Levator Scapulae and Rhomboids hypertonus - victim or cause?

It is quite common to have a patient point to the levator scapula or rhomboids as symptomatic when they come for their first treatment. Many have become resigned to the problem and will tell you it is chronic.  The patient will often complain of headaches neck and shoulder pain. Careful observation may reveal shallow breathing and a tight diaphragm.  Some of these patients are using incorrect postural mechanics (i.e. Kyphosis) or ergonomics which can be revealed in the interview with a bit of detective work. Many patients have tried massage, chiropractic, PT, exercise, taping and dry needling with temporary relief at best. If ergonomics, mechanization or posturography are not a contributing factor and conventional investigation and treatment isn’t producing the desired outcome, then we need to look further.

 

Of course it is important to investigate structural elements like ribs and vertebral alignment first to ensure there isn’t restriction or malalignment. If the patient returns with repeated restrictions patient chart notes will start to flag a pattern indicative of ligament instabilities. Some of those patients have had trauma or are hypermobile and prone to instabilities. This is where having a good working relationship with a prolotherapy practitioner is important. Combined proliferation therapy treatment with manual therapy and soft tissue treatment can result in decreased hypertonus as the ligament integrity improves. Tight muscles can point to sprained or weakened ligaments.

 Once restrictions are cleared and ligaments don’t appear to be the problem we can then direct our attention to the muscle groups that may be the drivers of joint and ligament problems. Erector spinae, teres major, coracobrachialis, pectoralis major and latissimus dorsi are vital stabilizers to the shoulder and dramatically improve ease in motion when optimally tensioned. Levator scapulae and rhomboid hypertonus are common victims resultant of dysfunction in this group. Functional deficits in this group are the result of chronic and progressive lateral deflection of segments due to the highest relative frequency of flexion at the shoulder and trunk. The latissimus dorsi is influenced by pelvic positional dysfunction which can translate to the shoulder girdle. In all cases, these muscles will be sensitive to cross fibre palpation with a hard ropy nature and limited pliability.  Functional tests should demonstrate decreased response time, decreased proprioception, weakness or pain upon isolation. Compensation will be observed in the neck, contralateral shoulder and axial rotation of the trunk during testing. Each of these muscles requires optimal function to restore function to the shoulder girdle.

Treatment techniques abound with varying levels of effectiveness and retention. SRT techniques provide immediate improved function, verified with functional testing. This eliminates compensation patterns in levator scapulae or rhomboids while simultaneously restoring stabilization, strength, proprioception and response time. Through neuromotor re-education the ANS is down regulated.

This is only one element of treatment. SRT full shoulder stabilization involves assessment and intervention of additional dysfunctional muscle groups which are addressed in the Level 2 - Upper Quadrant SRT course. These techniques can be applied to a plethora of shoulder and neck pathology.

STAMINA® Rehabilitation Therapy courses begin in January 2014 in California and are CPTA approved CEU accredited. See www.staminaacademy.com for course details.

 

 

Teens Back Health: Gameboy Back - The next generation of pathology

Have you noticed a rise in children and adolescents with low and mid back pathology, headaches, neck and shoulder pain? It is happening globally. Our electronic devices and sedentary lifestyles are responsible. The good news is that with some public education and awareness this can be significantly reduced.

On November 1^st, CBC News reporter, Kim Brunhuber, did a piece about an alarming trend for teens' back health as a result of electronics.  Dr Mark Erwin from the University of Toronto was interviewed about the effects of children’s developing spines and muscles being repetitively sustained in a “C” curve.

Many would agree that there is a vital role for PT’s and OT’s in schools and with parents providing patient education for correct postural mechanics in daily life. We need to get parents and kids thinking about their posture when they use electronics and when they aren’t using electronics. There has been a relaxed attitude about posture for a few generations and we are seeing it in the rise of hip, LBP, shoulder, neck and carpel tunnel patients. One of the key problems is external femoral rotation/ EFR which weakens psoas major immediately leading to kyphosis. From sitting cross legged on the floor to external rotation of hip while sitting these postures set us all up for pain and set the developing body up for a life of pain.

 A simple solution is to show parents, teachers and kids the importance of holding their devices up, sit with neutral or on the floor internal femoral rotation (like hero pose in yoga), and do their homework on the laptop or tablet at a table using correct ergonomics. The effects of poor posture are reversible in most instances.

From a therapy perspective, aligning the psoas major is a powerful first step in restoring hip flexion and extension through the thoracolumbar spine. We demonstrate this free technique on our website under courses/STAMINA® Rehabilitation Therapy. We encourage every therapist to learn the psoas technique as a main tool in their treatment protocol. This technique is only one of 38 techniques taught in the SRT courses for the full body protocol.  Once manual therapy assessment and treatment is performed STAMINA® Rehabilitation Therapy restores optimal function to 38 stabilizing load management muscles. This combined with the SRT patient education will put our youth back on track for ideal development and help them be more active.

Reference:

Brunhuber, Kim and Hurko, Marijka, CBC New, Nov. 15, 2013 6 am, Yoga can lead to hip injuries http://www.cbc.ca/player/News/TV+Shows/The+National/About+the+Show/Kim+Brunhuber/ID/2415699721/?sort=MostPopular

A primary trigger of gradual and acute onset MSK Pathology

External femoral rotation or EFR is everywhere you look. It’s easy to spot the footprints in the sand or snow, in gait patterns of people walking the street, while standing in line, when sitting, kneeling and lifting. You’ll find it in sports and fitness class, Yoga, Pilates, ballet and dance. Many therapists and fitness gurus unknowingly encourage EFR, intending to alleviate tight hips and back pain, but are in actuality doing the opposite.  EFR has been taken for granted for so long and is so deeply engrained in our movements it is never questioned. Just because we have always done it doesn’t mean it is the best thing for us.  We now have an epidemic of foot and ankle, knee and hip, SIJ and spine, wrist, shoulder, neck and jaw pathologies that can kinetically be traced back to EFR. EFR is literally costing our health care systems billions of dollars globally, not to mention the loss of productivity and increased worker compensation costs to businesses. So an in-depth look at what actually occurs with EFR is long overdue.

EFR acts as an immediate OFF SWITCH to the psoas/iliacus triggering a ripple effect throughout the kinetic chain.  This is due to the distal psoas attachment at the lessor trochanter.  Psoas/iliacus easily stabilizes trunk loads with neutral or internal femoral rotation (NFR/ IFR).  EFR immediately weakens psoas, resulting in unbalanced load transfer to the posterior body and dysfunctional compensation patterns. Weakness in psoas, a significant local and global stabilizer, leads to segmental vertebral shear which can lead to end plate lesions and other pathology.  Without the powerful extensor/flexor/stabilization psoas offers there is combined compressive load with shearing to the thoracolumbar vertebral discs overtaxing facet ligaments. Without adequate stabilization of psoas/iliacus the pelvic and sacral iliac joints and ligaments are compromised leading to pelvic positional dysfunction. Without optimal tension and line of pull from psoas there is unbalanced demand on quadratus lumborum, multifidus, gluteus maximus, piriformis and quadratus femoris. Without the balanced tension of psoas, erect posture is more difficult leading to kyphosis which in turn leads to decreased function in upper quadrant muscle groups tested.   When psoas is dysfunctional, compensation is significant throughout the kinetic chain in upper and lower quadrants with marked load asymmetry.

 

 It’s simple to demonstrate this chain of events. Testing is performed with the subject sitting on a bench or standing while performing perturbation. The objective helps patients kinaesthetically learn the value of NFR. This test demonstrates decreased stabilization, decreased response time, load transfer and compensation patterns.  The test subject is asked to stand with feet in neutral position and notice response to lateral, anterior/posterior perturbation. Then repeat with feet at 45° and notice the change in response. Many people are of the impression they are more stable with EFR and are surprised to find the opposite. Further observations such as load pattern in foot front to back, knee compression, weakness in core, and trunk posture deficits  can be done simultaneously while in both NFR and EFR. 

After performing these tests thousands of times in clinical practice and public demonstrations we enlisted the help of researcher Greg Kawchuck PhD, Canada Research Chair of Spinal Function at the University of Alberta. Early data is consistent with clinical findings. Further studies commence in January 2014. In lab testing we have a subject fitted in a motion capture suit sitting on a robot platform which provides unpredictable perturbation. We are collecting data from the subject in external rotation and internal rotation. We will also be using EMG to show more specific details pertaining to muscle response time.

The positive side to all of this is that EFR is correctable in nearly all patients. Patients generally feel empowered to finally understand the cause of many of their problems. This knowledge is integral to STAMINA patient education and a great asset for therapists to share with patients of all ages and lifestyle. The most powerful injury prevention involves:  Avoid EFR in active or passive situations –sitting, standing, squatting, running, exercising or resting.  The clinical data we collected a few years ago demonstrates that when the psoas drops in function and stabilization, supraspinatus was the second lowest functioning muscle out of 38 key stabilizers measured and graph charted each treatment. When psoas is dysfunctional it influences kyphotic posture. A weakened psoas will increase the chances for injury to everything from the ankles to the neck, from the shoulders to the wrists and is a leading contributor to most MSK pathology.

We are currently seeking other investigators who would be interested in joining us in other aspects of this research. We have seen significant immediate changes in athletic performance NFR and suspect this will decrease injuries in many sports and workplace injuries.

STAMINA® Rehabilitation Therapy or SRT is a full body treatment protocol which restores dynamic equilibrium and joint centration throughout the kinetic chain with neuromotor re-education. SRT restores optimal muscle fibre line of pull for optimal muscle alignment and function. There are many treatment approaches out there that go about this in various ways with varying degrees of effectiveness. SRT restores optimal function to psoas/iliacus benefiting the whole kinetic chain. Courses commence January 2014 California. To host a course in your area contact: academy@staminatherapy.com .

References :

McGill, Stuart, (2007, 2^nd Edition) Low Back Disorders, pg. 61, “In a recent study, we examined a matched cohort of workers-half of whom had a history of disabling low back troubles, while the other half had never missed work. Those who had a history, were asymptomatic at the time of the test, had significant loss of hip extension and hip internal rotation (but more external rotation). This is an interesting observation, given much clinical discussion regarding the “tight” psoas. Even though we do not fully understand the neuromechanics, this muscle as a clinical concern is worth studying further.”

Brunhuber, Kim and Hurko, Marijka, CBC New, Nov. 15, 2013 6 am, Yoga can lead to hip injuries http://www.cbc.ca/player/News/TV+Shows/The+National/About+the+Show/Kim+Brunhuber/ID/2415699721/?sort=MostPopular