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Supercharged

Therapist TM

Clinical features

This is a shoulder injury and neurolymphatic point stimulation case study.  A 44-year-old healthy female came to me presenting a 5 ½ months-post fall that caused a fracture to her greater tubercle and dislocated the humerus posteriorly.

Intervention and Outcomes Before using Chapmans Reflexes

A variety of interventions were performed by her physiotherapist before commencing treatment with me and the application of Chapmans reflexes.

Non-surgical relocation of the humerus was performed by her surgeon followed up with weekly rehabilitation therapy with physiotherapy using closed chain small exercises. To date, she has a humeral elevation close to 80 degrees. She was also seeing her regular chiropractor, Dr. Sandy [10 years +]. She has included acupuncture to try for more movement in the shoulder complex. Dr. Sandy referred her to me to address the still limited range of motion.

Interventions using Chapmans Reflexes and Various NMT

For the interventions using Chapmans reflexes, one treatment was applied per week for three weeks. Then one more 14 days later with follow-up in so that she could return to full ROM and strength. This also enables her to perform push-ups from a toe stance. The pain was significantly reduced to VAS less than 1/10. I also addressed her underlying chronic lower back pain complaint.

METHODS

INITIAL PRESENTATION

Mrs. W showed:

  1. tension/hypertonicity
  2. tight left lateral neck and shoulder
  3. some altered sensation
  4. numbness over the region of the lateral humerus. Her description of the region included “feels like a block” and
  5. “has a heaviness when trying to reach overhead”.

Over the last 10 weeks, she stated that the medial and anterior deltoid muscle “now finally getting the tone and feels like it is activating”. She had actively been doing her home care as instructed by the physiotherapist assigned to her. The home care included the use of heat packs to alleviate the tight and tense soft tissue.

Assessment

Her levels of stress were reported were extremely high. She stated that she felt like she was holding everything internally. She was unable to take full diaphragmatic breaths and her thoracic range of movement was limited in all ranges.

Strength testing was performed and showed moderate weakness on the diaphragm-supraspinatus isometric test. There is also a moderate weakness to the latissimus dorsi, the thoracic extensors, posterior deltoid/shoulder complex, and the external humeral rotators.

Treatments

Treatments for Mrs. W included the following:

  1. Chapmans Reflexes – Commenced by stimulation of the neurolymphatic points feeding the diaphragm and then teaching her diaphragmatic breathing to elicit the “relaxation response” and trigger the parasympathetic nervous system. Chapmans Reflexes were applied to the neurolymphatic points for the latissimus dorsi anterior and posterior points and the Tx and shoulder extensors, where I followed the protocol of vigorous but not deep rubbing for 30 seconds in each region. Once these areas were stimulated her strength had improved to very strong isometric holds of the shoulder muscles and increased ROM of humeral extension and internal adduction.
  2. Muscle Energy Technique – Following the neurolymphatic stimulation, I added a muscle energy technique to the humeral internal rotators. This will allow greater resting length in these muscles and increase mobility and ROM of humeral external rotation. During the post isometric relaxation phase, the resting length of the muscle will be greater. This technique has been found to effectively reduce capsular restrictions noted at the glenohumeral joint through ROM.
  3. Low load muscle activation – She then performed a low load muscle activation of the subscapularis in its closed position. The action of the subscapularis is internal humeral rotation as well as adduction of the humerus. This allows the target muscle to contract independently from the other muscles used in the action of the primary muscle.
  4. Neuromuscular techniques – Various neuromuscular techniques including glides and gentle cross fiber movements to the biceps, pec minor, posterior deltoid, and the fascial line between the triceps in supine were applied. Seated active movements of the head and neck in rotation to the left upper and mid trapezius and thoracic erector spinae, prone to the left latissimus dorsi, around the scapula, rotator cuff, and levator scapula were also applied. Mobilization of the bilateral Cx joints to address the left-sided stiffness. Both sides were painful but became less painful after 3 applications on each side.
  5. Homecare – This included activating the neurolymphatic points of the diaphragm, 10 diaphragmatic breathing, and breathing full breaths often through the day.

Mrs. W had plenty of resentment issues over the fall and the lack of support with those around her during the incident. So, we also discussed ways for her to do self-anger management and let anger become less of an impediment to her treatment progress.

2ND TREATMENT

Mrs. W did her homework using the breathing exercises to manage her stress and chest restrictions. She also wrote her resentment issues down on butcher paper and stated that she was “feeling like moving forward a bit more”. Her shoulder’s range had improved but still with pain and some mild swelling for a few days post-treatment. She attempted to do toe push-ups (did 3 this morning) which she had been unable to do.

Assessment

There were still some weaknesses with thoracic and humeral extensors and latissimus dorsi. Also, there was still weakness in recruiting the neck muscles to assist in the strength testing with a note to actively retracting the jaw in every movement. Strength testing also included weakness in neck flexion so the neurolymphatic point for the region was included. Assessment of supine rotations of the lower limbs to assess the balance of the soft tissues of the trunk lateral flexors, obliques, and deep lumbar rotatores, multifidi, and intertraversii muscles were done. Looking at the Anatomy trains and links to the functional backline, lateral line and spiral line with the connections from the shoulder and pelvis have led me to include lumbar muscle energy techniques to address rotations or torsions of the sacrum and/or ilia.

Treatments

  1. Chapmans Reflexes – These were applied to the left latissimus dorsi, thoracic flexors/humeral extensors, and sternocleidomastoid/deep neck flexors. Re-assessment of strength was markedly improved with almost complete full range of shoulder abduction.

 

  1. Local cross-fiber friction and neuromuscular techniques – These were applied to the upper anterior humerus/anterior deltoid tendon, subclavius, 2nd/3rd ribs at the sternalis region – using forced inspiration and expiration; myofascial ringing of my hands across the lateral humerus/ interosseous membrane just inferior to the deltoids with active humeral rotation, compression/stripping into the thenar muscle. These techniques were chosen to include the fascial arm lines of the Anatomy Trains. Studies show that restrictions along these superficial and/or deep arm lines will alter the biomechanical efficiency of the shoulder complex and cervical ROM. Lumbar muscle energy technique and gluteal stretches were included in this treatment. [Shoulder Injury & Neurolymphatic Point Stimulation – A Case Study]

 

  1. Homecare – A 30-second stimulation of the neurolymphatic points of the latissimus dorsi, thoracic flexors/humeral extensors, deep neck flexors/SCM, and diaphragm were prescribed including 2 minutes of diaphragmatic breathing. I started Mrs. W on the functional stabilizing activity of wall springing push-ups x 20 daily. This reduces the load of the shoulder complex and still offers eccentric and concentric contractions to any of the muscles with attachments to the scapula, humerus, or ribs.

 

3RD TREATMENT

Mrs. W had been doing the Chapmans activations each day. She has full pain free range of the humerus in all ranges, has been doing wall springing push-ups and today performed 15 toes push-ups for her physician. He has commented that her post-non-surgical relocation recovery has accelerated far greater than usual progressions. He is very happy with her outcomes.

Assessment

The latissimus attachment pain is finally settled and latissimus strength is 100%. Shoulder ROM was considered to be full range in all planes, though a painful taut band was noted on the left teres major. We are now focusing on an ongoing episodic complaint of lower back pain which is 6-7/10 on the VAS scale and can flare up with long hours standing at work. Strength testing showed the weakness of the left lateral sling including lateral trunk flexors, gluteus medius/minimus; weak right gluteus maximus, right hip flexor iliopsoas, right superficial front and back fascial lines with weakness in strength testing of the quadriceps, gastrocnemius, and tibialis anterior.

Treatments

  1. Neurolymphatic points stimulation  – This was applied to the weakened muscles tested listed above. Neurolymphatic points relevant to musculoskeletal dysfunction are found primarily on the anterior of the body, when there is chronic weakness/stress we also need to treat the associated posterior Chapmans Reflex points housed near the erector spinae of the relevant spinal nerves.
  2. Low load activation – I added low load muscle activation to the left rhomboid to increase the stability of the left rotator cuff of the scapula which affects the spiral line of the anatomy trains.
  3. Prone various neuromuscular techniques – These techniques were applied to the gluteus maximus, minimus, and medius, adding compressive mobilizing techniques to the sacral ILA, sacrotuberous and iliolumbar ligaments, complimenting with myofascial release/passive internal rotations of the deep hip rotators, also applied XFF to the tendon of the right quadriceps in supine with Mrs. W adding active femoral rotations.
  4. Homecare – Mrs. W continued to apply her 30 seconds of vigorous but not hard rubbing to the neurolymphatic points associated with the latissimus dorsi, thoracic flexors/humeral extensors, deep neck flexors/SCM, diaphragm and continue her diaphragmatic breathing each morning and if she felt she was going into a stress state. She will also include the low load muscle activation of the rhomboid muscle to address any dysfunction of the spiral line of the anatomy train.

 

4TH TREATMENT

Mrs. W booked in 2 weeks later – she had increased her University assignment load and she works full time as a registered nurse which added more stress to the shoulder and back. One episode of neuralgia from the right side of the neck resulted in a silent migraine occurred with excessive hours in front of the computer. Her shoulders were still maintaining full range of motion but last week, a feeling like a band or pressure developed across the posterior deltoid and over the shoulder which is still present today. No complaints of lower back pain since the last treatment.

Assessment

Full strength when testing the shoulder muscles which was encouraging. There was also a full range of movement though a feeling of the band over the deltoid still present. The taut band and pain commonly referred to as a “Trigger Point” was no longer present on palpation of the teres major. Lumbar rotations in supine were equal and full range. Sacral hypertonicity and painful areas were no longer a concern.

Treatments

  1. Local neuromuscular treatment – This was applied to the left shoulder commencing with positional release techniques to the external rotators of the humerus, glides to the pectoralis minor and major.
  2. Prone neuromuscular techniques – These techniques were also applied to the full-back, latissimus dorsi, lumbosacral and thoracolumbar fascia, shoulder rotator cuff, upper trapezius, and levator scapulae.
  3. Homecare – Activation of the Chapmans Reflexes three times a week and increase to daily if the range reduced in any of the humeral movements were advised. She would continue with the low load muscle activation of the rhomboid before stronger shoulder exercises. She would have to find strategies to add small breaks into the assignment writing tasks so that long hours working at the computer are broken up.

LAST TREATMENT

Two weeks further to follow up and all ranges are full, pain-free, and feel easy throughout the entire range. I added a bike exercise to help with stress management. She would continue with the low load muscle activation and Chapmans Reflexes point stimulation.

Treatments

  1. Therapeutic management – She asked to have a more relaxed treatment so I removed any neurolymphatic point stimulation or exercises to the treatment protocol and gave a general treatment including glides, effleurage, petrissage, myofascial release techniques, positional release techniques, some active and passive stretches.
  2. Homecare – She would continue with the physiotherapist’s exercise routine adding the low load and neurolymphatic point stimulation before these rehabilitation activities.

I followed up 6 and 12 months later and Mrs. W had no further need to intervene on her shoulder.

 

 

Paula Nutting Director Your Musculoskeletal Specialist
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