Exercise Interventions for the Cervical Spine

Question 1

5 main principles that are manipulated/adapted in spinal rehab

Answer 1

1) Kinesthetic awareness: training of safe movement & postures
2) Mobility/flexibility
3) Muscle performance: stabilization, endurance, strength, & power
4) Cardiopulmonary performance: aerobic training
5) Functional activities: body mechanics & skill based training

Question 2

Impairment based intervention selection for the spine

Answer 2

• General: Stage of healing
• Non-weight bearing/traction approach
• Extension bias
• Flexion bias
• Hypermobility & instability: stabilization
• Hypomobility: mobilization & manipulation
• Postural pain syndromes: exercise & conditioning

Question 3

Stages of recovery/healing

Answer 3

• Acute with inflammation (0-4 wks): constant pain, signs of inflammation, no position or movement completely relieves symptoms
• Acute without inflammation (0-4 wks): intermittent symptoms related to mechanical deformation, may be an extension/flexion/non-weight bearing bias
• Subacute (4-12 wks): some movements, ADLs, IADLs still provocate symptoms
• Chronic (>12 wks): chronic pain syndrome (>6 months), emphasis is placed on returning to high level demand activities requiring relativity loads on a sustained basis over a prolonged period of time

Question 4

Describe non-weight bearing bias

Answer 4

• patient does not tolerate being upright for basic ADLs & IADLs
• movement testing makes symptoms worse
• traction relieves symptoms

Question 5

Describe extension bias

Answer 5

• patient usually presents with flexed posture, a lateral shift may also be present
• extension tests decrease or centralize symptoms
• diagnosis may include intervertebral disc lesions, impaired fixed posture, fluid stasis

Question 6

Describe flexion bias

Answer 6

• patient usually presents with flexed posture & is more comfortable when flexed
• extension tests exacerbate or peripheralize symptoms
• diagnosis may include spondylosis, stenosis, extension load injuries, swollen facet joints

Question 7

Describe hypermobility/functional instability

Answer 7

• stabilization/immobilization approach
• patients present with hypermobile spinal segments, poor spinal stability
• diagnosis may include trauma, ligamentous laxity, spondylosis, or spondylolisthesis

Question 8

Describe hypomobility

Answer 8

• mobilization/manipulation approach
• restricted mobility in one or more spinal segments

Question 9

Describe postural pain syndrome

Answer 9

• exercise & conditioning approach
• patient presents with faulty posture, symptoms increase with sustained position
• diagnosis may include postural strain, crevice-genic headache, thoracic outlet syndrome, poor physical condition
• movement, posture correction, & exercise decrease symptoms

Question 10

Spinal precautions following spine surgery

Answer 10

• no bending
• no twisting
• no lifting greater than 10 lbs
• follow for 2-6 weeks
• log roll to get out of bed

Question 11

Post-op exercises for spine surgery

Answer 11

• begin 4-6 wks after surgery
• isometric neck exercises
• spinal stabilization exercsies
• U active motion to tolerance
• posture education
• strengthening of associated areas
• walking program or other cardiovascular based exercise
• screen for post-op infection, DVT, ensure proper pain management, review assistive device recommendations, & home exercise program (HEP) prior to discharge from hospital

Question 12

5 classifications for neck pain

Answer 12

• Neck pain with mobility deficits
• Neck pain with movement coordination impairments (WAD)
• Neck pain with headaches
• Neck pain with radiating pain
• Neck pain

Question 13

Common symptoms of neck pain with mobility deficits

Answer 13

• central and/or unilateral neck pain
• limitation in neck motion that consistently reproduces symptoms
• associated (referred) shoulder girdle or UE pain may be present

Question 14

Expected exam findings for neck pain with mobility deficits

Answer 14

• limited cervical ROM
• neck pain at end ranges of A/PROM
• restricted cervical & thoracic segmental mobility
• intersegmental mobility testing reveals characteristic restriction
• neck & referred pain reproduced with provocation of the involved cervical or upper thoracic segments or cervical musculature
• deficits in cervicoscapulothoracic strength & motor control may be present in individuals with subacute or chronic neck pain

Question 15

Acute interventions for neck pain with mobility deficits

Answer 15

• cervical spine neck ROM exercise progressions
• Levator scapulae stretch progression
• scalene stretch progression
• T spine mobilization progression
• scapulothoracic & UE strengthening program
• cervical spine mobilizations & manipulations
• time frame <6 weeks

Question 16

Thoracic spine mobilizations

Answer 16

• extension stretch over a foam roll/towel
• seated thoracic extension over chair with or without towel
• quadruped thoracic extension stretch
• self posterior to anterior mobilization with a tennis ball

Question 17

Subacute interventions for neck pain with mobility deficits

Answer 17

• neck & shoulder girdle endurance exercises
• thoracic manipulation & cervical manipulation and/or mobilization
• time frame 6-12 weeks

Question 18

Describe the different phases for neck & shoulder girdle exercises for neck pain with mobility deficits subacute

Answer 18

• Phase 1: neck ROM and resisted shoulder extension/shrugs
• Phase 2: isometric neck exercises and chest/lats stretches
• Phase 3: resisted neck exercises and resisted dynamic hugs & reverse fly

Question 19

Chronic interventions for neck pain with mobility deficits

Answer 19

• thoracic or cervical manipulation or mobilization
• mixed exercise for the cervical & scapulothoracic region
• dry needling, laser, intermittent mechancial/manual traction

Question 20

Common symptoms for neck pain with radiating pain

Answer 20

• neck pain with radiating pain in the involved extremity
• narrow band of lancinating pain
• UE dermatomal paresthesia or numbness & myotomal muscle weakness

Question 21

Expected exam findings for neck pain with radiating pain

Answer 21

• neck & neck related radiating pain reproduced or relieved with radiculopathy testing
• Cluster: ULLT-A, Spurlings test, cervical distraction, & cervical ROM <60 degrees rotation
  -may have UE sensory, strength, reflex deficits associated with the involved nerve roots

Question 22

Treatment for neck pain with radiating pain

Answer 22

• intermittent manual/mechanical traction
• repeated directional preference mobilizations (retraction/retraction with extension)
• nerve glides
• Acute: provide mobilizing & stabilizing exercises, laser, & short term use of a cervical collar
• Chronic: provide mechanical intermittent cervical traction in combination with stretching & strengthening exercises plus cervical & thoracic mobilization/manipulation, provide education & counseling to encourage participation in occupational & exercise activities

Question 23

Common symptoms for neck pain with coordination impairments

Answer 23

• mechanism of onset linked to trauma or whiplash
• referred shoulder girdle or UE pain
• referred varied nonspecific concussive signs & symptoms
• dizziness/nausea
• headache, concentration or memory difficulties, confusion, hypersensitivity to mechanical, thermal, acoustic, odor, or light stimuli
• heightened affective state

Question 24

Expected exam findings for neck pain with coordination impairments

Answer 24

• Pos. cranial cervical flexion test
• Pos. neck flexor muscle endurance test
• Pos. pressure algometry
• strength & endurance deficits of the neck muscles
• neck pain with mid-range motion that worsens with end range positions
• point tenderness may include myofascial trigger points
• sensorimotor impairment may include altered muscle firing parameters, proprioceptive deficit, postural balance & control
• neck & referred pain reproduced by provocation of the involved cervical segments

Question 25

What are the deep neck flexors

Answer 25

• longus colli
• longus capitis
• rectus capitis anterior
• rectus lateralis

Question 26

What are the deep cervical extensors

Answer 26

• semispinalis cevicis
• multifus
• rotators

Question 27

What are the cranio-cervical extensors

Answer 27

• rectus capitis posterior minor
• rectus capitis posterior major
• obliquus capitis superior
• obliquus capitis inferior
• spinalis cervicis

Question 28

Interventions for neck pain with coordination impairments

Answer 28

• education
• return to normal, non provocative pre-accident activities ASAP
• minimize the use of a cervical collar
• perform postural & mobility exercises to decrease pain & increase ROM
• reassure patient recovery is expected within the first 2-3 months
• multimodal intervention
• manual mobilization techniques plus exercise
• strength, endurance, flexibility, postural, coordination, aerobic, functional exercise for those expected to have a moderate to slow recovery
• conditioning exercises: deep neck flexor & cervical extensor strengthening progressions

Question 29

Cervical stabilization with progressive loading for neck flexors

Answer 29

• gentle craniocervical flexion/axial extension hold 10 sec for 10 reps
• Max to mod protection: shoulder flexion to 90 degrees, shoulder abduction to 90 degrees, & shoulder ER with arms at sides
• Mod to min protection: shoulder flexion to end range, shoulder abduction combined with ER to end range, & diagonal patterns
• Min to no protection: reaching forward, outward, upward in functional patterns & pushing/pulling & lifting activities
• Max to min support: supine, sitting, standing with wall support, standing with no support

Question 30

Cervical stabilization with progressive loading for neck extensors

Answer 30

• lift forehead off exercise mat hold 10 sec for 10 reps
• Max to mod protection: arms at side ER shoulder & adduct scapulae, arms in 90/90 position horizontally abd shoulders and add scapulae
• Mod to min protection: elevate shoulder in full flexion, arms abd to 90 degrees & ER elbows extended horizontally abd shoulder & add scapulae, UE diagonal patterns
• Min to no protection: reaching forward, outward, upward in functional patterns, and pushing/pulling/lifting activities
• Max to min support: prone forehead on treatment table, quadruped over padded stool or gym ball, standing back supported by wall, & standing no support

Question 31

Common symptoms for neck pain with headaches

Answer 31

• noncontinuous, unilateral neck pain & referred headache
• headache is precipitated or aggravated by neck movements or sustained postures

Question 32

Expected exam findings for neck pain with headaches

Answer 32

• Pos. cervical flexion rotation test
• headache reproduced with provocation of the involved upper cervical segments
• limited cervical ROM
• restricted upper cervical segmental mobility
• strength, endurance, & coordination deficits of the neck muscles

Question 33

Acute interventions for neck pain with headaches

Answer 33

• supervised instruction in active mobility exercise
• SNAG stretch
• deep cervical flexor training
• light stretching/strengthening/AROM
• postural education & training

Question 34

Subacute interventions for neck pain with headaches

Answer 34

• provide cervical manipulation & mobilization
• SNAG stretch

Question 35

Chronic interventions for neck pain with headaches

Answer 35

• provide cervical or cervicothoracic manipulation or mobilizations combined with shoulder girdle & neck stretching, strengthening, & endurance exercises

Question 36

Summary of what to do for the different neck pain classifications

Answer 36

• Neck pain with mobility deficits: C-spine ROM, T-spine mobilization, SNAGs, cervicothoracic strengthening
• Neck pain with radiating pain: repeated motions & nerve glides
• Neck pain with movement coordination impairments: cervical flexor & extensor conditioning exercise progressions
• Neck pain with headaches: combination of above techniques