AN UPPER QUARTER EXAMPLE - INTRODUCTION TO

The clinical diagnosis should lead practitioners to a treatment plan of some sort. And, as practitioners treat their patients, it is not uncommon to assess the patient’s progress continually, and to move from one treatment strategy to the next, based on the successful acquisition of neuromuscular skills. Taylor has devel- oped a good protocol-driven approach for the upper quarter, in which assessment and treatment are inti- mately linked.³² For a more in-depth examination of this protocol, refer to Taylor’s chapter in Clinical EMG for Surface Recordings, II.³² While the upper quarter is much more complicated than is depicted in this protocol,

trode atlas). Resting tone is tested in two postures—

hands in the lap and arms hanging at the sides. If elevated levels are noted, the practitioner should begin by making general postural adjustments. For example, sim- ply asking the patient to lower the shoulders may cause the activation pattern to disappear. If not, a relaxation- based treatment protocol is indicated. Second, the resting tone is checked out following movement. (This process is described in more detail in Chapter 8.) If the muscle does not return to a good resting baseline following movement, the practitioner should begin by teaching the patient how to rest the muscle completely following a given movement. These movements might include abduction to 90 degrees, flexion of the arms, or a shoulder shrug.

Once a good resting tone is present, the practitioner can proceed to Phase 2.

Phase 2: Postural Muscle Stretching

The site for assessment may stay with the trapezius or it may focus on the scalene muscles. Muscle shortness may be a substantial contributor to problems in this re- gion. In addition, the problem may be linked to respira- tion. The practitioner should examine the recording for large activation patterns that follow the breath, or ask the patient to take a deep inspiration and look for sym- metrical recruitment patterns here. For initial treatment, Taylor suggests a stretching protocol similar to that suggested by Travell and Simons²⁷for this site. He recommends lateral bending of the head, a passive stretch, and a protocol in which the patient is asked to breathe into the stretch and then relax into the stretch (relax-in-stretch). If the patient shows increased SEMG activity with the stretch, the goal is to teach the patient to reduce this activity while on stretch (see Figure 5–2).

Once the patient’s muscle is at a better resting length, the practitioner can continue to Phase 3.

Phase 3: Isolation of Phasic Muscles

The practitioner typically begins this phase after observ- ing that when the patient abducts the arms, the upper trapezius clearly dominates over the lower trapezius (with normal functioning, there is a better balance between the two muscles). This imbalance is thought to reflect inhibited lower trapezius activity, rather than overactive upper trapezius activity. (This issue is dis- cussed in greater detail in Chapter 8.) The electrodes are placed on both the right and left aspects of the upper Taylor takes the approach advocated by Janda,³³ in

which upper quarter dysfunctions are best described as an imbalance between the postural and phasic muscles.

He then provides a good model for assessing and treat- ing this type of disorder. Further exploration of Taylor’s approach to treatment is presented in Chapter 9.

Phase 1: Postural Muscle Relaxation

Relaxation of the postural tone is the first step in treatment (see Figure 5–1). Because posture is the foundation upon which movement rests, paying attention to the resting tone is essential to achieving successful treatment outcomes. The bilateral placement refers to inde- pendently monitoring the right and left aspects of the upper trapezius using a narrow placement (see the elec-

Bilateral upper trapezius placement

General relaxation

protocol

Postmovement recovery protocols Elevated

baseline

Elevated baseline

Delayed return to baseline Normal

Normal

*and/or flexion or shrug Seated, arms in lap

Seated, arms hanging

at sides

Phase 1: Postural Muscle Relaxation

Shoulder abduction*

and return

To Phase 2

Figure 5–1 Phase 1: Postural muscle relaxation assessment and treatment linkage.

and lower trapezius. The patient is asked to engage in an activity that would recruit the lower trapezius. If poor recruitment patterns are noted, then isolation training is initiated (see Figure 5–3). The goal here is to be able to

activate the lower trapezius, without cocontractions from the upper trapezius or contralateral lower trapezius.

Such training is described in Chapter 9.

Once the patient can isolate and contract the lower trapezius, the practitioner can move to Phase 4.

Phase 4: Postural/Phasic Muscle Balance

The purpose of this phase is to bring other muscles into play and to seek proper synergy patterns among them (see Figure 5–4). Again, the upper and lower trapezius are monitored. The patient does a simple abduction to Bilateral upper

trapezius placement (or bilateral scalenes, or sternocleidomastoids)

Relax-in-stretch protocols Exaggerated stretch reflex

Normal

Phase 2: Postural Muscle Stretching

Lateral or rotary

stretch

To Phase 3

Figure 5–2 Phase 2: Postural muscle stretching assessment and treatment linkage.

Upper trapezius and lower trapezius

placements (preferably bilateral)

Lower trapezius isolation training Poor lower trapezius recruitment and/or presence of upper trapezius cocontraction

*See Lewit³⁴ for other isolation exercises.

Phase 3: Isolation of Phasic Muscles*

Press elbows down

to arm- rests*

To Phase 4

Figure 5–3 Phase 3: Isolation of phasic muscles assessment and treatment linkage.

Upper trapezius/lower trapezius (or upper trapezius/serratus anterior)

placement; preferably bilateral

Bilateral lower trapezius or serratus anterior placement (preferably along with upper trapezei)

Motor copy Upper trapezius activity dominates

Good involvement of lower trapezius/

serratus anterior

Motor copy procedure Asymmetry (decreased activity on affected side)

*or flexion

Phase 4: Postural/Phasic Muscle Balance

Shoulder abduction*

and return

Shoulder abduction*

and return

To Phase 5

Figure 5–4 Phase 4: Postural/phasic muscle balance assessment and treatment linkage.

tures and to more complex movement patterns. A very strong focus on activities of daily living is encouraged. If excessive upper trapezius activity returns, more work is needed to promote generalization. In fact, it is better not to assume that the generalization of motor skills will occur. The training of the neuromuscular system is typically very specific, and generalization should be built into treatment procedures (see Figure 5–5).

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