Treating Technology Neck - Garry Adkins-NCBTMB …garryadkins.com › wp-content › uploads › 2017 › 12 › Treating-Technology-Neck.pdfProfessor Vladimir Janda, M.D. of Czechoslovakia,

Treating Technology Neck

Rapid Reconditioning for Restored Function and Performance

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Ending Forward Head Posture Pain

Interpreting hidden clues the body is trying to tell us

Defining Posture

We are all aware of faulty posture in the people we meet or members of our family. We might suggest exercises or “do this, but don’t do this” scenarios and leave it at that. When this person is in pain and comes to visit us as their therapists, everything changes. Posture is essentially the position of the body in space, the relationship of the body parts; head, trunk, and limbs to each other.

Due to the variety of body types, incorrect posture differs from person to person and is constantly changing. We commonly observe people with “poor” posture who are pain-free and other people with “good” posture who have pain. The type of activities performed by people varies widely, resulting in different stress demands on tissues of the body. There is no one ideal posture that exists for all people because tissues will adapt to meet the unique stress demands of each person. Injury occurs when tissues are unable to adapt to meet the demands of a given posture or task.

Posture influences

Poor posture can stem from many sources; one of the most significant sources deals with repetitive motion or bad habits without frequent breaks. The mind and emotional responses is a large contributor according to Erik Peper, PhD from San Francisco State University. In his research he assessed how posture affected an individual's ability to generate positive and negative thoughts.

Sitting up straight, participants relayed that they found it easier to conjure up positive thoughts and memories. Along these lines of thought, Psychological factors, especially self-esteem and depression. Pain leading to muscle guarding and avoidance of movement will affect posture, respiratory conditions, excess weight, which can lead to Loss of proprioception - the inability to perceive the position of your body in space.1,2

Body language affects how others see us, but it may also change how we see ourselves. Social psychologist Amy Cuddy talked about how “power posing” (standing in a posture of confidence, even when we don’t feel confident) can affect testosterone and cortisol levels in the brain, and might even have an impact on our chances for success. Amy Cuddy’s research on body language reveals that we can change other people’s perceptions and even our own body chemistry simply by changing body positions.3

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Improving Postural Awareness

Health care providers write exercise prescriptions for people to build regular movement and more effective posture into their daily habits all of the time. The reason this fails most of the time people are not told that to replace a bad habit they have been doing a long time with a good one requires first to recognize the importance to change. The person cannot eliminate a bad habit; they need to replace it with a better one. They do not need to be someone else; they just need to return to the person they used to be. (Golf slides)

One of the most common mistakes made when trying to help the person reach the goal of better posture is not being specific enough about what we the therapist wants, and what the person is willing to do to make it happen. Research shows that it is much easier to stay motivated when we have a very specific end point in mind, and can know at any moment exactly how far we still have to go. Also, the person should expect to have to work hard and realize that willpower can be zapped by everyday stress.

Progressive Muscle Relaxation

Progressive muscle relaxation is a technique that involves tensing specific muscle groups and then relaxing them to create awareness of tension and relaxation. It is termed progressive because it proceeds through all major muscle groups, relaxing them one at a time, and eventually leads to total muscle relaxation and better awareness.

Practice

Assume a comfortable position. You may lie down or sit in a chair; loosen any tight clothing, close your eyes and be quiet if possible, or record the instructions beforehand and play them back. Assume a passive attitude and slow down the breath. Focus on yourself and on achieving relaxation in specific body muscles. Tune out all other thoughts. Tense and relax each muscle group as follows:

• Forehead - Wrinkle your forehead; try to make your eyebrows touch your hairline for five seconds. Relax.

• Eyes and nose - Close your eyes as tightly as you can for five seconds. Relax.

• Lips, cheeks and jaw - Draw the centers of your mouth back and grimace for five seconds. Relax. Feel the warmth and calmness in your face.

• Hands - Extend your arms in front of you. Clench your fists tightly for five seconds. Relax. Feel the warmth and calmness in your hands.

• Forearms - Extend your arms out against an invisible wall and push forward with your hands for five seconds. Relax.

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• Upper arms - Bend your elbows. Tense your biceps for five seconds. Relax. Feel the tension leave your arms.

• Chest – Hug yourself for five seconds. Relax.

• Shoulders - Shrug your shoulders up to your ears for five seconds. Relax.

• Back - Arch your back off the floor or chair for five seconds. Relax. Feel the anxiety and tension disappearing.

• Stomach - Tighten your stomach muscles for five seconds. Relax.

• Hips and buttocks - Tighten your hip and buttock muscles for five seconds. Relax.

• Thighs - Tighten your thigh muscles by pressing your legs together as tightly as you can for five seconds. Relax.

• Feet - Bend your ankles toward your body as far as you can for five seconds. Relax.

• Toes - Curl your toes as tightly as you can for five seconds. Relax.

Focus on any muscles which may still be tense. If any muscle remains tense, tighten and relax those specific muscles three or four more times. Fix the feeling of relaxation in your mind. Resolve to repeat the process again.

In this relaxed state the body and mind is more susceptible to replace bad habits of ineffective posture. Have the person visualize perfect aligned posture with no stress on the major joints.

Have the person visualize what they look like and how they feel when standing with good effective posture. The shoulders are back, the spine is long and the head is reaching for the sky.

Have the person visualize what they look like and how they feel when they are walking with good effective posture. The shoulders are back, the arms are swinging, the spine is long and the head is reaching for the sky.

Next, how do they look and feel with good effective posture when they sit in their car, their favorite chair at home, or the chair they use when they are at work. The shoulders are back, the spine is long and the head is reaching for the sky.

Have the person practice this progressive muscle relaxation as often as possible. Not only will their posture improve, they find they do not absorb as much stress in their lives as before.

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Sagittal Balance of the Body

Looking at the person from the side position, the center of gravity in relation to stability normally falls about the level of the second sacral vertebra. This concentration of weight is exactly dependent on two factors; the body’s shape and mass distribution. When a person bends forward, the center of gravity line shifts anteriorly and inferiorly along with body mass distribution changes.

Consider the situation of a person concerned about falling forward.

When standing upright, the most stable position is when the center of gravity is posterior to the toes.

If this person bends forward at the hips to touch the ground and leans too far forward, the center of gravity moves anterior to the toes and the person falls over. One thing that would keep this from happening is the spine could deviate from its natural curves.4

This deviated position puts excessive strain on joints and requires muscle activity to maintain balance.

Therefore, it is not enough to encourage the person to sit or stand straighter.5

Treating the specific muscles that have become involved and rebooting the ones the person has forgotten about is the only way to be truly successful in bringing stability back to the body.

I look at this condition in the neck simply as “lesser is more”. Over time postural muscles (global stabilization) are subdued by lesser muscles that have become stronger from improper habits.

The postural muscles that used to support the vertebrae are now ineffective and gradually become weak. To make matters worse, the lesser muscles while still performing their primary function have taken on the job of supporting the vertebrae and the head.

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It is much easier to see why the lesser muscles have become stronger, they never stop working. The shoulder is different; the postural muscles are overworked and hypertonic whereas the lesser muscles are weak and also more easily fatigued.

Dissecting the Shoulder

A number of muscles of the shoulder remain major players in keeping an imbalance that over time multiplies compression to lead to disc degeneration. Professor Vladimir Janda, M.D. of Czechoslovakia, rehabilitation consultant for the World Health Organization was one of the first clinicians to bring this theory to light.

Professor Janda is perhaps best known for his identification of three postural syndromes: the upper (proximal) crossed; lower (distal or pelvic) crossed; and layer syndromes.

Briefly, each of these clinical scenarios described conditions in which the tone of antagonistic muscle groups became imbalanced and led to the predictable sequence of pain and dysfunction. Once the specific patterns of imbalance and impairment have been determined, a specific exercise program is implemented.

The general progression of treatment involves the normalization of peripheral proprioceptive structures, normalization of tight muscles, facilitation of inhibited or weak muscles, and finally coordination of movement patterns through specific exercise.

By researching Dr. Janda’s work, patterns started to emerge of tight muscles on one side and weak muscles on the other side. Essentially tight or tonic muscles shorten while phasic often weaken.

Type 1 or tonic fibers contract slowly and are able to burn oxygen more efficiently than phasic muscles, which allow them to work slowly and steadily over long periods of time.

Over time with misuse and disuse, these muscles will shorten. This is a clinically important distinction in tonic muscles response to stress.

Phasic or Type 2 fibers of which there are two main categories will weaken under prolonged stress and the fibers will tend to lengthen.

As I discovered it is not enough to just relax tight muscles. One must strengthen weak muscles and reeducate all

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associated muscles to achieve balance. Muscles must be trained reflexively to restore normal firing patterns, speed, and coordination with other movements.

Dr. Janda's unique Sensorimotor Training (SMT) program is the basis for restoring normal muscle function. SMT specifically targets the sensorimotor system through progressive proprioceptive exercises.

Janda Approach to Treatment

1. Normalize the periphery. 2. Restore Muscle Balance. 3. Increase afferent input to facilitate reflexive stabilization. 4. Increase endurance in coordinated movement patterns.

Janda’s approach emphasizes the importance of the Central Nervous System in the sensorimotor system, and its role in the pathogenesis in musculoskeletal pain. In particular: the neurological pre-disposition of muscles to exhibit predictable changes in tone, and the importance of proprioception and afferent information in the regulation of muscle tone and movement. Therefore, assessment and treatment focus on the sensorimotor system, rather than the musculoskeletal system itself. Using a functional, rather than a structural approach, the cause of musculoskeletal pain can be quickly identified and addressed.

In addition, Sherrington’s law of reciprocal inhibition (Sherrington, 1907) states that a hypertonic antagonist muscle may be reflexively inhibiting their agonist. Therefore, in the presence of tight and/or short antagonistic muscles, restoring normal muscle tone and/or length must first be addressed before attempting to strengthen a weakened or inhibited muscle.

Once I started to apply the theory of levers and pulleys and the concepts of Dr. Janda to rotational imbalances my results were not only more positive, but conditions like forward head posture, chronic low back pain, and frozen shoulder I had previously been unable to affect were now improving.

The shoulder complex is confusing for many therapists because once the structural integrity is compromised by injury every structure that inserts or is associated with the shoulder or arm is affected. It is not uncommon to find pain in one area, but the source is in another area.

To unravel this complicated region let us first look at the foundation of the bones. The shoulder itself is made up of the clavicle (which is the only boney attachment to the upper torso). The scapula, this bone is the main foundation of the shoulder which floats over the ribcage and is held in place by muscles. The humerus is held in place by muscles as well.

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The shoulder capsule itself absorbs tremendous pressure during any forceful pushing movements or bracing to protect us during a fall. If the position of anterior rotated shoulders is also present forceful movement will likely result in injury because the weakened muscles have stopped supporting the joint on their side.6

Scapula Orientation on the upper torso should be 30 Degrees anterior to the sagittal plane.

The anterior rotated scapula of at least 40 Degrees is common and is felt to be the underlying cause of many shoulder injuries and is present in dominant overhead-throwing athletes.7

So if it is true that the scapula is held in position by muscles all that is needed to disrupt the delicate balance of 30 degrees to the sagittal plane is stronger muscles on one side and weaker muscles on the other side.

Postural Muscles

Let us first explore what is termed as tonus (or postural) muscles of the shoulder which act predominantly to sustain posture in the gravity field. These muscles contain mostly slow-twitch muscle fibers and have a greater capacity for sustained work. They are prone to hyperactivity.

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Interesting enough of the four muscles of the rotator cuff that hold the humerus in place in the glenoid fossa only one is on the list of postural muscles. So with a rounded shoulder position the most activated muscle is the Subscapularis, no wonder it is so sensitive and over worked.

These muscles require lengthening and stretching because of hypertonicity and being over worked while still performing their primary function they have taken on the job of balancing as well.

Pectoralis Major - Primary function: Adducts, and rotates the arm medially

Pectoralis Minor - Primary function: Draws scapula forward and downward

Levator Scapula - Primary function: Elevates scapula

Trapezius (upper) - Primary function: Elevates lateral point of scapula

Subscapularis - Primary function: Internal rotation of the shoulder

Deltoid (anterior) - Primary functions: Flexes the humerus

Latissimus Dorsi - Primary function: Extension, adduction, and medial rotation of the humerus

Teres Major - Primary function: Extension, adduction, and medial rotation of the humerus

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Lesser Muscles

Phasic (or lesser) muscles contain mostly fast-twitch muscle fibers, and are therefore more suited to movement. They are prone to inhibition. They are also more easily fatigued.

Trapezius (middle) - Primary function adducts scapula

Trapezius (lower) - Primary function depresses scapula

Serratus Anterior - Primary function Protracts (fixes) scapula against the ribs, abducts and rotates the scapula

Supraspinatus - Primary function abduction of the humerus

Infraspinatus - Primary function is to externally rotate the shoulder

Deltoid (posterior) - Primary function: Extends the humerus

Rhomboid major and minor - Primary function: Adducts, elevates the medial border, and rotates the scapula

Postural muscles tend to shorten in response to over-use, under-use or trauma, whereas phasic muscles tend to lengthen and weaken in response to these types of stimuli. These effects can lead to musculo-skeletal imbalance and joint instability when postural and phasic muscles are located on opposing sides of the agonist-antagonist relationship.

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Passive Range of Motion Shoulder Assessment

These assessments are used to determine range of motion and in most cases pain will point to ligament damage. Medical authorization may be indicated to perform.

Shoulder flexion

Position of Subject: Seated with the arms at the sides.

Position of Therapist: Standing to the side of the subject. One hand grasps the forearm. The other hand may stabilize the shoulder.

Assessment: Therapist flexes the shoulder by lifting the arm.

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to lift your arm up”.

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Shoulder extension


Position of Therapist: Standing behind the subject. One hand grasps the forearm. The other hand may stabilize the shoulder.

Assessment: Therapist extends the shoulder by lifting the arm backward.

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to lift your arm back”.

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Shoulder abduction


Position of Therapist: Standing behind the subject. One hand grasps the forearm. The other hand may stabilize the shoulder.

Assessment: Therapist abducts the shoulder by lifting the arm to the side.

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to lift your arm to the side”.

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Shoulder horizontal abduction

Position of Subject: Seated with the test hand on the head.

Position of Therapist: Standing behind the subject. One hand grasps the elbow. The other hand stabilizes the scapula.

Assessment: Therapist horizontally abducts the shoulder by pulling the elbow backwards.

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to pull your elbow backward”.

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Shoulder horizontal adduction

Position of Subject: Seated with the test arm in shoulder flexion.

Position of Therapist: Standing to the side of the subject. One hand is contoured around the forearm at the elbow. The other hand stabilizes the opposite shoulder.

Assessment: Therapist adducts the shoulder by bringing the arm to the opposite side.

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to bring your arm to the opposite side”.

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Shoulder external rotation

Position of Subject: Seated with the test arm in shoulder abduction and in elbow flexion. (If shoulder injury is suspect, elbow is fixated against the side of the body)

Position of Therapist: Standing to the side of the subject. One hand is contoured around the wrist. The other hand stabilizes the elbow.

Assessment: Therapist externally rotates the shoulder by bringing the wrist backwards and upwards.

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to bring your wrist backward”.

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Shoulder internal rotation

Position of Subject: Seated with the test arm in shoulder abduction and in elbow flexion.

Position of Therapist: Standing to the side of the subject. One hand is contoured around the wrist. The other hand stabilizes the shoulder.

Assessment: Therapist internally rotates the shoulder by bringing the wrist downwards and backwards.

Instructions to Subject: “Look at the ceiling. Keep your shoulders down and relaxed. Allow me to bring your wrist downward”.

Continue your assessment by noting any weakness of muscle strength, lack of movement, or pain during movement.

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Muscle Assessment Protocol

In order to effectively treat the classic rounded shoulder posture, upper body pain assessment skills must be practiced and perfected.

These assessment tools will show us three things:

1. Are regions of the body compensating for structure instability? 2. Which specific muscle or tendon is affected? 3. Is it a muscle/tendon injury or ligament/joint injury?

Systematic evaluation of muscular imbalance begins with static postural assessment, observing muscles for characteristic signs of hypertonicity or hypotonicity. As you inspect, compare each area bilaterally, noting any indications of pathology as well as the condition and general contour of the anatomy.

An example with the scapula could be any asymmetry in the relationship between the scapula and the thorax which may indicate weakness or atrophy of the serratus anterior muscle and may present as a winged effect.

This is followed by a series of question and answers: When did you first notice the problem? Can a certain movement reproduce any pain? If you used any previous treatment, was it helpful? Any muscle aches, tension, or problems sleeping?

Next, characteristic movement patterns are assessed, and specific muscles are evaluated muscle function and strength. This is referred to as manual muscle testing.

There is such a wide variation of the grading scale with normal adults, for our purpose a much gentler version will be used. In most cases pain will point to muscle or tendon damage during these tests.


• Resistance or pressure from the therapist is only 1 to 2 pounds. • Direction of resistance follows black arrows on illustration. • Test is performed for a maximum of 5 seconds.

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Shoulder flexion

Position of Subject: Sitting with arms at the sides.

Position of Therapist: Standing at side of subject next to the test side. Hand giving resistance is contoured over the distal humerus just below the elbow. The other hand may stabilize the shoulder.

Assessment: Subject flexes the humerus to 90 degrees without rotation or horizontal movement.

Instructions to Subject: “Raise your arm forward to shoulder height. Hold it. Don’t let me push it down.”

Resistance is only “1 or 2” pounds.

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Shoulder extension

Position of Subject: Sitting with arms at the sides, palm open.

Position of Therapist: Standing at side of subject next to the test side. Hand used for resistance is contoured over the posterior arm just below the elbow.

Assessment: Subject extends the arm, keeping the elbow straight.

Instructions to Subject: “Move your arm back as far as you can. Hold it. Don’t let me push it down.”


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Shoulder abduction

Position of Subject: Sitting with arms at the side.

Position of Therapist: Standing behind the person. Hand giving resistance is contoured over the arm just above below the elbow.

Assessment: Subject Person abducts the arm to 90 degrees.

Instructions to Subject: “Lift your arm out to the side to shoulder level. Hold it. Don’t let me push your arm down.”


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Shoulder horizontal abduction

Position of Subject: Sitting with shoulder abducted to 90 degrees with elbow flexed.

Position of Therapist: Standing at side of subject next to the test side. Hand used for resistance is contoured over the posterior arm at the elbow.

Assessment: Subject horizontally abducts the arm, keeping the elbow bent.

Instructions to Subject: “Move your elbow up backwards. Hold it. Don’t let me push it forwards.”


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Shoulder horizontal adduction

Position of Subject: Sitting with shoulder abducted to 90 degrees and elbow flexed to 90 degrees.

Position of Therapist: Standing at side of subject next to the test side. Hand used for resistance is contoured around the elbow.

Assessment: Subject horizontally adducts the arm, keeping the elbow bent.

Instructions to Subject: “Move your arm across your chest. Hold it. Don’t let me pull it back.”


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Shoulder external rotation


Position of Therapist: Standing at side of subject next to the test side. One hand is used for resistance at the wrist. The other hand supports the elbow to provide some counter pressure at the end of the range.

Assessment: Subject moves the forearm through the range of external rotation.

Instructions to Subject: “Raise your arm to the level of the table. Hold it. Don’t let me push your hand forward.”


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Shoulder internal rotation


Position of Therapist: Standing at side of subject next to the test side. The hand giving resistance is just above the wrist. The other hand supports the elbow to provide some counter pressure at the end of the range.

Assessment: Subject moves the arm backward and upward through the range of internal rotation.

Instructions to Subject: “Move your forearm up and back. Hold it. Don’t let me push your hand forward.”


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Working "With" Instead of Working “On”

There are two approaches applied by therapists: "working on the person" and "working with the person." Working on the person pre-supposes that the person cannot help themselves; working with the person pre-supposes that the person has some practical responsibility for, and ability to change, their own condition. Every massage stroke is one or the other: doing it to the person or doing it with them; it is either forcing them to relax or helping them discover that they are contracting and teaching them to relax when, until then, they had forgotten how.

Utilizing Dynamic Extension Technique

One of my favorite techniques is a movement “Dynamic Extension Technique”. It is commonly known as a massage concept called “pin-and-stretch”, which is applying pressure to a muscle as you elongate it.

In addition, Sherrington’s law of reciprocal inhibition (Sherrington, 1907) states that a hypertonic antagonist muscle may be reflexively inhibiting their agonist. Therefore, in the presence of tight and/or short antagonistic muscles, restoring normal muscle tone and/or length must first be addressed before attempting to strengthen a weakened or inhibited muscle.

As a muscle contracts the motor nerve has been activated which is commonly known as a concentric contraction. The opposite or antagonist muscle relaxes known as an eccentric contraction.

If pressure is applied to a muscle while it is in the relaxed or lengthened eccentric state it will encourage the elongation of muscle tissue with less discomfort for the patient.

One of the obstacles I face with treating people is lack of awareness of their bodies.

With athletes, many train way past their pain threshold. In fact, the average person may suppress nagging discomfort with their day to day lives.

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As this warning signal is suppressed more and more the person may not be aware of a nagging irritation that has grown into a full blown injury until the therapist addresses it on the treatment table.

An added benefit of Dynamic Extension Technique is by having the person actively contract the opposite muscle of the one being treated will encourage awareness of this dysfunctional area and help to restore proper function and range of motion.

Manual Treatment Posterior Trunk

Mid back – Erector Spinae

• Start your forearm stroke up the back from the hip, just lateral from the spine, concentrating on the erector muscle area about T12 up to T6.

• Compress the lateral edge into the center of the spine to further release this muscle group.

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Upper back - medial scapula

• If range of motion permits, place the patient’s arm behind their back in internal rotation. Using thumb or fingers, stroke up and under the vertebral border of the scapula. Continue this line until the clavicle is reached.

• At the T7 area, return under the scapula. But this time follow any restriction, until it is smooth.

• Be aware of any restrictions or adhesions around the ribs.

Because of lack of mobility in the thoracic area it is common to find fibrous tissue at the level of T-2 through T-7 along the vertebral edge.

• Gently cross fiber the area from T-2 through T-7 lateral of the spinous processes. • Not only will this help to break up fibrous tissue but will also help in facilitation of

inhibited or weak muscles

Upper back- Dynamic Extension Release

Mid-thoracic pain is usually the result of facet joints that do not move back into place when the spine is extended.

• “Dynamic Extension Release” movement is performed by having the person start flat on the table and slowly arches their back while you stroke the area from T-2 through T-7 lateral of the spinous processes in a superior and inferior direction.

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Trapezius

• “Dynamic Extension Release” movement is performed by having the person start in cervical extension and slowly lowers the neck into cervical flexion while you stroke the trapezius.

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• If any adhesions are found, go against the grain and smooth out any restrictions. Note any referral pain patterns.

• “Dynamic Extension Release” movement can also be performed by having the person start in shoulder elevation and slowly lowers into shoulder depression while you stroke the trapezius.

Posterior Scapula

• This area is highly problematic because of the dominate pulling of the anterior muscles. “Dynamic Extension Release” movement is performed by having the person start with the arm at the side and slowly internally rotates and flexes the shoulder while you stroke the Infraspinatus, and Teres muscles.

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• If any adhesions are found, go against the grain and smooth out any restrictions. Note any referral pain patterns.

• Be sure to examine under the spine of the scapula and the acromion. • If pain or referral patterns are present, ice massage during the treatment will calm

down nerve receptors and limit an inflammatory response.

Upper-back glide

• If range of motion permits, place the patient’s arm overhead to stretch the muscles, and the intercostal spaces.

• Start your forearm glide down the back from C-7 to T-12 lateral to the spine, then with each stroke; move more laterally to treat the area closer to the scapula.

• Generally a minimum of 3 strokes, with the 2nd and 3rd stokes angle towards the hips.

• If any adhesions are found, go against the grain and smooth out any restrictions. • It is not uncommon in this position to find restrictions that inhibit the ribs.

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Manual Treatment Anterior Trunk

Chest- Pectoralis Major

• “Dynamic Extension Release” movement can be performed by having the person start in shoulder horizontal adduction and slowly lowers the arm into shoulder horizontal abduction while you stroke the muscle.

• Standing at the head, with the persons elbow locked to their side, hook under the Pectoralis major muscle at the axillary border with the fingers.

• Have the person externally rotate the shoulder by dropping the forearm. • Finish the stroke by dragging the fingers medially to the clavicle smoothing any

adhesions.

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Shoulder decompression

• With one hand grasp the Posterior Deltoid, and Coracoid process of the scapula. With the other hand, support the arm at the wrist or the elbow.

• Rotate the passive arm while holding the shoulder position as a fulcrum. • By using palpation and passive positions, find a position of no pain or tightness

and the position with pain and tightness. The position that relieves the pain or tightness is held for 20 seconds. The muscle can then be passively stretched beyond its previously restricted range.

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Shoulder torque

• Rotate the flexed arm while applying a mild torque in both directions. • Make sure the person does not engage the muscles. • Find a position of no pain or tightness and the position with pain and tightness.

Slowly move into the position of discomfort while allowing the person to remain relaxed.

• Do not continue moving if an area does not release. • By releasing some of the torque or changing directions may be helpful.

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Shoulder terminator

• Have the person position their hand on the abdomen with the elbow at the side. • Place both thumbs at the Coracoid process of the scapula while the fingers

stabilize the shoulder. • Have the person externally rotate the shoulder by keeping the elbow locked to the

side and bring the hand outward off of the table. • Drag the thumbs up to the top of the shoulder. If any adhesions are found, go

against the grain and smooth out any restrictions.

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The Foundation of the Head

I have concluded that people know every spilt second what position their head is in, but don’t have a clue as to what their neck is doing. Balance and equilibrium helps us stay upright and know where we are in relation to gravity. As the head moves, hair cells in the semicircular canals send nerve impulses to the brain by way of the acoustic nerve. The nerve impulses are processed in the brain to help us know where we are in space or if we are moving.

Forces beyond the Necks Control

Before effective treatment of the neck can begin we must first look at the tremendous forces at work. With a relaxed individual with minimal stress and excellent posture the neck balances the head equally on all sides. No one side is pulling more than the other.

If this relaxed person bends over things change in a fraction of a second. The muscles of the back of the neck have to stiffen to keep the head up and the eyes forward. This protective mechanism is called the “law of righting”. It states, “The eyes will always be level with the horizon regardless of what happens with the rest of the body”.

Many factors come into play in a person’s life, improper posture, injuries, emotional trauma, environmental, with the effect, if done often enough will affect the tissues of the neck to forget the balanced state it once had.

Most conditions of the neck from pain and tightness, to medical diagnoses of cervical radiculopathy, disc protrusion or herniation, and even osteophytic reactive changes can be traced back to previous trauma or imbalance.

But today is rarely thought of when treating the neck.8

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Dissecting the Neck

Before the musculature of the neck can be examined we must look at the movements we should be capable of. A rarely discussed subdivision of flexion and extension is capital and cervical function.

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Postural Muscles

Over time these postural muscles are subdued by lesser muscles that have become stronger from improper habits.

The postural muscles that used to support the vertebrae are now ineffective and gradually become weak.

To make matters worse, the lesser muscles while still performing their primary function have taken on the job of supporting the vertebrae and the head.

It is much easier to see why the lesser muscles have become stronger, they never stop working.

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Now as we explore the stronger lesser muscles, keep in mind this illustration of extreme collapsed posture with a forward head and hunched shoulders.

For every inch that the head moves forward in posture, it increases the weight of the head on the neck by 10 pounds!

In the example to the right a forward neck posture of 3 inches increases the weight of the head on the neck by 30 pounds and the pressure put on the muscles increases 6 times.

It is also interesting to note that there are twice as many extension muscles compared to flexion muscles.

Lesser is More

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Review of the Basics

As we continue to unravel this complex region, let us see what has been discussed so far.

• Most conditions of the neck can be traced back to previous trauma or imbalance. • Improper posture over time will cause the postural muscles to become ineffective

and gradually become weak. • Lesser muscles while still performing their primary function have taken on the job

of supporting the vertebrae and the head. • There are twice as many extension muscles compared to flexion muscles.

Assessment is the key

In order to effectively treat the classic forward head posture, in which most degenerative conditions arise, assessment skills must be practiced and perfected. Systematic evaluation of muscular imbalance begins with static postural assessment, observing muscles for characteristic signs of hypertonicity or hypotonicity.

Try the Wall Test for Neck Posture: - Stand with the back of your head touching the wall and your heels six inches from the baseboard.

With your gluteals touching the wall, check the distance with your hand between your neck and the wall.

If you can get within two inches at the neck, you are close to having good posture.

Or, fully retract your head backwards as far as possible, then release the last 10% of this movement.

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Passive Range of Motion Neck Assessment

These assessments are used to determine range of motion and in most cases pain will point to ligament damage. Medical authorization may be indicated to perform.

Capital extension

Position of Subject: Seated. Arms at sides.

Position of Therapist: Standing behind subject next to the head. Both hands are placed around the head.

Assessment: Therapist extends head by tilting chin upward in a nodding motion. (Cervical spine is not extended).

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to tilt your head up”.

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Cervical extension

Position of Subject: Seated. Arms at sides.

Position of Therapist: Standing next to subject’s head. One hand is placed over the subject’s upper back for support. The other hand is placed on the forehead.

Assessment: Therapist extends neck without tilting chin.

Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me tilt your head back”.

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Capital flexion

Position of Subject: Seated or supine with head on table. Arms at sides.

Position of Therapist: Standing at head of table facing subject. Both hands are placed around the head.

Assessment: Therapist tucks chin into neck. No motion should occur at the cervical spine; this is the downward motion of nodding.

Instructions to Subject: “Keep your shoulders down and relaxed. Allow me tilt your head forward to tuck your chin”.

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Cervical flexion

Position of Subject: Seated or supine with head on table.

Position of Therapist: Standing behind subject’s head. One hand is placed on the back of the subject’s head. Other hand is cupped around the shoulder for support.

Assessment: Therapist flexes neck by pushing head straight forward without tucking the chin.

Instructions to the Subject: “Keep your shoulders down and relaxed. Allow me tilt your head forward”.

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Lateral flexion


Position of Therapist: Standing next to subject’s head. One hand is placed on subject’s side of head to be tested. Other hand is cupped around the shoulder for support.

Assessment: Therapist lateral flexes neck by bring ear to shoulder; while pushing shoulder in opposite direction.

Instructions to the Subject: “Keep your shoulders down and relaxed. Allow me tilt your head to the side”.

Continue your assessment by noting any weakness of muscle strength, lack of movement, or pain during movement.

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Next, characteristic movement patterns are assessed, and specific muscles are tested for function and strength. This is referred to as manual muscle testing. There is such a wide variation of the grading scale with normal adults, for our purpose a much gentler version will be used. In most cases pain will point to muscle or tendon damage during these assessments.


• Resistance or pressure from the therapist is only 1 to 2 pounds. • Direction of resistance follows black arrows on illustration. • Assessment is performed for a maximum of 5 seconds.

Capital extension

Position of Subject: Seated or prone with head off of the table. Arms at sides.

Position of Therapist: Standing at side of subject next to the head. One hand provides resistance over the occiput. “1 to 2 pounds only”. The other hand is used if support is needed.

Assessment: Subject extends head by tilting chin upward in a nodding motion. (Cervical spine is not extended).

Instructions to Subject: “Look at the ceiling. Hold it. Don’t let me tilt your head down”.

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Cervical extension

Position of Subject: Seated or prone with head off of the table. Arms at sides.

Position of Therapist: Standing next to subject’s head. One hand is placed over the subject’s back of the head for resistance. The other hand is used if support is needed.

Assessment: Subject extends neck without tilting chin. Resistance is only “1 or 2 pounds”

Instructions to Subject: “Push on my hand but keep looking at the wall or ceiling. Hold it. Don’t let me push it down”.

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Capital flexion


Position of Therapist: Standing next to subject’s head. Hand for resistance is placed on subject’s forehead to give resistance in an upward and backward direction. Only 1 to 2 pounds. The other hand is used if support is needed.

Assessment: Subject tucks chin into neck. No motion should occur at the cervical spine; this is the downward motion of nodding.

Instructions to Subject: “Tuck your chin. Don’t lift your head. Hold it. Don’t let me push your head back”.

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Cervical flexion


Position of Therapist: Standing next to subject’s head. Hand for resistance is placed on subject’s forehead. Only 1 to 2 pounds. The other hand is used if support is needed.

Assessment: Subject flexes neck without tucking the chin.

Instructions to the Subject: “Flex your neck down, don’t lift your head. keep looking at the wall. Hold it. Don’t let me push your head back”.

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Lateral flexion


Position of Therapist: Standing next to subject’s head. Hand for resistance is placed on subject’s side of head to be tested. Other hand is cupped around the shoulder for support. Only 1 to 2 pounds.

Assessment: Subject lateral flexes neck without tilting the chin.

Instructions to the Subject: “Bring your ear to your shoulder; keep looking at the wall. Do not lift your shoulders. Hold it. Don’t let me push your head to the side”.

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Quiet Inspiration

Position of Subject: Supine

Position of Therapist: Standing next to subject at waist level. One hand is placed lightly on the abdomen just below the xiphoid process. Resistance of 1 to 2 pounds only is given (by same hand) in a downward direction.

Assessment: Subject inhales with maximal effort and holds maximal inspiration.

Instructions to Subject: “Take a deep breath . . . as much as you can . . . Hold it. Push against my hand. Don’t let me push you down.”

Diaphragmatic breathing inhibits the involvement of overactive accessory breathing muscles and keeps their activity to a minimum during rest.

Accessory breathing muscles are designed to assist breathing only during exertion to further expand the ribs but should remain primarily silent at rest.

The most important fault during breathing is lifting the thorax with the scalenes instead of widening it in the horizontal plane.

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Manual Treatment Posterior Neck

A combination of techniques and modalities are required to effectively treat the neck area. The goal is to lengthen short, hypertonic muscles with deep-tissue, myofascial release, friction massage, and active isolated assisted-stretching techniques, which I have found to elongate this dysfunctional tissue.

If your assessment skills are sound, you should have a good indication as to where you need to focus your work. Keep in mind Janda’s upper cross syndrome of predictable sequence of tightness and weakness. Through experience I have found most problems of the neck dealing with muscle tissue seem to come and go. With chronic complaints lasting years ligament damage and structural changes occur.

One of my favorite techniques is a movement I like to call “Dynamic Extension Release”. It is commonly known as a massage concept called “pin-and-stretch”, which is applying pressure to a muscle as you elongate it. The first order of business is to position the person on the table in a prone position.

This area will require much of your work, so I prefer to work one layer at a time with minimal discomfort to the person.

The person eventually turns over to a supine position, as we continue to attack this highly problematic area many times.

Always remember to work “with” the person instead of “against” them. Discomfort but not painful and always receive permission first.

As you can see in this illustration, muscle fibers cross in different directions, with each muscle having the ability to stick or adhere to the deeper layer.

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Trapezius

• In the prone position, warm up the tissue with gentle stokes, directed in either up or down movements.

• “Dynamic Extension Release” movement is performed by having the person start in cervical extension and slowly lowers the neck into cervical flexion while you stroke the trapezius.

• If any adhesions are found, go against the grain and smooth out any restrictions. In some instances, holding the restriction until it softens is helpful. Note any referral pain patterns.

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Extension muscles

• As the trapezius releases focus your intention working the deeper layers of the extensor musculature.

• Follow the same procedure as in the previous muscle. Smoothing any adhesions and use “Dynamic Extension Release” as described earlier.

Subocciptals

• If your treatment table is equipped with an adjustable face cradle, lower the angle a few degrees, or have the person tilt their forehead down into capital flexion to access the base of the neck.

• “Dynamic Extension Release” in this area is accomplished by having the person move slowly into capital flexion. While you stroke the Subocciptals.

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Intertransverse ligament

The fifth and seventh cervical intertransverse ligament is often injured. In the prone position it is easily accessible. To find this ligament, go inferior from the mastoid process and push laterally into the side of the neck. At the level of C3 you will need to push the anterior fibers of the upper trapezius posterior and remain anterior to these fibers.

You should find a semi-hard structure which is the transverse process. This area is also the attachment for the scalenes and levator scapula. Continue inferior until you cannot go any further, which is anterior to the trapezius.

This is the level of the C7 vertebrae which is the main culprit for medial scapular referral pain and limited side flexion or rotation.

After the transverse process is located, gently cross fiber in an anterior to posterior direction to treat the ligament. Note any referral pain patterns.

• Gently cross fiber any of the higher ligaments (C2-C6) if pain is present.

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Dowagers hump

“Dowagers hump” is an abnormal thickening of the area at the vertebrae of C7 found in many forward head postures. Compression of the front (anterior) portion of the involved vertebrae leads to forward bending of the spine (kyphosis) and creates a hump at the upper back. If untreated, in time osteoporotic changes will take place. Do not perform technique if client has advanced osteoporosis to prevent possible fracture.

If a fracture is not present, hypomobile facet joints at the C6-C7 level will prevent proper alignment and foundation for the cervical spine, even if balance of the musculature is restored.

• Have the person raise the head out of the face cradle. • As the person lowers their head, stroke upwards superiorly on this area.

• Continue this movement at least 2 more times and stroke in a downward inferior direction.

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Manual Treatment Posterior Neck

In this position the weight of the person’s head will allow you to generate pressure instead of just doing it yourself in the prone position. Be aware that your wrist has a tendency to flex or extend, which could cause you (the therapist) to strain.

Posterior musculature

Continue treating all of the muscles of the posterior region. The person’s head may be elevated by a pillow, supported with your other hand, or lying on the table.

• Treat trapezius and extensor muscles.

• If any adhesions are found, go against the grain and smooth out any restrictions.

• Note any referral pain patterns.

• Use “Dynamic Extension Release” to treat the extensor muscles.

• Have the person slowly move their neck into cervical flexion as you stroke up or down.

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Subocciptals

• Treat these muscles with the head rotated to the side.

• The person’s head may be elevated by a pillow, supported with your other hand, or lying on the table.

• Using “Dynamic Extension Release”, have the person move into capital flexion as you stroke.

Intertransverse ligament

• After the transverse process is located (inferior to and in line with the mastoid process), remembering to stay anterior to the trapezius.

• Gently cross fiber in an anterior to posterior direction to treat the ligaments of C2-C7. Note any referral pain patterns.

Dowagers hump

• Not to be performed if client has advanced osteoporosis to prevent possible fracture.

• Using medium pressure on the C7 area as the person moves into cervical flexion.

• Stroke in an inferior direction at least 2 times and 1 time going superior.

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Anterior Neck

This area of the neck is complex, not because of numerous muscles, but because most of the deep flexors are weak and right next to them (more laterally) are two muscles that are possibly too tight.

Weak muscles have a tendency to stay weak because of the reverse effect of the stretch reflex. By incorporating a spindle-stimulating technique to, in a sense “wake up the muscle”, it is more open to be strengthened.

Deep Neck Flexors

• With one hand (or pillow) elevate the head at least 30 degrees. • Position fingers just lateral to the trachea and behind sternocleidomastoid. Gently

push in at 45 degrees. • Begin 1 minute of medium paced circles in all directions from C2-C6. • If there is a chance the person might have a deep venous thrombosis this

movement is contraindicated.

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Sternocleidomastoid

In my experience I have found this muscle is lengthened most of the time, but only 50 percent in a weakened state. This might be because by nature it is a postural muscle that is subdued by stronger extensor muscles.

On the other hand, if these stronger extensor muscles have become injured the sternocleidomastoid has to spring into action to hold up the head.

• Grip this muscle with your thumb and fingers. • If your assessment points to weakness, incorporate 1 minute of fast paced circles

on the entire length of the muscle. • If your assessment points to tightness, incorporate “Dynamic Extension

Release”, by slowly having the person move from cervical flexion to cervical extension, while you stroke up and back down the muscle.

• If there is a chance the person might have a deep venous thrombosis this movement is contraindicated.

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Scalenes

This muscle is responsible for 50 percent of the compressive forces in the neck, which lead to disc degeneration. The Vagus nerve is also found in this region. The Vagus nerve lowers the heart rate and controls the function of the parasympathetic nervous system. To stimulate this area will go a long way in jump starting the relaxation response.

• With one hand (or pillow) elevate the head at least 30 degrees

• Place fingers posterior to sternocleidomastoid, gently push in at 45 degrees. Move in an anterior to posterior direction, then inferior to superior direction.

• If there is a chance the person might have a deep venous thrombosis this movement is contraindicated.

• Perform “Dynamic Extension Release”, by slowly having the person move from cervical flexion to extension (with a little side flexion away from the treatment side), while you stroke up and back down the muscle.

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Cervical distraction

• Gentle distraction must be emphasized. Use no more that 1 to 2 pounds of pressure during the pull.

• Place one hand with the radial carpal aspect at C2-C3 area.

• The other hand gently stabilizes the head.

• Move the person into capital extension.

• Lean away with your body weight only for up to 30 seconds or less.

Cervical reeducation

• Restore joint play and capsular flexibility by grasping the neck and gently move the person into capital flexion and then cervical flexion.

• Move into capital extension, then cervical extension.

• Finally lateral flexion on both sides.

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Temporomandibular Joint Disorder

This area is one of the most prominent muscle groups for lack of awareness with most people. The function of mastication should be evaluated to rule out its possible involvement in neck pain or positive signs of forward head posture. A recent study has also shown weakness of cervical extensor muscles in TMD patients.9, 10

Masseter

Origin: Zygomatic bone.

Insertion: Mandible (ramus).

Primary function: Mastication (closure of the jaw).

• Stroke this muscle from origin to insertion and reverse direction. • If any adhesions are found, go against the grain and smooth out any restrictions.

In some instances, holding the restriction until it softens is helpful.

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Medial pterygoid

Origin: Sphenoid bone, palatine bone, maxilla bone.

Insertion: Mandible (ramus and angle)


• Treatment of this muscle is performed by using your index finger to compress the inside portion of the ramus of the mandible. The thumb is placed on the outside aspect of the mandible for stabilization.

• Holding the restriction until it softens is helpful.

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Temporalis

Origin: Temporal bone.

Insertion: Mandible (tendon to coronoid process).


• Using gentle fingertip pressure, working 1 1/2 to 2 inches above the ear. • Holding any sensitive spots until it softens is helpful.

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Masseter (internal portion)

• Using exam gloves, place one finger inside the mouth (outside of the teeth).

• Place the other finger on the outside portion of the muscle.

• Pushing the fingers against each other, stroke and compress the inside portion while also working the outside portion.

• Holding any sensitive spots until it softens.

Temporalis tendon (internal portion)

• With inside finger directed towards the ear (outside of the teeth), have the person move their jaw toward the side being treated. This will open up a space for your finger to push closer to the ear.

• Gently push toward the ear and move back and forth.

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Jaw distraction (internal portion)

• Have the person open their mouth.

• Place your thumbs on the last bottom molars.

• Place your fingers around the ramus of the mandible.

• Have the person close their jaw as much as possible (without too much pressure on your thumbs). Then have the person relax their jaw.

• In a gentle scooping motion, using 1 to 2 pounds of effort to stretch the muscles by pushing the thumbs toward the feet and simultaneously stabilize the mandible with the fingers. Hold for ten seconds.

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Active isolated assisted-stretching the trunk

These movements will not only elongate tight muscles and ligaments that you have just released, reeducate the injured tissue, but will also strengthen weak areas without activating the stretch reflex.

Chest and shoulder stretch

• Have the person supine on the table and adduct the arm and shoulder.

• Have the person using muscles of the back, abduct and extend the arm and shoulder with 20% resistance from the therapist.

• At the end range, therapist provides gentle assistive stretch.

• Can also be done in the prone position by having the person place their hand on the back or their neck.

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Active isolated assisted-stretching the neck

Cervical flexion

• Have the person sit up straight and hold back the shoulders. • Instruct the person to tuck the chin as close to the neck as possible, contract the

anterior neck muscles and exhale during movement with 20% resistance from the therapist.

• Therapist provides gentle assistive stretch at the end of the movement by using the front hand to provide a gentle pushing effort.

• Rear hand to stabilize the shoulder. • 5 to 10 repetitions.

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Cervical extension

• Have the person sit up straight and hold back the shoulders. • Instruct the person to contract the posterior neck muscles by gently tilting the

head backward, and exhale during movement with 20% resistance from the therapist.

• Therapist provides gentle assistive stretch at the end of the movement by using the front hand to provide a gentle pulling effort at the forehead or jaw.

• Rear hand to stabilize at the cervical-thoracic juncture. • 5 to 10 repetitions.

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Cervical lateral flexion

• Have the person sit up straight and hold back the shoulders. • Instruct the person to contract the muscles on the opposite side of those being

stretched. • Have the person exhale and move head towards opposite shoulder with 20%

resistance from the therapist. • Therapist should stabilize the shoulder on the side being stretched to prevent

compensation. • Give gentle assistance for 2 seconds at the end of movement. • 5 to 10 repetitions. Repeat on the other side.

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Kinesiology tape treatment

I have found by using the addition of kinesiology tape after my treatments it has accomplished 2 objectives.

1. Affects the sensory receptors to help the person to be aware of areas or positions they might have forgotten about.

2. Aids in mechanical correction by utilizing the stretching qualities of the tape with pulling where it is needed to stimulate a sensation which results in the body’s adaptation to the stimulus.

Application essentials

• Clean the area with alcohol before application to remove any oil residue. • For overused or tightened muscles, the tape is applied from insertion to origin. • For chronically weakened muscles or where increased contraction is desired, the

tape is applied from origin to insertion.

Shoulder retraction

• Attach the anchor point along the spine of the scapula.

• Have the person externally rotate their arm away from you; apply with 25% tension around the shoulder.

• As you finish applying the tape below the clavicle, have the person extend their shoulder.

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Shoulder X retraction

• Attach the anchor point along the lower medial border of the scapula.

• Have the person externally rotate their arm away from you; apply with 25% tension around the upper trapezius on the other side of the body.

• As you finish applying the tape above the clavicle, have the person extend their shoulder.

Pectoralis minor

• Cut the tape in half because of this small area. Spilt the 2 halves to make a “V”. Attach the 2 ends at the level of the 3rd or 4th rib with 25% stretch (anchor point).

• Have the person rotate their shoulder away and down from you; apply with no tension just below the clavicle.

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Posterior neck

• Spilt the 2 halves to make a “V” (or use two separate strips).

• Have the person flex their head away from you.

• Apply the anchor point with no tension just halfway at the medial border of the scapula.

• Attach the 2 ends with 25% tension.

Self-Treatment

Other than the treatment you have given, the person’s best chance of success with their pain is realizing that the management of their posture is their responsibility. Self-treatment will be more effective in the long term management of their pain than any other form of treatment.

Encourage the person to be as active as possible even if they are experiencing pain. Awareness of improper posture and self-stretches will reeducate the upper body, retard scar tissue formation and will continue to improve range of motion.

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Mid back

This movement reeducates muscle tissue, releases stuck facet joints in the thoracic spine and realigns the ribs.

• Have the person lie on a foam roll or rolled blanket, at the level of the T-8 area.

• Allow the shoulders and arms to relax for a few seconds, up to 2 minutes.

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Chest

• Place shoulder and side of the body against the wall. • Push shoulder into the wall, while rotating the body away from the wall.

Having the arm straight with the hand below will stretch the biceps. Having the hand above will stretch the chest.

Side Dip

• Cross bent elbows overhead. • Lean upper body to one side. • Repeat on the other side.

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Shoulder release

Increase range of motion and reduces scar tissue formation from injuries.

• Place a towel in both hands behind the back.

• Saw back and forth, as far up and down until tension is felt.

• Complete on the other shoulder as well.

• Pinch fingers towards each other, as far up and down until tension is felt.

• Complete on the other shoulder as well.

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Neck retraction

This movement reeducates muscle tissue and gives the person feedback when their posture is correct.

• Have the person fully retract their head as far as possible.

• Then release the last 10% of this movement.

• A few repetitions a day, especially while sitting.

Retract Relax

Neck and Trapezius

This stretch will focus on stabilizing the shoulder while releasing the neck, trapezius, and the scalenes muscles.

• Grasp the wrist to stretch the same side.

• Pull the wrist to the opposite side of the body, so the elbow is bent.

• Gently tilt the ear to the bent elbow side.

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Neck extension

Looking up releases the anterior neck and encourages a better cervical curve.

• Caution for elderly population or anyone with vertebral insufficiency (POTS) if dizzy or feels strange to stop and only tilt back and to one side at a time, not straight back.

• Have the person look up as far as possible while bringing their sternum up and their upper thoracic down.

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Bibliography 1. Association for Applied Psychophysiology & Biofeedback. Increase or Decrease Depression: How Body Postures. Influence Your Energy Level. Erik Peper and I-Mei Lin (2012) Biofeedback: Fall 2012, Vol. 40, No. 3, pp. 125-130. Accessed May 23, 2013.

2. Sylvain Guimond, (2012) “Intricate Correlation between Body Posture, Personality Trait and Incidence of Body Pain: A Cross-Referential Study Report” PLoS One. 2012; 7(5): e37450. Published online 2012 May 18. doi: 10.1371/journal.pone.0037450

3. Ted.com. Your body language shapes who you are. Amy Cuddy Accessed May 23, 2013. http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are.html

4. Le Huec J.C., (2011) “Equilibrium of the human body and the gravity line: the basics” Eur Spine J. 2011 September; 20(Suppl 5): 558–563.doi: 10.1007/s00586-011-1939-7

5. Sefton JM, (2012)”Massage Therapy Produces Short-term Improvements in Balance, Neurological, and Cardiovascular Measures in Older Person” Int J Ther Massage Bodywork. 2012; 5(3):16-27.

6. Judit Takacs (2013) “The Role of Neuromuscular Changes in Aging and Knee Osteoarthritis on Dynamic Postural Control” Aging Dis. 2013 April; 4(2): 84–99. PMCID: PMC3659254

7. Ribeiro A, (2013) “Resting scapular posture in healthy overhead throwing athletes” Man Ther. 2013 Dec; 18(6):547-50. doi: 10.1016/j.math.2013.05.010. Epub 2013 Jun 20.

8. Avery RM., (2012) “Massage therapy for cervical degenerative disc disease: alleviating a pain in the neck?” Int J Ther Massage Bodywork. 2012; 5(3):41-6.

9. Armijo-Olivo S, (2012) “Patients with temporomandibular disorders have increased fatigability of the cervical extensor muscles” Clin J Pain. 2012 Jan; 28(1):55-64. doi: 10.1097/AJP.0b013e31822019f2.

10. Butts R., (2017) “Conservative management of temporomandibular dysfunction: A literature review with implications for clinical practice guidelines” J Bodyw Mov Ther. 2017 Jul; 21(3):541-548. doi: 10.1016/j.jbmt.2017.05.021. Epub 2017 Jun 1.

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Working "With" Instead of Working “On”There are two approaches applied by therapists: "working on the person" and "working with the person." Working on the person pre-supposes that the person cannot help themselves; working with the person pre-supposes that the person has some practical r...Utilizing Dynamic Extension TechniqueOne of my favorite techniques is a movement “Dynamic Extension Technique”. It is commonly known as a massage concept called “pin-and-stretch”, which is applying pressure to a muscle as you elongate it.In addition, Sherrington’s law of reciprocal inhibition (Sherrington, 1907) states that a hypertonic antagonist muscle may be reflexively inhibiting their agonist. Therefore, in the presence of tight and/or short antagonistic muscles, restoring normal...As a muscle contracts the motor nerve has been activated which is commonly known as a concentric contraction. The opposite or antagonist muscle relaxes known as an eccentric contraction.If pressure is applied to a muscle while it is in the relaxed or lengthened eccentric state it will encourage the elongation of muscle tissue with less discomfort for the patient.One of the obstacles I face with treating people is lack of awareness of their bodies.With athletes, many train way past their pain threshold. In fact, the average person may suppress nagging discomfort with their day to day lives.As this warning signal is suppressed more and more the person may not be aware of a nagging irritation that has grown into a full blown injury until the therapist addresses it on the treatment table.An added benefit of Dynamic Extension Technique is by having the person actively contract the opposite muscle of the one being treated will encourage awareness of this dysfunctional area and help to restore proper function and range of motion.Manual Treatment Posterior TrunkThe Foundation of the HeadI have concluded that people know every spilt second what position their head is in, but don’t have a clue as to what their neck is doing. Balance and equilibrium helps us stay upright and know where we are in relation to gravity. As the head moves, h...Forces beyond the Necks ControlBefore effective treatment of the neck can begin we must first look at the tremendous forces at work. With a relaxed individual with minimal stress and excellent posture the neck balances the head equally on all sides. No one side is pulling more than...If this relaxed person bends over things change in a fraction of a second. The muscles of the back of the neck have to stiffen to keep the head up and the eyes forward. This protective mechanism is called the “law of righting”. It states, “The eyes wi...Postural MusclesOver time these postural muscles are subdued by lesser muscles that have become stronger from improper habits.The postural muscles that used to support the vertebrae are now ineffective and gradually become weak.To make matters worse, the lesser muscles while still performing their primary function have taken on the job of supporting the vertebrae and the head.It is much easier to see why the lesser muscles have become stronger, they never stop working.Now as we explore the stronger lesser muscles, keep in mind this illustration of extreme collapsed posture with a forward head and hunched shoulders.For every inch that the head moves forward in posture, it increases the weight of the head on the neck by 10 pounds!In the example to the right a forward neck posture of 3 inches increases the weight of the head on the neck by 30 pounds and the pressure put on the muscles increases 6 times.It is also interesting to note that there are twice as many extension muscles compared to flexion muscles.Lesser is MoreReview of the BasicsAs we continue to unravel this complex region, let us see what has been discussed so far. Most conditions of the neck can be traced back to previous trauma or imbalance. Improper posture over time will cause the postural muscles to become ineffective and gradually become weak. Lesser muscles while still performing their primary function have taken on the job of supporting the vertebrae and the head. There are twice as many extension muscles compared to flexion muscles.Assessment is the keyIn order to effectively treat the classic forward head posture, in which most degenerative conditions arise, assessment skills must be practiced and perfected. Systematic evaluation of muscular imbalance begins with static postural assessment, obser...Try the Wall Test for Neck Posture: - Stand with the back of your head touching the wall and your heels six inches from the baseboard.With your gluteals touching the wall, check the distance with your hand between your neck and the wall.If you can get within two inches at the neck, you are close to having good posture.Or, fully retract your head backwards as far as possible, then release the last 10% of this movement.Passive Range of Motion Neck AssessmentThese assessments are used to determine range of motion and in most cases pain will point to ligament damage. Medical authorization may be indicated to perform.Capital extensionPosition of Subject: Seated. Arms at sides.Position of Therapist: Standing behind subject next to the head. Both hands are placed around the head.Assessment: Therapist extends head by tilting chin upward in a nodding motion. (Cervical spine is not extended).Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me to tilt your head up”.Cervical extensionPosition of Subject: Seated. Arms at sides.Position of Therapist: Standing next to subject’s head. One hand is placed over the subject’s upper back for support. The other hand is placed on the forehead.Assessment: Therapist extends neck without tilting chin.Instructions to Subject: “Look at the wall. Keep your shoulders down and relaxed. Allow me tilt your head back”.Capital flexionPosition of Subject: Seated or supine with head on table. Arms at sides.Position of Therapist: Standing at head of table facing subject. Both hands are placed around the head.Assessment: Therapist tucks chin into neck. No motion should occur at the cervical spine; this is the downward motion of nodding.Instructions to Subject: “Keep your shoulders down and relaxed. Allow me tilt your head forward to tuck your chin”.Cervical flexionPosition of Subject: Seated or supine with head on table.Position of Therapist: Standing behind subject’s head. One hand is placed on the back of the subject’s head. Other hand is cupped around the shoulder for support.Assessment: Therapist flexes neck by pushing head straight forward without tucking the chin.Instructions to the Subject: “Keep your shoulders down and relaxed. Allow me tilt your head forward”.Lateral flexionPosition of Subject: Seated or supine with head on table. Arms at sides.Position of Therapist: Standing next to subject’s head. One hand is placed on subject’s side of head to be tested. Other hand is cupped around the shoulder for support.Assessment: Therapist lateral flexes neck by bring ear to shoulder; while pushing shoulder in opposite direction.Instructions to the Subject: “Keep your shoulders down and relaxed. Allow me tilt your head to the side”.Continue your assessment by noting any weakness of muscle strength, lack of movement, or pain during movement.Next, characteristic movement patterns are assessed, and specific muscles are tested for function and strength. This is referred to as manual muscle testing. There is such a wide variation of the grading scale with normal adults, for our purpose a muc...Muscle Assessment Protocol Resistance or pressure from the therapist is only 1 to 2 pounds. Direction of resistance follows black arrows on illustration. Assessment is performed for a maximum of 5 seconds.Capital extensionPosition of Subject: Seated or prone with head off of the table. Arms at sides.Position of Therapist: Standing at side of subject next to the head. One hand provides resistance over the occiput. “1 to 2 pounds only”. The other hand is used if support is needed.Assessment: Subject extends head by tilting chin upward in a nodding motion. (Cervical spine is not extended).Instructions to Subject: “Look at the ceiling. Hold it. Don’t let me tilt your head down”.Cervical extensionPosition of Subject: Seated or prone with head off of the table. Arms at sides.Position of Therapist: Standing next to subject’s head. One hand is placed over the subject’s back of the head for resistance. The other hand is used if support is needed.Assessment: Subject extends neck without tilting chin. Resistance is only “1 or 2 pounds”Instructions to Subject: “Push on my hand but keep looking at the wall or ceiling. Hold it. Don’t let me push it down”.Capital flexionPosition of Subject: Seated or supine with head on table. Arms at sides.Position of Therapist: Standing next to subject’s head. Hand for resistance is placed on subject’s forehead to give resistance in an upward and backward direction. Only 1 to 2 pounds. The other hand is used if support is needed.Assessment: Subject tucks chin into neck. No motion should occur at the cervical spine; this is the downward motion of nodding.Instructions to Subject: “Tuck your chin. Don’t lift your head. Hold it. Don’t let me push your head back”.Cervical flexionPosition of Subject: Seated or supine with head on table. Arms at sides.Position of Therapist: Standing next to subject’s head. Hand for resistance is placed on subject’s forehead. Only 1 to 2 pounds. The other hand is used if support is needed.Assessment: Subject flexes neck without tucking the chin.Instructions to the Subject: “Flex your neck down, don’t lift your head. keep looking at the wall. Hold it. Don’t let me push your head back”.Lateral flexionPosition of Subject: Seated or supine with head on table. Arms at sides.Position of Therapist: Standing next to subject’s head. Hand for resistance is placed on subject’s side of head to be tested. Other hand is cupped around the shoulder for support. Only 1 to 2 pounds.Assessment: Subject lateral flexes neck without tilting the chin.Instructions to the Subject: “Bring your ear to your shoulder; keep looking at the wall. Do not lift your shoulders. Hold it. Don’t let me push your head to the side”.Quiet Ins

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Treating Technology Neck - Garry Adkins-NCBTMB …garryadkins.com › wp-content › uploads › 2017 › 12 › Treating-Technology-Neck.pdfProfessor Vladimir Janda, M.D. of Czechoslovakia,