Beyond the SCM - caduceushandouts.comcaduceushandouts.com/csm/2016/handouts/pedAPTA-2232193.pdf · Beyond the SCM: Anatomy of the Neck and Its ... *Positional Release Therapy: D’Ambrogio

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Beyond the SCM: Anatomy of the Neck and Its

Clinical Implications

Jean Anne Zollars, PT, DPT, MA

www.jazollarspt.com www.barralinstitute.com

Anjali Gupta, PT, MS

Disclosure

The presenters declare no conflict of interest or bias in

the content of this presentation.

Objectives

1. Identify anatomical structures of the neck and

thoracic inlet: muscles, fascia, organs, nerves,

arteries, and bones

2. Identify physiological, functional and symptomatic

issues associated with tightness in the above

structures in infants and children.

3. Identify clinical implications in regards to treatment

of infants and children, focusing on stretching,

positioning, AROM, and developmental treatment.

http://www.jazollarspt.com/


Outline

• Anatomical review with self-palpation of

neck/supraclavicular structures

• Discussion of symptomology to be aware of

with overstretching/compression of

neurovascular structures

• Clinical implications, evaluative procedures,

treatment suggestions

• Case studies

• Summary & Questions

• Anatomy of neck: muscle and fascial layers

• Neurovascular anatomy through layers

-accessory n

-cervical nerves

-ant neck & trachea/vagus

-subclavian a

-brachial plexus

• Signs of overstretching nerves: phrenic,

brachial plexus, vagus, cervical plexus

Anatomy of neck

• Muscle and fascial layers

• Neurovascular anatomy through layers

-accessory n

-cervical nerves

-ant neck & trachea/vagus

-subclavian a

-brachial plexus


Cervical Fascia

• Tubes within tubes

• Anteriorly: visceral sheath (trachea, esophagus, thyroid)

• Posteriorly: vertebrae

• Laterally: blood vessels

• Muscles and fascia

Illustration by Frank Lowen

Sternocleidomastoid

Superficial cervical fascia

Trapezius

Platysma

Superficial cervical fascia: Loose, disorganized connective

tissue. Surrounds external jugular vein.

(13)


Self-palpation

Sternocleidomastoid: Manubrium of sternum & medial clavicle

to mastoid process of temporal bone & via aponeurosis to lateral

½ of superior nuchal line of occiput. (Palpate sup to inf)

Trapezius: Med 1/3 superior nuchal line of occiput, SP C1-C7,

T1-T12 to acromium to lat 1/3 clavicle, acromium, scapular spine


(Punctum nervosum)

Punctum Nervosum: sensory branches of cervical

plexus nerves emerge at posterior border of SCM (at

C3 level)

Self-palpation: From angle of mandible, go posterior to SCM &

Inferior 1 vertebral level to feel for punctum nervosum

(C2)

(C2,C3)

Cervical Plexus: sensory

innervation to…

• Lesser occipital nerve: scalp posterior to

ear

• Greater auricular nerve: scalp/skin of

mastoid process & parotid gland, outer ear

• Deep transverse cervical nerve: skin of

ant/lat neck

• Supraclaviclavicular nerves: skin above &

below the clavicle

Spinal Accessory Nerve

• Cranial root: origin medulla

• Spinal root: origin - lat aspect of ventral horn in spinal cord from 6th cervical segment to junction of spinal cord with medulla. The fibers go sup through foramen magnum

• Spinal root joins with cranial root, exiting thru jugular foramen

• Gray’s Anatomy, 40th Edition, p.459 (Standring 2008)

*Manual Therapy of the Cranial Nerves by

Barral and Croibier.Barral Productions.

Illustration © Elsevier Masson and Éléonore Lamoglia.*


Spinal Accessory Nerve

• Pierces SCM 3 cm from mastoid process (@ level of C3, behind angle of mandible)

• Within SCM, SAN receives branches of C2-C3, creating Ansa of Maubrac

• Exits SCM at posterior border at level of hyoid/C4

(Kierner A et al 2000, Dailiana et al, 2001)

Self-palpation: from C3 (punctum

nervosum, palpate within belly of SCM

*https://upload.wikimedia.org/wikipedia/common

s/4/4b/Gray793.png

Suboccipital nerve: (C1 posterior

branch) innervates rectus

capitus posterior minor between

occiput/C1 (connected to

spinal duramater)& vertebral

artery

Greater occipital nerve: innervates posterior

cranial dura, scalp & pierces trapezius




Self-palpation: Find Greater

Occipital N & C2 Posterior N

• From sup nuchal line (midine @ EOP), go 1 finger lat, 2 fingers inf

• (If feel pulse of > occ artery, just go medially)

• Find C2 nerve: from C2 spinous process, go laterally & cephalad into laminar groove to feel nerve & bud





Mid-cervical fascia

Fascia of infrahyoid muscles and pretracheal fascia

Attachments:

-Sup: hyoid

-Inf: upper border of scapula near the scapular notch (origin of omohyoid), post edge of clavicle, scalene tubercle and cartilage of rib 1, medial clavicle and post sternum.

Functions:

-Orients the hyoid muscles

-Surrounds all veins (brachiocephalic, thyroid, subclavian), thus maintains the patency of veins

*The Thorax. Barral JP 1991. Eastland Press. p 27

Thieme Lat view hyoid


Middle cervical fascia

Omohyoid

Sternohyoid

Sternothyroid

Self-palpation: Superficial & Middle Cervical Fascia

Superficial

cervical fascia


Visceral Sheath: Contains trachea, esophagus

& thyroid gland

Visceral sheath:

Vascular sheath:

• Thyroid gland

• Trachea

• Esophagus

Carotid artery

Jugular vein

Vagus nerve

Self-palpation: With back of your fingers, gently feel trachea. Swallow, that

movement is esophagus. Just lateral & posterior, feel pulse of carotid artery

Within the vascular sheath with jugular vein & vagus nerve



Jugular vein

Carotid artery

Vagus nerve

Vascular Sheath

Vagus Nerve

Deep Cervical/Prevertebral Fascia (32 &

handout)• Covers longus colli,

longus capitus and scalenes

• Deepest part goes from occiput to T3, where if fuses with ant long lig

• Anterior scalene attaches to tubercle of 1st rib

• Finding anterior scalene or subclavian artery can guide us to brachial plexus, pleural dome

Anterior scalene

Middle scalene Longus colli


Deep cervical fascia

Longus colli

Anterior scalene

Medial and

(Prevertebral fascia)

posterior scalene

Levator scapula


Self palpation of anterior scalene

Sit slouched. Backs of fingers 2-4 between 2 heads of a

of SCM. Feel TPs. Follow sternal head to sternum. Post

is ant scalene.

*Clemente (1997) Anatomy p.448

• Mostly C4, some C3, C5• Mixed motor (diaphragm) & sensory• Sensory: pericardium, pleura,

diaphragm, upper peritoneum.

• Connects to: subclavian n, stellate ganglion, vagus, hypoglossal, and sympathetic nerves of the neck.

Phrenic Nerve

*Manual Therapy of the Peripheral Nerves by




Subclavian

artery & brachial

plexus descend

posterior to

clavicle, between

clavicle &1st rib

Consider implications

of compression

on clavicle when

stretching

Subclavian

artery & brachial

plexus pass under

pectoralis minor

Consider tension

of pectoralis minor

Muscle Spindle Physiology• Intrafusal Muscle Fibers:

fibers of muscle responsible

for sensing the muscle

length and, the rate of

change of muscle length.

Sensory organ within

intrafusal fiber = muscle

spindles

• Extrafusal Muscle Fibers:

responsible for muscle

contraction

*Positional Release Therapy: D’Ambrogio & Roth. Mosby 1997


Muscle Spindle Physiology• When muscle stretched,

impulses go to spinal cord

(via Ia & II neurons)

• Synapse in ventral horn of

spinal cord

• Gamma motor neurons

send impulses to muscle

spindle to contract spindle

as a protective mechanism

so muscle does not get

overstretched or torn

• Alpha motor neurons send

impulses to extrafusal

fibers to contract

*Positional Release Therapy: D’Ambrogio & Roth.

Mosby 1997

Gamma Gain• In resting conditions, gamma motor

neurons maintain a level of

discharge into the intrafusal muscle

fibers, such that there is always

some muscle tone (not flaccid).

• Gamma motor neurons are like a

volume control, creating more or

less background tension in the

muscle.

• Gamma motor neurons are under

control of the bulboreticular

formation of the brainstem

• So, if too much gamma gain, person

has high resting tension in muscle,

or in CNS lesion, spasticity

• If someone has more activated

ANS, normal resting muscle tone is

higher

*Positional Release Therapy: D’Ambrogio &

Roth. Mosby 1997

What happens with muscle spasm?• If the muscle is quickly stretched or

overstretched, impulses are sent back via Ia

afferents to spinal cord at that level, above

& below, & to brain.

• Gamma motor neurons send impulses back

to intrafusal muscle fibers to further

contract muscle to protect it from injury

• If gamma activation continues or is higher

than usual, muscle spasm continues

*Positional Release Therapy: D’Ambrogio &

Roth. Mosby 1997


Nocioceptors: Pain receptors• Found in body’s connective

tissues including muscles

ligaments, tendons, joint

capsules, the outer wall of all

larger blood vessels, visceral

fascia (peritoneum) and in the

neural fascia (epineurium/dura).

(Schleip, R 2003)

• Nocioceptive reflex is spinal

reflex, such that if you touch a

hot burner, you quickly take

your hand off.

Peripheral Nerve Innervation

Nervi nervorum – nerve of nerve

2 types:

Sympathetic fibers: -Around arteries, regulating

vascularization due to diameter

change

Multinodal fibers:-Innervates CT of peripheral n’s,

n roots, & ANS/visceral NS

-Nerve monitors its own

sensitivity & nocioception

-Neuropathic pain

Peripheral Nerve

*Manual Therapy of the Peripheral Nerves by Barral and

Croibier.Barral Productions. Illustration © Elsevier and Hardlines.*

Nocifensive Reflexes

• Nocifensive reflexes: muscle contracts in response to

nociceptor activation (pain) in the involved tissues. (How

the body protects inflamed or damaged tissues).

• Nociautonomic reflexes are neural connections to the

autonomic nervous system that can result in autonomic

responses such as vasodilation, bronchodilation, or

gastrointestinal stasis. Skeletal muscle, for example, (due

to the presence of beta adrenoreceptors) will “engorge” or

swell under the influence of these reflexes due to the

release of chemicals such as histamine and bradykinin.

(Van Buskirk RL 1990)


Noxious Stimulus

Nocioceptor Vasodilation & Tissue

EdemaSpinal Cord

Nocifensive Reflexes

Skeletal Muscle Shortened

Maintain Shortening

Connective Tissue Reorganized

In Shortened Form

Sympathetic

Activation

Model of Nociceptive Origin & Maintenance of

Somatic Dysfunction

(Modified from Van Buskirk RL 1990)

Inappropriate Stretching

• Gamma gain is high

causing increased muscle

spasm

• Nociceptive reflex

activated: pain &

increased muscle spasm

• Nociautonomic reflex

activated

*The American College of Sports Medicine recommends that for maximal effect, stretching should NOT exceed the point of discomfort.(Garber et al 2011)

(Punctum nervosum)

Revisiting nerves and muscles…what are we

stretching?


*Manual Therapy of the Cranial Nerves by Barral and Croibier.Barral Productions.


Phrenic Nerve

Manual Therapy of the Peripheral Nerves by Barral and Croibier. Barral

Productions. Illustration © Elsevier and Hardlines.*

Brachial

plexus

Subclavian

artery

Consider implications

of compression

on clavicle when

stretching


Signs of Possible Irritation/Compression

of Nerves in Neck/Supraclavicular Area

• Punctum nervosum: increased sensitivity to

skin in and around lateral neck, scalp, head

• Greater occipital (posterior branch of C2):

increased tension in posterior trap, sensitivity in

back of scalp

• Phrenic: hiccupping, diaphragmatic spasm

• Accessory: increased tightness in SCM, trap

• Brachial plexus: Tension around shoulder, may

contribute to difficulty weight bearing in prone

Appropriate Stretch: Clinical

Practice Guidelines (Kaplan et al 2013)

• Stretch without stimulating the nocioceptors and

nervi nervorum (stretch without causing pain)

(Van Buskirk RL 1990, van Vlimmerman 2006,

Taylor 1997)

• Low-intensity, sustained , pain-free stretches to

avoid microtrauma (van Vlimmerman 2006)

• If the baby is crying, neck ROM does not increase,

muscle tightness still present, your stretching is

not helping.

Physiology of Stretching

• Muscle afferents responsible for cardiovascular changes:

• Group III – mechanoreceptors – sensitive to mechanical forces.

• Group IV – metaboreceptors – sensitive to metabolic changes.

• Elicit cardiovascular changes through parasympathetic withdrawal (tachycardia) and sympathetic activation (HR).

• (Drew 2008, Fisher 2005, Gladwell 2002, Farinatti 2011)

• Valsalva maneuver (VM) reduces the venous return, cardiac output (induces a baroreflex responses) and increases BP.

(Farinatti 2011, Lima 2011)


The nucleus of the tractus solitaries receives afferents from the carotid baroreceptors via the glossopharyngeal nerve and from the aortic baroreceptors from the vagus nerve (Klingler

2014) .

www.studyhttpsblue.com/notes/note/n/1-

vascularphysiology-4/deck/12427959

Vagus Nerve

• Sensory from ear, pharynx, larynx, palate, face, epiglottis, esophagus, lungs, abdominal viscera

• Motor to pharynx, larynx, palate, thoracic & abdominal viscera

Esophagus

Gastroesophageal

junction

Stomach

Vagus Nerve


Vagus Nerve

• Important part of the ANS

• Often involved with dysregulation of the ANS

• Viewed as a modulator of the nervous system in the field of neuropsychology (Polyvagal theory, Porges,1999, 2001, 2007, 2009 )

48


Signs of ANS dysregulation/vagal nerve

• Digestion issues: reflux, bloating, gas, constipation• Baby with irritability• Baby who is easily overwhelmed• Baby who is not sleeping well• Baby who does not want to make eye contact, or with

vacant eyes, dissociating.• Baby who is tacitely defensive (pulling away, muscles

tightening).• Baby with breathing difficulties, or noisy breathing.

49

Reprinted with permission from John W. Kimball

Nerve Reflexes to consider

• Laryngeal Cough Reflex: Yim et al (2010) demonstrated that irritation of the internal branch of the superior laryngeal nerve (branch of vagus nerve) causes a cough and a color change.


Superior Laryngeal Nerve

• Branch of vagus nerve

• Sensory to larynx, back of tongue, epiglottis & vocal cords

• Motor to cricothyroid muscle, inferior constrictor and laryngeal mucosa

• When tight or aggravated, affects swallowing, speech, produces cough

• (Yim et al 2010) *Manual Therapy of the Cranial Nerves by Barral and Croibier.Barral

Productions. Illustration © Elsevier Masson and Éléonore Lamoglia.*

https://www.studyblue.com/notes/note/n/anatphys-test-4-part-2

/deck/1654106

The sensory nucleus of the trigeminal nerve also receives afferents from the Gasserian Ganglion and has efferent connections to the MOTOR nucleus of the vagus nerve (Klingler

2014).

Tissue response to trauma

Aggressive stretching/positioning may perpetuate microtrauma and inflammation (Ercole 2010).

Trauma

Inflammation

Repair

Tissue remodel

https://www.studyblue.com/notes/note/n/anatphys-test-4-part-2


Habitual posture/chronic

tissue deformation

Localized tissue ischemia or edema

Scarring of soft tissue leading to

trigger point/nodule

Connective Tissue Tightness Mechanism

WHOLE BODY ASSESSMENT

Beyond the SCM: What else do you notice?

• Elevated shoulder• Flared ribs• Internally rotated shoulder• Trunk flexion• Elevated pelvis• Increased hip external rotation and

abduction• Tibial internal rotation• Tightness through metatarsals/metacarpals


SURROUNDING THE NECK

Fascial tightness Upper trap

is prominent while SCM is being stretched

Fascia has contractile ability

• Straubesand et al (1996) verified the ability of human fascia to actively contract and identified the presence of myofibroblasts or smooth muscle cells embedded within the fascia itself (Yahia LH, et. al (1993), Straubesand J, et. al, 1996).

• Subsequent experiments performed by Schleip in 2006 verified the presence of Type III and IV sensory endings, autonomic nerve fibers and contractile cells in fascia

Alternatives to Manual Stretching

• Myofascial release

• Joint Blocking

• Elastic Taping

• Positional release

• Neural manipulation


MYOFASCIAL RELEASE

FASCIA BASICS

• Fascia is comprised of:• connective tissue that surrounds and links bones, muscle, vessels and

nerves • smooth muscle cells, giving it the ability to contract

• Fascia also glides on itself; this allows for glide/shear between the structures it surrounds

• (Klingler 2014, Stecco 2013)

http://thewellnessdigest.com/fascia-the-unknown-factor-in-muscle-movement-and-soft-tissue-pain/

FASCIA BASICS

• Studies now show that fascia has a mechanical role in movement and force generation

• Additional myofascial units may be recruited over time if the original injury is not treated immediately (fibrosis)

• Tension causes the fascia to shorten and solidify anywhere along the line of pull

• Fascia will begin tightening down before changes are noticed in the muscle itself

(Klingler 2014, Stecco 2013)


WHAT IS MYOFASCIAL RELEASE?

• A gentle sustained pressure to treat soft tissue dysfunction causing increased tissue heat to increase viscoelasticity (Stecco 2013, Mattein 2009, Stern

2006).

• Soft tissue dysfunction can include (Stecco 2013): – limited AROM/PROM, – soft tissue adhesions, soft tissue tightness, and/or postural or

alignment dysfunction.

• Does not add tension to the neurovascular bundle under or within the tissue being stretched.

MYOFASCIAL ASSESSMENT/TREATMENT

• Maintain body mechanics

• Use the flat of your hands, not your fingertips

• Lightly traction the skin in all directions (like a compass) to determine area of restriction

• Approximate maximally restricted tissues to allow realignment

ELASTIC TAPING


ELASTIC/FLEXIBLE TAPING

• Principles of elastic taping make it a suitable modality for relaxing tight muscles/fascia.

• Depending on the degree of tightness and the patient’s tolerance, use relaxation techniques specific to the manufacturer

• Consider taping larger muscles due to skin sensitivity at the neck

ELASTIC TAPING

• Trim to fit patient’s size

• For muscle techniques: “Insertion to Origin in a lengthen position”

• Consider relaxing: cervical extensors if have a capital extension moment, traps, pectorals, latissimus, arm, trunk extensors, trunk fascia, leg

• Educate parents on cues of adverse reaction: stress cues, changes in eating/sleeping patterns, inconsolable

JOINT BLOCKING

• Uses positioning and body weight for a slow, low load “joint mobilization”

• Use to treat pelvic misalignment

• By correcting pelvic misalignment, you create normalized tissue length lower in the chain allowing for increased slack in the soft tissues higher in the chain.

• EXAMPLE: to correct an upslip, place a small towel roll under the upslip ischial tuberosity with the baby in supine. Can repeat as needed until neutral alignment is reached


“Pseudotumors”: Tender

Points/Fascial tightness

• With fibrosis, there are vascular changes, often

edema, then ischemia, so these areas need

special consideration.

• In order to release these areas, often the

muscle/fascial/neural/vascular structure needs

to be shortened to decrease gamma bias, and

inhibit the nocioceptors, the nocifensive &

nociautonomic reflexes

Positional Release TechniquesThese techniques are the opposite of direct stretch, such that the

muscle or joint is moved towards comfort to allow muscle

spindles to rest & reduce nocioceptive activity. They all use

tender points (TPs) and position of comfort or ease. Differences:

• Strain-counterstrain: uses TPs and reports of decreased pain to

assess efficacy of treatment (Jones 1997)

• Functional positional release: uses TPs, but relies on decreased

muscle hypertonicity, not pain

• Facilitated positional release: indirect MFR, uses TPs, position

of ease, then distraction, shear, etc to further decrease tension

• Total motion release for tots: indirect treatment in position of

ease

Total Motion Release for Torticollis


Positional Release Techniques

Research

Strain/counterstrain

• Systematic Review/meta-analysis: reduction of

pain TPs, no harm, only adults (Wong 2014)

• Decreased Hoffman reflex in patients with

Achilles tendonitis (Howell 2006) & plantar

fasciitis (Wynne 2006)

Neural Manipulation

• Neural Manipulation (NM)

is a gentle hands-on therapy

which helps to free up the

nerves and the connective

tissue around the nerves

(dura mater), the bones

around the brain (cranium)

so that the nervous system

functions better.

(Barral & Croibier 2007)

74

NM & UE Nerves

• NM can release compressed brachial plexus’ & UE nerves, thus allowing greater shoulder girdle mobility & UE to develop strength

• Gibson quotes Hilton, British anatomist and surgeon of the early 1800’s,“The same trunk of nerves whose branches supply a joint also supply muscles that move the joint and their articular insertions, as well as the skin covering the joint” (Gibson, 1955). 75


NM/VM Neck & Thorax

By releasing:• Left vagus nerve: help

with protective muscle

spasm L lateral neck

• T1/T2, ribs 1 & 2: help

with retraction of L ribs,

scapula

76

By releasing C2 (greater occipital nerve, help to

release trapezius, C1, C2 and posterior cranial

duramater

77

*Manual Therapy of the Cranial Nerves by Barral and Croibier.Barral

Productions. Illustration © Elsevier Masson and Éléonore Lamoglia.*

By releasing:

• L Accessory N: help to

release and lengthen L

SCM, trapezius

• L Phrenic N: help to

release C3-C5, anterior

ribs and diaphragm

• L brachial plexus: help

to free clavicle, 1st rib,

anterior shoulder

tension78


Neural Manipulation Research

• Most studies have been performed with “neural mobilization”, which is stretching the nerve through active movement along the nerve’s pathway. (This might be what we are doing with direct manual stretching of the neck).

• With Barral & Croibier’s neural manipulation, the neural restriction is first released gently in the “direction of ease”, where the tissues want to go, and only when the nerve is ready to lengthen, do you lengthen the nerve. One never fights with a nerve or tight tissue, otherwise the nerve tightens to protect itself.

79

Neural Mobilization/Stretching

Research in Adults• Much clinical research has been done by Barral, Croibier

(2007, 2009) and therapists trained in this technique; however, EBP is lacking both with adults and children.

• Chhabra’s study of 37 subjects with cervico-brachial pain concluded that neural tissue mobilization was a more effective treatment approach than cervical lateral glide (Chhabra et al., 2008).

• By using high-resolution ultrasound, Coppitiers and colleagues (2009) confirmed that the median nerve was longitudinally lengthened with six different neural stretching exercises.

• In a systematic review of 10 articles pertaining to neural mobilization, Ellis and Hing (2008) found current research to be lacking in the quantity and quality needed to support the use of neural mobilization.

80

WITH YOUR NEW RANGE

• Strengthen cervical flexors depending on age and tightness:

– Find the pacifier in either SL or supine depending on strength

– Visually attend to a toy at eye level then bring toy slowly down to chest area

– In sitting maintain a neutral pelvis while playing with toys at or below waist level


Video

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