Friday, March 13, 2020

Evidence Based Therapeutic Exercise for Cervical Spine Disorders

Summary of key points from seminar by Dr Deborah Falla, BPhty(Hons), PhD.
University of Birmingham

Common forward head position with shortened sternocleidomastoid (SCM)- Source: 

Neck Pain
-       Relatively common complaint.
-       Affects 70% of individuals at some time in their lives
-       Annual Prevalence of neck pain 30-50%         
-       Tends to be persistent and recurrent disorder
-       85% of people can expect some degree of ongoing pain for many years after their first episode.
-       Most concerning is the recurrence.  Recurrences are partially attributed to ongoing dysfunction of the neuromuscular system (motor control) Carroll et al, Spine, 2008
-       When pain & Injury occur, the strategies used by the CNS to control movement and/or posture can be substantially compromised.

Clinical Implication:  Not only treat & reduce pain, but to prevent further episodes.

Common findings with neck pain
1.   Reduced force output and maintenance of force output.
2.   Reduced Deep neck flexor (DNF) activity (longus colli and capitus that is responsible for cranio-cervical (CC) flexion and support of the cervical spine) with subsequent increased compensatory SCM activity.
a.   co-contraction of SCM & Splenius
b.   SCM activity increased regardless of the severity/ intensity of the symptoms

Slide from D. Falla seminar

Injected saline solution to upper traps resulting in immediate pain.

Slide from D. Falla seminar

1.   Reduced directional specificity
2.   Reduced Semispinalis cervicis activity
3.   Poor postural endurance
4.   Structural changes present over time with chronicity ( > 3months)
- muscle fiber transformation from Type 1 to Type 2   (Uhlig et al, 1995)
- Increased fatty infiltration
Occurs soon following neck trauma, but not immediately, Andrey et al, 1998, Hallgren et al 1994, McPartland et al 1997, Kristjansson 2004, Elliott et al 2006
Use this window of time following neck trauma to minimize the secondary structural adaptations

Clinical Implication:
Changes are primarily in motor control.  However, if alterations in motor control is sustained beyond the acute pain phase, its effects may contribute to chronicity of neck pain & structural changes. 
Motor control training must be initiated in early rehab.

Deep neck flexor training using Bio-Feedback

Key Rehab Principles for Cervical Spinal Pain & Therapeutic Exercise Program
For both rehabilitation and prevention of recurrences.

1st phase - Motor control to target the deep postural muscles
2nd phase - Introduce higher load strength & endurance training. 

-       Need for Selectivity and specificity of exercise
-       Target & activate Deep Neck Flexors (DNF) with low load specific exercises.
-       Retrain endurance capacity of DNF
-       Retrain the patterns of activation of deep & superficial neck muscles
-       Co-contraction exercises (DNF and extensors)
-       Re-ed the use of muscles in posture & ADL
-       Address strength & endurance for functional requirements

Re-education of co-activation of deep cervical flexors/extensors using developmental position- prone 3 month position 

Re-education of deep neck flexors using isometrics

Reflexive activation of deep cervical muscles using a theraband

Long term efficacy for neck specific exercise.  Landén Ludvigsson et al., Eur J Pain, 2015

-       Participation in a neck-specific exercise intervention, in contrast to general physical activity, was the only factor that consistently indicated higher odds of treatment success.
-       At 12 months, patients in the neck-specific exercise intervention had up to 5.3x higher relief of disability reduction, and 3.9x higher odds of pain reduction compared to those in the physical activity group.

Clare Frank is the founder of Movement Links, Inc, a company borne out of a desire to enhance clinicians’ understanding of the movement system. She is the program director of Azusa Pacific University Advanced Fellowship in Movement & Performance and clinical faculty of Kaiser Permanente Spine Rehab Fellowship.  Clare is a lifelong learner, implementor and advocate for the movement system.

Key References:

Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Phys Ther. 2007;87(4):408-17.

Jull G. Whiplash, Headache, and Neck Pain, Research-based Directions for Physical Therapies. Elsevier Health Sciences; 2008.

Neck pain: combining exercise and manual therapy for your neck and upper back leads to quicker reductions in pain. J Orthop Sports Phys Ther. 2013;43(3):128.

Sremakaew M, Jull G, Treleaven J, Barbero M, Falla D, Uthaikhup S. Effects of local treatment with and without sensorimotor and balance exercise in individuals with neck pain: protocol for a randomized controlled trial. BMC Musculoskelet Disord. 2018;19(1):48.

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