Interventions for the cervical region
I have posted about the cervical region a lot. It isn’t an area that I love to treat though I do like working with young athletes who have spine pain in general. Instead, I think it is because these patients seem to take longer to get better and I know that my outcomes aren’t as good in this area. I don’t need a database to tell me this, I think about the cervical region a lot because sometimes I am at a lost for what to do. There are certain interventions that I need to utilize more often instead of the general upper body strengthening and scapular activation. I think that we miss a lot of people because we have become so enamored on the posterior chain muscles in cervical pain.
This is a call to myself to improve my outcomes and to improve my intervention strategies. I started thinking about this at the gym today. There are two guys that I always see and I secretly judge (like most therapists do when we go to the gym and see people performing exercises that make us laugh) them based upon what they do. They do pure neck strengthening exercises. They both grab a 35/45 pound plate and perform non-weight bearing flexion/extension/sidebending/rotation cervical AROM with the plate resting on their head. Today, one of these gentlemen (they are both over 60 years old), performed a bridge maneuver with his head acting as the fulcrum point cranially with weight being placed through his neck while in extension. It was impressive! Curious me finally decided to ask this guy one question.
Have you ever had neck pain? “No”
He has never had neck pain. I explained to him why I wanted to know (this exercise was extreme!) and that I found it amazing that he could even do that. I just found this to be amazing, he has been doing these exercises for 20 years and he has never had neck pain. From my previous posts, much of this is attributed to the true definition of pain and where it comes from. He must have arthritis and compression in his cervical region but these exercises don’t bother him! Wow! Shows the power of pain and the fact that it comes from the brain and not the structure almost no matter how badly something may be off.
Anyway, are we missing this? Maybe not a compression/extension weight bearing cervical exercise but maybe I am missing something. I know for me it is often times that conservative nature taking over because it is the cervical region. I am not a conservative therapist at all (if you know me then you know how accurate that statement is) but I think I treat these cervical components a little too conservatively. Doesn’t mean that I want to abandon my usual ROM increasing program but I need to definitely take into account the anatomy and nerve firing more in the cervical region.
To increase A/PROM:
- Already went over this many times but this includes
- Mackenzie based exercises
- Band pull or ball squeeze plus cervical AROM
- Instrument assisted soft tissue
- Mobilizations/manipulations on restricted segments
- Eye movement preceding cervical AROM movements (thanks Morgan!)
To increase proprioception (eyes closed)
- Use a target board (maybe 3 or 4 rings spread out over 8-10 inches in diameter), cut a hole in a cup for the patients eye then have the patient close their eyes and attempt to perform cervical AROM looking for them to find there resting place without use of their ocular system.
- Easy to take home and try. Have them focus on adjusting their movement with their eyes closed so that they can find where they are supposed to stop. Then ingrain that into their system but repeatedly performing this.
Deep neck flexors
- I really don’t do this enough. When I do try this I see a lot of compensations and difficulty with control during this relatively simple exercise. I recently had a patient with long term neck pain perform this and could barely hold it 3 seconds.
- Should assess on majority of cervical pain patients but especially anything termed as chronic pain. SCMs have shown to be dysfunctional in neck pain/headaches so by working on the deep neck flexors this should help take pressure off these. If someone has trouble with end range extension then this is the deep neck flexors as well (cervical extensors start the movement).
- Sometimes the patient has more difficulty with getting into the position so I usually start with placing them into cervical flexion and then ask them to hold this position. As they get better at this then you can vary a towel height behind their head and have them progress to neutral or flat against the table.
- The numbers in the research vary but most show times that should be over 20 seconds and it should be clean. Big difference between clean and dirty and all the compensations.
- Make this harder by training them with various upper extremity and lower movements.
Shoulder blade retraction with shoulder shrug
- I really like this one. They should completely retract their shoulder blades then come into a shoulder shrug. Check unilateral and bilateral. Sometimes there will be a difference between the sides.
- The trapezius is one muscle that is split into three distinct sections. The upper/middle/lower traps are all innervated by the same nerve (spinal accessory nerve) and attach to the occiput.
- Every patient’s cervical spasms usually are in the upper traps. Why don’t we activate these muscles? If someone has middle trap spasms then we focus on retraction right? Usually they are already stretched to the end point of their function so we shouldn’t stretch even further. All we are doing is contributing to this issue. Activate!
- We all know that you can’t train the VMO specifically of the other quad muscles mainly for the fact that the same nerve innervates all of them (and attachment point pretty much makes it impossible). I know that fiber alignment will make one muscle more active than another with scapular movement but what if we are missing this simple activation? It is the same nerve and one muscles fires then they all fire to some extent.
- When both the traps fire then they assist with cervical extension due to their insertion in the occiput.
Rows/bilateral shoulder extension/ ER with retraction/ and Y/T/I/W exercise
- Yes, still do these. Usually my main goal in the cervical region is to achieve extension anyway we can and this especially includes thoracic extension.
- Use these as the pain free exercises to decrease the PNS/CNS awareness and hyper alertness
- Incorporate these with other movements and positions such as the bird dog position or single leg stance (any balance exercise).
- Can be done many different ways but PNF patterns are great facilitators
- Can perform in the SFMA position with arm in IR and band pull to make sure they go through full AROM
- Progress to weight bearing
- Progress to weight bearing with cervical head position in varying places.
Cervical AROM with Upper body exercises
- Perform exercises like the shoulder flexion with head movement preceded by eye movement.
- Cervical region really is meant to move with the body so retrain it to move with the body
- Use this with box lifts/carry/overhead movements/etc.
- If you have something available. Like the bike and treadmill for walking
- This increases blood flow and reduces the nervous system’s alertness.
- Progress slowly if they are having trouble and educate them to start walking at home
- Anything to get there mind off the “pain” can only be a good thing
Do what is appropriate and necessary. Do not scare the patient into thinking that these muscles are weak which is why they need to be done. If the patient is fearful then gradually introduce them to the program. Be mindful of what they are doing at home. Have your most important/need to be done interventions before adding the others in.
As always comments/suggestions are welcome! And encouraged!
Also I am going to try to add a question-answer/case study section that others can post about or ask for help or just teach in general. I am always looking for guest posts as well. If you see something then say something. This is about learning from everyone who reads this.
~ TJ Slowik