Exercise for Reducing Neck Pain and Enhancing Dynamic Stability www.fisiokinesiterapia.biz
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
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
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
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
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
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
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
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
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
Janda s Upper Crossed Syndrome
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
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
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
Deep Cervical Muscle Progression Hold cranio-cervical cervical flexion while performing dynamic upper extremity exercise
Suboccipital Muscle Progression Lack of literature isolating suboccipitals from the trapezius muscle as cervical extensors. Begin with isometric theraband resistance.
Suboccipital Muscle Progression Seated theraband resistance with SB and rotational forces. Rectus Capitus lateralis ipsilateral SB Obliquus Capitus Superior-ipsilateral ipsilateral SB
Isometric Rotation Rectus Capitus Lateralis, Rectus Capitus Posterior Posterior Major, Obliquus Capitus Inferior all ipsilaterally rotate
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
Dynamic Neck Stabilization-Swiss Swiss Ball
Dynamic Isometric Exercises Isometric Extension with Backward Walk
Dynamic Isometric Exercises Isometric Flexion with Forward Walk
Dynamic Isometric Exercises Isometric SB with Sidestepping
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
Lower Trapezius-Blackburn Blackburn s
Lower Trapezius with Tubing
Lower Trapezius with Pulleys
Stretch Pectoralis Minor-No Money
Strengthen Serratus Anterior-Supine
Strengthen Serratus Anterior-Ball Alphabets
Strengthen Serratus Anterior-Ball Rhythmic Stabilization
Strengthen Rhomboids-Universal Posture Correction TheraBand
Strengthen Rhomboids-use Kendall MMT Position
Stretch Upper Thoracic Spine
Stretch Upper Thoracic Spine
Upper Thoracic Manual Stretch
Summary-Reducing Neck Pain Minimize activation of upper trapezius, SCM, and Anterior Scalene Refrain from using seated manual isometric resistance to flexors! With Exercise
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