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1 Cervical alignment Consideration of Adjacent Regions Shirley Sahrmann, PT, PhD, FAPTA Mary Kate McDonnell PT,DPT,OCS Washington University School of Medicine -St. Louis Cervical movement Diagnoses with treatment ideas Additional Case Studies Most people who experience neck pain do not experience a complete reduction of symptoms. 50% to 80% will have a reoccurrence in the next 1-5 years. Px: Younger > better. Poorer > poor health, prior neck pn episodes, poor psychological health, worrying. Need for Future Research Neck pain is multifactorial in its etiology and in its impact on affected persons. Future research should be directed to assessing the impact of modifiable risk factors through innovative treatment approaches. Changes in public policy which address these risk factors may significantly reduce the burden and cost of neck pain in society. Increasing thoracic curve increases cervical lordosis = forward head position Good alignment Effect of slumping Inward curve Influenced by length intrinsic muscles of cervical spine muscles of shoulder girdle that attach to cervical spine Alignment of the thoracic spine Kendall, FP et al, Posture & Pain. Kendall, FP et al, Posture & Pain. St. Louis Sahrmann & Associates 1

2 Good Alignment of cervical spine Cervical spine extension Kendall, FP Kendall, FP Forward Head > Cervical Spine Extended & Translated Forward not Flexed Facets are approximated Increasing thoracic curve increases cervical lordosis / extension Good alignment Effect of slumping Effect of alignment on associated muscle - Increase length of the anterior, flexor cervical muscles and supra and infra hyoid muscles Kendall, FP - Decrease length of the posterior, extensor muscles Consideration of Adjacent Regions for Assessment and Treatment Lumbar Spine Alignment Thoracic Spine Alignment Scapular Alignment Weight of the extremities Movement of the extremities Black KM et al, Spine 1996 Mechanical Neck Pain - Porterfield & DeRosa St. Louis Sahrmann & Associates 2

3 A more neutral sitting posture reduces the demand on the cervical extensor muscles. Improves neck range of motion. Edmondston SJ. Ergonomics. 2010/ Caneiro et al. Man Ther. 2010/ Cleland et al. PTJ 2009/Lau KT et al Man Ther 2010 Correcting lumbar, thoracic alignment before correcting cervical spine alignment is critical Thoracic alignment = Kyphosis or Sway Radiculopathy - Dec sensation 4&5 th digit - Dec triceps strength Assumed posture: - Scapulae abducted - Forward head First correct scapulae position > Adduct then correct neck alignment Difficult to perform but no increase in sxs The musculature of the shoulder girdle affects the alignment and the stress on the cervical spine structures. Evidence Scapular Upward rotation & Posterior Tipping decreased in flexed head position Ludewig PM, Cook TM. Jrnl Occup Rehab, 1996 Position of scapular depression > increases stress on upper trapezius muscle Asevedo D et al Eur J Pain, The alignment of the shoulder girdle should be addressed in the treatment of cervical pain problems. Restricted rotation range of motion Passive elevation of shoulder girdle increases range of motion and decreases pain Compressive loading of the cervical spine from a transfer of the weight of the upper extremities to the cervical region through cervicoscapular muscle attachments Ha S et al. Man Ther VanDillen,LR et al ClinJnlPn,2007 Andrade GT et al JOSPT,2008, McDonnell MK et al JOSPT,2005 Elevated Shoulder Girdle Test Ha S et al. Man Ther VanDillen,LR et al ClinJnlPn,2007 Andrade GT et al JOSPT,2008, St. Louis Sahrmann & Associates 3

4 Test: fully support UEs with muscles relaxed Assess ROM and pain Treatment? Support the weight of arms during functional activities / improve strength of scapulotthoracic muscles to support limbs yo Rotation = 70 0 Sidebending = 45 0 Extension = 85 0 Flexion = yo Rotation = 50 0 Sidebending = 25 0 Extension = 55 0 Flexion = 50 0 Youdas JW et al. PTJ. 96 Movement evenly distributed through segments. Flexion & extension slightly greater in lower segments Flexion of the cervical spine Flexion/ Extension: Coupled motion of translation and sagittal rotation Sagittal rotation = Rolling = rotation about a frontal axis Flexion Extension [young adults] Lengthening of posterior structures, separation of spinous processes Full flexion cervical spine includes upper thoracic flexion St. Louis Sahrmann & Associates 4

5 Flexion rolling & translating Extension greater translation at end range Follow up test? Correct thoracic, scapulae alignment, cue rolling Rotation: Coupled motion of side- bending and rotation in the same direction Rotation about a vertical axis Rotation Sidebending [young adults] Compressive forces on cervical spine Weight of head Muscle contraction Downward pull of shoulders Right rotation good rotate about a vertical axis Left rotation compensatory sidebend and extension Follow up test? Correct scapulae position, instruct to rotate about a vertical axis, keep head upright and do not let sidebend, manual assist Intrinsic neck muscles become weak or long - compromise fine control of vertebral motion Extrinsic neck muscles become dominant adding to compressive, rotational, & shear forces exerted on the cervical spine St. Louis Sahrmann & Associates 5

6 The syndrome is identified by the direction of the movement that most consistently is associated with pain and the movement is usually impaired. Correction of the movement decreases or eliminates the symptoms. Extension Rotation-extension* Rotation Rotation-flexion Flexion * Most common in my practice **Cervical dx will have an associated scapula and/or humeral movement dx Pain with cervical extension Limited cervical flexion Forward head posture > anterior translation, extension DDD > anterior translation Upper cervical > Headaches - resting alignment > 10 0 extension Movement Impairments: Starting alignment - normal cervical alignment - excessive posterior translation. Dominant activity of levator scapulae, reduced activity of posterior cervical extensors. Forward head posture (degenerative disc disease) anterior translation limit extension range of motion. Upper cervical extension greater than Lower Movement Impairments: Flexion range limited or cervical spine does not flex at all segments Poor control of motion during active extension and return Shoulder flexion compensatory cervical extension Quadruped rocking compensatory cervical extension Forward head with increase upper thoracic flexion Flexion lower spine remains extended St. Louis Sahrmann & Associates 6

7 Upper cervical extension greater than Lower cervical Follow up test? Correct scapular position, then initiate with lower cervical extension Limited cervical flexion Compensatory cervical extension with shoulder flexion Follow up test perform w/o cervical extension Alignment Impairments Thoracic kyphosis > increases cervical lordosis Scapula depression or abduction - trapezius & levator in a lengthen position, downward pull that exerts a compressive force on facets, narrow the intervertebral foramen, traction on the brachial plexus. Changes in alignment > increase extension > increase length of the anterior cervical muscle and mandible depressors > decrease strength Key muscle changes Short extensors & Long flexors Forwardhead Posture = Increase Cervical Extension Muscle Impairments: Lengthened intrinsic neck flexors - test weak, decrease endurance dominant extrinsic neck flexors dominant levator / upper trapezius short cervical extensors - lordotic position St. Louis Sahrmann & Associates 7

8 Intrinsic Neck Flexors Longus capitis TP s C3-6 > Occiput Longus colli TP s C3-C5 > C1 arch Bodies of T1,2,3 > TP s C5,6 Bodies of C5-7, T1-3 > Bodies of C2,3,4 Poor performance of deep neck flexors Function - Cervical flexion with Sagittal rotation Requires assistance to maintain correct position Mechanical Neck Pain - Porterfield & DeRosa Evidence - Impairments of the deep neck flexors with patients with dx of Cervicogenic Headaches (CH) & Chronic neck pain patients Watson DH et al Cephalgia 93 Beazell JR Jrnl Man & Manip Th 98 Placzek et al Jrnl Man & Manip Th 99 Jull et al Cephalgia 99 Falla D et al, Cl Neurophys 06 O Leary KT et al. Man Ther 11 Increase recruitment during anterior translation with flexion O Leary S. Man Ther Anterior, Middle Scalenes Sternocleidomastoid Significant decrease in STRENGTH & ENDURANCE of the deep neck flexors Semispinalis Capitis & Cervicis Splenius Suboccipitals Function: Posterior sagittal rotation Greater anterior translation than sagittal rotation Mechanical Neck Pain Porterfield & DeRosa St. Louis Sahrmann & Associates 8

9 Function - cervical extension, sagittal rotation - roll the head up Levator Scapulae posterior translation of cervical spine Upper Trapezius posterior translation of cervical spine Mechanical Neck Pain Porterfield & DeRosa Levator scapulae Trapezius extension posterior shear Longus colli & capitis flexion Mechanical Neck Pain Porterfield & DeRosa Levator scapulae posterior shear force counteracts anterior shear of cervical curve Confirming Tests: pain with neck extension passive elevation of girdle - decrease pain with extension Vandillen et al 2007, Ha et al 2011 limited cervical flexion poor performance of the deep neck flexors Porterfield & DeRosa, Mechanical Neck Pain St. Louis Sahrmann & Associates 9

10 Confirming Tests - Shoulder Flexion with Cervical Flexion (w/o extension) Confirming Test Elevated Shoulder Girdle Test Patient needs to totally relaxed not active contraction of shoulder girdle muscles. If positive explain to the patient how supporting arms during the day will be helpful. Weakness of the intrinsic neck flexors O leary et al. MT 2011 Translation greater than sagittal rotation Start with correct alignment of lumbar, thoracic and scapula before cervical spine alignment. Lau KT et al. MT 2010/Wegner S et al. MT 2010 Decrease compression and shear from upper trapezius & levator scapulae Decrease resistance from latissimus dorsi, pectoralis major and minor when shoulders are flexed Increase support from middle, lower trapezius & serratus anterior - support extremities Treatment: Limit amount of cervical extension - ADL s Forward translation and/or looking up Improve extensibility of posterior cervical muscles Improve intrinsic cervical muscle control and strength Improve control / strength of intrinsic neck flexors Falla et al Clin Neurophys 2006/Jull et al MT Improve length of cervical extensors Habits - bifocals, sleeping with arms overhead, position of computer? St. Louis Sahrmann & Associates 10

11 Education restore and educate sagittal rotation movement minimize anterior translation strategies posterior translation, bifocals - lower part of glasses Alignment - wall modify thoracic kyphosis, depressed chest Unload spine - support upper extremities Schuldt K et al. Scand J Rehabil Med Andrade GT et al. JOSPT 08/ Ha et al MT 11 Exercises Abdominals Correct scapula position Cervical exercises Lengthen posterior structures - capital head flx Strengthen intrinsic neck flexors Strengthen intrinsic neck extensors Supine or Against the Wall - sitting: Shoulder Flexion Shoulder Abduction, Lateral Rotation Rocking back - maintaining neutral cervical spine - chin to front of neck Sitting against the wall - arms supported 1. lumbar spine alignment 2. thoracic spine / scapula alignment 3. cervical alignment - capital head flexion 4. shoulder flexion and/or abduction Sitting against the wall - arms supported, correct: lumbar spine alignment thoracic spine / scapula alignment Then try 1. Capital head flexion roll head And / or 2. Active shoulder flexion and/or abduction Look down > Shoulder flexion, Shoulder abduction lateral rotation Add Tband to arm exercises - keep head/chin down St. Louis Sahrmann & Associates 11

12 Patient with neck pain and radiculopathy Poor alignment of thoracic spine, neck and scapulae Wall slides with capital flexion add theraband Wall exercise - emphasizing abdominal recruitment and scapula elevation. Significant forward head prevents full correction of neck alignment - stiff posterior cervical structures Capital Flexion > Roll head Cervical Flexor Strengthening < Poor Performance Not translation Yes < Better Correction - ideal alignment / not excessive translation Capital flexion vs Chin tuck Poor alignment - forward head Best Perfomance > Requires assistance & towel roll for correct performance St. Louis Sahrmann & Associates 12

13 EXERCISE Poor function of deep neck flexors requires assistance Improve intrinsic neck extensor function but avoid end range extension Roll head back Brush nose against the hand Prefer to perform in Hands and Knees Roll head - pole through ears Keep chin down when rocking back St. Louis Sahrmann & Associates 13

14 Good exercise chin in as rocking back Incorrect associated compensatory extension Contributing factors to consider addressing during treatment: Habitual nodding Use of bifocals Sleeping with arms overhead Position of computer Make patient aware of positions and habits that assume positions of extension. Educating patient about daily habits and preferred alignments contribute to extension movement patterns Keep nose and chin down, look down, during activities St. Louis Sahrmann & Associates 14

15 Movement: rotation range limited, during rotation deviates from vertical axis - extension or lateral bending. Pain with rotation, occurs earlier in the range if the head and neck are extended & delayed if spine in neutral. Alignment: forward head, cervical lordosis asymmetry in the paraspinals hearing, eye problems? depressed downwardly rotated scapula more common Contributing Activities: telephone, repeated overhead with resistance, golf, one arm activities Relative Flexibility/Stiffness specific cervical segments more flexible than other segments. Key test - single arm raise Muscle Impairments: Cervical extension impairments Segmental rotation > insufficient control of intrinsic neck flexors. Confirming tests: Passive shoulder girdle elevation Unilateral shoulder flexion Shoulder flexion can cause cervical rotation: Indicative of excessive mobility of cervical vertebrae Kendall Cervical rotation to the right during left shoulder flexion Right shoulder flexion Left shoulder flexion Spinous processes to left Left rotation: pain and cerv.ext With arms supported: no pain and improved axis of rotation St. Louis Sahrmann & Associates 15

16 Holding telephone with shoulder Sitting with head turned watching TV Sleeping prone with arm overhead and head turned to opposite side Sleeping on couch with head resting on arm rest Falling asleep sitting up Bifocals and computer screen Start with Cervical Extension dx treatment Cervical rotation about a vertical axis with correct, supported scapula alignment supine, sitting against a wall, facing wall - arms supported overhead Educate risk of one arm activities, encourage bilateral arm activities Functional - head phones, position of computer, avoiding repetitive, prolonged rotated position, effect of one arm activities ROTATION CORRECTED ACTIVELY GUIDING CORRECT AXIS OF MOTION Cervical rotation avoiding compensatory extension & side bend chin down / slightly lean in opposite direction of rotation HANDS & KNEES ARMS SUPPORTED ON WALL Left rotation: pain and cerv.ext With arms supported: no pain and improved axis of rotation St. Louis Sahrmann & Associates 16

17 Shirley Sahrmann, PT, PhD, FAPTA And Associates Right rotation: pain & limited With arms supported: no pain and improved range Neck pain decreased by supporting shoulders & decreasing cervical lordosis Neck pain Initial visit 2 weeks later Initial visit 2 weeks later Contributing factors: long trunk, short arms, large breasts with bras straps adding to downward pull of trapezius and levator scapulae muscles Poor sitting alignment Corrected sitting alignment Cervical rotation to the right during left shoulder flexion Right shoulder flexion Left shoulder flexion Spinous processes to left St. Louis Sahrmann & Associates 17

18 Cervical Surgery twice still had constant pain Neck Pain - Cervical Surgery Twice Initial Visit Two Months later Initial Visit Two Months Later Neck Pain - Cervical Surgery Twice Initial Visit Two Months Later Lower cervical spine is flat and flexes easily Unilateral shoulder flexion - rotation Cervical spine flexes more easily than the thoracic spine - often flat thoracic spine Flexion / Flat cervical spine Pain with flexion and with rotation of cervical spine Often have been involved with activities that emphasize cervical curve and depressing shoulders - Ballet dancers St. Louis Sahrmann & Associates 18

19 Encourage to flex thoracic spine less cervical flx Cervical pillow Neck extension - prone, quadriped Avoid excessive cervical flexion raise computer screen, working surface book holder Rotation without compensatory flexion Additional Exercises: Improve cervical extensor mm function Strengthening of the cervical extensors poor function of cervical extensors > cueing cervical paraspinal mms by rolling the head back and down Prone, Hands and Knees Mechanical Neck Pain 1 st 2 attempts faulty - translation > saggital rotation 3 rd attempt increase use of intrinsic spinal extensors greater saggital rotation Functional Instruction: During sitting activities: Slump! Do not attempt to have very straight thoracic spine and relax neck allowing chin and nose position to be slightly up. Wall slides without compensatory flexion Allow thoracic flexion to diminish cervical flexion St. Louis Sahrmann & Associates 19

20 Functional Instructions: Wear eye glasses at appropriate position to allow neutral neck position during computer use > do not exaggerate flexed position Avoid sustained positions of rotation Summary; Alignment of cervical flexion chin up Flat thoracic spine / stiff into flexion > cervical flexion Allow thoracic spine to flex AROM: Excessive motion into flexion avoid extremes of range Rotation diminish compensatory flexion Improve cervical extensor muscle function Passively support arms in elevated position Use towel or soft collar to unweight the head Check size and type of pillow, sleeping position beware of cervical pillow for older patient in particular pillow under arms Note cervical body language, activities such as telephone, furniture arrangement Note pattern of motion during rotation, exaggerated extension or side flexion When supine the patient should turn to side to go from supine to sitting Do not hesitate to use cervical support such as collar, towel folded, or even having the pt use their hand McDonnell MK, Sahrmann SA, VanDillen LR. A Specific Exercise Program and Modification of Alignment for Treatment of Cervicogenic Headache: Case Report. JOSPT. Jan yo male with a 7 year hx of HA s and neck pain Pain located: bilateral posterior neck & upper trapezius region that could radiate into the posterior cranium. HA behavior: constant, varying intensity from 5/10 to 10/10. Neck Disability Index [NDI] score = 31 indicating severe disability St. Louis Sahrmann & Associates 20

21 Flexion = 40 0 painful Extension = 25 0 painful Rotation right = 39 0 painful Rotation left = 40 0 painful Elevated shoulder girdle test: Rotation R = 50 0 dec pn Rotation L = 50 0 dec pn Forward head Thoracic kyphosis Excessive scapula abduction & depression. Scapulae abducted 7 bilaterally. Humeri in medial rotation Shoulder flexion = P - excessive scapula abduction and lack of scapula elevation. Associated cervical extension & translation. Upper cervical mobility: flexion - limited, stiff rotation - limited, stiff Cervical extensors - short Pectoral major - short Pectoral minor - short Latissimus - short Lower abdominals: 0.4/5 Levels Lower trapezius: 2/5 Middle trapezius: 2/5 Rhomboids: 3/5 Palpation: HA s reproduced with palpation of the suboccipital mms & passive upper cervical flexion. Four exercises were prescribed to address 1) the specific strength & length deficits of the scapulothoracic and abdominal muscles, and 2) postural alignment deficits of the cervical and thoracic region. Emphasis of the instructions during exercise was to have the patient avoid inappropriate recruitment of the muscles of the upper quarter during ex. Specific instructions: Avoid compensatory lumbar extension, rib cage elevation, or cervical extension. St. Louis Sahrmann & Associates 21

22 Specific Instruction: -Recruit lower abds -Elevate & abduct scapulae -Perform capital head flexion without compensatory movements Treatment sitting against the wall capital head flexion Specific Instruction: Avoid rib cage elevation & neck extension during shoulder abduction, lateral rotation. Seen for 7 visits over a 3 1/2 months Exercises were progressed to sitting against the wall Emphasis was to perform without associated movement faults of the upper quarter region. HA - 1 episode in a 3 week period -1/10. Uses exercise to abolish HA NDI = 11 = mild disability Resting alignment = 4 1/2 abduction MMT: lower trapezius - 3/5 middle trap = 3/5 rhomboids = 4/5 deep neck flxrs = 2/5 lower abds = 1A/ 5 Levels AROM: Flexion = 31 0 NP Rotation R = 50 0 NP Extension = 40 0 NP Rotation L = 50 0 NP Shoulder flx NP Functional improvement in sitting tolerance at the computer sleep through the night without medication perform horse care activities with less pain St. Louis Sahrmann & Associates 22

23 Summary - phone call 5 month after initial visit Improvement continued Headaches infrequent Improved function continued The patient case demonstrates that addressing alignment and movement impairments at the cervical, scapulothoracic and lumbar region identified in this patient resulted in improvement in the patient s function. 23yo PT student, migraines since 16, 1 0 c/o HA s, neck pain and right scapula pain (rhomboid/trap region). Aggravated with sitting in class. Activities - Weight lifting aggravates sx s, runs every day which does not aggravate it. Ran in college competitively. NDI = 11 = min disability / Rate pain 4/10 ROM: Rotation R=55 0, L=45 0 / Elevated both sides. Rest in 10 0 of extension Mobility Testing - Significant LOM of AA Rotation - Elevate scapula > AA rotation increases! Muscle length/strength: Primary movement fault scapula depression Short lats, weak lower abd with dominant rectus Trap and rhomboid testing on right WNLs but painful and difficult to position. Left side no problem Preferred position of right thoracic rotation, decrease left rotation rom. St. Louis Sahrmann & Associates 23

24 Lower abdominals Latissimus lengthening in supine Hands and Knees * All exercises start with correct recruitment of abdominal Lower abdominal recruitment > Rectus dominant Lower abdominals - Arms in abduction and lateral rotation to decrease rectus dominance > Expand rib cage and contract Latissimus lengthening in supine - recruit abds Preferred alignment Corrected alignment St. Louis Sahrmann & Associates 24

25 Sitting wall - just abdominal recruitment later progressed to cervical capital head flexion and rotation Functional > during the day Sitting recruit lower abdominals *** Reduce right thoracic rotation during sitting activities. Preferred alignment Corrected alignment H&K s - Neutral spine Lower Abdominal recruitment Capital head flexion Tspine down Gentle rocking back - hip flexion 1. The alignment and movement patterns of the shoulder and thoracic spine have an impact on the painful region [Cervical and TMJ]. 2. Cervicoscapular musculature can limit as well as cause motion of the cervical spine. 3. The exam and treatment of a patient TMJ pain must include considerations of the cervical, thoracic and shoulder girdle, 4. The patient s habitual mannerisms and activities also must be included in the exam and treatment. Linda VanDillen PT, Phd Shirley Sahrmann PT, Phd, FAPTA Colleagues at WUPT Program in Physical Therapy - Washington University - St. Louis Nancy Bloom, PT, DPT, MSOT Cheryl Caldwell, PT, DPT, CHT Suzy Cornbleet, PT,,DPT, MA Marcie Harris Hayes, PT, DPT, OCS Gregory Holtzman, PT, DPT Renee Ivens, PT, DPT Debbie McDonnell, PT, DPT Mary Kate McDonnell, PT, DPT, OCS Tracy Spitznagle, PT, DPT, WCS St. Louis Sahrmann & Associates 25