Roots

Women's Healing Through Therapeutic Touch

Best Practices

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Nerve Flossing 101

 

 

Nerve compression can cause a variety of discomforts, including tingling, numbness, a burning sensation or radiating pain.  The nerves can be entrapped by muscles, bones or fluid.  Clients with entrapped nerves can benefit greatly from massage therapy.  Active release techniques to alleviate tension in the muscles causing the nerve impingement can bring welcome relief for nerve discomfort.  If the nerve entrapment is caused by pressure from excess fluid rather than muscle tension, then Manual Lymphatic Drainage is the perfect thing.  However, in addition to our session time, I always try to give my clients something they can do at home to help themselves.  For basic nerve issues, I often suggest trying a nerve floss.

Sometimes called a nerve glide, this technique involves mobilizing the nerve.  By slowly and gently gliding the nerve, it is possible to restore stretch and allow the nerve to move freely.  This often decreases inflammation and painful sensations.  It is done with a back and forth movement of the nerve along its pathway, much like the movement of dental floss in between teeth.  The nerve is tensioned first in one direction and then the other.  Once this movement can be comfortably done, you can also stretch both “ends” of the nerve into maximum stretch by stretching into opposite directions at the same time – but it’s best to get comfortable with the flossing motion first.

Clients report very positive results, and I enjoy doing nerve glides on myself.  However, there should always be a word of caution with procedures done at home without the supervision of a therapist!  So here goes:

CAUTION: These movements should always be done GENTLY and SLOWLY – there should be no jerky or aggressive movements.  Once or twice a day, for 5-10 repetitions, is plenty.  It is always advisable to start with the technique for only 1-2 repetitions at a time, to make sure it doesn’t cause further flare-ups of the inflamed nerve.  There can be a slight feeling of discomfort associated with this technique, but it is normally just experienced as a mildly pleasurable pulling sensation.  It should not cause pain, so if there is pain involved, STOP immediately.  Nerve flossing should NOT be done with active inflammatory conditions, acute neurological conditions such as Complex Regional Pain Syndrome, or acute demyelinating diseases such as Multiple Sclerosis.  When in doubt, always consult with your health practitioner.

SCIATIC NERVE:

The most common nerve complaint in my practice is sciatic nerve pain.  There are two doctors, Dr. Brian Abelson and Dr. Evangelos Mylonas, who form “Kinetic Health”, who have some of my favorite nerve flossing videos available online.  Here are two I find very helpful for sciatic nerve impingement, as well as the peroneal nerve further down the leg.

Here is another I like from “The London Chiro” Owain Evans, which is quick and to the point for those who don’t need the full explanation or anatomy lesson.

 

MEDIAN, RADIAL, ULNAR NERVES:

Second most common complaints in my practice are upper extremity entrapments (if you like you can read my previous posts on Carpal Tunnel Syndrome and Thoracic Outlet Syndrome).

Dr. Jo is another Physical Therapist with informative, easy to follow videos online.  Here is her all-in-one video on the median, radial and ulnar nerves and how to floss them.  She has excellent individual ones, as well – you can visit her website for more.

If you like these guys from above, here are Kinetic Health’s videos on the radial and ulnar nerves.

 

I am always looking for ways to empower my clients to take charge of their own bodies and healing.  Barring serious conditions, nerve flossing can be an easy, inexpensive tool to use at home as a complement to other therapies.

 

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Pain Science Reframe: Your Body Is NOT “All Messed Up”

 

At some point during the first intake, almost every new client declares that her body is a “complete disaster”, pointing out everything from tight traps to herniated disks to bad knees.  While it is important for us to discuss and address any areas of injury, I am always careful to gently steer the narrative away from “I’m a mess.”  We are all in desperate need of a reframe in the way we view our bodies, myself included.  I genuinely want to listen to everything a client has going on, and I always want my client to know that she is heard.  However, I want to make sure we are also reworking the pathology paradigm, together.  Bodies deserve more credit, and as scary or counter-intuitive as it may seem at times, we need to have confidence that our bodies “work”.  For the most part, bodies are capable of functioning and healing very well, despite the presence of one or more conditions we consider pathologies, and even despite the presence of pain.  Part of the tunnel vision in seeing only what’s “wrong” and the ensuing feeling of helplessness is ingrained in our system of allopathic medicine.  I have already written a blog post explaining my philosophy around this here.  Unpacking the fear of movement associated with pain and injury is another critical piece in healing.  Perhaps the most important piece in this shift, however, is to look at how we conceptualize pain and attempt to better understand its mechanisms.

Thinking of our bodies as being “all messed up” breeds fear of movement, which is counterproductive to healing.  We need to make some adjustments when dealing with an acute injury, but smart movement is not only possible but necessary.  Strengthening the muscles that support an area of injury as well as any weakened muscles that cause compensation in other areas has been shown to improve overall function.

Gentle, fluid movement increases lymphatic flow, helps the muscles rid themselves of cellular waste, improves joint function and generally decreases pain.  The more we are afraid to move, the less our bodies will ultimately BE ABLE to move.  If instead of thinking of our bodies as “broken”, we think of them as awe-inspiringly capable, with a few caveats, we have a much better paradigm.  This doesn’t mean we have to push through acute pain, continuing to run with an injured achilles tendon, for example.  That would be detrimental to the body (and stupid – I’ve done it).  This means we can’t be afraid of ALL movement, because there is inevitably some beneficial movement that can be done.  These days, even Western surgeons have their patients up and moving just hours after surgery!

 

Of course the other piece to the fear of movement is the avoidance of pain, which is the tricky and complicated part – especially when we get into the realm of prolonged chronic pain. Chronic pain is still not fully understood.  However, recent developments in pain science can help us decipher the multiple causes for pain and what it might actually be signaling.  Here is a great article by Lorimer Moseley on pain.  I will summarize his four key points:

  1. Pain does not provide a measure of the state of the tissues.   In human pain experiments, researchers were able to deliver a non-harmful noxious stimulus to the subjects’ nociceptors (pain receptors) and elicit a pain response, in the absence of actual tissue damage.  In this case, the assessment is inaccurate: there is pain without tissue damage.  In the reverse, there can be tissue damage without pain.  In the now famous MRI study testing the correlation between herniated disks and back pain, asymptomatic herniated disks were found in 52% of the subjects who reported NO back pain.  This experiment has been replicated multiple times, leading to the conclusion that a herniated disk does not necessarily cause back pain.  Again, the relationship between tissue damage and pain is not always correlative nor causative – it’s not that simple.
  2. Pain is modulated by many factors from across somatic, psychological and social domains.  Pain is governed by the central nervous system and has been shown to be affected by emotional states, anxiety and stress.  In my clinical experience, chronic back pain is often affected more by stress and anxiety than it is by anything at the tissue level in the back muscles themselves.  Moseley mentions inflammatory mediators, as well, and through understanding the genomics work that my boyfriend does, I have come to see how chronic inflammation in the body can affect the nervous system and amplify pain.  Our own attention to and expectation surrounding pain is yet another factor in pain modulation.  Anecdotally, we have probably all had the experience of being engaged in a sport or other physical activity, and looking down to find ourselves lightly bleeding from a cut somewhere that we didn’t notice. Once we pay attention to the cut, it starts to hurt.  Studies have shown that if we expect something to hurt, we report the pain as being more intense than if we don’t – and it is postulated that this phenomenon is related to anxiety and stress. Perhaps the most interesting related finding of the studies Moseley cited … believing pain to be an accurate indicator of the state of the tissues is associated with higher pain ratings, whereas believing that the nervous system amplifies noxious input in chronic pain states decreases the perception of pain.  In other words, fear around the belief that pain means our bodies are damaged increases pain levels.  This is not to say the pain is “all in our heads” – the pain is real, and the fear increases the actual pain.
  3. The relationship between pain and the state of the tissues becomes less predictable as pain persists.  As pain becomes chronic, changes occur in the neural pathways and they become sensitized, causing us to experience increased pain even when the painful stimulus no longer exists.  Whitney Lowe, one of my favorite massage educators, explains sensitization very eloquently here and here. Essentially, the nervous system can become more sensitive to certain stimuli once exposed to pain over time.  This is common in the case of trauma survivors, and once the sensitization exists, even a mild stimulus can elicit an extreme pain response.  The two most common clinical manifestations of the changes in the sensitized nervous system are hyperalgesia (formerly painful stimuli become more painful) and allodynia (formerly non-painful stimuli become painful).
  4. Pain can be conceptualized as a conscious correlate of the implicit perception that tissue is in danger.  In other words, when our brains perceive that we are under threat, pain results as one of the outputs of the central nervous system.  Pain is real and can feel debilitating.  His point is that the pain output occurs as a result of the perception of threat, not because of the state of the actual tissue.

 

The good news is that our bodies are not all messed up!

Adopting more proactive beliefs about the body’s potential for good health can help us release some of our fears around movement.  Understanding the effects of anxiety and trauma may empower us to seek out somatic therapy.  Grasping the importance of proper methylation and controlling inflammation may lead us to seek out the guidance of a holistic practitioner.  There is still room for massage therapy in this paradigm, too!  Massage addresses the nervous system, and regular massages may help to alleviate some of the symptoms of central nervous sensitization.  Additionally, massage encourages body awareness, which is key to understanding pain.  It has been shown that even reproducing pain or eliciting a new sensation in a non-threatening environment can begin to rewire neural pathways. As massage therapists, we have the capacity to support agency in our clients by interpreting feedback and learning together how their pain works – we become their partners in shedding some light.  For those of us on tighter budgets, simply educating ourselves on the role of the nervous system in pain management is incredibly impactful, as is finding a buddy who will support and encourage smart movement.

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Simple Ways to Soothe Yourself During a Moment of Anxiety

In this historical and cultural moment, sadly, anxiety has become a part of our everyday lives.  Many of us experience nervous system “red alert” more often than we would like.  I know I do, and I consistently see it in my clients. I am intellectually aware of the ways in which our bodies and minds try to protect us from threats.  I also have a decent understanding of the ways in which these protection mechanisms often go haywire and end up creating or at least perpetuating a sense of threat instead.  (Read here and here for two blog posts I wrote about trauma and the mind-body connection.)  However, rational thought doesn’t help us when we get into a spiral of worry, panic and fear.  For me, it can easily feel like my body and mind are betraying me, since I know I am not in danger and yet I FEEL like the world is caving in on me.  I have been working on reframing this, so that my body is instead my best friend, a safe haven, the only little sanctuary that truly belongs to me on this earth.  The idea is to calm the physiological signals using the body, so I can get myself out of sympathetic nervous system activation and realize that I am safe.

It is worth mentioning that anxiety is complex and multi-factorial.  There are many systems in the body that could be experiencing a disturbance or pathology: musculoskeletal, neurological, biochemical, electrical, energetic and others.  However, in my experience I have found the following to be true for many people:  anxiety disturbs our mind-body connection, scrambling our interpretations as to what is actually happening at the moment.  Mindfulness and body awareness, in my experience, are some of the natural enemies of anxiety.  The more we can connect to our bodies and truly pay attention to what we are feeling, the more we can understand our bodily processes and even use them in our favor.  Using our bodies to self-soothe is obviously not a new idea – as children we did this all of the time.  In many photos of me as a little girl, I am staring distrustingly into the camera, either twirling my hair or sucking my thumb.  As an adult, however, I clearly needed smarter tactics!  Somatic therapy, yoga and massage help, but what about tools to help in a pinch during a stressful moment?  Here are a few that work for me – I hope you find one or two that are helpful.

 

BREATHING TECHNIQUES

Breathing is a fundamental part of any discussion about anxiety.  It’s a cliche for a reason!  The breath is the life force.  At the onset of stress, we might find ourselves momentarily freezing in place, interrupting breathing altogether.  As the heart rate quickens, the breath returns but at a faster pace in the form of shallow breathing.  As we continue to respond to stress, our muscles tighten, including the thoracic diaphragm and other muscles responsible for inspiration and exhalation.  Our stomach muscles often tense up in order to protect our organs, making a full inhale and exhale even more difficult.  Most of us, unless we have specifically done some type of breathing practice, do not take full breaths as we brace ourselves against discomfort.  This, of course, leads to more panic and anxiety.  So the first and best line of defense against anxiety is full, deep breathing.

In order to take a full breath, we must fill our lungs to the sides and down into the thoracic diaphragm as well as the upper part of our chest.  I find it helpful to put my hands around myself in a sort of “self hug”, but down around my ribs.  You can simply put your hands on your ribcage on the same side of your body, too;  I just like the “swaddled” feeling I get with my arms wrapped around my middle.  (It looks less conspicuous if you are in public, too.)  Once your hands are on the ribcage, apply the slightest pressure and slowly breathe out into your hands as much as you can and then fully exhale.  Take a few seconds each for the inhale and exhale and really pay attention to how you feel.  Imagine the stress leaving your body with each exhale. Visualization is another great tool to aid in breathing.  I learned these visualization techniques from Carole Osborne, one of the most respected educators in the field of perinatal massage:

Imagine your torso as a folded umbrella with the edge of the umbrella at your lower ribcage. As you inhale, see the umbrella opening. Exhaling, imagine it closed against the center pole. Continue to open and close the umbrella in your imagination as you breathe for another several minutes.

Once you are able to fill up the lungs out to the sides, place your hands on your belly OR one hand on the belly and one hand on the chest.  Again slowly breathe into your hands so they are rising and then allow a full exhale.  For those of us who grew up on Jane Fonda … this is not the time to be sucking in your stomach.  Allow your belly to look big and round!

The visualization (again, from Carole Osborne):

Imagine that your torso is a beach and that your hands are driftwood on that beach rising and falling with the water’s peaceful movements. With your inhale, watch in your mind’s eye as your “driftwood hands” rise with a gentle wave touching the shore. Let your abdomen swell more extensively than your chest. Feel your hands sink on your torso when you exhale, as you imagine the wave retreating.  Continue to watch the rising and falling of the driftwood on the gently surging and retreating water as you continue to breathe fully for several minutes.

Full, slow breathing practices are generally great for me and easy to do in public, but there are many different types of breath exercises out there.  Andy Caponigro’s book “The Miracle of the Breath: Mastering Fear, Healing Illness, and Experiencing the Divine” is full of good suggestions, including a “Tarzan” breath, a rapid breath of fire and some grounding exercises.

FINGERHOLD PRACTICE FOR MANAGING EMOTIONS AND STRESS*

I learned this from a wonderful woman who works for the National Center on Domestic Violence, Trauma & Mental Health.  She gave me this handout (printable version here), and I would like to share the fingerhold practice in case it is helpful for some of you.  I find it calms me, combined with breathing.

Practicing fingerholds can help to manage emotions and stress. Hold each finger, in turn, with the other hand, holding for as long as it feels comfortable. Hold gently, but firmly. As you hold your finger, breathe in a way that feels comfortable. Many adults feel relief after 2-5 minutes per finger, and children often need to hold their fingers for much less time (30 sec. – 1 min.) for it to feel useful. You can work with either hand, and you can also work with just one or two fingers if that feels most helpful (or you don’t have a lot of time).

 

Key:

Thumb – tears, grief, emotional pain, feeling upset

Pointer/Index finger – fear, panic, feeling scared

Middle finger – anger, rage, resentment, feeling mad

Ring finger – worry, anxiety

Little finger – having self-doubts, not feeling good about ourselves or feeling bad

* This handout was adapted from Capacitar’s Emergency Tool Kit by Jen Curley, National Center on Domestic Violence, Trauma & Mental Health.

 

USING YOUR SENSES

Aromatherapy and music therapy are two quick and easy ways to ameliorate anxiety.  Both affect the brain.  Our olfactory system directly affects the limbic system (“the emotional brain”), which affects those parts of the brain that control heart rate, blood pressure, breathing, memory, stress levels, and hormone balance.  There is a reason why you inhale bergamot oil and instantly feel happy!  I have used essential oils to make inhalers for friends that they can carry around with them.  The inhaler essentially looks like a lipstick;  inside is a cotton wick that holds the essential oils.  They are inexpensive and the wick can be swapped out to use a different recipe.  The recipes can be modified to be safe for children, as well.  A very basic recipe using oils that many people already have is: 5 drops each of bergamot, lavender and frankincense.  Here and here are two other great blends from Aromatics International, and here is a video of Aromatherapist Andrea Butje making her Anxiety Away Blend.

 

Another trick is to sneak headphones on and play music that you find calming.  Every once in a while I wake up at 2:30am worrying about something and I can’t go back to sleep.  When this happens, I put on music:  whale sounds, nature sounds, singing bowls or soothing music.  Even if I can’t fall back to sleep, at least I am awake and calm as opposed to awake and freaking out.  Music has been used as therapy for ages.  Research shows that listening to music stimulates more areas of the brain than any other human function.  Among many other things, music lowers levels of the stress hormone cortisol, so it has a powerful effect on stress.   According to a large scale McGill University review, listening to music prior to surgery was more effective in reducing patients’ anxiety than prescription medication.  Music therapy is currently being successfully used to alleviate anxiety in patients with dementia, cancer, chronic pain and depression.

 

VAGUS NERVE STIMULATION

The vagus nerve plays an important part in the parasympathetic nervous system, or the “rest and digest” system.  It runs from the brainstem through the neck to the heart, lungs and other internal organs – it’s amazing how many body systems this nerve is involved with (it’s name derives from the Latin word for “wandering”, if that tells you anything). It keeps the body in balance through neurendocrine-immune axis activity and the regulation of metabolic homeostasis.  This nerve mediates sensory information to the brain and has direct and indirect connections to the neural circuit which pertains to emotional and cognitive functions.  People with low vagal tone often suffer from depression and/or anxiety (among other things), since the ability to get into “rest and digest” is compromised.  Research has been mixed, but the concensus seems to be that stimulating the vagus nerve may offer benefits, including stress reduction.

Vibration in the throat is the easiest way to stimulate this nerve.  All of the below would do the trick, plus most are fun:

  • gargling
  • chanting
  • singing
  • laughing

You all know I love doing the “horselips” and it’s even better if I combine it with a low guttural noise before or after.  Laughter, in this case, truly can be the best medicine.  I keep a few “bloopers” style seconds-long videos on my phone for moments of panic.  These videos make me belly laugh every single time and the anxiety magically lifts.

The vagus nerve responds to cold exposure, so to possibly alleviate anxiety in a pinch, you could splash cold water on your face.  I haven’t tried this one specifically for anxiety, but I do enjoy a cold shower post-run and have noticed uplifting effects on my mood (which could have been the run, too).

 

MUSCLE DECOMPRESSION FOR TENSION RELEASE

JAW

Those of us who hold tension in our jaws will find relaxing the mouth and jaw works wonders in combatting worry and anxiety.  My first step is normally to flap my lips in “raspberries” or “horse lips” fashion.  I look ridiculous but I can’t believe how much doing this calms me down.  I then place my hands on the sides of my cheeks, apply pressure and slowly drag down, allowing my mouth to open if necessary as my hands glide down my face.  I know most people are accustomed to pulling the cheek skin up rather than down for vanity purposes, but the point is to traction the masseter muscle away from its origin.  In other words, we want to apply pressure in the opposite direction of normal contraction.

SHOULDERS

It can be helpful to exaggerate a tensed posture first in order to get a better release of tension.  With the shoulders, you can tense up and shrug your shoulders for three seconds and then drop the shoulders dramatically as you exhale, sighing audibly if that feels good.  This one does not work for me, personally, but I have friends and clients who swear by this method of tension release.  I have modified the idea in a way that works better for me:  I tense my shoulders back rather than up, squeezing the rhomboids for 3 seconds, which also allows the chest to open up, and then I drop the shoulders into relaxation.

CHEST

Tightness in the chest is a common complaint accompanying feelings of anxiety.  The breathing techniques above are all great for decreasing this tightness.  In addition to breathing, however, I like to externally manipulate the chest (which helps to facilitate the breathing).  One way to do this is to stretch the pectoralis muscles in something like a doorway stretch (blog on that here).  However, when I am feeling anxious, I find that feeling contained feels better, again like swaddling.  Anxiety is individual, so you can experiment and see what feels best for you.  I like to put one or both hands over my sternum.  I can feel my heart and lungs, which makes me feel very safe.  This also connects me to my heart center, reminding me of my gratitude practice.  I then put the slightest pressure on my sternum, just enough to get good traction on the skin, and I move the skin around in slow big circles, or sometimes just move the skin laterally and hold for a few moments and then do the other side.

I will admit that I do not fully understand the mechanism through which this might work, but it does (for me).  As skin stretch is the major modality used in dermoneuromodulation, I suspect the answer may be found here.  A very simplified version of this theory is that by engaging mechanoreceptors in the skin through skin stretch, we are giving the nervous system input that helps it downregulate nociception.  By providing the cutaneous nerves with novel stimuli, we are affecting the nervous system in a broader sense.  I have only begun to scratch the surface of Diane Jacobs pivotal work, so forgive the crude explanation.  All I can say with certainty is that a slow gentle skin stretch on the sternum greatly reduces a sense of panic in me personally, and I use it often.  You can try it and decide for yourself if it helps.

 

GROUNDING YOURSELF

Making ourselves feel “safe” appears to be a big factor in alleviating anxiety.  One way to do this is to feel that we are on solid ground, bringing us back to “earth”.  Connecting with the natural earth, if it’s available to you, is best, but even feeling the floor in your office beneath you can be reassuring.  A few suggestions for feeling grounded:

  • walk on grass, barefoot if possible (watching out for dog poop, glass, etc)
  • stomp your feet on the ground to feel how solid it is beneath you, knowing you are supported
  • put your back up against a wall, again so you feel supported, with something to “lean” on

 

SUPPLEMENTS

As supplements are outside of my scope of practice, I asked genomics expert and functional medicine practitioner Ryan Frisinger if he had any safe over-the-counter supplements to combat anxiety.  He gave me a GABA spray (that included things like L-Theanine, L-Carnosine, and pterostiblene) that worked great for me, taken before bed to wind down or anytime I felt stressed, but he cautioned me that it was not for everyone.  The spray worked with my particular genetics, but could be harmful to someone else.  He suggested Hyland’s Biochemic Phosphates, which are specifically formulated for anxiety and nervous system exhaustion and generally safe for everyone.

However, he was clear that anxiety is complicated and deserves a more thorough examination.  Here is what he said:

A lot of anxiety is driven by foods that are excessive in tyrosine, tryptophan, sulphur and methione.  All of those have the potential to activate the fight or flight response and imbalance neurotransmitters.  The first step is to eat an anti-inflammatory diet: no grains, dairy or sugar.  Additionally, many things in our modern medicine toolkit cause antibodies to the GAD enzymes, which make it hard for the body to change glutamate into GABA to help move the brain from a state of excitation to inhibition.  We must also look at broad scale nutrient deficiencies (B-vitamins, magnesium, zinc, vitamin D, lithium orotate, vitamin C), because the biochemistry of the brain is downstream and if there is an insufficient supply of nutrients, we have uneven production of neurotransmitters.  There are lots of supplements on the market that propose cures for anxiety like nervines (passionflower or Kava), or GABA sprays and capsules (Kavinace). Most of those are too generalized to treat anxiety effectively as the problem is always multifactorial in nature.  It is also important to draw a distinction between anxiety and depression.  Monitoring sleep quality is crucial because that will undermine the neurotransmitter system’s function and the circadian biology of the cells and organs.  Finally, we need to be mindful not to overstep energetic boundaries, as some of this anxiety is caused by lifestyle choices that lead to chronic exhaustion of the nervous system.

I couldn’t agree more:  diet, sleep and lifestyle are the areas to target when thinking about optimum functioning, which includes nervous system and emotional states.  Until we have these dialed in, however, we need little tools to get us through stressful times.  When I pressed him for a short-term suggestion to combat acute stress, he emphasized the importance of reengaging the brain to stop the spiral of anxiety.  (That will be the subject of another post in the near future.)  He agreed with all of my suggestions above, with the walk in nature being his top go-to, but added that 10 minutes of Tetris is HIS quick way to halt anxiety/panic attacks in their tracks.  (If you are intrigued and want to hear more about Ryan’s work, I have listed some podcasts in the resources below).

These are just a few of the tricks I have learned along my journey of self-knowing.  When I start to go down the spiral of worry, fear and panic, I try to be as compassionate with myself as humanly possible.  None of these tricks works for me EVERY time, except for maybe the breathing techniques, but the more I develop body awareness, the more I find I can handle my stress with equanimity.

 

ADDITIONAL RESOURCES:

Vagus Nerve Stimulation Study

Vagus Nerve Stimulation Article

 

Ryan Frisinger Podcasts:

Open Source Medicine

Robb Wolf

Beyond Your Wildest Genes

Tangentially Speaking

The Bledsoe Show

The Lost Files

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Upper Trapezius: The Case For Strengthening

This is the second part of a two-part post about strengthening the musculature in the posterior neck and shoulder region.  Please read part 1 for the reasoning behind why this may help ease discomfort in this area (and for ideas on how to strengthen your rhomboids).  This post will focus on a muscle we all know well … the upper trapezius!  Many, many of us experience some type of discomfort in the upper part of the shoulder.  We often attribute this sensation to tightness in the upper trapezius.  However, I have found that stretching and massaging those fibers rarely provides any lasting benefit.  Both of these interventions feel great and increase body awareness, which is one of the most important aspects of healing.  In terms of prolonged benefit, however, I haven’t had much success.  (Stretching and massaging the muscle directly beneath the upper trapezius, levator scapulae, is a different story altogether – this works wonders, and will be the subject of another post in the future.)  

Yet, there is something going on with this muscle in many of my clients, as they exhibit the typical pain referral patterns and “question mark shaped” headaches associated with it.
Like the rhomboids, clients often feel a tautness in the upper trapezius accompanied by a constant throbbing sensation, suggesting that it is probably weak and overstretched rather than “tight”.   Again, in these cases, clients will benefit more from strengthening than stretching.

ANATOMY & PHYSIOLOGY:

The trapezius is a large, superficial muscle that connects the collarbone and shoulder to the entire cervical and thoracic spine.  The part I am concerned about in this post is the upper trapezius, which originates on the occiput, ligamentum nuchae in the neck and the spinous process of the C7 vertebra (some sources say all 7 vertebrae, some say just the connective tissue and C7).  It inserts into the lateral third of the clavicle.  In other words, it runs from the base of the skull and the fascial fibers in the back of the neck to the outer portion of the collarbone.  There is some controversy as to the function of this muscle, and it is hard to separate the upper fibers’ function from the rest of the muscle.  All of the fibers work together, although during different actions some areas of the muscle work harder than others.  The standard anatomy answer is that the upper trapezius is a prime mover of scapular elevation,  which means it raises the shoulder blade.  However, there is some excellent research (see resources below) to suggest that, due to the transverse direction of the upper trapezius fibers, its main function is to move the clavicle medially, thereby transferring compression loads from the cervical spine to the sternoclavicular joint (where the collarbone meets the sternum).  This essentially means that the weight of the arm and anything it carries is transferred to the chest and mid-body rather than the neck.  Pretty important!  It would make sense then that if this muscle is weak, we might have some neck pain.  This also makes the case for strengthening.

It is worth mentioning again that movement is complicated and muscles perform various functions to varying degrees, depending on the orientation of the body.  In this case, the upper trapezius DOES perform scapular elevation and upward rotation in conjunction with serratus anterior, once the movement is already started.  It appears to be strongest when the arm is already slightly raised away from the body in abduction.  We can use this to our advantage, as it gives us an easy movement to perform in order to strengthen the upper trapezius!  The added benefit is that any overhead exercises eliminate the action of the levator scapulae, which is already overworked in most people.

Just as in my rhomboid post, these exercises are general suggestions.  Unless you have specifically done these before, or are familiar with exercise physiology, please consult a personal trainer prior to incorporating these into your exercise regimen.  It is important to start with the lightest weight (or no weight) first to make sure you have the proper form and to move slowly and gently (NO jerky movements).  Always pay attention to your breathing during any movement – the general rule being exhale upon exertion.  Finally, if you google these you will find some conflicting information.  Many trainers and physiotherapists think that, “in general”, upper traps need to be stretched rather than strengthened.  In addition to anything you may find on your own, I urge you to read the resources I have included at the bottom of the post and then make your own decision as to what you think might be happening with your shoulders.

Here are two exercises for strengthening:

OVERHEAD SHRUG

The overhead shrug is a great exercise for the upper trapezius, provided you do not have a problem with shoulder mobility (in either flexion or abduction).  Start without weight just so you understand the motion.  Lift your arms directly above your head (from a standing or seated position, but I prefer standing), with slightly bent elbows.  From that position, reach your arms more toward the ceiling and perform a shrugging motion.  In the video below, her arms are straight, but I think it’s better to do them with slightly bent elbows like the picture above (forearms are still perpendicular to the floor, this is NOT a Y-shape).  Ask a personal trainer which might be better for you. Some things to notice:

  1.  Make sure your ribcage is not flared out when your arms come up.  If it is, use lighter weight, OR you may need to work on your shoulder mobility for a few weeks prior to attempting this exercise.  For the yoga people, let yourself hang out in a child’s pose for a few minutes daily until your shoulders can more easily go overhead without the rib flare.
  2. Make sure you are solid in your core as your arms go up.
  3. Make sure you are breathing properly.

If you do not like overhead movements and choose to do standard shrugs instead, I like Adam Meakins’ “Monkey Shrugs”.  In order to properly engage the upper trapezius, your arm can not be in a neutral position; it must be in at least 30 degrees of abduction (away from the body).  So he suggests taking weights in your hands with your arms at your side, sliding your hands up to about waist level and shrugging from THAT as your starting position.  This will ensure that you are working the upper trapezius.

WALL SLIDES

This exercise is excellent for upward rotation, which is a problem for many of us.  It works both upper trapezius and lower trapezius.  The photo and description are from flexibilityrx.com

Begin with your forearms in contact with the wall, shoulder width apart. The elbows are bent at ninety degrees and wrists in line with the elbows. Keeping your forearms in contact with the wall – slide your arms up and out – without shrugging the shoulders. Controlling the lower part of the shoulder blade with the lower trapezius helps prevent the shoulders from elevating during the movement.

I use the term ‘pack scapula down’ – not to describe a rigid position – but a controlled retraction of the scapula during its upward rotation (see illustration). Focusing on lower trapezius engagement as the scapula rotates out to the side creates this position of dynamic stability.

 

Integrating Lower and Upper Trapezius
At the top of the movement – with the arms extended, pull the arms back 2-inches retracting the shoulder blades (part B). A slight shrug while pulling the arms off the wall engages the upper trapezius for full upward rotation. Note – the shoulders remain relaxed down as the arms slide up and out (part A), before a shrug is added at the top position to pull the arms back (part B).

This motion is similar to an overhead barbell shrug where a shrug at the top of the lift is used to enhance upward rotation – as the scapula is controlled by the lower trapezius. This timing of lower and upper trapezius activation takes some practice – the initial focus should be upward rotation without elevating the shoulders (part A of the exercise).

After pulling the arms back off the wall (part B) return the arms to the wall and slide them back down to the starting position – maintaining contact with the wall (part C).

Some things to notice:

  1.  As your arms slide up the wall, make sure you are not making a circle and bringing them together – the point HERE is to go out into a Y shape.
  2. Make sure your hands are not turning inward into medial rotation as you slide up.  The outside of your hand should remain in contact with the wall.
  3. Make sure you are breathing properly.

 

RESOURCES:

“The Upper Trapezius Does Not Elevate the Shoulder”, Hammer, Warren, MS, DC, DABCO

“Anatomy and Actions of the Trapezius Muscle”, Johnson, G., Bagduk, N.

“The Upper Traps:  Overassessed, Overblamed and Very Misunderstood”, Meakins, Adam (DISCLAIMER:  This man is a sports physiotherapist and makes some brilliant points. However, his personality is caustic and he is completely against manual therapy. In my opinion, he takes a very simplistic view of the benefits of manual therapy and does not respect the gains to the nervous system and the importance of fostering body awareness. While I fundamentally disagree with his views on manual therapy, I still very much respect his knowledge of sports physiotherapy!)

“Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula.”, Pizzari, T, Wickham, J, Balster S, Ganderton, C, Watson, L