Upper Cross Syndrome: Assessment & Management in Family Practice HKDU Symposium Dec 2014

Transcription

1 Upper Cross Syndrome: Assessment & Management in Family Practice HKDU Symposium Dec 2014 Dr. Ngai Ho Yin Allen Family Medicine Specialist PGDipMusculoskeletal Medicine MBBS(HK), DCH(London), DFM(CUHK), DipClinDerm(London), FRACGP, FHKCFP, FHKAM(Family Medicine)

2 Janda s Crossed Syndromes Muscle imbalances can spread through the muscular system in a predictable manner Janda (1987, 1988) has classified these patterns as: 1. Upper crossed syndrome 2. Lower Crossed syndrome & 3. Layer syndrome The crossed syndromes are characterized by alternating sides of inhibition and facilitation in the upper quarter and lower quarter

3 The Upper Crossed Syndrome Facilitation of: Suboccipital muscles Upper trapezius, Levator scapulae, Sternocleidomastoid, and Pectoralis muscles Inhibition of: Deep cervical flexors Lower trapezius, Serratus anterior, and Rhomboid muscles

4 The Upper Crossed Syndrome Weak deep cervical flexors Tight suboccipitals, upper trapezius, levator scapulae Tight sternocleidomastoid, pectoralis muscles Weak lower trapezius, rhomboids, serratus anterior

5 Muscles Inhibited in UCS Deep neck flexors Lower trapezius Serratus anterior Rhomboid muscles

6 Anterior Head Positioning Forward head posture increases stress on upper cervical segments Cervicogenic headache occured more often in people with anterior head positioning (J Manipulative Physiol Ther. 2004) According to Travell & Simons trigger point theories, anterior head positioning has significant contributions to the perpetuation of myofascial TrPs in the head, neck and shoulder muscles, as well as TMJ disorders

7 Consequences of UCS (1) Suboccipital, posterior cervical, upper trapezius and splenius capitis muscles contract and shorten to bring the head into extension to allow the eyes to gaze forward Loss of cervical lordosis & flattening of cervical curve TrPs development causing headache and neck pain

8 TrP Referred Pain Pattern of Suboccipital Muscles

9 TrP Referred Pain Pattern of Posterior Cervical Muscles

10 TrP Referred Pain Pattern of Upper Trapezius

11 TrP Referred Pain Pattern of Splenius Capitis

12 Consequences of UCS (2) Sternocleidomastoid and splenius cervicis placed in a mechanical disadvantaged position as a result of reduced cervical lordosis Muscle overloading & TrP development causing headache and neck pain

13 TrP Referred Pain Pattern of Sternocleidomastoid Sternal division Clavicular division

14 TrP Referred Pain Pattern of Splenius Cervicis

15 Consequences of UCS (3) Suprahyoid and infrahyoid muscles placed in stretched position Counteracting force of mandibular elevating muscles Muscle TrP development causing ear pain, facial pain and jaw pain Increased intra-articular pressure of TMJ TMJ Dysfunction

16 TrP Referred Pain Pattern of Digastric Muscle Posterior belly TrP Anterior belly TrP

17 TrP Referred Pain Pattern of Temporalis Muscle

18 TrP Referred Pain Pattern of Medial Pterygoid

19 TrP Referred Pain Pattern of Lateral Pterygoid

20 TrP Referred Pain Pattern of Masseter Muscle

21 Consequences of UCS (4) Increased cervical extension compression of C0/1, zygapophyseal joints and nerve roots Compression of C0/1, zygapophyseal joints and nerve roots Degenerative changes of zygapophyseal joints and cervical nerve root impingement

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23 Consequences of UCS (5) Tightness of pectoralis and upper trapezius creates an anterior force on glenohumeral joint and limits scapular upward rotation, external rotation and posterior tilt Reduction in subacromial space Subacromial impingement syndrome, rotator cuff tendinosis and tear

24 Assessment of Upper Crossed Syndrome

25 Inspection Patient is observed from: 1) In front 2) Behind 3) From the side Concentrate on head position and any asymmetry

26 Inspection From Front Observe: 1) Eye levels 2) Chin position 3) Shoulder elevation

27 Inspection From Side Observe: 1) Ear lobe position 2) Exaggerated or reduced lordosis Ideal position from side: straight line passing through earlobe and AC joint of shoulder

28 Anterior Head Positioning Clinically, assessment of anterior head position is probably the single most useful postural parameter in a patient with head and neck pain complaints A simple test: 1. Looking at the patient from the side and place a real or imaginary plumb line on a tangent to the crest of the thoracic spine kyphotic curve 2. Then measure the distance from this line to the depth of the cervical curve 3. This distance should be ~6cm Measurements > 6cm indicate anterior head positioning

29 Inspection From Behind Observe: 1) Head position 2) Shoulder elevation 3) Scoliosis of thoracic spine

30 Other Examinations Other examination directed by patient s symptoms. These may include: 1. Cervical spine palpation and range of motion examination 2. Neurological examination of upper limb 3. Shoulder palpation and range of motion examination 4.Shoulder impingement tests 5. Temporomandibular joint examination 6.Head and neck, shoulder trigger point palpation

31 Management

32 Management in Family Practice Depends on clinical expertise. These may include: 1. Office and daily activities ergonomic assessment 2. Medications: simple analgesics and second-line analgesics as temporary pain control 3. Trigger point injections or dry-needling 4. Manual therapies 5. Home exercise prescription and postural correction (most important for long-term management)

33 Trigger Point Injection Different approaches: Local anesthetic without corticosteroid and adrenaline, e.g. 0.5% procaine (less myotoxic), 1% lidocaine Dry needling (more post-injection soreness) One MUST know the anatomical danger zones before injection. E.g. rhomboid injection can cause pneumothorax Sternomastoid trigger point injection

34 Manual Therapy Randomized controlled studies showed that spinal manipulative therapy (SMT) is effective for cervicogenic headaches, particularly those focused on treatment of the upper cervical segments (Spine 2002) Systematic reviews of randomized control trials using manual therapy in cervicogenic headache patients suggest better outcomes compared to no treatment (Man Ther ) Direct and indirect techniques. Generally post-isometric relaxation is much safer than high-velocity low amplitude (HVLA) techniques

35 Muscle energy technique for releasing the left levator scapuae HVLA thrust technique for treating a C5 FRS Left dysfunction

36 Exercise Prescription (1) Sternocleidomastoid and Upper Trapezius stretching exercises

37 Home Exercise Prescription (2) Pectoralis stretching exercises

38 Home Exercise Prescription (3) Levator scapulae stretching exercises

39 Home Exercise Prescription (4) Deep neck flexor strengthening exercises Eccentric deep neck flexor exercises

40 Home Exercise Prescription (5) Lower trapezius strengthening exercises

41 Home Exercise Prescription (6) Rhomboid strengthening exercises

42 Home Exercise Prescription (7) Serratus anterior strengthening exercises

43 Simple Shoulder Postural Exercise Stand with feet ~4 inches apart, arms at the sides and thumbs pointing outward Tighten the buttocks to stabilize the lower back Rotate the thumbs, arms and shoulders out and back while inhaling, squeezing the shoulder blades together in back Maintain this position while pulling the shoulders down and exhaling Hold this position while breathing normally and correct the head posture (see following slide)

44 Simple Head Postural Exercise Perform the shoulder postural exercise first Once the shoulder posture has been corrected, gently move the head backward to bring the ears in line with the shoulders This must be accomplished without moving the nose up or down and without opening the mouth

45 Postural Avoidance (1) Positioning of the pillow to produce relief of the sternocleidomastoid: 1. Patient supine with the corners of the pillow tucked between the chin and shoulders. NOT to place pillow under the shoulders 2. Patient side-lying with the pillow between the head and shoulder. NOT to place pillow under the shoulder so that the chin lies in the hollow of the shoulder placing the SCM and scalenes in shortened positions

46 Postural Avoidance (2) Support for short upper arms: when the patient s upper arms are short in relation to torso height, they do not reach the armrests of most chairs. This imposes sustained gravity stress on the trapezius Select chairs with armrests of the correct height to provide elbow support Hands-in-pockets posture can also help to relieve strain on upper trapezius

47 Postural Avoidance (3) Avoid working at a desk with the head turned to one side and projected forward to see documents or a display screen Avoid the so-called birdwatching posture for prolonged period The above postures place the splenius cervicis in sustained contraction

48 THE END