upper extremity nerve special thanks … extremity nerve entrapment syndromes facilitated by bob...
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UpperExtremityNerveEntrapmentSyndromes
FacilitatedByBobMcAtee,LMT,CSCS
Pro-ActiveMassageTherapyColoradoSprings,COwww.stretchman.com
#AMTAconv
SPECIALTHANKS
• Wemoveourprofessionforwardbysharingandbuildingontheworkofothers.Thankstothesecolleagueswhoallowedmetostandontheirshoulderstoday:
• DavidLauterstein andTheDeepMassageBook
• JoeMuscolino D.C.,prolificauthor,forhisbeautifulanatomyexamples.
• GroveHigginsD.C.forconsultingandstrategizingonthecoursecontent.
• WhitneyLoweforpermissiontousehisvideoassessments.
LearningObjectives
• Uponcompletionofthiscourse,participantswillbeableto:
• 1.Discussthecommonmechanismsofnerveinjuries.• 2.Delineatethepathwaysofthemedian,ulnar,andradialnervesthroughthearm.
• 3.Listthemajorentrapmentsitesforthemedian,ulnarandradialnervesoftheupperextremity.
• 4.Demonstratetypicalnerveassessmenttests.• 5.Discusspracticaltreatmentinterventionsformassagetherapists.
NerveInjuryMechanisms
• Stretch• Tear• Entrapment/Compression• CumulativeInjury(repetitivestress)• Crush(Double-Crushphenomena)
NerveEntrapment/Compression• AKA:Nervecompressionsyndrome,compressionneuropathy,orentrapmentneuropathy.
• Usuallydefinedasdirectpressureonasinglenerve.
• Symptomsvarywidelyandmayincludepain,tingling,numbness,andmuscleweakness.
CompressionInjurySchematic
DoubleCrushSyndrome• Aperipheralnervecompressionsyndromeinwhichthereisa'central'compressiononanervebundle(e.g.atthenerverootorthethoracicoutlet)anda2ndmoreperipheralcompression(e.g.atthecarpaltunnel).
UENerveEntrapmentSites• 1. spine• 2. scalenes• 3. 1st rib/clavicle• 4. pec minor• 5.coracobrachialis
NerveDistributionRegions ThoracicOutletSyndrome
• Thoracicoutletsyndrome(TOS)describesagroupofdisordersthatresultfromcompression,injury,orirritationofneurovascularstructuresattherootoftheneck,theupperthoracicregion,orbeneaththepectoralisminormuscle.
TOSLocations• AnteriorScaleneSyndrome:entrapmentbetweenanteriorandmiddlescalenemuscles.
• CostoclavicularSyndrome:impingementbetweenclavicleandfirstrib.
• PectoralisMinorSyndrome:entrapmentbetweenpectoralisminorandunderlyingribs. PhotoCourtesyofJoeMuscolino
Brachialplexus(C5–T1)
• Thelastfourcervicalspinalnerves,C5throughC8,andthefirstthoracicspinalnerve,T1,combinetoformthebrachialplexus
• Atangledarrayofnerves,splitting,combiningandrecombining,toformthenervesthatservetheupperextremityandupperback.
NeuralTOS• NeurogenicTOS=95%ofcases,morecommoninwomen
• Bonyand/orsofttissuesinthelowerneck/upperchestcompressandirritatethenervesofthebrachialplexus.
• Symptoms:• Weaknessornumbnessofthehand(esp.4th-5thfingers).
• Atrophyofhandmusclesontheaffectedside.• Pain,tingling,prickling,numbnessandweaknessintheneck,chest,andarms.
ArterialTOS
• Impingementofthesubclavianarterybybonyorsofttissues.
• Symptoms:• Coldsensitivityinthehandsandfingers• Numbness,painorsoresofthefingers• Poorbloodcirculationtothearms,handsandfingers.
• Skinmaybepale.
VenousTOS• Venous:causedbyimpingementtothesubclavianvein.Thisveindoesnotpassthroughthescalenes,soisnotaffectedbyanteriorscalenesyndrome.
• Theconditiondevelopssuddenly,oftenafterunusualandtiringexerciseofthearms.
• Symptoms:• Swellingofthehands,fingersandarms.• Heavinessandweaknessoftheneckandarms.• Theveinsintheanteriorchestwallmayappearswollen.Skinmaybebluish/purple.
Assessment• AccurateassessmentofTOSsymptomsinourclientsisimportantbecauseTOSrespondswelltomassageandbodyworktreatments.
• Duetotheoverlappingofnatureofsymptoms,it’softendifficulttomakeadefinitiveassessment.It’scommontohaveneuralandvascularentrapmentsimultaneously.
Tests• Thesethreeproceduresstartwithlocatingtheradialpulse.Adiminishedpulseduringthetestindicatesarterialimpingementatthestructurebeingassessed.Neuralsymptomsmayalsoincreaseduringtesting.
• Adson’sTest:AnteriorScaleneSyndrome
• Eden’sTest:CostoclavicularSyndrome
• Wright’sTest:Pec.MinorSyndrome
PalpateRadialPulse• Assessmentofthestrengthoftheclientsradialpulsewhentheclientisrelaxedandinaneutralposition.
• ThisisdoneatthebeginningoftheassessmentforeachofthethreeTOSlocations.
Adson’sTestforAnteriorScaleneSyndrome
• Theclientrotatestheheadtoward(oraway)fromtheaffectedside,thenlaterallyflexesawayfromtheaffectedside,thenextendstheneck,whilethepractitionerpalpatestheradialpulse.
• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(scalenesarerespiratorymuscles).
• Decreaseinstrengthoftheradialpulseispositiveforanteriorscalenesyndrome.
EdensTestforCostoclavicularSyndrome
• Clientpullstheshouldergirdlebackanddownandpushesthechestforward(militaryposture),whiletheradialpulseispalpated.
• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(liftsribstighteragainstclavicle).
• Decreaseinstrengthoftheradialpulseispositiveforcostoclavicularsyndrome.
WrightsTestforPec.MinorSyndrome
• Passivelymovetheclient’sarmupandback,whiletheradialpulseispalpated.
• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(liftsribstighteragainsttautpec.minor).
• Decreaseinstrengthoftheradialpulseispositiveforpectoralisminorsyndrome.
TreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.
• Long-term:correctupperquadrantposturalasymmetries(slumpedshoulders,forwardheads,hyperkyphosis,etc.)tokeepthethoracicoutletopen.
AddressingScalenes
• Reducinghypertonicityinthescalenes,especiallytheanteriorandmiddlebellieswillhelprelievepressureonthebrachialplexusasitexitsthecervicalspine.
• Caution:deepmassagetothescalenes whenthey’realreadytootightiscounterproductiveandmaycausemoreirritationtothenervoussystem.
• Considerusinglightpressureasthiscanbemoreeffectiveinhelpingrestorepropertone.
ScalenesandElevatedShoulders
• Reducingscalenehypertonicityallowsthewholeribcagetodrop,releasingthechronicallyelevatedshouldergirdleandcreatingspacebetweentheclaviclesandthefirstribs.
ScaleneHypertrophy• FromMikeReinold.com:• Oneofthemajorreasonsthat
thoracicoutletsyndromeoccursinbaseballpitchersisfromhypertrophyofthescalenemuscles(andSCM).Throwingabaseballcausesmanyadaptationstothebody,includingthisincreaseinscalenesize.
• Herearephotosoftheathleteinhalingwithhisheadturnedtoeachside.NoticethesignificantlylargerscaleneandSCMonhisrightside.
TreatmentInterventions:Scalenes
• Scalenes Sweep
• Scalenes FacilitatedStretch
ScaleneSweep• Themostcomfortablewayto
workscalenes,whichalsohelpspulltheforwardheadbackandupontopoftheshoulders,istosweepacrossthemfromtheanteriorneckallthewayaroundtothespinousprocesses,thusassistingtheotherneckmusclestomigrateback.
• Inallcases,erronthesideofconservativenesswithyourpressure.Thepointistodrawthemusclesback,nottopressintotheneck- especiallynotpressinghardintotheanteriorandlateralaspect.
CourtesyofDavidLauterstein’s“TheDeepMassageBook”
ScalenesStretchontheTable
1. Active lateral flexion of the neck to stretch the scalenes.
2. Easy isometric contraction of the stretched scalenes.
3. Active stretch to new range motion Askmetodemonstratetheshrug
stretchoption.
AddressingPectoralis Minor
SincethePectoralis MinorisacommonentrapmentareainThoracicOutletSyndrome,reducingthehypertonicity inthethisareaiscritical.
PalpatingPectoralisMinor
• Withtheclientsupine,layyourthumbalongtheclavicle,thenslideinferiorlyintothesofttissue.
• Slidelaterallyuntilyoucometothefirstbonyprominence(thecoracoid),whichisusuallyquitetender.
• Pecminorattachmentisat7o’clock(leftside).
• Coracobrachialisat6o’clock,• Bicepsbrachiiat5o’clock.
TreatmentInterventions:Pectoralis Minor
• PinandStretch
• FacilitatedStretch
PinandStretchTechniquePectoralisMinor:
•Withclientsupine,usethepadsofyourfingerstopalpatethepectoralisminoratthecoracoidattachment.
•Gentlystretchthemuscleinferiorly,awayfromthecoracoidprocess,whiletheclientpullstheshoulderstowardthetableandbringstheshoulderbladestogetheranddown,asifputtingtheminthebackpockets.
•Thenasktheclienttoexternallyrotatethearmsandslidethemupthetabletowardtheirheadtoincreasethestretchonthepecminor(andthepecmajor).
PecMinorStretch• Thisstretchreduceshypertonicityin
thepecminorandmayreducecompressionontheneurovascularstructures.
• Holdtheclient’shandtokeepthearmfrombouncingaround.
• Clientfirststretchesbypullingtheshouldertowardthetableandslidingthescapuladowntheback.
• Duringtheisometricphase,theclientattemptstopushtheshouldertowardtheceiling.
CommonMedianNerveCompressionSyndromes
• PronatorTeresSyndrome
• CarpalTunnelSyndrome
MedianNervePathway MedianNerveEntrapmentSites
• 1. spine• 2. scalenes• 3. 1st rib/clavicle• 4. pec minor• 5. coracobrachialis• 6. ligament of struthers• 7. pronator teres• 8. flexor digitorum arch• 9.carpaltunnel
IllustrationsofEntrapment1.Entrapmentatthepronatorteres
2.Fibrousarchoftheflexordigitorumsuperficialis.
3.Lacertusfibrosus(bicipitalaponeurosis)
4.supracondylarprocessandligamentofStruthers
AssessingNerveMobility
• GlidersandSliders• Usingassessmentstohelppinpointpossibleentrapments
PronatorTeresSyndrome
• Acompressionneuropathyofthemediannerveatthepronatorteres.
• Oftenaccompaniedbymedialepicondylitis
PronatorTeresSyndrome
• Symptoms:• Paresthesiainthumb,index,middlefingerandradialhalfofringfinger(similartocarpaltunnelsyndrome).
• Paresthesiaoftenmadeworsewithrepetitivepronation-supination.
• Differentiate fromcarpaltunnelsyndrome(CTS):• exacerbatedbyrepetitiveelbowflexion• achingpainoverproximalforearm• lackofnightsymptoms
PronatorTeres Syndrome Assessment• The client stands with the elbow in 90 degrees of flexion.
• Place one hand on the client's elbow for stabilization and hold the client's hand in a handshake position.
• The client holds this position as you attempt to supinate the client's forearm (forcing the client to contract the pronator muscles).
• While holding this isometric effort, straighten the client's elbow (stresses flexor digitorum superficialis).
CarpalTunnelSyndrome(CTS)• Compressionneuropathyofthemediannerveasitpassesundertransversecarpalligament.
• Oftenresultsfromtenosynovitisoftheflexortendonsinthecarpaltunnel.
• Consideredarepetitivestresscondition.
• DoublecrushconditionmakesthenervemoresusceptibletoCTS.
CarpalTunnelAnatomy• The carpal tunnel,
formed by the carpal bones and the flexor retinaculum, contains 9 sheathed tendons:
• 1 flexor pollicislongus
• 4flexordigitorum superficialis• 4flexordigitorum profundus• Andthemediannerve.
CarpalTunnelSyndrome(CTS)• Symptoms:• Paresthesia,numbness,paininthemediannervedistributionofthehandandfingers.Atthewrist,thenerveiscomposedofover90%sensoryfibers.
• “Nightsymptoms”causedbysleepingwiththewristsflexed.
• PrimaryAssessment:• Phalen’s Test
NoteAboutCarpalTunnel• Truecarpaltunnelsyndrome
doesnothavesensorylossoverthethenar eminence.
• Thisisbecausethepalmarcutaneousbranchofthenerve(sensory),whichinnervatesthatarea,branchesoffthemediannerveandpassesoverthecarpaltunnel.
• Thisfeatureofthemediannervecanhelpseparatecarpaltunnelsyndromefromthoracicoutletsyndrome,orpronatorteressyndrome.
CarpalTunnelSyndromePhalen’sTest
• Theclientpressesthebackofthehandstogethertoflexthewriststoapprox.900.
• Ifpain,paresthesiaornumbnessinthemediannervedistributionarereproducedwithinabout60seconds,thetestisconsideredpositive.
CarpalTunnelTetheredMedianNerveTest
• Usefulindetectingchronic,low-grademediannervecompression.
• Producesthegreatestamountofdistalnerveexcursioninthecarpaltunnel.
• Performbyhyperextendingthesupinatedwristandtheindexfingerforoneminute.
CarpalTunnelTinel’s Test
• Lightpercussionoverthemediannerveasitpassesunderthetransversecarpalligament.
• Theleastsensitiveofthemediannervetestsbutisthemostspecifictestformedianneuropathyatthecarpaltunnel.
MedianNerveTreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.
• Long-term:identifyandcorrectperpetuatingfactors.
EffectiveTreatment Interventions
• PinandStretchTechniques
• TransverseFriction
• FacilitatedStretching
PinandStretch:ForearmFlexors• Clientsupine.• Supinatedforearmfullysupportedonthe
treatmenttable,withthewristfreetoflexandextend.
• Beginningatthefully-flexedwrist,useyourloosefisttoapplyafirmglidingstroketowardtheelbow,alongthelengthoftheforearmwhiletheclientslowlyextendsthewrist&fingers.
• Formorespecificwork,useasmallercontact,suchasaflatthumbpointingalongthelengthoftheforearm.
PinandStretch:PronatorTeres• Clientsupine.Upperarmfullysupported
onthetreatmenttable,withtheelbowbent.
• Withtheforearminneutralorsomewhatpronated,useabroadthumborloosefisttoapplyafirmglidingstrokediagonallyfromtheradialattachmenttothemedialepicondylewhileslowlysupinatingtheforearm.
• OKtokeeptheforearmonthetableandusealoosefistforthestroke.
TransverseFriction:Forearm• Usetransversefrictionworkto
addressadhesionsinmuscles,tendonsandligamentsandtoreleasethemediannerveentrappedinthesetissues.
• Startwithgeneralfrictiontoanentirestructureandthengetmorespecificasnecessary.
• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.
TransverseFriction:Wrist• Usefingersorthumbtoapply
transversefrictiontothetendonsandtheretinaculumatthewrist.
• Startwithgeneralfrictionandthengetmorespecificasnecessary.
• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.
FacilitatedStretching:WristFlexors• Clientsupine,forearmfullysupported
onthetable,wrist&fingersfullyextended.
• Matchyourfingersandthumbtoclient,useyourotherhandtostabilizetheforearm.
• Directtheclienttoslowlytrytoflexthewristandfingers,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.
• Aftertheisometric,theclientactivelystretchesbyextendingthewristandfingerstoanewROM.
FacilitatedStretching:Pronators• Clientsupine,elbowbent,forearmsupinated.• Supporttheforearmwithonehandandplacetheotheracrossthewristandhand.
• Directtheclienttoslowlytrytopronate,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.
• Aftertheisometric,theclientactivelystretchesbysupinatingtoanewROM.
CommonUlnarNerveCompressionSyndromes
• CubitalTunnelSyndrome
• Guyon’sCanalSyndrome(cyclistspalsy)
UlnarNervePathway
UlnarNerveEntrapmentSites
• The6sitesofpotentialulnarnerveentrapmentaroundtheelbow:arcadeofStruthers,medialintermuscularseptum,medialepicondyle,cubitaltunnel,deepflexorpronatoraponeurosis(betweentheheadsoftheflexorcarpiulnaris)andGuyon’scanal.
ArcadeofStruthers• Thinaponeurosisextendingfrommedialheadoftricepstothemedialintermuscular septum.
• NottobeconfusedwiththeLigamentofStruthers(whichmaycompressthemediannerve).
• Located8-10cm(3-4in.)proximaltothemedialepicondyle.Notalwayspresent.
CubitalTunnelSyndrome• Ulnarnervecompressionattheelbowisthe2nd mostcommonnerve
entrapmentoftheupperextremity,aftercarpaltunnelsyndrome.• Thecubitaltunnelisformedbythetwoheadsofflexorcarpiulnaris.
Oneheadblendswiththeflexortendonattachmentsatmedialepicondyle(humerus),theotherattachestotheolecranonprocess(ulna).They’reconnectedbyanaponeurosis.
CubitalTunnelSyndrome• Symptoms mayinclude:• pain,paresthesia,burning,andweaknessinthefifthfingerandulnarsideofthefourthfingerandnumbnessinthedorsalulnaraspectofthehandandfingers.
CubitalTunnelSyndromeElbowFlexionTest
• Clientstandswithelbowsflexedandwristsextendedfor30-60seconds.
• Thispositioncompressestheulnarnerveatthecubitaltunnelandaddssomestretchatthelevelofthewrist.
• Symptomsmayappearinlessthan30seconds.
Cyclist’spalsy
• Duetocompressionoftheulnarnerveatthewrist(Guyon’scanal).
• Symptomsincludepinsandneedlesinthelittleandringfinger.
• Mayalsoincludeimpairedmotorfunction.
• Oftenpresentalongwithcubitaltunnelsyndrome(double-crush).
UlnarNerveTreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.
• Long-term:identifyandcorrectperpetuatingfactors.
EffectiveTreatment Interventions• UlnarNervetreatmentfocusesonthesamemusclegroupsasforMedianNerve,withtheadditionofcoracobrachialis.
• PinandStretchTechniques
• TransverseFriction
• FacilitatedStretching
Coracobrachialis
• Noticethecompactrelationshipbetweenbicepsandcoracobrachialis.
• Palpationandfrictionworkontheinsideofthearmwillhelpidentifynerveentrapmentineitherthemedianortheulnarnerve(ArcadeofStruthers).
CommonRadialNerveCompressionSyndromes
• RadialTunnelSyndrome
• PosteriorInterosseousNerve(PIN)Syndrome
RadialNervePathway RadialNerve&TeresGroup
• Theradialnervedivesposteriorandpassesnexttothelongheadofthetricepsandthroughthespacebetweentheteres minorandtheteresmajor.
RadialNerveEntrapmentSites
• RadialnerveentrapmentistheleastcommonofthethreemainUEnerves.
• Themostfrequentsiteofcompressionisattheradialtunnel(ArcadeofFrohse)attheproximaledgeofthesupinatormuscle.
ArcadeofFrohse• Theedgeofthearcadeisnormallythinandmembranous.
• Athickened,tendinous proximaledgeisdevelopmental,occurringin30–100%ofpeople,likelyduetorepetitivepronation–supination.
RadialTunnelSyndrome• Compressionofthesensoryfibersoftheradialnerve.
• Symptoms: pain,paresthesia,ornumbnessnearthelateralepicondyle.Achingorburningsensationalongthelateralaspectoftheforearm,mimickinglateralepicondylitis.
RadialNerve(PIN):PosteriorInterosseusBranch
• Posteriorinterosseousnervesyndrome(motorfibers):weaknessoftheextensormusclesoftheforearm.
• Alsocalledsupinatorsyndrome.
RadialTunnelSyndromeAssessmentIsometricMuscletests:1.Clientattemptssupination,withelbowextended(tominimizebicepsbrachii recruitment).2.ResistedLongFingerExtension.PositiveTest=increasedpainorweakness.
RadialNerveTreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.
• Long-term:identifyandcorrectperpetuatingfactors.
EffectiveTreatment Interventions
• PinandStretchTechniques
• TransverseFriction
• FacilitatedStretching
PinandStretch:ForearmExtensors
• Clientsupine.
• Thepronatedforearmisrestingonthetreatmenttable,withthewristfreetoflexandextend.
• Beginningatthefully-extendedwrist,useyourloosefisttoapplyafirmglidingstroketowardtheelbow,alongthelengthoftheforearmwhiletheclientslowlyflexesthewrist&fingers.
• Formorespecificwork,useasmallercontact,suchasaflatthumbpointingalongthelengthoftheforearm.
PinandStretch:ForearmSupinator• Clientsupine.Holdthe
forearminneutral,upperarmrestsonthetreatmenttable.
• Beginningatthedistalendofthesupinator,useyourloosefisttoapplyafirmglidingstroketowardthelateralelbow,whilepassivelypronatingtheclientsforearm.
• Formorespecificwork,useasmallercontact,suchasaflatthumb.
TransverseFriction:Forearm• Usetransversefrictionworktoaddress
adhesionsinmuscles,tendonsandligamentsandtoreleasethemedianentrappedinthesetissues.
• Startwithgeneralfrictiontoanentirestructureandthengetmorespecificasnecessary.
• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.
FacilitatedStretching:WristExtensors
• Clientsupine,forearmsupportedonthetable,loosefistwiththumbinside.
• Wrapyourhandoverthefist,useyourotherhandtostabilizetheforearm.
• Directtheclienttoslowlytrytoextend(open)thewristandfingers,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.
• Aftertheisometric,theclientactivelystretchesbyflexingthewristandfingerstoanewROM.
FacilitatedStretching:Supinator• Clientsupine,elbowbent,forearmpronated.• Supporttheforearmwithonehandandplacetheotheracrossthe
wristandhand.• Directtheclienttoslowlytrytosupinate,whileyoupreventthe
movement.Holdthisisometriccontractionfor6seconds.• Aftertheisometric,theclientactivelystretchesbypronatingtoanew
ROM.
PalpationPractice
• Locatecoracoidprocess(whatmusclesattachhere?)
• Coracobrachialisinupperarm• Arcadeofstruthers(ulnarnerve)• Ligamentofstruthers(mediannerve)• Pronatorteres(mediannerve)
AssessmentWorkflow• ClientHistoryandSymptomPattern
• WorkingHypothesis:TOSorOther
• AppropriateNeuralTests– TOS:Adson’s,Eden’sWright’s
– AssessforPronatorTeres Syndrome,CarpalTunnel(Phalen’s),CubitalTunnel(ElbowFlexion),RadialTunnelSyndrome.
– NerveGlides
TreatmentStrategies
• Protect(Don’tOver-Treat,WorkinthePain-FreeZone)
• PinandStretch• TransverseFriction• FacilitatedStretching
• Nerveglides
BruggerReliefPosture
• Sitwithyour“sitbones”attheedgeofthebench/chair.
• Lengthenyourbackandneckandtuckyourchin.
• Dropyourshoulders.• Externallyrotateyourarmssothepalmsfacetotheside.Keepyourfingersaswideaspossible.
• Holdthispositionfor10seconds,relax,repeat5-10times.
Self-Care:ResistanceBandPulldowns
• Thisexerciseengagesthescapularretractorsanddepressorsasyoupullthebandslowlyoutwardanddownwardtothebaseoftheskull.
• Tuckyourchintoyourthroatandkeepyourearsoveryourshoulders.Don’tbendtheneckforward.
• Yougetthemostbenefitfromtheeccentricphaseoftheexercise.
Self-Care:ResistanceBandPulldowns
• Exhaleasyoupullthebanddownandout.
• Complete8-10repetitionsperset.
• Performingthisexercisebetweenclientsessionswillretrainyourshoulderandupperbackmuscles.
RecommendedReading• OrthopedicAssessmentinMassageTherapy
• byWhitneyLowe
• FreedomfromThoracicOutletSyndrome
• ByJoeMuscolino,D.C.• AMTAJournal,2006• http://www.amtamassage.org/articles/3/MTJ/detail/1666
References• Miller,T.andReinus,W.NerveEntrapmentSyndromesofthe
Elbow,Forearm,andWrist.AmericanJournalofRoentgenology,2010195:3,585-594,http://www.ajronline.org
• Elhassan,BandSteinmann,S.EntrapmentNeuropathyoftheUlnarNerve.JAmAcad Orthop Surg November200715:1,672-681
• Tubbs,RS,etal.ThearcadeofStruthers:Ananatomicalstudywithpotentialneurosurgicalsignificance.Surg Neurol Int.2011;2:184.
• Graham,B.CarpalTunnelSyndrome.TheWorkplaceSafetyandInsuranceAppealsTribunal,Ontario,Canada.May2001.
• http://www.wsiat.on.ca/english/mlo/carpal.htm
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