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Deep Neck Flexor Endurance
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Deep Neck Flexor Endurance - March 4, 2005 9:19:00 AM
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JLS_PT_OCS
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Since seeing recent literature relevant to neck disorders, I have been doing a lot of deep neck flexor training for my patients and noting good results.
Here is an abstract from CSM about using a simple, easily applicable test/treatment for using this as part of your approach for neck pain.
Any comments are welcome...are you using something like this now? Why or why not?
Anyone care to discuss the role this has in therapy programs?
Reliability of a Clinical Test for Deep Cervical Flexor Endurance
AUTHORS (ALL): Olson, Lee1; Millar, Lynn1; Dunker, Jeremy1; Hicks, Jennifer1; Glanz, Devin1.
INSTITUTIONS (ALL): 1. pt, andrews university, Berrien Springs, MI, USA.
ABSTRACT BODY:
Purpose/Hypothesis : Strength and endurance deficiencies of the cervical musculature are associated with neck pain in the literature. Further, increases in cervical strength have been associated with pain reduction. Some theories implicate inadequate deep flexor initiation and endurance in cervical dysfunction. Cervical endurance and strength testing studies have typically relied on expensive and/or complicated equipment not widely available and not specific to the deep flexors. The purpose of this study was to determine intrarater and interrater reliability of a clinical test of deep cervical flexor endurance in persons without neck pain.
Number of Subjects : Twenty-seven subjects between the ages of 20 and 35 without history of neck pain or injury were tested by three different researchers.
Materials/Methods : Subjects were positioned in supine and instructed in maintenance of a test position involving two components; 1) chin tuck (craniovertebral flexion) and 2) lower cervical flexion (maintaining the occiput approximately one inch above the table). Subjects practiced three times before being timed. Determination by the tester that either component was lost ended the test. Every subject was examined twice by each of three examiners (a total of 6 trials for each subject) with one to two days between trials.
Results : The average time for tester 1 was 18.6 sec with a standard error of 1.9; for tester 2 the average was 19.9 1.7 sec, and for tester 3 it was 25.0 3.1. All ICC values were significant at the 0.5 level of probability or less. Intratester reliabilities were .83 for tester 1, .849 for tester 2, and .884 for tester 3. The intertester reliability for all three testers was .776 for test 1 and .853 for test 2. There was a significant learning curve noted in test performance with an average improvement of three seconds. Averaging two test scores improved ICC values and also decreased the influence of individual variability.
Conclusions : The cervical flexor endurance test was demonstrated reliable with both intratester and intertester reliabilities falling within the good range. The rate of individual variability noted by the standard error coupled with the observed learning curve would suggest that obtaining the mean of two measurements improves reliability.
Clinical Relevance : Clinicians involved in preventing and treating neck pain and dysfunction require simple, inexpensive, and reliable clinical tests for deep neck flexor endurance. The test examined in this study appears to be a reliable instrument particularly if two trial times are averaged.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Deep Neck Flexor Endurance - March 4, 2005 9:32:00 AM
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Shill
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Jason,
I think neck strengthening is one of those treatment methods that often is not done, but the exclusion has NO good rationale. We strengthen knees, shoulders, lumbar spines, everything else, but the neck often gets isometrics only and some stretching. Why? I dont know. Makes no sense to me either. Anecdotally, I too have had quite nice results with strengthening necks that look horrific on films, and in presentation. However, I dont limit the strengthening to the deep flexors.
Take advantage of the adaptability of the body!
_____________________________
Steve Hill PT
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Re: Deep Neck Flexor Endurance - March 4, 2005 9:42:00 AM
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steve
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I would agree that the deep cervical neck flexors play an important role in rehabilitation as demonstrated by some of the research by Jull et. al but I would like to point out a few things. Firstly, this test was done on asymptomatic individuals and we dont have any info here to correlate increased holding time with increased function or decreased pain. Clinically, I think this as a testing mechanism would not be very applicable or sensitive to change as this is quite a high level activity and would only demonstrate change at the end of their rehabilitation.
Steve
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Re: Deep Neck Flexor Endurance - March 4, 2005 9:47:00 AM
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JLS_PT_OCS
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Several studies have demonstrated a possible benefit to strength/endurance training of the deep flexors. Steve, how would you suggest we test or progress this activity?
I have to say, I use this progression they describe with all my chronic necks, and people seem to do real well. Initially people may just be doing the activity with head in contact with the table and a Stabilizer or BP cuff underneath, progressing to PRE's.
For those who strengthen the neck in other ways, how do you go about it? How would you measure the strength/endurance level and how do you gauge improvement?
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Deep Neck Flexor Endurance - March 4, 2005 10:08:00 AM
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steve
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Jason,
I agree and use the progression that you use but I dont get patients into one inch off the table until well into their rehab. Attempting this test early on would likely flare them significantly, kind of the equivalent off testing single leg with eyes closed balance with a acute ankle sprain.
Steve
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Re: Deep Neck Flexor Endurance - March 4, 2005 10:22:00 AM
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apolipo
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I have found that using the Stabilizer for motor control training is also effective. Rather than shooting for a maximal contraction, having the pt. learn how to move the needle to different levels of mmHG for repetitions or for timed holds seems to be beneficial.
mike t
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Re: Deep Neck Flexor Endurance - March 4, 2005 11:37:00 AM
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SJBird55
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I'm not very talented in the way of using the blood pressure cuff deal. Maybe it's just me, but it just doesn't seem terribly functional to be lying on the table shoving into a BP cuff.
I tend to use gravity. Most folks that I have treated with chronic cervical pain tend to do decent in the prone position doing scapular exercises (with the cervical spine basically positioned as you all have described). So, I'm not really technically focusing on strengthening because gravity is a constant, but I focus more on endurance and work up to about 90 repetitions of scapular exericses with light to medium resistance.
What really makes cervical spine musculature work is to put them on a ball supine balancing with their trunk supported and have them maintain decent cervical alignment as you all described it above. Killer exercise doing basically nothing but maintaining that position against gravity. It may initially start with 5 sets of 5 second holds because that's all the person can handle... but I try to progress them by diverting their attention and having them do some sort of upper extremity motion while maintaining the cervical position and hope to see a good 3 sets of 30 repetitions without their cervical muscles screaming at them. Seems to work decent, but then again, I haven't tried the blood pressure cuff thing. But, I'm try to be efficient and if I can pick an activity seems to kill two birds with one stone and the patient can do it at home independently at some point in time, I tend to favor that kind of approach.
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Re: Deep Neck Flexor Endurance - March 4, 2005 4:29:00 PM
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Shill
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I do AROM versus gravity. No flashing lights, bells or whistles. Chin tuck to whatever extent needed to keep it from being painful. I dont, (but admittedly probably should )objectively measure the strength to begin with. The BP cuff is one way to do it, but needs to be done exactly the same way every time, or your numbers are meaningless. The amount of beginning pressure, the size of the cuff and extent to which it is folded up matters....I think.
The correlation with neck strength and lack of pain is not well known, to the best of my knowledge, and therefore I simply use decreased symptoms as an indicator of efficacy for that specific patient. For me, the patients that this works best for are those who have fairly nasty degenerative necks, and dont respond to other things I typically use. (repeated movements is my mainstay).
_____________________________
Steve Hill PT
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Re: Deep Neck Flexor Endurance - March 5, 2005 2:12:00 AM
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SJBird55
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When we measure "strength" are we really measuring "strength?" I've come to the conclusion that maybe we don't. Maybe we really measure a person's tolerance and ability to do a particular resistance test? If I remember my sports med stuff and physiology stuff correctly, I believe I learned that it takes 8-12 weeks to build strength and have myofibril changes. If you think about geriatric patients who are dehabilitated, it does seem take a large chunk of time to get what I really would think as strength gains to show a change in function (timed stands test). But, for someone with chronic pain... if the focus is on some manual technique and "strengthening" and the person has goals met and is discharged in 4-5 weeks - did we really "strengthen?" Honestly, I really don't know what happens or what I'm truly doing.
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Re: Deep Neck Flexor Endurance - March 5, 2005 5:06:00 AM
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srcase
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SJ, in the first couple of weeks you are probably doing neuromuscular reeducation, and the "strength" gains you observe are from motor learning. The deep cervical flexor training is more muscular endurance training than "strengthening" because this are postural/tonic muscles. I use the cuff intially to train the movement correctly and avoid substitution of the SCM or neck extensors (pushing head into pillow). Then I work on holding the position in sitting (usually on a Swiss Ball with added arm or leg movements), then prone (with scapular training) then quadruped with arm and leg movements. On neat thing I have tried: the patient is quadruped with their forehead on a Swiss Ball and they have to maintain the cervical alignemnt while raising one arm up, alternating sides. That one is tough!
Sarah
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Re: Deep Neck Flexor Endurance - March 7, 2005 2:14:00 AM
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JLS_PT_OCS
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I would agree with Sarah that "strengthening" is doing a lot of things -- in this case, proprioception/neuromuscular type work, pain modulation, posture control, etc, etc.
It has been my experience that many neck pain patients can not activate these muscles well, and the supine BP cuff/Stabilizer does a good job of teaching them how to use these muscles again. Often times, as Sarah mentions, substitution is the rule. I have never found this progression aggravates anyone's symptoms, regardless of chronicity, but will agree with Steve who notes that it needs to be progressed properly.
I have a home exercise sheet i made up for this, if anyone wants it, let me know, I'll be happy to email it out.
Jason
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Deep Neck Flexor Endurance - March 7, 2005 2:39:00 AM
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Shill
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I essentially define strength as the ability of a tissue to tolerate stress. This applies to all tissue because we will probably never know which one changes to result in improvement, despite our beating our collective heads against the wall to try to figure this out. Ligaments, muscles, bones, cartilage, (gulp) nerves,etc, whatever happens to be moved with an exercise or manual technique could be the tissue that is "strengthened".
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Steve Hill PT
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Re: Deep Neck Flexor Endurance - March 7, 2005 3:50:00 AM
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SJBird55
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Sarah, I think so too. It doesn't seem to make sense that true strengthening is what is occurring.
Sure, Jason, I'd like to see it.
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Re: Deep Neck Flexor Endurance - March 7, 2005 3:56:00 AM
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JLS_PT_OCS
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For those who want the HEP sheet, please send me a private message, thanks.
SJ, what is "true strengthening"? I think the word "strengthening" is commonly thought of in terms of increasing the force generation capacity of a given muscle-tendon unit, but as Sarah pointed out, there is a lot more going on with our attempts to 'strengthen'. That approach addresses lots of different things, as Shill pointed out.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Deep Neck Flexor Endurance - March 16, 2005 3:19:00 PM
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VagusX
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Jason
I have ben trying the DNF exercies on three of my cervical patients. All three of them are noticing increased head pressure and feeling woozy when arising after the activity. One patient reported increased heachache after working at it for a few minutes.
The exercises to strengthen the neck do make a lot of sense to me both from personal experience and from the research. If you have noticed this report of increased head pressure, how have you been addressing it as far moderating the exercise?
Thanks
Dan
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Re: Deep Neck Flexor Endurance - March 17, 2005 3:10:00 AM
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JLS_PT_OCS
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I think like any other exercise, it needs to be progressed properly, as you have made good reference to.
I think a big problem many neck pain patients have is that they compensate for their deep neck flexors by using scalenes and SCMs.
So, early on, the patient does not lift their head off of the surface, they merely are tucking the chin. The use of a blood pressure cuff or towel roll under the neck often helps patients get the right feel for it.
When sufficient strength and comfort is reached, they then are allowed to lift the head, if they can keep good posture.
Occasionally, I do have patients who are unable to tolerate the exercise or who have more headache issues with it. To me, this says that I should do less strength work and more mobs for a week or two, and retry.
Really, I should have two separate sheets, one for isometric with head on table, one for isometric with head off table, but it seems I have to rely on a colleague to bring in a digital camera, so until I get one...
Try that.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Deep Neck Flexor Endurance - March 17, 2005 3:29:00 AM
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OaksPT
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Dan,
I attribute alot of what you describe, too proprioceptive sensors in the upper c-spine, it's kind of like when you put on glasses with a new prescription, and are disoriented for a few moments while your brain processes the new input. I see this fairly often also, and while of course changes in BP could be what they are feeling, new feedback from activated proprioceptors, is also a likely culprit.
Scott
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Scott Oaks PT,DPT
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Re: Deep Neck Flexor Endurance - March 18, 2005 2:27:00 AM
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bravocosta
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Helo Vagus,
Also check for patients holding their breath during this or the more isometric manuevers, something we see quite a lot in the clinic.
T.
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Re: Deep Neck Flexor Endurance - March 18, 2005 11:32:00 AM
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srcase
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From: Michigan
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Vagus,
Also check for trigger points in the SCM which can lead to feelings of dizziness or vertigo. I tell patients to only use 20% of their maximal effort...that seems to keep them from substituting with phasic muscles, and really more on tonic stabilizers.
Sarah
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Re: Deep Neck Flexor Endurance - March 18, 2005 7:54:00 PM
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january
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Jason,
[QUOTE]It has been my experience that many neck pain patients can not activate these muscles well[/QUOTE]Hypothesis: patients are unable to activate the “original” program (neural network) associated with this movement. They are too “late” or too “soon”.
Solution: reinitialize the proper activation by a focused attention on a movement. But the muscles are organized in different layers and have different innervations. More, the deep ones are less sensitive than the superficial ones and haven't the same “functions”.
So we're in a dead end?
No, we have just to “provoke” the “normal” program in a situation where it is mandatory to act.
I put my hands over the patient's shoulders. I ask him to lift up slowly the shoulders, as hard as they can against my resistance and then relax them slowly. 3 / 4 repeats. The movement is not static and has no stay phase!
Thomas, breathing is a key of life!
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