Forward Head Posture Fix

Forward Head Posture Fix

This ebook guide teaches you the muscles that you need to work to make sure that you have excellent posture all day long, and that you will have the benefits that go along with good posture. You will be able to get rid of many headaches, brain fog, and aching neck muscles by using this workout. There is no need to look old! Stooping is the sign of old age Even if you are an older person you too can work out this muscle group to give you the powerful posture of a much younger person! This bad posture that we are correcting is called texting neck. It comes when you look down at something (like a book or your phone) too often, which puts a huge strain on your neck. You will learn how to fix this problem and help your neck to be in better shape today. Your neck is supposed to remain vertical; we can help put it back where it goes to make sure that you stay healthy for years to come. Read more...

Forward Head Posture Fix Summary


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Sternocleidomastoid And Trapezius Muscles

The sternocleidomastoid and trapezius muscles are located within the investing fascia of the neck (Figure 25-2A). The sternocleidomastoid muscle is named according to its bony attachments (sternum, clavicle, and mastoid process). The sternocleidomastoid muscle creates the borders for both the anterior and the posterior triangles of the neck, and is innervated by the spinal accessory nerve (CN XI). This muscle flexes the neck, pulls the chin upward, and assists in elevating the rib cage during inspiration. The trapezius muscle attaches to the occipital bone, nuchal ligament, spinous processes of C7-T12, scapular spine, acromion, and the lateral part of the clavicle. The sternocleidomastoid muscle is innervated by CN XI. V During a physical examination, the functions of the sternocleidomastoid and trapezius muscles are evaluated together because they share the same innervation. During the examination, the physician looks for signs of muscle atrophy or weakness. To test the...


Sternocleidomastoid to act in this capacity, the head and neck must be held in a stable position by the neck flexors and extensors. This muscle pulls from its skull insertions and elevates the sternum, increasing the A-P diameter of the chest (39). It contracts during moderate and deep inspiration. When the lungs are hyperinflated, the stern-ocleidomastoid is especially active. Electrical activity is sometimes evident during quiet inspiration (34). This muscle is not active during expiration. (See pp. 125 and 148, 149.)

Respiration Big Picture

During the deep or forced inspirations that occur during vigorous exercise, the volume of the thoracic cavity is further increased by activation of the accessory muscles. Accessory respiratory muscles, including the scalenes, sternocleidomastoid, and pectoralis minor, elevate the ribs more than occurs during quiet inspiration.

Job or Sportrelated Habits

An athlete who breathes through the mouth rather than through the nose may have a problem with allergies or frequent colds, which in turn makes nose breathing difficult. Breathing with the mouth open results in the tongue moving forward and downward to the floor of the mouth. The weight of the tongue and open jaw puts more weight forward. As a result, the suboccipital muscles are forced to overwork. To allow better air flow, the athlete will extend the neck and move the head forward. This will eventually lead to a forward head posture and cervical dysfunction. If the athlete habitually has a forward head position or excessive midcervical lordosis, the jaw forward position contributes to muscle imbalances of the flexor and extensor muscles of the head and neck. The tonic neck reflex (TNF) plays a primary role in an individual's ability to achieve correct head-neck posture. There is an interrelationship with the vestibular and ocular systems with the TNF. If the tonic neck reflexes or...


A forward head posture places the lower cervical spine in flexion with increased activity of the anterior neck muscles. In particular, longus capitis and longus colli increase tension on the hyoid bone (Rocabado M). With the hyoid pulled downward the mandible is pulled down and back (in relation to the maxilla), causing occlusion and swallowing problems. STERNOCLEIDOMASTOID MUSCLE Hypertonus in the sternocleidomastoid is a key sign that the mandible shoulder girdle area and cervical spine are not functioning harmoniously.

Factors that affect the range of movement

As the desiccation of the disc and the growth of osteophytes, play a significant role in the loss of movement (Dalton and Coutts 1994). Quite significant losses of range can be seen in some individuals with marked degenerative changes. Usually movement loss is symmetrical however, such changes are not necessarily symptomatic. The decline in range that occurs with age affects the anterior-posterior mobility as well as the physiological movements. There is a significant loss of retraction, particularly in the fourth and sixth decade, and individuals come to adopt a more forward natural head posture, especially in the sixth decade (Dalton and Coutts 1994). However, there is considerable variance at different ages, and in part major movement loss may be related to years of poor posture and lack of use.

Presentation of Evidence in Court

At court, be smartly dressed and be punctual. Adopt a good posture in the witness box. In giving the answers to the questions, be precise and accurate, without being technical. If the answer is not known, this should be stated. If there are attempts by the legal practitioners to mislead, confuse or misstate your evidence, remember that the judge is there to correct these misconceptions. With diligent application in the laboratory and in the courtroom, the materials will have been correctly analysed and the findings successfully reported.

Effect of posture on cervical spine

In slumped, relaxed sitting with lumbar flexion, the thoracic spine is also fully flexed this causes the lower cervical spine to be Hexed and the head protruded (McKenzie 1990). Conversely, in a more upright posture the head is more retracted (McKenzie 1990 Lee et al. 2005). If the individual is looking forward, then the upper cervical spine is in extension. Weak but positive correlations have been found between forward head posture and increased cervicothoracic kyphosis and upper cervical extension (Raine and Twomey 1994). It is important that the patient realises the link between the position of the lumbar and the cervical spine. As mentioned above, the starting position has an effect on the available range of movement (McKenzie 1990 Haughie et al. 1995 Walmsley et al. 1996). For instance, there is 10 degrees more extension in upright sitting (Haughie et al. 1995) and less rotation in extreme retraction and protraction compared to neutral (Walmsley et al. 1996). It is easy to...

What is the treatment of whiplash injury

Whiplash injury is a term used to describe an acute cervical sprain or strain that results from acceleration and deceleration motion without direct application of force to the head or neck. Whiplash commonly affects the cervical facet joints and related musculature (trapezius, levator scapulae, scalene, sternocleidomastoid, and paraspinals). Although the symptoms of nonradicular neck and shoulder pain are often self-limiting (6-12 months), many people continue to experience more chronic symptoms. Treatment options include cervical traction, massage, heat, ice, ultrasound, isometric neck exercises, a soft cervical collar, and NSAIDs and or short-term analgesic use. Patients with persistent pain may have annular tears, coexisting degenerative joint and disc pathology, nerve root entrapment, spinal stenosis, or myelopathy. Neurologic symptoms or intractable pain symptoms that are not responsive to treatment indicate the need for further evaluation.

Fibromyalgia Tired of Being Sick and Tired

Feel around for a sore spot at the end of your clavicle or collarbone, LU-1 (Central Residence). With your fingers in a loose fist resting against your chest, use reinforced fingers, breath deeply, and hold these points for two to three minutes. Mild pressure may be applied as you exhale release as you inhale. This will invigorate your neck muscles and stimulate circulation in your lungs.

Cervical Spine Extension And Flexion

Cervical spine extension in a typical forward-head posture. Note the similarity in the curve and the positions of the markers to those in the example above. Often, this slumped posture is mistakenly referred to as flexion of the lower cervical spine and extension of the upper cervical spine. However, the extension is more pronounced in the lower than in the upper cervical region.

Middle Peripheral Lesions

The syndrome is comprised of weakness of the ipsilateral vocal cord, palate, and pharynx and the trapezius and sternocleidomastoid muscles. A lesion in the retropharyngeal space is responsible for Villaret's syndrome, which involves cranial nerves IX, X, XI, and XII and produces anesthesia of the palate, larynx, and pharynx weakness of the trapezius and sternocleidomastoid muscles atrophy and weakness of the tongue and a Horner's syndrome. This last feature is due to involvement of cervical sympathetic fibers.

Communicative behaviour

This relies mainly on body posture and facial expression Body posture - a relaxed cat will walk around with its tail down but when greeting other cats or humans to whom it is friendly it will approach with its tail raised (Fig. 13.7). An aggressive cat will hold its tail close to its body while a frightened cat will arch its back and raise its tail. The hairs along the back and covering the tail will be erected to make the animal look larger and more formidable. Fig. 13.7 Body postures used by the domestic cat (a) Relaxed posture (b) Greeting posture (c) Aggression (d) Fear (e) Conflict - the cat is frightened, but may attack if cornered Fig. 13.7 Body postures used by the domestic cat (a) Relaxed posture (b) Greeting posture (c) Aggression (d) Fear (e) Conflict - the cat is frightened, but may attack if cornered Sounds range from miaows, which change according to their demands - some owners claim that their cats talk to them -to loud, carrying yowls, particularly those associated...

Sitting posture and its effects on pain

If during the history-taking the patient is seated unsupported on a treatment table or examination couch, we are able to observe their natural unsupported seating posture. Posture is best observed without the patient being aware that you are doing so, such as during the history-taking. Often patients sit slouched, in a posture of lumbar and thoracic flexion, which produces a protruded head posture of lower cervical flexion and upper cervical extension. Some patients are more aware of the relationship between their posture and pain and make an attempt to sit upright as experience has told them this is more comfortable, but such patients are unusual. Regarding recognition of a protruded head posture, it may be helpful to imagine dropping a plumb line from the patient's chin. If this would fall in space some way in front of their trunk, then head posture is protruded would this fall onto their chest, then head posture is reasonably upright. This model can also be helpful to explain to...

Skateboarding Rollerskating And Windsurfing

These activities can help athletes maintain or increase body posture, proprioception, core stability and muscle function with low impact, subject to good technique and the avoidance of new injuries from unnecessary falls. These kinds of activities have become very popular for younger people and must be considered as alternative training methods for fit athletes.

Anterior Aspect Fig 256 Boney

Suprahyoid Common carotid artery Infrahyoid Sternocleidomastoid Sternocleidomastoid The sternocleidomastoid can spasm on one side, causing a torticollis deformity. Palpate the full length of the muscle for swelling or defects. Both sides go into reflex spasm following a whiplash or a significant hyperextension or side flexion mechanism. There are myofascial trigger points in the sternal and clavicular portions of the sternocleidomastoid muscle. Active trigger points are found along the length of the sternal portion of the muscle and refer pain around the eye and into the occipital region of the head, auditory canal, and even the throat (during swallowing). Active trigger points in the deeper clavicular portion refer pain to the frontal area, ear, cheek, and molar teeth. The myofascial trigger points for the platysma muscle are usually in front of the sternocleidomastoid muscle and refer a prickling pain to the skin below the mandible. The suprahyoid muscles, according to Yanda, tend...

Symptoms and Incidence

An estimated 300,000 concussions occur each year from sports-related activity (Centers for Disease Control and Prevention CDC , 1997). In high school football, there are 40,000 concussions per year, for a 3 to 5 incidence (Powell and Barber-Foss, 1999). High-risk sports include contact and collision sports such as football, ice hockey, rugby, wrestling, and to a lesser extent, soccer and basketball. Women may be more prone to concussion in some sports (Tierney et al., 2005), for unclear reasons, with further research needed. Younger players also may be more prone to concussion because of less developed neck muscles and the higher relative weight of the head compared with the rest of the body. In addition, children may sustain more serious concussions because of their immature nervous system.

Clinical Assessment Of S4

S4 also is usually sensitive to changes in venous return and filling of the heart. Maneuvers that reduce venous return, such as standing posture, will tend to decrease the intensity or abolish the S4 all together. Rapid volume expansion, cold pressor test, and isometric hand grip will accentuate the S4 (93). Isometric hand grip tends to raise heart rate, cardiac output, and the blood pressure (96,97). It can also raise the peripheral resistance.

Muscles Of The Neck Big Picture

The muscles of the neck are organized and grouped with the cervical fascia (Table 25-1). The platysma muscle is located within the superficial fascia, and the sternocleidomastoid and trapezius muscles are located within the investing fascia (part of the deep cervical fascia). Vertebral muscles (prevertebral, scalene, and deep cervical) are located within the prevertebral fascia. The suprahyoid muscles are deep to the investing fascia, whereas the infrahyoid muscles are within the pretracheal fascia. The vertebral muscles are within the prevertebral fascia.

Beliefs on Which It Is Based

Alexander and his current followers believe that his exercises, properly practiced, enable students to unlearn those habits of movement and posture that cause difficulty, and to learn proper posture and movement that put the body back into alignment. Alexander believed that bad habits develop very slowly, starting in childhood, so they often go unnoticed until later in life. Pilates is based on the idea that the conscious mind can coordinate the muscles. It incorporates the classical Greek ideal of the person who is equally balanced in body, mind and spirit. When he developed his exercise system in the 1920s, Joseph Pilates believed that then-modern lifestyle, bad posture and inefficient breathing were the roots of poor health. The exercises he designed were meant to correct muscular imbalance and improve posture, coordination, strength and flexibility, and also to increase breathing capacity and organ function.

Cranial Nerves In The Neck

CN XI exits the jugular foramen with CN IX and CN X, providing motor innervation to the sternocleidomastoid and trapezius muscles. Hypoglossal nerve (CN XII). CN XII exits the skull via the hypoglossal canal and courses into the submandibular triangle, providing somatic motor innervation to the tongue muscles (except the palatoglossus muscle).

Language the world in symbols

Living in groups where strong social interaction occurs requires a certain amount of communication. In primates this occurs through body posture, eye gaze, physical contact and position. Grooming, which requires use of the hands, is an important part of social interaction and primates spend a lot of time doing it. One primate, which uses its hands for grazing, has taken the step of vocal grooming. These animals sit together in large herds and make continual noises, sounding like speech. If, in our evolutionary past, we required prolonged use of our hands, we might have become very vocal in the same way. Similarly, chimpanzees use verbal and hand signals to hunt in teams.

Management mechanical diagnosis and therapy

Patients must also be made aware of the posture of their head and neck. Relaxed sitting posture usually involves a protruded head posture, which should be avoided during the repair process. It will be more comfortable and better long-term if a neutral head position can be maintained - head over shoulders. This should be discussed with the patient, including the importance of maintaining a lumbar lordosis to achieve it.

Artifacts In Eeg Recording

Muscle activity isolated spikes caused by contraction of the neck muscles or scalp it is a good idea to place a cylindrical cushion behind the volunteer's neck in patients suffering from headache due to tension a continuous electromyographic activity is observed in the frontal or occipital regions.

Transient pain and paresthesia of the upper extremity

Nique or associated collisions with an opponent may result in long-term complaints. Soccer seems to include more close contact, and it is reasonable to enforce standing rules and increased severity of penalty for dangerous play. The mass of the football is about 400 g and it may hit the head at speeds exceeding 100 km h. Based on various assumptions, the calculated force against the head may exceed 2000 N. The forces that have to be counteracted by the neck muscles can thus be far beyond the forces occurring in common car collisions.

Thyroid Eye Disease Thyroid Orbitopathy

The total muscle volume of the extraocular muscles increases as the disease worsens. The volume can be computed by averaging serial CT sections. Indications for treatment of thyroid ophthalmopathy include diplopia, abnormal head position, a large horizontal or vertical strabismus, and loss of vision. Generally, the preferred treatment is orbital decompression if loss of vision is threatened. Nonsurgical management of the patient includes prisms to alleviate the diplopia in primary position. Eye muscle surgery can be performed with adjustable sutures.

Garattini MC Meazzini

A skeletal diagnosis is then carried out. Our main tool in this case remains cephalometry. A lateral and oftentimes a frontal cephalogram, when any type of asymmetry is present, are needed. Again of the utmost importance is the ability to study cephalometry never separating it from clinical appearance. In this regard we suggest the use of natural head position as a reference line, which was demonstrated to be remarkably reproducible (Moorrees and Kean, 1958). Skeletal diagnosis allows for a more accurate assessment of skeletal discrepancies and thereby in growing patients, an approximate growth prediction, and in non growing patients, possible needs for dental compensations or orthognathic surgical needs.

Physical examination

Gentle pressure at the chin and thoracic spine cormcts the head posture (87). Gentle pressure at the chin and thoracic spine cormcts the head posture The posture should be examined. The normal thoracic spine is kyphotic, but an increase should be noted. A protruded forward head posture is often associated with increased thoracic kyphosis, especially around the cervicothoracic junction area. Scoliosis may be present but not relevant to the symptoms (Dieck et al. 1985). The relevance or lack of relevance of any postures is best tested by changing the posture and noting symptom response. Thus, if the patient is Sitting with increased thoracic kyphosis and protruded head, symptoms are noted, posture correction is performed and any symptom change is recorded (Procedure 2).

Inflammatory Neuropathies

The traditional description of a rapid progression of ascending symmetric weakness starting in the lower extremities and moving to the upper extremities is often useful, but variations are quite common. Indeed, early development of proximal weakness is frequently seen, and involvement of upper extremities before lower extremities is not rare. In general, the presentation is one of rapid progression of an ascending symmetric weakness, usually starting in the lower extremities and moving to the upper extremities. Patients may initially complain of pain and paresthesias in the back and proximal limbs. The progressive weakness that involves the legs as well as the upper extremities, trunk, intercostals, head, and neck muscles may take several days to 4 weeks and often results in paralysis. There may be mild sensory impairment in the extremities, early loss of DTRs, and bilateral facial nerve palsy in up to 40 of patients. Nerve conduction studies demonstrate demyelination, and the CSF may...

Obstructive Sleep Apnea

The reason for the more frequent occurrence of OSA in men than in women is not known. Men tend to have longer narrower upper airways, which may predispose them to airway collapse. The airway may be more compliant in men and may close at lower pressures for a given airway diameter. Women also show a greater augmentation of genioglossus activity in response to inspiratory loading, which may indicate a less collapsible airway. Testosterone may lead to increased bulk of neck muscles and may lead to a preferential deposition of fat in upper airway structures.

Choice of Neck Dissection

A modified neck dissection can be done, because most nodal metastases from thyroid carcinoma do not invade adjacent anatomic structures. Lymph node metastases are rarely found within the substance of the sternocleidomastoid muscle, even when there is extensive nodal involvement.9,36 It is therefore unnecessary to sacrifice this muscle. In most

Rotational And Torsional Sports

Thus, the key in the stance and coil position is balance, eye focus, and body readiness to start the stride. What happens before this coiling mechanism is not of great importance, but body and head position in the coiled portion of the swing should at least place the bat in a position that will facilitate the stride. The midsection is the core of the swing action from which the hitter generates power.29 Maintaining a center axis of motion and balance plays a critical role in maintaining head position. Too much head motion equals loss of both coordination and visualization of the ball. Locking the head to the center of axis of rotation is a key to the stride and swing positions. The bat in the coiled position is approximately at a 45-degree angle. As it comes through, there is a relative leveling of the bat, usually with less than 10 degrees of angulation. The pitch starts high because the pitcher is on the mound and throwing downward, whereas the bat comes through level. There will be...

Papillary Thyroid Carcinoma Rationale for Total Thyroidectomy

After total thyroidectomy, the removed thyroid gland is inspected to be sure that it does not contain a parathyroid gland. If a parathyroid gland has been removed, it should be dissected off the removed thyroid, a small biopsy taken for frozen section confirmation, and the remnant kept in iced saline. If this proves to be a parathyroid gland, it should be autotransplanted in 1-mm pieces in separate muscular pockets within the sternocleidomastoid muscle and marked with a suture or clip.

Corrective Exercises Posture

The exercises below are designed to help correct some common postural faults. Additional corrective exercises are located at the end of chapters that follow. Specific exercises are done to improve muscle balance and restore good posture.To be effective they should be done every day for a period of weeks, plus daily practice in assuming and maintaining good posture until it becomes a habit.

Section Iv Painful Conditions

TIGHTNESS OF POSTERIOR NECK MUSCLES Neck pain and headaches associated with tightness in the posterior neck muscles are most often found in patients with a forward head and a round upper back. As shown on pages 152 and 153, the compensatory head position associated with a slumped, round upper back results in extension of the cervical spine. The faulty mechanics associated with this condition chiefly consist of undue compression posteriorly on the articulating facets and posterior surfaces of the bodies of the vertebrae, stretch weakness of the anterior vertebral neck flexors, and tightness of the neck extensors, including the upper trapezius, splenius capitis and semi-spinals capitis. Headaches associated with this muscle tightness are essentially of two types occipital headache and tension headache. The greater occipital nerve, which is both sensory and motor, supplies the semispinalis and splenius capitis muscles. It pierces the semispinalis capi-tis and the trapezius near their...

Bilateral Stance On Unstable Surface

Single Leg Stance Foam

In the upper extremity, it is common to see patients who present with tightness in the anterior structures, such as the pec-toralis musculature, and consequently exhibiting a protracted, forward head posture. This can lead to several shoulder pathologies, such as impingement due to the protracted and anteriorly tilted scapular position.43 Furthermore, the authors believe that loss of internal rotation (IR) in most throwers is due to posterior rotator cuff tightness and osseous

Congenital Neck Masses

Second branchial cleft abnormalities are by far the most common. These usually manifest as masses anterior to the sternocleidomastoid muscle with or without a fistulous opening. The sinus tract passes between the external and internal carotid arteries and ends in the tonsillar fossa. Treatment is

Section Iii Neck Muscle Tests

ANTERIOR NECK FLEXORS Fixation Anterior abdominal muscles must be strong enough to give anterior fixation from the thorax to the pelvis before the head can be raised by the neck flexors. If the abdominal muscles are weak, the examiner can provide fixation by exerting firm, downward pressure on the thorax. Children approximately 5 years of age and younger should have fixation of the thorax provided by the examiner. Note The anterior vertebral flexors of the neck are the longus capitis, longus colli and rectus capitis anterior. In this movement, they are aided by the sternocleidomastoid, anterior scaleni, suprahyoids and infrahyoids. The platysma will also attempt to aid when the flexors are very weak. Weakness Hyperextension of the cervical spine, resulting in a forward-head position. ERROR IN TESTING NECK FLEXORS If the anterior vertebral neck flexors are weak and the sternocleidomas-toid muscles are strong, an individual can raise the head from the table (as illustrated) and hold it...

Cervical Spine Assessment

Temporomandibular joint injury or faulty mechanics can lead to myofascial trigger points and referred pain into the neck musculature. Problems with visual acuity can result in changes in head carriage. The individual may tilt, rotate, or move the head forward to assist in focusing. This can lead to cervical muscle fatigue and imbalances. Problems with hearing can also alter the head position with the individual turning the stronger ear toward sounds. This can lead to altered cervical spine mechanics and muscle imbalances. The cervical nerve roots are most affected by osteophytes of the uncus or facet joints rather than by acute disc prolapses. 5. The head positions are controlled by the movements of the upper vertebrae that, by antagonistic and synergistic action, give the appearance of pure movements.

Parotid Gland Tumour Mri Radiology

Scan Mono Lymph Nodes

Axial contrast enhanced CT of the maxillofa-cial soft tissues with a cystic mass interposed between the left submandibular gland and sternocleidomastoid muscle, consistent with a type II branchial cleft cyst. Figure 2.54. Axial contrast enhanced CT of the maxillofa-cial soft tissues with a cystic mass interposed between the left submandibular gland and sternocleidomastoid muscle, consistent with a type II branchial cleft cyst. parapharyngeal space. It may have a fistulous connection to the external auditory canal or the skin surface. Infected or previously infected cysts may mimic a malignant tumor. Although not typically associated with either the parotid or submandibular glands, the second branchial cleft cyst, which is found associated with the sternocleidomastoid muscle and carotid sheath, may extend superiorly to the tail of the parotid or antero-inferiorly to the posterior border of the submandibular gland. It has imaging characteristics similar to the first...

Posterior Pelvic Till

Psoas Muscle Throat

The flat-back posture, as the name implies, is a straight back in both the lumbar and thoracic areas, except that some degree of flexion in the upper thoracic area accompanies the forward head position. The opposing force that prevents an increase in the curve must be provided by the anterior abdominal muscles (most specifically the lower abdominals). Tests and exercises specific to these muscles should be applied. Weakness of the lower abdominal muscles is a common finding among otherwise strong individuals, and it presents a potential hazard in regard to lifting. Strengthening the abdominal muscles, however, can affect more than merely the stability of the back. Pope et al. found that intradiscal pressure fell when abdominal pressure was increased. Thus in the standing posture intradiscal pressure is decreased coincident with increased abdominal muscular activity (27). An adult might be comfortable without a pillow when sleeping on the back or abdomen, but would probably not be...

Surgical Anatomy of the Thyroid and Parathyroid Glands

Thyroid Lymphatic Drainage

The normal adult thyroid gland weighs about 17 g. It is wrapped around the anterolateral portion of the upper tracheal rings and larynx. Each lobe occupies a bed between the trachea and the esophagus medially the carotid sheath posteriorly and the sternocleidomastoid, the sternohyoid, and the sternothyroid muscles laterally and anteriorly. If the sternothyroid and sternohyoid muscles are to be divided transversely, they must be transected high, at the cricoid level, to preserve their motor nerve, the ansa hypoglossi. Section of the strap muscles has no clinical functional consequence.

Special Test In Poliomyelitis Therapeutic Exercise By Kisner And Colby

J Am Phys Ther Assoc 1968 48 319. Kendall HO. Kendall FP, Boynton DA. Posture and pain. Baltimore Williams & Wilkins, 1952. Reprinted Melbourne, Florida Robert E Krieger, 1971. Kendall FP. Range of motion. The correlation of physiology with therapeutic exercise. New York American Physical Therapy Association, 1956. Kendall FP. A criticism of current tests and exercises for physical fitness. J Am Phys Ther Assoc 1965 45 187197.

Expansive Laminoplasty

Radiografia Cervical

Tsuzuki et al. developed a new type of open door expansive laminoplasty by inserting ceramic spacers into the opened spaces between the laminae and the inner edges of the facet joints. With this procedure, the preserved bone-ligament complex acts as a tension band and enables patients to start early neck muscle exercise to prevent contracture of the neck muscles. This procedure was devised because the authors thought that neck muscle reconstruction by active exercise is an

The Prevention And Management Of Pressure Sores

Degree Tilt Pressure Care Pictures

Gebhardt (1995) argues that pressure is rarely applied uniformly and that the subsequent distortion leads to shearing. Shearing may occur if the patient slides down the bed. The skeleton and tissues nearest to it move, but the skin on the buttocks remains still. One of the main culprits of shearing is the back-rest of the bed which encourages sliding. Chairs which fail to maintain a good posture may also cause shearing. Once ill patients start to be seated out of bed, they are perceived to be 'mobile' and so may be left in the chair for long periods of time without being moved. Many hospital armchairs are in a poor state and fail to give any pressure relief or maintain a good posture (Dealey et ai, 1991). Chairs should be checked and replaced or repaired in the same way as mattresses. Many chairs have a reclining back of between 15 and 40 which puts the patient in a semi-reclining posture. This may make it more difficult for the patient to stand. Ideally, a chair should have a recline...

Sustained loading and creep

The study of Harms-Ringdahl (1986) has shown in the cervical spine the effect of sustained loading in healthy volunteers. They maintained a protruded head posture and began to feel pain within two to fifteen minutes, which increased with time until they were eventually forced to discontinue the posture. Abdulwahab and Sabbahi (2000) looked at the effect of sustained neck flexion for twenty minutes in patients with cervical radiculopathy and in controls. This had the effect of significantly increasing the radicular pain in the patient group, but also producing discomfort in some of the control group who were without prior neck symptoms. Gooch et al. (1991) studied in vivo creep of the cervical spine in sustained flexion in a mixed group of patients and controls. Over the ten-minute period, creep occurred in those who were able to sustain the position, with the effect of increasing the angle of cervical flexion. A third of the forty-seven individuals were unable to sustain the original...

Lateral Approach for Parathyroid Exploration

The lateral approach for parathyroidectomy was first described by Feind.73 This approach involves dissection between the anterior border of the sternocleidomastoid muscle and the posterior border of the strap muscles.74 The omohyoid muscle is usually divided. Retraction of the sternocleidomastoid muscle and the carotid sheath laterally and the strap muscles medially exposes the lateral aspect of the thyroid gland, the tracheoesophageal groove, the recurrent laryngeal nerve, and the parathyroid glands. The lateral approach is preferable in parathyroidectomy under local anesthesia because the limited dissection and moderate retraction of the neck muscles are well tolerated by patients.68 Another indication for the lateral approach is parathyroidectomy after previous neck surgery. The lateral approach in these patients provides a dissection plane more likely to be devoid of scar tissue from the previous operation.75

Swollen Right Carotid Artery

Inspection Thyroid Gland

Cervical chain along the sternocleidomastoid muscle to feel for the superficial cervical chain hooking around the sternocleidomastoid muscle to feel for the deep cervical chain deep to the muscle into the anterior triangle region up to the jaw margin to feel for the tonsillar group along the jaw to feel the submaxillary chain to the tip of the jaw for the submental nodes and up to the anterior auricular chain in front of the ear. This sequence of examination is shown in Figure 9-9. There are two approaches to palpating the thyroid gland. The anterior approach is carried out with the patient and examiner sitting face to face. By flexing the patient's neck or turning the chin slightly to the right, the examiner can relax the sternocleidomastoid muscle on that side, making the examination easier to perform. The examiner's left hand should displace the larynx to the left, and during swallowing, the displaced left thyroid lobe is palpated between the examiner's right thumb and the left...

Supracla Vicular Region

The supraclavicular region has well-defined limits, with the collarbone located at the base, the posterior margin of the sternocleidomastoid muscle located anteriorly, and the trapezius muscle located posteriorly. This triangle is identified by the skin depression found within its limits the supraclavicular fossa. The supraclavicular fossa is covered by the skin, the subcutaneous lax tissue, and the cutaneous supra-acromial and supraclavicular branches of the superficial cervical plexus. The second layer comprises the superficial cervical aponeurosis, or fascia, that envelops the muscles defining the limits of the supraclavicular region (i.e., the sternocleidomastoid and trapezius muscles). A third anatomic layer in turn contains the middle cervical aponeurosis, enveloping the omohyoid muscle that crosses the supraclavicular region the muscle can be easily identified by palpation, and the external jugular vein runs along its surface. The cross-sectional anatomy at the level of the...

Faulty Head And Neck Positions

The right, the same subject sat in a typically slumped position, with a round upper back and a forward head. As illustrated, the cervical spine is in extension. Forward Head with Attempted Correction In Figure Forward Head, Marked In Figure D, the subject shows an extremely faulty alignment of the neck and thoracic spine. The degree of deformity in the thoracic spine suggests an epiphysitis. This patient was treated for pain in the posterior neck and occipital region.

Management of Cervical Metastasis

Postauricular Injection

Radical neck dissection, however, is cosmetically deforming and produces a characteristic shoulder disability that has been termed the shoulder syndrome. 7 In an effort to lessen the morbidity of classic RND, various modifications have been proposed that preserve non-lymphatic structures that are normally sacrificed during this procedure but still remove all of the nodal tissue excised in RND. These modifications in general include preservation of the spinal accessory nerve (SAN) and can also involve preservation of the internal jugular vein (IJV) and or the sternocleidomastoid muscle (SCM). More recently, further modifications of neck dissection have been proposed which preserve all of the non-lymphatic structures removed in then-RND but do not remove all of the lymphatic tissue on the involved side of the neck. These operations, which have been termed selective neck dissections, are based on observations that cancers of the head and neck tend to metastasize in predictable patterns...

Child With Overdeveloped Muscles

Knock Knee Ray Pronated Feet

Segmental alignment faults may be noted with or without the plumb line. Observe whether the knees are in good alignment, hyperextended, or flexed. Note the position of the pelvis as seen from the side view and whether the anteroposterior curves of the spine are normal or exaggerated. Also note the head position (forward or tilted up or down), the chest position (whether normal, depressed, or elevated), and the contour of the abdominal wall. Findings are recorded on the chart under the heading Segmental Alignment. Good Posture Good Posture Increased forward curve in the neck. Almost always accompanied by round upper back and seen as a forward head. Forward head Stretch cervical spine extensors, if short, by trying to flatten the cervical spine. Strengthen cervical spine flexors, if weak. A forward head position is usually the result of a faulty upper back posture. If neck muscles are not tight posteriorly, the head position will usually correct as the upper back is corrected....

Lower Motor Neuron Pool

The cervical plexus is formed by the anterior primary rami of C1 through C4 behind the sternocleidomastoid and in front of the scalenus medius and levator scapulae muscles. The motor branches of the plexus supply the muscles of the neck. Injuries to the cervical plexus are infrequent,

Painful Conditions Of The Upper Back

Pectoralis Minor Length Test

Subjects with a round upper back often develop symptoms in the posterior neck. As the thoracic spine flexes into a kyphosis, the head is carried forward, the eyes seek eye level to preserve the erect position of the head, and the cervical spine is extended (see pp. 152 and 153). Symptoms associated with this problem are described under Tightness of Posterior Neck Muscles on page 159. Unless symptoms are severe and clearly defined, conservative treatment should emphasize increasing the space of the thoracic outlet by improving the posture, correcting the muscle imbalance, and modifying the occupational, recreational, and sleeping habits that adversely affect the posture of the head, neck and upper back. Cooperation by the patient is essential to success. The patient should be taught self-stretching exercises to relieve tightness in the scaleni, sternocleidomastoid, pectoral muscles and neck extensors. (See p. 116 and exercise sheets, p. 357.) Learning to do diaphragmatic breathing will...

Applied Surgical Anatomy

Anatomic subdivisions of the neck define its borders and are important to recognize.7 Recently, the Committee for Head and Neck Surgery and Oncology of the American Academy of Otolaryngology-Head and Neck Surgery has proposed an update of the neck dissection classification.8 The new guidelines present some minor revisions but do not differ substantially from the previous guideline. The sternocleidomastoid muscle is the most prominent landmark and covers the major vessels of the neck the carotid artery and the internal jugular vein. Six major nodal regions can be distinguished and are expressed as levels in the classification. A superior or submandibular and submental triangle (level 1) is bounded by the mandible, the hyoid bone, and the posterior belly of the digastric muscle. The anterior belly of the digastric muscle divides the superior triangle in a submental part anteriorly and a submandibular part posteriorly. The submandibular gland is part of this region. Three jugular regions...

Describe the course of the vertebral artery in the cervical spine

Vertebral Artery

A skin incision is made along the anterior aspect of the sternocleidomastoid muscle and is curved toward the mastoid process. The platysma and the superficial layer of the deep cervical fascia are divided in the line of the incision to expose the anterior border of the sternocleidomastoid. The submandibular gland and digastric muscle are identified (Figs. 25-5 and 25-6). Sternocleidomastoid muscle Sternocleidomastoid muscle 18. What two vessels are ligated once the sternocleidomastoid is retracted A transverse incision is made over the interspace of interest in Langer's lines to improve the cosmetic appearance of the surgical scar. The incision is carried slightly laterally beyond the anterior border of the sternocleidomastoid muscle and almost to the midline of the neck. The subcutaneous tissue is divided in line with the skin incision. The platysma may be divided along the line of the incision, or its fibers may be bluntly dissected and its medial-lateral divisions retracted (Fig....

Technique of Parathyroidectomy

Preferentially in a natural skin crease, 3 to 4 cm cranially to the suprasternal notch. An incision that is located too close to the suprasternal notch is likely to become a hypertrophic scar. The incision should not extend beyond the sternocleidomastoid muscles. After incising the platysma, the cranial skin-platysma flap is dissected upward to the notch of the thyroid cartilage and downward to the suprasternal notch. A self-retaining retractor is used to withdraw the upper and lower skin-platysma flaps. A midline incision is made in the cervical fascia from the cricoid cartilage down to the suprasternal notch. The sternohyoid and sternothyroid muscles are separated from the underlying thyroid and thymus. If present, the middle thyroid vein must be divided to allow the thyroid lobe to be retracted anteriorly and medially. Transection of the strap muscles is unnecessary because they can be retracted sufficiently by a wide blunt retractor, held by the second assistant standing at the...

Boundaries And Divisions Of The Anterior Triangle

Submandibular Lymph Nodes

The midline down the neck. Posteriorly. The sternocleidomastoid muscle. Superiorly. The lower border of the mandible. CAROTID TRIANGLE The superior belly of the omohyoid and the posterior belly of the digastric and sternocleidomastoid muscles form the boundaries of the carotid triangle (Figure 26-2B). The triangle contains the superior portion of the common carotid artery (hence, the triangle's name), which bifurcates at the thyroid cartilage into the external and internal carotid arteries. Sternocleidomastoid m. Sternocleidomastoid m. Sternocleidomastoid m.

Floor Of The Posterior Triangle


Spinal accessory nerve cranial nerve (CN) XI . Exits the jugular foramen and obliquely descends along the preverte-bral fascia en route to the sternocleidomastoid and trapezius muscles. 1. Sternocleidomastoid m. Sternocleidomastoid m (cut) Sternocleidomastoid m (cut) Figure 26-1 A. Boundaries of the posterior triangle of the neck. B. Cross-section and lateral view of the deep investing fascia surrounding the sternocleidomastoid and trapezius muscles. C. Cross-section and lateral view of the prevertebral fascia covering the prevertebral muscles. D. Prevertebral fascia removed from the posterior triangle of the neck. Figure 26-1 A. Boundaries of the posterior triangle of the neck. B. Cross-section and lateral view of the deep investing fascia surrounding the sternocleidomastoid and trapezius muscles. C. Cross-section and lateral view of the prevertebral fascia covering the prevertebral muscles. D. Prevertebral fascia removed from the posterior triangle of the neck.

Example of clinical reasoning process

She reports that the pain in the arm has gone completely, and she relates this to sitting upright during the movement testing. The need to examine the effect of repeating some of the movements to find the most suitable is explained to her, and also that then she will be able to do something regularly at home. Initially she finds retraction difficult to perform, partly as she has so little movement available. After four or five sets often to fifteen repetitions, though, the movement is increasing, and she says the more she does the easier it gets. The focus is on her posture and her technique, with encouragement as appropriate. After a number of sets of repetitions she is told to stop and relax, but keep sitting upright. She reports the symptoms still to be right-sided neck, scapular and shoulder pain. On re-examination of her movements, however, there are changes. Retraction now has minor to moderate loss and she is able to extend about halfway with some lower cervical movement now...

General Carriage and Movements

Excessive cervical lordosis, forward head, or cervical muscle spasm should be looked for and recorded. Any cervical or upper thoracic problems will make it necessary to rule out spinal pathology that might affect the whole quadrant. Excessive cervical lordosis forward Excessive cervical lordosis in the mid and lower cervical head spine with a forward head position leads to problems anywhere

Lateral View Fig 31 Boney

CRANIAL CARRIAGE (FORWARD HEAD POSTURE) A forward head position results in a tight extended suboccipital cervical spine, a flexed mid to lower cervical spine, an extended upper thoracic spine, and elevated scapulae. This position results in uneven forces through the cervical spine facet joints and the intervertebral disc. Stress is also placed on the cervical nerve roots, ligaments, and muscles. This forward head position causes elevated scapulae and anteriorly rotated clavicles, which in turn leads to sternum depression and decreased glenohumeral flexion. The suprascapular nerve can be stretched by this forward head posture, resulting in lateral and posterior shoulder pain, acromioclavicular pain, and infraspinatus and supraspinatus dysfunction. The accessory movements of humeral head glide and roll are inhibited in the anterior head position so that normal physiological movements may be lost.

Effect of posture on symptoms in normal population

Harms-Ringdahl (1986) explored the effects of sustained slumped postures in volunteers without current or past neck symptoms. They maintained a posture of lower cervical and thoracic flexion and extreme upper cervical extension that is seen in a typical protruded head posture. All ten volunteers began to perceive pain within two to fifteen minutes, which increased with time, eventually forcing them to discontinue the posture after sixteen to fifty-seven minutes. Once they discontinued the position, the symptoms abated. Most experienced similar pains the next day, but when these occurred is not reported. Pain was generally localised around the neck and upper scapulae, but radiated into the arms in a few individuals. This study demonstrated how individuals without pre-existing spinal symptoms can have transient pain created by sustained mechanical loading. During this sustained protruded head posture, the muscular activity in the trapezius, splenius, thoracic erector spinae and...

Joint Movements Of The Cervical Spine

Movimenti Cervicale

The normal anterior curve of the spine in the cervical region forms a slightly extended position. Cervical spine extension is movement in the direction of increasing the normal forward curve. It may occur by tilting the head back, bringing the occiput toward the seventh cervical vertebra. It also may occur in sitting or standing by slumping into a round-upper-back, forward-head position, bringing the seventh cervical vertebra toward the occiput. It is essential that the subject be placed as close to the ideal postural alignment of the upper back and neck as possible before taking range of motion measurements. Starting with a forward head position will limit movement in every plane. Sternocleidomastoid b NECK MUSCLES Sternocleidomastoid ANTERIOR AND LATERAL NECK MUSCLES

Postural syndrome aggravating factor sitting

In a review of the optimal sitting posture it was concluded, regarding the cervical spine, that minimising forward head posture and cervical flexion is associated with higher comfort ratings (Harrison et a . 1999). It should be explained to patients that when we sit, especially when preoccupied, a relaxed posture is adopted. The spine takes up the shape of the chair, or if sitting unsupported, eventually the slouched posture is adopted. Unless a conscious effort is made, or a well-designed chair with appropriate support is used, it is a universal phenomenon that within a short period of sitting individuals will adopt a relaxed, slouched posture. This flexed posture places ligaments, capsules and other peri-articular and articular structures under tension. If this posture is maintained, as creep occurs, greater tensile stress is placed upon these soft tissues. Eventually, if maintained without respite, enough mechanical tension can be generated to trigger nociceptor activity. If it is...

Table 162 Ototoxic Medications

In hyperkinesias, key information is obtained by observing the patient at rest in complete repose without talking. Relaxing these patients and finding the best rest position can be a challenge. It is important to recognize that a sitting position is one of rest for the extremities, but one of activation for the trunk. In dystonia, in which movements are often absent during rest and activate with a maintained posture, the examiner must be particularly vigilant to correctly identify postures that are resting and active. As such, in truncal dystonia, a kyphotic posture may be present when the patient is sitting erect or standing in seeming repose, because the trunk muscles are activated in these positions. To test for resolution or diminution in the rest posture, these patients must lie supine or prone. Likewise, neck hyperkinesias must be studied with great care to achieve a rest position. Cervical dystonia may be prominent with the patient quietly sitting, but in fact, the neck muscles...

Roof Of The Posterior Triangle

The roof of the posterior triangle of the neck consists of the investing layer of the deep cervical fascia that surrounds the neck, enveloping the sternocleidomastoid and trapezius muscles (Figure 26-1B). The sensory branches of the cervical plexus and the external jugular vein pierce the investing layer of cervical fascia. SENSORY BRANCHES OF THE CERVICAL PLEXUS The sensory branches of the cervical plexus course between the anterior and middle scalene muscles piercing the investing fascia at the posterior border of the sternocleidomastoid muscle en route to their respective cutaneous fields (Figure 26-1B). Lesser occipital nerve (C2 contribution). Ascends along the posterior border of the sternocleidomastoid muscle en route to the skin of the neck and scalp, behind the ear. Great auricular nerve (C2 C3 contributions). Ascends over the sternocleidomastoid muscle en route to the skin of the parotid region and ear. Transverse cervical nerve (C2 C3 contributions). Courses horizontally...

Consequences of postural neglect

As men and women age, their natural head position tends to progress to a more forward position their ability to retract the head declines, whilst protrusion range is maintained, and there is an overall decline in antero-posterior mobility (Dalton and Coutts 1994). Between young adulthood and older age there is a reduction in all planes of cervical movements of 20 - 45 (Worth 1994), and a reduction in all planes of lumbar movements of about 30 (Twomey and Taylor 1994). In a meta-analysis of normative cervical motion, multiple studies demonstrated a decrease in cervical range with age (Chen et al. 1999). Although a large part of this may be the natural effects of ageing, there is also an element of variability in the degree to which people become restricted in range of movement and in resting postures. The mean range of movement decreases decade by decade, This means that protruded head positions and stooped postures are not simply an inevitable consequence of ageing. Movement that is...

Neurogenic and Vascular Tumors of the Head and Neck

In those hemangiomas that arise deep within the substance of either the parotid gland or neck musculature (masseter, sternocleidomastoid, scalene or trapezius muscles), a mobile, ill-defined, deep neck mass without any overlying skin changes is the usual presentation (Figure 16-2).5 The diagnosis of these hemangiomas may be confirmed by radiographic imaging with intravenous contrast (CT MRI) that will demonstrate varying degrees of contrast enhancement.5,6

Clinical Application of Indicators of Thyroid Tumor Aggressiveness

A convenient clinical approach to regional lymph node metastases in low-risk patients indicates that, for preoperatively palpable lymph node metastases in the neck, a function-preserving modified neck dissection is adequate. Such a functional neck dissection would include, at the very least, preservation of the spinal accessory nerve and the submandibular area with the ramus mandibularis. In addition, preservation of the sternocleidomastoid muscle and jugular vein should be attempted because limited selective dissection of the lymph nodes themselves is adequate. The phenomenon of wound implantation with differentiated thyroid carcinoma is rare. If lymph node metastases are not felt preoperatively but are observed or are palpable at the time of thyroid surgery, these nodes and the central compartment containing fat and nodes should be removed without extending the thyroid incision. Limited lateral neck dissection should be done to include palpable node metastases. Such central...

Cervicogenic Headache

Patients at risk for cervicogenic headache include those with a history of arthritis with cervical spondylosis and degenerative disc disease, or those with a history of neck trauma, particularly whiplash type injuries. Examination may reveal tenderness or muscle spasm of the cervical paraspinal and neck muscles, and limitations in cervical range of motion. Exam cervical range of motion limitations, awkward head position

Procedure 3 Postural correction

Sitting over the end or side of the treatment table, the patient is instructed to adopt a relaxed slouched posture with the lumbar and thoracic spine flexed and the head and neck protruded (Photo 54) . The patient then smoothly moves into the extreme of the erect sitting posture with the lumbar spine in maximum lordosis and the head and chin maximally retracted (Photo 55). Some clinician guidance using gentle hand pressure on the patient's lumbar spine and chin may assist in the learning process. The patient is then instructed to relax back into the slouched position. This cycle should be repeated ten times so that the patient moves from the extreme of the slouched posture to the extreme of the upright extended and retracted posture. After completing ten cycles of the procedure the patient should hold the extreme of the good position for a second or two and then release 10 of the strain (Photo 56). This is the posture the patient must aim for on a daily basis. It is the learning...

Procedure 2 Retraction and extension

An increase in the range of extension can be achieved with the addition of a rotary component applied while the head and neck are held in the fully extended position. A minimal rotary adjustment of the head position is repeated five or six times so that the nose moves only one centimetre (half an inch) to either side of the mid-line. During this process the patient is urged to move further and further into extension so as to gain maximum end-range (Photo 43). The patient should then return to the starting position.

Procedure 2 Posture correction

Gentle pressure at chin and thoracic spine corrects the head posture (109). Gentle pressure at chin and thoracic spine corrects the head posture be repeated ten times so that the patient moves from the extreme of the slouched posture to the extreme of the upright extended and retracted posture. After completing ten cycles of the procedure, the patient should hold the extreme of the good position for a second or two and then release 10 of the strain. This is the posture the patient must aim for on a daily basis. It is the learning process for maintaining correct posture and is also therapeutic as some patients achieve centralisation of their pain using this procedure alone.

Postural syndrome aggravating factor standing

Patients rarely report cervical postural pain that occurs in standing, presumably as this position allows greater postural variety and they escape sustained end-range postures. Occasionally someone who works standing in a position of sustained neck flexion or protruded head posture may present.

Alternative positions for Procedure 2 Retraction and extension

As with extension in sitting, a small rotary movement can be applied in the extended position to further increase the range of extension. A minimal rotary adjustment of the head position is repeated five or six times so that the nose moves only one centimetre (half an inch) to either side of the mid-line. During this process the patient is urged to move further and further into extension so as to gain maximum end-range (Photo 47).

Supraclavicular Plumb Bob Technique

Plumb Bob Approach Supraclavicular Block

The patient's head is turned slightly to the contralateral side. The patient is asked to raise the head slightly off the table so that the lateral border of the clavicular head of the sternocleidomastoid muscle can be identified as it inserts onto the clavicle. This point is marked as the entry point. After skin preparation, an insulated needle is inserted at the entry site as if it were a weight ( plumb bob ) under gravitational pull (i.e., in a parasagittal direction) ( Fig. 2026 ). If appropriate nerve stimulation of the forearm or hand is not obtained, the needle is returned to the skin and redirected cephalad in small steps through an arc of 20 degrees. If this is not successful, the needle is returned to the skin and redirected through an arc of 20 degrees in a caudal direction. Once muscle contraction in the forearm or hand is elicited at an mA less than 0.5, 30 mL of local anesthetic is incrementally injected.

Head And Neck Surgery

Block of the cervical plexus produces skin anesthesia of the occipital scalp, the neck, and the upper surface of the shoulders, and relaxation of the deep and superficial neck muscles. It is suitable for soft tissue surgery of the area described. If the surgical site is well localized, blockade of only some of the branches of the plexus is adequate in some cases. Thus, removal of the subcutaneous lesion in the occipital region may be performed under block of the

Cervical Nerves Anatomy

Skin of a great proportion of the dorsal scalp, the neck, and the shoulders is supplied by sensory branches of the upper four cervical nerves ( Fig. 20-13 ). The dorsal rami of C2 to C4 supply the back of the neck and the scalp as the greater occipital nerve. The ventral rami of C1 to C4 form the cervical plexus. The deep branches supply the muscles of the neck and the diaphragm. The superficial cervical plexus pierces the posterior border of the sternocleidomastoid at its midpoint to fan out and supply sensation from the lower border of the mandible to as low as the second rib. The terminal branches are the lesser occipital, great auricular, transverse cervical, and supraclavicular nerves.

Brachial Plexus Block

It was not until 1887, when George Crile exposed the brachial plexus behind the sternocleidomastoid muscle to help control tetanic spasms in a young boy, that the block was used with some regularity. While he was at the Cleveland Clinic, Crile expanded the use of the brachial plexus block to include surgical anesthesia for upper extremity procedures.1461 His original article of 1902, published in The Journal of the American Medical Association, spoke favorably of the block as being superior hemodynamically to general anesthesia for amputations of the shoulder joint. It is noteworthy that at this time in history, shoulder amputations were dangerous surgeries, with large blood loss potential and high subsequent mortality.143 A procedure that could effectively provide anesthesia as well as limit inherent surgical risk would be a popular discovery.

Aids To Block Performance

In patients with difficult anatomy (e.g., morbidly obese), in whom the interscalene groove is difficult to palpate, the interscalene groove may be located by drawing lines laterally from the cricoid and along the lateral border of the clavicular head of the sternocleidomastoid muscle as described. Where these lines intersect, a mark should be made 2 cm laterally along the line from the cricoid. The insulated needle should be inserted at this mark perpendicular to skin planes, and slightly caudad. If phrenic stimulation occurs (diaphragmatic stimulation), the needle has been placed too far anteriorly and should be redirected more posteriorly. If posterior shoulder contractions occur, the needle should be redirected more anteriorly.

The Jugular Venous Pulse

The internal jugular vein provides information about the wave forms and right atrial pressure. The pulsations of the internal jugular vein are beneath the sternocleidomastoid muscle and are visible as they are transmitted through the surrounding tissue. The vein itself is not visible. Because the right internal jugular vein is straighter than the left, only the right internal jugular vein is evaluated. Measurements from the external jugular system, which is easier to visualize, are much less accurate and should not be used.

Branchial Cleft Cyst Clinical Summary

A branchial (aka pharyngeal) cleft cyst arises from the incomplete obliteration of one the branchial clefts during embryogenesis. There are four paired branchial arches that form on the external surface of the embryo. The spaces in between these arches are the branchial clefts. The branchial arches ultimately develop into structures of the head and neck. As the obliteration of the clefts occurs, a portion of a cleft may remain forming a cystic space. The anatomic location of a branchial cleft cyst depends upon the specific arch cleft involved. Involvement of the first branchial cleft may result in a cyst in the region of the parotid gland, the pre or postauricaular area, or inferior to the angle of the mandible. A second cleft anomaly may be found along the anterior border of the sternocleidomastoid muscle or deep into it in the vicinity of the carotid arteries. Third and fourth arch cleft anomalies are very unusual. The cysts usually present clinically when they become infected and...

Complications of Neck Dissection

Hematoma Following Neck Dissection

The modified neck dissection is designed to remove all of the metastatic lymph nodes in the lateral neck yet minimize morbidity. In experienced surgical hands, modified neck dissection is a safe procedure with minimal morbidity.10-36-94 Resection of the spinal accessory nerve results in paralysis of the trapezius muscle with a shoulder drop and decreased abduction of the arm. Besides loss of function, paralysis of the trapezius muscle is disfiguring. The choice of the incision as well as the preservation of the sternocleidomastoid

Important questions to be asked about the present symptoms in athletes with groin pain

Various functional tests to evaluate the balance and the pelvic stability can be performed. These could include a one-leg balance test evaluating the ability to maintain balance (e.g. for 30 s standing on one leg), exercises on a soft surface evaluating the athlete's ability to adjust body posture to sudden changes in the surface, a lunge test to evaluate dynamic stability and others.

What is the most common type of torticollis

Congenital muscular torticollis is the most common type of torticollis. It presents in the newborn period. Its cause is unknown, but it has been hypothesized to arise from compression of the soft tissues of the neck during delivery, resulting in a compartment syndrome. Radiographs of the cervical spine should be obtained to rule out congenital vertebral anomalies. Clinical examination reveals spasm of the sternocleidomastoid muscle on the same side as the tilt causing the typical posture of head tilt toward the tightened muscle and chin rotation to the opposite side. Initial treatment is stretching and is successful in up to 90 of patients during the first year of life. Surgery is considered for persistent deformity after 1 year of age. Common problems noted in patients with congenital muscular torticollis include congenital hip dysplasia and plagiocephaly (facial asymmetry).

What features suggest that torticollis is due to atlantoaxial rotatory subluxation

Features that suggest that torticollis is due to atlantoaxial rotatory subluxation include prior normal cervical alignment and motion, history of recent upper respiratory infection (Grisel's syndrome), normal neurologic examination, and spasm in the sternocleidomastoid muscle on the side opposite the head tilt. This posture has been termed the cock robin deformity. It is distinct from congenital muscular torticollis, in which muscle spasm occurs on the same side as the head tilt. Plain radiographs are frequently difficult to interpret but typically show asymmetry of the C1 lateral masses on the anteroposterior (AP) odontoid view. A cervical computed tomography (CT) scan can be obtained to confirm the diagnosis. Recommendations for the optimal type of CT study include a cervical CT scan with standard sagittal and coronal reconstructions, a dynamic rotational CT scan, and a CT scan performed with the patient under general anesthesia.

How is the halo skeletal fixator applied

The patient is placed supine with the head position controlled by the physician in charge (Fig. 18-10). The correct ring size (permits 1-2 cm of circumferential clearance around the skull) and vest size are determined. Critical measurement to determine correct vest size include

Posterior Fossa Meningiomas

Tentorial Meningioma

Primary jugular foramen tumors are probably one of the rarest subgroups of meningiomas. The most common presenting symptoms are hearing loss, swallowing difficulties, and weakness in the trapezius or sternocleidomastoid muscles. The senior author has successfully resected these tumors through either a suprajugular, transjugular, or retrojugular approach.5 The most common dysfunction following surgery was transient deficit in ninth and tenth cranial nerve functions. Transient twelfth nerve deficits that resolved within a month were also noted.

Directed Neurological Examination

Impaired execution of fine finger movements is tested by bringing each finger of one hand separately in succession to the tip of the thumb. All fingers tend to flex simultaneously, and the ability of the thumb to keep a correct posture is impaired. Investigating a variety of more complex tasks, like buttoning or handling objects, may demonstrate disturbance of activities of everyday life. Prehension involves moving the hand to an object, a coincident shaping of the hand in anticipation of the object, and a finally closing of the fingers to formulate the grasp. y Cerebellar subjects open their fingers excessively wide in anticipation of the object and close their fingers with undue force grasping the object (signe de la prehension). Writing is often affected. Maintaining a low isometric force between thumb and index finger, for example, when holding a pen while writing, is impaired.y The pencil is held incorrectly and is pressed too firmly on the paper. Writing becomes labored and...

Directed Neurological Examination Cranial Nerve Xi

A unilateral hemispherical lesion does not usually cause marked deviation of the head, although some weakness may be present. In cortical or subcortical strokes, the head can deviate to the side of the lesion, away from the hemiparetic body, making rehabilitation efforts frustrating. Atrophy and fasciculations are not present in an upper motor neuron lesion.y Irritative cortical foci may result in seizures accompanied by forced deviation of the head to the contralateral side. y A unilateral supranuclear lesion in the upper brain stem may produce dissociated weakness, with ipsilateral weakness of the sternal head of the SCM and contralateral weakness of the trapezius. Nuclear lesions of CN XI are rare. These lesions result in muscle weakness as well as atrophy and fasciculations. Unilateral nerve lesions produce weakness of the involved muscles as well as some deviation and possibly winging of the scapula. Bilateral nerve lesions result in diminished ability to rotate the neck, and the...

Associated Neurological Findings

Lesions of the ninth or tenth cranial nerve nuclei usually affect adjacent brain stem structures, producing ipsilateral sensory disturbance of the face from involvement of the fibers of the descending tract and nucleus of cranial nerve V, vertigo from vestibular nuclei, contralateral limb sensory changes from the lateral spinothalamic, and ipsilateral limb ataxia caused by involvement of the inferior cerebellar peduncle. The ninth and tenth cranial nerves travel closely together between the brain stem and the jugular foramen and consequently are rarely affected independently of one another in their intracranial locations. More peripherally, a lesion at the jugular foramen also affects the spinal accessory nerve, which passes through this opening with the glossopharyngeal and vagus nerves. In addition to disturbance of speech, swallow, and gag, the patient demonstrates weakness of the sternocleidomastoid and trapezius muscles. The twelfth cranial nerve may be involved...

Muscle And Musculocutaneous Flaps

Deltopectoral Flap

Reconstruction.29,30 Other myocutaneous pedicled flaps used less often for reconstruction of posterior or lateral defects in the head and neck region include the tem-poralis muscle, latissimus dorsi, trapezius, sternocleidomastoid and platysma muscles.28,31-34 Although regional muscle and myocutaneous flaps are useful options for head and neck reconstruction, they often cannot reach the defect due to a limited arc of rotation (imposed by the vascular pedicle), and may result in incomplete survival of the skin island. In addition, donor sites are very noticeable, particularly when skin grafting of the defect is required.

Operative Vaginal Deliveries

Nie Kegla Kobiety

Essential for safe operative vaginal delivery is optimal readiness. The laboring woman should understand the reasons why operative delivery has been chosen, with documentation in the chart. She should then be placed in a position in which her legs are maximally open, preferably in stirrups, with the perineum at the edge of the bed. Usual washing and draping is performed. The bladder is emptied. Adequate anesthesia makes placement of instruments easier and improves maternal cooperation. Pudendal block is often adequate for procedures when the fetal head is at the outlet. However, conduction anesthesia is often used. The cervix should be completely dilated and the membranes ruptured. Station, position, and attitude of the fetal head should be known. The fetal head should be engaged. Palpation, maternal sensation, or contraction monitoring can help identify the timing of contractions. Facilities for cesarean section should be available. Decision to use forceps or vacuum is based on...

History And Definitions

Important characteristics used to describe and classify hyperkinesias include regularity, velocity and duration, and anatomical distribution. In terms of regularity, tremors are generally rhythmical to-and-fro movements, and likewise, tics and stereotypies are repetitive movements that are highly predictable in quality, although intermittent in frequency. In contrast, chorea is best characterized by rapid movements flowing irregularly from one body part to another without a predictable pattern. In terms of velocity and duration, rapid movements include myoclonus, chorea, ballism, clonic tics, and some tremors. Slow movements are dystonic or athetotic, showing a sustained contraction of muscles, often with a twisting component. Finally, several hyperkinesias have a propensity to involve certain body regions, for example akathitic movements almost always affect the legs, and tics tend to be most prominent in the face, eyes, and neck. Dystonic movements occur in all body regions but are...

Normal Continuous Murmurs The Venous Hum

The venous hum was described by Potain in 186755 and is the most common type of normal continuous murmur. It is universal in children and occurs in normal young adults26,33 even in the absence of thyrotoxicosis, anemia, or pregnancy.52 Maximal intensity is in the supraclavicular fossa just lateral to the sternocleidomastoid muscle. The

Posterior View Fig 227

Muscle spasm of these muscles occurs with nearly all the cervical conditions it protects the underlying cervical dysfunction. According to Yanda, the upper trapezius, levator scapulae, and suboccipital muscles will develop tightness. Poor posture (forward head) or trauma can accelerate the tightness and lead to muscle imbalances, which can lead to cervical dysfunction. Weakness of the scapular retractors (rhomboids, serratus anterior) will cause the scapula to rotate and wing, resulting in increased interscapular space. Tightness of the upper trapezius and levator scapulae accompany this weakness. This pattern of weakness accompanies the forward head position and leads to excess stress in the cervicocranial and eervicothoracic junctions.

Jugular Foramen Syndrome

Patients with lesions of the jugular foramen have a combination of cranial nerve palsies. The jugular foramen syndrome may include unilateral occipital or postauricular pain and progressive hoarseness or dysphagia. Signs include weakness of the palate, vocal cord paralysis, weakness and atrophy of the ipsilateral sternocleidomastoid muscle and the upper part of the trapezius, and occasionally Horner's syndrome. Papilledema has been reported as a result of compression of the sigmoid sinus or the jugular vein by the tumor. Ipsilateral weakness and atrophy of the tongue is sometimes noted, indicating extension of the tumor to the hypoglossal nerve. Metastasis to the jugular foramen is the most common cause of this syndrome.21,27,28,53,55,66

Interventions for Dysarthria and Aphasia

Ties in daily living (CADL) and the pragmatic protocol164 are useful assessment tools. Behavioral training techniques can improve skills in eye contact, body posture, initiating and staying on a topic, turn-taking during conversation, adapting to listener needs, and using speech to warn, assert, request, acknowledge, or comment.

Averaging Faces

Although it has been suggested that standardization for lighting, view, facial expression, and makeup, is not necessary when making average faces from samples larger than 30 individuals (Rowland and Perrett 1995), this does not argue against using standardized images. While it is true that a small number of images that deviate from standardized conditions have little power to affect averages made from large numbers of highly standardized photographs, the case seems to be different for small samples of poorly standardized images. Poorly standardized photographs are likely to include variations between many images increasing their power to affect the mean. Such variations are unlikely to be random, particularly in smaller samples (n 50), resulting in different means in comparison to highly standardized images. Even when methods and equipment designed for repeatable and highly standardized craniofacial photography are used, some variation between the images usually remains (Stephan et...

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