How do we record the activity of the deep cervical flexor muscles?

Transcription

1 Management of Cervicogenic Headache: Assessment and Retraining of the Deep Cervical Flexors Deep Cervical Flexors Longus colli and longus capitis Segmental support Counter bending of the cervical lordosis Deborah Falla extensor contraction compression of the head MOTOR LEARNING AND TRAINING LABORATORY CENTER FOR SENSORY-MOTOR INTERACTION AALBORG UNIVERSITY, DENMARK Vitti 1973, Winters and Peles 199, Conley et al 1995, Mayhoux-Benhamou et al 1994, 1997, Panjabi et al 1998 Orbicularis Oris Muscle Vestibule of Mouth Lower Lip Lower Teeth Sublingual Gland Depressor Anguli Oris M. How do we record the activity of the deep cervical flexor muscles? Facial Vessels Hypoglossus Muscle Genioglossus M. Mandible Mylohyoid M. Pharynx Posterior oropharyngeal wall Longus Colli / Longus Capitis 1

2 Connection to suction tubing Inhibition of the deep cervical flexor muscles in patients with neck pain disorders 1cm Suction portal Electrode contacts Nasopharynx Dens Oropharynx Nasal septum Bipolar Suction Electrode Uvula Deep Cervical Flexors Tongue Visual feedback display Cranio-cervical flexion Pressure Biofeedback Unit DCF normalised RMS values (%) Neck pain Stage of C-CFT (mmhg) Falla et al, Physical Therapy; 23 Falla, Jull, Hodges. Spine; 24 Stages of the cranio-cervical flexion test Longus colli/capitis Impaired performance of the deep cervical flexors muscles is unique to cervicogenic headache Anterior Scalene Sternocleidomastoid Neck Pain Longus colli/capitis Anterior Scalene Sternocleidomastoid Normalized RMS values Cervicogenic Migraine Tension-type Test stages (mm Hg) Falla, Jull, Hodges. Spine; 24 Jull et al., 27 Activation of the deep cervical flexors improves following specific training Symptomatic relief following intervention in patients with cervicogenic headache DCF normalised RMS (%) C-CF training Strength training Stage of the CCFT (mmhg) Stage of the CCFT (mmhg) Treatment Group Cranio-cervical flexion training Proportion >5% reduction Proportion 1% reduction 31 4 Post Pre Jull, Falla, Vicenzino, Hodges, 29 Jull et al. Spine. 22 2

3 How do we assess the performance of the deep cervical flexor muscles clinically? Challenge: How to assess the DCF clinically? Muscles are deep Muscles cannot be seen or palpated Muscle strength tests, test all muscles in a group Invasive techniques not acceptable in a clinical environment Development of the clinical test of cranio-cervical flexion: Muscles anatomical action (C-CF) SCM extends the cranio-cervical region and flexes the neck, scalenes are neck flexors Low load, holding action Does not encourage recruitment of other muscles Replicates function Method of quantification Cranio-cervical flexion test: Stage 1: Analyse Activation Capacity - Movement pattern (rotation or retraction) during the 5 stages of the test (22-3 mmhg, increments of 2 mmhg) - Movement slow and controlled - Rapid movement - Over use of superficial flexors Stage 2: Test Endurance - Pressure level can hold steadily, without dominant activity of superficial flexors Pattern of movement Each progressive stage of the C-CF test must be associated with a progressive increase in C-CF not retraction Falla et al, 22 Percentage of full ROM The average pressures achieved and repetitions for each age group asymptomatic population (n = 18) Age (years) Target Pressure Repetitions (n=43) 8.1 ± 1.8 mmhg 8.6 ± (n=37) 7.4 ± 2.3 mmhg 9.3 ± (n=28) 7. ± 2.2 mmhg 8.4 ± 2.9 Total population 7.6 ± 2.1 mmhg 8.8 ± mmHg 24mmHg 26mmHg 28mmHg 3mmHg Pressure level 3

4 The average pressures achieved and repetitions for each age group cervicogenic headache population (n=2) Age (years) Target Pressure Repetitions (n=45) 4.4 ± 2.1 mmhg 7.1 ± (n=98) 3.9 ± 2.1 mmhg 6.5 ± (n=57) 3.4 ± 1.8 mmhg 5.2 ± 4.1 Total population 3.9 ± 2.1 mmhg 6.3 ± 7.5 Cranio-cervical flexion test No age or gender effects Asymptomatic subjects = mmhg Neck pain patients = mmhg Poor performance reflects inhibition of the deep longus colli and longus capitis muscles Falla et al, 24 Useful for differential diagnosis of cervicogenic headache Retraining Principles How do we train the deep cervical flexor muscles in patients with cervicogenic headache? Low load, tonic holding capacity of specific target muscles (in relative isolation in the first instance) Precision is required Exercises should be pain free Exercises should be short of fatigue Correct movement pattern Multiple repetitions Training the DCF Progression Train in supine lying (in relative isolation) Facilitate with eye movement Emphasise precision and control of the rotation movement of CCF (avoid retraction) Avoid fatigue substitution Palpation or EMG feedback for superficial flexors Ensure correct pattern Increase holding time (1 x 1 sec holds) Increase level of pressure as able, aim to train to 28-3 mmhg Train formally, twice per day Train with postural correction multiple times per day Train frequently within postural control exercises 4

5 Training posture Facilitated vs Un-facilitated posture First treatment De-load neck from unnecessary strain Facilitate support muscles Correction of posture from the lumbo-pelvic region Reposition shoulder girdle DCF EMG amplitude (µv) Occipital lift (not retraction) Un-facilitated Facilitated Falla et al, Man Ther, 27 Summary Poor performance on the cranio-cervical flexion test has been shown to discriminate cervicogenic headache patients from other headache types This is especially when the test is performed in combination with other assessments of musculoskeletal impairment (ROM, segmental dysfx) Training the deep cervical flexor using the craniocervical flexion action has been shown to be effective for patients with cervicogenic headache Both in terms of headache and neck pain relief and improved muscular control 5