Stretches:
1. Wall Angels/Floor Angels = Pecs
2. Doorway stretch = Pecs, good to treat for upper cross syndrome, do in 3 different
positions (high, middle, low)
3. Shower Stretches: Warm loosens tissues
4. Passive stretching = Flex, lateral bend, rotate head to stretch scalenes, semispinalis
mms, levator scapula, and traps
5. Stretching the shoulder mms:
a. Infraspinatus + supraspinatus
i. Mouth Wrap abduction + external rotation of the arm
ii. Hand-to-shoulder blade test of adduction and internal rotation of the
arm at the shoulder.
6. Levator Scapula: Laterally flex and rotate the neck away while holding onto the chair
seat.
Exercises:
1. Resistance Bands:
a. Rows: For rhomboids and upper to midback
b. Standing Row: for Rhomboids and Triceps
NOTE: Rows are essential for UPPER CROSSED SYNDROME AND
POSTURAL SYNDROME.
c. Shoulder Blade Squeeze: For scapular retraction, rhomboids
d. Pull downs: Lats
e. Shrugs + Shrug-squeeze: Upper traps and levators
f. Overhead
g. Shoulder external rotation: Rhomboids, post. Shoulder, rotator cuff
h. Punches: Serratus Ant., stabilizes scapula
f. Reverse Flies: Rhomboids, Lats
g. Thoracic Extension
h. Thoracic/trunk rotation
2. Spray and Stretch:
a. Intermittent cold and stretch technique
b. Stretch is the ACTION and the cold spray is the DISTRACTION
c. Spray at a 30 degree angle at about 18 inches away from the skin. The sweep
should be slow and about 1 inch/sec.
d. Especially good for rhomboids and QL
3. Self-Treatments:
1. Foam Roll: Stretches out the back mms.
2. Ball on the Wall Therapy: Massages upper back and shoulder mms.
3. Theracane Massage Tool
4. Mini thumper messager
5. Ice and Heat Packs:
i. Ice sore areas (20 mins on/20 mins off) for flared up areas and reduce
swelling and inflammation. Ice emersion usually is good for this.
ii. Heat sore areas (20-30 mins on/20 mins off) to soften tight mms and
loosen tight joints
6. QL Hip Hiker
Evaluating the Bed (Mattress)
a. Too soft:
i. Sleeping supine = flexion all night and check fore soreness of post. Structures
ii. Sleeping on side = Lateral bend so check for tightness of upper sleeping side
b. Too firm:
i. Sore shoulders, sore hips, sore side on down sleeping side
Evaluating the Bed (Pillow)
a. Side Sleeping:
i. 2x the height of the pillow you use when sleeping on your back.
ii. Too big or too thin a pillow ill cause side-bending of the neck.
iii. Prop pillow under arm to avoid prolonged horizontal adduction.
iv. Bottom arm Problem: set it up to avoid sustained shortening of the
subscapularis.
b. Back Sleeping;
i. Not too much flexion
Note: Make sure head/neck is not rotated. So avoid sleeping on stomach to avoid rotating
the neck.
Note: Wrap hand with towel to avoid wrist issues
SCOLIOSIS:
4 curve patterns:
a. Thoracic
b. Lumbar
c. TL
d. Double
Idiopathic Curves management Guidelines:
a. Curves less than 20 degrees:
- Conservative care
- WATCH AND WAIT
- Skeletal immature patients:
- Tx with non-invasive means (unless growth spurt or evidence of
progression).
to the left. Than we would take a tissue pull where most of our tension will be on the pts
left side. Than we do our chiropractic thing and adjust.
Essay Question (10 points): Please write out an extensive and complete treatment plan
for a patient to do at home over the next month to help with Upper to Mid-thoracic
discomfort. Include exercises, stretches, ice/heat, ergonomic tips, etc. Give instructions
on how to do the various procedures and if appropriate discuss the intent of the
procedures. Drawings are welcomed. Go for it MORE is better. (Of course in your
office you will do adjusting, this is just for the patients home care.)
Take home exercises protocol:
A. Heat any areas that are really tender or really restricted first. This can be done using
heat pads put on for 15-20 mins or coming right out of a hot shower or bath. Than finish
with preventative icing of the involved area after strength training.
B. Stretching comes first before any strength training. This should be done before and
after strength training. I would demonstrate all these exercises and get the patient to do it
right after. All stretches should be for about 15-30 secs and should be done 3 times.
I. Stretching exercises are:
1. For trapezius muscle:
a. Wall Angels:
- Prayer hands + elbows together
- Elbows above head
- Than do a regular snow angel
2. For Pec muscles so as to avoid upper cross syndrome which can affect
the upper to mid-thoracic area:
a. Doorway stretch
3. Passive stretching will help for the upper and mid-back mm as well:
a. Side bending of the neck with your hand to apply extra pressure
b. Rotation of the neck with your hand to apply extra pressure
4. For Levator scapula:
a. Laterally flex and rotate neck away with the ipsi hand applying
more pressure while contralateral hand holding onto the chair seat.
5. For rhomboid and lat stretch:
a. Hold onto a pole and do a cut purr as far as you can.
b. This can be done in 3 different positions (upper, middle, lower)
to hit all the fibers of the rhomboids
C. Strength training using weights, free weights, or resistant bands. This will dependent
on the patient (we will assume patient wants to use only the theraband and that he/she
will be a moderate level so probably green theraband). Also patient shouldnt do all these
exercises at once but should mix it up to keep things not too boring. So one day, patient
will do Rows, Standing rows and shoulder blade squeeze to effectively work the
rhomboids.
1. Rows:
- For rhomboids and upper to midback strengthening.
2. Standing Rows;
- For Rhombooids
- For upper cross syndrome and postural syndrome.
3. Shoulder blade squeeze:
- Scapular retraction
- Rhomboids
- Squeeze your shoulder blades together. Hold and slowly return.
4. Pull downs:
- Lats
5. Shrug + Shrug
- Upper traps
- Levators
6. Punches:
- Serratus Anterior
7. Reverse Flies:
- Rhomboids
- Lats
Ergonomic tips to avoid upper back problems:
1. When using computer or laptop:
- Try avoiding prolonged computer use. If needed, than get up every 15
mins and perform the stretching exercises given.
- Elbows and forearms should be parallel to the desktop and floor.
- The monitor should be at upper 1/3 of eye level.
2. When Driving:
- Make sure to drop shoulders when driving.
- Keep your head rest up as high as the top of your head.
Essay Question (10 points)
Please write out a treatment plan for a 14 year old asthenic female patient who has come
to your office with a 20 right thoracic idiopathic scoliosis. Her Risser sign is 4. The
scoliosis was diagnosed when she was 12 years old at 15 and the treatment has been to
monitor the progression. She has a 35 thoracic kyphosis and anterior head carriage- her
EAM is 1 inch anterior to her AC joint. Her shoulders are rolled forward. The plumb line
falls anterior to her knees by 1 inch. She has some aches and pains in her back and neck
and decreased mobility on motion palpation in various areas of her spine.
Part 1: Describe to the patient what it means to have scoliosis. Tell her what things
seem to work, what risk of progression there is, etc.
Part 2: Describe what exercises and stretches, and any other things she should do at
home to help her control her scoliosis.
Part 3: Describe at least 3 varieties of modified adjustment techniques to fix her
scoliosis. Include any other procedures you would like to do to treat her in your office.
TREATMENT PLAN
1. Description to patient about her scoliosis:
- Scoliosis is occurring more and more during these days. I see that you were
diagnosed at the age of 12. I just want to let you know that females most commonly get
scoliosis. Your scoliosis is a little different b/c adolescents who are diagnosed with
scoliosis have a higher chance of progression. However, in your case you are almost
fully mature in your skeletal growth, so progression wont probably be as severe.
Conservative care has been shown to be very promising for ppl who have scoliosis curves
of 20 degrees or less. There has been promising research that suggest chiropractic care
with exercise therapy in combination, helps reduce progression of scoliosis.
2. Home exercises and stretches:
- People who have scoliosis usually have really tight on muscles on the side where
rib humping is located and weak mms on the concave side of the scoliosis. We want to
really focus on those tight mms and weak mms so as to have a good balance. B/c you
have signs of upper cross syndrome we will also strengthen and stretch those mms
involved in that syndrome.
- Exercises will include, rhomboid, trapz, serratus anterior, pecs strengthening for
the weak muscle. Stretching of the overactive mms to allow easier strength training for
you.
- Woogon research that might help with her anterior head carriage. Typing the
upper 1/3 superior of the glasses to reduce her anterior head carriage.
- Teach her the Schroth physiotherapy System
- Rotation breathing and exercises
3. Assuming right thoracic:
a. We can use a leander mechanical traction table where we set the patient up as if
he had a left scoliosis. The pts hip should be pointing to the right whereas, his/her upper
thoracic should be pointing to the left. Than we would adjust accordingly from left to
right (pushing the spinouses from left to right)
b. We can do the same thing using cox flexion
c. If the patient prefers A-P, than we can set up the patient the same way as above
but we would use an anterior thoracic adjustment instead. So the patient would be seated
supine, with hip and legs shifted to the right and his/her upper thoracic should be shifted
Essay Question: (10 points)
A 30 year old mesomorphic female patient presents with classic symptoms of Postural
Syndrome.
1) Describe Postural Syndrome in detail.
- Postural syndrome is commonly presented in people who tend to have faulty
posture. People who are in desk jobs commonly get this b/c of there computer overuse.
Patients will have burning pain between scapula.
- Upper cross syndrome will probably be presented in correlation with people who
have postural syndrome..
a. Tight mm in:
- Upper trapz
- Levator scap, scalenes, SCM
- Pec major and minor
b. Weak mm in:
- Deep neck flexors
- Lower stabilizers of scapulae
2) Create an Incremental Home Treatment Plan. This means give a week by week plan of
what exercises, stretches, any modifications in activities of daily living that you would
give. You may assume that she will be in your office weekly for her adjustments
- Look abovethat will be my treatment for this as well. But more focus with
rhomboids and serratus anterior. We need to really strengthen the serratus anterior. In
addition, ergonomics will be a HUGE player in this case.