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Re: neck pain and scapular stabilization exercises ??

 
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Re: neck pain and scapular stabilization exercises ?? - December 5, 2004 10:48:00 PM   
jbeneciuk

 

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CertMDT:
good points about Sahrmann...I'm currently going through her book..it is a diiferent approach frommy education, yet very useful in the clinic and enlightening to read..
I agree regarding your last wager..we do need full joint mobility before we can even properly test a muscle with a Kendall-type MMT..without proper joint mobility, optimal muscle function cannot occur..this is also why we test the integrity of the joint before we test the performance of a muscle through its range....this is the approach I learned , and it does make sense to me...
again...this is why we sometimes see specific strength deficits, in only particular ranges....this is why i feel manual scapular exercises are very beneficial, as opposed to prone scapular adduction (example)...the dermatologist may have had difficulty with this movement, however how do you think this would improve if:
1) thoracic mobility,(etc) was improved
2) she was taken through a few sessions of manual scapular exercises to focus on specific deficits

**would she lets say 2 weeks later be able to perform prone scapular adduction with improved ability ??

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Re: neck pain and scapular stabilization exercises ?? - December 7, 2004 9:06:00 AM   
eam

 

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Good thoughts everybody. I pulled some of Gwen Jull's research off of medline.
There were obviously several citations. Some of the more recent and notable ones.
Spine 2004 Oct 1: 29(19):2108-14 Patients with neck pain demonstrate reduced EMG activity of the deep cervical flexor muscles during performance of the craniocervical flexion test.

Spine 2004 Jul 1: 29(13):1436-40. Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task. (it did not say what the task was in the abstract. But the conclusion was patients with neck pain may have an altered pattern of motor control in scm, ant. scalenes, and utraps. to compensate for reduced activation of painful muscles.)

JElectromyogr Kinesiol 2004 Aug 14 94): 463-74 Spatio-temporal evaluation of neck muscle activation during postural perturbations in healthy subjects. (conclusion: feed-forward activation of scm and cerv. extensors is necessary to ensure stabilization and protection of the cervical spine.)

Exp. Brain Res 2004 Jul; 157 91):43-8 Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. (cervical flexor mm are vulnerable to reactive forces from arm movement due to the delay in this muscle activity associated with movement of arms in patients with neck pain).

The feedforward mechanisms are interesting to me especially when someone performs repetitive upper limb tasks,like my dermatologist. Wonder how one would increase that in deficient patients????


I saw my dermatologist yesterday. She is actually better; more optimistic etc. I agree that regaining joint mobility is paramount in her case, specifically throacic extension. That was the focus early on. In that regard, she has improved, not 100%-her uppper t spine is still a little stiff. Flexibility-obviously the pecs play a huge role with her-how can we effeciently train postural muscles with reduced t spine ext and some pretty tight pectoral mm ( and I mean TIGHT)??
With regards to the neck retraction and scap. exercises. I don't know if and when she gains FULL t spine extension (if she ever gets it) she will be able to perform some of these scap exercises better. My point being, I am not going to wait around for that, I am going to work on scap. ex at the same time. I gave her the neck retraction exercises which I think will be important for her. I tested her scap retraction in standing with and without neck retraction. Similiar to how she stands over patients while performing procedures. I guess like Sahrman- when she was standing 'normal' -FHP etc-mm lengthened. The motions were fairly good. I had her stand with a chin tuck and do the same thing and she could barely do it. Sort of just made that one up-but wanted to try it. I also tested cervical flexors and she did test fairly weak-no difference side to side.
colarado Julie made a good point about being strong throughout ROM -you see alot of that in knee patients-why not extrapolate to the scapula?? I have been doing scap. manual resistance with her ensuring that she is in a better position as opposed to letting her go sit on a Cybex machine and do it all wrong. She has isolated weakness here-primarily scap. depressors. With your typical prone, row stuff this is tough to isolate-not that you really isolate it but at least there are other exercises that will work better.
I have gone on way toooo long here.
Just a few thoughts,
Erica

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Re: neck pain and scapular stabilization exercises ?? - December 7, 2004 12:52:00 PM   
Shill

 

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Erica,
Glad she is getting better. With the neck retraction she is now doing, what are the parameters? How frequently does she do this, how many reps, in sitting, or in supine? May seem unimportant to some, but this matters. What is the effect of neck retraction on symptoms when present? Im just curious to hear the parameters you have chosen, before I offer my 3 cents as to what I might do.
The intent of neck retraction can be to relieve pain, or increase motion, but it works to one's advantage to have the intent be both. This requires that the patient rate pain and locate pain before and after, noting any change. When done at regular intervals during the day, the patient gets a better idea of when the pain is more of a problem, and, if prompted, reflects on what she is doing at that time, helping you know what activities need to be modified to bring about consistent daily improvement. OK, I gave you some of my thoughs already. Sorry, I cant seem to shut that off.
Steve

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Re: neck pain and scapular stabilization exercises ?? - December 7, 2004 11:22:00 PM   
jbeneciuk

 

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Shill:
good question regarding how many and how often we have patients perform a neck retraction movement as part of their HEP or while in the clinic..

interesting to see how others handle this..
my approach is I'll have the patient perform the exercise in the clinic while i monitor them for a few minutes, trying to hold for 5-10 seconds...if they appear to be doing the execise correctly with no substitution from the SCM (superficial neck flexors),...i set a goal of having them perform numerous times throughout the day for 10 reps...with 5-10 sec holds...more specifically, depending on their profession...possibly 1 set every 30 minutes...

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Re: neck pain and scapular stabilization exercises ?? - December 8, 2004 3:17:00 AM   
goodlooks58

 

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Interestingly, a few years ago a Biofeed back rep came to my office and mentioned about some research article about sitting posture e.g at a computer work sation, and neck pain. As far as I remember, he said that the research stated that out of the 100% of the people working on a computer only 60% may end up with neck and upper back pain due to poor posture. Howevere, the rest 40% who sit in the worst posture posible e.g. laptop with the feet up and totally slouched: these people do not end up with any neck or upper back problems. Then he went on to say that these 40% of the people have somehow inherently learned to keep the upper trapezius musculature in a very relaxed position eventhough it may seem like they were sitting in a slouched posture. The key is that these 40% were realxed, type B personalities and of course the rep was trying to sell me the biofeed back machine trying to explain that if we can teach these RSI patients to learn to control tension in the upper trapezius then it would be a very valid treatment for RSI and upper extermity spain/strains. Has anybody read this kind of research article?

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Re: neck pain and scapular stabilization exercises ?? - December 8, 2004 1:48:00 PM   
Shill

 

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Goodlooks,
The rep was trying to sell you a device, which you realized may have contributed to his strong opinion. Id like to see the article from which the info was obtained, as well as who funded the study! I think, and this is my opinion, that the information was likely made up. I'll see if it exists on pub med.
Nothing exists specific to this within the last 8-9 years, that I can find.

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Re: neck pain and scapular stabilization exercises ?? - December 8, 2004 11:10:00 PM   
jbeneciuk

 

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totally agree with Shill

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Re: neck pain and scapular stabilization exercises ?? - December 9, 2004 10:03:00 PM   
eam

 

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Shill,
I told my patient to do about 3 sets of 10 reps of the neck retraction, every couple of hours. I know she won't do it that often but it is a goal. Position wise, at least for her, is going to be done probably in standing. Because I know she is not going to go supine or sit, that is for sure. Why do you ask? Do you prefer a certain position?

I saw her tonight and her upper back pain was better but she was so stressed out with all the holiday parties, no sleep and certainly no HEP, that her upper traps were like earrings. These were not her initial symptoms-so I treated it like an acute exacerbation. So, next time I will resume plan. It certainly is frustrating treating patients with neck pain in this day and age. I see alot of Univ. Students who constantly c/o of neck pain, alot of computer usage, stress and very poor posture. I am probably dating myself but when I was in school, I don't recall me or any of my friends having ANY of these problems. I am treating 2 Univ, Students now, one pre-med, the other law, who have such arm pain, long h/o RSI who are using voice communication software b/c they cannot type. 22-24 years old. This just blows me away. Anyway, I am diverging.
Erica

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Re: neck pain and scapular stabilization exercises ?? - December 10, 2004 5:29:00 PM   
Shill

 

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Erica,
Good job on the every two hours. Now just find out what happens after the 3 sets. Any change in symptoms? If so, (improvement) have her continue in sets of 10 until the improvement stops. If this reduces her pain, and she wont do it more frequently, ask her how it makes sense that she wont do it. Make her responsible for reducing pain when present. Make her responsible for keeping it away by using the excellent postural and ergonomic advice you have already given her.
Position is important, as supine is more disruptive to the daily routine, and wont get done as frequently. Standing or sitting can be done anywhere, at any time, and therefore there is NO excuse for non compliance. However, if sitting doesnt work, retraction should not be abandoned. Supine may be needed due to the relative cervical unloading. If supine relieves symptoms, again there is no argument for not doing it. Sure its a pain to lie supine and do this, but its a pain to wear a sling after an AC injury, wear a cast after a fracture, use crutches after a foot injury, you get the drift. Try to start at minimally disruptive to the daily routine, and progress from there, based on symptom relief, or lack thereof.

Tell her that holiday parties are for fun, not for stress. Let loose and chill out, she should. Although she should stop short of dancing like Elaine on Seinfeld.

I agree on computers, especially laptops ripping our patients up. I saw on CNN (so it must be true!) that men shouldnt use a laptop on their laps, as it may heat up enough to affect sperm motility. At least we can now get them out of this position!

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Re: neck pain and scapular stabilization exercises ?? - December 13, 2004 10:23:00 PM   
eam

 

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Well, the most recent holiday party problems went their merry way; so we are back to the "upper back" dilemma again with my patient. Shill, I have asked her to inform me what the neck retractions have on her sx's. (will see her again Wed.) She mentioned to me that over the weekend she read a book for approx. 2 hours and her sx's returned again. As far as I am concerned, 2 hours of static positioning reading a book, isn't good for anybody.

Clearly, exercise and movement REALLY help her. She came in early tonight, did the treadmill, stretches on foam roller and this made a huge difference in her presentation.

My current tx consists of thoracic mobs,the neck retractions, some UT taping (PRN)-she gets itchy, manual scap work (PNF, prone con/ecc work, seated scap work with proper neck positioning,) pec stretches on foam roller. 50% of her problem, I believe is awareness of the issue which she admits, helps her and the other is weakness etc.
If anyone can think of anything else, progressions etc -it would be a help.
I truly feel if she realizes that her patients can wait like 5 mins, so she can do a stretch on the foam roller in her office or whatever, she will make gains quickly.
But, one thing that still bugs me is that when she sits with her arms on a pillow (UT's relaxed) she still has neck pain. What gives with that?
Erica

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Re: neck pain and scapular stabilization exercises ?? - December 14, 2004 10:09:00 AM   
Shill

 

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Erica
The reason she still has neck pain with her arms supported is that the pain has nothing to do with her upper traps. A strong opinion, but you asked, so I gave.
Rather than wondering what more you can do, do more of what has worked so far. If she had no problem running on treadmill, foam roller stretch, you basically kept her out of her position that causes CONSISTENT worsening, and magically she felt better. Show her this fact. Repeatedly.
If the retractions bring about relief, or even reduction, ask her to have the patients wait only 2-3 minutes, instead of 5 while she does 3-5 sets of 10 retractions to relieve pain. She is more apt to do this, due to less disruption to daily routine. IF she has to stop, drop, and (foam) roll, she is less likely to do it.

[QUOTE] She mentioned to me that over the weekend she read a book for approx. 2 hours and her sx's returned again. [/QUOTE]You have to convince her that she simply cant do these things for two hours and expect to get better. Bring the reading surface up to her, not the head down to the reading surface.
You are helping her get better, without a doubt, and the speed with which this is occurring is fine. Dont try to do more, just work with more of what has helped so far. Make her pay attention to the small details of how positions help or hinder.
Steve

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Re: neck pain and scapular stabilization exercises ?? - December 14, 2004 3:48:00 PM   
Mac

 

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eam, I routinely do a couple of things that are quite effective but are not at all evidenced based. I use my thumbs and give a deep massage to the longitudinal arches of the feet from mid-foot to the great toe, under this toe then along the medial aspect of the great toe. If this area is really tender then the patient usually is afforded good relief. I also use a percussor and work around the circumference of the scapula and in the infraspinatus fossa focusing on tender regions.

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Re: neck pain and scapular stabilization exercises ?? - December 14, 2004 10:12:00 PM   
eam

 

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Shill,
Totally agree. Sometimes we all need a little validation every once and awhile. I believe in the conviction of my Plan and often have to remind myself and the patient; the longer one has a problem the longer it takes for them to get symptom relief; Being a physician, I think she understands but you want to "do well by her" b/c she is a respected MD in the community. Thus, the urge to do more.
I don't think her upper traps have anything to do with her main problem either-I actually never really focussed on them except when she came in after her holiday parties-but that all resolved itself. What is blatantly clear is that a little bit of exercise goes a very longgggggggggggg (sorry! had to do that!!!) way with her and making her aware of that and the other small changes she needs to make will do her far better than any mobilization or exercise (just my opinion!!).
Am seeing her tomorrow so we will see.

Tim, maybe it is the late hour or the cold but how will deep massage to the arches of the feet help here?
Thanks!
Erica

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Re: neck pain and scapular stabilization exercises ?? - December 14, 2004 10:51:00 PM   
FLAOrthoPT

 

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that is his second post about feet, i think i smell a fetish...

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Re: neck pain and scapular stabilization exercises ?? - December 15, 2004 7:34:00 AM   
Sebastian Asselbergs

 

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FLA - I think you mean a "feetish"...
Smells like reflexology to me.

Erica, I think Steve was 100% right on with his post and I think you are on the right track. A ENT surgeon who spends 12 hours in OR two days a week took a very long time to realize that there was no easy fix without having his work "habits" adjusted - in between cases, he now stands up and stretches as if saluting the rising sun: neck in gentle extension, arms in slight abduction, lateral rotation and extension, scapulae in retraction and spine in general extension. Works well for him - took about three months and three series of two sessions to get him to do that. I was slow in convincing him.

Sebastian

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Re: neck pain and scapular stabilization exercises ?? - December 15, 2004 10:36:00 AM   
Mac

 

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Erica, check out some info on reflexology. Much of it sounds hokey but... it frequently is helpful. Like anything else it is not the be all or end all yet it can be effective. I use it when someone is very tight and tender- it helps to loosen the area without having to treat the area directly which can be painful for the patient. I have used it when treating some of my skeptical physicians but once they experience the increased ROM or increased SLR they usually don't say much more. (By the way the other posting regarding working on the feet had to do with plantar fascitis).

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Re: neck pain and scapular stabilization exercises ?? - December 16, 2004 8:46:00 AM   
eam

 

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Yes, I think convincing the patient that work habits need to be adjusted is great in theory but difficult to implement at times. Last night, I saw my patient and spent the better part of the session just trying to convince her that she will not get better 1)if she reads a book for 2 hours and does not move, 2) if she does not take some breaks to do simple stretches t/o the day. 3) and above all, she has proven to me that exercise ALWAYS makes her better (aka movement!!). I think that this is pretty convincing in and of itself. Sebastian, being persuasive and trying to convince someone to change habits of a lifetime is a tall order, especially a physician. Hopefully, she will do the same as your ENT guy.
In the past, she told me that soft tissue mob., massage etc never helped her. Probably, b/c it was passsive tx. She did not get a chance to inform me re: chin tucks, next time. Just goes to show you that she still has not changed her habits. Will post again when I see her on Monday. Thanks!

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Re: neck pain and scapular stabilization exercises ?? - December 20, 2004 9:12:00 PM   
eam

 

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Just a quick update on my patient. Saw her tonight and she did not complain much about anything. She had a light day today but she did ok. Over the weekend I thought was a real test. She said she had alot of errands to run and MOVED alot and she did not have any pain in her upper back. Key in that sentence is movement. Told her that since her schedule is light and she is not running around crazy this may be a good time to start incorporating some of those in between patient stretches and retractions. Will see how she does.
Erica

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Re: neck pain and scapular stabilization exercises ?? - December 20, 2004 11:13:00 PM   
Jon Newman

 

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Hi Erica,

I'm curious about this: "She said she had alot of errands to run and MOVED alot and she did not have any pain in her upper back. Key in that sentence is movement."

What intrigues me, if I'm reading this correctly, is that she was able to make herself pain free without choreographed movement versus the scapular retraction or stretches. Not that those things aren't good to do but somehow they also were not necessary for her to be pain free. It's intriguing to me anyway.

This is not meant to be critical, it just caught my eye. Good job, sounds like she's getting better.

jon

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Re: neck pain and scapular stabilization exercises ?? - December 21, 2004 5:33:00 AM   
nari

 

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Erica..

I do have to add to jon's post, that free movement, unconscious movement not aimed at any muscle/joint/whatever, can be very helpful. Any conscious attempt to 'control' certain muscle action can possibly enhance nociceptive messages.
Free movement removes the focus on the affected area...just a thought.

Tim, I have to say that aspects of reflexology do work. I do not know much about it, but attention to the medial side of the foot, along the fascial plane, does relieve LBP. No idea why, but..there is a lot we do not know the answer to!

Nari

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