5 minutes: Attendance and Breath of Arrival. 50 minutes: Problem Solving Torso

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2 5 minutes: Attendance and Breath of Arrival 50 minutes: Problem Solving Torso

3 Punctuality- everybody's time is precious: o o Be ready to learn by the start of class, we'll have you out of here on time Tardiness: arriving late, late return after breaks, leaving early The following are not allowed: o o o o o o Bare feet Side talking Lying down Inappropriate clothing Food or drink except water Phones in classrooms, clinic or bathrooms You will receive one verbal warning, then you'll have to leave the room.

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6 Upper border of the thoracic rib cage where structures either exit or enter

7 Thoracic outlet syndrome (AKA: TOS) Several pathologies involving compression of arteries, veins, or nerves near the thoracic outlet. TOS is a complex condition that is often overlooked or misdiagnosed. Structures that may be involved in TOS: o Brachial plexus o Subclavian artery o Subclavian vein

8 True neurogenic TOS o Rare. Brachial plexus compression between C7 rib and clavicle. o Neurogenic Originating in nervous tissue. o No soft tissue treatment can remove the cervical rib obstruction. o The techniques for the other syndromes can help this syndrome.

9 Anterior scalene syndrome o Neurovascular compression between anterior and middle scalenes.

10 Costoclavicular syndrome o Neurovascular compression between the clavicle and first rib.

11 Pectoralis minor syndrome o Neurovascular compression between pectoralis minor and ribs.

12 o o o Medial cord: ulnar 1/3 of the fingers and hand (blue) Lateral cord: radial 2/3 of the fingers and hand (yellow). Posterior cord: radial 2/3 of dorsum of the hand (pink).

13 Acute: often caused by a direct blow to the clavicle. Chronic: postural distortions with resultant muscular dysfunction o Prolonged shoulder abduction (hairstyling, playing the violin). o Wearing a heavy backpack or carrying heavy objects.

14 Upper extremity o Pain o Paresthesia Feeling of pins and needles. o Feeling of heaviness o Coldness o Discoloration

15 Thenar muscle atrophy o Thenar muscles First and fifth finger abductors and flexors. o Atrophy Wasting away of muscle tissue. o Anterior and middle scalene tension compresses the brachial plexus.

16 Coracobrachialis and biceps brachii tension pull the coracoid process inferiorly. This causes the pectoralis minor to shorten and become hypertonic resulting in compression of the brachial plexus against the ribcage.

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18 Postural re-education, stretching, and strengthening o Effective. Surgery o Variable effectiveness: most effective for true neurologic TOS.

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20 o Treat the soft tissues in ALL possible areas of compression. o Address postural dysfunctions by using frequent postural corrections. o Stretch cervical and shoulder girdle muscles to the point of mild pain or discomfort. This elongates the connective tissue component of the muscle, and changes the rate of stimulation in the neuromuscular component of the muscle, thus reducing tension.

21 o Exacerbation of neurological symptoms during muscular stretching may be due to stretching of neural tissues. Neural stretching may help to improve neural mobility. It is repetition, not tensile load that encourages greater mobility of the nerve between it and adjacent structures. Only perform the neural mobility technique after the entire upper extremity has been treated because it is more effective when the soft tissue along the path of the nerve is relaxed.

22 o In more severe cases where the suggested techniques aggravate the symptoms, simply reduce the pressure applied and focus on using the MET technique described above.

23 Vertebrobasilar insufficiency Decreased blood flow to the brain. Caused by compression of the vertebral artery by the combined actions of neck rotation and hyperextension. Symptoms are dizziness, vertigo, blurred vision, or fainting.

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25 Supine Assessment Cervical Soft-Tissue Manipulation: Overview Vertebrobasilar insufficiency test Superficial fascia assessment Myofascial release Rectus abdominis Deep Massage the Lauterstein Method Pectoralis major Deep Massage the Lauterstein Method Swedish Deep longitudinal stripping Cervical Swedish Scalene Trigger point deactivation Deep longitudinal stripping Deep longitudinal stripping with active lengthening Pectoralis minor pin and stretch Neural mobilization technique Stretches Lateral neck flexion Neck rotation

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27 o During the interview, instruct the client: Look up and over your shoulder to one side. Hold this position for 30 seconds. o The test is positive if the client experiences any of the following: Vertigo Perception of a spinning motion (due to dysfunction of the vestibular system). Dizziness Sensation of feeling off balance. Nausea Sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. Double vision or blurred vision. o Vertebrobasilar insufficiency is a contraindication for active cervical flexion with longitudinal stripping.

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29 Cervical superficial fascia assessment o Work without lubricant o Use your palm and fingers to apply light tangential pulling pressure o Place your fingertips flatly on the skin surface o Press in just enough to traction the superficial fascia without sliding o Slowly traction in all directions taking note of restrictions o Use before and after treating superficial fascia to gauge progress

30 Cervical myofascial release o Work without lubricant sitting at the head of the table facing down toward the feet o Place both hands flatly on the skin surface about 4-6 inches apart o Use your fingers or palms to apply light tangential pulling pressure o Press in just enough to traction the superficial fascia without sliding o Hold. Wait for a subtle tissue release or indication from the client o Repeat in different directions and areas to address restrictions in the anterior, lateral, and posterior cervical areas.

31 Pectoralis major Deep Massage the Lauterstein Method Rectus abdominis Deep Massage the Lauterstein Method

32 Pectoralis major Swedish o Effleurage o Kneading o Repeat until the muscles are thoroughly warmed and softened

33 Pectoralis minor deep longitudinal stripping o This region can be tender. Adjust pressure accordingly o Use thumbs to strip inferiorly toward ribs 3, 4, and 5 o Immediately stop if neurovascular symptoms are reproduced

34 Cervical Swedish o Use thumbs to work on one side of the neck at a time o Effleurage longitudinally along all cervical muscles o Fulling with one thumb across the cervical muscle fibers o Repeat until the muscles are thoroughly warmed and softened

35 Scalene trigger point deactivation o Use client report and palpation to locate trigger points o Melt in using the steps of the fulcrum. Hold points for 8 seconds o Repeat to address all trigger points

36 Scalene deep longitudinal stripping o Be cautious of blood vessels, nerves, and the trachea o Address the accessible portions of anterior and middle scalenes o Roll head slightly away from the area to be addressed o Use fingertips or thumb to work in 2-4 inch sections o Work in an inferior direction o Pause or repeat in areas of palpated or reported tension o Progress from moderate to deep pressure within client comfort o Be cautious of superficial vascular, respiratory, and neural structures

37 Scalene deep longitudinal stripping with active lengthening o Vertebrobasilar insufficiency contraindicates this technique o If the client is uncomfortable with their head off the end of the table, use a bolster or pillow under the upper back so there is room to move the into hyperextension. o Instruct the client: Move toward the head of the table to hang your head off the edge and turn it slightly to the left/right. I will support it. (This results in the practitioner holding the client s head in one hand with it rotated to one side) Now take the weight of your head. Lift your head slightly and hold for a 5-8 seconds. (isometric) Slowly relax your head. (post-isometric relaxation) Slowly lower your head toward the floor. o As the client does this, strip the accessible scalene fibers with your 2 nd and 3 rd fingers inferiorly. head

38 Pectoralis minor pin and stretch Use fingertips to make positive contact with pectoralis minor in a way that does not reproduce neurovascular symptoms Instruct the client: Keeping your arms alongside your torso, reach as far down toward your toes as possible. (scapular depression) Pin the pectoralis minor: apply moderate to significant pressure to pectoralis minor within the client s comfort tolerance Instruct the client: Bring your shoulders up toward your ears. (scapular elevation) As the client does this, maintain your pressure or strip inferiorly. Repeat several times for all three bellies of pectoralis minor.

39 Neural mobilization technique o Stand along the side of the table by the waist facing toward the head Instruct the client: Keeping your nose pointing toward the ceiling, slide your head toward your left/right shoulder. (lateral neck flex) Abduct the arm 90 Flex the elbow 90 and hold it with the inside hand Hyperextend wrist and fingers with the outside hand so that the fingertips are pointing inferiorly. Holding this configuration, bring the arm and hand toward the client s ear. Do not hold the final stretch position. Bring the arm back to neutral and repeat several times.

40 Lateral neck flexion stretch Neck rotation stretch

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