Saturday, November 7, 2009
Are your muscles dysfunctional? Treating neck pain: Part 3
Almost everyone you talk to claims to be an expert in mechanical neck pain (MNP). Hundreds of books, articles and now even a blog has been written on the topic. Prescribing any combination of exercises and techniques may be useful. However, when establishing a protocol for rehabilitation certain goals and objectives should be considered. This column will discuss the process of treating MNP in a continuation of Part 1 & Part 2 of our series on neck pain.
How do I guide my rehabilitation for MNP?
It is important to have a treatment plan in place. Without one we would be giving exercises with no real purpose. Consider the following:
When research is used to study the effectiveness of rehabilitation often protocols can be extensive. Patients in these studies will be diligent performing exercises everyday for long periods of time. Furthermore, such studies incorporate supervision of treatment with a protocol of progression and monitoring. After all this, results still may only produce 60-80% improvement. Such a study would be deemed a success. How much improvement do you think you will achieve with a housewife of three kids? How about if you give a patient 20 unsupervised exercises?
Guiding rehabilitation is never easy but the concept of applying it is. Simply ask yourself what am I trying to do? Rehabilitation for MNP should include the following two objectives:
1) Training individual muscle groups
2) Addressing problematic functional activity.
Addressing functional activity
Here a rehabilitation treatment plan should address those activities which are problematic. The list of activities may be extensive but posture is often the main culprit.
Do not underestimate your advice when educating a patient about posture. Studies have shown those patients which are given instruction achieve a more effective correct posture then those which are not given any instruction. Furthermore, these patients also achieve better activation of deep cervical flexor muscles (Importance discussed in Part 2). 
Patients also usually need daily reminders to keep adjusting their posture. Every fifth phone call you receive talk while standing. Adjust your work chair every five minutes. Often patients can put little stickers on different areas of their workplace. These stickers should be placed in areas that will only be seen if they take on a problematic posture. The patient now remembers once seeing the sticker to change their posture.
Training individual muscle groups
This goal also works in synergy with addressing functional activity. This is because patients who display good muscle activation also favour a less problematic posture. These muscles now promote less of a forward head carriage or sloped shoulders.
Exercise # 1
Training deep lower cervical extensor muscles
Patient should be in a four point kneeling position with their weight distributed on their elbows and knees. Starting in this position the patient should slowly lower their head into flexion and then slowly extend back to the starting position. Most of the movement should be coming from the lower cervical region. This isolation of movement can be facilitated with proprioceptive feedback and verbal cues by the therapist.
Exercise # 2
Training deep cervical flexor muscles
Patient should be in a supine position with their head rested on a small towel for support. With the forehead and chin lying parallel with the table the patients head is now in a neutral position. The patient should then be instructed to bring their chin towards their sternum slowly while slightly lifting their head off the towel. The patient should aim to not flex the head forward (as in the starting attempt of a sit up) but merely to sustain the neck in a slightly flexed posture. This position will best facilitate the deep cervical neck flexors.
In those patients who experience MNP with upper limb activity and scapular dysfunction a program of axioscapular exercises should be implemented. (Part 2).
What intensity of training should I use?
This is a good question and often can be confusing to physical therapist. The best way to guide your intensity level is again to ask yourself the question what is it exactly you're trying to do? These patients merely want a rehabilitation program that can help them in their everyday activities and reside some of their pain.
When considering rehabilitation for MNP low-level intensity exercises (approx 20% maximal voluntary contraction) is often the best choice. Consider the following:
Low level intensity training has been shown to
-Incorporate better coordination between both deep and superficial muscle groups 
-Assist activation of deep cervical flexor muscles 
-Produce hypoalgesic affects more so then higher-load exercises 
-Be more transitional to daily functional activities (20-50% MVC).
In summary, one should always remain critical yet open to different forms of treatment. However, a purpose should be appointed to everything you do. This point is emphasized all the time when patients, colleagues and lawyer will question your actions. So remember the next time you treat MNP, sometimes the best way to sink a golf ball is with a good putting game and not a long drive. Dr. Wayne Button, BSc, D.C
O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872
Schwarz, J. (2008). Recruitment of the Deep Cervical Flexor Muscles during a Postural-Correction Exercise Performed in Sitting manuelletherapie, 12 (2), 76-77 DOI: 10.1055/s-2008-1027472
Jull GA, & Stanton WR (2005). Predictors of responsiveness to physiotherapy management of cervicogenic headache. Cephalalgia : an international journal of headache, 25 (2), 101-8 PMID: 15658946
OLEARY, S., FALLA, D., HODGES, P., JULL, G., & VICENZINO, B. (2007). Specific Therapeutic Exercise of the Neck Induces Immediate Local Hypoalgesia The Journal of Pain, 8 (11), 832-839 DOI: 10.1016/j.jpain.2007.05.014