Understanding Tech Neck

Tech Neck is a condition that occurs due to poor posture while using electronic devices. When we use our phones or tablets, we tend to flex our neck and shoulders, leading to further strain on the muscles and joints. The more we do this, the more tension builds up, leading to pain and headaches.

The Importance of Good Posture

Good posture is crucial for maintaining good health. It helps prevent muscle and joint pain, improves breathing, and enhances physical performance. By sitting more upright, we can reduce the strain on our muscles and joints, and avoid developing Tech Neck.

Awareness is the first step in solving the issue of Tech Neck. Most children may not be aware of their bad posture while using their devices, so it’s important to point this out to them and remind them to sit more upright. By bringing their chest up and lifting the phone to align their gaze straight, they can avoid flexing their neck and shoulders.

Simple Steps to Combat Tech Neck

In addition to improving posture, it’s important to avoid remaining in the same position for a long period of time. Taking a break every 30 minutes, even if it’s just to roll the shoulders and turn the neck side to side, can help reduce tension buildup. These simple actions will not only help combat Tech Neck but also improve overall posture and prevent other issues related to bad posture.

Tech Neck Video Transcript

You might have noticed your kids are spending a lot of time on their phones and tablets. If they are, then they might have “Tech Neck.” So, what is Tech Neck? It develops when you’re in a poor position while using your devices. This is quite a common issue that you might see with your kids.

Now, why is this a problem? The more flexed you are, the heavier your head is. This creates more strain and tension on your muscles and joints. If you let this build up over time, it can lead to pain and headaches.

Tech Neck Fix

So, what can you do about it? How can you help your kids correct this posture? The first step is just awareness. They are likely not aware that they’re doing this because they’re focused on their devices. So, you can point this out to them and gently remind them when you notice that this is happening. If they become aware of it, what you can do to correct it is simply sitting more upright. So, if we’re down like this, actually bringing the chest up and lifting the phone so the gaze is more straight as opposed to looking down. You can also look at the phone just with a gentle nod of the head, rather than a bend through the back and the upper neck.

Tech Neck Exercises

The last thing you can do, which is the most important, is to not remain in this position for a long period of time. So, every 30 minutes, it’s encouraged to just roll the shoulders, turn the neck side to side. Even that simple break will help stop the buildup of tension that leads to pain and headaches.

I encourage you to give this a try and encourage your kids to give this a try. If you do have any trouble or you’re still finding that there are problems, feel free to comment “Tech Neck” below, and we’ll be in touch.

Conclusion:

By following these simple steps, you can help yourself, and your children combat Tech Neck and improve your overall health. Remember, good posture is essential for maintaining good health, and simple actions such as taking regular breaks and sitting more upright can make a big difference. If you are experiencing any trouble, don’t hesitate to seek professional help from your local physiotherapist. Let’s move better, feel better!

Your Temporomandibular Joint , is the most used joint articulation in the body. Your TMJs (jaw joints) are involved with eating, talking, breathing and, probably most importantly, expressing your feelings and emotions. When things go wrong with your TMJ, it is known as Temporomandibular Disorder (TMD). (1)

TMD is a common condition, signs of which appear in up to 60–70% of the population.(1) The peak incidence is seen in adults aged 20–40 years. Women are at least four times as likely to suffer from the disorder.(3) TMD can be annoying and persistent or acutely disabling.

Treatment of the jaw for pain, clicking and locking can be challenging. We often get referrals from dental specialists for patients with prolonged or acute temporomandibular pain and restricted movement.

Anatomy

The Temporomandibular Joint (TMJ) complex consists of two joints on either side between the skull and jaw bone. There is small fibrous shock absorbing disc within the joint that needs to shift correctly for normal pain free jaw movements such as opening and closing your mouth, yawning and chewing. There are many small muscles that are involved in ensuring smooth, precise TMJ movement, and can contribute to increased strain in the joint.

Symptoms

You may or may not experience jaw pain or tenderness with TMJ dysfunction. The most common symptoms include:
• jaw clicking
• grinding
• limited jaw opening, or jaw deviation while opening
• an inability to fully clench your jaw. (1)

TMD sufferers are often teeth grinders or clenchers. TMD can cause jaw headaches, ear pain, dizziness and neck pain. Some TMJ patients report pain or inability to eat, talk or sing. Tinnitus or ear ringing can be associated with TMJ dysfunction.

Causes of TMD

Successful management of TMD involves identifying and managing contributing factors.1 It is important to distinguish between muscle related causes of TMD and intra-articular disorders of the joint itself. TMJ pain may also be caused by referral from the neck or more remote areas. Muscle related disorders are the result of tension, fatigue or spasm of the masticatory (chewing) muscles, whereas intra-articular disorder stems from mechanical or inflammatory disruption of the joint itself.
Soft tissue dysfunction is the most common cause of TMD. Teeth grinding, clenching and abnormal posture, stress and anxiety, may all contribute to masticatory muscle pain and spasm. Cognitive and psychiatric disturbance, such as depression and anxiety, and autoimmune disorders, fibromyalgia and other chronic pain conditions are also frequently associated with TMD and may be a part regional pain syndrome.
Intra-articular causes of TMD include internal joint derangement, osteoarthritis, hypermobility and traumatic injury. Inflammatory conditions, such as rheumatoid arthritis may lead to internal joint derangement. Articular disc displacement from the normal position is the most common joint related cause of TMD. In our experience careful assessment often reveals stiffness in the joint gliding.(2)

Treatment

Physiotherapy has been shown to be effective in the management of TMD, especially with regards to improving joint range of motion.(4)
Behaviour modifications, including improving sleep hygiene, stress reduction and elimination of bad habits such as teeth clenching and grinding, are particularly important.
A careful, comprehensive assessment of the joint and the muscles that control movement: some which are internal and difficult to access is essential to find and treat the dysfunctions that cause pain and disordered movement. Close examination of the neck, upper back and posture is also important in order to get best results. A structured home exercise program is essential.

If you have pain or disturbed movement in your jaw area or persistent headaches, you need to have an TMJ assessment as part of a comprehensive treatment approach. At Northwest Physiotherapy Group we look at the whole body to find and treat the main contributors of your pain.

References

1. https://physioworks.com.au/pain-injury/jaw-pain-tmj-pain/tmj_dysfunction/
2. https://www1.racgp.org.au/ajgp/2018/april/temporomandibular-dysfunction
3. Sharma S, Gupta DS, Pal US, Jurel SK. Etiological factors of temporomandibular joint disorders. Natl J Maxillofac Surg 2011;2(2):116–19. doi: 10.4103/0975-5950.94463. Search PubMed
4. Ahmed N, Poate T, Nacher-Garcia C, et al. Temporomandibular joint multidisciplinary team clinic. Br J Oral Maxillofac Surg 2014;52(9):827−30. doi: 10.1016/j.bjoms.2014.07.254. Search PubMed

She is a mum in her early 40s who had been suffering a 5 year history of neck, shoulder pain and headaches. The headaches were at the base of her skull and would occur twice weekly and last for several hours. While there were no features of migraine, Mrs P found the headaches quite debilitating, as often her neck and shoulder pain would worsen with them.

Her neck movement was severely restricted also, finding it hard to reverse the car, check blind spots and also to look up with activities like hanging the washing and reaching up to cupboards. Mrs P played netball and found shooting in netball was also painful, and so she had stopped playing. In fact, her enjoyment of life had really taken a hit. She couldn’t enjoy playing with her young daughter as she wanted. She was frustrated and felt down.

She was otherwise in good general health.

Mrs P had also tried other practitioners, including other Physios, with no long term help.

Examination Findings

On initial assessment, we found lots of unhappy areas in Mrs. P’s body that could contribute to her problems. Most notably she had neural tension in all 4 limbs and through the upper cervical spine. This had to be treated first to ensure she responded well to further manual therapy and her results would hold.

There were several muscles in the neck, shoulders, jaw and lower back that were tight and in a protective state, as well as joints in the neck and thoracic spine. The main movements that were restricted were neck rotation (we haven’t shown these for privacy reasons), shoulder internal and external rotation, shoulder abduction and passive neck flexion/rotation. The last test has been shown to correlate well with the incidence neck related headaches.

Below are the pictures of limb range before and after nerve clearing. All tests are performed to the first point of resistance/muscle guarding.

Problem Solving Process

Through a systematic process of treatment trials and clinical reasoning, we narrowed down to a list of 15 structures that were affecting Mrs P’s neck and shoulder movements. With further treatment we narrowed down further to the primary contributor to Mrs P’s condition. This was a segment in her upper neck which was essentially ‘’stuck” (C2) and not gliding to the right as it normally should. There was a secondary contributor in her left shoulder (infraspinatous).

Treatment to this structure made significant changes to Mrs P’s movements, and all other problematic structures.

Results

Over a period 4 weeks (interrupted by Covid!), Mrs P’s movements returned to an optimal state. Concurrently her headaches ceased, her neck and shoulder pain resolved and she was able to finally enjoy playing with her young daughter, as well as move normally and return to netball without pain!

We gave Mrs P strategies to manage her condition long term, including postural, strengthening and motor control exercises, as her posture affected her neck tension and head position.

Postural Corrections

These postural corrections were made for Mrs P, as the corrected position reduced strain and tension on the primary contributors in the neck. Thees new postures will require practice and awareness over time to become natural postures. Mrs P was shown how to check for tension in her neck and whether she was in the correct posture.

Mrs P was overjoyed and quite emotional with her result. She felt that after so many years, she had finally found an approach that worked. She felt confident in her body, and empowered to prevent the condition recurring. She was relieved and excited about enjoying her upcoming holiday, finally being painfree.

This is an example of how a thorough, whole body, systematic problem solving approach can work well for persistent long term musculoskeletal problems.

There are several different types of headaches with different causes, and it is well accepted in clinical settings as well as in research findings that the neck can either cause or contribute to the pain of headache. But if structures like tight muscles and stiff joints in the neck can contribute to headaches, why can’t similar structures further away from the neck, such as in the shoulders or thoracic spine, contribute to headaches? And how can this be explained if it is possible?

In our experience at NWPG, more remote regions can contribute to headaches, and we have examples of clients that have had significant improvement in frequency, duration and intensity of their headaches when other remote contributors have been found and treated.

But first, let’s look at one of the more common contributing areas of headache, the neck. Understanding the contribution of the neck will open the door to understanding how remote areas can contribute to headaches.

Cervicogenic Headaches

Cervicogenic headache is a type of headache with distinct signs and symptoms that has been classified by the International Headache Society, an organisation that researches and classifies all types of headaches.

Headaches are generally classified as Primary or Secondary. Primary headaches occur without an identifiable source within the body or CNS(Central Nervous System). Examples are migraine, tension and cluster headaches.

Secondary headaches arise from an identifiable source, such as the eyes, sinuses or neck, or potentially other musculoskeletal regions.

Cervicogenic headache (CGH) is a secondary headache, and research shows that it makes up for 15-20% of all chronic and recurrent  headaches. (1)

The good news for sufferers of CGH is that there is scientific evidence that it can be treated effectively once it is recognised and diagnosed (2).

How do I know if I have Cervicogenic Headache?

CGH is defined as pain that occurs in the neck or occipital (back of head) region but may spread forward to the side or front of the head. It is generally aggravated by neck movements or sustained neck postures, eg sitting at a computer or driving.

You may also experience one or more of the following characteristics:

1. The pain is generally dull and not throbbing or piercing.
2. It is generally one sided but you may also experience shoulder pain on the same side.
3. May be eased by massage or external pressure over the neck.
4. There may be a history of trauma to the head or neck/shoulder from a fall or car accident.
5. You may be able to feel tension/tightness in the muscles at top or bottom of the neck, and there may be “lumps” in the muscles that may be tender to touch
6. You may notice stiffness or even pain when you turn your head to one side.
7. CGH is more common in females. 

What Causes CGH?

The pain of CGH is thought to be of somatic origin, ie arising from joint capsules, ligaments or muscles in the neck, especially the upper cervical segments C1-3. These structures are innervated by sensory nerves that detect excessive load or inflammation. When these nerves are stimulated, impulses are sent to the brain (noxious input) where these signals are processed. If these signals (noxious input) exceed a safe threshold, then the brain perceives there is a problem, ie it cannot maintain balance in the body. It then sends an output signal to our conscious awareness that there is a problem and we need to address the underlying cause. The pain of a headache is an output signal from the brain that the body is out of balance.

So why do these structures become irritated?

Well it is usually as a result of joint stiffness or muscle tension developing, ie dysfunction.  Why does this occur? This is a slightly more difficult question to answer, as there may be several factors involved. One of the main factors is poor neck and back posture, which may be accentuated in sitting, especially at a poor workstation . There may also be muscle imbalances or weaknesses in the upper body that may lead to neck pain and headaches, such as weakness in shoulder blade retractors , elevators or deep neck flexors. Finally there may be degenerative changes in the facet joints or discs of the neck which can cause inflammation and hence irritation of sensory nerves.

Dysfunction in the upper cervical segments may give rise to neck pain, but could also give rise to pain in the back, side or front of head. Pain can even be transferred to the eye socket, jaw or temple region. Pain that originates in one part of the body, in this case the upper cervical segments, but is felt in other regions is called Referred Pain. The headache pain of CGH is a type of referred pain, and usually originates in the cervical segments C1-3. This region of the neck has nerve connections with nerves that supply the head and face (Trigeminal Nerve) and so the brain can misperceive the origin of this pain, ie the brain sends the signal to us that the pain is in the head when it is actually originating from the neck. This is similar to Sciatic pain, which is leg pain referred from the lumbar spine (low back) usually secondary to disc bulge or prolapse.

There are characteristic referral patterns that relate to the specific segments that pain is arising from in CGH. 

O- C1: a band of pain around the head much like head band/sweat band.
C1-2: an arc of pain over the head between each ear.
C2-3:  pain radiating for the back of head/occiput into the eye/orbital region.   

So if you have pain in any of these areas, there is a good chance that you may have Cervicogenic Headache.

Can Other Areas of the Body Contribute to Headaches?

From our experience the answer to this question is a resounding “YES”!

There is a growing body of evidence (4,5) that suggests “seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint. “

This is called the Regional Interdependence Model of musculoskeletal dysfunction. Put simply, it is the theory that the body is interconnected, and impairments or dysfunctions in one region can influence other anatomically remote regions.

We have a few case studies on clients who have had significant remote contributors to their headaches. Finding and treating these made a big difference to their headaches.

How can remote dysfunctions contribute to headaches?

If we consider that all dysfunctions in the body( tight muscles, joints that are stiff, nerves that do not glide, altered movement patterns, etc), are detected as noxious input by the brain. When the total level of all these inputs exceeds a safe level, then the brain may perceive there is a problem and create a warning to signal to the individual. This warning signal may be in the form of a headache.
This is called the Accumulative Strain theory of Musculoskeletal Health.

So what do I do if I think I have CGH, or suspect other areas may be contributing to my headaches?

The good news is that there is scientific evidence that CGH can be treated effectively with Physiotherapy (2, 3). Research has shown that cervical manipulation and specific exercise can reduce the frequency, severity and duration of CGH when compared to placebo treatments (sham treatments), and that these results are maintained at 1 year follow up.

Determining if remote areas are contributing to your headaches requires a systematic whole body problem solving approach, called Ridgway Method. This is a method we practice at NWPG. It is important with this approach to assess a good objective measure of upper cervical dysfunction to determine if other areas of the body are contributing to headaches. The cervical flexion/rotation test has been shown to be a valid measure of musculoskeletal contribution to a headache (1). This means, if this test is restricted in a headache sufferer, and we can change it by treatment to dysfunctional areas of the body, those areas may be contributing to the headache symptoms.

Physiotherapy may also have a role in the treatment of other types of headache, such as tension headaches or migraines, as these headaches may have a cervical or remote musculoskeletal component, ie neck, spinal or other dysfunctions may contribute to pain inputs to the brain which can make you more susceptible to headache.

So if you think you may have CGH, or other areas in your body that may be contributing to your headaches, book in for an assessment at Northwest Physiotherapy Group

The initial consultation (1hr) includes a comprehensive assessment of cervical and spinal posture, range of movements, muscle strength and imbalance tests, nerve tests and passive spinal segmental mobility tests to determine the cause of your headaches and any possible musculoskeletal factors that may contribute to them. We will treat all associated dysfunctional areas to restore balance to your musculoskeletal system.

Simply call our rooms on 9370 5654 to book your appointment, or send us a request through our website.

References

1. T. Hall*, K. Robinson(2004): The flexion–rotation test and active cervical mobility comparative measurement study in cervicogenic headache. Manual Therapy 9 (2004) 197–202
2. Gert Bronfort, DC, PhD,a Willem J.J. Assendelft, MD, PhD,b Roni Evans, DC, Mitchell Haas, DC,c and Lex Bouter, PhDd (2001). Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review
3. Journal of Manipulative and Physiological Therapeutics 24:(7)2001.
4. Niere K, Robinson P (1994): Determination of manipulative Physiotherapy outcome in headache patients.
5. Manual Therapy 1997: 2(4):199-205.
6. Wainer RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther(2007); 37(11): 658-660.
7. Sueki DG, Cleland JA, Wainner RS(2013): A Regional Interdependence Model of musculoskeletal dysfunction: research, mechanisms and clinical implications. J Man Manip Ther 21(2):90-102

In our experience, most people who present with pain or injury have postural imbalances that contribute significantly to their problem. Improving posture, strength and mobility can help you move more freely with less pain and stiffness.

What we find in our assessments

1. Tightness and trigger points in the muscles at the front of the chest and shoulder: usually the pec major and minor, upper trapezius and levator scapulae (which run from the shoulder blade to the neck) and biceps.
2. The shoulder joint is often sitting forward with posterior tightness in the joint capsule and weakness in the muscles that stabilise the shoulder blades and bringing them back towards the midline.
3. Restricted movement in the neck and thoracic spine, particularly rotation and extension and reduced  movement in the ribs.

Why is this important to know?

This posture results in an increase strain of the neck muscles because the head is pitched forward and it takes increased muscle activation to keep your eyes level.
Decreased mobility in the thoracic spine and ribs reduces capacity for breathing and full movement of the diaphragm.
These immobile and weak dysfunctional regions can also contribute to pain in other, more remote areas of the body.

Why does this happen?

Poor posture has become more common because many of our modern work tasks  involve prolonged  sitting and computer based work. We don’t move enough and our head and shoulders are held fixed and slumped forward.
A generation ago more people had manual jobs which required being on their feet, changing positions and moving between work areas. This constant movement allowed for better mobility in the neck and shoulders and strain did not build up to the same degree because of static loading.
Prolonged static postures cause a accumulation of strain in our bodies. When the amount of strain exceeds a safe threshold, our brains are alerted to send out protective guarding responses which can lead to feelings of pain and stiffness.
This protective guarding cycle leads to poor movement patterns due to pain and relative immobility.
All these are warning signs for us to change our behaviour or seek help.

What this looks like

What you can do about it

The first step is to change your posture so there is better alignment between you neck, shoulders and pelvis in standing and sitting. Good cues are to sit tall, draw in your chin and square your shoulders. In standing, try drawing in your tummy and standing tall.

If this does not help to reduce pain, careful assessment and then treatment to improve joint stiffness, nerve gliding, muscle tightness will reduce the protective guarding response initiated by the brain,improve mobility and reduce pain.

Along with careful systematic assessment and treatment, we also suggest three simple exercises to improve posture and joint mobility. The video below will take you through how to do these.

1. Step in front of an open door with your elbows and shoulders level and the forearm supported by the doorway frame. Gently lean forward and let your shoulders open up and feel a  stretch in the front of your shoulder and chest. Make sure you keep your neck neutral and relaxed as you perform this exercise. Hold for 10 seconds by five repetitions.
2. To improve the thoracic rotation sit in a comfortable chair with your feet flat on the ground to keep your pelvis stabilized. Gently turn your shoulders, turning your spine using your arms on your thighs to assist. Make sure you breathe normally and don’t strain. Hold the  stretch for 10 seconds and alternate from left to right
3. Sit on the floor with your knees bent and feet flat on the ground. Reach behind you placing your palms on the ground with your arms straight. From this position gently lift and open your chest while squeezing your shoulders back and your shoulder blades together. Feel a stretch in your chest and in the front of your shoulders. Feel the shoulder blades squeeze together. Do five stretches holding for 10 seconds.

These are three simple exercises that when done regularly help to gently and progressively stretch away from joint stiffness caused by prolonged sitting and working a desk or computer.
These exercises work both on mobilising joints and muscles and places a steady stretch on the connective tissue around joints which gradually adapt over time. These exercises work very well over time and should be incorporated into a daily stretching or warmup program.
Remember that mobility is the key to good health and as a consequence you have more freedom of movement, can exercise more effectively and just feel a whole lot better.

How you can self test

Do a quick scan of your mobility by first looking at your posture in the mirror. Is your head forward with your shoulders slumped and rounded?
Try turning your head to either side and then your trunk and reaching overhead. How far can you go? How comfortable is the movement?
If indeed you do feel your movements are restricted or painful, it may be worthwhile to start these exercises.
If you continue to have problems with pain or stiffness and  would you like more information about managing these issues.

Feel free to call us at Northwest Physiotherapy Group, either through our website or message us through our Facebook page.

We are here to help!

‘Unknown’ and forgotten even amongst health practitioners (trust me I know!!). The subscapularis is a large triangular shaped muscle that lies between your ribcage and shoulder blade. Why an entire blog post about just one muscle? I hear you ask.. From our experience the subscapularis muscle is a common source of pain for many of our clients, both local (shoulder region) and remote pain. Subscapularis also happens to be the muscle that relieved remote pain in my own body and hence is another reason I have chosen to write my first blog post on this incredibly annoying but fundamental muscle.

Subscapularis – What? Where? Why?

The image above to the left shows the subscapularis muscle insertion, the lesser tubercle of the humerus or upper arm bone. The second image on the right shows the muscles origin on the flat surface of the shoulder blade (subscapula fossa).

Ever heard of the rotator cuff? Subscapularis is one of four muscles that makes up the rotator cuff, which creates stability of the shoulder joint. The rotator cuff works similarly to that of the four guy ropes on a tent, should one become too tight or loose the other three are impacted creating an imbalance. As we know any malalignment within our bodies has the potential to produce pain.

The muscle is innervated by nerves travelling out of the neck. 

In our experiences, when subscapularis muscle becomes dysfunctional often it has the potential to lead to a number of other conditions, and very rarely produces local pain at the site of the muscle. Common referral patterns of a tight and unhappy subscapularis muscle include neck, back and shoulder pain, arm and wrist pain and you may also find reduced strength in these areas (Perry, 2018). 

How does Subscap become problematic?

Prone to becoming tight and shortened, this muscle is most commonly accessed by clinicians via the armpit. There are many different reasons why this muscle can become dysfunctional and aggravated. The most common we find is posture… There’s a reason why you were constantly reminded as a child to sit and stand tall!!

In certain positions and postures the subscapularis muscle can be shortened such as at the desk with use of a mouse, especially with the arm held away from the body. Other repetitive action also have the ability to produce dysfunction such as activities that involve a reaching action behind the back, common in swimming and racket sports.

A fall onto an outstretched hand in most cases will lead to prolonged periods of immobilisation such as a cast on the wrist or a sling for a shoulder injury, but did you know it can also  cause dysfunction to the subscapularis muscle. Once the immobilisation and rehabilitation period are complete, you may still find yourself feeling that things are ‘just not the same since that fall/break/accident’. This could potentially be due to unresolved dysfunction of the subscap. 

Even sleep position, one where you are side lying onto the shoulder, arm outstretched can lead to an accumulation of strain within the subscapularis muscle and resultant issues…. JUST FROM SLEEPING!

… I hear the cogs ticking over now….

How do you know if your Subscapularis needs attending to? 

STEP 1.

• Assess your posture using a mirror.
• Where are your shoulders sitting in relation to the rest of your body?
• Do you have a gorilla’s posture? (arms and shoulder position rolling inwards) 

STEP 2.

• Assess your Range of Motion
• Can you comfortably reach over head or do your shoulders feel restricted and tight?
• Can you complete a Subscap Stretch against wall as pictured below?

STEP 3.

• Identify Weakness using the Lift-off Test
• Leaning on an angle, shoulders resting against and feet slightly forward.
• Place hand behind back palm contacting the wall.
• Press the palm into wall as your body subsequently travels forward. 

If you noticed your posture is looking gorilla-like and/or had difficulty completing steps 2 and 3 it is likely your subscapularis muscle has been suffering in silence… or you have been soldiering on in pain!!

Addressing the subscapularis is relatively easy (unfortunately I cannot promise it will be completely pain free) but following on from treatment you will be sure to notice a difference! The catch, we can not do all of the work for you, if order to achieve long-term and effective results you will need to commit to simple postural correction, strengthening exercise and gain an understanding of how to assess and manage this area in future. If you are interested to learn more or found yourself to have some positive tests, please call our clinic to book your appointment. We are ready to help you!

References:

1. Kenhub (2018). Available at: https://www.youtube.com/watch?v=_NvVjLUL3F4 [Accessed 13 Jun. 2018].
2. Perry, D. (2018). Subscapularis Trigger Points: The Icicles of Shoulder Pain | TriggerPointTherapist.com. [online] Triggerpointtherapist.com. Available at: http://www.triggerpointtherapist.com/blog/subscapularis-trigger-points/subscapularis-trigger-points-shoulder-pain-icicles/ [Accessed 30 May 2018].
3. Vizniak, N. (2012). Muscle manual. Professional Health Systems.

Mr M is a 64 year old lawyer who presented with a 5 day history of worsening low back pain which had become so severe that he attended the ED of John Fawkner Hospital. The pain had developed insidiously without any particular incident or change in routine. There was no radiation of pain into the legs, but the pain was worse in standing and walking, and eased by lying down.

Mr M was managed with medication in ED and referred for Physiotherapy with us by his attending emergency physician.

No red flags. General health good. Walks and goes to gym regularly. Meds: Anti- inflammatories, Codeine, Paracetamol as required.

He had a history of intermittent LBP of similar but less intense nature, generally aggravated by gardening.

No obvious psychosocial factors or limiting beliefs.

Important client values:

1. To understand the cause of the condition and how to prevent recurrence.
2. To regain full painfree function to return to normal lifestyle again and enjoy gardening.

We performed a whole body assessment with Mr M and found several restrictions, not only in his back movements, but also the hips, hamstrings (worse on the right), as well as the neck and shoulders. He also had nerve tension (adverse neural tension) in the left upper limb, both lower limbs and the upper cervical region.

Joint signs, ie local stiffness to passive accessory movement, were detected in the lumbar facets on the right L1-3, L5 -S1, as well as T9-12 on the right and the C3/4 facet joint on the left (neck).Hip flexon R= 90deg; L= 115deg

Hamstring range (tested to R1- first point of reactive resistance): R= -50deg; L= -40deg.

According to patho-anatomical classification criteria (Ford et al, 2011, 2012) Mr M’s condition would be classified as a lumbar facet joint condition. This would be treated with local manipulation/mobilising of the lumbar facet joints, then exercises to address strength, flexibility and motor control impairments.

However, we wanted to determine which dysfunctional structure needed treatment to give the best result for Mr M, and we did not assume that it would be the lumbar facets because there were a host of other structures that may have been also contributing to his condition.We needed a movement test to demonstrate changes in Mr M’s condition as a response to treatment.

We chose, in consultation with the client, and based on research and guidelines for effect re-testing,  that hamstrings range would be a good test to use. This also related well to his low back condition (Halbertsma et al, 2001).

We performed treatment trials to all of the problematic areas we found on Mr M’s initial assessment, including lumbar, thoracic and cervical facet joints, using the limited hamstring range (tested passively to R1).After the first round of treatment trials, Mr M’s hamstring range had improved from -50deg to -20deg, a great result.

On follow up the next day, there had been some regression in Mr. M’s movement signs. Further treatment to eliminate contributing structures revealed that the C3/4 facet on the left was continuing to make the best changes to Mr M’s right hamstring range, as well as right hip joint flexion.

Further treatment to the C3/4 followed by reassessment revealed that the thoracic and lumbar joints had also improved, in response to mobilisation of the C3/4 joint. All lumbar movements also became full and pain-free.

At the start of the session on Day 4 of treatment, Mr M’s LBP had resolved, and he rated himself as 90% in terms of function and recovery. This treatment was administered in the same week.

At this point, Mr M’s lumbar joint signs had also resolved, and given the left C3/4 facet was more mobile but still not in an optimal state of passive resistance(ie it was still stiff), we labelled this as the primary contributing factor to his low back pain. Working on it further continued to improve the hip and hamstring signs.

Why was this neck joint such a problem for Mr M? After we had discovered this, he revealed that he had had a long history of neck pain which preceded his back pain, but he generally managed this himself. Looking further into his sitting posture at work revealed some static loading issues, ie the way Mr M was sitting at his desk was creating tension in his neck, and his neck was contributing to his back pain.

Postural correction and client awareness was required to then  achieve a long term result and prevent recurrence, as well as exercises to address neck tension and habitual postural adaptations.

If Mr M’s neck was contributing significantly to his back problem, as we found it to be, not addressing this important part of his condition would suggest that he may be more vulnerable to relapses and recurrence with his back condition. It would also suggest that we are not fully addressing what was important too him at the start, which was to find the cause of the condition and understand how to prevent it.

On 3 month follow up, Mr M had been reasonably diligent with his exercises. He reported an “occasional twinge” in his lower back that did not eventuate and improved quickly with exercise. He was unrestricted and pain free in all his daily activities, including gardening and gym. His objective signs had regressed a little and further work on the neck continued to improve these. Mr M’s self management exercises and postural strategies were progressed.

6 month follow up was better, where Mr M reported he had been “generally good.” Again, hamstring and hip flexion range had regressed but lumbar range was full and pain-free. Further treatment to the neck and some local work to the lumbar spine also improved his signs again to earlier levels.

Mr M has been very satisfied with his result and is now aware that his neck tension and posture contributes to his back pain. 12 month follow up is pending.

This case really highlights the value in not making assumptions and looking at the whole person and how their body is interconnected to achieve the best long term result for the client.

If you are struggling with this pain, this whole body approach could work for you. Contact us and speak to one of our experienced Physiotherapists.

References

1. Wainer RS, WhitmanJM, Cleland JA, Flynn TW. Regional Interdependence: a musculoskeleltal model whose time has come.
   J Orthop Sports Phys Ther. 2007;37(11):658-60.
2. Sueki DG, Cleland JA, Wainner RS. A Regional Interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications.
   J Man Manip Ther. 2013; 21(2):90-102
3. Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial.
   Man Ther. 2005;10(2):127-35
4. Power CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective.
   J Orthop Sports Phys Ther. 2010;40(2):42-51.
5. Halbertsma JPK, GoehenLNH, Groothoff JW, Eisma WH. Extensibility and stiffness of the hamstrings in patients with non specific low back pain.
   Arch Phys Med Rehab 2001; 82(2):232-238

The young man tested weaker for left hamstring strength and had increased left paraspinal muscle guarding in standing. Transferring from sitting cross legged to standing was difficult and increased his hamstring pain.

He underwent a full body assessment and on testing and treating the main dysfunctional structures the best improvement came from mobilising his mid thoracic spine. Hamstring strength, pain free range of movement and ease of transfers all improved. We treated the thoracic spine and retested the other objective signs which also improved. He was given a course of postural awareness and thoracic strengthening exercises to continue independently.

 The young man is fully participating in his sport with no restriction.

Today, we will show you a simple test to monitor the build up of muscle tension in the upper trapezius, a muscle at the base of the neck.

It’s important to be aware of increased muscle tension which can lead to strain and later, pain. Cath will show you how to feel for tension in the upper trapezius by raising her shoulder or stretching her neck.

When testing, the muscle should be soft and relaxed, if tensed, it it often due to the shoulders rolling forward and the upper trunk being bent. Correct this by gently straightening the upper trunk and pulling the shoulder blades back and down. Ideally, check for muscle tension and correct every 30 to 60 minutes. If you still can’t reduce tension in the upper trapezius by correcting your posture, visit our website for a simple routine of exercises.

If tightness or tension persist, there may be other issues that we can address, call Northwest Physiotherapy Group on 9370 5654.

Mrs M. main goals: (self rated as 10/10 being pain free and full function)
To reach overhead e.g. hanging clothes, reaching in high cupboard (3/10)
To carry bags without pain (6/10)
To do weight bearing activity e.g. Pilates exercises (5/10)

We performed a systematic assessment of Mrs M’s musculoskeletal system and found the following imbalances:

1. Neurodynamic tension in both upper limbs
2. Severely restricted shoulder movement bilaterally (Flexion, Abduction, External Rotation)
3. Tight posterior shoulder capsule bilaterally
4. Muscles guarding around both shoulders and right side of the neck (scalenes, upper trapezius)
5. Stiff neck (C6-7) and thoracic (T1-2, T9-10) segments
6. Over-activation of upper trapezius with active shoulder movements

Through a clinical reasoning approach, we worked out together that Mrs M’s right shoulder external rotation was a good test to measure changes in her condition. Through a process of treatment trials and reassessment, we found the biggest and quickest change in this test occurred with a release of her neck (C6-7). It increased her right shoulder movement by more than 50% and even improved her left shoulder by 30%. When re-testing the main dysfunctions in her body, most of them had improved (decreased muscle tension around shoulder, increased hamstring flexibility, increased thoracic and neck movements).
Following the reassessment, we were confident that we had found the main driver of her shoulder problems. With more treatment of her neck, the shoulder mobility got to 90% and it only needed a few minutes of local work on each shoulder to get back to full range.

Mrs M. achieved all her goals and even more. In the week that followed the treatments, she found out her neck was a lot freer allowing her to reverse the car easily, her hamstrings were less tight so it was easy to do some Pilates exercises that she was struggling with.

To make sure she doesn’t overload her neck area again, I gave her postural exercises and attended a Pilates reformer session with her to make sure she was doing the exercises appropriately. I also discussed Mrs M’s condition with her Pilates instructor and strategies to prevent recurrence of her problem

This case demonstrates that even if there is a diagnosis of local problems where the pain is, other areas in the body can affect the overall condition and without a thorough assessment, we can’t be sure we are treating the main driver of the condition to get the best result.

If you would like to learn more about the neuroscience behind the approach we used with Mrs M, please click here.