These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Sternocleidomastoid (SCM)
Assessment for Shortness of Sternocleidomastoid (see also Box 4.10)
Assessment for SCM is as for the scalenes – there is no absolute test for shortness but observation of posture (hyperlordotic neck, chin poked forward) and palpation of the degree of induration, fibrosis and trigger point activity can all alert to probable shortness of SCM. This is an accessory breathing muscle and, like the scalenes, will be shortened by inappropriate breathing patterns which have become habitual. Observation is an accurate assessment tool.
Box 4.10 Notes on Sternocleidomastoid
- Sternocleidomastoid (SCM) is a prominent muscle of the anterior neck and is closely associated with the trapezius. SCM often acts as postural compensator for head tilt associated with postural distortions found elsewhere (spinal, pelvic or lower extremity functional or structural inadequacies, for instance) although they seldom cause restriction of neck movement.
- SCM is synergistic with anterior neck muscles for flexion of the head and flexion of the cervical column on the thoracic column, when the cervical column is already flattened by the prevertebral muscles. However, when the head is placed in extension and SCM contracts, it accentuates lordosis of the cervical column, flexes the cervical column on the thoracic column, and adds to extension of the head. In this way, SCM is both synergist and antagonist to the prevertebral muscles (Kapandji 1974).
- SCM trigger points are activated by forward head positioning, ‘whiplash’ injury, positioning of the head to look upwardly for extended periods of time and structural compensations. The two heads of SCM each have their own patterns of trigger point referral which include (among others) into the ear, top of head, into the temporomandibular joint, over the brow, into the throat, and those which cause proprioceptive disturbances, disequilibrium, nausea and dizziness. Tenderness in SCM may be associated with trigger points in the digastric muscle and digastric trigger points may be satellites of SCM trigger points (Simons et al 1998).
- Simons et al (1998) report: When objects of equal weight are held in the hands, the patient with unilateral trigger point [TrP] involvement of the clavicular division [of SCM] may exhibit an abnormal Weight Test. When asked to judge which is heaviest of two objects of the same weight that look alike but may not be the same weight (two vapocoolant dispensers, one of which may have been used) the patient will [give] evidence [of] dysmetria by underestimating the weight of the object held in the hand on the same side as the affected sternocleidomastoid muscle. Inactivation of the responsible sternocleidomastoid TrPs promptly restores weight appreciation by this test. Apparently, the afferent discharges from these TrPs disturb central processing of proprioceptive information from the upper limb muscles as well as vestibular function related to neck muscles.
- Lymph nodes lie superficially along the medial aspect of the SCM and may be palpated, especially when enlarged. These nodes may be indicative of chronic cranial infections stemming from a throat infection, dental abscess, sinusitis or tumour. Likewise, trigger points in SCM may be perpetuated by some of these conditions (Simons et al 1998).
- Lewit (1999) points out that tenderness noted at the medial end of the clavicle and/or at the transverse process of the atlas is often an indication of SCM hypertonicity. This will commonly accompany a forward head position and/or tendency to upper chest breathing, and will almost inevitably be associated with hypertonicity, shortening and trigger point evolution in associated musculature, including scalenes, upper trapezius and levator scapula (see crossed syndrome notes in Ch. 2).
Since SCM is only just observable when normal, if the clavicular insertion is easily visible, or any part of the muscle is prominent, this can be taken as a clear sign of tightness of the muscle. If the patient’s posture involves the head being held forward of the body, often accompanied by cervical lordosis and dorsal kyphosis (see notes on upper crossed syndrome in Ch. 2), weakness of the deep neck flexors and tightness of SCM is suspected.
Functional SCM Test (see Fig. 5.14A, B)
The supine patient is asked to ‘very slowly raise your head and touch your chin to your chest’. The practitioner stands to the side with his head at the same level as the patient. At the beginning of the movement of the head, as the patient lifts this from the table, the practitioner would (if SCM were short) note that the chin was lifted first, allowing it to jut forwards, rather than the forehead leading the arc-like progression of the movement. In marked shortness of SCM the chin pokes forward in a jerk as the head is lifted. If the reading of this sign is unclear then Janda (1988) suggests that a slight resistance pressure be applied to the forehead as the patient makes the ‘chin to chest’ attempt. If SCM is short this will ensure the jutting of the chin at the outset.
MET Treatment of Shortened SCM (Fig. 4.35)
The patient is supine with the head supported in a neutral position by one of the practitioner’s hands. The shoulders rest on a cushion or folded towel, so that when the head is placed on the table it will be in slight extension. The patient’s contralateral hand rests on the upper aspect of the sternum to act as a cushion when pressure is applied during the stretch phase of the operation (as in scalene and pectoral treatment). The patient’s head is fully but comfortably rotated, contralaterally.
Figure 4.35 MET of sternocleidomastoid on the right.
The patient is asked to lift the fully rotated head a small degree towards the ceiling, and to hold the breath. When the head is raised there is no need for the practitioner to apply resistance as gravity effectively provides this.
After 7–10 seconds of isometric contraction (ideally with breath held), the patient is asked to slowly release the effort (and the breath) and to place the head (still in rotation) on the table, so that a small degree of extension occurs.
The practitioner’s hand covers the patient’s ‘cushion’ hand (which rests on the sternum) in order to apply oblique pressure/stretch to the sternum, to ease it away from the head and towards the feet.
The hand not involved in stretching the sternum caudally should gently restrain the tendency the head will have to follow this stretch, but should not under any circumstances apply pressure to stretch the head/neck while it is in this vulnerable position of rotation and slight extension.
The degree of extension of the neck should be slight, 10–15° at most.
This stretch, which is applied as the patient exhales, is maintained for not less than 20 seconds to begin the release/stretch of hypertonic and fibrotic structures. Repeat at least once. The other side should then be treated in the same manner.
CAUTION: Care is required, especially with middle aged and elderly patients, in applying this useful stretching procedure. Appropriate tests should be carried out to evaluate cerebral circulation problems. The presence of such problems indicates that this particular MET method should be avoided.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
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