Muscle Imbalance
Evaluation and Treatment
of the Neck, Upper Back
and Shoulder Areas
Jose S. Figueroa, D. O.
Physical Medicine and Rehabilitation,
NMM/OMM
IOMA, Spring 2010
1
Objectives
• Review some concepts of muscle imbalances and the
evaluation and treatment of key muscles as contributors to
chronic musculoskeletal dysfunction in the neck, upper back
and shoulder areas.
• Be introduced to the evaluation and treatment of muscle
imbalances of the upper quarter:
–
–
–
–
–
Evaluate Proprioception
Evaluate for the presence of faulty muscle “firing” patterns
Diagnose and manually treat tight/short muscles
Diagnose weak or pseudo-paretic muscles
Teach a home exercise prescription to address the tight/short and
weak or pseudoparetic muscles
– Follow-up for re-evaluations and exercise adjustments
– Teach patients how to self-treat certain common somatic dysfunctions
2
Most of the information in this
lecture is derived from the works
of
• Phillip Greenman, D.O.(he is the one in the
pictures)
• Dr. Vladimir Janda, a specialist in rehabilitation
medicine at the University of Charles, Prague,
Czechoslovakia, deceased in 2006
3
Road Map
 Common UE muscles and their reaction to injury
• Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
• Evaluate Proprioception
• Evaluate for the presence of faulty muscle “firing” patterns
• Diagnose and manually treat tight/short muscles
• Home exercise prescription (HEP) for the tight/short
muscles
• HEP for the weak or pseudoparetic muscles
• Summary and Conclusions
4
Table 1. Common upper
extremity muscles and their
reaction to injury
5
Body Region
Function: Primarily Function:
Postural/Tonic
Primarily Phasic
(Short and Tight)
(Weak)
Neck and Trunk
Erector Spinae
Group
-Lumbar Region
-Cervical Region
Quadratus
Lumborum
Scalenes
Sternocleidomastoid
Deep Cervical
Spine Flexors
Erector Spinae
muscles
-Mid-thoracic
Rectus
Abdominis
External
Obliques
Internal Obliques
Transversus
Abdominis
6
Body Region
Function:
Primarily
Postural/Tonic
(Short and Tight)
Function:
Primarily Phasic
(Weak)
Shoulder Girdle Levator Scapulae
Middle Trapezius
Lower Trapezius
Rhomboids
Supraspinatus
Infraspinatus
Serratus Anterior
Deltoid
Extensors of UE
Upper Trapezius
Pectoralis Major
Latissimus Dorsi
Flexors of UE
7
Stand Up, Please
8
Please ½ of You Remain Still and look for:
• Forward shoulders (“rounded shoulders”)
• Head placed in a forward position
• Arms internally rotated
9
Upper Crossed Syndrome
•
•
•
•
•
Forward head
posture
Straightening of
the cervical
lordotic curve
Extension of the
upper cervical
spine
Increased
kyphosis of the
cervico-thoracic
junction
Internal rotation
of the shoulder
girdles.
10
http://medical-dictionary.thefreedictionary.com/syndrome
Road Map
 Common UE muscles and their reaction to injury
 Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
• Evaluate Proprioception
• Evaluate for the presence of faulty muscle “firing” patterns
• Diagnose and manually treat tight/short muscles
• Home exercise prescription (HEP) for the tight/short
muscles
• HEP for the weak or pseudoparetic muscles
• Summary and Conclusions
11
Diagnosis of Muscle Imbalances
Three Specific Types of Clinical Testing
•
Evaluate Proprioception
–
•
Through balance testing
Evaluate the sequence of muscle contraction
(muscle “firing” patterns) during specific
movements to evaluate which muscles contract out
of sequence, acting as if they were weak
Evaluate asymmetry in muscle lengths
•
–
Muscles are isolated as much as possible and then
tested for symmetry in their lengths and compared with
estimations of normal
12
Treatment of Muscle Imbalances
General Principles:
• Goal: restoration of proper muscle length, strength
and control of muscle function
• Start with OMM
• May need a home exercise prescription (HEP)
• HEP should address muscle control (i.e.,
proprioception re-training)
• When treating muscle imbalances: Quality of movement is
more important than quantity
13
General Treatment Sequence
1. Establishing a process of re-evaluations to
monitor progress
2. Establish a level of patient commitment to
follow through
3. Re-training proprioception
– home exercises (single leg stance)
– PT (more advanced intervention)
14
General Treatment Sequence
4. Stretching the tight muscles
– manual stretches in the office (Dr. or PT)
– home stretches (self-stretches)
5. Re-training or strengthening late contracting
(pseudoparetic) or weak muscles
– home “strengthening” exercises
6. Teaching the patient how to self-treat
specific recurring somatic dysfunctions on
their own
15
HANDS-ON SESSION
DIAGNOSIS AND TREATMENTS OF
COMMON MUSCLE IMBALANCES OF
THE NECK, UPPER BACK AND
SHOULDER
16
Road Map
 Common UE muscles and their reaction to injury
 Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
 Evaluate Proprioception
• Evaluate for the presence of faulty muscle “firing” patterns
• Diagnose and manually treat tight/short muscles
• Home exercise prescription (HEP) for the tight/short
muscles
• HEP for the weak or pseudoparetic muscles
• Summary and Conclusions
17
Evaluate and Treat Impaired
Proprioception
• Goal: the capacity to symmetrically stand on
one leg with arms crossed and eyes closed for
30 seconds (eyes open and eyes closed)
– Do the best possible if unable to reach goal
18
Look to your feet, Please
• Remove your shoes
• See if you can shorten one of your feet now
• Let’s test each other’s SINGLE LEG standing
balance
19
Road Map
 Common UE muscles and their reaction to injury
 Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop:
 Evaluate Proprioception
 Evaluate for the presence of faulty muscle “firing” patterns
• Diagnose and manually treat tight/short muscles
• Home exercise prescription (HEP) for the tight/short
muscles
• HEP for the weak or pseudoparetic muscles
• Summary and Conclusions
20
Evaluating Muscle Firing Patterns
of
Upper Quarter Muscles
21
Upper Quarter Firing Pattern Tests
•
•
•
•
Cervical Flexion Test Supine
Shoulder Abduction Test
Scapular Stabilization Test
Scapular Depression Test
Cervical Flexion Test Supine
• Start position patient is supine
• Cervical Test Normal: the neck curls as it flexes
• Cervical Test Abnormal: the neck cannot curl
and the head is thrust forward due to weak
deep neck flexors and overactivity of the
sternocleidomastoids (SCMs).
Shoulder Abduction
• The muscle firing pattern (sequence of
contractions) is evaluated.
• Normal sequence for shoulder abduction
while seated is:
1.
2.
3.
4.
5.
Supraspinatus
Deltoid
Infraspinatus
Middle and lower trapezius
Contralateral quadratus lumborum
Shoulder Abduction
• Most common substitution pattern is:
– Shoulder elevation by the levator scapulae and
upper trapezius (can lead to and perpetuate
impingement)
– Early firing of the quadratus lumborum even on
the ipsilateral side
Scapular Stabilization Test
• Position one: patient
on hands and knees
on the table
• Position two: patient
lifts one hand. The
scapula on the side
with the hand on the
floor is evaluated for
winging.
1
2
Scapular Stabilization Test
• Excessive winging of the medial border of
the scapula occurs because of weakness
and lack of stabilization by the lower
trapezius, serratus anterior, and rhomboid
muscles
Road Map
 Common UE muscles and their reaction to injury
 Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop :
 Evaluate Proprioception
 Evaluate for the presence of faulty muscle “firing” patterns
 Diagnose and manually treat tight/short muscles
 Home exercise prescription (HEP) for the tight/short
muscles
• HEP for the weak or pseudoparetic muscles
• Summary and Conclusions
28
Evaluating and Treating
Muscle Length Asymmetry
of
Upper Quarter Muscles
29
Evaluate Asymmetry of
Muscle Lengths
• Isolate to one muscle as best possible
• Find the tight muscles and treat them with
manual stretching at the clinic.
– “Supercharges” the patient’s home stretching
routine
– Sustained Stretch: 20-30 secs, 2 or 3 reps.
– Muscle Energy: Post-isometric Relaxation and
Stretch
• Then give them home stretches
30
Upper Trapezius/SCM: Length Test and
Manual Stretching
Upper Trapezius/SCM: Self Stretch
Levator Scapula: Length Test and
Manual Stretching
Levator Scapula: Self Stretch
Scalenes: Length Test and Manual
Stretching
Scalenes: Self Stretch
Pectorales Major: Length Test and
Manual Stretching
Pectorales Major Test/Manual Stretch
Supine
Pectorales Minor: Observe for
Tightness
• Patient supine
• Operator observes for
the relative anterior
posterior position of the
shoulders.
• Tightness of the
pectoralis minor is
shown as one shoulder
elevates off the table.
Pectorales Major: Self Stretching
Latissimus Dorsi: Length Test and
Manual Stretching
Manual Stretch
41
Latissimus Dorsi: Self Stretching
42
Re-Evaluate the Sequence of Muscle
Contraction
• In order to assess for weak muscles or
pseudoparetic muscles
• Prescribe strengthening (or re-training)
exercises at home if needed
• Again: Quality of motion is most important
Road Map
 Common UE muscles and their reaction to injury
 Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop :
 Evaluate Proprioception
 Evaluate for the presence of faulty muscle “firing” patterns
 Diagnose and manually treat tight/short muscles
 Home exercise prescription (HEP) for the tight/short
muscles
 HEP for the weak or pseudoparetic muscles
• Summary and Conclusions
44
Strengthening / Retraining
of
Upper Quarter Muscles
45
Cervical Flexors
Lower Trapezius
Serratus Anterior
Rhomboid and Lower Trapezius
Lower Trapezius Strengthening
Rhomboid Strengthening
HEAD AND SHOULDER POSTURE EXERCISE
Sit Up Straight, Please
•
•
•
•
Stand with feet four inches apart
Arms at side, thumbs point forward
Tighten buttocks
Rotate thumbs, arms and shoulders out and back
while inhaling, squeezing the shoulder blades
together in the back
• Maintain this position while pulling the shoulders
down and exhaling
• Hold while correcting the head posture:
– Bring head back to bring ears in line with shoulders
– Do not point nose up or down, do not open mouth
51
Re-training Exercises Usually Target
•
•
•
•
•
•
Deep Cervical Flexors
Lower Trapezius
Serratus Anterior
Rhomboids
External Rotators of the shoulder
Core strengthening, especially in patients who
are active in sports and / or manual labor
Road Map
 Common UE muscles and their reaction to injury
 Overview of Diagnosis and Treatment of Muscle Imbalances
Hands On Workshop :
 Evaluate Proprioception
 Evaluate for the presence of faulty muscle “firing” patterns
 Diagnose and manually treat tight/short muscles
 Home exercise prescription (HEP) for the tight/short
muscles
 HEP for the weak or pseudoparetic muscles
 Summary and Conclusions
53
Summary: Designing and Sequencing the HEP
• OMM Treatment first, if there are somatic dysfunctions
present
• Get a Commitment to Exercise from the patient
• Evaluate balance and Tx if needed
• Evaluate the tight muscles, do manual stretches and
prescribe stretches
• Evaluate for weak muscles if the stretches do not take
care of the problem.
• Prescribe re-training/strengthening exercises if needed
• Once muscles start to act more balanced, start a
general bilateral aerobic & strength training program in
line with the patient’s goals
54
If Not Progressing
• Assess for Non Compliance
• If Compliant…Perpetuating Factors like:
– Undiagnosed Pathology (ex: Myofascial pain,
ligament laxity, etc.)
– Ergonomic derangements at home or work
– Poor sleep
– Poor sports training (usually over-training)
– Aerobic or Anaerobic Deconditioning, thus
requiring cardio or resistance training
– Other: vitamin deficiency, etc.
55
Conclusion
• Exercise: long history in the healing arts
• Numerous exercise equipment systems have
been developed and are currently in the
market
• But many health professionals have limited
knowledge and understanding of how to
prescribe exercises that are appropriate for
their patients
56
Conclusion
• Generic programs can be helpful
• Each patient is an individual and may require an
exercise program specific for his/her problem
• If you practice the preceding principles and
procedures you will have the added skill to identify
specific problems and prescribe appropriate
exercises to restore proper muscle symmetry and
control, and ultimately improve the function of your
patients.
57
Questions
??????????????
58