Sternocleidomastoid syndrome

Treatment

Passive care (3x / week for 2 weeks)

The patient received passive care three times per week for the first two weeks. The treatment included diversified manipulative therapy of the affected joints; trigger point therapy (ischemic compression) of SCM and upper trapezius muscles; passive stretch of SCM, pectoralis, scalenes, suboccipitals, and upper trapezius muscles; and post isometric relaxation (PIR) of the SCM muscle.

The SCM stretch was an essential part of the each treatment, with the patient placed in a supine position with her shoulders at the edge of the table, her head held at the base of occiput, rotated away from the affected side, laterally flexed toward the affected side, extended at the lower cervical and flexed at the upper cervical (chin tuck with neck extension). This stretch was held from five to forty-five seconds, dependent on patient tolerance. PIR was accomplished by instructing the patient to actively raise her head slightly when it was rotated. This effort was resisted by the practitioner to allow for an isometric muscle contraction. The SCM muscle was then stretched in the same fashion as before.10

Postural advice was provided during the course of passive care to prevent further aggravation of the region. The patient was instructed on exercises to carry out at home three to five times a day. These involved standing with her buttocks and shoulder blades gently against a wall, then slowly retracting her head backward until her skull touched the wall. This position would be maintained for thirty seconds. The goal of this exercise is to make the patient aware of their posture and over time to develop better postural habits.


Phase I Rehabilitation (3x / week for 4 weeks)

The second phase of treatment started in week three with the addition of a rehabilitation component to the passive care described above. This phase was performed at a frequency of three times per week, and lasted for four weeks. The patient was re-evaluated once every two weeks so appropriate modifications to the exercises could be implemented.

Initially the patient was trained on proper self stretch of the upper trapezius-, pectoralis major and minor-, sub-occipitals, levator scapula- and SCM muscles. She was then instructed on a number of exercises designed to facilitate the lower-, middle trapezious and deep neck flexors. The muscle facilitation was accomplished through specific exercises, such as the following:

  • Wall angels (shoulders abducted, elbows flexed, gradually brought back to sides, while retracting scapula)

  • Bruegger exercise (sit at the edge of chair, anterior pelvic tilt, chin tuck, hands turned outward, thumbs up pointing upward and behind shoulders, fingers wide apart)

  • Chin tucks

  • Dead bug (supine, knees and hips bent, spine in neutral position, maintain abdominal bracing as arms and legs are moved back and forth)

  • Quadruped (on hands and knees, spine in neutral position, abdominal bracing, head neutral position, arms and legs raised)

  • Upper back cat (on hands and knees, chin tuck, move buttocks toward ceiling).7,10

Proprioceptive exercises play an important role in retraining primary stabilizers of the spine and reprogramming subcortical connections to improve balance.14 Both rocker and wobble boards were used for proprioceptive training with eyes open for the first week and eyes closed for the second and third week.14 Isometric neck exercises were conducted during the first week using a medium size ball against the wall to strengthen weak neck flexors, extensors, rotators and in lateral bending. During week three the ball was replaced with surgical tubing which would allow full neck ranges of motion with resistance.11



Phase II Rehabilitation (3x / week for 8 weeks)

In this stage the passive treatments such as manipulation and trigger point therapy were performed only when indicated. Previous exercise programs were continued with increased intensity and free weights were introduced to continue to strengthen the lower and middle traps.

This was accomplished using the Zinovieff technique for one arm rows, seated rows, shoulder shrugs, shoulder press and upright row and latismus dorsi pull downs. The Zinovieff technique is a good beginner protocol, made of three sets of ten repetitions with one minute interval rests in between, three times per week.11 The first set is at 10 repetitions maximum (RM), second set 75% of 10 RM and the third set at 50% of 10 RM.

three sets of ten repetitions with one minute interval rests in between, three times per week





The patient was also trained on proper breathing techniques. Diaphragm breathing inhibits the involvement of overactive accessory breathing muscles and keeps their activity to a minimum during rest.8 Accessory breathing muscles are designed to assist breathing only during exertion to further expand the ribs but should remain primarily silent at rest.8

Once the second phase of rehabilitation was completed, the patient reported experiencing relief from over 80% of her original symptoms. It was clear that the patient's physical and emotional challenges as a mother of two young children could be expected to continue to test her physical limits. Therefore, the importance of a continued self directed exercise program, coupled with occasional supportive care at our office (so as to prevent deterioration of her physical condition to a critical level once again) was discussed. The patient was open to the idea, and appeared determined to follow through with her exercises and an occasional visit to our office to monitor her progress.