Role of Deep Cervical Flexor In Chronic Neck Pain

Hồ Quang HưngDepartment of Rehabilitation, Cho Ray Hospital

drhungho.com30/11/2018

1The 4th annual meeting of Saigon ITO

Content

• What is Deep Cervical Flexor (DCF)• DCF in Chronic Neck Pain• Assessment of DCF• Implications in physical therapy

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Deep cervical flexors

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Superficial neck flexorsDeep neck flexors

DCF Origin Insertion ActionLongus capitis

Basilar portion of the occiput

The anterior tubercles on the transverse processes of C3-C6

Head flexion

Longus colli

Anterior parts of cervical spine

Anterior parts of cervical, thoracic spine

Neck flexion

Activation of DCF in chronic neck pain

4Falla (2004), Manual Therapy 9:125–133

fMRI of different cervical flexion exercises

5Cagnie (2008). J Appl Physiol 104: 230–235

CF-CCF

CF

CCF

RCTs on DCF exercise and neck painExperimental Group Control group Outcome measures

Chiu (2005) CCF exercise and dynamicstrengthening exercise + IR and neck care advice

nonexercise (IR and neck care advice)

Pain, disability and isometric neck muscle strength

O'Leary (2007) CCF exercise CF exercise Isometric strength and endurance of Craniocervical flexor muscles

Jull (2009) CCF training Strength training EMG, VAS, NDI

Chung (2012) CCF exercises Neck isometric exercises Ultrasound, NDI

Lee (2012) CCF exercise basic stretching exercises Head tilt angle, neck flexion angle,forward shoulder angle, and the result of CCFT

Iqbal (2013) Craniocervical flexion exercise + conventional exercises

Justconventional exercises

VAS, NDI

Javanshir (2015) CCF exercise CF exercise VAS, NDI, ultrasonography

Gogoi (2015) Cervical endurance training Cervical isometric (conventional) exercise

Endurance, pain intensity, disability,range of motion, and muscle power

Izquierdo (2016) CCF exercise Cervical proprioceptionexercise

CCF test, pressure pain threshold,level of pain and disability

6Arimi, S. A.(2017). American journal of physical medicine & rehabilitation, 96(8), 582-588.

Conclusion: The results of reviewed studies are in favor of specific low-load craniocervical flexion exercise, which seems to be a highly effective exercise regimen compared to other types of exercises in improving DCF muscles impairments in patients with chronic neck pain.

CPR: Clinical Prediction Rule

• CPR identifies patients who may respond well to a certain treatment.

• Ex:– Cervical manipulation: Tseng YL (2006). Man Ther.

11:306-315

– Cervical traction: Raney NH (2009). Eur Spine J. 18:382-

391.• BUT to date: no CPR available for deep

cervical flexor exercise7

Kelly J, Ritchie C, Sterling M. (2017). Clinical prediction rules for prognosis and treatment prescription in neck pain: A systematic review. Musculoskelet Sci Pract. 27:155-164.

How to know clinically DCF weakness

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The craniocervical flexion test

Falla (2003). Phys Ther 83:899-906.Jull (2008). Journal of manipulative and physiological therapeutics, 31(7), 525-533.

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Clinical protocol:Stage 1: Analysis of performance of the craniocervical flexion action.Stage 2: Testing isometric endurance of the deep cervical flexors at test stages that the patient is able to achieve with the correct craniocervical flexion action

DCF endurance test• Timer stopped when one of

four criteria are met:1. pain2. fatigues & unwilling to

continue3. loss of chin tuck4. head raised off of the fingers

• Repeated 2x and average -with a 15 second rest

• Normal Values: Men: 38.9s, Women: 29.4s

10Harris (2005). Phys Ther. 85:1349–1355Dominech (2011). PM R. 3(2):105-10

1 inch or 2 fingers

Neck pain classificationICF ICD Clinical findings Intervention fir chronic phase

1 Neck pain with mobility deficits

Cervicalgia or pain in thoracic spine

Cervical active range of motion (ROM)Cervical flexion-rotation testCervical and thoracic segmental mobility tests

Manipulation/MobilisationMixed exercise, postural trainingDry needling, laser, intermittent traction

2 Neck pain with headaches

Headaches or cervicocranial syndrome

Cervical active ROMCervical flexion-rotation testUpper cervical segmental mobility tests

Manipulation/mobilization combined with stretching, strengthening, and endurance exercise

3 Neck pain with movement coordination impairments (WAD)

Sprain and strain of cervical spine

Cranial cervical flexion testNeck flexor endurance tests

EducationMobilization combined with progressive exercise, cognitive behavior therapyTENS

4 Neck pain with radiating pain

Spondylosis with radiculopathy or cervical disc disorder with radiculopathy

Neurodynamic testsSpurling’s testDistraction testValsava test

Mechanical intermittent cervical traction, combined with stretching, strengthening exercise plus cervical, thoracic mobilisation/manipulation

Blanpied, P. R., Gross, A. R., Elliott, J. M., Devaney, L. L., Clewley, D., Walton, D. M., ... & Boeglin, E. (2017). Neck pain: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 47(7), A1-A83.

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DCF in exercise program

• DCF activation• Neck stabilisation• Postural training: Forward-Head Posture,

rounded shoulder• Upper crossed syndrome

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Crossed syndrome

13Page P (2006). Journal of Bodywork and Movement Therapies 10:77–84

Implications in physical therapy

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ROM exercise

Stretching exercise

Strengthening exercise

Steps in flexors strengthening

15O'Leary S (2009). J Orthop Sports Phys Ther 39(5):324-333

Firstly: Deep cervical flexor

Secondly: General cervical flexors in Cranio-Cervical Flexion Position

“Chin-tuck” exercise

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Alternatives to pressure biofeedback

*Overactivity of SCM in “chin-tuck” exercise

Forward head posture in female workers

Summary

• DCF has reduced activity in chronic neck pain

• We should pay attention to DCF in the exercise program

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Thank you for your kind attention

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