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Archive for February, 2011
Saturday, February 26th, 2011
Here is another good article by Mark Heller who lives in the States
The lower cervical spine is a key area for neck pain, cervical nerve root pain, thoracic outlet problems and referred pain to the upper thoracic spine. Frequently, tennis elbow, carpal tunnel, and forearm tendonitis have a cervical component.
I believe that the most clinically significant lower cervical subluxations are usually missed, neither detected nor corrected by most DCs. This article will tell you how to find anterior lower cervical subluxations, and how to correct them.
Anterior Lower Cervical Subluxation Patterns
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Most of us screen the lower cervicals from behind the patient as part of our palpatory exam, but I find that the anterior neck is rarely assessed or treated. We’ll focus on the anterior restriction, where C6 or C7 resist posterior glide. You have to palpate sitting to find this problem. When the patient is supine, this lesion partially self-corrects and becomes impossible to feel.
I first started appreciating this area when I studied Dr. John Bandy’s “cervical disc syndrome.” Dr. Bandy uses weakness of the biceps to indicate C6 nerve root problems, the triceps to show C7 impingement, and the finger abductors to indicate C8 nerve problems. He assesses for a “stressed” position – usually flexion combined with lateral bending and rotation into the involved side – which further weakens these muscles. The muscles may test strong in neutral posture and only show weakness in the stressed position. When I started to use this protocol on my patients, subluxation patterns emerged.
The subluxed vertebra is usually translated forward, lateral, and tipped inferior. In dynamic terms, it resists posterior glide, lateral to medial motion, and inferior to superior motion. This is a nonphysiological restriction, which does not follow the joint planes. This confused me for years, until I integrated Barral’s understanding of this area. Barral talks about the anterior fascial pulls and their influence. When these fascial structures are tight and restricted, they pull the neck in an inferior direction. My next article (May 20 issue) will focus on the inferior fascial pulls and how to find and correct them.
Related Literature
Dr. Lewit speaks of the importance of key segments, mostly in transition zones, including the cervicothoracic junction, “where the most mobile section of the spinal column is joined to the relatively rigid thoracic spine.”
In Motion Palpation and Chiropractic Technic, Schafer and Faye state: “One of the two most common fixations in the lower cervical spine involves (restriction of) simultaneous flexion and A-P rotation.”
In The Thorax, Jean Pierre Barral emphasizes the fascial components pulling on the front of the neck.
The chief complaint coming from lower cervical problems is often a referred pain felt in the upper thoracic region or experienced as shoulder/arm discomfort or sensory changes. Dwyer, Aprill, and Bogduk have done a beautiful job of outlining referral patterns from the cervical spine based on injection responses.
Lower cervical dysfunction correlates with Janda’s upper-crossed syndrome, in which the head carriage is forward in a “chin-poke” posture, the scalenes and SCM are hypertonic, and the deep neck flexors are inhibited.
Eighty percent of these patients will have an inferior component to the lesion, resisting superior motion. Approximately 20 percent of the time the pattern will be forward, lateral, and superior – more along the lower cervical facet lines. It’s quite significant that the usual pattern is nonphysiological – not along the joint planes. Since we don’t have a facet line along which to adjust, we have to use low-force correction, and we must address the fascial restrictions.
Diagnosis and Palpation of the Subluxation
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How do we find this problem? Screen the sitting patient’s lower neck with gentle palpation using initial response testing (IRT), feeling for rigid areas over the front of the lower neck. In IRT we assess the very beginning of the motion rather than the end range. Go through the SCM muscle by pushing it gently backward to access the anterior part of the transverse processes. If you feel an arterial pulse, your contact is more medial than it should be. The cervical transverse process is a sensitive area on almost anyone, but it will be hypersensitive and rigid over an area of dysfunction. To motion palpate, passively flex the head forward and laterally bend it toward the involved side with one of your hands, while the palpating fingers or thumb of your active hand counter this motion by gently pushing anterior to posterior, and simultaneously pushing medially. You will feel a lack of movement at the significant level. Add your third dimension by determining whether the stuck vertebra resists superior motion, the common pattern, or resists inferior motion along the facet line. If the patient has a severely irritated cervical nerve root, lateral motion will not be tolerated, so just assess A-P and I-S motion in these cases.
Correction: Three Variations on Low-Force Adjusting
How do we adjust over the very sensitive anterior portion of the neck? I use these low force methods with the patient sitting. It’s a lot like the palpation assessment. I’m either behind the patient, as pictured, or standing in front on the involved side. I begin by gently side-bending the patient’s head to the involved side. I primarily use engage, listen, follow (ELF) to correct the restriction. I engage the elastic, soft part of the barrier with my thumb or index finger, then push gently and slowly posteromedially on the involved segment, while my upper hand simultaneously rocks the head anterolaterally toward the involved side. I fine tune for the usually superior direction of restriction. Once I have engaged the lesion, I listen for the exact 3D direction the tissues want to release toward, and follow to completion. This is a variant on direct myofascial release, gently and directly moving into the elastic barrier, pushing the C6 or C7 vertebrae in a posterior, medial, and superior direction. This is done slowly three to five times.
A second technique involves adding postisometric relaxation (muscle energy) to the same setup. I use this when my direct ELF doesn’t seem to completely release the area. Begin as above and move directly into the barrier. When you reach the first barrier, have the patient very gently and isometrically bring the head laterally against your upper hand’s resistance into opposite side-bending for four to seven seconds. This is done with minimal pressure. After the contraction, let the patient relax and follow with your direct mobilization toward the barrier. Repeat three to five times. One key is to take the segment just to the soft edge of the barrier. We do this by backing off slightly before you have the patient begin to contract. The other key is teaching your patients to contract their own muscles very gently. They always push too hard the first time. I coach them by saying, “Give me about one-fourth of that much pressure, and as soon as you feel my resistance, just hold, don’t continue to try to push further.”
A third technique, which can be combined with the other two, would be recoil. This is best described as engage and release. Engage the restriction in all three dimensions, pushing only to the soft part of the barrier, and then suddenly release your pressure. Unlike toggle- recoil, there is no thrust inward, just a sudden release away. This can be used at the beginning or end of ELF, or on its own for an acute case when motion cannot be tolerated here.
Always recheck after your correction. The area should be less tender, more mobile, and any muscle weakness should be gone.
Using these concepts may transform your approach to the cervical spine. Look to the anterior lower cervicals whenever the patient complains of pain in the lower neck, shoulder blade or upper back, or whenever an upper extremity pain or sensory change is not resolving fully.
My next two articles will address the fascial and muscular components of the anterior cervical syndrome.
Resources and References
* Greenman P. Principles of Manual Medicine, 2nd edition. Williams and Wilkins, 1996.
* Lewit K. Manipulative Therapy in Rehabilitation of the Locomotor System. Butterworth, Heinemann, 1991.
* Schafer RC, Faye LJ. Motion Palpation and Chiropractic Technic: Principles of Dynamic Chiropractic. Motion Palpation Institute, 1989.
* Advanced AK Seminars with John Bandy, 1987, Austin, Texas.
* Barral JP. The Thorax, Eastland Press, 1991.
* Heller M. Low-force adjusting techniques (including ELF). Dynamic Chiropractic, Sept. 1, 2001;19(18), pp. 32,34, www.chiroweb.com/archives/19/18/07.html.
* Heller M. Initial response testing. Different ways to approach the barrier. Dynamic Chiropractic, July 30, 2001;19(16), pp. 24,34, www.chiroweb.com/archives/19/16/12.html.
* Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. A study in normal volunteers. Spine 1990;15:453-7.
The Link to Mark Heller`s Article
Tags: neck pain
Posted in Osteopathy | No Comments »
Wednesday, February 16th, 2011
This article on upper neck pain was found by one of my patients who does not like traditional strong manipulation. I was trained at the European School of Osteopathy and learned cranial ostepathy, traditional osteopathy, massage, muscle energy. One of the most important practical sessions included how to approach and treat acute neck pain without causing distress to the patient.
This is not as easy as it seems, but in Edinburgh you can find osteopaths who use more modern approaches such as counter strain and muscle energy.
The below article by Marc Heller, an American Chiropractor describes in great deal the benefits of this low force adjustment. Please note that this is time consuming which is why sometimes these techniques are neglected in favour of normal high force manipulations.
C1 C2 ARTICLE by Marc Heller, DC
You probably read enough of my articles to know that our work is about using minimal force. This is especially critical for the upper cervical spine, for two obvious and connected reasons: one is the real risk of vascular injury to the convoluted vertebral artery, which bends in the upper cervical spine; the second is the perceived risk of cervical adjustments due to media overkill. Whether the real risk is one in 100,000 or one in 10 million, if a stroke happens to your patient after you adjust him or her, the rarity of the event will not help you feel any better about the situation. I always attempt to correct the upper cervical spine with low force methods first. Whether you use ELF (“engage, listen, follow”), recoil, or an Activator, why not do this first and then recheck? If the problem persists or doesn’t change, and has an articular, hard feel rather than a meningeal “gooey” feel, I proceed with a traditional adjustment, avoiding the combination of rotation and extension. Yes, I adjust the upper cervical region in my patients who need it, but I rarely do a high-velocity, low-amplitude thrust here. Low force adjustments are real and effective!
I won’t try to share C2 methods, as I rarely use them. For the anterior or lateral C1 patterns, I use the simple ELF or recoil (engage-release), usually with the patient supine; occasionally done sitting or side-lying. I’ll use a contact on the head to move the occiput in a countermotion to where I want the atlas to go.
I would like to share a specific technique for C1 when it is compressed against the occiput. This is the work of Alain Gehin, another European osteopathic teacher, who focuses on the cranium in most of his teaching. His excellent text is An Atlas of Manipulative Techniques for the Cranium and Face. This is primarily a one-handed technique, which involves holding the occiput with your third, fourth, and fifth fingers, while your index finger is placed on the posterior arch of the atlas. The patient is supine, with the head in “neutral,” as you can’t reach the atlas once the head tips back. You’ll be far more effective with this technique if you tune into the cranial rhythm and release the atlas inferior during the expansion (flexion) phase. As you feel the occiput move into flexion, with its inherent movement taking it inferior and anterior, guide the atlas caudal away from the occiput. You do this by separating your index finger from your other fingers. Follow the rhythm four to 10 times, until you feel the atlas release.
Our tour of the upper cervical spine would be incomplete without at least a brief assessment of the musculature. I will refer you to an in-depth review of these concepts by Craig Liebenson,DC, in the Journal of Bodywork and Movement Therapy. Two of the significant players are the sternocleidomastoid (SCM) and the rectus capitus posterior minor. The SCM becomes hypertonic. It’s easy to assess. Just gently pinch it between your thumb and second finger, working down from the upper neck; if the SCM has knots in it, and if it is tender, it probably needs to be released. Stretching this muscle is tricky.
Though it’s easier to feel the posterior arch of C1, don’t forget to assess from lateral to medial, and from anterior to posterior. When the atlas is stuck forward, it creates big problems, which are only made worse by adjusting from behind. You can palpate for this and get accurate information, but remember to be gentle. Tenderness is always an excellent additional guide. The atlas area is very sensitive, so rough force will be painful for almost everyone.
C2 is always a puzzle. It is very frequently fixated, but this is deceptive. In my experience, and in the works of Jean Pierre Barral, C2 is almost always secondary: a witness to tensions in the rest of the body reflected in the neck. Once you learn how to use inhibition to prioritize subluxations, which I outlined in the September 12 issue of DC (http://www.chiroweb.com/archives/19/19/06.html), you will almost never adjust C2. A good rule of thumb is to balance everything else first; if C2 still shows up, then correct it. You probably read enough of my articles to know that our work is about using minimal force. This is especially critical for the upper cervical spine, for two obvious and connected reasons: one is the real risk of vascular injury to the convoluted vertebral artery, which bends in the upper cervical spine; the second is the perceived risk of cervical adjustments due to media overkill. Whether the real risk is one in 100,000 or one in 10 million, if a stroke happens to your patient after you adjust him or her, the rarity of the event will not help you feel any better about the situation. I always attempt to correct the upper cervical spine with low force methods first. Whether you use ELF (“engage, listen, follow”), recoil, or an Activator, why not do this first and then recheck? If the problem persists or doesn’t change, and has an articular, hard feel rather than a meningeal “gooey” feel, I proceed with a traditional adjustment, avoiding the combination of rotation and extension. Yes, I adjust the upper cervical region in my patients who need it, but I rarely do a high-velocity, low-amplitude thrust here. Low force adjustments are real and effective!
I won’t try to share C2 methods, as I rarely use them. For the anterior or lateral C1 patterns, I use the simple ELF or recoil (engage-release), usually with the patient supine; occasionally done sitting or side-lying. I’ll use a contact on the head to move the occiput in a countermotion to where I want the atlas to go.
I would like to share a specific technique for C1 when it is compressed against the occiput. This is the work of Alain Gehin, another European osteopathic teacher, who focuses on the cranium in most of his teaching. His excellent text is An Atlas of Manipulative Techniques for the Cranium and Face. This is primarily a one-handed technique, which involves holding the occiput with your third, fourth, and fifth fingers, while your index finger is placed on the posterior arch of the atlas. The patient is supine, with the head in “neutral,” as you can’t reach the atlas once the head tips back. You’ll be far more effective with this technique if you tune into the cranial rhythm and release the atlas inferior during the expansion (flexion) phase. As you feel the occiput move into flexion, with its inherent movement taking it inferior and anterior, guide the atlas caudal away from the occiput. You do this by separating your index finger from your other fingers. Follow the rhythm four to 10 times, until you feel the atlas release.
Our tour of the upper cervical spine would be incomplete without at least a brief assessment of the musculature. I will refer you to an in-depth review of these concepts by Craig Liebenson,DC, in the Journal of Bodywork and Movement Therapy. Two of the significant players are the sternocleidomastoid (SCM) and the rectus capitus posterior minor. The SCM becomes hypertonic. It’s easy to assess. Just gently pinch it between your thumb and second finger, working down from the upper neck; if the SCM has knots in it, and if it is tender, it probably needs to be released. Stretching this muscle is tricky.
Go to www.drmarcheller.com/scm_stretch.htm to download a wonderful stretch for this muscle. It involves teaching the patient to: 1. grab the SCM muscle (and at the same time); 2. lift the chest; 3. tuck the chin; 4. turn (rotate) toward the side of muscle involvement; and 5. tip (sidebend) away from the side of involvement. Once you do all of these simultaneously, you will feel a stretch in the SCM, right under your pinching hand. To get a stronger stretch, pull the muscle gently downward with your pinching fingers. You’d better try this yourself first before you try to show it to your client. Yes, it’s complicated, but worth learning and teaching to your patients. Feel free to download the instructions and print them out for your patients.
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The rectus capi-tus posterior minor is accessible through suboccipital trigger point work by adjusting the upper cervicals, as well as strengthening its antagonists, the deep lower cervical muscles, through a gentle sitting or supine chin-tuck. The key to an effective chin tuck is to activate strictly the deep cervical flexors, not the SCM or scalenes. Do this by having the patient Do this by having the patient lift the sternum as he or she pushes down with the chin. Provide a gentle resistance under the chin with one hand. While learning this, use the other hand to monitor how quiet the SCM and scalenes remain.
I hope these concepts are useful to you and your patients.
Helen How
Registered Osteopath
14 Craighall Gardens
Edinburgh EH6 4RJ
0131 551 1044
A one hour treatment costs £35.00.
A standard follow up treatment costs £35.00 for one hour
A simple follow up treatment of 30 minutes costs £20.
Posted in Osteopathy | No Comments »
Saturday, February 12th, 2011
As we all know, persistent chronic pain can cause a string of unwanted events, such as slowing down the metabolic rate which makes people vulnerable to increased weight. It can also cause emotional problems ranging from mild feelings of frustration to clinical depression.
Research shows that any therapy or counselling that encourages people to examine causes of unhappiness throughout their lives, despite enabling emotional healing, can trigger physical pain.
Physiotherapists, chiropractors and osteopaths are aware of the negative effects of pain and it is our job to give you as many self help tools, advice and other information to enable you to have improved physical and emotional health.
While the NHS is the biggest provider of healthcare, it can’t provide complete physical and emotional care for everyone. We can all contribute towards keeping ourselves as well as possible.
Helen How
Registered Osteopath
14 Craighall Gardens
Edinburgh
EH6 4RJ
0131 551 1044
A one hour treatment costs £35.00.
A follow up 30 minutes treatment for simple conditions costs £20.00.
Tags: Chronic Back Pain, Emotional Pain
Posted in Uncategorized | No Comments »
Friday, February 11th, 2011
Here in Edinburgh I using current modernised clinical approaches to sports injuries and other soft tissue injuries and believe I am the only osteopath in Edinburgh who uses a unique combination of the G5 massage machine with ultrasound. I include traditional osteopathy or cranial osteopathy within my holistic approach which lasts for an hour. For example one chronic case of an achilles tendonopathy which bas prevented an athlete from running and playing hockey for over 5 years has come in this month October 2011 and his tendon is no longer causing him to limp after a full game of hockey and he can go on tour abroad with his National Team.
We are both delighted as he can has tried and tried and tried to find a treatment process for his tendon.
The G5 vibrator is able to provide a pain-free massage, stimulating the collagen fibres to untangle. Then ultrasound – sound waves travelling at over one million cycles per second – enable a good quality repair of damaged tendens such as biceps tendonpathy, tennis elbow, golfers’ elbow. It also can treat all the hard tense muscles of the neck and shoulders caused by prolonged sitting behind computers in the office.
In this picture of damaged collegen fibres within an achilles tendon – you can see how deep the fibres are within the tendon. The vibration of the G5 stimulates the flow of repairing nutrients to the damaged fibres, while the ultrasound provokes the healing cells to produce more collagen bricks and repair the damaged fibres. This is a cutting edge approach and proving to be very beneficial in many stubborn cases which fail to respond to pain killers and rest.
The clients are giving positive feedback which is encouraging
Helen How
Registered Osteopath
14 Craighall Gardens
Edinburgh
EH6 4RJ
£35 all inclusive one hour
£20 for simple follow up sessions (Ultra Sound/Vibrotherapy)
Website of Physio Med to see more about electrotherapy and more products.
Tags: Achilles tendon, back pain
Posted in sports injuries | No Comments »
Friday, February 4th, 2011
Osteopaths are trained to work with muscles. If required, they can use manipulation, myofascial osteopathy or soft tissue massage. Since I wrote this article many months ago there has been many enquiries about why does tennis elbow return even after the “magical injection of corticosteriod injections and exercises. I attended the first ever sports and exercise Course Sponsored by the European Professional Golf Tour which was held November 2011 near Harrogate. This must be one of the best Sports Medicine Courses for Golf and the Elite Golfer that I have ever attended in over 30 years of attending courses .
So here is the website and the current research which will explain when research if followed up on injections of corticosteriods the normal end of the research is after 6 weeks only. HOWEVER, IN MANY CASES THE PAIN RETURNS and as corticosteriods weakens the strength of the ligaments because is delays or stops the healing and repair of collagen fibres corticosteriods injections are not given as a general protocol to the professional athletics as it is considered old fashioned.
As the golfers are prone to elbow pain the PGA Medical Team are of course keeping up to date with current research and developing better, stronger and long lasting management plans for elbow pain Click Here Please to read further
Here are the eccentric exercises which you need to strengthen carefully after you have had treatment with your osteopath, physiotherapist or chiropractor.Click Here
Osteopaths often work with tennis elbow. Currently I am treating several patients with this condition. Below is a good image of muscles and tendons associated with tennis elbow.
Pain from this condition can be treated with a corticosteriod injection. However a side effect from this is the slowing down or cessation of healing of the collagen fibres. See diagram.
The injection only removes pain- it does not help the torn tendon to heal. What can help is for the osteopath to work up and down the extensor muscles of the forearm. This elongates the forearm muscles which shorten and by traction make micro tears in the extensor tendon.
I use the deep flexmatic trigger head which doesn’t cause pain but loosens off the shortened hardened forearm muscles to aid healing and good quality collagen fibres. After that I give some sports massage and then apply an effective dose of ultrasound which stimulates a better quality mending of the tear.
I advise patients to do normal gentle pain-free stretches and some massage at home to keep stimulating the healing of those micro tears.
Helen How
Registered Osteopath
!4 Craighall Gardens
Edinburgh EH6 4RJ
0131 551 1044
07889304762
£35.00 for one hour / simple follow up treatments £20 for 30 mins
Tags: Tennis Elbow
Posted in Elbow Pain, Osteopath | No Comments »
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