Disclosures I have nothing to disclose. Use of Deep Cervical Flexor - PowerPoint PPT Presentation

5/31/2013 Disclosures • I have nothing to disclose. Use of Deep Cervical Flexor Exercises in Reducing Cervical Spine Pain Sarah Pawlowsky, PT, DPT, OCS Assistant Clinical Professor UCSF Core Faculty UCSF/SFSU Graduate Program in PT UCSF Spine Symposium 2013 Objectives Background • Describe two clinical tests for deep cervical • Exercise therapy effective for neck pain. (Kay et al 2005) flexors. • Local cervical segments may be vulnerable to • Describe exercises to strengthen deep cervical instability in the absence of deep muscle flexors. activation . (Falla 2011) • Summarize the current evidence pertaining to how deep cervical flexor exercises can be used to treat cervical spine pain. 1

5/31/2013 Potential Ways to Test DCF Deep Cervical Flexors (DCF) • Cervical Flexion • Longus Colli & Longus Capitis – SCM and AS provide 83% cervical • Craniocervical flexion, counter flexion capacity (Vasavada 1998) lordosis • Actions of sternocleidomastoid • Craniocervical Flexion Test (SCM) & anterior scalene (AS) • Craniocervical Flexion with Cervical Flexion Pictures from Cagnie et al 2008 fMRI Results Craniocervical Flexion Test (CCFT) Procedures from Jull 2008 • Cervical Flexion: Higher SCM activity • Use of Stabilizer pressure biofeedback cuff • Head nod action from 20 to 22 mmHg, 2-3 s hold • Repeated through each 2 mmHg to 30 mmHg • Craniocervical Flexion: Higher • Clinician monitors for substitution Longus Capitis activity • SCM and AS should not be active • 10 sec hold, 3 times each target level • Craniocervical Flexion with Cervical Flexion: Maximal recruitment of Longus Colli, Longus Capitis, & SCM Picture from Jull et al 2008 Results and Pictures from Cagnie et al. 2008. 2

5/31/2013 DCF Endurance Test (Craniocervical Craniocervical Flexion Test Flexion with Cervical Flexion) • Reduced performance of CCFT is associated • Chin tuck and lifted head 2.5 cm with DCF dysfunction. (Falla et al 2004) • Line drawn across 2 anterior-lateral skin folds • Excellent intratester reliability. Excellent • Hand with stacked fingers under occiput repeatability between test and re-test. (James • Test repeated, maintaining contact with 2010) tester’s stacked fingers • Patients with neck pain demonstrate inferior performance on CCFT (Jull et al 1999 and Jull et al 2000) ICC: 0.6. Confidence Interval: 0.34- 0.86 (Domenech et al 2011) Picture and protocol from Domenech et al 2011 Treatment: What is Best Type of Training for DCF? Domenech et al 2011 • Men: 39.1 ± • Low-load training increased DCF EMG 20.0 seconds amplitude and decreased amplitude for SCM • Women: 29.3 ± and anterior scalene. 13.7 seconds • No change in DCF amplitude for high-load • Activity level training group. (Jull et al 2009) and age not correlated with endurance 3

5/31/2013 Strengthening DCF and Pain Reduction Treatment: Activation of DCF in Sitting (Falla et al 2012) • 14 women, >6 months neck pain • EMG of DCF • 2 weeks of higher when treatment • Treatment by a PT 1x/week x 6 weeks. HEP: facilitated into improved BID for 10-20 mins upright pattern of • After 6 weeks of training, patients with posture versus cervical muscle greatest percent change in activation of DCF unfacilitated activity in CCFT. showed greatest pain relief from training. (Beer et al 2012) spontaneous • Patients with least activation of DCF at upright sitting. (Falla et al 2004) baseline showed greatest change in activation post-training. Picture from Beer et al 2012 Other Studies That Support DCF Conclusions Strengthening to Manage Pain • Manipulative therapy, exercise, and combination • Patients with neck pain show decreased equally effective in reducing symptoms of HA and activation of the deep cervical flexors. neck pain. Results maintained in long-term. (Jull et • Literature supports two clinical tests of DCF al 2002) • Low-load and high-load training for DCF strength – CCFT & DCF Endurance Test. correlated with significant reduction in pain and • Low-load exercise training in the CCFT position NDI score. (Jull et al 2009) and DCF activation in sitting have been shown • Higher pain levels associated with greater delays to increase strength of DCF. in activation of DCF during rapid flexion of shoulder and lower amplitude of activation • Strengthening of DCF has been shown to during isometric DCF contraction. (Falla et al 2011) improve pain in patients with neck pain. 4

5/31/2013 References • Beer A, Treleaven J, Jull G. Can a functional postural exercise improve performance in the cranio-cervical flexion test? -- A preliminary study. Manual Therapy 2012; 17: 219-224. • Cagnie B, Dickx N, Peeters I, et al. The use of functional MRI to evaluate cervical flexor activity during different cervical flexion exercises. J Appl Physiol 2008; 104:230-235. Thank You • Domenech MA, Sizer PS, Dedrick GS, et al. The Deep Neck Flexor Endurance Test: Normative Data Scores in Healthy Adults. P M R 2011; 3: 105-110. • Falla DL, Jull GA, Hodges PW. Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test. SPINE 2004; 29 (19): 2108-2114. • Falla DL,O’Leary S, Fagan A, Jull GA. Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual Therapy 2007; 12: 139-143. References Continued References Continued • • Falla DL, O’Leary S, Farina D, Jull. GA. Association Between Jull GA, Trott P, Potter H, et al. A Randomized Controlled Trial of Intensity of Pain and Impairment in Onset and Activation of the Exercise and Manipulative Therapy for Cervicogenic Headache. Deep Cervical Flexors in Patients With Persistent Neck Pain. Clin J Spine 2002; 27 (17): 1835-1843. Pain 2011; 27 (4): 309-314. • Jull GA, O’Leary SP, Falla DL. Clinical Assessment of the deep • Falla DL, O’Leary S, Farina D, Jull GA. The Change in Deep Cervical cervical flexor muscles: the craniocervical flexion test. J of Flexor Activity After Training Is Associated With the Degree of Pain Manipulative and Physiological Therapeutics 2008; 31(7): 525-533. Reduction in Patients With Chronic Neck Pain. Clin J Pain 2012; 28: • Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic 628-634. exercise on activation of the deep cervical flexor muscles in people • James G, Doe T. The Craniocervical Flexion Test: Intra-Tester with chronic neck pain. Manual Therapy 2009; 14: 696-701. Reliability in Asymptomatic Subjects. Physiother. Res. Int. 2010; 15: • Kay T , Gross A , Goldsmith C , et al. Exercises for mechanical neck 144-149. disorders . Cochrane Database Syst Rev 2005 ; CD004250. • Jull G, Barrett C, Magee R, et al. Further clinical clarification of the • Vasavada AN, Li S, Delp SL. Influence of muscle morphometry and muscle dysfunction in cervical headache. Cephalalgia 1999;19:179– moment arms on the moment-generating capacity of human neck 85. muscles. Spine 23: 412–422, 1998. • Jull GA. Deep cervical flexor muscle dysfunction in whiplash. J Musculoskeletal Pain 2000;8:143–54. 5