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Re: neck pain and scapular stabilization exercises ??

 
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Re: neck pain and scapular stabilization exercises ?? - December 21, 2004 10:08:00 PM   
eam

 

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Jon, Nari-
Interestingly enough over the weekend she said she was just generally busy ( I guess moving around!) and did not have the time to get to the gym at all. From the beginning she told me that exercise always helped her and massage, soft tissue mobilization etc did not. aka passive versus active. She had been elsewhere for PT and was doing "exercise" from the choreographed standpoint and was not getting much better. So I thought I would try a different approach, maybe the missing link, who knows?
At the beginning, frankly, I was not sure which path that would take. Since she is such a good historian and volunteered this information before I asked it, I started thinking that a different approach would be useful. She usually came in early for sessions and used that time to work out on the treadmill and foam roller. And whatever pain she came in with was down within minutes, and I mean literally minutes. So by the time our time came to work together, she was generally 50 to 75% better than when she walked in. So my plan was to try and formulate a strategy for her during the day when she did not have the luxury to hop on the treadmill or the foam roller (although she did purchase 2, one for home and the other for the office!). And I think that is where the difficulty was or still is! As I have mentioned before in this thread, she has to change her patterns and do some movement, be it retractions etc, during her work day and she will do well.
Being a very focussed physician generally, for her to focus more on specific mm movement may not be the recipe for her, we will see.
Erica

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Re: neck pain and scapular stabilization exercises ?? - January 10, 2005 9:28:00 PM   
eam

 

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Hi everybody-
I just wanted to re-post on this patient. I had nothing new to report on her over the holidays. She was not working as much-her symptoms were clearly better. I took the opportunity at that time to get her to consciously assess and correct her movement patterns-when she was not busy. She did well with that.
Today, for example, she had a hectic day-"non stop" with patients all day. She told me that her symptoms do not appear until much later in the day and she was able to manage them. She finds herself stopping frequently throughout the day to "look up at sky, pull her shoulders back and just generally move a little bit in a better position for her neck as opposed to looking down at her patients all the time.
I have also added some upper trap/levator strengthening-this may be contraversial for some but I re-evaluated her and she clearly has the appearance of a depressed shoulder girdle. I had given her some exercises at home to do regarding this but she was not doing them that much. She had also mentioned that when she wears coats, she feels she cannot bear the weight of the coat on her shoulders and she needs to use arm rests all the time. I mentioned this earlier in the thread.
Perhaps UT's-long and weak. She tests fair at best on a MMT. Her scap-humeral rhythm demonstrates minimal elevation and upward rotation. To make a long story short, she is doing much better and I just wanted to post her progress. This was such an engaging thread.
Erica

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Re: neck pain and scapular stabilization exercises ?? - January 15, 2005 9:48:00 AM   
bravocosta

 

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Hello eam,

Interesting case study. On a side note,many physicians sit on stools with now back rest and slouch whilst they write or use their electronic pens. This often resembles a functional kyphosis type pattern with forward head, rounding in of shoulders etc.., etc... .
Perhaps a useful adjunct would be to teach her to sit without a backrest and tilt the pelvis forward. This would immediately improve her alignment whilst helping to strengthen her postural muscles for endurance. Next show her that in this position she can relax her upper torso, UT's, neck etc..., as they no longer require constant muscular activation. This can be a revelation for some folks and works well. If she has trouble getting the tilt right, use the swiss ball.
In my own experience I was getting vague and at times nauseating referred pain from the T-spine until I used this trick with my stool sitting. Also check to see if she is a chest breather which increases body wide tension. If so teach her (12 days to a new habit) diaphragmatic breathing. Whew. Continue success to you...Thomas

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Re: neck pain and scapular stabilization exercises ?? - January 16, 2005 8:38:00 AM   
eam

 

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Thomas-
Yes, she is an interesting patient. Actually, she stands most of the day doing procedures and we have worked on some things in standing similiar to what you described in sitting. Will try your idea as she does not do procedures on Thursdays and does basically sit all day dictating notes.

Last week she had to spend two days sitting and interviewing new residents and was very apprehensive about this because she did not think this would be a good thing for her neck/upper back. Based on my hypothesis of shoulder depression/UR, I taped both shoulders into elevation and upward rotation (sort of winged the UP part), I probably got more elevation than anything- a little unorthodox I know. It seemed to work as she had no problem at all and was quite surpised at that. I told her also to find a good chair with armrests so she can relax the UT's.

The real test will be when she gets full swing into her schedule for the new year.

Based on the original post re: manual scap. stab. exercises, I have to say I did more manual scapular work. con/ecc and more education re: movement patterns (way of thinking etc) and significantly much less in the way of traditional PRE's, machines etc. I did not really do any manaual therapy to her neck at all, did alot of thoracic mobs-traditional PA's as well as sitting, and quadruped mobilization with movement.

I will keep re-posting on her progress.

Thanks!
Erica

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Post #: 44
Re: neck pain and scapular stabilization exercises ?? - January 16, 2005 8:48:00 AM   
Jon Newman

 

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Hi Eam,

I found this statement interesting:

"Last week she had to spend two days sitting and interviewing new residents and was very apprehensive about this because she did not think this would be a good thing for her neck/upper back."

What is "not..a good thing" about the activity? In your professional opinion, is she correct in her assessment that she was likely to do harm? In general, what has been your experience with people in pain...does apprehension make their pain better or worse or have no effect?

jon

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Re: neck pain and scapular stabilization exercises ?? - January 16, 2005 10:10:00 AM   
bravocosta

 

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Hello eam,

Could you describe the quadriped with mobilization that you performed, sounds interesting. The taping sounds good as this probably gave her proprioceptive feedback. These types of cases likely do improve with less of the traditional push/pull machine approaches etc.. because "awareness" sounds like part of the problem, as well as acquired stiffness of T-spine, love those foam rollers. You probably already know this but , keep the home/ self Rx stuff brief as "compliance" (hate that word) always an issue. With regards...........Thomas

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Re: neck pain and scapular stabilization exercises ?? - January 17, 2005 8:11:00 AM   
eam

 

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Hi Jon and Thomas-
Jon-In my mind, she most likely believed that sitting all day in a chair doing interviews one after the other would cause her to have sx's in her neck. Do I think that sitting like that would cause her harm? In my professional opinion, I think that it would be mildly exacerbating for her, given her history of "movement makes her better". On the other hand, if we did not tape her, she may have been ok. My gut is she would have been achy. But only for a short period of time. I think everybody deals with pain differently. In some apprehension makes their symptoms worse and others it doesn't.
Thomas, The position is actually not quadruped but hands and knees (sorry if I miswrote!) and you have her cross her arms in an "I dream of Jeannie" like pose and put them on the treatment table. They are kneeling on the floor. You can raise and lower the table to achieve the desired effect of thoracic extension. She could not do that at first but now is able to. I learned this in a course. If they do not want to get on the floor you can have them sit and put their hands in the same position and slip your hands through and manually perform the thoracic extension. And she has 2 foam rollers, one for home and one for the office. In her case, awareness was a key component of her treatment plan.
Thanks for replying!
Erica

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Post #: 47
Re: neck pain and scapular stabilization exercises ?? - February 4, 2005 1:40:00 PM   
JLS_PT_OCS

 

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JOSPT had an interesting neck pain patient case study in it.
They utilized a muscle retraining strategy, with deep neck flexor retraining that shows promise from research.

I have a lot of luck with a lot of my neck people in assessing and treating this....esp the headache people that the study found so helpful.

_____________________________

Jason Silvernail DPT
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jasonsilvernail@gmail.com

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Re: neck pain and scapular stabilization exercises ?? - February 4, 2005 6:22:00 PM   
Synergy

 

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I think this is the article Jason is speaking of. [URL=http://www.jospt.org/members/fulltext/2005/january/January2005-CR-McDonnell.pdf]A Specific Exercise Programand Modification of Postural Alignment for Treatment of Cervicogenic Headache: A Case Report[/URL]

I haven't read the entire article yet, but it is interesting nonetheless!

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Chris Adams, PT, MPT

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Re: neck pain and scapular stabilization exercises ?? - February 4, 2005 9:39:00 PM   
eam

 

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Just read this article-photocopied it for my colleagues. She brings home alot of important points not just relevant to HA. I use alot of the Sahrmann principles fairly frequently and this case study brings home some concepts that sometime get lost when we are treating specific joints.
Erica

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Re: neck pain and scapular stabilization exercises ?? - February 5, 2005 10:07:00 PM   
jbeneciuk

 

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A great article!! I think the most enlightening aspect of the article was on the compensatory mechanisms discussed during the examination process. Sometimes, I think we all can overlook areas during a physical exam, which may be relating to a patients problem. The Sahrmann text is a great reference (in my opinion), in that she explains these compensatory behaviours and then also describes treatment approaches to address them. Great article and great text related to this topic !! thank you all

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 9:05:00 AM   
bravocosta

 

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Thanks for the article posting Chris, good stuff
and a reminder to look at the whole forest instead of the bark on one tree. Here's a little blurb on cervical HA's.

http://www.aptei.com/library/viewReport.jsp?report=168

And another one on strengthening DNF (deep neck flexors) in the clinic.

http://www.aptei.com/library/viewReport.jsp?report=138

Love how these threads wind and turn.
Cheers....Thomas

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 2:11:00 PM   
Synergy

 

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Thanks for the interesting links Thomas! It is not at all suprising that Group 4 didn't progress as well as Groups 1-3. Even though I don't manipulate (but do mobilize) the upper cervical spine, I disagree with the statement
"If muscular retraining is as clinically effective as manipulations, perhaps upper cervical manipulations should be left as a last resort, considering their unlikely but potential harmful risks."

Granted, there are risks with just about any technique if done improperly, but if all measures are taken (cervical clearing tests, etc.) prior to manipulation then I see no reason to consider them a 'last resort'.

The PBU study was interesting as well. I have tried this technique with a plain ol' blood pressure cuff as I'm sure quite a few of you have. It works well and provides the patient great feedback, but also requires cuing by the therapist as well.

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 3:10:00 PM   
SJBird55

 

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Chris, the problem is that there is no gold standard for cervical clearing tests.

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 4:20:00 PM   
bravocosta

 

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Hello Chris,

For a recent grad, you certainly don't have very much left to learn. Maybe be taking one of your courses in the not too distant future! Where did you go to school ? Perhaps the reviewer is suggesting that 10% more improvement is not that important, and too manipulate if it is not attained. (Don't manip.myself-never trained in it) Manipulation accidents of the upper C-spine are rare, and most likely have occurred (per lit.) with repeated endrange rotational manipulation.

SJBird makes a good point as well. In the few court cases perused, it appears that the so called clearing tests are not deemed reliable.

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 7:34:00 PM   
nari

 

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I agree that the VAT (Vertebral Artery testing) is NOT reliable with false positives and worse,false negatives.
I understand the cuff/PBU testing can be done to the deep flexors with much the same principle applied as for Multifidus. Deep flexor retraining has been around for many years, and seems to have held up to scrutiny fairly well.

nari

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 11:01:00 PM   
Synergy

 

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SJ,
I agree with you, but I still take each of my patients through them prior to performing manual techniques. Do you have any studies that you can point me to in reference to the VAT?

Bravocosta,
I appreciate the compliment! I went to school in Abilene, TX (3 hours West of Dallas) @ a school called Hardin-Simmons University. I received my undergrad degree there as well. They have an excellent faculty there I must say!

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Chris Adams, PT, MPT

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 11:19:00 PM   
steve

 

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There was a good study in Manual Therapy, issue 9 (1) by a physiotherapist in Saskatchen named Rosenblood. Of the top of my head he looked at Doppler imaging with a variety of head positions and found that only rotation and the premanipulative hold for the AA joint occluded blood flow to the vertebral artery. Of course this was performed on asymptomatic individuals so we have no idea of sensitivity/specificity.

With respect to the frequency of accidents with upper cervical manipulation, they may be more frequent (And not attributed directly to the manipulation) than some of the original research suggests:

http://stroke.ahajournals.org/cgi/content/abstract/32/5/1054

http://stroke.ahajournals.org/cgi/content/abstract/32/5/1054

http://collection.nlc-bnc.ca/100/201/300/cdn_medical_association/cmaj/vol-163/issue-1/0038.htm

Not trying to ruffle any feathers here (Particularly as most research has been done on chiros but likely physios who manip also run risks), just pointing out that there are some differing opinions on the fequency and what is acceptable.

Steve

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Re: neck pain and scapular stabilization exercises ?? - February 6, 2005 11:38:00 PM   
steve

 

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Here's the study on Doppler imaging and vertebral artery blood flow:

[URL=http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WN0-49V79W3-4&_user=10&_handle=B-WA-A-W-AZ-MsSAYWW-UUW-AAAUBVZZWC-AAUDEWDVWC-EUBZEWZAD-AZ-U&_fmt=summary&_coverDate=02%2F29%2F2004&_rdoc=3&_orig=browse&_srch=%23toc%236948%232004%23999909998%23475928!&_cdi=6948&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=2f9e65eb657d93523705ffb43860c429]http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WN0-49V79W3-4&_user=10&_handle=B-WA-A-W-AZ-MsSAYWW-UUW-AAAUBVZZWC-AAUDEWDVWC-EUBZEWZAD-AZ-U&_fmt=summary&_coverDate=02%2F 29%2F2004&_rdoc=3&_orig=browse&_srch=%23toc%236948%232004%23999909998%23475928!&_cdi=6948&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=2f9e65eb657d93523705ffb438 60c429[/URL]

Steve

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Re: neck pain and scapular stabilization exercises ?? - February 7, 2005 6:27:00 AM   
JLS_PT_OCS

 

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I rarely use manipulation in the cervical spine.
The few times I have, it was in the lower (C3-C7) cervical spine, and I did not use any premanipulative testing. I have seen no evidence to suggest that it can possibly predict anything one way or another.

The research I have read shows that manipulation is in fact no better in terms of outcomes than mobilization is. So I rarely have cause to use it.

Some individual patients may have a movement problem that is significant, not resolving with mobs/ METs/self-mob, and I believe is a contributor to their pain state. It's those people I would or would consider manipulating.

I think it would be interesting to study the effect of mobilization or manipulation on the activation of the deep neck flexors, I am betting it would be improved after a bout of manual therapy.

At CSM there will be a paper on this for the lumbar spine showing the effect of manipulation on TrAbd function.

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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