User talk:Fattypratty

Im starting an article on Lower Trapezius and how to reactivate it, but first i need to findout how to create the page so ive got a lotta reading to do

The trapezius muscle (Figure 1) has a central role in the shoulder girdle complex (SGC). It is important in providing both stability and mobility to the scapula that is essential for normal upper limb function. The focus of this paper will be the lower trapezius (LT), specifically weakness of this muscle and the consequences on shoulder function

Anatomy
The trapezius is a large, triangularly shaped muscle of the posterior thorax and neck and is commonly divided into upper, middle and lower portions (Figure 2). It extends laterally on both sides of the spine from the medial third of the superior nuchal line and external occipital protuberance of the occipital bone, the ligamentum nuchae, the spinous processes of C7 to T12 and the interposing supraspinous ligament (Standrins et al. 2005). From this origin the upper fibres run inferolaterally to attach on the posterior border of the lateral one-third of the clavicle; the middle fibres traverse horizontally to insert on the medial aspect of the acromion and along the superior margin of the spine of the scapula; and the lower fibres run superolaterally to attach on the inferior lip of the crest of the medial scapula spine (Standrins et al. 2005). The spinal accessory nerve (cranial nerve XI) courses through the posterior triangle of the neck to form the sole motor innervation of the trapezius muscle. The ventral rami of C3 and C4 contribute to its proprioceptive innervation (Chan & Hems, 2006) and the dorsal rami of C3 to T12 contribute to its skin sensory innervation (Palastanga 2002).

Functions
The trapezius muscle has an important role in scapulohumeral rhythm (SHR). Throughout this synchronised motion of the scapula and humerus the trapezius works synergistically with other muscles in force couples to control scapula movement (Figure 3). During the setting phase of SHR (0-60o flexion or 0-30o abduction of the glenohumeral joint) the trapezius works with other muscles including, levator scapulae and serratus anterior to stabilise the scapula position (Malone et al. 1997). Beyond this range of arm elevation the upper and lower portions of the trapezius works synergistically with serratus anterior to upwardly rotate the scapula (Ebaugh et al. 2005). Three-dimensional studies of scapula motion during arm elevation have identified additional movement components of external rotation and posterior tipping of the scapula (Ludewig et al. 1996; Lukasiewicz et al. 1999; Ludewig & Cook 2000; McClure et al. 2001; Tsai et al. 2003; Ebaugh et al. 2005). As the scapula is upwardly rotated, the upper and middle fibres of the trapezius work with serratus anterior to externally rotate the scapula. The LT stabilises and posteriorly tilts the scapula to provide a stable base for rotator cuff action. Additionally, the LT works with latissimus dorsi to allow rotation of the elevated arm on a stabilised scapula (Ellenbecker 2006). In addition to its role in SHR, the different portions of the trapezius have some specialised actions. Fibres of the upper trapezius (UT) elevate and retract the pectoral girdle and extend the neck; the middle portion adducts the scapula; and the LT depresses and adducts the scapula (Standrins et al. 2005). It should be noted that different portions of the trapezius do not act in isolation but rather they work together to provide stability or produce movement of the SGC complex (Bigliani 1985).

Causes of Weakness
Research articles focusing on injuries sustained specifically to the LT muscle were difficult to locate. A variety of databases including MeSH, PubMed, Ovid Medline and Cochrane library  were employed with inclusion criteria set as english, human and full text. It should be noted that this is an area that definitely requires further investigation due to the lack of sufficient publications readily available on a muscle that plays a significant role in the functioning of the SGC. Below is a collection of some findings. 1. Accessory Nerve Lesion Damage to the accessory nerve can be painful, debilitating and potentially result in paralysis to the trapezius muscle.
 * Mechanism of Injury

- Trauma

After acromioclavicular or sternoclavicular dislocation;

A direct blow or stab wound to the base of the lateral aspect of the neck;

Traction injury due to excessive scapula depression (axonotmesis). {(Teboul et al. 2004)} - Iatrogenic Biopsy, resection of the lymph node or radical neck dissection in the posterior triangle (Figure 4) (neurotmesis); Occasionally the nerve has to be sacrificed (radical dissections eg cancer) but the remaining C2-4 innervation must be preserved. (Magee 2002; Shultz, Houglum & Perrin 2005; Chan & Hems 2006; Orthopaedics 2007). Traditionally physiotherapists have tested scapula function alone but compensation by levator scapulae can mask signs of altered scapula function; Symptoms such as pain, limitation in abduction and winging are also common in other shoulder conditions; Atrophy of the trapezius may not become apparent until later and can be hard to identifyin obese patients. (Chan & Hems 2006) Altered SHR with active abduction limited to around 80-90° and accompanied by pain and weakness (Magee 2002; Shultz, Houglum & Perrin 2005; Chan & Hems 2006; Orthopaedics 2007); Patients are more prone to brachial plexus palsy, frozen shoulder, subacromial impingement, and thoracic outlet syndrome (Chan & Hems 2006; Orthopaedics 2007). (Refer to section 5 for more information on altered biomechanics)
 * Diagnosis – Reasons why is it commonly missed in the early stages
 * Symptoms


 * Examination: Winging differential diagnosis

Scapula winging is a common sign of accessory nerve palsy, long thoracic nerve palsy and conditions affecting serratus anterior function. It usually presents with maximal flexion and abduction of the shoulder; Therapist resists external rotation of the glenohemeral joint in neutral with elbow flexed to 90° (Figure 4); Without stabilisation by the trapezius and rhomboids, external rotation by infraspinatus and teres minor results in winging of the scapula (Figure 5); This test unfortunately mainly focuses on the middle fibres of the trapezius muscle. (Chan & Hems 2006)
 * Treatment

An accessory nerve lesion can be successfully sutured if identified within a few days resulting in optimal rehabilitation, but if undiscovered the nerve retracts (Wallerian degeneration). Within a seven month period a graft can be applied to a retracted nerve with similar success to suturing (Teboul et al 2004; Chan & Hems 2006). Beyond this, surgical transference of levator scapulae and rhomboids to the scapula (Eden-Lange procedure) is recommended (Teboul et al. 2003; Chan & Hems 2006). However, Teboul et al. (2004) does not recommend this for older patients, preferring conservative management. Conversely, Bigliani et al. (1985) argues that resistance exercise alone can not sufficiently strengthen the adjacent scapula muscles enough for them to substitute for the trapezius muscle.

2. Middle and lower trapezius strain

Sustained posture of forward shoulders or round upper back can lead to a stretch weakness of the middle and LT. These postures may result from tight anterior shoulder muscles (eg. pectoralis minor) and occupations requiring use of the arms in a forward position (eg. pianist). To aid in reducing strain on the middle and LT muscle, a shoulder support brace (Figure 6) is commonly used. Other treatment options include general advice and education about correct posture, stretching tight anterior shoulder muscles and strengthening the weakened trapezius muscle (refer section 7) (Kendall 2005). 3. Facioscapulohumeral Muscular Dystrophy

Facioscapulohumeral muscular dystrophy (FSHD) is a common form of adult muscular dystrophy. It causes progressive loss of skeletal muscle (Figure 7) and associated weakness that starts rostrally and descends as it progresses. Early involvement of the facial and scapula stabilizing muscles results in a distinctive clinical presentation (Table 1). At the present time treatment options for FSHD are very limited and have been of limited success. Treatment often involves the use of ankle foot orthosis to control foot drop, scapula fixation surgery to improve upper limb range of motion (varied outcome), corticosteroid injections to control inflammation and medications and exercise to increase muscle mass. FSHD can also be mistaken for scapuloperoneal syndromes & limb-girdle muscular dystrophy (Katirji et al. 2002).

Consequences of Weakness
As the trapezius has a central role in scapula positioning and motion, weakness can significantly impair upper limb function. In a resting position with the arms by the side, there is downward rotation, winging and protraction of the scapula giving the shoulder a drooped appearance. This position can cause pain due to traction on the brachial plexus and increased stress on other structures (Chan & Hems 2006). As the arm is elevated, scapula movements (as described in section 3) are altered resulting in a decrease in the amount of upward and external rotation and posterior tilting. These alterations can lead to: a reduction in the subacromial space which increases the potential for impingement and associated pain during arm elevation altered glenoid fossa positioning resulting in decreased static stability of the glenohumeral joint and reducing available range of motion changes to the muscle length tension relationship of the deltoid and rotator cuff muscles resulting in weakness and decreased range of motion. compensation by surrounding muscles potentially resulting in other problems eg. biomechanical abnormalities or rotator cuff strains (Cooles et al. 2003). Dysfunctional SGC movements can lead to an increased risk of conditions such as adhesive capsulitis (Patten & Hillel 1993).

Assessment
Below is a summary of the potential positive assessment findings for weakness of the trapezius muscle. For a full shoulder assessment see Magee (2006).

Physiotherapy Management
There is very limited information on the physiotherapy management of LT conditions and retraining in this area. Current literature suggests the patient should be trained to control the biomechanics of the shoulder region in order to return to a higher level of functioning. The use of therapeutic exercise, manual therapy, and electrophysical modalities has been shown to improve function and reduce pain (McNeely et al. 2004). However, there are difficulties associated with this due to muscle activation and scapula control which can be challenging due to the relatively small changes in its orientation. It is also difficult for the patient to visualise scapula motion, palpate specific contractions and muscle overactivity (Jull et al. 2004). Below is a general collection of treatment techniques (presented in no specific order) that a patient may perform when retraining the LT muscle. 1. Advice & education

It has been shown that LT weakness can either be a cause for further injury (section 5) or a consequence of an injury sustained directly to the muscle or the shoulder region (section 4). Due to this, the early stages of rehabilitation focus on educating the patient on pain free postures that allows them to maintain some normality while in their current status. This involves informing the patient of aggravating factors that can worsen the problem and providing advice on posture and exercise technique so that the patient can correctly perform the exercise in the gym and feel confident in performing a routine at home.

2. Therapeutic & manual therapy

Initially, retraining should concentrate on exaggerated movements before progressing to increased contraction intensity, as it is important for the patient to feel the correct movement and improve muscle timing. Emphasis on relaxation of unwanted muscle activity (e.g. UT) and control of the movement is essential (Cools et al. 2003; Jull et al. 2004). Visual and verbal cues can assist in this aim e.g. 'draw the scapula in'. Alternatively, taping has been used to encourage correct activation patterns of shoulder girdle muscles however there is mixed results clinically with this technique (Morin et al. 1997; Cools et al. 2002 ; Alexander et al. 2003). Below is a general sample of techniques available to physiotherapists.

3. Electrophysical Agents EMG: Maximum activity of the LT is produced with the patient lying in prone with the arm abducted to 120° and resistance applied to the arm as it is raised in                diagonal extension (Brandell & Wilkinson 1991; Ekstrom et al. 2005). An alternative position for subjects who may have shoulder pain with arms raised            above their shoulder is with the arm abducted to 90° and externally rotated (Ballantyne et al. 1993; Ekstrom et al. 2005).

Other Modalities (e.g. TENS, HVS, Interferential): There is limited evidence to suggest that muscle stimulation with electrical modalities is more effective than active exercise. However, it is a treatment option that may be utilised as a means of increasing muscle activation and reducing pain levels (Watson 2000).