L19-20: Cervical muscle and sensorimotor treatment

Question 1

What are 7 impairments in muscle function in neck pain?

Answer 1

1. Altered relationships within
   
   1. neck flexor synergy
   2. neck extensor synergy (probable)
   3. axioscapular muscles
2. Loss of feedforward response
   
   1. Muscles are delayed (acting in feedback pattern–> more risk of injury)
3. Morphological changes
4. Loss of muscle support in posture and movement
5. Loss of endurance at different contraction intensities
6. Loss of strength/ endurance
7. Fatigability

Question 2

What are 5 exercise mode(s) best for neck pain disorders?

Answer 2

1. Motor relearning
2. Flexibility training
3. Endurance training
4. Strength training
5. Cardiovascular training

All beneficial for pain management: Depends on primary outcome

Question 3

What are 2 exercises if pain is the primary outcome for neck pain disorders?

Answer 3

Evidence:

1. both motor learning
2. strength training

Question 4

What are exercises if prevention/prevention of recurrent neck pain is the primary outcome?

Answer 4

Suggest exercise must restore normal muscle behaviour and function

Question 5

What type of exercise should be prescribed?

Answer 5

Question 6

What are 5 outcomes tested in motor relearning and strength training?

Answer 6

1. CCFT
2. Functional tasks
3. Posture
4. Feedforward
5. Strength/ fatigue of the SCM and AS

Question 7

What is the ouctome of CCFT for strength training?

Answer 7

Strength Training ✖

General head lift exercise failed to address altered muscle behaviour

Strength training did not improve in CCF (therefore must target management)

Question 8

What is the ouctome of CCFT for motor relearning?

Answer 8

Motor relearning ✔

Specific low load exercise successfully addressed altered muscle behaviour

Both deep and superficial muscles improved with CCF low load training (motor control)

Question 9

What is the variations between individuals (idiopathic neck pain) in initial presentation related to pain intensity?

Answer 9

High levels of pain = less effect of training (might take longer)

Question 10

What is the relationship between change in pain and magnitude of improvement in deep cervical flexor activation after training?

Answer 10

Once deep flexors are changed –> some changes are seen

Question 11

What are 2 ways that very high pain states can affect motor relearning?

Answer 11

1. Chronic WAD- No change SCM activity in CCFT after 10 weeks training
2. in higher NDI and widespread mechanical and cold hyperalgesia

• No sensory change threshold (cold..etc) = improved better
• Sensory changes = less improvements

Question 12

What is outcome for the functional task (tapping task)? What does does the outcome mean?

Answer 12

• no significant change activity post-intervention for either exercise group✖
• Similar results trapezius ✖

Suggests task specificity is also required in training

• Eg. scapular while adding functional task

Question 13

What is the outcome of posture change? What does does the outcome mean?

Answer 13

Change in cervical angle during the computer task in response to training?

• motor relearning program ✔
• strengthening program ✖

To postures (since they are low load endurance muscles)

Question 14

What is the outcome of feed forward? What does does the outcome mean?

Answer 14

Improved timing of the deep cervical flexors motor learning program better

Question 15

What is the outcome of strength? What does does the outcome mean?

Answer 15

Higher load exercise required to improve strength

Question 16

What is the outcome of fatiguability? What does does the outcome mean?

Answer 16

Higher load exercise required to improve SCM and AS fatigability

Question 17

What are 2 types of tasks?

Answer 17

1. Formal
2. Functional –task specific

Question 18

What are 5 tasks for muscle system in neck pain disorders?

Answer 18

1. Some evidence that improvements following exercise translate to improvements in automatic function of the cervical muscles
2. Similar changes observed with specific training of the deep trunk muscles (TrA)
3. Better response to low load craniocervical flexion training which emphases a motor learning approach
4. More work to be done on dose of training
5. Specific training of the DCF is associated with improvements in control of working posture

Question 19

What are 4 ways to correct postures?

Answer 19

1. Higher neck extensor muscle activity in slumped posture
2. Comparison of correction with thoracic extension versus lumbopelvic neutral technique
3. Both Th Ext and L/P correction → more neutral head neck posture (but thoracic extension → high thoracic erector spinae activity)
4. Neither changed activity in the upper trapezius (ie scapular posture)**

Question 20

What is the study: request to sit up straight versus facilitation of neutral upright posture?

Answer 20

Higher activation levels in DCF and lumbar multifidus

• Facilitation (activating muscles) is more effective then instructing to sit up

Question 21

Does task specific exercise help muscle control?

Answer 21

• Conscious elongation of cervical spine facilitates longus colli
• Outcome of CCFT after two weeks of training with posture correction with ‘occipital lift’ (not retraction)
  
  • Most effective for activating CCF

Question 22

Can exercise assist fatty infiltrate extensors ?

Answer 22

• Current data suggests that fat index can be changed with exercise
• Further development of measure

Question 23

Does therapeutic exercise- change pain?

Answer 23

1. RCT cervicogenic headache
2. RCT in the management of chronic whiplash

Question 24

What are 4 characteristics of scapular retraining?

Answer 24

1. Motor control perspective: can change pattern of activation the three portions of trapezius with a scapular postural correction exercise
2. Can address control, strength and endurance of axio-scapular muscles with specific exercise (evidence in shoulder disorders)
3. Case studies neck pain - efficacy of treating scapular dysfunction
4. No RCTs as yet looking uniquely at the effect of re-educating scapular in neck pain

Question 25

What are 3 characteristics of "correcting" scapular position (deloading)? What is the main feature?

Answer 25

1. reduced neck pain 2. increased cervical ROM 3. improved proprioception **Active correction of scapular position, not passive, decreased neck tenderness** * Tape can be used in adjunct to other active treatment (not on its own)

Question 26

What are 3 features in Phase 1: Rehabilitation of muscle control aspects of the exercise program? What are 3 impairments?

Answer 26

Deeper muscles (turn off superficial muscles)

Question 27

What is a feature in Phase 2: Strengthening and endurance program of the exercise program? What are 2 impairments?

Answer 27

Of all muscles

Question 28

What are 9 exercise pointers?

Answer 28

1. Pain = immediate change in cervical muscle function 1. Pain inhibits muscle activity 2. Both cervical motor control and peripheral adaptations 1. Eg. when doing CCF --\> should not be getting pain, if they start to get excessive superficial neck or scapula muscles (could be due to pain compensation) 3. Tailored exercises for specific impairments based on assessment 4. Commence exercise early usually day 1 1. (at least one exercise) 5. Exercise should not provoke neck pain 6. Precision in exercise is emphasized in the motor learning process 1. Ensure that exercises are done correctly (if not, will add to the poor movement --\> can cause pain) 7. Train muscles specifically and task specific 8. Repetition is essential muscle control 9. Compliance is critical- Patient’s must understand the rationale Ensure that exercises are done correctly (if not, will add to the poor movement --\> can cause pain)

Question 29

What are 2 symptoms of sensorimotor control disturbances?

Answer 29

1. light-headedness, unsteadiness, dizziness 2. visual disturbances - blurred vision, reading difficulties

Question 30

What are 4 signs of sensorimotor control disturbances?

Answer 30

1. Altered Neck joint position\* and movement sense\* 2. Eye movement - eye follow\*, gaze stability, * eye head co-ordination 3. Balance 4. Trunk head co-ordination * Occurs neck pain - idiopathic, wad, elderly and younger * Worse in those with dizziness

Question 31

What are 4 treatment directed to neck only in sensorimotor control management?

Answer 31

1. **Manual therapy/ Acupuncture**-Decreased dizziness, improved JPE improved balance 2. **Craniocervical retraining** - improved JPE 3. **Chiropractic management**-manip, mob, massage, spine stab exercises- improved JPE 4. **Improve muscle fatigability**- improved balance WAD JPE: joint position error

Question 32

What are 5 treatment not directed to neck only in sensorimotor control management?

Answer 32

1. **Revel’s Eye-head coupling rehab program**- Decreased neck pain, drug intake, increased JPE and ROM 2. **Oculomotor convergence and motility exercises** - improved balance eo and ec wad 3. **Tailored JPE, gaze, SPNT and eye head co-ord** improved JPE, pain and disability 4. **Gaze stability**- head, arm movement improved JPE, pain? 5. **Vestibular rehab program** improved balance and dizziness

Question 33

What are 2 management suggestion- multimodal?

Answer 33

1. Normalise afferent input 2. Tailored Sensori-motor control exercises

Question 34

What are 5 characteristics of "normalise afferent input" in multimodal management suggestion?

Answer 34

1. Manual therapy 2. Acupuncture 3. Address muscle changes 4. Pain relief 5. Increased range of motion

Question 35

What are 5 characteristics of "tailored sensori-motor control exercises" in multimodal management suggestion?

Answer 35

1. cervical joint position and movement sense 2. eye head co-ord, smooth pursuit, gaze stability 3. balance 4. trunk head co-ordination 5. based on vestibular type program but bias neck- ie slower movements

Question 36

What are 6 recommendations for exercises for sensorimotor control?

Answer 36

1. Base selection of exercises on assessment findings 2. Relate exercises to level of dysfunction 3. Address each individual impairment 4. Consider combinations of eye and balance exercises 5. Exercise 2-3 times per day 6. Need to provoke dizziness but not exacerbate neck pain or headache Vestib, visual and proprioception system interaction

Question 37

When should treatment start (4)?

Answer 37

1. JPE appear early after WAD, especially in those with moderate to severe symptoms 2. Balance changes also seen within three weeks 3. **Treatment begin immediately and be non-pain provocative** 4. Can be primary treatment in acute whiplash when manual or exercise treatments are pain provocative

Question 38

What are the 4 characteristics of the change in muscle and sensorimotor control improves pain and disability for therapeutic exercise approach for the cervical region?

Answer 38

1. RCT cervicogenic headache: 2. RCT in the management of chronic whiplash 3. RCT sensorimotor 4. RCT kinematics