It was great meeting everyone this past weekend.
Nick- thanks again for posting this article. In class we learned several ways to clear out the shoulder and multiple test clusters to rule in or rule out certain pathologies. I like how this article focused mainly on the principals of consistency through the skills of observation: inter/ intra reliability.
Questions:
1) Segarra et al. focuses on maintaining sub-occipital neutral positioning during cervical extension. Maybe they’re trying more to isolate cervical extension while at the same time observing upper cervical stability? Maybe we’re “unloading” the lower cervical spine by decreasing the force potentially that could be caused by vectors from a shearing force if the upper cervical spine was not in neutral? Who knows. All I know is that I want to learn how to collect observational data points. I’m still trying to keep an open mind and potentially learn how to make the best correlations through “maybe related” statements. Regardless, we’re looking encouraging lower cervical extension. This weekend we saw an exercise that emphasized stretching the lower cervical spine in sitting, this maybe a postural cue or it could turn into an exercises or both. In past rotations, I try to think of exercises that patients could do through out the day. Many people sit throughout the day, so why not work on exercises there. My cue would me to sit up straight, apply a superior-inferior force via shoulders, see where they break, find a “neutral spine” position and cue a neutral upper cervical position and “imagine a string tied to the back of your heard and it’s lifting you up towards the ceiling”. Some of my patients loved it (to my surprise). They reported feeling “lighter, stretching, etc”. I would encourage that motion and progress to a hip hinge first in cardinal planes and then multiple plans (maintaining a neutral spine with changes in moment arms). So far that works for some patients and quadruped is a great progression from there.
2/3) GUESSE WHAT! I used the occipital release technique (not manip) on a patient today and she LOVED it (making friends.. great).. I backed tracked today and I gathered some more subjective information. My first thought was “hypermobile, floppy neck, duh… stability (what a rookie mistake)”. Her pain presentation seemed somatic in nature and followed the C2/3 referral pattern. My focus on this severely irritated in multiple directions patient is to figure out what relieves symptoms and work from there. She was irritable on her R C2/C3 facet glide and I practiced my prone grade II PAs. I wanted to be ambitious but realized I had to take it easy. It’s interesting how she can complete cervical flexion/ ext/ SB/ rotation though a painful motion. My question was “where is she gaining this movement when she’s moderate/ severely hypomoble in her right C2/C3 and mod hypomoble C3/C4”? These are things that I’m trying to observe. I’m now not just checking cervical cardinal plan motions, but I’m looking at quadrants. I want to see her impairment and further isolate that motion. I gave her cervical binder exercises in supine so that she could learn how to control her neck without compensations of traps, levator, superficial muscles.
Further questions I ask myself:
How do I start making “maybe related” bold statements that draw a clearer picture? How do I continue to encourage movement through a hypomobile segment without further encouraging hypermobile segments? Why is a particular facet hypomoble and how do I further prevent that motion? How do I continue to build salience of exercises throughout the day without patients falling back into their habitual patterns?
I also agree with Laura about spontaneous movements. I try to see how a person first performs an exercises after a simple demonstrations, observe the movement and then provided the appropriate cue.