Saturday, November 28, 2009

Need Another Reason To Text? How About Losing Weight?

With the rise of obesity in our society people will try almost anything to lose weight. This can include different diets, workout regiments and even surgery. The research and market exposure tackling such a topic is outstanding. However, a new study from the University of California purposes a different method to losing weight...texting?

Subjects in the study were sent 3-5 text messages a day with friendly tips and reminders on nutrition and weight control. Furthermore, calls would be carried out throughout the study to subjects by a health counselor.
Participants of the study lost on average slightly over 6lbs in 16 weeks. This was 4lbs more than those who were not texted during the study. Although 6lbs seems like a minor loss this is fairly significant considering no other adjustments were made to these people's lives.

The study purposes an interesting method of assisting people in losing weight. With the rise of child obesity and the popularity of cell phones such an idea isn't too far-fetched. New IPhone applications are always arising regarding diet tips and nutritional advice. In addition, one could use such a protocol when needing advice or motivation from their trainer which is not always present. So the next time you text your overweight friend try texting them some diet advice. Who may go over well.

Dr. Wayne Button, BSc, D.C

Patrick K, Raab F, Adams MA, Dillon L, Zabinski M, Rock CL, Griswold WG, & Norman GJ (2009). A text message-based intervention for weight loss: randomized controlled trial. Journal of medical Internet research, 11 (1) PMID: 19141433

Wednesday, November 25, 2009

Biking Injuries: Handlebar Palsy - Riding my bike is bad for my wrist?

It is pretty hard to walk along the canal on a nice day in Ottawa and not see a herd of bicycles pass you along the way. Biking is becoming increasingly popular in both transportation and recreational settings. In China bicycling is the number one form of urban transportation.

Due to these reasons bicycling injuries are becoming more and more common. However, most of these injuries can be avoided with just a few simple tips or minor adjustments to a bicyclist form or bike.

"Handlebar Palsy" is a term used to describe a nerve injury which occurs to bicyclist. This injury is often caused by prolonged compression or repetitive damage consistently to the Ulnar Nerve in the wrist. This nerve runs along the outside of the wrist and can carry both motor and sensory components. Depending on where the nerve gets damaged can dictate which components are corrupted. (Observe Picture).

However, the motor branch of the nerve is most commonly affected. This means pain, numbness and tingling aren't presented as symptoms. However, muscles will begin to lose their strength and function leaving bicyclist curious of why an onset of sudden hand weakness has occurred.

Signs and Symptoms

Often cases of "Handlebar Palsy" occur in individuals who have performed an excessive amount of biking. Cases have been published on people biking across the country or going on biking trips. However, there is also cases of it occurring due to an acute direct trauma.

Symptoms include unexplained weakness, clumsiness and muscle atrophy of the hand. Patients have also reported not being able to perform normal hand functions such as playing piano or using surgical equipment.


Handlebar Palsy can often be avoided by a proper placement of one's wrist on the handlebars. Those suffering from HP will usually display a faulty grip position. This can include hyperextending the wrist which will apply tension to the nerve (Picture to the left). Furthermore, one may grip the handlebars in a position which leaves the ulnar nerve exposed to being compressed. Try gripping your handlebars with a neutral wrist and leave the outside of the hand exposed. (Picture to the right)

In addition, bicyclist should always be fitted by a professional to make sure thier seat, frame, handlebars and pedals are placed properly for them. Try adjusting your seatt to place you in a more upright manner and avoid applying pressure on your hands and wrist. Attempt to take frequent breaks whenever carrying out long bike rides. When riding constantly adjust your position on the handlebars avoiding a consistent compression point. Whenever possible one should attempt to distribute the weight along the outside of their hands rather then the center of their palms. Using bicycling gloves and soft gripping for handlebars can also help reduce the force of vibrations being transmitted to your hands. Lastly, attempt different hand and wrist stretches before going for a ride.

I think I already have this injury?

Get the possible injury assessed by a health professional. Attempt to find a professional in your area who has a specialty or interest in sports injuries. There are multiple more serious neurological conditions which can replicate this injury (ALS, MS) and shouldn't go ignored without being looked at.

Cases of handlebar palsy may take weeks to months to reside. However, bicycling should also be ceased until the nerve is given time to regenerate. This is a slow process (approx 1mm a month) and will be hindered if the nerve is still left exposed to consistent vibrations. After the injury is confirmed by testing and shown to resolve one should take precautions before returning to the bike. Strength of the muscles in the hands and wrist should be returned to full form and again the patients biking mechanics should be looked at.

In summary, multiple bike injuries can be avoided with simple precautions and changes in biomechanics. We often wear helmets to protect our head but forget about the other body parts which are crucial in our everyday life such as our hands. Dr. Wayne Button, BSc, D.C

Capitani D, & Beer S (2002). Handlebar palsy--a compression syndrome of the deep terminal (motor) branch of the ulnar nerve in biking. Journal of neurology, 249 (10), 1441-5 PMID: 12382163

Monday, November 23, 2009

New Ground Breaking Research on MS

New MS story--ground breaking research

Does Your Pelvis Move Too Much????

Form Closure vs Forced Closure and the Active SLR

Often many people wonder why the SacroIliac Joint (SIJ) is designed the way it is? The SIJ is in an area where a lot of forces are transferred from the lower body to the upper body and vice versa. Due to this reasoning one may wonder why the SIJ has such flat articulation. The SIJ is designed to deal with compressive and bending forces but not shear forces. This is why it would make more functional sense for the SIJ to be glued together.

So how does the SIJ compensate?

1. Wedged shaped sacrum stabilized by inominates

2. Not a normal smooth articular cartilage (view images)
3. Cartilage covered bony protrusions into the joint (view images)

These three mechanisms represent the SIJ's way of achieving what is called Form Closure.

But if the SIJ was molded perfectly it would have no mobility?

This is why the SIJ needs to find a perfect equilibrium between movement and stability. With the muscles, fascia and ligaments around it, the SIJ now finds a way to create what's called Force Closure. Using anatomical structures to create force and allow the SIJ to move and be stable.

How does the SIJ achieve this "SelfLocking" or "SelfBracing Mechanism"?

1. Ligaments
               - Dorsal Sacral Ligaments (Nutation=Tension)
                  -When the sacrum experiences nutation it uses the dorsal sacral ligaments like a hammock. Resting on these ligaments now creates tension and thus provides friction/stability to the SIJ. Often this ligament can be dysfunctional or tender amongst pregnant women. This relationship explains how now a more mobile pelvis has to use ligaments around it for stability.

               - Sacrotuberous Ligaments (Loading = Decreased Mobility)
                  - Studies have shown that by loading the sacrotuberous ligament mobility of the SIJ will be decreased. This ligament will become loaded by tension in the muscles that attach to it such as the Bicep Femoris, Glut Max, Piriformis and Tharacolumbar Fascia. Again this connection can be supported by the correlation of pregnant women having tight hamstrings. The hamstrings attempt to load the sacrituberous joint and work harder to keep this now mobile SIJ stable.

2. Thoracolumbar Fascia
               - Multiple muscles attach to the thoracolumbar fascia allowing it to the act as a connection point between muscles of the lower back, pelvic and proximal aspect of the lower extremities. This fascia creates stability by producing tension when these muscle contract. The Multifidus may contract and balloon up into the fascia allowing it to tighten and thus brace its surroundings.

3. Musculature Slings
               - There are multiple slings of muscles which envelope the SIJ allowing it to be stabilized. The anatomical pattern of these slings gives premise for rehabilitation to be performed on these muscles in an attempt to create SIJ stability. If one creates a rehabilitation program to strengthen these muscles the movement and pain from the SIJ may be reduced.

Three Musculature Slings

1. Longitudinal Sling 
Multifidus-Sacrum-Deep Layer of TLF-Sacrotuberous Ligaments-Bicep Femoris

2. Posterior Oblique Sling
Latissimus Dorsi-TLF-Glut Max

3. Anterior Oblique Sling
Ext Obliques-Int Obliques-Transverse Abdominus-Piriformis-Rectus Abdominus-Linea Alba-Inguinal Ligament

So what if I don't have this "Selflocking" mechanism?

Problems may occur in this area if an equilibruim is not created between stability and movement.
-This can create diminished muscle power causing muscles to have to work more towards stabilizing the SIJ and not working towards other functions.
-Secondly, this may create an imbalance between muscle function and not allow muscles to work in synergy together towards other goals like creating core strength.
-Thirdly, this can create excessive ligament tension around the SIJ.
-Lastly, this will cause an excessive amount of mobility in the SIJ similar to someone who is pregnant.

Combine all these factors and you will experience a consequence of PAIN.

Is there anything else I can do?

There are mechanisms of producing this type of forced closure that your SIJ needs.

Pregnant women often try using a maternity belt for posture. Furthermore, athletes are now using what is called "Core Shorts" and getting great results.

Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, & Mens JM (1998). Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to 'a-specific' low back pain. Manual therapy, 3 (1), 12-20 PMID: 11487296

Thursday, November 19, 2009

Self Diagnosis: Why you should tell your doctor what the diagnosis is

Ever look up your symptoms on the internet? Ever have a friend diagnose you with something they have had previously?

With the internet today more and more people are taking initiative to diagnose themselves.  New research shows there is some merit in telling your doctor what you believe you may have. The British Medical Journal recently published an article discussing the new phenomenon of “Self Diagnosis” or “Self Labeling”.

Reports have been made that “Self Diagnosis” can initiate a correct finding in 18% of consultations. Furthermore, the “presenting complaint” of a patient may guide the diagnosing process 70% of the time. This indicates the importance of a patient communication to their doctor. If you have multiple symptoms a diagnosis may be established by your initial complaint.

Conditions accurately diagnosed by self labeling: Urinary tract infections, recurrent uveitis, schistosomiasis and head lice.

However, don't over estimate the power of self diagnosis. Wrongful incidence of self diagnosis can occur when treatment is initiated by the patient before consulting their doctor. Women who purchase over the counter antifungal treatment with the suspicion of having an infection are a great example.  A high percentage of these women actually have a bacterial form of infection not fungal.

In addition, self diagnosis can be at times very unsafe. Cases have been reported of a heart attack being mistaken as indigestion and rectal bleeding thought to be due to haemorrhoids only to be discovered as colon cancer.

Conditions often misdiagnosed by self labeling: pregnancy, yeast infections and scabies.

So remember always consult a health professional with your problems but don’t be afraid to give them some pointers.  Dr. Wayne Button BSc, D.C


Ryan, M. (1979). USSR letter: Self-diagnosis. BMJ, 2 (6196), 979-980 DOI: 10.1136/bmj.2.6196.979

Wednesday, November 18, 2009

Carpal Tunnel Syndrome a real pain in the neck?

Often in school when we are thought the nervous system our instructors will use pretty pictures from text books.  Blue represents the L5 dermatological distribution or pink is where the median nerve travels. Although these pictures give great insight towards mapping out the nervous system they can at times be diagnostically useless. This is because they are based on the belief every nerve carries out the exact same pattern in every person. In addition, it is wrong to believe every nerve which obtains a pathology will present with similar symptoms consistently.

The nervous system is one of the most complex systems the body has to offer. Studies have shown Ulnar Nerve abnormalities in patients with Carpal Tunnel Syndrome (CTS), which is a condition involving the Median Nerve.[1] Furthermore, studies have also demonstrated a decrease in pressure of the Guyon's canal (a common site for Ulnar nerve entrapment) after Carpal Tunnel surgeries have been performed.[2]

This gives premise to the concept that nerves in one area may very well affect nerves in another area. It seems the nervous system may work as a whole and not in just different subsets of entities.  When considering this concept it doesn't surprise me that CTS has been shown to also relate to neck disorders. [3,4].

A recent study in JOSPT evaluated this relationship further. The article attempted to analyze if forward head posture (FHP) and cervical range of motion (CROM) is related to CTS or median nerve abnormalities. Subjects with CTS were compared with healthy controls. In addition, subjects were paired based on age, occupation and hand dominance. Occupations consisted of desk worker, housewife, cleaning lady and teachers.

Results indicated a significant correlation to both a reduction in CROM and increased FHP in the group with CTS. CROM differences ranged from 12-18 degrees less in those with CTS. Furthermore FHP ranged with a difference 8-9 degrees in those with CTS.

Although this correlation is an interesting finding it can not create a cause and effect relationship. The study also found these findings to not be related to pain or symptoms of CTS.

In summary, one cannot say CTS is caused by postural abnormalities of the neck. The authors suggest these findings may be due to the CTS itself. A similar example is when patients will often have an antalgic posture when herniating a disc in their back. This purposes the concept that we should explore the option of treating the neck in patients with CTS. Furthermore, if postural corrections are made in patients with FHP will this decrease the prevalence of CTS? Only one case study to date has assessed a multimodal approach to treating a patient with CTS [5]. Hopefully, the following study will promote more research into this relationship.

Ginanneschi, F., Milani, P., & Rossi, A. (2008). Anomalies of ulnar nerve conduction in different carpal tunnel syndrome stages Muscle & Nerve, 38 (3), 1155-1160 DOI: 10.1002/mus.21070

Mondelli M, Ginanneschi F, & Rossi A (2009). Evidence of improvement in distal conduction of ulnar nerve sensory fibers after carpal tunnel release. Neurosurgery, 65 (4) PMID: 19834374

Chow CS, Hung LK, Chiu CP, Lai KL, Lam LN, Ng ML, Tam KC, Wong KC, & Ho PC (2005). Is symptomatology useful in distinguishing between carpal tunnel syndrome and cervical spondylosis? Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand, 10 (1), 1-5 PMID: 16106494

Reading, I. (2003). Anatomic Distribution of Sensory Symptoms in the Hand and Their Relation to Neck Pain, Psychosocial Variables, and Occupational Activities American Journal of Epidemiology, 157 (6), 524-530 DOI: 10.1093/aje/kwf225

Valente R, & Gibson H (1994). Chiropractic manipulation in carpal tunnel syndrome. Journal of manipulative and physiological therapeutics, 17 (4), 246-9 PMID: 8046280

De-la-Llave-Rincón, A. (2009). Increased Forward Head Posture and Restricted Cervical Range of Motion in Patients With Carpal Tunnel Syndrome Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.3058

Friday, November 13, 2009

Rare Diagnostic Case of the Month: Notalgia Paresthetica

The next time you buy an orthopaedic textbook take a look at the chapter list. You will probably find the shortest chapter to be on the thoracic spine. With that said the list of differentials  for T Spine and interscapular pain is usually short for most manual therapist. This is why although perhaps rare, reading about Notalgia Paresthetica sparked my interest.

What is it?

Notalgia Paresthetica (A.K.A Hereditary Localized Pruritis, Posterior Pigmented Pruritic patch and Subscapular pruritus) is a sensory neuropathy which involves dorsal spinal nerves. The neuropathy usually first presents itself with extreme itchiness and then may progress to pain, paresthesia, hyperesthesia and eventually a hyperpigmented patch of skin.

What causes it?

The flaw in research regarding NP is there are multiple causes which are purposed. Most studies looking into NP denote one specific cause and only investigate that particular pathophysiology. NP has been deemed to be due to hereditary conditions, chemical toxicity, increased dermal innervations and spinal nerve pathology either due to trauma or entrapment.

The hereditary and toxicity notion is often dismayed because of the rare reports and anecdotal evidence. However, there seems to be a strong correlation with spinal changes and NP.  Firstly, dorsal spinal nerves in the upper thoracic spine appear to pierce the Multifidus in a right angled manner. Such an anatomical position leaves the nerves exposed to trauma and easily being impinged.

In addition, recent small cased studies have found the majority of NP patients to have some form of T Spine pathology (7/10 & 9/12). These pathologies consist of degeneration, bulging disc and past history or prior upper back and neck complaints. Interestingly enough the dermatological pattern of patients symptoms correlated with their imaging findings. For example if a patient presented with symptoms from T1-T3 it was found they had degeneration in this particular area. In addition, these findings were discovered by a radiologist blinded to the patient's complaint.

How do I treat it?

Multiple forms of treatment have been performed on NP patients. Majority of treatment options consist of dealing with hypersensitive nerves and skin. These options are limited to paravertebral nerve blocks, epidural injections, topical creams, acupuncture and botuline toxin injections.

However, what does one do when these forms of treatment are not at their disposal? How do you treat an area which is to painful to even touch?

A recent experimental form of treatment has been published. This treatment is based on the premise that NP may be due to the long thoracic nerve being injured. Thus with such an injury the Serratus Anterior is dysfunctional and now needs to be rehabilitated.

In this particular study subjects carry out Electrical Muscle Stimulation (EMS) of the Serratus Anterior.  Although results were recorded anecdotally, an improvement of 70% was found in some subjects.
More importantly this study provides insight into options for rehabilitative practitioners into treating NP.

Consider the following: If the Serratus Anterior is dysfunctional then the scapula may be positioned in a slightly retracted manner. The Trapezium and Rhomboids are now pulled under tension. This tension may apply traction or impingement to dorsal spinal nerves. This ideology may purpose a relationship between NP and Serratus Anterior dysfunction. If such a relationship is proven then this gives a rehabilitative premise for manual therapist to work with NP patients.

Additional research has also attempted to show analgic effects of using transcutaneous electrical nerve stimulation (TENS) amongst NP patients. However, results of this study were minimal displaying 30% improvement at best.

In addition, if one does find a correlation of T Spine pathology with an NP patient they should focus on the actual pathology. Degenerative changes could be treated with glucosamine supplementation and disc herniations with Mckenzie exercises.

So Remember

-Attempt to discover the cause of your patients NP.  Consider taking radiographs.
-Work with other professionals such as dermatologist to relieve symptoms such as pruritis.
-Incorporate Serratus Anterior rehab exercises into your treatment plan.
-Attempt to re-educate nerves with EMS and numb them with TENS.
-Focus on the actual T Spine pathology such as a herniated disc or degeneration which may be causing symptoms.

In summary manual therapist should be knowledgeable in the diagnosis of NP. Knowing such a diagnosis allows one to consider it in their differential list. Furthermore, NP allows us more insight into other causes of neuropathic pruritis which is often forgotten and not known about. Dr. Wayne Button, BSc, D.C


SAVK, O., & SAVK, E. (2005). Investigation of spinal pathology in notalgia paresthetica Journal of the American Academy of Dermatology, 52 (6), 1085-1087 DOI: 10.1016/j.jaad.2005.01.138

Raison-Peyron, N., Meunier, L., Acevedo, M., & Meynadier, J. (1999). Notalgia paresthetica: clinical, physiopathological and therapeutic aspects. A study of 12 cases Journal of the European Academy of Dermatology and Venereology, 12 (3), 215-221 DOI: 10.1111/j.1468-3083.1999.tb01031.x

Wang CK, Gowda A, Barad M, Mackey SC, & Carroll IR (2009). Serratus muscle stimulation effectively treats notalgia paresthetica caused by long thoracic nerve dysfunction: a case series. Journal of brachial plexus and peripheral nerve injury, 4 PMID: 19772656

Savk E, Savk O, & Sendur F (2007). Transcutaneous electrical nerve stimulation offers partial relief in notalgia paresthetica patients with a relevant spinal pathology. The Journal of dermatology, 34 (5), 315-9 PMID: 17408440

Wednesday, November 11, 2009

Diabetes: The alarm clock that wakes you up in the morning

The alarm goes off loudly and stirs my slumber. Anxiously I slap the button and bring the room back to silence. I do this knowing I will fall back asleep only to have the beginning of my day depend upon my back up alarm. Soon enough the alarm attacks and makes its second attempt to get me jump started. Shamefully, it is the third alarm who is the victor. I now arise from the bed knowing this was my last alarm which I have set.

For years I have felt plagued with guilt knowing I start every day with this protocol. However, after reading some of the newest research I find myself not only disburdened but also somewhat health conscious.

Need another reason to fall back asleep?

Within the last decade studies have shown a correlation between type 2 diabetes and sleep deprivation. Since the 1960's, the percentage of the population which obtains <7 hours of sleep a night has more than doubled (15.6%-37.1%). Oddly enough a similar pattern has been observed as well with the populations rise in Type 2 diabetes.

Scientist believes this may be due to a hormone called Leptin. After eating a meal Leptin will be released by our fat cells. Our brain will then receive a message to decrease our appetite. However, people who are sleep deprived will have lower concentrations of Leptin. This lower concentration will spike our appetite and may slowly lead to obesity and eventually diabetes.

But I am young and healthy and don't need to worry.

A correlation between sleep deprivation and a high body mass index (BMI) has been found in children as young as 5 years old. Furthermore, a loss of one hour in sleep amongst adolescents has been deemed as an 80% increase in risk for developing diabetes later on in life. Those numbers are scary when considering adolescents to be highly sleep deprived and the prevalence today of obese children.

So the next time your reach over to shut the alarm off don't feel guilty. You're simply being health conscious. Dr. Wayne Button, BSc, D.C

For more info on this topic check out the following links and videos Health Column, The science of sleep 1The science of sleep 2

Spiegel, K. (2005). Sleep loss: a novel risk factor for insulin resistance and Type 2 diabetes Journal of Applied Physiology, 99 (5), 2008-2019 DOI: 10.1152/japplphysiol.00660.2005

Saturday, November 7, 2009

Are your muscles dysfunctional? Treating neck pain: Part 3

Almost everyone you talk to claims to be an expert in mechanical neck pain (MNP). Hundreds of books, articles and now even a blog has been written on the topic. Prescribing any combination of exercises and techniques may be useful. However, when establishing a protocol for rehabilitation certain goals and objectives should be considered. This column will discuss the process of treating MNP in a continuation of Part 1 & Part 2 of our series on neck pain.

How do I guide my rehabilitation for MNP?

It is important to have a treatment plan in place. Without one we would be giving exercises with no real purpose. Consider the following:

When research is used to study the effectiveness of rehabilitation often protocols can be extensive. Patients in these studies will be diligent performing exercises everyday for long periods of time. Furthermore, such studies incorporate supervision of treatment with a protocol of progression and monitoring. After all this, results still may only produce 60-80% improvement. Such a study would be deemed a success. How much improvement do you think you will achieve with a housewife of three kids? How about if you give a patient 20 unsupervised exercises?

Guiding rehabilitation is never easy but the concept of applying it is. Simply ask yourself what am I trying to do? Rehabilitation for MNP should include the following two objectives:
1) Training individual muscle groups
2) Addressing problematic functional activity.

Addressing functional activity

Here a rehabilitation treatment plan should address those activities which are problematic. The list of activities may be extensive but posture is often the main culprit.

Do not underestimate your advice when educating a patient about posture. Studies have shown those patients which are given instruction achieve a more effective correct posture then those which are not given any instruction. Furthermore, these patients also achieve better activation of deep cervical flexor muscles (Importance discussed in  Part 2). [2]

Patients also usually need daily reminders to keep adjusting their posture. Every fifth phone call you receive talk while standing. Adjust your work chair every five minutes. Often patients can put little stickers on different areas of their workplace. These stickers should be placed in areas that will only be seen if they take on a problematic posture. The patient now remembers once seeing the sticker to change their posture.

Training individual muscle groups

This goal also works in synergy with addressing functional activity. This is because patients who display good muscle activation also favour a less problematic posture. These muscles now promote less of a forward head carriage or sloped shoulders. 

Exercise # 1

Training deep lower cervical extensor muscles

Patient should be in a four point kneeling position with their weight distributed on their elbows and knees. Starting in this position the patient should slowly lower their head into flexion and then slowly extend back to the starting position. Most of the movement should be coming from the lower cervical region. This isolation of movement can be facilitated with proprioceptive feedback and verbal cues by the therapist.

Exercise # 2

Training deep cervical flexor muscles

Patient should be in a supine position with their head rested on a small towel for support. With the forehead and chin lying parallel with the table the patients head is now in a neutral position. The patient should then be instructed to bring their chin towards their sternum slowly while slightly lifting their head off the towel. The patient should aim to not flex the head forward (as in the starting attempt of a sit up) but merely to sustain the neck in a slightly flexed posture. This position will best facilitate the deep cervical neck flexors.

In those patients who experience MNP with upper limb activity and scapular dysfunction a program of axioscapular exercises should be implemented. (Part 2).

What intensity of training should I use?

This is a good question and often can be confusing to physical therapist. The best way to guide your intensity level is again to ask yourself the question what is it exactly you're trying to do? These patients merely want a rehabilitation program that can help them in their everyday activities and reside some of their pain.

When considering rehabilitation for MNP low-level intensity exercises (approx 20% maximal voluntary contraction) is often the best choice. Consider the following:

Low level intensity training has been shown to
-Incorporate better coordination between both deep and superficial muscle groups [3]
-Assist activation of deep cervical flexor muscles [3]
-Produce hypoalgesic affects more so then higher-load exercises [4]
-Be more transitional to daily functional activities (20-50% MVC).

In summary, one should always remain critical yet open to different forms of treatment. However, a purpose should be appointed to everything you do. This point is emphasized all the time when patients, colleagues and lawyer will question your actions. So remember the next time you treat MNP, sometimes the best way to sink a golf ball is with a good putting game and not a long drive. Dr. Wayne Button, BSc, D.C 

O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872

Schwarz, J. (2008). Recruitment of the Deep Cervical Flexor Muscles during a Postural-Correction Exercise Performed in Sitting manuelletherapie, 12 (2), 76-77 DOI: 10.1055/s-2008-1027472

Jull GA, & Stanton WR (2005). Predictors of responsiveness to physiotherapy management of cervicogenic headache. Cephalalgia : an international journal of headache, 25 (2), 101-8 PMID: 15658946

OLEARY, S., FALLA, D., HODGES, P., JULL, G., & VICENZINO, B. (2007). Specific Therapeutic Exercise of the Neck Induces Immediate Local Hypoalgesia The Journal of Pain, 8 (11), 832-839 DOI: 10.1016/j.jpain.2007.05.014