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[MANAGEMENT FOCuS] small amount of posterior, medial and lateral accessory motions. TM joint gapping can be assessed by lightly palpating over one TMJ with your fingertips while the other hand applies downward pressure through the mandible through contact of the thumb on the lower molars. After assessing distraction, you can use the same hand placement, to evaluate anterior glide by gently pulling forward on the mandible. Posterior, medial and lateral glide can all be assessed with similar hand placement. If any of the above findings are positive, it’s important to look more closely at the masticatory system’s role as the probable symptom driver. If you feel overwhelmed at the prospect of fully assessing and treating the TM joint you could collaborate with a TMD specialist in your area or consider further training in this field. Niche Services and Referrals We have found TMJ rehabilitation to be a welcome need in our community and one of our strongest avenues for new patients coming to our practice. Our TMJ clients arrive by way of their primary care provider, referral from an oral surgeon, dentist or neurologist, or direct from the community. If you can establish a niche service that meets an unmet community need, patients will seek you out, whether through their primary physician or specialist, support group, the internet or simple word of mouth. n Monica Vitenson and Katherine Tan are co-owners of BodyFit Physical Therapy and Wellness in Manhattan. ARE YOUR PATIENT VISITS DROPPING? ARE YOU NO longer ENJOYING THE HIGH NUMBERS YOUR PRACTICE USED TO have? We will give you the solutions to INCREASE PATIENT VISITS & MORE! MEG is a PT OWNED & OPERATED practice management consulting company with the nation’s only ON-SITE MANAGEMENT TRAINING facility. We work 1-on-1 with PT owners & eectively organize & train sta. You can trust that we’re not like any other consulting rm. *Ask us why today? (727) 599-5787 Dear Practice Owner, I invite you to visit MEGBUSINESS.COM and watch our videos to learn about us and our work with over 200 practice owners nationwide! Brian Gallagher, PT Practice Owner of Cypress Creek Therapy PATIENTS WITH FORWARD HEAD POSTURE? ANTERIORLY WEIGHTED 1-5 POUNDS PATIENTS WITH CERVICAL IMMOBILITY? ONE POUND PROPORTIONALLY BALANCED CERVICAL EXERCISE TOOL • Improves neurological function Halo Products are Patented and Manufactured by White Sky, LLC Contact@HaloRejuvenator.com 888-884-4256(HALO) E-MAIL info@megbusiness.com VISIT www.megbusiness.com www.megbusiness.com ADVANCE for Physical Therapy & Rehab Medicine 9
[uPPER-ExTREMITy REHAB] Diagnosis: ‘SICK’ Scapula This condition can be alleviated through appropriate education and active involvement with home exercise By Daniel lorenz, DPT, PT, lAT, CsCs The scapula is a critical component of upper-extremity function. It provides a base from which the glenohumeral joint and elbow can execute the function of throwing overhead. The scapula has somewhat of a paradoxical role in shoulder function because it must be mobile enough to allow full functioning of the upper extremity, but stable enough to not contribute to shoulder and elbow pathologies. Because so many muscles attach to the scapula, alterations in posture, muscle length or strength, or neuromuscular coordination can lead to suboptimal length-tension relationships and ultimately, upper-extremity dysfunction. Burkhart et al previously described the “SICK” scapula as a method to categorize various forms of scapular dysfunction. SICK is an acronym for Scapula Inferior Coracoid Dyskinesis. 1 Essentially, this moniker is used to describe faulty positioning of the scapula due to a combination of muscle tightness of the pectorals, specifically pectoralis minor, and weakness of the interscapular muscles. Dyskinesis has been defined as either the presence of scapular winging (prominence of any border away from the thorax) or dysrhythmia (presence of aberrant movements. 2 Types Type I scapula is characterized by inferior border prominence. Inferior border prominence indicates anterior tilting of the scapula from a combination of lower trapezius weakness and pectoralis minor tightness. More than likely, patients with a Type I scapula also have an increase in thoracic kyphosis. The increase in thoracic kyphosis typically limits thoracic extension, which enables a normal resting position of the scapula. Type II scapula is characterized by medial border prominence. Medial border prominence indicates there is not only rhomboid and middle trapezius weakness, but also an internally rotated and protracted scapula. Furthermore, there is potentially weakness of serratus anterior, leading to the appearance of winging. The position of the scapula in this situation will lead to abnormal firing of the rotator cuff 10 ADVANCE for Physical Therapy & Rehab Medicine and scapular stabilizers as well as place the humerus in an internally rotated position. The internally rotated position effectively puts the rotator cuff in an impingement position with arm elevation. Finally, Type III scapula is characterized by superior border prominence. In this case, there is overactivity of the upper trapezius and levator scapulae, leading to a superior malposition of the scapula. The physical therapist may notice that the patient has superior humeral head migration during elevation, causing overactivity of the upper trapezius. Or to avoid use of a painful rotator cuff, the athlete may “shrug” the shoulder as he executes the overhead movement. Rotation Deficit One other critical component of the SICK scapula is glenohumeral internal rotation deficit (GIRD). Although the actual source of GIRD is a topic of debate, it is generally accepted that repetitive throwing leads to posterior rotator cuff and joint capsule shortening. Because of this, the overhead athlete may lack sufficient internal rotation of the throwing shoulder. Lack of internal rotation of the throwing shoulder can lead to superior migration of the humeral head during follow through, which can lead to rotator cuff pathology. The therapist should measure both internal and external rotation at 90 degrees of abduction in supine. When those numbers are added up in both shoulders, they should be symmetrical. Currently, it is recommended that 15 percent or more discrepancy of internal rotation in the throwing shoulder signifies the athlete has GIRD, which should be addressed as part of a comprehensive treatment plan. A thorough history, posture examination, muscle length and strength testing, and observation of movement will help guide a treatment plan. In general, mobility and muscle length must first be restored before muscle strength. Furthermore, the physical therapist should assess mobility of both the acromioclavicular and sternoclavicular joints. Both of these joints are critical to shoulder function because the clavicle elevates and rotates with proper shoulder function. The patient should also be screened for tight hip flexors because this could lead to a compensatory increase in thoracic kyphosis, since tight hip flexors are one cause of increased lumbar lordosis. Stretching and Taping Secondly, the physical therapist should teach stretching techniques for the pectoralis minor and anterior shoulder. To assess for pectoralis minor tightness, the therapist can have the patient lie supine. The distance between the treatment table and the posterior edge of the acromion should be no more than an inch. Any increase beyond one inch indicates that the patient has pectoralis minor tightness. As a complement to stretching and posture retraining, taping of the scapula can be considered. This serves as a proprioceptive cue to keep the shoulders retracted and will help maintain pectoralis minor length after stretching. To address posterior shoulder tightness and GIRD, the “sleeper stretch” is a very useful technique to increase length of the posterior rotator cuff and joint capsule. Once mobility and length are restored, a comprehensive strengthening program for the rotator cuff and scapular stabilizers should take place. Prone rowing, prone shoulder extension, prone horizontal abduction, external rotation exercises, prone scaption raises and supine punches are just a few examples of exercises advocated for strengthening the shoulder. Elevation in the scapular plane (“full can”) is also strongly encouraged in lieu of “empty can” raises. All elevation exercises should be performed in the scapular plane. Resistance Regarding resistance, the rotator cuff has 50 percent each of Type I and Type II fibers. Therefore, strengthening and endurance exercises should scapula continued on page 21 JoHN CIuPPA
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Page 7 and 8: [lETTERS To THE EDIToR] Referral-fo
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Page 15 and 16: [CoVER SToRy] componentry repair wh
Page 17 and 18: [NEuROLOGIC REHAB] Miracle Movers B
Page 19 and 20: [NEuROLOGIC REHAB] supplemented by
Page 21 and 22: [PIlATES] patterns. Breathing is of
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