Disclosures Use of Deep Cervical Flexor Exercises in Reducing Cervical Spine Pain I have nothing to disclose. Sarah Pawlowsky, PT, DPT, OCS Assistant Clinical Professor UCSF Core Faculty UCSF/SFSU Graduate Program in PT UCSF Spine Symposium 2013 Objectives Describe two clinical tests for deep cervical flexors. Describe exercises to strengthen deep cervical flexors. Summarize the current evidence pertaining to how deep cervical flexor exercises can be used to treat cervical spine pain. Background Exercise therapy effective for neck pain. (Kay et al 2005) Local cervical segments may be vulnerable to instability in the absence of deep muscle activation. (Falla 2011) 1
Deep Cervical Flexors (DCF) Longus Colli & Longus Capitis Craniocervical flexion, counter lordosis Actions of sternocleidomastoid (SCM) & anterior scalene (AS) Potential Ways to Test DCF Cervical Flexion SCM and AS provide 83% cervical flexion capacity (Vasavada 1998) Craniocervical Flexion Test Craniocervical Flexion with Cervical Flexion Pictures from Cagnie et al 2008 fmri Results Cervical Flexion: Higher SCM activity Craniocervical Flexion: Higher Longus Capitis activity Craniocervical Flexion with Cervical Flexion: Maximal recruitment of Longus Colli, Longus Capitis, & SCM Results and Pictures from Cagnie et al. 2008. Craniocervical Flexion Test (CCFT) Procedures from Jull 2008 Use of Stabilizer pressure biofeedback cuff Head nod action from 20 to 22 mmhg, 2-3 s hold Repeated through each 2 mmhg to 30 mmhg Clinician monitors for substitution SCM and AS should not be active 10 sec hold, 3 times each target level Picture from Jull et al 2008 2
Craniocervical Flexion Test Reduced performance of CCFT is associated with DCF dysfunction. (Falla et al 2004) Excellent intratester reliability. Excellent repeatability between test and re-test. (James 2010) Patients with neck pain demonstrate inferior performance on CCFT (Jull et al 1999 and Jull et al 2000) DCF Endurance Test (Craniocervical Flexion with Cervical Flexion) Chin tuck and lifted head 2.5 cm Line drawn across 2 anterior-lateral skin folds Hand with stacked fingers under occiput Test repeated, maintaining contact with tester s stacked fingers ICC: 0.6. Confidence Interval: 0.34-0.86 (Domenech et al 2011) Picture and protocol from Domenech et al 2011 Domenech et al 2011 Men: 39.1 ± 20.0 seconds Women: 29.3 ± 13.7 seconds Activity level and age not correlated with endurance Treatment: What is Best Type of Training for DCF? Low-load training increased DCF EMG amplitude and decreased amplitude for SCM and anterior scalene. No change in DCF amplitude for high-load training group. (Jull et al 2009) 3
Treatment: Activation of DCF in Sitting EMG of DCF higher when facilitated into upright posture versus unfacilitated spontaneous upright sitting. (Falla et al 2004) 2 weeks of treatment improved pattern of cervical muscle activity in CCFT. (Beer et al 2012) Strengthening DCF and Pain Reduction (Falla et al 2012) 14 women, >6 months neck pain Treatment by a PT 1x/week x 6 weeks. HEP: BID for 10-20 mins After 6 weeks of training, patients with greatest percent change in activation of DCF showed greatest pain relief from training. Patients with least activation of DCF at baseline showed greatest change in activation post-training. Picture from Beer et al 2012 Other Studies That Support DCF Strengthening to Manage Pain Manipulative therapy, exercise, and combination equally effective in reducing symptoms of HA and neck pain. Results maintained in long-term. (Jull et al 2002) Low-load and high-load training for DCF correlated with significant reduction in pain and NDI score. (Jull et al 2009) Higher pain levels associated with greater delays in activation of DCF during rapid flexion of shoulder and lower amplitude of activation during isometric DCF contraction. (Falla et al 2011) Conclusions Patients with neck pain show decreased activation of the deep cervical flexors. Literature supports two clinical tests of DCF strength CCFT & DCF Endurance Test. Low-load exercise training in the CCFT position and DCF activation in sitting have been shown to increase strength of DCF. Strengthening of DCF has been shown to improve pain in patients with neck pain. 4
References Thank You Beer A, Treleaven J, Jull G. Can a functional postural exercise improve performance in the cranio-cervical flexion test? -- A preliminary study. Manual Therapy 2012; 17: 219-224. Cagnie B, Dickx N, Peeters I, et al. The use of functional MRI to evaluate cervical flexor activity during different cervical flexion exercises. J Appl Physiol 2008; 104:230-235. Domenech MA, Sizer PS, Dedrick GS, et al. The Deep Neck Flexor Endurance Test: Normative Data Scores in Healthy Adults. P M R 2011; 3: 105-110. Falla DL, Jull GA, Hodges PW. Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test. SPINE 2004; 29 (19): 2108-2114. Falla DL,O Leary S, Fagan A, Jull GA. Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual Therapy 2007; 12: 139-143. References Continued Falla DL, O Leary S, Farina D, Jull. GA. Association Between Intensity of Pain and Impairment in Onset and Activation of the Deep Cervical Flexors in Patients With Persistent Neck Pain. Clin J Pain 2011; 27 (4): 309-314. Falla DL, O Leary S, Farina D, Jull GA. The Change in Deep Cervical Flexor Activity After Training Is Associated With the Degree of Pain Reduction in Patients With Chronic Neck Pain. Clin J Pain 2012; 28: 628-634. James G, Doe T. The Craniocervical Flexion Test: Intra-Tester Reliability in Asymptomatic Subjects. Physiother. Res. Int. 2010; 15: 144-149. Jull G, Barrett C, Magee R, et al. Further clinical clarification of the muscle dysfunction in cervical headache. Cephalalgia 1999;19:179 85. Jull GA. Deep cervical flexor muscle dysfunction in whiplash. J Musculoskeletal Pain 2000;8:143 54. References Continued Jull GA, Trott P, Potter H, et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine 2002; 27 (17): 1835-1843. Jull GA, O Leary SP, Falla DL. Clinical Assessment of the deep cervical flexor muscles: the craniocervical flexion test. J of Manipulative and Physiological Therapeutics 2008; 31(7): 525-533. Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Therapy 2009; 14: 696-701. Kay T, Gross A, Goldsmith C, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev 2005 ; CD004250. Vasavada AN, Li S, Delp SL. Influence of muscle morphometry and moment arms on the moment-generating capacity of human neck muscles. Spine 23: 412 422, 1998. 5