Dowagers hump...
dawnray said:
He is 42, not very interested in self-care, unfortunately. He generally doesn't "like" anterior neck work, even though it's what he needs. He won't really allow me work that area.
I am still a newbie therapist. Breathe, help me with the hip posture, if you will. How do I evaluate that? Check to see if the ASIS's (?) are level? And?? Can I send you the photo link, would it help?
I know he needs to do a lot of self care such as stretching and walking and such, but he seems content with the path he's on.
If the client isn't interested in following up with self-care, there's probably not much you can do for a forward head posture. But if he WERE interested in improving posture, (through stretching, strengthening,) you would start with a visual and ROM assessment, looking for anterior tilt (or less commonly, posterior,) high ilium, one leg forward, one or both knees locked. Test ROM when on the table, psoas (hip extension), internal/external rotation of hip, flexion of knee, etc.
To check if the ilium are level, make sure they are lying straight on the table, head in neutral, no bolster, then close your eyes and palpate to the PSIS. Keep your finger on the landmarks on either side, then open your eyes and look. If on one side your finger is higher, voila! look for an imbalance - tight muscles on one side of the back, pulling the ilium up.
You can do the same thing in supine with the ASIS, but that is a little more complicated to know what to do for low ASIS. You can check Whitney Lowe's work for some interesting discussions on innominate rotation, and lateral tilt.
In forward head posture, you really can't get a lasting change in posture if you don't balance the rest of the body. Pelvic imbalances affect tensions on the spine. (short leg can also affect head posture, but you need to eliminate restrictions in the pelvis before you can get a good estimate at possible leg length discrepancy issues.)
After that work, you can then look at the muscles that pull the head forward, and others that have to tilt it back up once it's pulled forward. It's not relaxation work. You do need to get deep into the anterior neck, and although it doesn't have to hurt, it's not the type of work you would do in a relaxation setting.
Erik Dalton and James Waslaski* have some great protocols for dealing with forward head posture (upper crossed syndrome) and pelvic balance.
You say you're a newbie therapist. Don't be afraid to work on people with complicated conditions, but if you're going to do cervical work, make sure you're doing all necessary tests (I learned about that this weekend- and I have to say I have NOT been doing the necessary tests - alar ligament, VBA insufficiency and cervical compression/distraction- so glad I haven't yet had any issues. *gulp*) Be conscious of learning about what you want to try and be aware of the science behind treatment work-- primarily, is what you are doing creating balance, or contributing to imbalance? (Primary example of that is doing deep tissue to loosen up the rhomboids for thoracic pain. WHY would a therapist do that? Who in here has ever seen a shortened rhomboid? Yes, the rhomboids need work, but don't be lengthening an overstretched muscle and expect long lasting benefits.)
But...
The client must have a desire to change their postural habits and their self-care, otherwise, why waste your efforts? Use the situation for what it's worth... a real life example that you can use as a learning tool to become a better therapist. But do not expect change from a client who is not looking for it. You will only be disappointed.
You can educate your client though:
"I'd like to show you something Mr. Forward Head. Massage therapy can do more than just take your stress down, it can increase your comfort in your body, and we might be able to change some of those headache issues (after we
and your doctor have ruled out any serious conditions.) We can do that by lengthening these muscles so that your lower back has more room, your upper back is less curved and your neck muscles don't have to work so hard to keep your head up and stable.
Let me show you in this book which muscles I am concerned about: (show nice big pictures.) If you want to try these techniques in your next session it requires a commitment, because to keep any gains we make, you will have to do some stretching for a few minutes every day at home, and later on, some specific strengthening. Do you think you might want to try something like that?"
Your dialogue may vary, but treatment work is a collaborative process. If your people are coming in, getting on the table, pointing and saying "fix me," then lying quietly or chatting for an hour while you rub them, it is palliative work. Palliative work has tremendous health benefits, but it has a lesser effect on structural issues.
* I'm familiar with the work of these three educators, having taken workshops with them or studied their published works. There are many fine educators out there doing and teaching structural bodywork, so others might prefer the work of another teacher.
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