exercise for reducing neck pain and enhancing dynamic

Exercise for Reducing Neck Pain and Exercise for Reducing Neck Pain and Enhancing Dynamic StabilityEnhancing Dynamic Stability

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Presentation OutlinePresentation Outline

Compare/Contrast Lumbar Exercise Compare/Contrast Lumbar Exercise Literature to Cervical SpineLiterature to Cervical SpineDiscuss Neck Musculature and Motor Discuss Neck Musculature and Motor Control in the healthy and painful neck and Control in the healthy and painful neck and itit’’s relationship to exercise prescriptions relationship to exercise prescriptionReview Current Exercises for Reducing Review Current Exercises for Reducing Neck Pain Neck Pain

Hodges 1996, Hides 1994, Van Dien et Hodges 1996, Hides 1994, Van Dien et al 1995al 1995

Core Exercise Concepts in Lumbar Core Exercise Concepts in Lumbar SpineSpine

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

Akuthota and Nadler 2004Akuthota and Nadler 2004

Core Exercise Concepts in Lumbar Core Exercise Concepts in Lumbar SpineSpine

Stability of the lumbar Stability of the lumbar spine requires:spine requires:–– Passive stiffnessPassive stiffness

Osseous and Osseous and ligamentousligamentous structuresstructures

–– Active StiffnessActive StiffnessMuscle FunctionMuscle Function

–– Adequate strengthAdequate strength–– Normal sequencing Normal sequencing

(motor control) (motor control)

Jull 2004, Conley 1995Jull 2004, Conley 1995

Is Core Stability in the Neck Similar Is Core Stability in the Neck Similar to Lumbar Spine?to Lumbar Spine?

Neck and Lumbar anatomy are quite different so a direct Neck and Lumbar anatomy are quite different so a direct extrapolation of one to the other is not possibleextrapolation of one to the other is not possibleThe work of Hodges and others does support current clinical theoThe work of Hodges and others does support current clinical theory ry in the neck. in the neck. In the In the painfreepainfree neck:neck:–– Deep neck flexors (Deep neck flexors (longuslongus capituscapitus and and longuslongus collicolli) help control posture ) help control posture

with continuous tonic (low torque) activity. (Conley 1995)with continuous tonic (low torque) activity. (Conley 1995)Upright postureUpright postureHead lift in supineHead lift in supinePostural control during basic overhead tasksPostural control during basic overhead tasks

–– Superficial neck flexors (SCM and AS) play a major role in high Superficial neck flexors (SCM and AS) play a major role in high torque torque production (production (phasicphasic activity).activity).

–– When performing repeated isometric shoulder contractions in the When performing repeated isometric shoulder contractions in the painfreepainfree neck, the upper neck, the upper trapeziustrapezius will relax; itwill relax; it’’s ability to relax will s ability to relax will diminish in the presence of neck paindiminish in the presence of neck pain

Beeton & Jull 1994, Grant et al 1998Beeton & Jull 1994, Grant et al 1998

Cervical Spine Motor ControlCervical Spine Motor ControlIn the presence of neck In the presence of neck pain, the deep cervical pain, the deep cervical flexors lose endurance flexors lose endurance capacity.capacity.Deep Deep CxCx flexor testflexor test–– Change in 10mm Hg goodChange in 10mm Hg good–– Pts with neck pain hover at Pts with neck pain hover at

about 2about 2--4mm4mm–– EMG monitors SCM and EMG monitors SCM and

ASAS*Test not yet validated*Test not yet validated

Falla and Jull 2004, Uhlig et al 1995Falla and Jull 2004, Uhlig et al 1995

Cervical Spine Motor ControlCervical Spine Motor ControlFallaFalla and Jull found an and Jull found an increase in SCM and AS increase in SCM and AS electrical activity with electrical activity with reduced cervical flexion reduced cervical flexion force at 25% MVC.force at 25% MVC.Biopsy studies on chronic Biopsy studies on chronic neck pain patients have neck pain patients have found loss of Type I found loss of Type I muscle fibers and muscle fibers and increase of Type II fibers.increase of Type II fibers.

Conley et al. 1995, Hallgren 1994, and Conley et al. 1995, Hallgren 1994, and McPartland 1997McPartland 1997

Cervical Spine Motor ControlCervical Spine Motor ControlSuboccipitalsSuboccipitals–– Conley et al. noted their Conley et al. noted their

continuous activity in continuous activity in postural studiespostural studies

–– HallgrenHallgren and and McPartlandMcPartlandnoted their atrophy in noted their atrophy in presence of chronic neck presence of chronic neck painpain

No clinical tests yet No clinical tests yet validated to detect validated to detect suboccipitalsuboccipital strength strength deficitsdeficits

Fredin et al 1997, Janda 1994Fredin et al 1997, Janda 1994

Cervical Spine Motor ControlCervical Spine Motor ControlPts with neck pain (post Pts with neck pain (post whiplash injuries) have whiplash injuries) have demonstrated inability to demonstrated inability to relax upper trapezius relax upper trapezius between repeated between repeated isometreicisometreic contractions of contractions of shoulder flexion.shoulder flexion.JandaJanda reported overuse reported overuse of of levatorlevator scapula in scapula in presence of neck pain presence of neck pain along with weakness of along with weakness of lower lower trapeziustrapezius. .

Janda1994, Jull 1994, Sahrman 1994, Janda1994, Jull 1994, Sahrman 1994, Kendall 1993Kendall 1993

ScapuloScapulo--thoracic Posturethoracic Posture

Posture of the shoulder girdle is closely linked to Posture of the shoulder girdle is closely linked to cervical posture and needs to be addressed in cervical posture and needs to be addressed in the presence of neck painthe presence of neck pain–– Loss of postural control/function of particular scapular Loss of postural control/function of particular scapular

muscles such as muscles such as SerratusSerratus anterior, rhomboids, and anterior, rhomboids, and lower trapezius is a common clinical findinglower trapezius is a common clinical finding

–– Basic Kendall Basic Kendall MMTsMMTs, individual muscle length testing, , individual muscle length testing, and observation of scapular function during and observation of scapular function during scapuloscapulo--humeral rhythm will help detect aberrant motion and humeral rhythm will help detect aberrant motion and function. function.

JandaJanda’’ss Upper Crossed SyndromeUpper Crossed Syndrome

Designing a Neck Stabilizing Designing a Neck Stabilizing ProgramProgram

Just like in the lumbar spine, strengthen Just like in the lumbar spine, strengthen the deep segmental muscles first. These the deep segmental muscles first. These include:include:–– LongusLongus capituscapitus and and longuslongus collicolli (deep (deep

Flexors)Flexors)–– SuboccipitalsSuboccipitals

Deep Cervical Muscle ProgressionDeep Cervical Muscle Progression

The most basic way The most basic way to facilitate the deep to facilitate the deep cervical muscles is in cervical muscles is in a gravity eliminated a gravity eliminated position. position. The time honored The time honored ““Chin TuckChin Tuck”” ExerciseExercise


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


Hold Hold craniocranio--cervical cervical flexion while flexion while performing dynamic performing dynamic upper extremity upper extremity exercise exercise

SuboccipitalSuboccipital Muscle ProgressionMuscle Progression

Lack of literature Lack of literature isolating isolating suboccipitalssuboccipitalsfrom the trapezius from the trapezius muscle as cervical muscle as cervical extensors.extensors.Begin with isometric Begin with isometric therabandtheraband resistance.resistance.

SuboccipitalSuboccipital Muscle ProgressionMuscle Progression

Seated Seated therabandtherabandresistance with SB resistance with SB and rotational forces.and rotational forces.–– Rectus Rectus CapitusCapitus

lateralislateralis ––ipsilateralipsilateral SBSB–– ObliquusObliquus CapitusCapitus

SuperiorSuperior--ipsilateralipsilateral SBSB

Isometric RotationIsometric Rotation

RectusRectus CapitusCapitusLateralisLateralis, , RectusRectusCapitusCapitus Posterior Posterior PosteriorPosterior Major, Major, ObliquusObliquus CapitusCapitusInferior all Inferior all ipsilaterallyipsilaterallyrotaterotate

SuboccipitalSuboccipital and Deep Flexor and Deep Flexor Muscle ProgressionMuscle Progression

Prone or quadruped Prone or quadruped cervical chin tuckscervical chin tucksHold chin tuck, push Hold chin tuck, push crown of head into the crown of head into the Swiss ball, hold 6 Swiss ball, hold 6 secondsseconds

Dynamic Neck StabilizationDynamic Neck Stabilization--Swiss BallSwiss Ball

Dynamic Isometric ExercisesDynamic Isometric Exercises

Isometric Extension Isometric Extension with Backward Walkwith Backward Walk


Isometric Flexion with Isometric Flexion with Forward WalkForward Walk


Isometric SB with Isometric SB with SidesteppingSidestepping

Dealing with a hypertonic Upper Dealing with a hypertonic Upper TrapeziusTrapezius

Some evidence Some evidence suggests stretching suggests stretching the upper trapezius is the upper trapezius is not effectivenot effectiveStrengthen the lower Strengthen the lower trapezius since:trapezius since:–– It is commonly weakIt is commonly weak–– Facilitating it will Facilitating it will

reciprocally inhibit the reciprocally inhibit the over working upper over working upper trapeziustrapezius

PNF Scapular Posterior Depression

Lower TrapeziusLower Trapezius--BlackburnBlackburn’’ss

Lower Trapezius with TubingLower Trapezius with Tubing

Lower Trapezius with PulleysLower Trapezius with Pulleys

Stretch Stretch PectoralisPectoralis MinorMinor--No MoneyNo Money

Strengthen Strengthen SerratusSerratus AnteriorAnterior--SupineSupine

Strengthen Strengthen SerratusSerratus AnteriorAnterior--Ball Ball AlphabetsAlphabets

Strengthen Strengthen SerratusSerratus AnteriorAnterior--Ball Ball Rhythmic Stabilization Rhythmic Stabilization

Strengthen RhomboidsStrengthen Rhomboids--Universal Universal Posture Correction Posture Correction TheraBandTheraBand

Strengthen RhomboidsStrengthen Rhomboids--use Kendall use Kendall MMT Position MMT Position

Stretch Upper Thoracic SpineStretch Upper Thoracic Spine

Upper Thoracic Manual StretchUpper Thoracic Manual Stretch

SummarySummary--Reducing Neck Pain Reducing Neck Pain With ExerciseWith Exercise

Minimize activation of Minimize activation of upper trapezius, upper trapezius, SCM, and Anterior SCM, and Anterior ScaleneScalene–– Refrain from using Refrain from using

seated manual seated manual isometric resistance to isometric resistance to flexors!flexors!

Ylinen et al 2003Ylinen et al 2003

SummarySummary--Reducing Neck Pain Reducing Neck Pain With ExerciseWith Exercise

Do facilitate the deep cervical flexors with low intensity, Do facilitate the deep cervical flexors with low intensity, high repetition exercisehigh repetition exerciseDo facilitate the deep neck extensorsDo facilitate the deep neck extensors–– TheraThera--band isometrics seated and dynamic walking exercisesband isometrics seated and dynamic walking exercises–– Quadruped chin tucksQuadruped chin tucks

Strengthen Lower TrapeziusStrengthen Lower TrapeziusStretch Stretch PectoralisPectoralis MinorMinorStrengthen Strengthen SerratusSerratus AnteriorAnteriorStrengthen RhomboidsStrengthen RhomboidsStretch and mobilize T1Stretch and mobilize T1--T3 if restrictedT3 if restrictedInclude Aerobic Exercise Training at least 3 times a Include Aerobic Exercise Training at least 3 times a week (week (YlinenYlinen et al 2003)et al 2003)

exercise for reducing neck pain and enhancing dynamic

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