Writing

 

What is That Bump on the Back of My Neck? -June, 2018

 

When I was finishing graduate school in 2006, I had a friend who was also 29 years old who pulled me aside at a BBQ. She told me about how she had noticed a strange new development in her anatomy. While she was away on vacation in Argentina, she had the opportunity to dance tango and don open back tops and dresses. She had had a ton of photos taken of her while she was away, and she noted a burgeoning bump at the base of her neck. She showed me a couple of photos in which the spot in question was pronounced by lighting. My friend was healthy- she had no medical conditions or issues. I knew immediately what my friend was witnessing- joint hypomobility at her cervicothoracic junction.

The cervicothoracic (CT) junction is where the highly mobile cervical and small cervical spine transitions into the stiffest most immobile section of the spine- the thoracic spine.

The limited mobility of the thoracic spine is due to the two ribs that articulate with each thoracic vertebra. Unlike the lumbar or cervical vertebra (which each have two facet joints that guide mobility), the thoracic spine has two facets plus four costovertebral joints. The attachments to the ribs and sternum highly stabilize the thoracic spine.

In order to navigate the transition zones if the spine, segments of the last few cervical spine and first few thoracic spine resemble one another. The cervical facets and transverse processes of C6 and C7 (the last couple cervical vertebra) are more like thoracic vertebrae in orientation.

The visible bump you can sometimes see and feel is most likely associated with stiffness at the CT junction- the lowest cervical vertebra and the upper most thoracic vertebra. The vertebra are sliding backwards (towards the back of your body) and becoming stiff/ resistant to sliding toward the front of your body. This is often called forward head posture.

My yoga teacher, Tias Little, has dubbed this position “tech neck”. But this issue has been pervasive in bipeds and discussed by such greats as Thomas Hanna and Vladimir Janda. Dr. Janda has described this posture that results in the “CT junction bump” as crossed body patterning. He correctly identified the following in clients exhibiting this:

  • Weak longus colli (deep cervical spine flexors)
  • Tight suboccipital muscles
  • Weak mid trap and medial scapular muscles
  • Tight anterior chest

The simplest movements solutions you can take for this problem:

  • You will notice there is no stretching assigned for the neck. This is because the neck is inherently too mobile. Strengthen and contain the forward progression of your head. Yes, of course, the muscles on the tops of your shoulder (upper trapezius) are rocks- but that is because they are attempting to keep your head from falling further forward. Rather than treating them directly, try the techniques below so they can relax on their own accord.
  • Watch your posture!
  • Get rolling
  • Strengthen your back

 

  • Watch your posture!:

learn how to strengthen the deep cervical flexors and actively open the suboccipital muscles at the back of the skull. When they become strong they will enhance your proprioception and you will better be able to feel your alignment

Try this at home: Lie on your back without a pillow behind your head. Perform a gentle head nod “yes”. Maintain this “yes” position of the head as you begin to lift the weight of your head off the ground. You may only get 25 or 50% of the weight of your head up. That’s OK. Go slow. If you can lift 100% of your head do not lift more than 2-3 cm. Hold whatever you can for a slow count of 5. Perform 10-20 reps everyday.

  • Get rolling:

Open your pectoralis major and minor and mobilize your thoracic spine anteriorly by lying on the foam roller

Try this at home: Lie on your back on the foam roller. Let your hands rest at your sides. Turn your palms to face up. Gently rock right and left while breathing diaphragmatically. This will allow your anterior chest to open up and your shoulder blades to fall back. Perform 5 minutes 2-3 x a day.

  • Strengthen your back:

Strengthen the forgotten muscles of the mid back (between the shoulder blades). These muscles are meant to be the “core” of our cervical spine. Focus on the middle and lower trapezius, the external rotators of the shoulder and the rhomboids.

Try this at home: Is,Ts,Ws, Ys

Lie on the floor, face down. Roll a small towel and place it under your forehead. (Is)Reach your arms down at your sides, palms down. Engage your abs, glutes and draw the shoulder blades into a down and back position. The arms may lift- but keep them no more than 1 inch off the floor. Hold 10 seconds, repeat 15 times.

(Ts) Begin in the same position, but with your arms out like airplane arms, palms down. Draw the shoulder blades down and back, arms may hover off the ground. Hold 10 seconds, repeat 15 times.

(Ws) Arms in “W” position with palms down. Draw shoulder blades down and back. Hold 10 seconds, repeat 15 times.

(Ys) (Best done over a gym ball) Reach both arms overhead with the thumbs up in a “Y” position. Draw the shoulder blades down your back. This one is really tough. If you cant lift your arms without lifting your shoulder blades don’t! Hold whatever you can for 10 seconds. Repeat 10 times.

 

Why Riding the Bike May Not Be the Best Recovery Tool Following a Knee or Hip Joint ReplacementMarch, 2018

I have been in orthopedic practice as a physical therapist (PT) for over 12 years (though I have been working in PT since 1995). During that time, I have had front row seats to the evolution of joint replacements. I have witnessed changes in the process for how surgeons decide who needs one and who does not, I have witnessed varied surgical techniques (in the operating room), I have provided changes in post surgical rehabilitation and I have noticed the evolution of techniques and prosthetics (the metal and plastic components that are put in place inside of the patient’s body).

One variable that has been consistent throughout my career is the recommendation to spend time riding a stationary bike (now this is true both for hip and knee replacements).

Now I love riding bicycles- even stationary ones. I have had a stationary bike at every clinic I have ever worked at, and though I don’t profess to love stationary bicycling in my free time, I will occasionally take a spin class. I use our stationary bike almost every day- especially when I am doing interval work for people who have difficulties walking. Stationary bikes are very useful.

One thing about riding bikes (as anyone can profess who has ridden one) is that your body is in a fairly stationary position throughout the process. Now, I am not talking about Tour de France athletes who are out of the saddle, hanging off the side as they corner sleek ridges. Nor am I writing to mountain bikers who again, are largely flying down hills and over jumps with their back ends trailing the bike by about a foot and hovering in the air.

I am writing about stationary bike riders. If you have ever ridden a stationary bike, please picture how it felt. Your pelvis is resting on the seat. If you are fortunate enough to be on an upright bike (and there is a reason to ride an upright or recumbent which relates to the spine, which I will not have a chance to get into- maybe another time), your pelvis is fixed on a seat. Hopefully you have adjusted the height of said seat so your knees are not crunching up into your armpits ala wicked witch of the west. And hopefully the seat is not so high so that you are rocking side to side with each down stroke. And I hope there is an adjustment that allows you to modify how far your seat is from the handle (arm reach is extremely variable).

So we’re assuming your set up is ideal.

The stationary bike (both recumbent and upright) basically assume a seated posture (even when the set up is ideal for your body). One thing we know about a seated position is that (for better or for worse) it does a few things well: shortens the 2 joint hip flexors and knee extenders, lengthens the glutes. It does other things as well (potential sciatic nerve traction and or compression) but again, that is for another time. Biomechanically, we are shortening the front of the body and lengthening the back. The gluteals (the large muscles you normally sit on which are required to be the shelf for our spine) have difficulty contracting when they are lengthened or we are sitting on them (please, give it a shot the next time you are sitting). The above mechanical shifts are really closely tied to why sitting is getting such a bad rep (please see Kelly Starett’s Sitting is the New Smoking for more on that topic).

Layer on top of this the reason behind why osteoarthritis develops in the knee in the first place: weak gluteals coupled with poor flexibility of what we call the two joint structures (to name names: iliopsoas, hamstrings and rectus femoris.

As a clinician, I find in 99% of patients I work with following a joint replacement have the above findings (weak rear end and tight anterior structures).

Why would surgeons make recommendations to get on the bike given all that it doesn’t do? (Strengthen the butt and get you out of hip flexion)?

I think the reason that the stationary bike is so often referenced in post surgical plans for lower body joint replacement is for 2 really good reasons:

  • The bicycle strengthens the quadriceps, hamstrings and allows you to progress through range of motion (the available movement across your knee)
  • The bicycle is non weight bearing (which allows the weight bearing structures to have a break in healing)

In addition, a surgeon’s training is spent largely on skills to become a successful surgeon. Not to become excellent at movement retraining or rehabilitation. That is the sole career focus of a physical therapist.

After a joint replacement, use the bicycle sparingly for recovery. For range of motion the bicycle is fantastic. But make sure, especially if you are a cyclist, not to skimp on time with your Physical Therapist. He or she will work with you to cultivate a bespoke movement program that follows post surgical precautions and guidelines. It will include edema control, range of motion techniques and progressive exercises so that you can gently return to function. Most importantly, you need to get out of the movement patterns you were in prior to having your surgery (and I would be very surprised if you did not have weak buns prior to surgery).

This process is known as muscular re-education and proprioceptive training and it takes time and work

And if you continue to have knee clicking or emerging pain in your hip do not hesitate to follow up with your PT.