Joined: January 31, 2005
May I answer your question with a question?
Is the "spasm" and motor activity you describe a defect to be corrected and forced down, or a defensive movement you should be encouraging?
It seems that you have been treating this as if it is a defect, when in fact this is a defense. Look centrally, treat the neck. There's probably nothing "wrong" with the trapezius, it is a common site for referred pain and one of my favorite referrals from well-meaning but essentially clueless medical doctors: "upper trap strain". :) J
Joined: July 31, 2005
I agree with that as well. The traps are just responding to other forces. I think for many people, the scap and shoulder stabilizers are so weak that the shoulder basically hangs from the neck by the upper traps, which can lead to a number of problems.
Try this with these patients. Palpate upper traps and ask them about tenderness or discomfort. Ask them sit up straight, elbows at the side and bent to 90 degrees, hands in front. Then, have them perform a scap retraction by pulling the scaps back together, so that they pinch your finger which is placed on the spine. Palpate the traps again. Often you will find a significant different.
Many of these types of patients will have a hard time performing a scap retraction without the use of their arms to cheat. This is why I have them set up like I do. The elbows should stay at the side and hands should stay front. If they cant do it correctly, then that may be part of the problem.
I dont really do much to the traps, other than to work out some triggers to help it relax. I spend more time working on their tight pecs and subscaps, and strengthen the scap stabilizers and rotator cuff. I also address any cervical and thoracic dysfunction, as well other things such as weak deep neck flexors, overactive accessory muscles of respiration, etc.
excellent response Jason. You must be a clinical instructor. I work on scapular posture and head posture. Pec minor and major are probably tight, rhomboids are probably weak, and postural habits are probably bad. These increase the loads on the UT and make them fatigue, since they are postural muscles, they can't simply quit, they go on autopilot. Reduce the load and reduce the spasm.
Joined: October 9, 2001
From: Pittsburgh, PA USA
Odds are the problem is from the neck, as others indicate. Postural issues, even holding a phone against the shoulder/ear compound matters, and that wonderful word STRESS comes into play also. Having a crappy neck myself, (with so many knots that my wife, a massage therapist, say's its the most f_cked up she has ever worked on) I know how they feel.
The interesting part is the fact that the pain is referred, yet still causes localized contraction and trigger point development. I remember a few years back when flared up, and I was lifting with the ortho spine surgeon. I suggested he inject the trigger points (no steroid) with anesthetic, just to see what would happen. Of course, I ended up with a huge region of numbness, but could still reproduce the pain at the trigger point with cervical motion.
Loczlized treatment works, but one has to get to the root cause of the problem.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
John M. Duffy, PT Board Certified Orthopaedic Clinical Specialist www.PTupdate.com
The last four I have had have all been MVA's. I have not had great success with working on the cervical/thoracic spine - what types of things are you doing. I totally buy into the cervical/thoracic spine causing the problem, just does not give me the results I am looking for.
Interestingly enough three of the four ended up going to the MD for an injection with moderate lasting pain relief noted after. So I am not sure if I am treating the cause or effect.
Joined: March 12, 2004
I can't add much here as most have provided good feedback already. I'll usually manipulate mid to upper t-spine and add some scapular/shoulder PNF with the neck in various positions to help improve motor control.
Joined: February 27, 2005
From: Melbourne Victoria
scpt your patients with an MVA history may well be so highly irritated , with the effect of inanvertant stretch occasioned during the decelleration moment of their MVA, that best attempts at reversing their joint protective responses are met with an advance of irritability . Not the time perhaps to be pursuing mobs /manips of spinal joints. At least not with any hope of immediate effect in reducing referred ( trap ) muscle spasm. Seems Buddy has ideas that fit with this , I don't disagree with the notions about the neck being involved , just that under the extreme sensory load likely with the so called "whiplash ' effect, many hands on treatments seem to cause as much pain and tightness as they relieve. Hot packs . rest, gentle movements and stretches may help as much as anything. At least till the state of irritability is reduced. Under these circumstances the best efforts of the anaesthetist and chemist often do more than manual therapy can.
Joined: February 7, 2006
When the MVAs come in I usually do what has already been said. Stretching, heat, modalities, etc.
When they come in with I/O of spasms, I usually try and find out their daily activities. Most often unilateral spasms might be due to working environments. Especially if they are at a desk all day. Are they left handed/right handed, is the computer monitor in front or over to their side (L/R). Ive had them switch the monitor and lower their seat and that seems to help with some.
Scpt, I would agree with all above rationale (except Zeke/doc/whoever) but would add that you make sure the ping pong ball sized spasm in the upper trap is not actually an elevated first rib, try some first rib ossilations, C3 work to inhibit scalenes, decrease the pain and guarding and maybe a 1st rib manipulation if you find it hypomobile, teach self mobs, ect, along with other interventions already mentioned this work can help to reduce tone and spasm. Good Luck Rick
Joined: July 31, 2005
Speaking of irritated muscles...
Recently, I have been seeing a number of people after an acute injury or flare up. I usually start these people at 3 times per week, but a few tell me they can only make it twice. Usually, the 2 times a week drag on with no improvement until I insist they come in 3 or 4 days in a row. Then, they seem to do great. Have any of you had similar experiences?
Also, there are other cases that show no improvement no matter what, so I refer or call their MD to have muscle relaxers and antiinflammatories prescribed, and that seems to do the trick.
Regardless of what ends up helping, I'm noticing that the acute and irritated muscles will be stubborn for many days and pain will be consistent, then once they start to relax and feel better they improve substantially overnight. They'll go from an 8/10 one day, right down to a 2/10 a few days later (after the increase in freq of care or meds).
No one has yet mentioned unloading the peripheral neural system. The fastest way I've ever found is to 1. put the patient prone with arm hanging straight down (ninety degrees flexion) head supported in a face hole that can extend or flex the neck, as is comfortable for the patient; 2. sit down by the patient's arm, grasp it lightly with one hand somewhere just above the elbow, while palpating the golf ball with the other; 3. turn the arm, or even just the skin layer of the arm, into internal rotation (usually) until the golf ball collapses; 4. hold the arm in that position until the nervous system becomes refreshed/reoxygenated enough that it won't try to "defend" itself again by using the trap to lift the shoulder up off the brachial plexus.
The bonus is that the patient's motor planning brain thinks it did this lengthening out thing itself, which it did, and no spinal bones or facets or soft tissue were annoyed in the process.
Joined: January 31, 2005
Great idea, Diane.
I have met many people with these "upper trap spasms" who had positive ULNT/ULTT and their trap was working hard to unload the plexus. Obviously it makes no sense to "stretch" or "strengthen" or "massage" the trap in that situation, as the hyperactivity is a defense that needs to be assisted and not a defect that needs to be obliterated. Sometimes taping is helpful in those cases also. J
Thanks Chris and Jas. Taping is very helpful. Just a strip along the trap after the golf ball is gone. A "deeper" level of examination of the whole gestalt of the problem is to look at the axilla in sidely to see if the arm goes back into gravity past vertical abduction. If it goes all the way to horizontal/in line with the body, no problem. More tips: If it doesn't, the lateral cutaneous nerves are likely hung up in association with 1. non-lengthening lat; 2. non-lengthening serr.ant.
Or else the brachial plexus is still hung up in association with 3. non-lengthening pec/coracobrachialis 4. non-lengthening teres major 5. non-lengthening long head of triceps/non-sliding axillary nerve.
All these areas mop up well with mild skin stretch.
(I'm writing up a little manual with these ideas in it that I plan to publish some day. I think I'll call it "Work smart not hard", or, "How to be an effective manual therapist without wrecking your hands so you can still work when you are 70." Something like that. :) )
Joined: October 26, 2005
Zeke may appreciate this one. I agree with Jason, often the upper traps spasm is a protective mechanism.
If neural length testing of the neck or upper extremity is restricted but not amenable to treatment due to irritability then mobilise the neural system lower down e.g. across the thoracic, hip, and lower limb. You'd be suprosed how effective this is for upper traps pain.
I'm yet to see anyone who has 'strained' their upper traps!