Exercise for Reducing Neck Pain and Enhancing Dynamic Stability.

Transcription

1 Exercise for Reducing Neck Pain and Enhancing Dynamic Stability

2 Presentation Outline Compare/Contrast Lumbar Exercise Literature to Cervical Spine Discuss Neck Musculature and Motor Control in the healthy and painful neck and it s s relationship to exercise prescription Review Current Exercises for Reducing Neck Pain

3 Core Exercise Concepts in Lumbar People with LBP have changes in the strategy for control of the deep trunk muscles (Hodges 1996, Hides 1994) There is evidence that people with LBP tend to adopt a strategy for increased stiffness and stability at the expense of spinal function (van Dien et al, 1995) Spine Hodges 1996, Hides 1994, Van Dien et al 1995

4 Core Exercise Concepts in Lumbar Stability of the lumbar spine requires: Passive stiffness Osseous and ligamentous structures Active Stiffness Muscle Function Adequate strength Normal sequencing (motor control) Spine Akuthota and Nadler 2004

5 Is Core Stability in the Neck Similar to Lumbar Spine? Neck and Lumbar anatomy are quite different so a direct extrapolation of one to the other is not possible The work of Hodges and others does support current clinical theory in the neck. In the painfree neck: Deep neck flexors (longus( capitus and longus colli) ) help control posture with continuous tonic (low torque) activity. (Conley 1995) Upright posture Head lift in supine Postural control during basic overhead tasks Superficial neck flexors (SCM and AS) play a major role in high torque production (phasic( activity). When performing repeated isometric shoulder contractions in the painfree neck, the upper trapezius will relax; it s s ability to relax will diminish in the presence of neck pain Jull 2004, Conley 1995

6 Cervical Spine Motor Control In the presence of neck pain, the deep cervical flexors lose endurance capacity. Deep Cx flexor test Change in 10mm Hg good Pts with neck pain hover at about 2-4mm EMG monitors SCM and AS *Test not yet validated Beeton & Jull 1994, Grant et al 1998

7 Cervical Spine Motor Control Falla and Jull found an increase in SCM and AS electrical activity with reduced cervical flexion force at 25% MVC. Biopsy studies on chronic neck pain patients have found loss of Type I muscle fibers and increase of Type II fibers. Falla and Jull 2004, Uhlig et al 1995

8 Cervical Spine Motor Control Suboccipitals Conley et al. noted their continuous activity in postural studies Hallgren and McPartland noted their atrophy in presence of chronic neck pain No clinical tests yet validated to detect suboccipital strength deficits Conley et al. 1995, Hallgren 1994, and McPartland 1997

9 Cervical Spine Motor Control Pts with neck pain (post whiplash injuries) have demonstrated inability to relax upper trapezius between repeated isometreic contractions of shoulder flexion. Janda reported overuse of levator scapula in presence of neck pain along with weakness of lower trapezius. Fredin et al 1997, Janda 1994

10 Scapulo-thoracic Posture Posture of the shoulder girdle is closely linked to cervical posture and needs to be addressed in the presence of neck pain Loss of postural control/function of particular scapular muscles such as Serratus anterior, rhomboids, and lower trapezius is a common clinical finding Basic Kendall MMTs,, individual muscle length testing, and observation of scapular function during scapulo- humeral rhythm will help detect aberrant motion and function. Janda1994, Jull 1994, Sahrman 1994, Kendall 1993

11 Janda s Upper Crossed Syndrome

12 Designing a Neck Stabilizing Program Just like in the lumbar spine, strengthen the deep segmental muscles first. These include: Longus capitus and longus colli (deep Flexors) Suboccipitals

13 Deep Cervical Muscle Progression The most basic way to facilitate the deep cervical muscles is in a gravity eliminated position. The time honored Chin Tuck Exercise

14 Deep Cervical Muscle Progression Next, work on facilitating the deep cervical muscles against gravity (cranio( cranio- cervical flexion). use a BP cuff or Chattanooga Stabilizer to control MM Hg change and if possible surface EMG to limit SCM activity. Inflate to baseline of 20mmHg, work in 2 mmhg progression up to 10 mmhg change

15 Deep Cervical Muscle Progression Hold cranio-cervical cervical flexion while performing dynamic upper extremity exercise

16 Suboccipital Muscle Progression Lack of literature isolating suboccipitals from the trapezius muscle as cervical extensors. Begin with isometric theraband resistance.

17 Suboccipital Muscle Progression Seated theraband resistance with SB and rotational forces. Rectus Capitus lateralis ipsilateral SB Obliquus Capitus Superior-ipsilateral ipsilateral SB

18 Isometric Rotation Rectus Capitus Lateralis, Rectus Capitus Posterior Posterior Major, Obliquus Capitus Inferior all ipsilaterally rotate

19 Suboccipital and Deep Flexor Muscle Progression Prone or quadruped cervical chin tucks Hold chin tuck, push crown of head into the Swiss ball, hold 6 seconds

20 Dynamic Neck Stabilization-Swiss Swiss Ball

21 Dynamic Isometric Exercises Isometric Extension with Backward Walk

22 Dynamic Isometric Exercises Isometric Flexion with Forward Walk

23 Dynamic Isometric Exercises Isometric SB with Sidestepping

24 Dealing with a hypertonic Upper Some evidence suggests stretching the upper trapezius is not effective Strengthen the lower trapezius since: It is commonly weak Facilitating it will reciprocally inhibit the over working upper trapezius Trapezius PNF Scapular Posterior Depression

25 Lower Trapezius-Blackburn Blackburn s

26 Lower Trapezius with Tubing

27 Lower Trapezius with Pulleys

28 Stretch Pectoralis Minor-No Money

29 Strengthen Serratus Anterior-Supine

30 Strengthen Serratus Anterior-Ball Alphabets

31 Strengthen Serratus Anterior-Ball Rhythmic Stabilization

32 Strengthen Rhomboids-Universal Posture Correction TheraBand

33 Strengthen Rhomboids-use Kendall MMT Position

34 Stretch Upper Thoracic Spine

35 Stretch Upper Thoracic Spine

36 Upper Thoracic Manual Stretch

37 Summary-Reducing Neck Pain Minimize activation of upper trapezius, SCM, and Anterior Scalene Refrain from using seated manual isometric resistance to flexors! With Exercise

38 Summary-Reducing Neck Pain With Exercise Do facilitate the deep cervical flexors with low intensity, high repetition exercise Do facilitate the deep neck extensors Thera-band isometrics seated and dynamic walking exercises Quadruped chin tucks Strengthen Lower Trapezius Stretch Pectoralis Minor Strengthen Serratus Anterior Strengthen Rhomboids Stretch and mobilize T1-T3 T3 if restricted Include Aerobic Exercise Training at least 3 times a week (Ylinen( et al 2003) Ylinen et al 2003