New blog!

I haven’t written in this blog in a couple years but I recently started blogging about physical therapy again at another site. Please visit, like, follow!

https://striveforwardptblog.wordpress.com/

Instagram: @teddy1137 and @striveforwardptblog

Facebook: https://www.facebook.com/striveforwardptblog/

 

Thanks, TJ Slowik DPT USAW

 

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Interventions for the cervical spine

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).

Shoulder diagonals

  • Can be done many different ways but PNF patterns are great facilitators

Thoracic rotation

  • 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.

Cardio

  • 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

Disclaimer:

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

Follow up: Case Study: Cervical pain post concussion

Follow up to Case study: cervical pain post concussion

I treated patient on 11/13 two days after the initial evaluation. Patient reported that her neck pain and movement was a lot better and working on HEP throughout day including at school. She continues to have no headaches or dizziness. Her major complaint now is with sidebending and lack of activity. She really wants to be ready for indoor soccer season which starts in a couple weeks.

Re-check of measurements:

  • Bilateral Rotation and sagittal AROM of cervical remains full and only a 1/10 pain (in upper traps)
  • Her cervical retractions look great and can repeat without incident
  • Thoracic rotation actively is good
  • Upper trap spasms continue but subjective report of much improvement and no more medial scapular border pain
  • Sidebending is limited to about 50% of max (she has a long slender neck and should get a lot of motion in this directions) and has moderate pain

Treatment

  • C-T distraction again
  • IASTM to upper traps and cervical paraspinals
  • Weight bearing cervical retraction with sidebending
    • Reported a lot of pain and was apprehensive to continuing
  • Non-weight bearing cervical retraction with sidebending
    • Tolerated much better and performed until able to get what looks like full PROM
  • Revisited the weight bearing cervical retraction with sidebending
    • Able to tolerate now and improves her motion and pain but still not full AROM that she had passively and pain is still present.
  • Supine mobilizations of cervical segments (right to left and left to right)
    • Moved into more closing with reps
    • Rechecked AROM sidebending and now improved and only mild pain to perform
  • Attempted Upper rib manipulation to left side to reduce upper trap spams but unable to get a good lock and no cavitation. Did on right side and same result
  • Bike, bird dogs, mid/low trap (T/Ys), planks and squats
    • Performed some mild exertion activities to increase blood flow and to begin exertion training for return to sports.
    • No neck pain and no concussion symptoms throughout this part of the program
  • HEP:
    • Same as previous, added the exertion components listed above, cervical retraction with sidebending and also gave a towel pull (isometric horizontal abduction) with row.
    • The towel pull with row seems to get some scapular retraction without flaring up the upper traps

What could I have done different? What would you have done differently?

Any advice on the sidebending? Any advice on upper trap/cervical spasm reduction?

What would you give next visit?

Case Study: cervical pain post concussion

Case Study: cervical pain post concussion

Meant to post this earlier in the week once I saw the patient then update it after seeing her for a second time. Here is the original evaluation then the follow up is at the end of the post.

On 11/11 I had an eval for cervical pain post concussion/whiplash. Prior to seeing the patient I talked to our vestibular therapist to give me an update on her. She was highly symptomatic (headaches/dizziness) last week but today she was doing well with no complaints of headaches or dizziness. The most glaring issue was that she was unable to test any head thrust and VOR measures due to the lack of cervical rotation due to pain.

Subject:

  • High school female soccer (outdoor and indoor) and track athlete.

Past medical history:

  • No prior concussions or neck injuries. Did have bilateral hip pain last year during soccer season but did not have any pain this season.

Incident:

  • Was elbowed in head during a soccer game in the middle of October. Initial symptoms consisted of headaches, dizziness, concentration difficulties and fogginess.

Subjective history of current events:

  • Started having neck pain a couple days after concussion and was in vestibular two weeks after the incident. After first visit vestibular therapist referred her to ortho to address neck pain and to get full AROM so that they could progress on with therapy. She missed the first eval and wasn’t able to get in to see me until 11/11.
  • The pain is constant and gets worse as the day goes on. Hasn’t been involved in any sporting activities or working out due to the concussion. No headaches now so unrelated to neck pain currently though she did report that the neck pain would go up and give her headaches previous to this week.

The initial evaluation:

  • Pain
    • Pain is moderate at rest and severe with cervical AROM
    • Pain centralized to bilateral upper traps and down middle of cervical spine radiating out to the medial bilateral scapular regions
  • Cervical AROM
    • Right/left rotation = 32 degrees with increased pain (severe) on both sides of neck and upper traps
    • Sagittal = 60 degrees with increased pain in both directions (same areas/intensity)
    • Sidebending is restricted to left= 24 and right = 20 with severe pain as well
  • Tenderness (for completeness)
    • Upper traps, sub-occipitals, cervical paraspinals, medial scapular soft tissue and in the thoracic/cervical with P-A over the spinous processes.
  • Strength:
    • Normal shoulder strength and no myotomal weakness
    • Mid/low traps= 3/5, rhomboids= 4+/5
  • PROM
    • Full flexion/extension in supine.
    • Left/right rotations limited due to severe pain but able to get about 75 degrees
    • Sidebending to 45 degrees with severe pain limiting motions
  • The AROM restrictions of O-A, mid cervical vs lower cervical are limited due to the pain
  • Spasms and blocks movement with attempts at any sideglides to cervical region

Treatment

  • PT assisted Non-weight bearing (supine) Mackenzie exercises for extension
    • This includes:
      • Traction with retraction (5 reps) then moved straight into traction- retraction- extension followed by nodding maneuver at end range extension
    • Response:
      • Increased pain with first rep but no red lights -> finished 10 reps
    • I performed to gain extension which often times helps all motions as well. Probably more of a neurological feedback than actually placing anything into proper alignment (helps to decrease apprehension of tissues blocking movement?)
    • Once sitting I re-check motions and had improved flexion/extension greatest but pain at end ranges still. Mild improvements in rotation and pain.
  • Performed C-T distraction and audible cavitation (patient was not impressed! Haha)
    • Improved flexion to near end range with decreases in pain with both flex/ext
  • Weight bearing Mackenzie exercises for extension
    • 10 reps of cervical retraction
    • 10 reps of overpressure
    • 10 reps of retraction- overpressure- extension with nod
    • Full extension now with only mild pain and less upper trap spasms/scapular pain
  • Instrument assisted Soft tissue to upper traps and cervical paraspinals bilateral
    • About 75 degrees of rotation, sidebending is improved but still an issue with pain
    • Reduced spasms quite a bit through cervical region/upper traps
    • I choose to use IASTM vs trigger point releases because…
      • What are trigger points?
      • Seen much better results in session and sustained with follow ups
  • Final: Horizontal abduction pull on theraband with cervical AROM in all plans
    • Just 8 reps of rotation to each side, flexion and extension
    • Full rotation bilateral now with only mild pain at the endranges. Extension and flexion is full and only a 1/10 pain.
  •  HEP:
    • Weight bearing Mackenzie extension exercises
    • Horizontal abduction pull with AROM
    • Weight-bearing thoracic rotation exercise with band pull (was restricted and now full thoracic rotation)
    • Bilateral External rotation with retraction and breathing
    • Patient was finally impressed at the end of the session when she could rotate her head for the first time in weeks.
  • Final thoughts:
    • I always like going NWB manual Mackenzie exercises to start. I feel like it helps the patient adjust more by putting it in my hands vs their own. I always try to finish with HEP weight bearing though.
    • Love IASTM to cervical region for reduction of “spasms”. In my experience the carry over for improvements if you follow it up with the band pull with AROM and Mackenzie exercises is very good.
    • In previous post I love the band pull with AROM when there is a clear limitation in AROM vs PROM. Helps to improve a lot of things including thoracic rotations.

Rolling…yeah I roll

Rolling…rolling…really? This is something that I have done enough times that I have seen great responses with. It has a purpose and if done and followed through with can be very beneficial. Even though I have done this several times I still continue to get questions and stares in clinic from both physical therapists, students and patients.

When do you decide to roll?

In the SFMA course that I took, the instructor (Greg Rose DC) referred to it as turning the switch on. For whatever reason, your “switch” has been turned off and we need to turn it back on. This “switch” is the motor control switch. Usually, in more chronic or longer lasting issues (pain or faulty movement patterns) there is this global motor control issue.

So, when you test functional movements and then break it down into individual segments there are many deficits. Each time you test a passive vs active ROM there is this overwhelming amount of full PROM and limited AROM. Also, the AROM looks “dirty” as in they compensate greatly to achieve a desired outcome. I will test rolling when someone has asymmetrical global weakness (such as in the hips or shoulder), when they show me poor movement patterns in deep squat/backward bend/full body rotation/lumbar flexion and/or they can’t activate their glutes (with prone hip extension they say they feel it in their hamstrings and/or they have a lot of compensations to get the leg smoothly up).

Why do you roll?

It is actually quite simple. If someone can’t roll correctly then how can they possibly perform exercises in any other position such as half/tall kneeling and standing? The way we develop, we start by rolling and then crawling then standing. We can’t skip steps!

The reason why we can’t roll?

I really think, from seeing the patients who fail at it, that we develop faulty movement patterns over the course of time. This could be a result of a previous injury years ago, our very sedentary lifestyles/jobs or the result of our chosen sport. The longer we go with a poor movement pattern then the more engrained into our nervous system that pattern becomes. Rolling is just the first step.

How do you test rolling?

There are four quadrants in both supine and in prone. I usually start in supine. You want to move one body part only and attempt to roll using that one body part. If you are going to use the upper body then the lower body is paralyzed and not allowed to help at all. If there is any activation then that attempt doesn’t count and they should redo it. The patient has to be honest with you and usually after seeing a couple good movements then most times you can see the compensation. Once the upper body is tested in supine then you test the lower body when the upper body is paralyzed.

Supine right shoulder flexion -> supine right leg flexion -> supine left shoulder flexion -> supine left leg flexion

Prone right shoulder extension -> prone right hip extension -> prone left shoulder extension -> prone left hip extension.

How do you treat rolling?

Most often times you will see one area that is especially dysfunctional though there may be multiple areas that need to be worked on. Say the right hip extension is dysfunctional. In order to treat that (this way is easier so that they can replicate it at home versus using a sport cord) dysfunction you place a pillow under there right hip/torso (decreases difficulty by 25%). If they still can’t do this properly you add another pillow to make it 50% easier and so on until they can easily roll.

Once they accomplish the rolling task with, let’s say two pillows, then you want to take one pillow out and make them work for the 25%. Once they pass a step I would make them do a bunch of reps first before increasing the difficulty. Do this at each stage until they are able to roll successfully from the floor.

What can it help clear up?

Remember, whenever you want to make a quick fix always have that movement or test that they failed and retest after they perform the intervention to see if it helped clear anything up. So, if they failed prone hip extension because of both poor active ROM and excessive hamstring activation then you want to go back to that test and see if it is better. It may not be an excellent grade after but you should see a considerable change. This change should be enough to allow you the “in” to start working on those individual motor control deficits.

Sometimes over the course of the session they still aren’t able to roll without assistance. That is okay! That would be there HEP and to progress to the floor. You can give a few small, simple motor control exercises after rolling but I would make their HEP following their initial evaluation focused on the rolling. The changes should maintain and stay as long as they are consistent with working on the movement at home. Most likely these patients will have a lot of deficits to slowly work on because their entire system has been shut off for so long. Those inhibitory muscles, overtime, can become actually weak as well.

What patients will this help?

Most athletes and people who have sedentary jobs where that extension mechanism is just lost. Chronic pain patients where the general programs just haven’t work to decrease their pain or improve their function.

Runners: usually their injuries are a lack/loss of active hip extension when running. This hip extension needs to be from the glutes and not the hamstrings or lower back. Ankle injuries/shin splints fall in line with this as well. Activate the glutes and entire posterior chain extension mechanism.

Swimmers: who have been using their shoulders/neck/lower back and hamstrings for long periods in the water will sometimes just need that relearning of proper muscle activation to go with all that motion.

Baseball players: Like swimmers, upper/lower body sports require better movement patterns

Golfers: they lose that motor control with rotations which can translate up/down the chain

Flexion based activities: just because they can’t reach down and touch their toes doesn’t mean tight hamstrings or lack of mobility. Often times they have impaired whole body movement patterns.

Questions…?

TJ Slowik PT DPT

Active Vs Passive ROM (Cervical Spine)

Active VS Passive ROM (Cervical)

This is my first post relating to active vs passive ROM testing and treatments. I want to start in the cervical region.

One thing that I noticed going through school and then as a floater and now as a clinical instructor is how little therapists respect the great knowledge that you can gain by knowing the difference between active and passive ROM. Many, if not all, therapists check active/passive ROM of the shoulder. We mobes/PROM shoulders that have restrictions in both. If just active is limited but passive is full then we work on correcting the deficits in shoulder strength/control. Why don’t we take this into account throughout the rest of the body?

In school and in practice I see many people using the cervical ROM diagram. It allows us to easily list ROM, pain, stretching, radicular symptoms, etc. in one easy to find/use space. It works well and acts as a quick reference for busy times. The problem is: why is there only one of these on most initial evals? There should be one for active AND one for passive ROM. When one of these diagrams looks like the following:

pain diagram

Then we assume (as manual therapists) that there is a closing restriction on the right side. We then put them supine and check each individual segment for mobility and pain. I don’t want this to turn into a discussion of our palpation skills. That can be saved for another time. In short, they are not good. Have you seen a cadaver?

If AROM is limited in all planes or just one plane but passive ROM is full then we really need to start thinking motor control! If AROM and Passive ROM are both restricted then we do need to asses to see where that restriction is coming from. This passive restriction can have many components and that is where we use our heavily developed manual skills to address then retest and check for improvements. Most times, if there is a passive restriction to motion and you clear that up with manual therapy then there is usually a motor control deficit to follow when you re-test the AROM and PROM. Also, don’t just check that first day but rather continue to check the Active vs Passive ROM.

Passive ROM restrictions is a result of something. It doesn’t just happen (like hamstring tightness which is a very long future post). Often times, if you fix that passive restriction they may have full AROM right after as well. This doesn’t mean that there isn’t a motor control issue to address. This change in AROM can be a result of the neurological feedback that you get with manual therapy. It can help reset the system including the active restraints to motion. Re-test the PROM/AROM the next visit to make sure that the PROM remained. If it didn’t then suspect a motor control issue that is preventing motion on continual basis. Follow your manual therapy up with some motor control exercises and see what happens the next visit. If they are consistent with their HEP then there should be those lasting changes.

When I first started thinking of adding more motor control exercises (opposed to the usual row/shoulder/scapular therex) into my treatment plan I was skeptical that it would carry over from one treatment to the next. Once I saw the results I was excited. I always question how we can be better at treating patients and the thought processes behind certain treatments. If PROM is full and AROM of the cervical region is limited then how can I regain full/painless AROM?

I hear a lot of experts talk about the reasons why we aren’t great at treating patients and areas that we need to improve upon. In the SFMA course I took over the summer (the philosophy behind there treatments pretty much changed the way I treat) they had mentioned that diagnosis is the area that we struggle in the most and that we are passible with the interventions. I don’t disagree with that assessment. We struggle with the “real” diagnosis with many patients, that is, in regards to what are focus should be on. But, I also think we really struggle with our treatments. This includes doing too much, not enough, poor progression, targeting the wrong areas, etc.

The big area that we struggle in regards to treatments is wanting to strength train everyone. Motor control is a huge component of a lot of areas and compensations. This is a talk for maybe my next post and many, many posts after that. For now, let’s talk about just improving that cervical AROM. In some ways I don’t even care what is limiting AROM. AROM involves contractile movements as well as non-contractile structures. If PROM is free and clear then what is more of a concern to me is how I can access that motor control system or nervous system.

It isn’t about strengthening the muscles or stretching non-stop to restore motion but rather about the amount of inactivation that is occurring. The motor control system just isn’t working. Overtime, the patient, somehow, developed a poor movement pattern. This poor movement pattern is possibly a result of a poor nervous system activation. It is not strength! You can do all the muscular strengthening and upper trap stretching you want but if you can’t get the system to respond normally then there will not be lasting changes. The body is a system of nerves, nervous system firing and brain mapping that churns out a desired response.

Try going weight bearing first and then if they can’t complete the below exercises go to supine and work on first.

Pull a thera-band apart into shoulder horizontal abduction with both hands and then have the patient actively rotate their head to the left then right. Once finished with that have the patient relax the band back to a relaxed state. Repeat ten times. Then do the same with any other motion that is restricted.

Horizontalabductionpull

You should see an instant improvement in AROM. It will look cleaner, be less painful and the patient should also instantly see/feel the results. I am not saying that it will be pain-free but there should be a noticeable difference in pain levels as well as AROM. If they are still painful then try some sustained overpressure with movement (at some level of the cervical spine from posterior) while they complete the above exercise. This can provide a little neurological feedback to the system and help with the perception of pain.

There is no one definition of motor control or what happens/why we see altered movement patterns when there is pain present. Why/how the nervous system goes about its processes is poorly understood and needs a lot more research focused on this. Hodges and Tucker have a good article on this process in 2011 (see below). A possible mechanism could be through the nervous system. If we can activate a “core” muscular group such as the scapular stabilizers in the upper quarter then maybe this will feedforward. The goal of this exercise is to get the CNS firing first then performing the abnormal movement hoping that it restores the correct timing/coordination of muscles thereby reducing the perception of pain.

Remember this is just one way of improving that active ROM and should be combined with other techniques and ways to reduce the hyperactivity of the nervous systems in through the cervical region. I will only quickly mention the couple other ways that I use as well but save for another post.

Mackenzie extension (clean up PROM/AROM)

Instrument assisted soft tissue massage to the cervical region (neurological feedback not scar tissue!)

Nerve tensioning/slides/glides/release via David Butler

I intend on going through the rest of my cervical treatment interventions to decrease pain and increase ROM as well as increasing function in following posts. I believe that it is very important to know why you perform the interventions as opposed to just assigning interventions because “you have always done it like that”. My interventions and treatment strategies have changed a lot over time and it is because I am trying to constantly look for ways to improve my outcomes and question the norm.

TJ Slowik PT DPT

Hodges, P.W., Tucker (2011). Moving differently in pain: A new theory to explain the adaptation to pain.

Hodges, P.W (2011). Pain and Motor Control: From laboratory to rehabilitation.