You are on page 1of 42

Neck and Shoulder


Angie Dubis

What Is Fascia?
Connective tissue cells secrete a number of substances into the space around themselves. They
also secrete what is commonly called ground substance. Those connective tissue cell
secretions (primarily collagen, retinacular fibers, elastin fibers and the ground substance) can
combine with cellular components to form a variety of connective tissue structures, such as
cartilage, bone, tendon, blood, adipose tissue, lymphatic tissue and fascia.
The combination of connective tissue secretions are often collectively referred to as The
Extracellular Matrix (ECM) - you may also hear it called The Living Matrix or the Connective
Tissue Fabric. Regardless of name, almost every cell in the human body is imbedded in this
pervasive matrix that, among other things, provides a supportive framework for cells to anchor
to and move around on, separates tissues from one another, nourishes cells by providing a
mechanism for the diffusion of nutrients and that regulates intercellular communication.
The Connective tissue properties are determined by the local components of the Extracellular
Matrix. In the case of Fascia, elastin and collagen fibers are secreted into the ECM along with
ground substance by the connective tissues cellular components (fibroblasts, mast cells,
adipose cells, macrophages, plasma cells, and leukocytes) to form this ever pervasive network.
This fascia network weaves its way through the body in every direction without interruption. It
surrounds the cells of every nerve, blood vessel, organ, muscle and bone. An injury in one part
of this dynamic web affects all other parts, which is why a client can have a resistant
hyperextension in the upper cervical muscles as a result of a constricted planar fascia!

The Body Talks

Often when people think of communication systems of the body they think of nerve impulses
and chemical pathways not energy waves, oscillations and vibrations. Somehow, when used by
physicists the word energy is understood as science (as in E=MC), but when used in
reference to life force it can become something esoteric and mysterious. This has been partly
due to the lack of empirical evidence available on the subject. Until recently, cellular research
has focused on the liquid portion of the cell. Scientists have used techniques to separate the
fluid matter from cells, throwing out the solid matter as unimportant.
As it turns out, this solid matter is made up of some of the same insoluble structural proteins as
fascia (elastin and collagen with some actin, myosin and keratin). Like the connective tissue, the
solid matters importance is just now beginning to be recognized. These insoluble structural
proteins form the internal structure and framework of every cell (cytoskeleton) and some of

these vital proteins extend across the cellular membrane to anchor the cell to the extracellular
matrix/connective tissues.
Isnt it fascinating that the cells cytoskeleton, the extracellular matrix and the connective
tissues (collectively referred to by James Oschman as The Living Matrix) are all made of the
same substances, are all anchored together in one continuous fabric and have all been
consistently ignored as unimportant by almost every discipline that studies the body?
As the importance and continuity of these structural components have come to light, research
has begun to demonstrate that the nervous, hormonal and chemical systems only account for a
portion of the communications occurring in the body. The Living Matrix is the ONLY system
that connects to every cell in the body. It is an all pervasive communication network that
conducts energy and information at speeds so fast it makes nerve impulses look like they are
running on dialup. Energy and information, including physical and emotional trauma, can also
be processed and stored within the matrix.
Healing occurs at a cellular level. If the flow of energy in the living matrix is disrupted it can
cause breakdowns decreasing the ability of the system to communicate and coordinate
immune defenses and repair processes. Whether an injury is a gaping wound or a paper cut,
the repair process is completed by the connective tissues and individual cells. The connective
tissue fabric summons the cells needed for healing by sending a variety of potential signals
through the matrix and the needed cells begin migrating to the injured tissues. Much of this
cell migration takes place as cells break existing connections and make new ones along the
connective tissue fabric in essence the cells use the living matrixs structural scaffolding to
crawl to the injury.
In my opinion, understanding how cells of the connective tissue fabric store energy, process
trauma and communicate with each other through vibrations, oscillations and waves (among
other things) can have a tremendous impact on the quality of care health practitioners offer

What Does the Heart Have To Do with It?

In the book "The Little Prince," by Antoine de Saint-Exupry, the Fox says to the little prince.
"And now here is my secret, a very simple secret: it is only with the heart that one can see
rightly; what is essential is invisible to the eye." The meaning of this quote is very powerful with the eyes one can see wealth, beauty and fame, but with the heart one can feel and
perhaps even understand love, loyalty, friendship and truth.
If the heart is simply a pump, how can it help us feel or understand love? Researchers like
those at the Institute of HeartMath are working to answer this and other questions, such as,

how the heart communicates with the brain and how it influences information processing,
perceptions, emotions and health. This research has established that the heart functions as an
information processing center that is hardwired for bidirectional communication with the brain.
Interestingly enough, the neural connections going from the heart to the brain outnumber the
connections coming from the brain to the heart. Additionally, many of the connections from
the heart terminate in key brain centers that affect perception and autonomic response such as
the thalamus, hypothalamus, and amygdala.
Other than acting as an information processing center, the heart is also an endocrine gland,
which has cells that produce and release the neurotransmitters norepinephrine and dopamine,
as well as the hormone oxytocin. Oxytocin is sometimes referred to as the "love hormone"
because recent research indicates that this hormone is involved in cognition, tolerance,
adaptation, social recognition, pair bonding and maternal behaviors. Fascinatingly enough, the
concentrations of oxytocin found in the heart are greater than those found in the brain.
Besides neural and chemical communication, it has been found that each time the heart beats a
pulse of electricity flows from the heart through the circulatory system. As a result of this
electric current, a magnetic field is created in the surrounding space that has been measured up
to 15 feet away from the body. Have you had an experience where you walked into a room and
immediately sensed that something was wrong? Perhaps, it was your hearts magnetic field
that turned your brain on to the disharmony in the environment. The rhythm of the heart beat
itself varies based on emotional state specifically negative emotions can result in heart
rhythms that are erratic and disorganized, while positive emotions tend to increase harmony
and coherence in the heart rhythms.

The Liquid Body

Water molecules surround the genetic material in DNA in a way that directly influences its
structure. The DNA double Helix is entirely covered by water molecules. These water
molecules in combination with ions actually hold the DNA together. Every molecule in the body
is framed by water and ions. If you removed the water from this framework all of the molecules
in your body would be pushed apart rapidly. Water actually neutralizes the electrical charges of
the atoms that make up the molecules.
Water doesnt just hold your bodys atoms together; it lubricates them and creates a cushion to
protect your tissues from shock - it allows force to be distributed across the system. Water acts
as a transportation network that delivers vitamins, minerals and other essential elements to the
bodys tissues and organs. It also provides the pathway for the removal of waste products, such
as metabolites and toxins.

When collagen fibers become dehydrated they elicit an acute inflammatory response resulting
in the release of histamine, dopamine and other chemical mediators which result in increased
fascial tension. If the dehydration is persistent this could lead to excessive bonding of collagen
fibers, scar tissue formation and adhesions in the fascial net. As a result of this process the
tissue loses its ability to move freely, elasticity is lost and the ground substance begins to
Since the fascia is primarily collagen fibers and ground substance, dehydration can have a
profound effect on cellular activities within the fascia. Since fascia provides the communication
pathways for the nervous, circulatory and immune systems, dehydration can affect the bodys
ability to transfer and convey messages. Luckily, some of these negative consequences of
dehydration can be counteracted by rehydrating and performing active range of motion
exercises for individuals with chronic dehydration further steps may be needed. Conveying
this information to clients may help them understand why water is so important. Everyone
knows that should stay hydrated, they just dont always understand the profound effects of not
doing it.

Where there is congestion, FLOW cannot exist. Although not impossible, it is difficult to feel at
ease when things are stuck. Nasal congestion can make you feel like your head is going to
explode, traffic congestion can frustrate even the calmest of us, mental congestion can paralyze
our decision making processes to the point of complete self-destruction and bodily congestions
cause pain, restricted movement (of both body and internal processes) and diseases such as
atherosclerosis and cancer .
Flow or being in the zone on the other hand can result in feeling a sense of openness,
freedom, peace, joy, elation and ZEN. Perhaps you have experienced periods of flow. When in
the flow the road opens up before you, obstacles magically disappear, concentration is
effortless, tasks seem to complete themselves, time stands still, and all other sensations
disappear from perception as the material body seems to become one with the energy of the
world around it. Experiences of flow can be described as moments of true inspiration,
connectedness and complete ease.
I would say that the vast majority of people who end up on a massage therapists table are
there because they are experiencing some sort of congestion in their minds or bodies. The
complaints may be minor or more severe. Their congestion or dis-ease (lack of ease) may
manifest as chronic pain, edema, restricted range of motion, digestive problems or
hypertension. It is our job as therapists to try to help clients move from a state of dis-ease to
one of ease by using a variety of techniques to help release these congestions caused by

fibromyalgia, trauma, postural distortions, long hours of sitting and stress among other things,
but how do we help clients tune in to the flow? Unfortunately, flow cannot be created; it can
only be experienced by letting go.
So the question becomes how can a therapist facilitate clients in letting go of the congestion
that is restricting their ability to flow? Of course, there isnt one answer to this question. Each
client has their own unique relationship with their body.
We are going to start by trying to bring awareness to what that relationship looks like. For
example, I frequently find that clients, especially those with chronic pain, have unconsciously
grown to resent their bodies for betraying them. After all that damn leg (arm/shoulder/
hip) has restricted their ability to do the things they want to do. As a result, the client has often
unknowingly anchored in the congestion/pain/injury by putting the injured area on the
Realizing that it matters how they speak to or about their body may seem like a foreign concept
to some clients so we can explain it like this:
Each cell in your body is a living being. You can remove it from your body, place it in a
petri dish and it can continue to grow and live. That being said you probably already
know that your body talks to itself. It tells itself where to send blood and nutrients;
when it is time to eat, sleep and excrete; and it communicates with itself to produce
healing. So each cell has its own life and its life is dedicated to helping you not only
survive, but to thrive and adapt to all the challenges you face. When the cell needs help
it asks for it and if that need isnt met it will scream for it you may experience this as
discomfort, pain or eventually disease.
After the point has been made we will ask the client:
Have you ever had a friend come to you hurting and in need of your advice or
Typically they respond yes. If so, ask them:
How would that person feel if you yelled at them or berated them?
Often the response to this question is I would never do that! An appropriate reply would be:
I wouldnt think you would, but do you do it to your body? Isnt your leg your friend?
Hasnt it taken you places and supported you? Isnt it asking for your help? How do you
think it feels when you yell at it? Do you think it helps it heal?

This very simple conversation can have profound effects on how a client perceives their
relationship with their body. It can help them release frustrations they have been harboring and
it opens the door to flow. Start listening to the language your clients use in regard to their
bodies to see if there are opportunities to foster flow by releasing pent up resentments and
frustrations that may be attributing to an inability to let go of congestion.

What is ideal posture, what's not ideal and what are the
detrimental effects of poor posture? We will assess posture,
and you will learn that we alter posture simply by assessing
it. There are many things that alter posture, the time of day,
the types of activities we participate in (sitting at a
computer compared to playing baseball), the shoes we' re
wearing and the objects around us (the chair you sit in or a
musical instrument you play). Not to mention any
emotional, cultural or familiar patterns we've adopted into
our movement patterns.
Oh, and let's not forget holding patterns, breakdown
patterns, in-utero and birth experiences, toxins in the
environment, how our caregivers held or carried us as
infants, the list goes on and on and on. That being said, well
learn to compare our clients today with how they could be
tomorrow. And while doing so, we must remember how we
assess their posture now could change in five minutes. There is one constant, posture is not
static, it is dynamic. It can change moment to moment, as it should.
Posture is a team sport. There are a bunch of individual players that come together as a
unit to create what we see as posture. The shapes of the bones, the strength of the muscles,
the elasticity of the connective tissues, and the range of motion the joints allow all have a
factor in determining the posture displayed. If there is injury or restriction or atrophy or
weakness in the bones, muscles, connective tissues, or joints it will affect posture and how the
body moves. What moves the body is the neural firing from the brain to the muscles causing
them to contract and pull on the bones. This pattern of neural firing sets the body in motion,
at least, to the point allowed by the tissues. There is a constant interaction between structure
and function. How we use our body affects our posture and our posture affects how we use
our body.

As you work with clients it's important to remember that their body has created their
posture for a reason. It may not be the most efficient or the most effective posture, but it is
still theirs! They've created it based on their activities, their social life, their psychological life
and their relationship with gravity. So before you go jumping in trying to change their posture,
be gentle, no one likes their balance point reset too quickly. It is not a good idea to try to
impose a new posture on someone. Posture is a habit, and fundamentally, understanding is
required to change any habit. Start by assessing posture and acknowledging it for what it is.
Then move into a plan that you and the client create together. As Tom Myers puts it, "the idea
is to grow out of the tension-to literally grow up into something that is more functional-more
them-more authentically themselves. We don't do that by imposing more tension on top of
the tension they already have. We do that by exposing the patterns and letting them grow out
of them. Hopefully together you can cultivate their posture into something more functional
and efficient for them.
As we try to figure out what ideal posture is, we have to remember that ideal posture is going
to be different from one person to another person. Some people are tall while others are
short. Some are top-heavy others bottom heavy. So the way that individuals carry their weight
is different even though they may weigh the same amount numerically. Regardless, the key to
being pain free is that gravity be our friend. If it is not, our muscles will spend an extraordinary
amount of energy trying to counteract its force, which is constant. One consistency regardless
of your theory of ideal posture is that the planes of motion should meet at 90 angles. Patrick
Mummy, of Symmetry for Health, calls this the right angle fundamental. Basically, the body
should maintain right angles around the planes of motion as it pertains to the load bearing
Planes of Motion
Frontal the frontal plane divides the body into front and back
portions. Abduction and adduction are the movements that occur
along the frontal plane. Head forward postures cause deviations in
Sagittal the sagittal plane divides the body into left and right
portions. Flexion and extension are the movements that occur
Transverse - the transverse plane divides the body into top and
bottom portions. Rotation is the movement that occurs along the
transverse plane.

The body wants to be stable so it will sacrifices movement to ensure stability

o In head forward postures as the head moves forward the extensor muscles
fascial bags adhere to one another to maintain balance resulting in limited
mobility. The extensor muscles must isometrically contract to resist the pull of
gravity on the head.
Regardless of where an individual holds their weight, ideal posture exists when their weight is
carried by the skeletal system. In order for the skeletal system to effectively weight-bear, the
three planes of motion should meet at 90 angles. Notice in the image above how the
transverse, sagittal and frontal planes all meet to form 90 angles. When the right angle
fundamental is met the bodys eight load-bearing joints are vertically and horizontally aligned
to the line of gravity and the horizon respectively. In this case minimal effort is needed from the
muscles and ligaments to maintain balance.
So what happens if the right angle fundamental is not met? Let's start with the
fundamental concept of planal deviation. Imagine in the image above that each of the lines
representing a plane of motion is a pane of glass. If one shoulder shifted higher than the other,
the glass would break. This would be a transverse plane deviation. If the spine curved to the
right from a scoliosis, the pane of glass would break. This would be a sagittal plane deviation.
If the shoulders anteriorly rotated or the head jaunted forward from working too many hours at
the computer, again the glass would break. This would be a frontal plane deviation. Notice
how it each of these examples , the movement that breaks the glass is away from the
movement of the plane. Flexion and extension occur in the sagittal plane (and strength of the
sagittal plane). While abduction/adduction break the sagittal plane (but
strengthen the frontal plane). Since our bodies are designed to move a
problem only occurs when our bodies don't go back to the right angle
By assessing all three planes together we can assess alignment three
dimensionally. A deviation in one plane affects all planes. As a result of
these deviations, the skeletal system is no longer effectively weight-bearing
and gravity is no longer our friend. The stretch sensors (muscle spindles and
the golgi tendon organs) deep in the muscles detect excessive or sudden
changes in muscle tension and the righting reflexes are invoked. There are
five righting reflexes designed to restore optimal position when the body has
deviated from it. The reflexes attempt to correct the deviation through a
signal relayed from a reflex mechanism that causes a muscular contraction.

In the case of an athlete, such as a gymnast, the righting reflexes are strong and
enhance performance by allowing the athlete to overcome the effects of sudden head
movements. However, once the righting reflexes function improperly, the body enters into a
state of compensated motion. The muscular system will adapt any way necessary to maintain
balance against the force of gravity and to keep the eyes parallel with the horizon. For
example, if a client has an elevated right hip (transverse deviation) their body may compensate
by elevating their left shoulder (transverse deviation), bowing their spine (sagittal deviation)
and anteriorly rotating their hips and/or shoulders (frontal deviation) to keep their eyes parallel
with the horizon.
Ideally, we can move our body through its full range of motion. The agonistic and
antagonistic muscle groups are balanced and hold the body in proper alignment. If this is the
case the body can typically move efficiently and effectively in all three planes of motion.
However due to physical or emotional trauma, poor ergonomics or attitude, posture may
become compromised. In this case the bodys ability to move properly through all three
planes of motion also becomes compromised, further affecting the balance and structure of
the soft tissue system (muscular, fascial, etc).
MOVEMENT DETERMINES STRUCTURE! Children love to move! According to Patrick
Mummy movement is an instinctual priority for children. They run for fun, jump up and down,
climb EVERYTHING and twist their little bodies every which way. Children move in all three
planes (frontal, sagittal and transverse), and every joint gets used through its full range of
motion EVERYDAY! As a result, children tend to have proper alignment. Their structure is ideal
because they move properly. However for many individuals, something happens that disrupts
their ability to move properly. Maybe it's a fall or a car accident or repetitive stress from typing
too much or the restricted posture of depression. Often it's sitting. From the age of five when
children begin school, sitting (flexing) begins to dominate movement patterns. Erik Dalton calls
our society "flexion addicts" because we spend so much time sitting curled around our desks
or keyboards. As a result of this and other body patterns our ability to move becomes limited.
Now movement is determined by our structure, instead of our structure being determined by
our movement.
In order to meet the right angle fundamental, homeostasis must exist between tonic
(postural/intrinsic) and phasic (dynamic) muscles. Tonic muscles are smaller muscles that do
not change length with external force and cross only one joint, while dynamic muscles do
change length with external force and cross more than one joint. Tonic muscles, also known as
postural muscles are responsible for maintaining posture. They have more Slow Twitch (Type 1)
muscle fibers. Phasic muscles on the other hand are responsible for moving our body through
time and space. They have more Fast Twitch (Type II) muscle fibers. The slow twitch muscle

fibers are often referred to as red fibers. They have a higher number of capillaries, are slower to
produce maximal tension, and are more resistant to fatigue than type II fibers. The high
concentrations of slow twitch fibers in postural muscles enable long-term contractions
necessary for stabilization and postural control. Fast twitch fibers are often referred to as white
fibers. They are quick to produce maximal tension and fatigue more quickly than type I fibers.
The high concentrations of fast twitch fibers in dynamic muscles enable quick force and power.
All muscles have a combination of slow and fast twitch fibers. Muscles are categorized into
postural or phasic groups based on their predominant activity. It is also been found that the
number of slow and fast twitch fibers can change in any given muscle depending on activity.
When under stress tonic muscles react by becoming short and tight and phasic muscles react by
becoming inhibited and weak. Stretching and releasing a tight hypertonic muscle leads to an
automatic regaining of strength of its antagonists.
Dynamic or phasic muscles - prone to develop inhibition and weakness
Gluteus maximus, medius, and minimus
Vastus medialis and lateralis
Thoracic extensors of the spine
Trapezius i, ii, and iii
Triceps brachii
Anterior tibialis
Postural/tonic or antigravity muscles - prone to develop tightness
Pectoralis major
Levator scapula
Biceps brachii
Lumbar and cervical extensors of the spine
Quadratus lumborum (qlo)
Psoas major
Rectus femoris
Vastus intermedius
Gastocnemius and soleus
Adductor magnus, brevis, and longus

Biceps femoris
Tensor fascia latae (tfl)
Erector spinae muscles

Let's think about this another way. Have you ever played tug-of-war? I often use this
example to help my clients understand the pulley system of the body. Imagine your bones are
the flag in a three-dimensional game of tug-of-war between the muscles on the front of your
body and the muscles on the back of your body (and side to side/ up and down). Now in a
game of regular tug-of-war, if one team pulls the flag to their
side, the rope is shorter between them and the flag in
comparison to the other team, whose rope is now longer
between them and the flag. In the image to the right who has
to work harder in order to get the flag on their side? The child
Not only is she smaller, but she also has more ground to make up. Can you imagine how
tender, tired, over-worked and frustrated the child must feel? How much do you think giving
her a backrub would help her win the game of tug-of-war? Probably not very much! She's
already under the gun, relaxing her might feel good, but it won't help her win.
Now, let's extend this example to our body. The adult represents pectoralis major and minor
which are short, tight and facilitated while the child represents the rhomboids and trapezius
which are stretched, weakened and inhibited. Remember in this case, your shoulder is the flag.
As the pectoralis muscles pulls the shoulder forward the brain initially fires to the rhomboids,
telling them to pull the shoulder backward. The rhomboids become tender, overworked and
tired of fighting a battle they cannot win.
Now there's another factor we haven't talked about yet! Do you remember the term
reciprocal inhibition? Well, here we have altered reciprocal inhibition - muscle inhibition
caused by a tight agonists, which decreases neural drive of its functional antagonist. To give

you a different example, a tight hip flexor (psoas) would decrease the neural drive of the hip
extensor (gluteus maximus), resulting in muscle imbalances.
Okay, let's rewind a little. When we talk about the kinetic chain we are talking about the
muscular, skeletal, and nervous systems working together. If any one segment is not working
properly we become misaligned and our bodies don't function properly, resulting in predictable
patterns of dysfunction. We call these predictable patterns of dysfunction postural distortions
or movement compensations. Once our bodys compensation becomes functional (the body
has integrated the compensation) there is a lack of structural integrity and decreased
functioning of one or more components of the kinetic chain (muscular, skeletal, and nervous
This lack of structural integrity comes in the form of altered length-tension relationships,
force-couple relationships, and arthrokinematrics. A length-tension relationship refers to the
length at which a muscle can produce the greatest force (Clark, et al). Each muscle has its ideal
length that allows the potential for maximal force production of that muscle. If a muscles
length is altered as a result of poor posture (or injury, etc) that muscle will not be able to
generate proper force to allow for efficient movement and its surrounding muscles will also be
affected and therefore they will also be unable to produce proper force , resulting in a lack of
structural integrity. Remember our tug-of-war?
Now consider Davis law, which states that if a muscle is lax for an extended period of time its
muscle spindles will take up the slack. This explains why when someone is casted in a flex
position when the cast is removed the muscle can't fully extend. Davis law can also occur in
hip flexors from sitting for prolonged periods of time.
Our second consequence of lack of structural integrity occurs when force-couple relationships
are altered. Force-couple relationships simply refer to muscle groups moving together to
produce movement around a joint. When muscles are working in a force-couple they are
providing divergent pulls on the bone or bones they connect with. Each muscle has a different
attachment point, pulls at a different angle, and creates a different force on a joint. When the
muscles of the force-couple fire in proper order it ensures proper joint motion as well as
eliminating any unwanted motion. Without proper length-tension relationships the forcecouple relationships cannot work properly, resulting in poor arthrokinematics (or joint motion).
One last term for you, synergistic dominance, this is the neuromuscular phenomenon that
occurs when inappropriate muscles take over the function of a weak or inhibited prime mover.
So you get sick at work, and someone else is brought in to do your job. It's not their job. They
don't know how to do it. They don't do it as well as you do, they are just doing the best they
can. Our nervous system reacts much the same way; let's say that your psoas is tight, leading

to reciprocal inhibition of the gluteus maximus. Now the glute can't do its job, which is hip
extension so it synergists (other muscles capable of hip extension) (hamstrings, adductor
magnus, and erector spinae) takeover to compensate for the weakened gluteus maximus. This
can cause faulty patterns which lead to Arthrokinetic (joint) dysfunction and altered forcecouple relationships; all of which decrease neuromuscular efficiency and eventually lead to
postural compensations and injury.
Head Forward Postures: Possible Head/Jaw RelationshipsClass I NORMAL
Head balanced eyes level Jaw and Cranial base aligned with transverse plane
Class II RETRUSIVE (Extensor dominant neck)
Excessive Curve in the Mid-Neck from shortened/hypertonic capital and cervical
extensor muscles
Open the fascial bags of affected muscles: Semispinalis Splenius Longissimus
trapezius Levator Scapulae and SCM
Lengthen Capital Extensors such as Suboccipitals and hyoid and Scalenes
Superficial Back Line perpetual pull resisting flexion causes thick bands (Achilles,
hamstrings, erectors, occipital ridge)
Class III PROTRUSIVE (Flexor dominant) (Military Neck)

Very Challenging to replace curve

Usually Begins in the pelvis

CED Capital-extensor-dominant straight neck

Very common with computer use

Cervical extensors are overstretched and tight (eccentric) Semispinalis Cervicis
Capital Extensors are short and hypercontracted (concentric): Semispinalis Capitis,
Splenius Capitis, Longissimus Capitis, Suboccipitals, Upper Trap

Diaphragmatic breathing
Diaphragmatic breathing is one of the best ways to center oneself. The process opens
energetic pathways throughout the body. As you rhythmically breathe in and out, muscles
slowly unwind, releasing tension, stress, and locked up energy. This progressive melting of the
body leaves a feeling of peace behind. I have taught clients diaphragmatic breathing for years

and am still constantly amazed at how much pain can be eliminated from the body in minutes.
All from just breathing correctly!
Diaphragmatic breathing is not just any form of breathing but a very specific one.
Inhalation is initiated by the diaphragm - the muscular sheet that separates the chest cavity
from the abdominal cavity. Diaphragmatic breathing is a long, slow process which allows the
body to maximally absorb oxygen. As the diaphragm contracts it presses down on the
abdominal viscera, the abdomen expands, and oxygen fills the lungs as it rushes into the
vacuum created by the expanded chest cavity. (Majid, 2007) Exhalation releases the breath
slowly, ridding the body of carbon dioxide. When we exhale our bodies relax, resuming
essential body functions and activating the parasympathetic nervous system in the process.
Sometimes we hold our breath when we are scared or in pain. Once we release the breath on
exhale, ahh... the relief. Try it: Hold your breath for 10 seconds or so and then let it go. Now
feel how your body reacts to the exhale.
Diaphragmatic breathing is the way we were meant to breathe - it is how babys
breathe. Unlike babies, adults tend to take shallow breaths much higher in their chests.
Additionally, when adults feel nervous, anxious, fearful, or excited their breath may become
faster and shallower, potentially increasing physical tension and stress. Diaphragmatic
breathing increases oxygen consumption while decreasing muscle hypertension which provides
a more beneficial breath than one gained by a shallow chest breath. As a result of sedentary
life styles, high stress levels, and in some cases, paradoxically enough, over-developed
abdominal muscles, some peoples diaphragms become dysfunctional. With such clients, it is
especially important to focus on slow inhalation and slow exhalation. Although the diaphragm
is intended to do the bulk of the work, many people are unaware of how to use this vital
muscle. Diaphragmatic breathing may initially be difficult for clients, but with practice it can
reinstate itself as the normal breathing pattern.
Diaphragmatic breathing can be used as a tool in moments of fear or stress. As
discussed earlier, when we have a fear based response to something in our environment, our
limbic system takes control of the brain, releases a mix of strong hormones, and temporarily
disconnects the frontal lobes of the brain. At this point our Amygdala has hijacked our brain.
We can use our breath to encourage parasympathetic activation - counteracting the fight or
flight response. This is done by taking several slow, long, deep, cleansing breaths. Another way
to reduce tension and stress is to become conscious ofhow our breath can be used as a tool to
help us relax. In stressful situations, pause by taking a deep breath: inhale through your nose
from your abdomen, then slowly exhale.

Diaphragmatic Breathing Exercises

Guided Breath
1. Have the client, clothed or unclothed, lie comfortably. If unclothed ensure that the
client is properly draped and warm enough.
2. Place one hand on the clients chest and one on their stomach. Have the client do the
3. Ask the client to inhale slowly either through the nose or through pursed lips (this slows
the intake of air).
4. As the client inhales, feel the stomach expand. If the clients chest expands instead, ask
her to focus on breathing with the diaphragm. You can tell her to push your hand
toward the ceiling with her breath.
5. Instruct the client to pause for one or two seconds prior to exhaling.
6. Ask the client to exhale slowly through pursed lips to regulate the release of air.
7. Allow the client to rest if necessary, and then repeat.
8. After several minutes of practice, ask the client if she notices any changes in her body.
9. Once the client is able to maintain the diaphragmatic breathing, remove your hands.
Allowing the client to continue on her own without your guidance.
10. You may now proceed with massage or other therapies you decide to include in the
You may choose to add suggestions or visualizations to the guided-breath exercise. Depending
on the clients situation suggestions can be added to the inhalation, exhalation or both. The
message should be appropriate for the clients individual circumstance. For example, if the
client is in pain, or experiences pain, you might instruct her to carry a message via her breathe
to all the cells of her body- I know you are hurting. Is there anything I can do to help you let
go? would be appropriate. The same client might follow with this message on the exhale Let
my breathe carry the pain away.
"The Complete Breath"
The Complete Breath is a technique taught in yoga classes. It adds thorax and chest
expansion to diaphragmatic breathing. The Complete Breath helps create the maximum flow
of life force (Prana) through the body.
It must be noted that some breath therapists and breathing teachers feel diaphragmatic
breathing is better than The Complete Breath for maintaining balanced breathing. Their

reasoning goes as follows: We take some 20,000 breaths a day. If we expand the thorax and
chest with each breath, the scalene, trapezius and sternocleidomastoid muscles overwork as
they contract to pull up the chest wall with each breath. This is wholly unnecessary and is
therefore a waste of energy since the lungs are more fully oxygenated with diaphragmatic
breathing. (Majid, 2007) For these reasons, I tend to agree that diaphragmatic breathing is
better for a persons normal breathing patterns; however, I feel The Complete Breath is
beneficial when the purpose is to open energy pathways during therapy.
8-4-8 Breathing
8-4-8 breathing is a great exercise to give clients for homework. Practicing the breathing
exercise for 5-10 minutes once or twice daily assists clients in becoming more relaxed. Clients
can use it to calm themselves by simply exhaling and their bodies will take over and supply the
rest of the response.
1. Sit in a relaxed position. Uncross your arms, fingers and legs. Put your feet flat on
the floor. Relax your hands.
2. Close your eyes and visualize a relaxing image: curtains blowing in the wind, a
sandy beach where you can hear the ocean, a color (white, blue, etc.)
3. Inhale from your abdomen, through your nose, to a count of 8.
4. Hold your breath to a count of 4.
5. Make your mouth open into a big O, and exhale through your mouth, to a
count of 8.
6. Repeat steps 3, 4, and 5 for several minutes (5 minutes does an incredible job of
relaxing your body!)
You can lower your blood pressure by 30 points and your pulse rate as much as 20-30 percent
in 5 minutes, with practice. Use this technique before entering a potentially emotional situation
or after you have participated in a highly charged situation, to maintain choice over your
Visualization is a tool used to assist clients in becoming self-aware (physically,
emotionally and mentally) by focusing their attention - resulting in a greater ability to manifest
their desired outcomes. Using guided imagery a client can revisit, revise, and reintegrate past
experiences allowing them to choose how the experience can best serve them in the future.
Visualization exercises help clients see their options.
Research has shown that the use of visualization techniques can have powerful effects.
Researchers, for instance, found that cancer patients who were offered a combination of
relaxation and peaceful imagery rated their quality of life during chemotherapy higher and
reported fewer side effects than patients who had received only the relaxation sessions. The

imagery group also had "enhanced lymphokine-activated killer cytotoxicity, higher numbers of
activated T-cells and reduced blood levels of tumor necrosis factor" (Utay and Miller, 2006)
Guided imagery is a very diverse technique that can be used in many different
situations. It can be used independent of, or as a complement to, other techniques. It may be
integrated throughout an entire session or, when appropriate, a short specific visualization may
be spontaneously added at any point in a session. For example, if my client is having difficultly
relaxing while I am palpating a trigger point, I may have the client visualize a little knot tied up
in the fibers of his muscle. I will ask the client to watch the knot struggle as it tries to free itself.
I may ask the client to talk to it, tell it everything is okay and to relax as the client visualizes
untying it. It always amazes me how just connecting to how the body is feeling and
acknowledging that feeling almost automatically creates change. When and how you use this
tool will depend on the needs of your client, your setting, and your own comfort level using the
"Take a slow deep breath in through your nose good feel your chest fill with oxygen
slowly exhale through your lips notice how your body sinks into the massage table as you
release tension with your breath good a few more times . Inhale feel your diaphragm
expand from under your ribs good Exhale invite any stress (tension/pain/etc) you feel to
leave with your breath good Inhale . Feel for any discomfort or pain in the area of your
head and face Again invite any pain or discomfort to leave your body with your breath
Feel the warm, vibrant energy of your breath travel into your neck and shoulder area, note any
spot where there is pain or discomfort as your breath scans your body As you breathe in
acknowledge any area your breath has difficulty accessing GoodNow fill any such areas
with the warm, vibrant energy of your breath.... feel those tissues sigh as you exhale, feel
them release any tension they are holding . Bring your breath down your spine good feel
your breath expand your belly and pelvis. Make a mental note of areas of pain and
discomfort, and notice as your breath travels down that your relaxation increases with each
breathNice deep breath as you fill your legs and arms releasing tension as you exhale a few
more timesslowly inhale feel your body breatheand exhale.feel your body
relaxGoodYour journey through your body is both productive and rewarding as areas of
discomfort are revealed to you. lets bring your minds eye to the area of your body that
sent you the strongest message of discomfort and focus on the message that awaits you
there can you tell me what the message says?......(Wait for a response this could take
several minutes)
(If the client has a message, fill in the next line. If not wait a few breaths and ask again. If
still no message, if appropriate, move on with an adaption.)

Breathe in a slow deep breath to this area of greatest restriction goodand exhaleAs
you breath in have your breath carry a message imagine the your breath quietly whispering
to the tissues surrounding the restriction.. (use whatever is appropriate)
I feel your ______________________ (pain, tightness, etc)
I hear your message and I understand
Thank you for trying to protect me
I am listening and I accept you just as you are.
I know you are scared, but it is okay to let go (forgive, move on, cry, etc)
Wonderful is there anything else this area needs or wants to tell you?....... (If so repeat
above) Are there other places in your body where you have noted strong pain or discomfort
during your body scan? If so, go to that area now when you are there, acknowledge the
pain. (Repeat the process as many times as needed) Great job! See how youre able to
identify the areas of blocked energy take your time feel your body feel its vibrance
feel its energy flow through you thats right nicedeepbreaths.

Hands-On: Demonstrated in Class

Assessing Posture
We want to observe the body as a whole. How it moves as a unit. Is there an exaggerated
movement in one segment to make up for a lack of movement in another? We are looking for
both what is symmetrical and what is not. We must consider the bodys experiences and
incorporate them into our assessment. Often clients will enter our offices with a specific pain
or complaint they want to address, it is our duty to look deeper to find the underlying factors of
their complaint. We will observe the body in static position and during dynamic movement.
While you do a palpation assessment you want to work with relaxed hands. This will
allow you to get even the subtlest sensory information about your clients soft tissues. When
we conduct a palpation assessment we are trying to get as much information as possible
without activating the body's protective response. Press your fingers into your masseter
muscle. Just notice what that feels like. Now actively relax the muscle and check again. Does
the tissue feel any different? Now actively contract the muscle and check again. What's the
difference this time? Can you feel the contraction of the muscle push your finger out? This
protective mechanism is activated subconsciously by the sympathetic nervous system in
situations of potential and perceived danger. If you jab somebody with your finger they're

going to contract to push you out. If you instead slowly push your finger or your hands into
their relaxed arm you can get much better information about their soft tissues. With our
palpation assessment were evaluating temperatures, textures and movements of the soft
Temperature feel for localized areas of heat or cold
Textures- hyper/hypotonic muscles, scar tissue, restricted fascia, trigger points, and
Movements limited range of motion and stiffness
Rhythms- breathing, pulse, craniosacral
o It is essential to determine which tissues are hypertonic and which are
hypotonic. Then one must decide whether to increase or decrease tone.
o Place client in a supine position on massage table.
o Using light pressure feel for differences in texture, tone and temperature as you
bilaterally palpate from head to toe
o Chart difference
Assessment of Skin Temperature
If circulation or energy is restricted the area may be cool to the touch. This could
indicate ischemia (reduced blood supply) which is sometimes caused by partial patients and
hypotonic muscles. If energy is stuck in an area, that area may be warm to the touch. Heat can
also be a sign of inflammation or fever, either of which potentially could be a specific or a
general contraindication for massage.
Textures and Movement of Soft Tissues
The better your palpation skills, the more able you will be able to distinguish the
difference between scar tissue and restricted fascia. These tissues feel as if they are bound
down and stuck together and sometimes they have a grainy, gristly feeling. Hypertonic muscles
feel resistant or tight, regardless of whether they're in a relaxed position or passively
contracted. Trigger points feel like little knots within the muscle, and it hurts when you palpate
them and sometimes pain radiates to other parts of the body. Edema or swelling can feel
spongy or like a water balloon full and squishy. Pay attention to what healthy muscle tissue to
feels like compared to unhealthy muscle tissue. Healthy tissue is soft and pliable compared to
ropey or sticky or gristly.
Match your clients breathing, what does it feel like?

Visual Assessment
Find the greatest disparity first then continue until you see the least. Remember, you are
looking for anything that is skewed from right angles around three-dimensional space first. It is
what we refer to as red flags.

Here is the list:

a. Feet everted, pronated or supinated.
b. Hand forward or rounded more than the other.
c. Forward rotation of the pelvis.
d. Upper torso rotation (one arm in front more than the other).
e. Scapulae protracted, retracted, or elevated.
f. One hip higher than the other.
g. More space between one arm and the torso versus the other.
h. Knees medial or external or one knee medial and the other external.
i. Knees varus or valgus.
j. Offset of the torso.
k. Offset of the head.
l. Knee flexion or hyperextension.
m. Forward displacement of the pelvis or head from the frontal plane.
n. Also, take notice of muscular misdevelopements such as one calf
larger than the other, etc.

Your mind and body are designed to process energy - designed to adapt to the situation
at hand. It is only when mind and body do not successfully process and adapt to a given
experience that stress or as Don Cohen and John E. Upledger (1996) put it distress is stored in
the body. This stress is often palpable in clients soft tissues during massage.

In their book, Introduction to Craniosacral Therapy : Anatomy, Function, and Treatment,

Cohen and Upledger (1996) discuss stress storage in the membrane system of the body. They
state that somatic tension can both be affected by and affect emotional and mental issues.
When somatic tension patterns are released a client may experience emotion. The emotion is
not necessarily, but could be associated with past memories. It is possible that symptoms the
client experiences are related to painful memories that have been blocked from the conscious
mind. Memories can come in many forms. They can be wanted or unwanted, conscious or
unconscious, physical or emotional, traumatic or mundane, neurological or somatic. There are
different organs and organ systems responsible for specific types of memory. The amygdala,
for example, remembers the emotional content of experiences while the hippocampus stores
the dry facts. (Goleman, 1997)
State-Dependant Memory is the tendency for information learnt in a particular mental
or physical state to be most easily remembered in a similar state. (Coleman, 2001) A statedependant memory can be any memory that is triggered by duplicating the original body
position, sensory input, location, body movements, emotions or nervous system activation that
was experienced at the time of the original event. The memory can be of a pleasant or
unpleasant nature. Mood dependant memory is a term used for emotional state-dependant
memories. Research has shown that positive experiences are more likely to be remembered by
a person who is happy and negative experiences by someone who is unhappy.
Imagine you are driving down the highway. The interstate wall is on your left, a semi
truck on the right. As you cross a bridge you hit black ice on the road, you loss control of your
car and as your car is spinning out of control, you see the headlights of the semi truck 3 feet
from your drivers side door. You get lucky, your car is spinning fast enough that instead of
getting run over by the semi it instead smashes into the interstate wall screeching as it slides
down the wall 20 feet before it stops facing oncoming traffic. By now your amygdala has
certainly activated the sympathetic portion of your autonomic nervous system (ANS); a few of
your bodys physiological reactions may be an increase in blood pressure, pupil dilation, and
slowed respiration. This intense amygdala arousal has burned the characteristics of this event
into memory to be stored in case a similar situation occurs again. The amygdala may potentially
send a surge of anxiety through your system every time you are in an even slightly similar
situation - a reaction that may not always be appropriate and even dangerous depending on
the physiological reactions that accompany the anxiety!
I should know, this actually happened to me. I couldnt figure out why my neck would
feel great after a massage and then an hour later would hurt again, that is until my therapist
walked me to my car one day. She pointed out to me that as soon as I closed my door and
latched my seatbelt my entire body tensed, my shoulders crawling up like earrings! My body
was preparing for danger and I didnt even notice! I used visualization and breathing

techniques to relax myself before and right after I got in my car. After a week my neck no
longer hurt and I noticed that I wasnt as jumpy driving.
State-dependant memory interacts with the ANS. Massage affects the ANS and can
trigger state-dependant memory by placing the clients body in certain positions, by using
certain movement patterns, or by replicating a particular pressure sensation. This can happen
both intentionally and unintentionally. When unintentional, the client may get confused or
scared if the memory is overwhelming, especially if it is related to unresolved trauma. It is
important for the therapist to make sure the client feels safe and understands that nothing is
wrong with him/her - it is but energy being processed. The client may even be able to resolve
on his/her own some of the energy associated with the memory, just as I did with my anxiety.
Professional counseling may also be helpful in assisting the client in working through memory
patterns associated with deep trauma issues and to develop strategies for resolving,
integrating, and transcending the trauma itself. (Salvo, 2003)

Holding patterns are the bodys tissues representation of emotional trauma. Holding
patterns may manifest in obvious or inconspicuous ways. You may see it as the withdrawal reflex
of an abuse survivor or the rigid posture of someone who isnt going to be pushed around by
anyone anymore! It is also important to remember that not all postural habits are holding
patterns, so dont go around making hasty generalizations about why people hold themselves
the way they do. Everyone is unique and your ability to assess and differentiate will only
improve if you really tune in to all communication from clients, verbal and non-verbal.
Sometimes neither you nor the client will be aware of emotionally traumatic holding patterns
until they are released - and even then, you may have no idea where they came from unless a
memory and/or emotion is also present at the time of release.
Where holding patterns are the bodys way of storing emotional energy, breakdown
patterns are the bodys way of adapting to physical trauma or micro-trauma. (Cohen &
Upledger, 1996) When the body suffers an injury from an accident or fall, from a disease
process, or from maladaptive use patterns (e.g. sitting at a desk 6 hours a day) it will adapt in any
way necessary to function. Our bodies will posturally compensate to take the weight off of a
sprained ankle to avoid pain and allow the best possible gait despite the injury. In the case of
postural compensations and maladaptive use patterns, gravity is not your friend and only
perpetuates the breakdown patterns. The body adapts to function; therefore, it does not
recognize that its functioning is dysfunctional rather, it just accepts the new patterns as
normal. Because of this acceptance, the body keeps these patterns even after the injury has

healed or the disease has been cured. It can be tremendously burdening to the system. Massage
is a wonderful tool to help clients release breakdown patterns and restore optimum health.
Holding and breakdown patterns can occur independently of each other, as reactions to
each other, or simultaneously. Lets take as an example an auto accident. If a young girl breaks
her leg, she may develop breakdown patterns; if she walks away unharmed physically, but is
berated by her father for being so stupid she may develop holding patterns; if she breaks her leg
and also endures her fathers wrath, she may develop both. The more powerful the experience,
the more embedded the tension patterns. Imagine the same girl broke several bones, ended up
in a coma for several days, and awoke to find out her boyfriend had died in the accident. Her
body/mind would have to process a level of both physical and emotional stress such that it is hard
to imagine. She would be facing a long rehabilitation process on top of her grief, anger, denial,
guilt, financial difficulties, etc. It is also possible for holding patterns and breakdown patterns to
prevent the processing or healing of each other. In the last example, the girls body may
associate the physical and emotional trauma she experienced with one another. As a result some
of the emotional trauma might be stored in the physical wound, preventing the girls broken
bones from healing as quickly or as well as they should. Simply put, it is essential to consider both
why a client has specific symptoms (cause) and why they arent going away (unsuccessful
processing). As regards to the latter, it is also important to realize that breakdown patterns can
pile up on top of each other, such as with athletes who experience frequent injury. Regardless of
cause, both holding and breakdown patterns are taxing to the body, and require an enormous
amount of energy form the autonomic nervous system, thus limiting available adaptive reserve.
Myofascial Tissue
The myo in myofascial refers to the muscles. The fascia in myofascial refers to a
specific type of deep fascia (connective tissue) that separates and defines muscle tissue. The
term myofascial is sometimes used to reference the fascia that is bound to muscles, and
sometimes to reference the muscle. Myofascial tissue surrounds each individual muscle fiber
(endomysium), bundles of muscle fibers (perimysium) and the entire muscle (epimysium). Each
layer of fascia has a function- the endomysium holds the individual muscle cells in place, the
perimysium provides a pathway for nerve fibers and capillaries to reach the muscle fibers, and
the epimysium separates the individual muscles from one another and from other structures,
and is continuous with the tendons of the muscles it surrounds.

The deep fascia of the muscles (myofascial tissue) is primarily avascular, yet highly innervated
with sensory receptors that detect pain and proprioception. Trixotrophy is the term used to
describe how fascial tissue can chance consistency with temperature changes, manipulation,
and pressure it can be thicker and harder, or more pliable and softer. Deep fascia also has the
capacity to contract, relax, and change its composition in response to sensory input. This ability
for deep fascia to add, reduce, or change its composition is called fascial remodeling.
It was believed that fascia was a passive tissue, but recent studies indicate that deep
fascia can indeed actively contract and relax. These investigations have discovered that fascia
contains smooth muscle-like fibroblasts allowing it to autonomously stiffen. (Schleip, Robert et
al, 2006) An example of rapid fascial contraction occurs during the fight-or- flight response to a
perceived treat (real or imagined). The fascia will temporarily increase in stiffness which
increases the tension in the fascia allowing the individual greater speed and strength in crisis.
(Wikipedia) The mechanoreceptors in the deep fascia can initiate relaxation when indicated.
The mechanoreceptors monitor for muscle tension, joint position, rate of movement, pressure,
and vibration. In order to avoid injury, the myofascial tissue will be triggered to quickly release
tension in response to rapid movements or sudden muscular overload.
Rib Release
The thoracic cage is comprised or 12 pairs of ribs, the 12 thoracic vertebrae, costal
cartilage, and the sternum. The 12 pairs of ribs attach to the vertebrae then wrap around
toward the anterior where they attach to the sternum via the costal cartilage. The thoracic
cage is designed to provide protection for the heart and lungs, and to provide attachment
points for muscles.

Donald W. Scheumann states that It is primarily through the breath that the body receives and
metabolizes the energy that is necessary to carry on its vital processes. (2002) For this reason,
it is impossible for a body to be balanced and to function efficiently if breathing is restricted.

Postural Deviations
Janda discovered that there are some predictable posture patterns that occur in the body. He
noticed that there were certain muscles that seem to be more prone to becoming tight and
other muscles were more prone to become inhibited or weak. For example, Janda's upper
crossed syndrome is a pattern of muscle imbalance typically characterized by tight facilitated
pectoral muscles - major and minor, upper trapezius, levator scapulae, sternocleidomastoid,
anterior scalenes, suboccipitals, subscapularis, and latisisimus dorsi and weak or inhibited
longus capitis, longus colli, hyoids, serratus anterior, rhomboids, lower trapezius, middle
trapezius, and posterior rotator cuff. You might recognize this forward head posture seen
commonly in our society - internally rotated shoulders, protracted scapula and head forward.
Head Forward Postures:
Class II RETRUSIVE (Extensor dominant neck)

shortened/hypertonic capital and cervical extensor muscles

Open the fascial bags of affected muscles:

Levator Scapulae
Lengthen Capital Extensors:
o Suboccipitals
o hyoid
o Scalenes
Superficial Back Line
o perpetual pull resisting flexion causes thick bands (Achilles, hamstrings,
erectors, occipital ridge)
Class III PROTRUSIVE (Flexor dominant) (Military Neck)

Very Challenging to replace curve

Usually Begins in the pelvis

CED Capital-extensor-dominant straight neck

Very common with computer use

Cervical extensors are overstretched and tight (eccentric)
o Semispinalis Cervicis
Capital Extensors are short and hypercontracted (concentric):
o Semispinalis Capitis
o Splenius Capitis
o Longissimus Capitis
o Suboccipitals
o Upper Trap


Muscles Typically Short, Tight and Facilitated:
Upper Trapezius
Pectoralis Major and Minor
Levator Scapular
Anterior Scalenes
Latisisimus Dorsi
Muscles Typically Weak and Inhibited:
Longus Capitis (Deep Neck Flexor)
Longest Colli (Deep Neck Flexor)
Serratus Anterior
Lower Trapezius
Middle Trapezius
Posterior Rotator Cuff

Upper Trapezius
The trapezius muscle fibers can be divided into
three groups: upper (descending) fibers, middle
fibers and lower (ascending) fibers. The upper and
lower fibers act as antagonists to each other in
elevation and depression of the scapula.
Action of
Upper Fibers:
Extends the Head and Neck
Laterally Flex the Head and Neck to the Same Side
Rotate the Head and Neck to the Opposite Side
Elevate the Scapula
Upwardly Rotate the Scapula
Origin of Upper Fibers:
Occipital Ridge, Ligamentum Nuchae,
Spinous Process of C7 through T 12
Insertion of Upper Fibers:
Lateral One Third of Clavicle, Acromiom
and Spine of the Scapula
The Upper Trap Can Combine Forces with the SCM
to Elevate the Shoulder and Drag the Head and
Neck Forward on the Sagittal plane

IAR neck
bring clients right ear to right shoulder
strip upper trapezius using knuckles from center to
attachments at the occipital Ridge and the spine of
the scapula
Using the heel of a your hand strip the Upper Trap

Pectoralis major is divided into three segments the clavicular, sternal and costal fibers. The upper
and lower fibers, perform opposing actions at the
shoulder joint - flexion and extension, respectively making this muscle and antagonists to itself.
All Fibers
Adducts the Shoulder
Medially Rotate the Shoulder
Assists in Elevating the Thorax in Forced
Upper Fibers
Flex the Shoulder
Horizontally Adduct the Shoulder
Lower Fibers
Extend the Shoulder
Medial Half of Clavicle, Sternum and Cartilage of the First
through Sixth Grade
Crest of Greater Tubercle of Humerus
Kyphosis is an abnormally increased curve in the thoracic
spine, sometimes called hunchback. Pectoralis major often times is
hypertonic and appears simultaneously with kyphosis. As a result of
hypertonicity in pectoralis major the arm is pulled into medial
rotation and the scapulas protract. Shoulder impingement
syndrome may occur as a result of the limited range of motion and
loss of function due to the altered scapula position.

IAR Shoulder
Therapist stretches pec major while maintaining a counter
pressure to resists arm movement
Pec Scoop
Attachment compressions

Pectoralis minor is deep to pectoralis major
and lies next to the rib cage. Pectoralis minor
helps to elevate the ribs for inhalation during
aerobic activity.

Depresses the Scapula
Abducts the Scapula
Tilt the Scapula Anteriorly
Assists Enforce Insulation If the Scapula Is Fixed
Third, Fourth and Fifth Ribs
Coracoid Process of the Scapula
Pectoralis minor can create neurovascular compression
when hypertonic, because the brachial plexus, axillary artery and
vein cross underneath it. This pathology is called pectoralis minor
syndrome and is a variation of non-specific thoracic outlet syndrome.
This variation of TOS is more likely to cosmological compression
symptoms then vascular ones. Typically TOS affects the ulnar nerve
it can however irritate the median nerve fibers in which case it may
be mistaken for carpal tunnel syndrome. Typically a chronic
dysfunction caused by poor posture habits or faulty biomechanics.
Specifically, forward head posture with an exaggerated upper
thoracic kyphosis and internally rotated shoulders, often resulting
from poor ergonomics in the workplace.

Bring target arm across body to shorten pec attachments

Palpate the ribs lateral to pec minor
Slowly glide fingers under pec major to palpate pec minor.
Strip pec minor slowly incorporating clients breath

The belly of the levator scapula naturally
twists around itself. When palpating the origin
on the transverse process of the cervical
vertebrae use the soft finger pad to avoid
compressing the nerves of the brachial
Extends the Head and Neck
Elevate the Scapula
Downwardly Rotate the Scapula
Laterally Flex the Head and Neck
Rotate the Head and Neck to the
same side
Transverse Process of the First through Fourth Cervical
Upper Region of the Medial Border and the Superior Angle
of the Scapula
Elevated shoulder is a postural deviation that can occur
unilaterally or bilaterally. This distortion generally occurs from
hypertonicity in the levator scapula or upper trapezius muscles.
Elevated shoulder is typically the result of chronic postural habits
such as holding the phone between your head and shoulder,
although chronic psychological stress can create holding patterns in
the body.

In supine cross arm of targetted LS cross body bringing the

arm high
From the head of the table apply static pressure to the
superior angle of the scapular whild circumducting the arm
Turn the client side lying
Strip the levator attachments posterior and down with

The sternocleidomastoid has a large belly with
two heads; a flat, clavicular head and a slender,
sternal head. The carotid artery passes deep and
medial to the SCM; the external jugular vein lies
superficial to it.
Flex the Neck
Assist in Inhalation
Laterally Flex the Head and Neck
the Same Side
Rotate the Head and Neck to the Opposite Side


Sternal Head:
Top of the Manubrium
Clavicular Head:
Media One Third of the Clavicle
Mastoid Process of The Temporal Bone And The Lateral
Portion Of Superior Nuchal Line Of Occiput
The SCMs along with the anterior scalenes and suboccipitals
can move the neck forward on the thorax and the head forward on
the neck. A pain-spasm-pain cycle can develop if the 11th cranial
accessory nerve is compressed due to forward head translation.
Torticollis is a condition that may be congenital, acute or
acquired, and spasmodic where an individual exhibits involuntary
muscle contractions that lead to abnormal positions and/or tremors
or spasmodic movement of the head and neck. Typically, the SCM
shows signs of shortening, and sometimes fibrosis, scoring or a
palpable mass.

Rotate clients head away from target SCM
Slightly elevate the ocipital ridge to shorten SCM
Pincer grip the SCM starting distal and moving proximal
pulling fingers anteriorly into the static thumb

There are three scalenes sandwiched
between the SCM and the anterior flap of
the trapezius. The anterior scalenes is
partially underneath SCM. The scalenes
elevate the upper ribs during normal
inhalation. The brachial plexus and
subclavian artery pass through a small gap
between the anterior and middle scalenes
Elevate the Ribs during Inhalation
Flex the Head and Neck
Laterally Flex the Head and Neck to the Same Side
Rotate the Head and Neck to the Opposite Side
Transverse Process of Third through Sixth Cervical Vertebrae
First Rib
When the brachial plexus and
subclavian artery are entrapped between the
anterior and middle scalene muscles a nonspecific thoracic outlet syndrome called the
anterior scalene syndrome occurs. As with
pectoralis minor syndrome nerve compression is more common.

Match clavicle angle with thumb or fingers

Lift clients elbow anteriorly until clavicle sucks fingers
under accessing scalene attachments on ribs
Gently oscillate on attachments while moving arm through
range of motion

The Deepest Muscles of the Upper Posterior Neck Are the Eight
Small Suboccipitals. These Muscles Stabilize the Axis and Atlas and
Create Small, Intrinsic Movements Such As Rocking and Tilting the
Head. These muscles are some of the most innervated all spinal
muscles and their unhappy. When put under stressed from
prolonged sitting reading or working in the computer.
Rock and Tilts the Head Back into Extension
Rotate the Head to the Same Side
Various Points along C1 and C2 Depending on Muscle
Inferior Nuchal Line and Transverse Process of the Atlas
Two of the eight suboccipital muscles, rectus capitis
posterior major and minor are guilty of inducing forward head
postures. If held an extended isometric contraction. The rectus
capitis major and minor muscles may become fibrotic and shorten.
When these muscles are hypertonic and short, they in combination
with the sternocleidomastoid and other head extensors slide the
occiput forward on the Atlas through the occipital condyles. This
forces the occiput to hyperextend on the Atlas compressing the
cranial and spinal nerves and vascular structures beneath the
posterior occipital-atlantal membrane. Hello headache!

Ocilating movement along transverse processes with thumb
or fingers
Posterior pull from transverse process to posterior process
Isolated pressure in restricted tissues while moving neck
through range of motion

The subscapularis is one of four rotator cuff
muscles; its the only one that attaches to the
humerus lesser tubercle and acts as the
primary anterior support for the
glenohumeral joint. It is located on the
scapula' s anterior surface between the
subscapular fossa and the serratus anterior muscle.
Medially Rotate the Shoulder
Stabilize the Head of the Humerus in the Glenoid Cavity
Subscapular Fossa of the Scapula
Lesser Tubercle of the Humerus
Together with pectoralis major latisisimus
dorsi and teres major, subscapularis
medially rotates the shoulder. When hypertonic, the increase in
medial rotation of the humerus causes increased protraction of the
scapula rolling the shoulder forward and creating a classic slumped
posture. As subscapularis shortens the rhomboids lengthen and
become weak and inhibited from reciprocal inhibition, therefore
increasing scapula protraction even more.

o Bring clients arm across body exposing lateral edge
of the scapula
o Slide flat hand onto anterior scapula and hold
o Take arm further across body anchoring scapula to
the table
o Anchor elbow on anterior surface of the scapula
o Bring arm anterior while resisting with anchored

The latisisimus dorsi is the broadest muscle of
the back. The origin and the insertion of the
latisisimus dorsi are both difficult to palpate. The
teres major is synergistic with the latisisimus
dorsi and is sometimes called "lat' s little

Extend the Shoulder
Adducts the Shoulder
Medially Rotate the Shoulder
Spinous Processes of the Last Six Thoracic Vertebrae, Last
Three or Four Ribs, Thoracolumbar Aponeurosis and
Posterior Iliac Crest
Crest of the Lesser Tubercle of the Humerus
Like subscapularis, the latisisimus dorsi medially rotates the
shoulder. For those clients who have a sedentary lifestyle and poor
posture slumped shoulders, upper thoracic kyphosis and head
forward posture are quite common and can lead to shoulder
pathologies, as well as disorders of the upper thoracic vertebrae.

o Strip LD from iliac crest to attachment on anterior

Military neck
Laterally flex the head and neck to the same side
Rotate the head and neck to the opposite side
Flex the neck and assist in inhalation (elevation of the rib cage)
Longus capitis
Laterally flex and rotate the head and neck to the same side
Flex the head and neck
Longus colli
Laterally flex and rotate the head and neck to the same side
Flex the head and neck
Forward head
With the ribs fixed, laterally flex the head and neck to the same side
Rotate head and neck to the opposite side
Elevate the ribs during inhalation
Flex the head and neck
Splenius capitis
Rotate the head and neck to the same side
Laterally flex the head and neck
Extend the head and neck
Upper trapezius
Extend the head and neck
Laterally flex the head and neck to the same side
Rotate the head and neck to the opposite side
Elevate the scapula (scapulothoracic joint)
Upwardly rotate the scapula
Semispinalis capitis Extend the vertebral column and head
Hollow chest- the sternum is depressed, upper ribs are compressed, and shoulders are pulled forward

Pectoralis major All fibers:

Adduct and medially rotate the shoulder (glenohumeral joint)
Assist in the elevating the thorax in forced inhalation
Upper fibers:
Flex the shoulder
Horizontally adduct the shoulder
Lower fibers:
Extend the shoulder
Pectoralis Minor Depress and abduct the scapula (scapulothoracic joint)
Tilt the scapula anteriorly
Subclavius Draw clavicle inferiorly and anteriorly
Elevate first rib (to assist in inhalation)
Stabilize the sternoclavicular joint
Internal intercostals Assist with exhalation by drawing the ribs inferiorly, decreasing the space of the thoracic cavity
Anterior deltoid
Flex, medially rotate, horizontally adduct Shoulder
Diaphragm Draw down the central tendon of the diaphragm
Rectus abdominus Flex the vertebral column
Rounded shoulders- shoulders are rotated medially
Upper trapezius
Extend the head and neck
Laterally flex the head and neck to the same side
Rotate the head and neck to the opposite side
Elevate the scapula (scapulothoracic joint)
Upwardly rotate the scapula
Lower trapezius Depress the scapula (scapulothoracic joint)
Upwardly rotate the scapula
Pectoralis major All fibers:
Adduct and medially rotate the shoulder (glenohumeral joint)
Assist in the elevating the thorax in forced inhalation
Upper fibers:
Flex the shoulder
Horizontally adduct the shoulder
Lower fibers:
Extend the shoulder

Pectoralis Minor Depress and abduct the scapula (scapulothoracic joint)

Tilt the scapula anteriorlyAnterior deltoid
Teres major Extend, adduct and medially rotate the shoulder (glenohumeral joint)
Serratus anterior Abduct and depress the scapula ( scapulothoracic joint)
Sagittal Plane Deviations
Lateral tilt of the head
Sternocleidomastoid Unilaterally:
Laterally flex the head and neck to the same side
Rotate the head and neck to the opposite side
Flex the neck and assist in inhalation (elevation of the rib cage)
With the ribs fixed, laterally flex the head and neck to the same side
Rotate head and neck to the opposite side
Elevate the ribs during inhalation
Flex the head and neck
Upper trapezius
Extend the head and neck
Laterally flex the head and neck to the same side
Rotate the head and neck to the opposite side
Elevate the scapula (scapulothoracic joint)
Upwardly rotate the scapula
Levator scapula Unilaterally:
Elevate and downwardly rotate the scapula
Laterally flex the head and neck
Rotate the head and neck to the at 830 same side
Extend the head and neck