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

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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

Disclosures

• I have nothing to disclose.

Objectives

• Describe two clinical tests for deep cervical

flexors.

• Describe exercises to strengthen deep cervical

flexors.

• Summarize the current evidence pertaining to

how deep cervical flexor exercises can be used to treat cervical spine pain.

Background

• Exercise therapy effective for neck pain. (Kay et al

2005)

• Local cervical segments may be vulnerable to

instability in the absence of deep muscle

• activation. (Falla 2011)

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Deep Cervical Flexors (DCF)

• Longus Colli & Longus Capitis
• Craniocervical flexion, counter

lordosis

• Actions of sternocleidomastoid

(SCM) & anterior scalene (AS)

Potential Ways to Test DCF

• Cervical Flexion

– SCM and AS provide 83% cervical flexion capacity (Vasavada 1998)

• Craniocervical Flexion Test
• Craniocervical Flexion with

Cervical Flexion

Pictures from Cagnie et al 2008

fMRI Results

• Cervical Flexion: Higher SCM activity
• Craniocervical Flexion: Higher

Longus Capitis activity

• Craniocervical Flexion with Cervical

Flexion: Maximal recruitment of Longus Colli, Longus Capitis, & SCM

Results and Pictures from Cagnie et al. 2008.

Craniocervical Flexion Test (CCFT)

• 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
• Clinician monitors for substitution
• SCM and AS should not be active
• 10 sec hold, 3 times each target level

Procedures from Jull 2008 Picture from Jull et al 2008

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Craniocervical Flexion Test

• Reduced performance of CCFT is associated

with DCF dysfunction. (Falla et al 2004)

• Excellent intratester reliability. Excellent

repeatability between test and re-test. (James

2010)

• Patients with neck pain demonstrate inferior

performance on CCFT (Jull et al 1999 and Jull et al 2000)

DCF Endurance Test (Craniocervical Flexion with Cervical Flexion)

• Chin tuck and lifted head 2.5 cm
• Line drawn across 2 anterior-lateral skin folds
• Hand with stacked fingers under occiput
• Test repeated, maintaining contact with

tester’s stacked fingers

ICC: 0.6. Confidence Interval: 0.34- 0.86 (Domenech et al 2011)

Picture and protocol from Domenech et al 2011 Domenech et al 2011

• Men: 39.1 ±

20.0 seconds

• Women: 29.3 ±

13.7 seconds

• Activity level

and age not correlated with endurance

Treatment: What is Best Type of Training for DCF?

• Low-load training increased DCF EMG

amplitude and decreased amplitude for SCM and anterior scalene.

• No change in DCF amplitude for high-load

training group. (Jull et al 2009)

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Treatment: Activation of DCF in Sitting

• EMG of DCF

higher when facilitated into upright posture versus unfacilitated spontaneous upright sitting.

(Falla et al 2004)

• 2 weeks of

treatment improved pattern of cervical muscle activity in CCFT.

(Beer et al 2012) Picture from Beer et al 2012

Strengthening DCF and Pain Reduction (Falla et al 2012)

• 14 women, >6 months neck pain
• Treatment by a PT 1x/week x 6 weeks. HEP:

BID for 10-20 mins

• After 6 weeks of training, patients with

greatest percent change in activation of DCF showed greatest pain relief from training.

• Patients with least activation of DCF at

baseline showed greatest change in activation post-training.

Other Studies That Support DCF Strengthening to Manage Pain

• Manipulative therapy, exercise, and combination

equally effective in reducing symptoms of HA and neck pain. Results maintained in long-term. (Jull et

al 2002)

• Low-load and high-load training for DCF

correlated with significant reduction in pain and NDI score. (Jull et al 2009)

• Higher pain levels associated with greater delays

in activation of DCF during rapid flexion of shoulder and lower amplitude of activation during isometric DCF contraction. (Falla et al 2011)

Conclusions

• Patients with neck pain show decreased

activation of the deep cervical flexors.

• Literature supports two clinical tests of DCF

strength – CCFT & DCF Endurance Test.

• Low-load exercise training in the CCFT position

and DCF activation in sitting have been shown to increase strength of DCF.

• Strengthening of DCF has been shown to

improve pain in patients with neck pain.

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Thank You 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.
• 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

• Falla DL, O’Leary S, Farina D, Jull. GA. Association Between

Intensity of Pain and Impairment in Onset and Activation of the Deep Cervical Flexors in Patients With Persistent Neck Pain. Clin J Pain 2011; 27 (4): 309-314.

• Falla DL, O’Leary S, Farina D, Jull GA. The Change in Deep Cervical

Flexor Activity After Training Is Associated With the Degree of Pain Reduction in Patients With Chronic Neck Pain. Clin J Pain 2012; 28: 628-634.

• James G, Doe T. The Craniocervical Flexion Test: Intra-Tester

Reliability in Asymptomatic Subjects. Physiother. Res. Int. 2010; 15: 144-149.

• Jull G, Barrett C, Magee R, et al. Further clinical clarification of the

muscle dysfunction in cervical headache. Cephalalgia 1999;19:179– 85.

• Jull GA. Deep cervical flexor muscle dysfunction in whiplash. J

Musculoskeletal Pain 2000;8:143–54.

References Continued

• Jull GA, Trott P, Potter H, et al. A Randomized Controlled Trial of

Exercise and Manipulative Therapy for Cervicogenic Headache. Spine 2002; 27 (17): 1835-1843.

• Jull GA, O’Leary SP, Falla DL. Clinical Assessment of the deep

cervical flexor muscles: the craniocervical flexion test. J of Manipulative and Physiological Therapeutics 2008; 31(7): 525-533.

• Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic

exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Therapy 2009; 14: 696-701.

• Kay T , Gross A , Goldsmith C , et al. Exercises for mechanical neck

disorders . Cochrane Database Syst Rev 2005 ; CD004250.

• Vasavada AN, Li S, Delp SL. Influence of muscle morphometry and

moment arms on the moment-generating capacity of human neck

• muscles. Spine 23: 412–422, 1998.