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). [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 [3]
-Assist activation of deep cervical flexor muscles [3]
-Produce hypoalgesic affects more so then higher-load exercises [4]
-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

The infamies Gluteus Medius

Often when we work out we focus on the muscles which get us the most attention. Everyone wants to have the six pack abs, the toned legs and bulging biceps. However,training in this manner causes us to forget about some of the more important muscles. The muscles that our body uses for stability and preventing injury. 

The Gluteus Medius is a small muscle which is found along the outside of the hip joint.  Despite its size the Gluteus Medius plays an important role in exercise and injury prevention. This particular muscle is involved in stabilizing the hip joint.  Often when someone has a weak Gluteus Medius their hip will jut outwards while doing such activities as a single leg squat.

         

What most people don’t know is that having a weak Gluteus Medius has also been linked to injuries of the hip, knee and even the back. Some of the most elite athletes will get injuries because of this reason. Exercises like running and cycling involve mostly forward motion and can cause outside muscles such as the Gluteus Medius to be neglected.

Exercises for Gluteus Medius 

Side-Lying Hip Abduction: Start in a side-lying position on an exercise mat. Keep both knees fully extended and your hips in a neutral position.Slowly lift the top leg upwards towards the ceiling until reaching 30°. Then return the top leg slowly to the starting position. To challenge this exercise further place an elastic band around both ankles or use ankle weights. 

Lateral Band Walks Start with an elastic band tied around your ankles. Keep your knees and hips flexed 30° while keeping your toes pointed forward. Place your hands on the side of your hips. Starting with feet shoulder width apart begin side stepping approximately 130% of your shoulder distance repetitively. To progress tie the elastic band tighter or use one with more resistance.

Bridges Start by lying on your back and placing an elastic band around your knees. Lye on your back with your knees bent and your toes lifted. While attempting to squeeze your gluteal muscles together push outwards on the elastic band. Push your heels into the ground until your buttocks lift up 4-6 inches above the exercise mat. Now gradually lower your pelvic back down. Further challenge this exercise by doing a single leg bridge.

Are your muscles dysfunctional? Assessing neck pain: Part 2

     One should not assess mechanical neck pain (MNP) in an attempt to locate a specific structure which is flawed. Rather, MNP is often a contribution of different factors which lead to an end result of pathology. These contributing factors are dysfunctional muscles. This is a continuation of Part 1 and will discuss methods of examining MNP.  

     Manual therapist often will perform examinations with the goal of developing a diagnosis. Test will be performed and objective findings recorded. However, often performing examinations in this manner can produce a lot of black and white while forgetting to addressee the gray areas. With MNP the gray areas can be the most important areas. 

     So how do I assess cervical muscle function?

     Firstly, when assessing muscle function one must understand this is an observational skill. Such a skill will improve with the experience of the examiner.  There are no objective criteria which will produce a positive or negative result. Furthermore, this fact alone will create discrepancies between examiners. What one person deems as dysfunctional another may not.

     1. The Cranial Cervical Flexion Test (CFFT)

    This test is designed to examine and train deep cervical flexor muscles such as the longus capitis and longus colli [1]. These particular muscles play an important role in the stability of spinal segments. By using this test, examiners can indicate if these muscles are dysfunctional. In addition, we can also purpose a cause for patients MNP. Furthermore, this test can also help guide the rehabilitation process by indicating which muscles need to be targeted. 

     The test incorporates two important components of the deep cervical flexion muscles 1) upper cervical flexion and 2) flattening of the cervical spine. Studies have found those with both traumatic and non traumatic neck pain to lack the ability to perform the CCFT. Furthermore, while performing the CCFT these subjects displayed an increase in EMG activity of the superficial cervical muscles. This is hypothesised to be due to a compensation of weak and inhibited deep cervical flexion muscles. 

     To perform this test the patient must be lying supine with the forehead and chin parallel to the table. To achieve this position often the head must be placed in a small opened head rest (chiro table). The purpose of this position is to place the neck in a neutral position not favouring flexion or extension of any kind.

     Instead of using an inflatable pressure sensor (as described in studies) one may use a blood pressure cuff to gage the patient’s pressure. Place the blood pressure cuff below the occiput and behind the neck. Inflate the blood pressure cuff until the space between the neck and the table is filled but not to produce pressure upon the neck.

The patient is then instructed to nod the chin towards the sternum. The movement should be done without creating flexion of the head as if one is attempting to do a sit up. This position is then held for 10 seconds and should be performed at a level high enough to raise the blood pressure cuff by 10mmHg. If testing for endurance then repeat the same movement 10 times.

     Inability to do the test or to increase the pressure indicates weakness of the deep cervical flexors [2]. Observe the following Video.

  Keep in mind this test can be used to also train patients who present with muscle dysfunction. Patients can be progressed by increasing pressure (4mmHg to 5 mmHg) or by simply increasing the number or reps.     
      2) The Link to Posture

     How do I assess if there is a postural component to my patients pain?

    Patients will experience neck pain with prolonged sitting, repetitive upper limb activities or while maintaining a sustained position. 

     Patients will show poor cervicalthoracic postural habits when asked to mimic the aggravating postures which create their pain. Sitting for example has been shown in those with MNP to produce an increased cervical lordosis. This lordosis occurs due to compensating for a progressive thoracic kyposis over time from prolonged sitting.   
     
     Patients will report lessening of symptoms with postural correction strategies. 

3) The Link to the Scapula

     Patients with MNP have been linked to dysfunctional axioscapular muscle activity. These are patients who will experience their neck pain while performing repetitive task of the upper limb. Muscles such as the upper Trapizium and the Levator scapulae can be the source of this connection. These muscles have the ability to produce abnormal forces through spinal segments due to the scapula dysfunction.

     Scapular dysfunction can be assessed in multiple ways and would require an additional column. However, a good test is to first have a patient perform an aggravating activity which involves upper limb movement. Often I will try to reproduce the patient’s pain by having them bounce a ball repetitively against a wall with their arms elevated overhead. A connection can be made to their neck pain if pain is reproduced.

     Now have the patient perform the same task as before but with their scapula repositioned in the proper manner. This repositioning can be performed manually with either the scapular retraction test or scapular assistance test. Both test are often used to test shoulder pathology and purposed by Kibler. Another method to help reposition the scapula is the use of tape. If the patient now can perform the same task but with symptoms lessened or resolved this indicates they may benefit from scapular setting exercises in their treatment plan.

     In summary, one should be aware of multiple observational strategies to assessing MNP.  These three valuable points will be overlooked if a practitioner simply focuses on objective findings and questionnaires. Pain may be resolved but could reoccur if these factors are not addressed. So remember don’t just examiner but assess and observe.

Falla, D., Jull, G., & Hodges, P. (2004). Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test Spine, 2108-2114 DOI: 10.1097/01.brs.0000141170.89317.0e   FITZGERALD, K. (2008). D.J. Magee, Orthopedic Physical Assessment (fifth ed.), Saunders Elsevier (2008) ISBN 978-0-7216-0571-5 1138 pp., Hardback, illus, CD-ROM, AUD 124.00 GBP 48.99. International Journal of Osteopathic Medicine, 11 (2), 69-69 DOI: 10.1016/j.ijosm.2008.02.002   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

Book Review: Low Back Disorders

Low Back Disorders: Evidence-Based Prevention and Rehabilitation. 2^nd Edition. Stuart McGill, PhD. Human Kinetics, 2007. 312 pages. 

Dr. Stuart McGill and his immense research based out of the University of Waterloo, Ontario can be summarized in this 2^nd edition of Low Back Disorders.  Although, the back is often seen as complex by many health professions alike, Dr. McGill’s book helps to put things into a perspective which is easy to understand. The book is divided into three parts. Part 1- “Scientific Foundation”, part 2- “Injury Prevention” and part 3- “Low Back Rehabilitation”. 

Although deemed to be the driest aspect of the book, the “Scientific Foundation” section helps set forth groundwork in understanding the low back. Here, the reader can grasp the concept of whom, how, and why people develop back problems so frequently. With his thorough evidence-based knowledge, McGill sets the record straight on the myths and realities of low back disorders. However, despite the validity in these concepts, much of section 1 can be eliminated for the common clinician who doesn’t want to be overwhelmed in the details of research and lab instrumentation.

The “Injury Prevention” section provides light at the end of the tunnel when assessing common risk for low back injuries in chapters 8 and 9. Here clinicians are provided with knowledge that can be recommended to almost every patient. Although ergonomics is not the cause in every patients back problem, McGill helps evaluate multiple scenarios to minimize forces and injury to the spine. 

The most appealing part of the book is found in section 3 Low Back Rehabilitation. Rehabilitating the spine is often one of the greater challenges when handling problems of the low back. This section provides great exercises that can be implemented for the most common sufferer of low back pain. Furthermore, McGill provides readers with an array of tools and tests that can help clinicians determine which patients are in need of these exercises. This section alone is worth the money and time spent in reading the book. 

This book is an important read for any health professional that deals with the low back. Although 312 pages of research and science can appear daunting, this book saves many clinicians the ample time it takes to research and understand the back. However, there is much more to understanding a patient's back pain and many factors have to be considered. It should be advised that Low Back Disorders should be used as a stepping stone in comprehending what a patient is experiencing and not to be deemed the complete guide in low back health. The book also tends to saturate many of the key points which can be simplified into a few pages. Constantly, referring back to itself in past and future settings the book appears to drag on leaving the reader at times uninterested. 

In comparison, to the 1^st edition not much more is amplified as it is stated in the book. More recent research is referenced, and there are additional photos and information provided, however nothing that appears to make the book significantly more valuable.  The 2^nd edition simply updates points which were already stated to be important in the 1^st edition. With this being said, the 1^st edition can be just as valuable to the curriculum as the 2^nd. However, no matter which edition, Low Back Disorders can be recommended to enhance the insight of any clinician, scientist, or student in tackling the issue of low back injuries. Dr. Wayne Button, BSc, D.C


Boyd, K. (2003). Low Back Disorders: Evidence-Based Prevention and Rehabilitation Physiotherapy Canada, 55 (02) DOI: 10.2310/6640.2003.37832