Many of our episodes have included clients on the hypermobile end of the spectrum with a stiff thorax.
How do you balance increasing thorax movement around a hypermobile shoulder girdle region?
How do you use sound clinical reasoning to design an exercise program to bring motor control to the shoulder girdle and improve thoracic mobility?
Join us as we bring this clinical scenario to light with the rehab program of an archer complaining of a stiff neck and inability to increase power!
This case involves the neurological, musculoskeletal, respiratory, and central nervous systems to make meaningful changes. A full approach to looking at the gaze and the upper CV joints, adding breath for the thorax, and an interesting motor control program are discussed in the light of clinical reasoning.
A glance at this episode:
- [3:10] Patient’s history and current condition
- [7:10] Upper cervical stiffness
- [10:05] Joint stiffness
- [11:48] Shoulder stabilization exercise
- [15:05] Changes of the thoracic motion
- [19:15] Kneeling to reconnect the ocular reflex
- [23:42] Practice makes permanent but not perfect
Susan Clinton 0:00
Hi, everybody. Welcome to podcast number 150. I’m Susan Clinton, one of your co-hosts for Tough To Treat. I wanted to just thank everybody for joining our website and coming in and seeing what we have. We’ve got some cool search features for different things so that you don’t have to sift through 150 podcasts to find stuff. So feel free to come in and do it and join the fun. We got a couple of exciting announcements coming up later in the spring. So stay tuned with us. And if you’re not already a member of our newsletter, that’s the best way to do it is to go to our website, www.toughtotreat.com, and sign up for our newsletter. That’s where you get the latest and best information about the podcasts that are being released and or any other things that Eric and I are up to. So enjoy the podcast. Thank you.
Susan Clinton 1:00
Hi, everybody. Welcome to podcast number 150. I’m Susan Clinton, your co-host and I’m here with my wonderful partner Erica, how are you?
Erica Meloe 1:09
I’m good. Susan, how are you?
Susan Clinton 1:10
I’m doing well. Thank you. We’re kind of in the middle of February and I’m not sure what the weather is for you Erica but we’re still in the teens or lower with a big snowstorm headed again tomorrow.
Erica Meloe 1:25
So jealous. We’re like in the 50s here, I can’t take it I need snow.
Susan Clinton 1:29
you’ll have to come to visit next winter. I know I really miss it hang out. I will have plenty of it for everybody. So okay, so we’re gonna talk a little bit today about it’s something that we’ve discussed in many of our podcasts, but it’s not so much the story of a hypermobile female. But what do we do when we have somebody who’s a bit hypermobile, and they have a very stiff mid to lower thorax? So because remember, people who have extra movement tend to seek stability. In other places, oftentimes we’ll see over-recruiting hamstrings, over-recruiting feet, forward hedges, shortened necks, different things that you’ll see. And this population, and I know I’ve talked a lot about this and dancers before, but this particular client that I wanted to talk about is one that I had a while ago, and it was a very interesting, client, I did it with a couple of other people. We were all in academia, and we all agreed to take a look at her, because, it was just a friend. And they were at a loss of what to do this person was a female who was in her early 30s. And she was an Archer and wanted to Yeah, I wanted I know, right?
We don’t usually talk about stuff like this, but I just thought in light of the whole How do you get the thorax moving when you’ve got shoulder blades that are hypermobile, shoulder girdles that are hypermobile, a system that’s a bit hypermobile, and she was attracted to this sport early on, she’s always been a horseback rider and outdoorsy type person and big, fit comes from a hat family of bow hunters, she doesn’t really interested in bow hunting, but she was certainly interested in becoming an archer, target.
And I really, really liked it and has the fancy equipment and all the stuff. We sport Yeah, yeah, it’s really, the equipment alone was just worth doing the assessment with and some of the treatment because, just complicated but anyway, one of the things that were happening, here’s what she was told. She was told that her drawback was weak, she was told that her right shoulder is too low that her right shoulder was unstable, and that her neck is too stiff. This is what she’s been told over and over and over again, when people and coaches and different people have tried to work with her she had one coach that was probably the best that taught her how to focus on her how to breathe, taught her how to center herself and do that the cuz you have to kind of slow your breath way down so you kind of in the zone for these types of things for this marksmanship type of work and this particular person said I’m not sure what’s going on with your body but if you could find somebody to help you with that part, you’d probably be an outstanding Archer. So anyway, she kind of trips through the years doing things and stuff. But anyway, it was interesting because it the pictures and the videos she sent us were all shot from behind. Everything was shot from behind so you can see this drawback with this shoulder that goes up in the air that the whole shoulder would go up in the air and then it would go back into full retraction with full winging, complete winging of the scapula. Yeah,
Erica Meloe 5:00
I’ve done archery and I and that she’s right-handed, I’m assuming, right? Yeah. Yeah, that is not easy.
Susan Clinton 5:05
No, it’s not an easy sport at all. Anyway, I thought it was interesting because of the only functor from behind. Yeah. So everybody’s been looking at her from one direction. So I kind of asked her, I said, Did anybody ever look at you from this side or the front? And she was like, well, people look at me from the side all the time. They ever film, you know? So she had her equipment, obviously. And so we just, the way that I always work is show me. Let me just see what’s going on. But it was interesting because when we looked at her from the side, and then from the front, one of the things that didn’t show up in the back, was as she began to pull back, she actually had a jutting of her lower ribs forward. Like I anterior translation, almost. Yeah, yep. And kind of a rib flare. Yeah. Yeah. And that was where she gaped. In my opinion. That’s where she was trying to get her stability from Yes, yes, yes. She couldn’t get it anywhere else. So she did that. And so she would get this, like, really kind of, talking, you’re tucking under if you will have the thorax down there. And really quite interesting. And also, because of the position she was in, there was a lot of right-side bending of the head and left rotation to see them, to see the target. So it’s kind of looking above and below what are the feet doing what’s happening in the feet?
Erica Meloe 6:26
Yeah, so nowadays, and support archery?
Susan Clinton 6:29
Yeah. Yeah. And, so the feet were okay. You know, she really, she was healthy, strong. Yeah. She just, this, she just didn’t have the motor control, that we would think somebody should have to do this. So here’s the first thing is like, if what she was doing was bad. I don’t know. But her thing was, she wanted more power. She wanted more accuracy and more power. And so and her neck bothered her a lot. You know, especially if she spent a long time working. And that would make sense, because the top of her head was always in that upper cervical, right side bending, left rotation. So you got a little bit of Upper Cervical stuff going on. And that goes in with the eye gaze and centering yourself and balancing the whole piece. My thoughts were when I was looking at this, it’s like, okay, she’s using a stiff, she’s getting either the thorax was stiff, to begin with. And she just knew how her brain just figured out how to leverage that. Or it became stiff over time to balance what she was doing with all of this stuff.
Erica Meloe 7:38
Yeah. Did she feel stiff?
Susan Clinton 7:39
Or does she just did she have my hands on her yet? So
Erica Meloe 7:42
I didn’t I’m sorry. I mean, did she say she was stiff?
Susan Clinton 7:46
Got it. No, she said her neck was stiff. Her neck is stiff? Yeah, got it. Her neck is too stiff. My I can’t lose my neck. And then it’s like, well, they’re kind of it’s kind of becoming the part that squished in between here. With what’s happening with the thorax in the upper cervical area. The neck was a smaller consequence to me at the moment, because I thought, well, if what we do changes her neck pain, then that’s great. Changes a ton of stiffness, but let’s just see what can happen. So I’m thinking about the upper cervical, I’m thinking about eye gaze, and I’m thinking about that maybe that eye gaze has become a bit fixed over time. Because when you hone in on it so much, do you ever really let that go? You know, yes, certainly, she could turn and turn her eyes in all directions and everything. But did she use that as a? You know, did she have that variability in her regular everyday movements? You know, or did it kind of stay kind of narrowed? Because she was so her sport requires that? Yes, yes. Yeah, no, and it was for her, it was a lifestyle, it wasn’t just a sport, she really wanted to do this and spent a great deal of time. This is like, her thing. And then, so the other thing is, is that she can quiet her, her breath, around activity, which, she knows how to shoot, she can bring herself in, so it wasn’t like a mental lapse, it wasn’t like, I get anxious and start breathing funny. None of that was a piece of this, which was, because she had worked really hard on that part. But, um, so, kind of thinking about that, then it’s kind of like time to put your hands on the thorax and see what what can happen here. And her thorax was stiff, when you get another ribcage, just you could just feel the stiffness in there. You know, if you laid her if we did lay her down and do some, some Pita a glides and definitely mythrax The lower thorax was quite stiff. And so, you can so the question becomes here, where do you what do you do? Do you mobilize the ribcage? What do you do? What are your thoughts here as you’re kind of like seeing this picture where you’d like to go, because I know you have some thoughts about this too.
Erica Meloe 10:05
Yeah, she reminds me of my question. And I’m treating where they’re just scapular bracing. They’re like, the interior, the hinge, because it’s a rotational sport, a lot of times, from what I’ve seen, at least in my patients, especially with that anterior hinge and any kind of upper extremity, unilateral movements. It’s more of like, what’s creating that stiffness is a joint stiffness. Not experienced, probably not, it’s more like a overactivity or a poor neuromuscular balance surrounding the thoracic cage, like bilateral, erectors, or like an oblique that sort of, depending on where she was because she didn’t arteries narrow, right. And she probably adapted well, and was barely centered. But, when you’re taking that into that rotation, a lot of these people depending on what their drivers is they get they dumped that scapula, the rhomboids, they get all very, she did, she didn’t say she was stiff, but you’re getting you feel like they’re stiffness there when n is in. And so in essence, it’s a stiffness created by muscles versus a joint stiff.
Susan Clinton 11:14
Yeah. Or the overlying nervous system recruiting or trial balance. And somewhere yeah,
Erica Meloe 11:20
exactly. The nervous system is going to turn on muscles that need to get turned on when you’re in doing something like that. And especially with her strategy, the nervous system has a reference for center. And that is certainly in an anterior translation. Right? And I bet you when you saw her from the side, you could probably see even see that even more. Right. And so that’s not optimal. When you’re when you’re shooting a when you’re an archer.
Susan Clinton 11:43
Yeah, it didn’t, and she didn’t, but nobody, she couldn’t ever really get it figured out. So one of the things that I did was I started thinking, okay, so everybody, she has been given shoulder girdle strengthening exercises, till the cows come home. And she can bench press, she can do a bench row, she can do some of this stuff. That’s not the issue. The issue is not a strength issue, the issue is a control issue. And what she needed was she needed to learn how to control from a reverse engineering point. So instead of trying to increase the Rasik, mobility and decrease shoulder girdle mobility, I went at it a different way, I thought, let’s start getting some shoulder stabilization positions in and get the thorax to move on that instead. So, we first Yeah, we started laying down and sitting up and standing up and whatever breathing look like and good. You take a deep breath in and what did we see? You know, and a lot of belly breathing, not a lot of chest, not a lot of pump handle and bucket handle movement of the ribcage, which didn’t surprise me too much. Because the ribs are kind of flared for, up, like you said that anterior translation, that happens there. So we just, we spent some time, because I wanted to see, I wanted to see how to get the thorax moving on the shoulder soldier girdle, so I decided that I was going to start her and in isometrics, thoracic scapular, work. And we did standing with hands forward on the wall, and she’s done this before. Right, she’s done that before where she puts her hands on the wall. And she’s supposed to squeeze your shoulder blades together, and she’s supposed to protract them. But when she does that, it’s all shoulder blade moving in the thorax doesn’t move. So we decided to do something different. We decided to get the hands on the wall, have her just kind of like, lean and turn the muscles on. And all we did there was just add breath and put my hands on her lower ribs and that wanted her to kind of fill up my hands with the breath while she held everything still, you know their hands for it on the wall. And then we switched it, we could do it at different places. We put the hands on the countertop and did a kind of almost a little like a like a 20-degree plank, onto a countertop so it wasn’t much but enough to get good work into the soldier girdle position without retracting and breathing instead. And then we did some work where she could put her hands standing put her hands down on a surface where she’s at 90 degrees of elbow, and her hands are flat on the surface like a table and press down there. Watch what’s happening at the scapula. She could do that. But then what we did was we added breath.
So I’d have her take a deep breath so we could get the pectoralis muscle to start doing the pump handle type of movement is my goal was she had to breathe he had to slow her breathing down. But she’s using her thorax in such a way that she can’t do Read with her, her ribs aren’t moving for breath. So she’s having to do it with her load with her belly. And which is kind of like, thoracic kind of gliding forward and back. Yeah, inefficient position. Yeah, yeah. So, obviously, the standing position was meaningful, but we had to get this going, in a number of different positions. So, once we got that happening, and she could get that pretty good, and she practiced it and stuff, then we put the bow in her hands. But we also put some Thera band around where the bowstring was, we put some Thera band on there. So obviously, she would have to hold the bow. So we don’t want to make it meaningful, right? So she’d have to hold the bow, and then she would, with a right hand start to draw, with the arrow and finger draw back, but she was using the theraband. So there was minimal resistance. And we did that in different places, like in the beginning, take a deep breath, bring it to here now SATs and take a deep breath. Yes, we did it in various positions of that, so that she could really begin to challenge her system, and a different way.
Susan Clinton 16:15
And then, so as she got better with just doing the positions and stuff, I decided that it was time to challenge her whole body. So rather than going to a stronger Thera band, which we will, obviously, we’re going to progress to where we’re actually going to go to a very lightly tied bow string to a very back to the stiffness that she wants to be able to work at. But you can kind of see the progression there. But what I did, which I thought was fun, because it is a narrow base, and what I was trying to do was figure out how to get her to, to actually use her abs lightly to stabilize herself rather than shoving her thorax forward. So as we were kind of working in standing with the Thera band, I’d have her like, exhale and just bring her belly and a little bit, so that she can begin to get that but she had so many there was I wanted to get her off her feet, I wanted to challenge that specific core system a little bit more. So I actually got her and tall kneeling and half kneeling to work on this
Erica Meloe 17:11
I’d love that. That’s that you right up my alley you thinking like I would be thinking
Susan Clinton 17:18
was like, I wonder what happens if we take away some of the whole lower extremity stuff and things like that. And it was very challenging for her but it was also really good because it made her have to use other muscles. And actually the ones that she ended up using a lot were like her, her, her hips or abductors, to stabilize your pelvis, but it just automatically helped her abdominal, kick in, because if she tried to shoot her her thorax forward in that position, she’d fall over over
Erica Meloe 17:51
and the nervous system in that position just it will it changes recruitment pattern, right, when you change the position, right, and that’s fantastic. I have a I have a patient that I’m treating similarly and that’s what I would do I would go right into kneeling so so go ahead keep going. I’m
Susan Clinton 18:08
curious Yeah, so we did we we even did it in the seated position. Yeah. When she couldn’t handle it and tall kneeling or half kneeling, it was like just sit down then so interesting. And that was still because she was trying to like through her pelvis trying to pull back and it was like this they still only this just really breaking down the motion and I know that it’s supposed to be a full motion in a circle and sometimes motor control people say don’t break it down but she needed to feel this at different and now a bunch of different ways would record was trying to increase her experiential piece rather than just make this linear type of exercise because she’d had those Yes, she’s had those her whole life and none of it changed the pattern. So it was like okay, I’m after pattern here. So the other thing that we did and as she was struggling and sitting and half kneeling, and kneeling was I started getting her to mobilize her own upper cervical spine. So that kind of the mulligan approach where you take a strap or a towel and you just hold that towel where it wraps around see to and all I had her do was Seidman left and turn to the right, yeah, the opposite of what she did. That’s all we did. She just did that through that as an exercise that’s part of your warmup just do it. But and then I gave her Of course, we started working with the clock yourself AP eyes on the wall, doing all the different eye gaze stuff faster, quicker, to just bring that variance back in and reconnect, different gazes with different appropriate receptors in this upper cervical spine and the, the vestibular system just to kind of reconnect that ocular reflex pattern there is no go ahead. No, so
Erica Meloe 19:49
in a kneeling, were you What were you doing in kneeling again? Were you doing theraband like, for like, what I would do is protraction the, like some protraction eccentric retraction I would do things like arm stuff is that what you were doing in we
Susan Clinton 20:03
did some of that we did a lot of the bow work most of Yeah, most of it, but that’s a great idea. And it’s probably something that I missed was we could have done with a theraband around the wrists, kind of pulling out like almost, in Tai Chi we’d call it g, which is like outwards, like a shield? Yeah, it would be kind of that type of motion, I would see now that could really help bring that in as like, because you’re working with a sword, it is kind of like, kind of, kind of fits into that, you know that how can I brace myself outward. To do this, rather than trying to do something inward. Those would be really good exercises to do. She, we did do the balls under the arms to play around with away from away from arch it just because it was fun. And something easy to do here, stick this up in your armpit, watch a little TV, stuff like that. And then as we kind of got her to where she could be stable on on top, she was better and half kneeling than tall, kneeling, tall, kneeling was the most challenging. And I think it would be for a lot of people to try to do that. But as we got her to where she could really actually, control and go through the motion and not feel like she was going to fall over all the time. And all of the things in the exhale, breath really helped with that. And she was pulling back to be exhaling that just drew the abdomen enough to kind of allow and then at the end, she could take a deep breath in and her abs were already engaged a bit. So we got the chest moving a little bit better for her. And then we just worked on kind of getting her onto a stiffer bowstring. You know, as she kind of went forward, it took a while I will tell you this, this was somebody that there wasn’t any such thing as telehealth at the time. We got the information on her and the videos on her before we saw her. We saw her we were able to see her about once a month once every six weeks. You know, it just was part of where we were and where she was and what was going on? Yeah, we did send videos back and forth. You know, because it was helpful, to kind of watch I agree accusin and stuff like that. But it took about a year. Yeah, yeah, people like think about this, this is not a two week, go see me and be solved type of thing. This is something that’s going to take time to that that pattern is very, very, very ingrained. And they’re gonna say that and I and you can’t take it away, because then she’s completely without, you’re just like pulling the rug out from underneath somebody. Yeah, you got to just change the shoes are standing on the rug, and a little bit and, and help her, she could mobilize a little bit she had her breathing exercise to do these things she did away from the, the ring. And then when she was back in the thing, she just just, I never told her to try to do these things while you’re doing that just do these things outside, eventually, it’ll start to change on the inside. That’s why we went to the bow and arrow probably a little bit before we should have, thinking about some of the stuff you were talking about giving her a few more exercises to do in those positions to gain trust for her system that she’s not going to fall over. But I did that on purpose, because as soon as we got the bow and arrow in there, and we could start the changes with the changes would start happening because what she was working on was meaningful to what she was doing. But it wasn’t like she needed to do it. Like you all have always done it this way. Now you’re gonna do it this way. That wasn’t gonna work. No, no, no, we, we allowed her to adapt to the new stuff. Yeah, yeah, to make the changes.
Erica Meloe 23:42
And she probably that movement pattern probably carried over throughout, other activities and things as well. And it, the brain, what does it say? practice makes permanent, not perfect. Right. And so, it’s like a math practice. And that’s, I got so many choices. Yeah, exactly. And you got something in common, once every six weeks, that’s hard, that’s hard for a vote, and that’s, and, but it is what it is, and you work with what you got, and, you that’s really when the when the patient has to do, a little bit more, I think in terms of their, their commitment level, so,
Susan Clinton 24:17
yeah, so anyway, there we are. I just kind of want it, the reason that I brought it up is that I know we’ve talked about this type of thing with people that are, easy movers high, whether they’re hyper mobile or not, they’re, the lanky generally easy movers or Gumby style versus your fire hydrant style style people. And we see this a lot with people in different things that they’re doing and that Trump becomes the anchor and the thorax especially and really being able to get that thorax more mobile and get it working more meaningful, and not just something everything else was pulling off of or pulling onto can be really challenging because they can cheat through all the exercises, you have, you haven’t put their hands on the wall and you tell them to protract and their trunk doesn’t move, the shoulder girdle moves around the trunk, which is fine. That’s okay, you can push a door open. You know, the problem is, is that, as soon as the trunk is staying very static and very still, and everything’s moving around the thorax, and it needs to be part of the movement. And so figuring out how to get the thorax to come into play. My choice in this particular case, and has been with a lot of other clients that I work with is using breath, and using it to restore bucket handle and pump handle movements, which are a key piece of, what our thorax should do? Does she need it to do to ventilate for her sport? No. But she did need it to help her thorax get into a better position. So that the the work between the shoulder girdle and the thorax would be much more dynamic. And not one sided? Yeah, that was a theory I went off of.
Erica Meloe 26:07
Yeah, no. And I think also, I think the, the shorty that I did last week. And then the one that we did together on impairments where we talked about getting patient into like a, like a, like a bit of a posterior tilt and moving them. You know, that’s another option for for for it depends on the patient, right? That your patient here has gotten, like she’s done all that she’s like that everywhere. And so I if I talked about shorty where I had this sort of question I’m treating, she still needs a reference for center. So what I did is I put half foam roller under her on the reformer as she was moving. So that will be last week, episode 149. Her like her thorax needs a reference for center. And it’s not it’s in the body and the brain has to figure that out. So changing the input, like you put your patient into kneeling, I did that as well with my patient, putting her on a half foam roller wall on a pilates reformer, that really you really got to find center, right, going on a BOSU ball. So at this point in the in the clinical reasoning is in advanced clinical reasoning. It’s not like about choosing what exercise is really choosing what environment and what’s the current impairment. What does she need now, not five years ago or four years. And that’s where the clinical reasoning comes in.
And I love it. I love I love it. That’s why I did archery. I have to say as an aside, I was in Ireland. And we did it in the pouring rain and in Mayo and I and we came back here and as a couple places in Brooklyn and I was like almost addicted I but I have like a shoulder issue myself. And I’m like, I found myself pulling that with the bow back. And I was like, oh, it’s very easy to get into that sort of rigidity that you feel in the scapula right. But it’s a great sport and I would it’s it’s always fun to treat people like that I have to say so. Very nice. Awesome. Well, everybody, we hope you enjoyed the episode.
Susan Clinton 28:04
Jump in. We’ll see you. We’ll see as we move forward. Alright. Thanks for supporting us through 150 episodes of tough to treat. Alright, bye, everyone.