How can you help these patients? What are you going to do differently than all the other healthcare providers who treated these people? I’ll tell you. Look outside the proverbial box for a First Rib Fixation Syndrome. A majority of doctors will overlook this syndrome as part of their initial examination and diagnosis. This is unfortunate because an elevated first rib can cause a myriad of symptoms and complications, leaving a patient to suffer unnecessarily for years.
Possible Symptoms:
· Trapezius Spasm
· Neck Pain
· Headaches
· Shoulder Pain
· Radiculopathy
· Jaw Pain
· Mid-back Pain
· Paraesthesia
· Chest & Sternal Pain
Anatomy and Mechanics
The primary components of the supraclavicular notch and muscular attachments to the first rib include: the anterior and medial scalenes, subclavius and serratus anterior. At risk of compression with an elevated first rib are the Sublavian artery and the three trunks of the Brachial Plexus.
Secondary kinetic movement muscles of the syndrome include: the pectoralis major/minor, sternocleidomastoid, trapezius, infraspinatus, subscapularis, supraspinatus, rhomboid major/minor, serratus posterior superior and the levator scapulae.
A superior rib develops in a person affected by a muscular imbalance condition known as ‘The Upper Crossed Syndrome.” In this syndrome, the subscapularis and infraspinatus are loaded with trigger points, resulting in weakness and the inability to keep the humeral head externally rotated and inferior. The humeral head translates superior and anterior affecting the acromioclavicular joint and sternoclavicular joint pivot mechanics. The cervical spine becomes kyphotic and the patient develops rounded shoulders and a hyperkyphotic thoracic spine. The scalenes, serratus anterior and sternocleidomastoid over compensate and develop active trigger points. Referred pain from these trigger points manifests as new and erratic symptoms. Due to the attachment of these spastic muscles on the first rib, superior elevation occurs. The trapezius has an instant reflex guarding mechanism and goes into tightness and spasm. Compression of the brachial plexus and subclavian artery may now cause Thoracic Outlet Syndrome.
Evaluation and Treatment
90% of your diagnosis should come from the patient history. Your examination is designed to confirm your diagnosis. During the patient history ask about sleeping habits. Elevated first ribs typically occur in patients that are stomach sleepers. They may sleep with one arm tucked under their head, or sleep with minimal or multiple pillows. Extensive work in front of computers and the use of a mouse may result in micro-traumatic contracture of the trapezius muscle. Patient will complain of constant dull achy pain and tightness in the trapezius muscle.
Hyperflexion/hyperextension injuries usually have a rib involvement. First Rib Syndrome is mandatory for evaluation in all athletes, particularly tennis players and weight lifters. Almost every athlete is affected by one component of the syndrome. This should be a mainstay of your clinical evaluation in athletes.
During examination palpate the supraclavicular notch for tenderness, spasm, and edema. A patient will inherently pull away when you touch an elevated first rib. Look for the ‘Jump Sign.” You will find active/latent trigger points in almost all of the muscles listed above, particularly the scalenes, SCM, and infraspinatus. X-ray the patient’s cervical spine with AP, lateral, and oblique views to rule out a possible cervical rib involvement.
Following are a list of therapies that are effective for treatment. A combination of all gives you greater success in clinical outcomes.
(Note: Therapy techniques are recommended prior to any manipulation)
· Laser therapy of the supraclavicular notch and all primary trigger points. Recommended dosage of 500 Joules in the notch and 250-500 Joules per trigger point. The cervical spine may need laser for relaxing the multifidus stabilizer muscles allowing for a more effective and longer lasting adjustment by reducing ‘muscle memory splinting’ reaction.
· Soft tissue mobilization per your technique (MFR, PNF, ART, TPT, etc) on all the muscles listed above. Pay close attention to the anterior, medial, posterior scalenes and the pectoralis major/minor.
· Manipulation (adjustment) of the first rib. Speed is of utmost important. Take a scissor stance on the opposite side of the rib involved. Laterally flex head to the involved side and find the tension point. Line of drive is superior to inferior and lateral to medial, towards the inferior angle of the opposite scapulae. Use a slight body drop and elbow torque with the contact hand to increase speed.
· Adjustments of the cervical and thoracic spine per your technique.
· EMS and heat of rhomboids and serratus posterior superior.
· Scapular retraction exercises. 3 Sets of 15-20 reps daily with resistance bands.
· Self Myofascial Release with Biofoam Rollers on the shoulder posterior capsule and thoracic spine 3x per week.
· Stretching of the pectoralis muscles.
· Revision of sleeping habits. Prescribe a cervical pillow and exercise bands.
By taking a little extra time to investigate areas outside the focal point of pain you can have a profound impact on a patient’s quality of life. Remember, if you chase pain you will forever be lost. Now you can be the one physician who gets to the root cause of a problem. Your patient’s will thank you for it. I know I would!
INTRODUCING A NEW ONLINE SERVICE FOR FITNESS PROFESSIONALS!
This May, a new online service for fitness professionals will be launched that will help you incorporate current science into your client interactions.
But first, some background information. My name is Dr. Shawn Thistle, and three years ago I launched the original Research Review Service, an online subscription-based service for physiotherapists, chiropractors, and other manual medicine therapists. Thus far the RRS has been very well received, with subscribers in 16 countries worldwide.
Now, we are launching a Research Review Service for fitness professionals – personal trainers, conditioning specialists and coaches.
RESEARCH REVIEW SERVICE FITNESS is here!
This is the web address: http://www.fitness.
How does RRS-Fitness work?
Every week, RRS-Fitness posts 1-2 new reviews which analyze, contextualize, and put into practice the findings of a recently published scientific article from industry-leading peer-reviewed journals. Each review takes 5-10 minutes to read and focuses on the practical application of results and functional knowledge of research methodology. The reviews are all contained in a database that subscribers have full access to. Topical content is varied and comprehensive, ranging from exercise sciences to sports injuries and rehabilitation. The overall goal of RRS-Fitness is to increase knowledge translation from the scientific literature to those in contact with clients in all types of exercise and training environments. Further, RRS-Fitness will help subscribers collaborate more effectively with Chiropractors, Physiotherapists, and others who deal with common sports injuries – this can help GROW YOUR CLIENT BASE and INCREASE YOUR REVENUE!
FREE Sample Reviews:
We have posted 5 sample reviews on the site to give you an idea of the format and length of the weekly postings. They can be viewed here: http://fitness.
Existing Database:
There are currently over 120 reviews ALREADY in the RRS-Fitness Database – a significant amount of useful information for new subscribers! Weekly posting will begin in the next couple of weeks.
Subscription Plans:
All prices listed below are in Canadian Dollars. You can subscribe online using a credit card via PayPal, or offline with a check by downloading our Offline Subscription Form (Click HERE to download).
** Note: students must register using their student email address
Writing Opportunities with RRS-Fitness:
RRS-Fitness is looking for skilled writers, preferably those in the fitness industry with graduate level degrees and a working knowledge of research methodology and implementation. This is a paid position. If you are interested please send a resume/CV to me (shawn@researchreviewservice.
If you have any questions about the service, please do not hesitate to contact me.
Best Regards,
Shawn
SPECIAL BONUS!
Here is the first review that will be posted this May!
Study Title:
Exercises for spine stabilization: Motion/motor patterns, stability progressions, and clinical technique
Authors:
McGill SM, Karpowicz A
Publication Information:
Archives of Physical Medicine & Rehabilitation 2009; 90: 118-126.
Summary:
Spinal stabilization exercises have become very popular, and for good reason. They are commonly prescribed for a wide range of lower back and other musculoskeletal conditions. These exercises are aimed at improving motor control, endurance and coordination of key trunk muscles that contribute to spine stiffness, stability, and coordinated motion. Recent research has indicated that results of these exercises are improved when “neutral spine position” is maintained (1), so the reader should keep this in mind throughout this review. To this end, prudent conditioning specialists are very adept at making “on the fly” adjustments and modifications to patient performance of spinal stability exercises. Encouraging postures to spare painful joints, knowing when to engage in corrective exercise, and knowing when to adjust co-activation patterns to make an exercise more tolerable for a client are all crucial skills, yet little literature exists to guide us.
Sufficient spinal stability requires adequate activation of numerous trunk muscles. It has been well established that when these muscles contract, they create both stiffness and force. Muscle force may not be stabilizing, but muscle stiffness is ALWAYS stabilizing (2). Many clinical populations of LBP patients have compromised load bearing capacity, therefore exercises are preferred that impose minimal spinal load. In this study small basic science study (including only 8 healthy male subjects of university age), three such exercises that are well known by most evidence-based conditioning specialists – the curl-up, side bridge, and bird-dog (the “Big 3”) – were investigated for muscle activation, 3D spinal mechanics, and the influence of clinician correction. Challenging progressions for these exercises were also outlined and evaluated.
Pertinent results of this study include:
The results of this study will be discussed for each exercise individually, and will include technique recommendations for implementation and progression.
Spinal Bracing:
This technique was applied in the same manner with all exercises. Patients were instructed to contract and stiffen the abdominal wall as if they were about to be “hit in the belly” while not pushing out or sucking in. Facilitation was achieved with fascial raking, where the clinician rakes the obliques while not encroaching on the rectus abdominus with the ends of the fingers – firm but not painful pressure should be used.
CURL-UP (including the “DEAD BUG”):
Patient Instructions:
Results from the Study for the Curl-Up/Dead Bug:
SIDE BRIDGE:
Patient Instructions:
Results from the Study for the Side Bridge:
BIRD-DOG:
Patient Instructions:
Results from the Study for the Bird-Dog:
The Effect of Expert/Clinician Correction:
Results from Study for Clinician Correction:
Conclusions and Practical Application:
The “Big 3” exercises used in this study have been well researched. The data presented in this study can be used to assist clinical decisions regarding where to begin exercise progressions, how to implement corrective techniques, and which exercises to select. Most of the exercise progressions corresponded with predictable increases in difficulty and muscle activation. One finding that may contradict common thought and practice is that the addition of heavy breathing did not affect muscle activation to a significant degree versus abdominal bracing. Further, subjects showed varying muscle activity linked to inspiration and expiration, indicating that some patients can entrain their respiratory muscles to function independently of their spine stabilizing role.
Prudent fitness professionals should take time with their clients and athletes to teach and correct form on spinal stability exercises to ensure proper motor skill attainment, and minimization of unnecessary spinal loads. This study demonstrated that simple corrections using hands-on methods can have positive influences on exercise performance.
Study Methods:
Eight university aged, healthy male volunteers participated in this study, which included measuring EMG and orthogonal 3D spine position measurements during the three exercises. Five of the subjects repeated the exercises with the guidance of an experienced clinician. This data was collected and analyzed according to the methods previously used in this laboratory (Dr. McGill’s at the University of Waterloo), the leading authority on this topic.
Study Strengths/Weaknesses:
This study, despite having a small number of subjects, utilized well-described and previously published methods of data collection and exercise implementation. It should be noted however, that these subjects were healthy males with no history of LBP. Further research is necessary to clarify best practice for implementing these exercises effectively with LBP patients.
Additional References:
FOR WEEKLY REVIEWS LIKE THIS – REGISTER NOW FOR YOUR SUBSCRIPTION!
Pre-exercise preparation is frequently overlooked dynamic of a training regiment which can leave workouts lacking in their potential and can even cause serious injury. Lack of warm-up or even absence of the routines is not something too far fetched. The strength and conditioning world has become much more aware of its importance, especially for individuals like Nick Tumminello. Nick Tumminello of Performance University released a pair of DVD's which introduce an abundance of warm-up and mobilization exercises which could be vital to the world of strength and conditioning as well as the general population.
The DVD focusing on warm-up routines began with warm-up principles regarding the components of a routine. General and fundamental exercises, organization, simple and muscle activating are some of the basic principles outlined by Nick Tumminello. He then states the quote, “If it's important, do it everyday.” He then gives complete explanations and demonstrations of about 20+ warm-up exercises, most of which have beginner, intermediate and advanced forms. The exercises would be broken down very meticulously focusing on details as simple as protraction or retraction of the scapula or hand placement. At the conclusion of every exercise which was just demonstrated was a list of the three most important skill cues to guarantee safe and effective form of every motion. The effectiveness of the demonstrations and step by step demonstrations made the exercises extremely easy to mimic. In addition the explanations of the purpose of each exercise was given extensively. In the bonus features you are given an advanced level warm-up routine in real time from start to finish which elapses only about 4:00 minutes time.
The second DVD entitled Secrets of Self Joint Mobilization is formatted almost exactly the same as the warm-up routine video. This video as the title suggests focus's a lot of creating joint mobilization with very unsophisticated equipment. (yoga mat, wooden dowel, towel, tennis ball, taped, tennis ball, and a water bottle) Once again, Nick Tumminello gives basic principles about how to safely and effectively go about these types of motions. The number one principle entails moving through a pain free range of motion in addition to being progressive, purposeful and making sure that you are staying within your scope of practice. What I found most beneficial about this movie is that there were exercises many of us knew already but were given one extra twist to heighten the effectiveness of the movement and usually target more than one area. For example a deep diagonal squat off a physioball opens up the hip joints but while performing this movement the exerciser has their hands behind their head in the “cuffed” position pulling open the shoulder capsules. Combining movements such as this greatly increases the efficiency of your movements and decreases the time needed to perform a full routine.
Both of these video demonstrations give a great foundation for any strength coach, personal trainer or gym goer to write their own pre exercise routine. The video also encourages independent thinking and creativity by the viewers to branch off these ideas and even further improve the movements provided you keep the movements safe and effective. I personally found these videos highly educational and would recommend them to be viewed especially by fitness professionals looking to create or improve a pre-exercise regiment.
-Eric Discko
http://www.sbcoachescollege.com/TipsOfTheMonth/2009/tip6_2009_TumminelloReviews.htm
