Can you imagine getting up in the morning and not being able to support the weight of your head?

Sounds extreme but this is exactly the scenario of one of my clients last Friday. She had endured a long flight earlier in the week, deals with sleep apnea and ongoing issues in her lower spine.

Here’s what we worked on over two and a half hours to get her out of bed, walking and feeling put back together.

I hope you find some of these strategies useful!

Rules of thumb

  • consider neuro-muscular-fascial system as a whole
  • release muscles that are holding on
  • activate muscles that aren’t working
  • address local area of concern
  • address entire body
  • work distally in hands to address local pain and holding patterns in neck and shoulders
  • work from feet upward with long fascial lines to assess and address fascial tension

Demeanour

Client is distraught, in pain, worried, anxious

Teacher needs to be reassuring with a take-charge attitude that is compassionate but steadfast

Start position of client

Ask client to walk and assess motion in t-spine and ribs as well as contralateral arm swing

Then ask client to sit, upright with pillow behind back so there is external support for spine

Step 1: Start far away from pain centre

Ask her to move her toes up and down, scrunch them under and reach to sky; ask her to roll laterally over ankles

What you are looking for is the response up the chain in the affected area of neck and shoulders

Next, try tiny motions for pelvis and assess neck and shoulders for symptoms induced by pelvic motion

Next try passive circular ROM of fingers and release of interossei membrane in forearms (use your hands to move fingers and press into interossei membrane)

Step 2: Check to see if there are basic thorax movements during respiration

Check front to back breathing to see if there is any motion in the upper back

  • ask for breastbone to reach forward on the inhale and t-spine to move back
  • move hand up and down t-spine to see where there is motion and where there isn’t

Step 3: Sensory integration via touch

Gently rub and brush affected area to calm and stimulate dermatomes; way to address nerve endings in skin

Step 4: Assessing skeletal movements in affected areas

Check movement of SC joints on both sides

(use index fingers to gently press caudally on proximal ends of clavicles)

Check scapular adduction via traps

Check rib lateral shifting and rotation

Check head nods and lateral tilts

Many of these movements may induce symptoms of pain or muscle spasm; if this happens go back to rubbing and brushing affected areas or apply appropriate pressure.

Step 5: Addressing the thorax

Tap breastbone and clavicles to induce relaxation and muscle activation

Press on tight tissues to figure out if there is an amount that feels good to the client

Depending which way the spine is curved laterally, encourage opposite direction with fingers

If ribs are shifted laterally encourage fullness to concave side by asking client to move toward your hand; move your hand up and down side of ribcage to encourage movement in the entire thorax 

Step 6: Eye motion to wake up suboccipitals

Ask client to move eyes up and down to access flexion and extension actions of suboccipitals

Keep fingers at base of skull to assess activation pattern

If there is more activation on one side, ask client to close that eye and only work with other side

Try tiny head bobs; if this induces symptoms, stop and go back to Step 4: Addressing thorax

Step 7: Stand and address torso and pelvis

Ask client to do pelvic motions – side-to-side, rotary, figure 8’s

Ask client to do rib motions – side-to-side, rotary, figure 8’s

Then ask client to hold a rail or bar or wall and bend away from the external support (the side you hold with depends on which way the ribs are shifted laterally-aim for the client to bend away from the convexity of the curve

Then ask client to fill out posterior base of ribs (this may cause pain and spasm and if so, repeat other motions listed in Step 7; if that doesn’t work go back to Step 3 to help the tissues calm down via touch

Step 8: Try having client lie on her back on the floor without support for head

Getting client to the floor may take time and be somewhat uncomfortable

If possible avoid any support for head and neck so that neck muscles are required to give a small degree of support in the supine position

Assess contact of upper back with floor; there should be a strong sense of weightedness in upper back between the scapulae; if not, the length of time the client can stay in supine may be very limited

If this step is impossible to execute, ask client to return to standing and repeat Step 7.

Step 9: Work with neck and shoulders directly

Use hands to manually release levator scapulae, SCMs, suboccipitals

Ask client to do eye motions again

Ask client to make “horror face” to activate platysma

Ask client look at cheeks and then nod head from upper lip

Hold client’s head and ask her to look at cheeks, nod from upper lip, make back ribs very heavy and then attempt to lift head maintaining cervical flexion

If chin juts forward at all, try a couple more times with extra emphasis on holding head back and neck flexed

If it doesn’t work or tension begins to build again, go back to using your hands to manually release levator scapula, SCMs and suboccipitals

Step 10: Introduce movement in entire body in supine position; assess response in neck

If you have a sit fit balance cushion, slide it under client’s pelvis

Ask her to do pelvic rotations first and then forward/backward tilts

All the while, keep your fingers at the base of the occiput to assess response at the top of the cervical spine; there should be some movement; the client may say there is a tugging sensation in the neck; keep motions relatively small so as to avoid pain and spasm

Ask client bring one knee to chest at a time; ask for posterior pelvic tilting on the side where knee is being drawn to chest (it is likely that the client will feel a difference in the tension along one side of the body-likely the more affected-in-the-moment side

Try hip sway and ask client to keep back of ribs filled out

Step 11: Stand and resume thorax movements

Ask client to breathe again and assess breastbone and t-spine motion; it may be appropriate at this point to ask client to fill out lower back ribs as if they are expanding backward and upward simultaneously (like a posterior pump handle)

Ask client to stand and puff out posterior base ribs so there is a slight flexion movement in t-spine; try on inhale and on exhale

Ask client to stand with feet wider than hip width and turn torso while allowing arms to swing contralaterally

  • do with head still
  • do with head turning with thorax

Ask client to walk and assess motion in t-spine and ribs as well as contralateral arm swing