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).
Levator scapula ‘springing’ test (a) The patient lies supine with the arm of the side to be tested stretched out with the supinated hand and lower arm tucked under the buttocks, to help restrain movement of the shoulder/scapula. The practitioner’s contralateral arm is passed across and under the neck to cup the shoulder of the side to be tested, with the forearm supporting the neck. 11 The practitioner’s other hand supports the head. The forearm is used to lift the neck into full pain-free flexion (aided by the other hand). The head is placed fully towards side-flexion and rotation, away from the side being treated.
Figure 4.36 MET test (a) and treatment position for levator scapula (right side).
With the shoulder held caudally and the head/ neck in the position described (each at its resistance barrier) stretch is being placed on levator from both ends.
If dysfunction exists and/or levator scapula is short, there will be discomfort reported at the attachment on the upper medial border of the scapula and/or pain reported near the levator attachment on the spinous process of C2.
The hand on the shoulder gently ‘springs’ it caudally.
If levator is short there will be a harsh, wooden feel to this action. If it is normal there will be a soft feel to the springing pressure.
Levator scapula observation test (b) A functional assessment involves applying the evidence we have seen (see Ch. 2) of the imbalances which commonly occur between the upper and lower stabilisers of the scapula. In this process shortness is noted in pectoralis minor, levator scapulae and upper trapezius (as well as SCM), while weakness develops in serratus anterior, rhomboids, middle and lower trapezius – as well as the deep neck flexors.
Observation of the patient from behind will often show a ‘hollow’ area between the shoulder blades, where interscapular weakness has occurred, as well as an increased (over normal) distance between the medial borders of the scapulae and the thoracic spine, as the scapulae will have ‘winged’ away from it.
Levator scapula test (c) To see the imbalance described in test (b) in action, Janda (1996) has the patient in the press-up position (see Fig. 5.15). On very slow lowering of the chest towards the floor from a maximum push-up position, the scapula(e) on the side(s) where stabilisation has been compromised will move outwards, laterally and upwards – often into a winged position – rather than towards the spine.
This is diagnostic of weak lower stabilisers, which implicates tight upper stabilisers, including levator scapulae, as inhibiting them.
Treatment of levator scapulae using MET enhances the lengthening of the extensor muscles attaching to the occiput and upper cervical spine. The position described below is used for treatment, either at the limit of easily reached range of motion, or a little short of this, depending upon the degree of acuteness or chronicity of the dysfunction.
The patient lies supine with the arm of the side to be tested stretched out alongside the trunk with the hand supinated. The practitioner, standing at the head of the table, passes his contralateral arm under the neck to rest on the patient’s shoulder on the side to be treated, so that the practitioner’s forearm supports the patient’s neck. The practitioner’s other hand supports and directs the head into subsequent movement (below).
The practitioner’s forearm lifts the neck into full flexion (aided by the other hand). The head is turned fully into side-flexion and rotation away from the side being treated.
With the shoulder held caudally by the practitioner’s hand, and the head/neck in full flexion, sideflexion and rotation (each at its resistance barrier), stretch is being placed on levator from both ends.
The patient is asked to take the head backwards towards the table, and slightly to the side from which it was turned, against the practitioner’s unmoving resistance, while at the same time a slight (20% of available strength) shoulder shrug is also asked for and resisted.
Following the 7–10 second isometric contraction and complete relaxation of all elements of this combined contraction, the neck is taken to further flexion, sidebending and rotation, where it is maintained as the shoulder is depressed caudally with the patient’s assistance (‘as you breathe out, slide your hand towards your feet’). The stretch is held for 20–30 seconds.
The process is repeated at least once.
CAUTION: Avoid overstretching this sensitive area.
In order to commence rehabilitation and proprioceptive re-education of a weak serratus anterior:
The practitioner places a single digit contact very lightly against the lower medial scapula border, on the side of the treated upper trapezius of the seated or standing patient. The patient is asked to attempt to ease the scapula, at the point of digital contact, towards the spine (‘press against my finger with your shoulder blade, towards your spine, just as hard [i.e. very lightly] as I am pressing against your shoulder blade, for less than a second’).
Once the patient has learned to establish control over the particular muscular action required to achieve this subtle movement (which can take a significant number of attempts), and can do so for 1 second at a time, repetitively, they are ready to begin the sequence based on Ruddy’s methodology (see Ch. 10, p. 75).
The patient is told something such as ‘now that you know how to activate the muscles which push your shoulder blade lightly against my finger, I want you to try do this 20 times in 10 seconds, starting and stopping, so that no actual movement takes place, just a contraction and a stopping, repetitively’.
This repetitive contraction will activate the rhomboids, middle and lower trapezii and serratus anterior – all of which are probably inhibited if upper trapezius is hypertonic. The repetitive contractions also produce an automatic reciprocal inhibition of upper trapezius, and levator scapula.
The patient can be taught to place a light finger or thumb contact against their own medial scapula (opposite arm behind back) so that home application of this method can be performed several times daily.
Ruddy’s treatment method for the muscles of the eye is outlined in the notes below.
Osteopathic eye specialist Dr T. Ruddy described a practical treatment method for application of MET principles to the muscles of the eye:
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