PRESENTS Excerpt from Listen To Your Pain Assessment & Treatment of Neck Pain A B E N J A M I N I N S T I T U T E E B O O K www.benbenjamin.com Ben E. Benjamin, Ph.D.
2 THERAPIST/CLIENT MANUAL The Neck Neck Assessment Tests A full assessment of the neck which distinguishes between disc, ligament, muscle, and other injuries includes more than 40 assessment tests, which is beyond the scope of this book. Here I m focusing on ligament injuries, which are among the most common and least known causes of chronic neck pain. Damage to ligaments in the neck is indicated by the results of six passive tests: passive rotation to the right and left, passive side-flexion to the right and left, passive flexion, and passive extension. The major indicators differ somewhat between the supraspinous and intertransverse ligaments, as I ll discuss in the sections that follow. Passive rotation Stand at the client s left side and ask the person to turn the head to the left. Place your right forearm (not visible in the drawing) on the left scapula to stabilize the upper body, and place your right palm on the side of the head, with your fingers around the ear but not covering it. Ask the client to drop the chin in slight flexion. Then place your left hand on the client s right cheek with your fingers around the ear and gently rotate the neck to the end of range, taking up all the slack. Stop if there is any pain or discomfort. If there is absolutely no discomfort, give a very gentle overpressure (a slight motion, moving through less than a half-inch of space). Note any limitation of movement and the location of any pain. Now repeat the test on the other side. Passive side-flexion Stand behind the client and ask the person to tilt the head to the right, trying to bring the ear to the shoulder. Place your left hand on the left shoulder and your right hand on the left side of Passive rotation Passive side-flexion
3 THERAPIST/CLIENT MANUAL the head above the ear. Stretch to the end of range. If there is no pain, give a slight gentle overpressure. Note whether there is limitation, and note the location of any pain. Now repeat on the other side. If there is only a slight stretching sensation and it is the same on both sides, the test result is negative. Passive flexion Ask the client to lower the chin toward the chest, with the weight of the head hanging down. If there is no pain, place your middle and index fingers on the back of the head and gently stretch it further. In most individuals under 40, the chin should reach the chest. Passive extension Ask the client to look up at the ceiling, extending the neck as far as possible by himor herself. If there is no pain, place one or two fingers on the forehead and your other hand on the upper back for support. Gently press the head into further extension. Take note of any pain or limitation. Passive flexion Passive extension Neck Exercise Protocol There is one standard exercise for injured neck ligaments: Neck Exercise Protocol
4 THERAPIST/CLIENT MANUAL Lie supine with your neck supported by a pillow, so that your head is two or three inches in flexion. Slowly rotate your head moving gently, without force so that your cheek moves toward your shoulder. Perform twenty-five rotations, right and left, two to three times a day. This movement is a combination of rotation, slight flexion, and some side-bending. These combine to put the supraspinous and intertransverse ligaments under tension, preventing unwanted scar tissue from re-forming adhesions after treatment. If you feel pain while doing the exercise, discontinue it until you ve recovered sufficiently to do it without pain. If you feel a slight pulling sensation, that s okay. (Note: Friction techniques for all of the neck injuries described below are demonstrated in the DVD The Power of Precision: The Neck (see www.benbenjamin.net) Injury to the Supraspinous ligaments/nuchal ligament Supraspinous ligament (A) Major Indicators: Pain and limitation of movement on passive rotation, flexion, and extension. Extremely limited rotation indicates damage to the most superior ligaments. As shown above. Exercise Protocol: See the standard neck exercise described above. Friction Therapy: Sit at the head of the table, with the client lying supine, and place your hands under the client s neck. Using your middle or index finger, palpate the spinous processes. Feel their shape, depth, and alignment. Start by pressing the tip of your index finger in at the uppermost space, (below C2). Press your fingertip directly onto the central part of the spine, on the supraspinous ligament. Apply friction in one direction,
5 THERAPIST/CLIENT MANUAL Friction Therapy Friction Therapy B pulling your finger across the ligament repeatedly, for about 30 seconds. Then switch hands and friction in the opposite direction. On some people, you may feel a snap as you go over the ligament structure. Work your way down one by one to each ligament, working longer at the tender spots. Friction at each of these levels for about 20 or 30 seconds at a time, returning to each area two or three times. You can also perform this technique with the client in the prone position (see illustration). Variation with tilted head Tilt the client s head into side-flexion to the right, and reach your right hand under the neck to friction the lateral edges of the ligament on the left side. Then tilt the head to the left and switch hands to friction the opposite side. Work your way down the vertebrae one by one. Variation with tilted head
6 THERAPIST/CLIENT MANUAL Injury to the Intertransverse Ligaments Intertransverse Ligament Major Indicators: Pain on passive side-flexion and often on rotation as well. Pain may be felt on sideflexion away from the painful side (which stretches the ligament) or side-flexion toward the painful side (which compresses the ligament) Exercise Protocol: See the standard neck exercise on page 3. Friction Therapy: Friction of the Intertransverse Attachments and Zygapophyseal Capsules With the client lying supine, place your thumb or fingertip on the mastoid process. Move inferiorly until you are between the two uppermost transverse processes, and slowly allow your finger to sink into the tissue. When you feel the bone clearly under your finger, apply your pressure at the most superior edge, where the ligament attaches, and friction in an anterior-to-posterior direction. Then repeat this Friction Therapy A Friction Therapy B
7 THERAPIST/CLIENT MANUAL friction at the most inferior edge. Also work in between the processes, if you can. (Depending on the person s age and body structure, this may or may not be possible.) Friction each tender structure for 30 seconds to a minute, depending on the client s tolerance and the number of injured areas. Slowly work your way down toward the lower neck until you reach C6. Then, repeat the same technique on the opposite side. The zygapophyseal capsules, located posterior to the transverse processes, may also be inflamed. To access these capsules, move your finger slightly in a posterior direction until you feel another hard mass. Friction the capsules with the same technique you used on the ligaments. Friction of the TP7 Ligaments (Intertransverse Ligaments at C7) In the same position as above, support your thumb with your index finger curled beneath it, push the trapezius back out of the way, and place your thumb tip on the seventh transverse process (TP7). Work your way to the back of the process and friction in an anteriorto-posterior direction, while pressing slightly toward the midline. Friction of the TP7 Ligament, Prone This variation is easier for some practitioners. Ask the client to lie prone. Now, place your middle or index finger over the trapezius and pull it posteriorly. Press your finger onto the posterior portion of TP7 and friction in an anterior-to-posterior direction, while pressing slightly toward the midline. Friction of TP7 Ligaments Friction of TP7 Ligament, Prone