Tuesday, December 29, 2009

The Scalene Muscle & Potential pain generating factors from scalene

The scalene muscles are a group of three pairs of muscles in the lateral neck, namely the scalenus anterior, scalenus medius, and scalenus posterior. They are innervated by the spinal nerves C3-C8.

Origin and insertion
Scalenus anterior & medius: Scalenus anterior muscle arises from anterior tubercles of transverse processes of C3-6 vertebrae. It gets inserted into scalene tubercle on the first rib. Scalenus medius arises from posterior tubercles of transverse processes of C2-7 vertebrae. It gets inserted on the superior surface of the first rib behind the groove for subclavian artery. (J.Anat.Soc. India 55 (2) 52-55 2006 52)

On neck: All 3 scalene muscles produce rotation of the cervical spine to the same side. Maximum stretching of the scalenes should include rotation to the opposite side. (J Orthop Sports Phys Ther. 2002 Oct;32(10):488-96.)

On ribcage & respiration: The action of the anterior and middle scalene muscles is to elevate the first rib and rotate the neck to the same side; the action of the posterior scalene is to elevate the second rib and tilt (side flexion) the neck to the same side. They also act as accessory muscles of inspiration, along with the sternocleidomastoids.

Anatomy of interscalene triangle (IST): (J.Anat.Soc. India 55 (2) 52-55 2006 52)

IST is bounded by scalenus anterior muscle anteriorly, scalenus medius posteriorly and first rib between their insertions inferiorly. Enclosed within this triangle are:
(a) In the upper part of the triangle, ventral rami of C3, 4, and 5 taking part in the formation of phrenic nerve.
(b) In the lower part are the upper, middle and lower trunks of brachial plexus along with the subclavian artery.

I dare to compare the anterior & the middle scalene to the piriformis muscle. The piriformis allows the sciatic nerve to pass through it where as the space between anterior & the middle scalene allows many more structures through it.

Summary of anatomical relationships:
The scalene muscles have an important relationship to other structures in the neck. The brachial plexus and subclavian artery pass between the anterior and middle scalenes. The subclavian vein and phrenic nerve pass anteriorly to the anterior scalene as it crosses over the first rib.
The passing of the brachial plexus and the subclavian artery through the space of the anterior and middle scalene muscles constitute the scalene hiatus (the term "scalene fissure" is also used). The region in which this lies is referred to as the scaleotracheal fossa. It is bound by the clavicle inferior anteriorly, the trachea medially, posteriorly by the trapezius, and anteriorly by the platysma muscle.
Anatomical variations: To know the anatomical variations of IST one is referred to J.Anat.Soc. India 55 (2) 52-55 2006 52

Pain from scalene muscle

1. Role of scalene muscles in TOS:

Scalene muscles cause TOS (both vascular & neural effects) in one of the following ways:
(i) Tough and unyielding tendinous insertions, against which the soft neurovascular structures may be forced during certain movements.
(ii) Aponeurotic insertion of single scalene with sharp sickle shaped margin or both the scalenes joining to form u-shaped sling cause subclavian artery to be highly arched, which might result in kinking of the artery or thrombus formation with distal embolization.
(iii) Triangle can be narrowed to form slit like inter-scalene space by approximation of insertions of the two scalenes or the insertions may overlap resulting in high arching and scissoring effect (Thomas 1983).
(iv) Either of the scalene muscles may be larger than normal thus narrowing the space.
(v) TOCS may also result from spasm of scalenus anterior resulting in ‘scalenus anticus syndrome’.

The TOS & it’s varieties in nutshell

Thoracic outlet syndromes (TOS): caused by compression of the brachial plexus or vascular structures due to anatomical anomalies of the cervico-axillary region.
Varieties of TOS: Two main types are seen i.e. the neurogenic TOS syndromes and the vascular TOS syndromes. The neurogenic TOS syndromes make up 90% of all TOS cases. Females are more affected than males in their 4th or 5th decade. Neurogenic thoracic outlet syndrome (NTOS): NTOS is attributed to compression of the brachial plexus at the scalene hiatus. There are 2 distinct clinical entities of the NTOS i.e. the true & nonspecific NTOS.
True NTOS: have typical clinical and electrophysiological changes.
Nonspecific NTOS: have predominantly sensory signs, not well-defined electrophysiological changes.

Common symptoms of neurogenic TOS:
a. A common initial symptom is pain along the medial side of the arm, which may be more diffuse and accompanied by paraesthesiae.
b. Most of these patients suffer from amyotrophy and gradually progressive weakness of the intrinsic muscles of the hand, particularly the thenar eminence.
c. The association of vascular signs and symptoms is rare.
X-ray: In almost all cases cervical ribs or elongated transverse aprophyses of C7 are found on plain X-ray.
EMG & NCV: Characteristic changes are seen on electrophysiological studies.

2. Trigger point pain scalene producing referred symptoms: Travell & Simmons have described trigger points in scalene. The referral pattern:

1. supra-clavicular area, anterolateral chest
2. antro & postero lateral area of arm
3. antro & postero lateral area of fore arm & hand

3. Mechanical abnormality produced by tight scalene: One should view the impact of the tightness on the cervical spine arthrokinematics as well as the neural mechanics. The neural mechanics must be viewed with reference to David Butler’s neural tissue mobility specifically ULTT3.


What effect of scalene on cervical spine mechanics?

Imbalance in the anterior & middle scalene length of left & right side might lead to laterally translated vertebra on the same side & rotation to the opposite side along with mild flexion. A tight scalene hinders rotation to the opposite side. Hence, forcing the movement to opposite side of the tightness might lead to lateral translation of the lower & middle cervical vertebra to wards the tight side & rotation to the opposite side.

The key assessment involves T1&2 rib palpation for mobility & symptoms & neck rotatory mobility assessment to assess tightness of anterior & middle scalene muscles.

Manual therapy prospective of Scalene

1. Scalene stretch: opposite side rotation & downward pressure to 1st rib during inhaling & attempting apical expansion.

2. MET of Scalene when the effect is on cervical spine- fixation of the 1st rib + isometric holds to same ride rotation (20% of MCV).

3. MET of Scalene when the effect is on 1st rib- fixation of the neck in full rotation + stabilization of the shoulder girdle from above- then take deep inspiration for apical expansion.


1. Molina-Martínez FJ, Thoracic outlet syndrome, Rev Neurol. 1998 Jul;27(155):103-7.
2. Colli BO, Neurogenic thoracic outlet syndromes: a comparison of true and nonspecific syndromes after surgical treatment. Surg Neurol. 2006 Mar; 65(3):262-71; discussion 271-2.
3. Mobilization of the nervous system; David butler, Churchill-Livingstone
4. J.Anat.Soc. India 55 (2) 52-55 2006 52
5. J Orthop Sports Phys Ther. 2002 Oct;32(10):488-96.

Thursday, December 17, 2009

Coupling mechanisms in cervical spine

Radiographic study: coupling of cervical motions in lateral head translations.
The clinically common posture of lateral head translation results in an S-shaped cervical spine and may occur in side impact trauma. This posture has not been studied for cervical coupling patterns or range of motion (ROM) (2).

In a radiographic experimental study (2) on 20 subjects lateral (a mean of 51 mm) translation was produced by translating the head over a fixed thorax. The major coupled motion was lateral bending (z-axis rotation). The following was found:

1. S-shape in cervical spine was created & there is change in direction at C4–C5 disc space.
2. Upper cervical (C3–C4) lateral bending was contralateral to the main motion of head translation direction. Lower cervical and upper thoracic lateral bending was ipsilateral.
3. During the translation other segmental motions averaged less than 1 mm and 1°.

This study shows in cervical spine side bending usually there in nil-minimal involvement of rotational movements. On cervical spine observations if the spine is bend to the rt side it also rotated to the rt side.

Clinical implications: manual repositioning of cervical disc is described by Cyriax method via employing lateral translations in cervical spine (4).

Review of cervical spine coupling behavior (1):
1. 100% agreement in coupling direction (side flexion and rotation to the same side) in lower cervical vertebral segments (C2-3 and lower) but
2. Variation in coupling patterns in the upper cervical segments of occiput-C1 (during side flexion initiation) and C1-2.

Upper cervical spine coupling mechanics:

3-D MRI study (3) reveals:

1. The normal atlanto-occipital axial rotation varies approximately between (2-3) degrees. Similarly, atlanto-axial axial rotation is approximately (32-40) degrees.
2. With contribution of atlanto-occipital axial rotation the contribution of atlanto-axial axial rotation reduces.
3. Coupling mechanism is as follows:
a. Lateral bending is coupled with opposite side axial rotation at both atlanto-occipital & atlanto-axial levels. The degrees of coupling at for atlanto-occipital & atlanto-axial are different. For the atlanto-occipital joint side bending opposite side rotation is between 3-6 degrees, and for atlanto-axial joint side bending opposite side rotation is between 1-7 degrees.
b. In extension atlanto-occipital joint can axially rotate 10-18 degrees and atlanto-axial joint 4-10 degrees.


1. Cook C et al; Coupling behavior of the cervical spine: a systematic review of the literature. J Manipulative Physiol Ther. 2006 Sep;29(7):570-5.

2. Deed E Harrisona et al ; Cervical coupling during lateral head translations creates an S-configuratio. Arthroscopy. Volume 15, Issue 6, Pages 436-440 (July 2000)

3. Ishii T et al; Kinematics of the upper cervical spine in rotation: in vivo three-dimensional analysis. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E139-44.

4. Criax J; Text book of orthopaedic medicine vol.II, 11th edition, AITBS publication

Wednesday, December 16, 2009

Effect of eye position on neck muscle activity

Dominant eye assessment has been an integral part of spine conditions especially to reason out the spinal asymmetry.

Activity of splenius capitis (SC) is modified with gaze shift. Further, control of the neck muscles is coordinated with the sensory organs of vision, hearing and balance.

Impact of eye movement on cervical muscles & movements are not much studied in the context of management of cervical dysfunctions. we can pick up some clues from the study below:

The following is a study of division of physiotherapy (University of Queensland, Australia) which investigates interaction between eye movement and neck muscle activity in influencing the control of neck movement.

The effect of eye position on neck muscle activity during cervical rotation was studied on 11 subjects. Muscles to rt. Side cervical rotation (in sitting) was under real-time EMG surveillance i.e. right obliquus capitis inferior (OI), multifides (MF), and splenius capitis (SC), and left sternocleidomastoid (SCM). The cervical rotation was carried out with a fixed infra-orbital position.

The results show:

1. Right SC and left SCM EMG increased with rotation to the right, contrary to anatomical texts.
2. OI EMG increased with both directions
3. MF EMG did not change from the activity recorded at rest.

This study also shows during neck rotation SCM and MF EMG was less when the eyes were maintained with a constant intra-orbit position that was opposite to the direction of rotation compared to trials in which the eyes were maintained in the same direction as the head movement.
Hence the inter-relationship between eye position and neck muscle activity may affect the control of neck posture and movement.

Bexander, Mellor & Hodges; Exp Brain Res. Effect of gaze direction on neck muscle activity during cervical rotation 2005 Dec;167(3):422-32. Epub 2005 Sep 29.

Rotator cuff tendons & Biceps target area palpation

1. Supraspinatus:

Performance cues-
1. Sitting: HBB (Hand behind back)- Adduction & medial rotation of the arm brings the tendon from frontal plane to sagittal plane.
2. Tendon emerge under the anterior edge of acromion

2. Infraspinatus:

Performance cues-
1. Pr. Lying: prop up the patients on the elbows
2. Lateral rotation of the shoulder- ask the patient to hold to sides of the couch
3. Adduct the shoulder by shifting the affecting the elbow for 2-3 inches

Locating the tendon- The insertion of Infraspinatus tendon is just below the lateral end of the spine of scapula

3. Subscapularis:

Performance cues-
1. Sitting or ½ Lying: Therapist palpates for Bacipital tendon by repeatedly IR & ER of the arm. Just medial to the proximal tendon there is lesser tuberosity & the subscapularis (tendon feels as hard as the bone). The tendon extends down to the shaft of humerus distally.
2. Put patient’s hand on her thigh & apply the massage to specific points
3. Caution: Avoid the massage to the medial edge of the deltoid fibers & over the bacipital tendon

4. Bicep’s Long head:

Performance cues-
1. Patient Sitting or ½ Lying: patients hand on thigh
2. Palpation along the tendon: Resist the elbow flexion & palpate the tendon stiffen near the medial border
3. Palpation across the tendon: Therapist palpates for Bacipital tendon by repeatedly IR & ER of the arm.


Text book of orthopedic medicine

Friday, December 11, 2009

Dr Alsears letter to me- From medicine to meditation

From medicine to meditation

This entire article is by Dr Al Sears. This letter was received by me on my E-mail address, which made a fantastic reading for me.

Al Sears, MD
11903 Southern Blvd., Ste. 208
Royal Palm Beach, FL 33411

December 11, 2009

Dear satyajit,

When I was in India I met “yogis” or meditation masters who had remarkable powers of concentration.

Simply by focusing on their breath they could change their heart rate, raise their body temperature, and even walk on burning-hot coals.

In your daily life you probably don’t have the need or opportunity to walk on hot coals, but the power to quiet your mind gives you more control over your health than any pill or prescription.

Many of these yogis practice meditation. It’s easy enough to do on your own. There are even clinical studies that back it up.

Studies show meditation:

* Lowers blood pressure
* Improves sleep
* Reduces stress and anxiety
* Improves immunity
* Helps with pain management
* Increases productivity
* Improves concentration
* Heightens learning ability and creativity

A study published by the American Heart Association (AHA) found meditation to be as effective as medications for lowering blood pressure. The study involved 111 men and women between the ages of 55 and 85 with hypertension. About a third practiced meditation for 15 to 20 minutes twice daily. A second group practiced muscle relaxation. The third group cut back on salt and calories and practiced aerobic exercise.1

The meditation group showed the greatest improvement. Their systolic pressure – the top number – dropped an average of 10 points. And their diastolic pressure – the bottom number – fell an average of 5.6 points.2 The National Institute of Health (NIH) was so impressed with the results they granted $1.4 million for a follow-up study.3

Meditation is safe and easy. The technique is exceedingly simple. The most natural object of meditation is your breath. For beginners, I recommend mastering your focus on your breath before you try any other object of meditation.

* Find a quiet, comfortable place to sit.
* Rest your hands in your lap and close your eyes.
* For the first few minutes, focus on the natural rhythm of your breath.
* At first, don’t try to change it. Just follow your breath.
* The next step is to gently make your breath, quieter, slower, deeper and more regular.
* If your attention drifts to other things redirect it to your breath.

Try to meditate at least 10 minutes once a day. Twice a day is better.

During my trip to India I had wonderful teachers, but when I got home I felt like I was on my own. After asking around, my friends at Learning Strategies offered me a couple of great programs that make meditation a snap.

Seeds of Enlightenment takes you step-by-step through 8 simple meditations. You don’t need any experience and all you have to do is listen and follow along. One of my favorite parts is the meditation on the Laws of Attraction. It sharpens your awareness and helps you get what you want out of life. The experience is self-empowering.

You can apply this to anything: breaking free from what they call the “money and emotions game,” enhancing your quality of life and your daily experiences, even for personal and business coaching options… the possibilities are limitless.

Learn more about what’s really possible when your mind is clear and focused. This is something you should explore.

References of this article ( Dr Al sears

1 Goad, M. “A powerful case for TM” Portland Press Herald: November 27, 1995. 2 Khalsa, D. S. Brain Longevity, Warner Books, 1997: 309. 3 “The Effects of the Transcendental Meditation and TM-Sidhi program on the aging process,” International Journal of Neuroscience 16 (1): 53¬58, 1982.

Satyajit speaks: Friends & folks yoga does not belong to a particular religion or community. It is a part of health & well-being to all. By a change ancient Indian seers knew the way yoga meditation works.

Sunday, December 6, 2009

Effect of verbal cues on exercise performance

Muscle timing and activation amplitude and movement can be modified with verbal cues (Lewis & Sahrmann ,2009).

Lewis & Sahrmann tested the participants under 3 conditions: no cues, cues to contract the gluteal muscles, and cues to contract the hamstrings muscles. Hip and knee angle and electromyographic data from the gluteus maximus, medial hamstrings, and lateral hamstrings was measured while participants performed prone hip extension from 30 degrees of hip flexion to neutral. (see the figure above)

This information is important for clinicians using prone hip extension as either an evaluation tool or a rehabilitation exercise.

Pregnancy changes them all- Stability, continence and breathing. The role of fascia in these changes.

(Figure 1)

Pregnancy & pelvic Girdle Pain (PGP):

Pregnancy-related pelvic girdle pain (PRPGP) has a prevalence of approximately 45% during pregnancy and 20-25% in the early postpartum period. Most women become pain free in the first 12 weeks after delivery, however, 5-7% do not.

Pregnancy & urinary incontinence (UI):

Wilson, Herbison, Glazener, McGee & MacArthur (2002): found that 45% of women experienced UI at 7 years postpartum and that 27% who were initially incontinent in the early postpartum period regained continence, while 31% who were continent became incontinent.

The abdominal canister (container) in pregnancy and delivery:

Muscles and fascia of the lumbopelvic region play a significant role in
a. musculoskeletal function
b. continence and
c. respiration
It seems that there is an existence of an interlinked trio of lumbopelvic pain, incontinence and breathing disorders.

Musculoskeletal loading & the interlinked trio: (see figure 1 above)
Synergistic function of all trunk muscles is required for loads to be transferred effectively through the lumbopelvic region during of varying load.

While transferring load, there must be a balance in controlling the movement, maintaining optimal joint axes, maintain sufficient intra-abdominal pressure without compromising the organs (preserve continence, prevent prolapse or herniation) and support efficient respiration.

Non-optimal strategies for posture, movement and/or breathing create failed load transfer which can lead to pain, incontinence and/or breathing disorders.

Individual or combined impairments in multiple systems including the articular, neural, myofascial and/or visceral can lead to non-optimal strategies during single or multiple tasks.

Which faults are encountered in pregnency
1. Trauma to the linea alba and endopelvic fascia produces a non-optimal strategies for load transfer.
2. Fascial changes also occurs secondary to altered breathing behaviour during pregnancy.


1. Wilson, Herbison, Glazener, McGee & MacArthur (2002): Obstetric practice and urinary incontinence 5-7 years after delivery. ICS Proceedings of the Neurourology and Urodynamics, vol. 21(4), pp. 284-300.
2. Lee, Lee & McLaughlin: Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodyw Mov Ther. 2008 Oct;12(4):333-48. Epub 2008 Jul 1.

Tuesday, December 1, 2009

Therapy with amitriptyline or physiotherapy is equally effective in fibromyalgia!!!

You can learn about fibromyalgia from this blog site by typing “fibromyalgia” in the search box of this blog site. The search box is at top left of this page.

In an rural set up Indian study, first of it’s kind, comparing the effect of amitriptyline or physiotherapy in improving outcome in patients of fibromyalgia over a period of six months, Joshi et al found they are equally effective.

Usually fibromyalgia is treated by: antidepressants, analgesics, exercise, cognitive behavioral therapy.

1. Therapeutic Drugs used in fibromyalgia: amitryptiline and other tricyclic antidepressants, pregabalin, duloxetine and milnacipran.
2. Physiotherapy in fibromyalgia: Exercise in the form of cardiovascular training, strength training, aerobics, flexibility training, all can lead to improvement in fibromyalgia.

Joshi employed a trained physiotherapist to conduct a uniform structured physical training and aerobic session for patients in physiotherapy treatment group. The patients were advised to perform the exercises daily twice for at least 10 min. Further there was a step-up pattern of exercise regimen followed by relaxation, stretching and strengthening techniques.

In this experiment physiotherapy was compared with following dosage of amitriptyline.

Amitriptyline dose was 25 mg to 50 mg. No patient required further escalation of doses. All patients were also offered pharmacologic treatment with 50 mg tramadol in thrice daily doses and as required.

Reference: Joshi MN, Joshi R, Jain AP. Effect of amitriptyline vs. physiotherapy in management of fibromyalgia syndrome: What predicts a clinical benefit?. J Postgrad Med [serial online] 2009 [cited 2009 Nov 30];55:185-9. Available from: http://www.jpgmonline.com/text.asp?2009/55/3/185/57399