Two Ways to Prescribe Self-A/P glide of humeral head for HEP

Okay, long title sorry.

Attached is a video plus pictures on ways to prescribe a self-mobilization of the humeral head for your patients.  It goes along Mulligan’s philosophy of mobilization with movement and seems to work well if the condition does have a true impingement (and not just a CTJ derangement).  I am teaching the Pendulum (or Codmans) MWM to my post-op RTC patients vs the classical way (as shown in a past video below too).


Physical Therapy
Physical Therapy

My Drawing2

Here is your classical way to perform Codman’s:

C1-2 Dysfunction in CGH: From Evaluation to Treatment Part 3 of 3

Therapeutic exercises for treatment of C1-2 dysfunction can be vast and include a multitude of disciplines ranging from strengthening, neuromuscular re-education/ re-training, postural education, stretching, etc.  Details for all of these approaches is beyond the scope of this post so I am going to describe several other exercises that may be different than typically seen.

We all know to strengthen peri-scapula retractors, lower trapezius, serratus anterior, etc. that can be found in any journal article or book.  These approaches are usually in the strengthening phase of rehabilitation. Most of the approaches I describe below can give the patient relief and motion in the initial stage, which is typically the toughest stage to treat.

After manual therapy for pain relief, my first approach with exercise is obtaining pain-free ROM.  The following three exercises are a good start.

1. Cervical Spine Rotations with Towel Roll

I like to do this with cervical spine rotations c towel roll in subpainful range as shown below.  This can be completed with the towel roll at the crook of the neck but since we are addressing C1-2 mainly, I like to place it at the occiput.

2. Cervical Extension Isometric with Towel Roll

Another step to obtain joint mobility is with cervical spine isometric extension using towel roll at occiput.  It is somewhat difficult to see from the video, but the patient is actually pushing into the towel roll through the occiput.  I find this helps in “opening-up” the suboccipital space.  Amount of intensity varies but I would start around 20-30% of max. Shown is a general version but can be altered with various head positions (in Rrotation, LSB, etc.) to address more specificially an area.

3. Cane Protraction Supine

Bottom line, movement at cervicothoracic junction &/or scapulae are also very important.  I apologize for not showing a manual technique to this area as mobility here is key to success for all cervical pain (Let me know in comments section if you would like to be shown a technique).  Depending on the irritation, sometimes you will not even be able to address the cervical spine until pain subsides. There are many ways to address this area, but I find that cane protraction supine is a good start.

Most of the research with CGH (or any other musculoskeletal impairment at that) shows the combination of therapeutic exercise and manual therapy (mobilizations, manipulation, etc.) gives the most optimal outcomes.  Jull et al in a recent RCT just showed this in 2005 with a 75% of patients showing a 50% decrease in HA frequency here.  From what I see, I think results are better than that.  Nevertheless, I think our skills manually and prescribing exercise is how we can separate ourselves from other practitioners.

What do you think of the above exercises?  Do you think they are appropriate for C1-2 dysfunction?  I would like to know what other activities/exercises you do in the initial stages of rehab that can give relief other than manual therapy.

FYI: An excellent case report in a 2007 JMMT gives a thorough synopsis on evaluation & multimodal treatment for CGH (can also relate directly to C1-2 dysfunction).  You can find it here (very nice that you can access it without being a JMMT member!).  It would be of benefit as I did not delve into specific examination techniques other than FRT in this series. van Duijn et al describe not only manual techniques and postural re-education information, but also specific exercises to address musculoskeletal limitations. This is a great resource to refer back to.

FYI 2: For students out there who may be reading this, case reports really help give a basis of treating as it is difficult to know what to do without much experience. Academia usually doesn’t teach exercises for specific conditions so this is a great way to learn.  I know I used them to come up with ideas when I was on internships.

Exercises for axial pain that could cause more harm than good

I’m sure you can think of many therapeutic exercises that are not appropriate for certain patients with axial pain.  Most of the ones that come to my mind initially are higher level exercises; such as planks, prone-on-elbow manuevers or physio ball exercises.

These are for the more advanced and mostly for “out-of-pain” patients.  We know not do prescribe these to certain individuals based on clinical experience, but I am going to dial it down a notch and write about simple exerices that are prescribed on consistent basis.

I have found two muscle groups that physical therapists usually concentrate on that are considered typical therapeutic exercise treatment approaches for either cervical or lumbar pain.  If a layman or laywoman Googles an exercise, these will probably arise. They are also shown throughout the literature to be weaker, have altered neuro-muscular firing and needed to strengthen for proper posture & kinematics.

Don’t get me wrong, I think they are needed; but if implemented inappropriately, it can set them back.

Deep Cervical Flexors:

Refer back to a past post here on detecting strength and endurance of the DCFs, as well as if it is really needed anyway.

We typically strengthen this muscle group by using pressure biofeedback systems as ‘tucking the chin’, or even just actively as ‘taking the chin to the breastbone or Adams Apple’, but ‘dont protract the chin or lift occiput or whatever else can make this about the hardest exercise possible’ cueing.

If you have ever done this, even without pain, it usually isn’t comfortable at all and really, is it needed?  There are a lot of studies saying the deep cervical flexors will work “right” when pain is abolished. I see that prescribing this exercise doesn’t make symptoms any better, but sets the patient back.

Gluteus Medius:

I am a big advocate for strengthening the glutes, especially gluteus medius; but ‘for every good, there is an equal bad’.  As with DCFs, I feel strengthening this muscle group can have an adverse impact on low back pain if not implemented correctly.

Adverse effects can be due to incorrect form, body habitus or just because it is an extremely weak area and very strenuous for most to exercise it.  Does an individual really need to perform SLR abduction 30 repetitions to fix their back? I really don’t have an answer, do you? No research to back it up, just what I see.

What are your thoughts? Any other exercises do you feel set the patient back? Do you see any correlation with the above statements?  If so, how have you adjusted your treatment and if not, will you look for the cause-effect relationship now?

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