same argument Shirley Sahrmann made in her comments after the article. I agree that comparing static posture and strength is probably not even remotely useful, but I always go back to this article when my colleagues talk about how their patients have such terrible (static) posture, with the idea that this automatically leads to weakness or tightness. This was a major part of Kendall's focus, which made up the majority of musculoskeletal testing in school. Isometrically, at least, this isn't true.
We would be better off going to the source, but my understanding of a lot of Sahrmann's thoughts regarding muscle strength would indicate that in someone with functionally lengthened muscles, they would be strong in a lengthened position, but weak in a shortened or normal position, the normal position in this case being closer to what we would consider good posture. It would also affect strength through the motion, as you said. I think that this (decreased strength and endurance in the inner range of hip extension in professional cyclists) was found by Richardson, but I can't find the reference at the moment. Perhaps the scapular retraction exercises help to re-distribute the strength curve, changing the muscle mechanics if not the actual posture.

Hope that makes some sense.

Charlie

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Re: neck pain and scapular stabilization exercises ?? - December 5, 2004 6:38:00 PM   
certMDT

 

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jbeneciuk -

I would punch Gwen Jull and cervical into a PubMed search - she has researched cervical pain and muscle function exhaustively, focusing on deep versus superficial cervical muscles. She wrote an experimental article in Physical Therapy within the past year or so, which focused on the cervical chin tuck exercise with pressure feedback, and incidentally mentioned the addition of prone scapular exercises as needed. Unfortunately, I think that it was for whiplash patients, but it's a good start.
I tend to think of scapular strengthening exercises as similar to Stuart McGill's "Big Three" for the lumbar spine. If any of these motions are deficient, it calls for more of a focus on that particular exercise or direction. If there is no limitation, there is no need to perform the exercise (in my opinion, not McGill's).
In eam's patient who cannot do 10 prone horizontal abduction exercises, I agree that it would probably be important at some stage to ensure that she can, as that is relatively weak. What I don't know is how to determine who needs these exercises (lacking something like McGill's ratios for the low back, which are a useful guide), and who can improve simply through posture correction and movement, either general or direction-specific.
To REALLY play devil's advocate: I would wager that if eam's patient regained her cervical, thoracic, and scapular range of motion, specifically extension, and consequently decreased her pain, her performance of scapular retraction exercises would improve by at least 50% without any increased effort. Maybe I should go study that.

Charlie

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