PAGE 1. Managing Disc Degeneration of the Cervical Spine

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1 PAGE 1 Managing Disc Degeneration of the Cervical Spine VIVIENNE WILLIAMSON SEPTEMBER 2018 COURSE JOHANNESBURG

2 SUMMARY PAGE 2 Degeneration of inter-vertebral discs, sometimes referred to as Disc Degenerative Disease (DDD), is not actually a disease, but a condition in which natural, age-related wear-and-tear on a disc causes pain, instability and other symptoms. In this study, my client was affected by symptoms resulting from disc degeneration in the cervical region of the spine. The specific condition was nerve impingement of the right C8 nerve, which exits between the last cervical vertebra (C7) and first thoracic vertebra (T1). My objective was to assist my client on managing the condition as follows: Train and educate correct neck posture and bio-mechanics Devise a conditioning programme to stretch and strengthen the musculature of the cervical spine, aiming to better support and unload the bony structure.

3 TABLE OF CONTENTS PAGE 3 Page Number Anatomy of the Cervical Spine 4 Introduction 5 Conditioning Programme at home exercises 6-7 Conditioning Programme Pilates sessions 8-11 Conclusion 12 Bibliography 13

4 Anatomy of the Cervical spine The neck begins at the base of the skull and through a series of seven vertebral segments connects to the thoracic spine (the upper back). PAGE 4 The cervical spine is the most superior portion of the vertebral column, lying between the cranium and the thoracic vertebrae. It consists of seven distinct vertebrae: The first cervical vertebrae (C1) is known as the atlas. The second cervical vertebrae (C2) is known as the axis. The C7-T1 spinal segment, sometimes referred to as the cervico-thoracic junction, is located at the very bottom of the neck. This is where the neck (cervical spine) connects with the upper back (thoracic spine). The cervico-thoracic junction is unique because it is the point of transition from the highly flexible neck to the nearly completely inflexible upper back. It is also the point where the lordosis, or backward curvature of the cervical spine, reverses into kyphosis, or forward curvature, of the upper back. Cervical pain may be caused by natural spinal degeneration (Disc Degenerative Disease) of the cervico-thoracic junction over time. The spinal nerves extend from above their respective vertebrae, through the intervertebral foramen created by the joints at the articular processes. C7 is an exception. The C7 vertebra has a set of spinal nerves extending from above (C7) and below (C8) the vertebra. Therefore there are eight spinal nerves associated with seven cervical vertebra, which is a common source of confusion. Cervical nerves provide control and sensation to different parts of the body based on the spinal level from where they branch out. C8 controls the hands. The C8 dermatome covers the lower part of the shoulder and goes down the arm into the pinky side of the hand. Degenerative disc disease refers to the gradual degeneration of the discs that occurs over time as the spine ages. As the discs degenerate, the foramina may narrow and compress the nerve roots. The symptoms may vary, and some people who have disc degeneration do not have symptoms.

5 PAGE 5 INTRODUCTION Client: Mr. André Libenberg, Date of Birth: 09/04/1947 Age: 71 years old. HISTORY André is an experienced Pilates practitioner, and has been attending group mat classes for 10 years, on average twice a week. He started Pilates after suffering a herniated disc in his lumbar spine. He underwent, a discectomy and was advised to do Pilates to aid recovery and strengthen the core. Besides participating in Pilates, André is also an avid mountain biker. SYMPTOMS A few months ago, André started experiencing pain in between the shoulder blades and pain, weakness, numbness, and tingling radiating down the right arm. TREATMENT Physiotherapy relieved the pain between the shoulders but the other symptoms persisted. The physiotherapist referred André to a neurosurgeon. OUTCOME The neurosurgeon suspected compression of the C8 nerve on the right side. X-rays and a MRI were done and showed the following results: Multilevel osteoarthritis and disc degenerative disease. Anteriolisthesis at C7/T1 (grade 1) with the likely impingement of the right C8 exiting nerve root. FURTHER TREATMENT, CONTRA-INDICATIONS AND RECOMMENDATIONS End July 2018 Hospitalization for traction treatment over a two day period. No mountain biking. Stationary exercise bike allowed. Go ahead given by Doctor, for André to do private Pilates sessions. No bouncing, jumping or jarring movements. No forward flexion or sudden or harsh movements of the neck. Private Pilates Sessions 1 8 See the detailed conditioning programme on pages 8, 9, 10 & 11 Follow Up visit 7/09/2018 Traction was successful in releasing nerve impingement. Condition must be managed. Doctor recommended the use of a home traction kit. André was given the go ahead to start riding his mountain bike again. Doctor is pleased with the exercises I have been doing with André and has given the go ahead to do forward flexion so long as the neck is aligned and stabilised in the manner we have been practising.

6 PAGE 6 CONDITIONING PROGRAMME Home Programme A home programme of exercises to be practised at least once a day: Isometric exercises Isometric exercise is a form of exercise where you execute an isometric muscle contraction. In an isometric muscle contraction, the muscle exerts force without changing its length. A benefit of an isometric neck exercise is that there is less movement, therefore there is less risk for injury or reinjury, especially for people who are in the process of recovery and rehabilitation. In an isometric neck exercise, the neck is held in a non-moving or stable position to isolate the targeted muscle. The muscle is then allowed to grow stronger through resistance without movement or pain. 1. Chin Tuck (Static extension) This exercise helps strengthen the muscles that pull the head back into alignment over the shoulders (upper thoracic extensors) and also stretches the scalene and suboccipital muscles. To perform the exercise stand with the spine up against a wall with the feet out about 10cm from the bottom of the wall. Keeping the spine against the wall, pull the upper back and head backward until the head touches the wall. It is important to make sure that the chin is down so that the head is pulled straight back and not looking up. Hold the head against the wall for 5 seconds. Repeat this 10 times. 2. Static Flexion Put both hands on your forehead and gently push against their resistance. Tighten the neck muscles and try your best not to let your head move forward. Hold this position for around 8 seconds. Rest your neck, then repeat. 3. Isometric Lateral Flexion Place your right hand on the right side of your head, just above the right ear. Tighten your neck muscles and resist the pressure to move your head sideways. Hold the position for 5 seconds. Rest for 3 seconds then repeat. Do the same procedure to your left side.

7 PAGE 7 Range of Motion exercises Active range of motion exercises are important for maintaining the motion of the facet joints and encouraging proper postures. 1. Supine Side-to-Side Head Rotation Lie on your back with your knees bent and feet flat on the floor. Rotate your head to the right side. You may use your hand to gently pull your head deeper into the stretch. Hold this position for 20 seconds. Do the same procedure to your left side. Repeat 3 to 5 times on each side. Lateral flexion of the cervical spine I am reluctant to do lateral flexion of the neck as a specific range of motion exercise as I feel it may be too intense and aggravate the condition. I am of the opinion that the natural flexion that occurs whilst executing exercises in Pilates sessions will be sufficient. In session cues and watch points for optimal neck posture and correct bio-mechanics During Pilates sessions I will be extremely vigilant with regards to ensuring that correct neck posture is maintained. These are some of the cues and watch points I would implement: Supine: lengthen away the base of the skull soften the front of the throat down. look at cheek bones and feel the front neck (deep neck flexors) come into play. Prior to lifting head off mat, the above stabilisation must be done In Forward Flexion Use hands or props as assists when needed. Ensure that good alignment is maintained. Quadruped/Front Support Use pole as an assist to find ideal alignment. Use the imagery of a ball being held at the front of the neck, by the chin. Be careful not to press the chin down into the ball, but think of it more as an assist to get correct alignment of the neck. Seated Once again imagery of ball being held at the front of the neck. Imagine lifting the top edge of the sternum up into the ball rather than pushing the chin down into the ball. Pull the face backwards. Imagine pressing the back of the skull against a wall.

8 PAGE 8 Pilates Sessions André is an experienced Pilates Practitioner with about 10 years experience with the Mat work. Taking this into consideration, I added some intermediate and advanced exercises from the start of the programme. Session 1 and 2 PRE-WARM UP Discuss neck posture, head on top of spine. Go through the specific neck exercises for home programme. WARM UP SEATED ON STABILITY BALL Pelvic tilts, moving from neutral to posterior Spine Twist Single Leg lifts Keep a small range of motion and neutral spine throughout. FOOT WORK Reformer series. ABDOMINALS Reformer - Short Box. Due to the need to avoid forward flexion of the neck, I selected only the following exercises from the series: Flat Back Tilt Twist HIP WORK Reformer Frog, Circles (Down, Up), Openings. SPINAL ARTICULATION Mat Supine Posterior Pelvic Tilts only (no curl up to bridge). When the pelvis tilts posteriorly and the lumbar spine presses to the mat, use all the cues to ensure optimal neck posture. (See In session cues on Page 7) STRETCHES Reformer Standing Lunge Reformer Up Stretch 1 ARM WORK Reformer Supine series Mat Front Support. LEG WORK Wunda Chair Backward Step Down. As André is a cyclist, I added this exercise to challenge him and maintain his leg strength. LATERAL FLEXION/ROTATION Wunda Chair Side Stretch. Use tactile cuing to ensure good neck alignment and assist with support if needed. BACK EXTENSION Wunda Chair Swan Basic. Ensure good neck bio-mechanics are maintained throughout. Supporting the head in the prone alignment will help build strength in the muscles of the posterior neck. REST POSITION I chose Rest Position rather than Roll Downs which includes forward neck flexion, currently contra-indicated.

9 PAGE 9 Session 3 and 4 PRE-WARM UP Home programme exercises. WARM UP MAT Pelvic tilts, moving from neutral to posterior Spine Twist Supine Single Leg lifts and Leg changes FOOT WORK Cadillac series ABDOMINALS Wunda Chair Pike Sitting Standing Pike Reverse. Ensure that the neck and head are aligned in relation to the rest of the spine. HIP WORK Cadillac Basic Leg Springs SPINAL ARTICULATION Mat Supine Posterior Pelvic Tilts only (no curl up to bridge). When the pelvis tilts posteriorly and the lumbar spine presses to the mat, use all the cues to ensure optimal neck posture. (See In session cues on Page 7) STRETCHES Cadillac Shoulder Stretch. Cadillac Sitting Forward. Ensure that the neck and head are aligned in relation to the rest of the spine. ARM WORK Reformer Seated Series Reformer Up Stretch 2 LEG WORK Reformer Side Split. LATERAL FLEXION/ROTATION Reformer Side Over on Box. Use tactile cuing to ensure good neck alignment and assist with support if needed. BACK EXTENSION Reformer Breast stroke Prep. Ensure good neck bio-mechanics are maintained throughout. REST POSITION

10 PAGE 10 Session 5 and 6 PRE-WARM UP Home programme exercises. WARM UP SEATED ON STABILITY BALL Pelvic tilts, moving from neutral to posterior Spine Twist Single Leg lifts Keep a small range of motion and neutral spine throughout. FOOT WORK Wunda Chair. This series offers the ideal opportunity to work on neck and head alignment. ABDOMINALS Reformer - Short Box. Due to the need to avoid forward flexion of the neck, I selected only the following exercises from the series: Flat Back Tilt Twist HIP WORK Reformer Frog, Circles (Down, Up), Openings. SPINAL ARTICULATION Mat Supine Posterior Pelvic Tilts only (no curl up to bridge). When the pelvis tilts posteriorly and the lumbar spine presses to the mat, use all the cues to ensure optimal neck posture. (See In session cues on Page 7) STRETCHES Ladder Barrel Shoulder Stretches. Mat Front Support. ARM WORK Wunda Chair Shrugs Triceps Press Sit Frog Back Mat Leg Pull Front. LEG WORK Wunda Chair Backward Step Down. Forward Lunge. LATERAL FLEXION/ROTATION Wunda Chair Side Stretch. Use tactile cuing to ensure good neck alignment and assist with support if needed. BACK EXTENSION Wunda Chair Swan Basic. Ensure good neck bio-mechanics are maintained throughout. REST POSITION

11 PAGE 11 Session 7 and 8 PRE-WARM UP Home programme exercises. WARM UP MAT Pelvic tilts, moving from neutral to posterior Spine Twist Supine Single Leg lifts and Leg changes FOOT WORK Reformer ABDOMINALS Wunda Chair Pike Sitting Standing Pike Reverse. Ensure that the neck and head are aligned in relation to the rest of the spine. HIP WORK Cadillac Single Leg Supine. SPINAL ARTICULATION Mat Spine Stretch. STRETCHES Reformer Standing Lunge. Reformer Stomach Massage Series. ARM WORK Reformer Kneelung Series. Reformer Balance Control Front. LEG WORK Reformer Side Split. LATERAL FLEXION/ROTATION Reformer Side Over on Box. Use tactile cuing to ensure good neck alignment and assist with support if needed. BACK EXTENSION Reformer Breast stroke Prep. Ensure good neck bio-mechanics are maintained throughout. REST POSITION All future sessions. On André s follow up visit to the neurosurgeon, he demonstrated the home programme and neck posture and stabilisation we have been practising. The doctor was very happy and has given the go ahead for André to do neck forward flexion in the controlled and mindful Pilates manner. Pelvic Curl has also been given the green light. In sessions going forwards, most exercises can be included. The following would be contra-indicated: Any loaded neck exercises e.g. Roll Over, Short Spine, Long Spine, Jack Knife etc. Step Barrel work.

12 CONCLUSION PAGE 12 It has been a pleasure working with André who is already well established with the Mat work repertoire. Private sessions on the equipment have been beneficial in a number of ways: 1. André has been able to continue exercising. This has had a significant, positive psychological impact. He initially felt depressed, thinking it would be the end of meaningful sport and exercise participation for him. 2. An entire new realm of movement possibilities and challenges have opened up. 3. André has gained new insight on posture and mindful movement, including a deeper understanding of correct movement patterns and the principle of SIM. (Stabilise, Initiators, Movement) We are continuing with private sessions and in each session I see progress. When André goes back to group mat classes, he will do so equipped with knowledge and understanding. He will know how to modify and adapt exercises where needed and work with more awareness. This journey has been an evolution of learning for both myself as the instructor and André as the client. I have learnt that communication is vital. Concise, clear cues, both verbal and tactile, achieve the desired outcomes and keep both client and instructor safe. I strive to constantly apply the Pilates principles in order to give my client the most comprehensive, positive experience possible.

13 PAGE 13 Bibliography: Karen Sanzo head/neck tutorials