Neck Pain - Chronic & Recurrent (Part 2)
The talk about self-efficacy, and more home based treatment always resonated with me. Long drawn out traditional ‘just manipulation only’ treatments never appealed to me. I went off the reservation and focused on exercise, diet and nutrition, laser, shockwave, meditation, yoga, de-loading the joints, transverse friction techniques, fascial release, auto-correcting the spine, and other treatments, and yes always looking for the opportunity to adjust segments of the body. But ‘my home’ is assessing range of motion associated with pain, and bringing awareness to either lack of motion or excessive motion, trying to correct it with everything I have available, because this is often the correction to the movement problem.
The time I spend teaching patients to perform s-l-o-w corrective movements and the time the patient spends practicing repetitive s-l-o-w movements at first, and then progressing to faster real life movements, and with patience on every ones part, continues helping to enhance the effectiveness of treatments. Again, I measure, and bring awareness to the patient how they can move more natural and with less pain. At this point in my career I don’t want to spend a lot of money on expensive equipment to measure the brain (quantitative EEG’s). I get the evidence and see with my own experience the relation to lower back pain and neck pain that certain exercise interventions will change (and improve) that particular movement, and that the brain will ‘organize’ to perform that movement and pain seems to diminish.
Let’s use a typical forward head posture patient with chronic neck pain. Let’s give them a rehab exercise (training the deep neck flexors) and link motor movement, or the muscle performance to the brain mechanism telling the muscle to perform. Here’s my question to you practitioners, ‘Am I training deep cervical flexor activation or am I stretching the posterior cervical muscles and deloading the disc space or what?’
I start out with education, the patient will gain some awareness of whole body posture, discuss a little ergonomics, then move to deep neck flexor activation. This exercise is very convenient for patients with irritable cervical pain exacerbated by their desk job or are required to sit for long periods of time.
Sit tall, push the feet on the floor, with your arms by your sides and palms facing forward.
Pull your shoulders back and squeeze your shoulder blades together.
Reach towards the ground with your fingers and gently tuck in your chin while lengthening (lengthening or de-loading is key) the back of your neck. Keep your eyes looking down and forward and feel the back of your neck stretching (create awareness of stretch).
Hold this position for five to ten seconds and repeat five to ten times every 30-45 minutes. Build up to one minute holds to really create awareness. Breathe.
Progressing this further
Have your patient lean back in their chair so that their neck is angled posteriorly.
Ask your patient to "self check" their thoracic region alignment (no excessive kyphosis) and ensure the weight of their arms is supported by the arms of their chair.
This may require cuing “chest up” (thoracic extension).
Ask your patient to allow their head to fall back into alignment with their neck.
Your patient is going to chin tuck from this position, flexing their upper and mid-cervical spine while keeping chin tucked.
Here is where I start to work the visual system. I cue the patient to go from looking at the ceiling above their computer and then look down at their keyboard with chin tucked. They can look side to side as well.
Have them hold the most retracted position they can attain without compensation for 2-4 seconds and slowly return to the staring position.
Perform 12 - 20 reps.
Another cervical retraction move that creates awareness, core sensation, and activation of the cervical stabilizers is Prone Cobra on the floor or a Foam Roll.
Lie prone on a 3' long foam roller (half or full depending the patient’s stability). The top of the foam roll should end below the clavicle and manubrium.
Push the toes and balls of the feet into the floor. Dorsiflex the ankles. The knees can remain on the floor for added stability, or triple extension mechanics can be reinforced by extending the hip (contracting the glutes) and knees (contracting the quads).
Draw the belly button toward the spine.
Draw the chin away from the floor (activate the deep cervical flexors), be careful to retract, and not simply extend the neck. The nose should remain pointed toward the floor through the entire movement.
Initially, with the hands still on the floor, retract and depress the scapula. (This may result in some thoracic extension, adding the additional benefit of strengthening these commonly under-active muscles. Try to avoid lumbar extension which may activate already over-active lumbar extensors).
Maintain scapular depression and retraction, extend and externally rotate the arms reaching for the toes/heels. Do not cue arms toward the ceiling as this could result in anterior tipping of the scapula when terminal extension of the shoulder is reached. This range of motion is fairly small.
Hold the top position for 4-6 seconds reinforcing cues for cervical retraction, scapular depression and retraction, and triple extension mechanics in the lower extremities.
Slowly return to the starting position and repeat.
This same position can be used for prone abduction with external rotation, and/or scaption by cuing the appropriate arm position from step 5.
Abduction with external rotation: With elbows extended (arms straight), start with thumbs pointing up and arms abducted to roughly 80°. In this position cue reaching the hands toward the ceiling while maintaining scapular retractions and depression.
Scaption: With elbows extended, start with thumbs pointing up and arms abducted to roughly 130°. In this position cue reaching the hands toward the ceiling while maintaining scapular retractions and depression.
Again, I look for every opportunity to adjust segments, but I also combine isometric contractions for reawakening or reactivating muscles. Joints operate best when in a state of centration. Joints in proper position will have equal co-contraction of the agonists and antagonists. Muscle balance doesn’t require guarding, and the anticipatory reflective contraction is normal. I still love isometrics for neurological strength and muscle stabilization. People use isometrics in the gym all the time, often without even realizing it. Isometrics is a default move to help overcome sticking points in the execution of different exercises. For example, in the biceps curl, a sticking point usually occurs at the halfway or slightly below point of the dumbbell lift. Thus, the use of isometrics at the angles where you have the greatest difficulty can help you overcome the sticking point and make your lift more productive. I find the combination of joint manipulation combined with modalities like Magnawave, laser, shockwave, VR, nutritional coaching, education about healing, stress reduction, and proper isometric contractions is the ‘calling’ to the higher center brain levels. The stabilizer muscles are meant to be strong enough to hold the spinal segments in order while we move. But if there is a history of trauma like a rear end motor vehicle accident, it is important to test the muscles and exercise them with isometric contractions.
I’m still trying to figure out what matters: As mentioned above, call it biopsychosocial ‘stuff’, poor movement awareness, maladaptive changes in the brain and/or in the cervical muscles, or changes in some neuronal activity. Something led to head/neck posture changes, maybe even altered scapular mechanics, and activity of the muscles. With the intent of optimizing awareness, joint and muscle range of motion, neural recruitment, deep neck flexor activation exercises, I hope I’m on the right routine…
Please come join me at the ACA Rehab Council symposium in Tempe, AZ March 13-15, 2020. Registration is at www.ACARehabCouncil.org
Jeffrey Tucker DC DACRB
Dr. Tucker has been evolving and integrating contemporary concepts of chiropractic rehabilitation for more than three decades. He has lectured extensively and authored countless publications on these concepts.
References:
Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani, Muscles: Testing and Function with Posture and Pain: Fifth Edition © 2005 Lippincott Williams & Wilkins
Phillip Page et al, Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
Shirley Sahrmann and Associates, Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine © 2011 Mosby, Inc, an affiliate of Elsevier Inc.
Peolsson, A. L., Peolsson, M. N., & Jull, G. A. (2013). Cervical muscle activity during loaded arm lifts in patients 10 years postsurgery for cervical disc disease. Journal of manipulative and physiological therapeutics, 36(5), 292-299
Falla, D., Jull, G., & Hodges, P. W. (2004). Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Experimental brain research, 157(1), 43-48. (Delayed onset of DCF with arm movement)
Jull, G. A. (2000). Deep cervical flexor muscle dysfunction in whiplash. Journal of musculoskeletal pain, 8(1-2), 143-154.
Jull, G., Barrett, C., Magee, R., & Hodges, P. (1999). Further clinical clarification of the muscle dysfunction in cervical headache. Cephalalgia, 19(3), 179-185. (Decreased activity of deep cervical flexors)
Jull, G., Kristjansson, E., & Dall’Alba, P. (2004). Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Manual therapy, 9(2), 89-94
Falla, D., O'Leary, S., Farina, D., & Jull, G. (2011). Association between intensity of pain and impairment in onset and activation of the deep cervical flexors in patients with persistent neck pain. The Clinical journal of pain, 27(4), 309-314.
Falla, D., O’Leary, S., Fagan, A., & Jull, G. (2007). Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual therapy, 12(2), 139-143