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Re: Deep Neck Flexor Endurance
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Re: Deep Neck Flexor Endurance - March 29, 2005 8:03:00 AM
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jbeneciuk
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I find that if I spens alot of time with Passive and active-assisted ROM for this cervical movement...(axial Ext), it assists the patient in understanding the correct movement pattern...with active assisted movements, the monitoring of the pts force can be evaluated/monitored, to assure that they are not using too much force and substituting with the superficial neck flexors (Ex: SCM)...good topic, wondering how everyone decides when is the time to progress patients with these exercises...what do you use as a parameter of being able to progresss to the next phase ??
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Re: Deep Neck Flexor Endurance - March 29, 2005 8:43:00 AM
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JLS_PT_OCS
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Jan,
I agree with your hypothesis and solution, but I don't see how your exercise you described addresses this problem. Could you clarify for me? I'm having trouble visualizing.
Jben-
Good question about when to progress. I am in the process of revamping my DNF progression handouts. The new progression will be something like this:
1. Tuck chin into rolled towel or BP cuff or Stabilizer device to focus motion on deep flexors.
Hold 3-5 breaths (i like this better than seconds, as it discourages breath holding and reinforces importance of breathing while exercising). When they can hold a good tuck for about 30 seconds [timed by me], go to level 2.
2. Remove towel or support, head rests on surface, tuck chin straight down and hold 5-10 breaths. At this point, they really should be feeling the suboccipitals being stretched when they activate their DNF muscles.
When they can hold for 30 seconds here, go to level 3. Level 2 was part one of the first handout I had before (if I emailed it to you).
3. Still without support, tuck chin and raise head 1/2 inch [or 1cm for you non-americans :) ] off the table, maintaining the chin-below-forehead position. When they can hold this position against gravity for 30 seconds (and have them practice by counting breaths), go to level 4. Level 3 was part two of the first handout I had before.
4. Isotonic exercise. Tuck chin and lift head all the way off surface, taking care not to do a crunch with abdominals. Lower down slowly, keeping chin tuck position on the way down [people typically lose it on the way down]. Progress to 3-5 sets of 8-12 reps.
This was the second handout I had before, if I emailed them to you.
I also have some prone progressions I use with the periscapular/postural exercises I give to my neck people. Not sure where in the above progression they should be.
Prone position, head off table/bed. Maintain tucked chin position for up to 30 seconds. Maintain correct position when doing progressively more difficult periscapular exercises.
Now, I'm no expert or anything, this is just what I'm playing around with now. Use it if you like it, throw it away if it's not working, use at your own risk. :)
Jason
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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 29, 2005 11:49:00 AM
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steve
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Jason,
I like the progression you have, its very similar to what I do clinically for the first 3 steps. Once they can get to stage two, I usually begin doing functional exercises while they maintain the deep neck flexors.
A physiotherapist here in Canada does a lot of work in this area. Her name is Carol Kennedy - I took a course from her a couple of years ago and it really focussed on a lot of these ideas.
Steve
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Re: Deep Neck Flexor Endurance - March 30, 2005 3:55:00 AM
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JLS_PT_OCS
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Thanks, steve, these obviously aren't anything I came up with myself, just stuff I stole from others and fused with clinical experience. I think the balance of evidence is quite clear about how beneficial this muscle group is, and it's definitely worth using.
Additionally, I find that some of the chronic suboccipital pain/tightness and motion restrictions in the upper Cx spine I used to treat exclusively with mobs really seem to go away after a patient has been working on this progression for a while. It is really helpful, for me, to wean people off the manual techniques and move them toward an exercise based, independent program.
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 30, 2005 4:50:00 AM
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january
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Jason,
Some explanations and hypothesis;
If it is a dysfunction based upon a faulty “program” = neural networks disturbed by some parasites, we may consider that the normal program we had learnt is still remaining but simply disturbed by some added components which are “new”.
1/ deep muscles are movers and stabilizers but are less “sensitive” since they take in charge the gravitation too.
2/ superficial ones are true movers and are very sensitive with fast nervous fibers.
3/ if the primers are less sensitive (less controllable) than the second ones then you're facing to a big problem. How to move muscles that you do not control well since their primary function are to forge a good stable base to motion?
4/ The only way that we have is to use the superficial ones.
5/ The only way to activate the deep layer via the superficial ones is to engage the superficial muscles in an intense contraction forcing the synchronous contraction of the deep layer.
6/ since it is only a dysfunction, the intense activation is pain free and masked by the way by fast skin afferents and superficial muscles afferents.
It is a sort of reset!
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Re: Deep Neck Flexor Endurance - March 30, 2005 9:26:00 AM
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JLS_PT_OCS
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Jan-
I think I see where you're coming from, but I have to say I have found a lot of patients with neck pain who are overusing their superficial muscles, and a contraction there is painful.
When they learn to relax the SCMs/Scalenes and engage the deep flexors, they can do so painfree and acheive good results. At least I get a rate of improvement about or a little less than what the literature suggests.
So I would argue that the deep muscles are in great need of "waking up" and the superficial muscles are in need of "relaxing".
I think it's kind of like Lumbar Stabilization, in that we need to get the superficial muscles to relax while we learn to activate the deep ones.
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 30, 2005 6:53:00 PM
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january
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Jason,
I agree totally with your words.
The first stage is to re-engage the “normal” program then to learn to the patients how to relax their muscles. But it is quite almost impossible to relax something that you do not really feel.
Many patients have a poor control over the superficial layers because a constant activation brings an accommodation and such noise is “put” away by brain.
Many neck patterns carry a subtle shoulder elevation and patients do not feel it.
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Re: Deep Neck Flexor Endurance - March 31, 2005 4:05:00 AM
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JLS_PT_OCS
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Jan- totally with you there, and well said.
I think that's a good way to put it.
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 31, 2005 5:57:00 AM
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january
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Thanks Jason,
The advantages of this "exercise" is that it works even with acute problems. There is absolutely no risk since it's active and pain free.
I use a similar one (with some changes either) for the lumbar area.
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Re: Deep Neck Flexor Endurance - March 31, 2005 6:15:00 PM
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Synergy
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Okay...maybe I'm missing something or I am simply a complete noob. Jason, since you sent me those two DNF strategies, I have been using them quite a bit with my cervical population, but there is one thing that is causing me problems. For the life of me, I cannot 'quiet down' the d@mn STM or superfical flexors during the exercise. I'm afraid to progress my patients per your above sequence until I get the superficial group to go away.
I'm not sure why I'm having this problem and it may be something so minute in my technique. Maybe I need better verbal cues or something along those lines. Any thoughts? :)
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Chris Adams, PT, MPT
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Re: Deep Neck Flexor Endurance - April 1, 2005 2:13:00 AM
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Barrett
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Chris,
Maybe the patient wants these muscles to contract isotonically before the brain will allow relaxation to occur. Why would unconsciously generated activity persist otherwise?
Ever heard of ideomotor activity?
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Deep Neck Flexor Endurance - April 1, 2005 2:46:00 AM
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JLS_PT_OCS
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I would agree with Barrett (it's happening more and more lately, eh?) and say that when someone presents like that, telling them repeatedly to 'relax' is not going to help matters any. It will frustrate both you and the patient. You need to provide an outlet for that muscle activity.
Barrett refers to ideomotor action, and look it up and check it out if you're not sure what it is. In my studies of quackery and skepticism, I came across it a few years ago, and was immediately surprised I wasn't taught it in school in my motor control/motor learning classes. Once I started thinking about it, it's applicability started to occur to me.
Think of it like the Ouija (sp?) board. People are creating motion they are not conscious of. It is spontaneous, and to a degree, natural. You can't really suppress it consistently, but you can change the pattern. I think that's what this deep neck flexor business is about.
I think it is less about "strengthening" a "weak" muscle, and more about improving quality of movement and muscle tone/neural input in the area. Perhaps a calming of the neurological storm?
I think January gave an example of using a brief isometric contraction of those muscles first to help with this process. I think that is a helpful suggestion. Try it and see if it works for you. The mechanism is kind of like contract/relax stretching - ability to relax more comes after contracting, so to speak.
Overall, I have recently stopped telling people what to do (relax, move this, contract that, lift this, no that's wrong, do it like this, etc) and done more placing my hands on them or positioning them such that the movement becomes more natural for them and is easier to execute. This has immediately been a far superior approach, at least for me. And anything that helps me shut up is good. :)
To be more specific, try this:
1.patient supine on table. You seated at head of table in nifty therapy stool or chair. Patient's head resting on table, small towel roll under lordosis of neck for proprioception and feeling of support.
2. Patient does five slow breaths. Place hands either side of patient's head, thumbs on chin, fingers on suboccipital area, gently touching neck.
3.Get a gentle 5 second isometric contraction of chin into thumbs while leaving head in contact with table (upper cervical extension).
Relax and cue patient to immediately and gently tuck chin back 5 seconds, pressing into towel, encourage movement with your hands (upper cervical flexion and DNF activation).
You might find that sort of rhythmic activity, done slowly and deliberately, will be helpful. Remember PNF? Try not to do a lot of talking after the brief instructional setup. Let them find their own way with it without constantly looking to you to see if it's 'right'.
I think you'll find that once all that superficial contraction goes away, and they can activate the area better, progressing through the program will be easier. Or if their pain is significantly improved, they may not need to go all the way through it. Maybe you just needed to give those muscles an outlet for their activity and retrain a new movement, and that was all it took.
No upper cervical manipulation to toggle the atlas required. :)
Let us know how that goes...
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 - April 1, 2005 3:17:00 AM
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january
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Hi All,
[QUOTE]I think it is less about "strengthening" a "weak" muscle, and more about improving quality of movement and muscle tone/neural input in the area. Perhaps a calming of the neurological storm?
I think January gave an example of using a brief isometric contraction of those muscles first to help with this process. I think that is a helpful suggestion. Try it and see if it works for you. The mechanism is kind of like contract/relax stretching - ability to relax more comes after contracting, so to speak.[/QUOTE]Jason-
I do not use isometric contraction since the original state is already a high tone. I use my hands as a guide but with high resistance. It helps patients to re-feel their "lost" muscles.
I use often the sitting position but it is not mandatory (perhaps more natural for many?).
It is a contraction/relax "thing" but I educate patients to avoid "irradiation" in the relax phase. They musn't use the lats. to pull down the shoulders. When it fails I put the patient in front of a mirror.
The resistance is low to full when the shoulders are at the highest amplitude and it decreases as the patient lowers them.
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Re: Deep Neck Flexor Endurance - April 1, 2005 3:49:00 AM
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Barrett
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How can the therapist possibly know in which direction or with what sort of force the patient's unconsciously generated resolution will take place? (see Patrick Wall's description of instinctive response to painful signals in "A Consumatory Act" in the Bullypit)
How can anyone aside from the person in pain know what is corrective for that unique bit of mechanical deformation? Why would repeated isometric contraction be expected to do anything other than lead to a decrease in muscular activity for a very brief period?
Why do therapists (in my experience) continue to imagine that they always know which direction the patient must move in order to correct a problem the therapist cannot see and only the patient can truly sense?
Why do half of the people who attend my courses (all therapists) have chronically painful problems?
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Deep Neck Flexor Endurance - April 1, 2005 6:23:00 AM
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january
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Barrett,
Your questions are perfectly sensed and may bring some further explanations.
It is almost impossible to quantify the necessary force to achieve the recovery but one may say that it is not really necessary. I'm not concerned by the “strength” but more by the quality of the movement. But it is sure that the “more” (without pain) they give the fastest it works.
I have a great respect with the theories of WALL and MELZACK and I'm a fervent of neuromatrices but one may see a neuromatrix from the two “endings”/levels. A movement is an “enabled” neuromatrix, collection/pools of neurons.
This pool may be activated by order or by reflex but the matrix remains the same and thus it is possible to act on it at different levels.
One may see it at a conscious level, and some others may see the reflex in this same movement. But we are talking about the same movement.
A movement is at once, a reflex and a conscious action (I decide to move) and I could realize it consciously or not (let the “black box” do the job without control).
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Re: Deep Neck Flexor Endurance - April 1, 2005 6:31:00 AM
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JLS_PT_OCS
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Jan- sorry, didn't mean to mis-characterize your technique, I misunderstood.
Barrett,
I'm not really sure there is always available an "unconsciously-generated resolution".
Certainly if that is your contention (i'm not sure it is) then we should be pouring the research dollars that way, imagine what a revolution in care that would be. Seriously.
All this money towards manual/manipulative care, spine pain, and movement impairment related research in PT could be TOTALLY changed.
I have seen enough evidence to convince me that the addition of a deep neck flexor strength/endurance program can improve outcomes for neck patients, so that's why I do it.
I think that pain states are very difficult to understand and that our current understanding of them leaves much to be desired. I think you are right in that it is presumptuous of us to assume that we can either know what the problem is (mechanical deformation, neural afferent/efferent from central vs peripheral sources, etc), fix it ourselves, or know how to guide a patient to do such things themselves.
That's why the impairment-based approach makes the most sense to me.
I think an impairment-based model of approach to the problem has the most evidence to support it and seems the most common-sense to me. Therefore, for patients with this specific impairment of neck function, I approach it this particular way.
Why do half of your attendees have pain? Not sure. I thought that was a condition of being human, but also maybe we in health care tend to be more sensitized to things like that.
I've got my share of aches and pains and injuries, but I think it's better than sitting on the couch and getting fat, dying of a CV event.
I think our education aids us in the evaluation and treatment of our personal MSK problems, but does not grant us immunity from them.
I'm not sure what you're getting at there with that question? Did I miss something? Sorry, it's a friday, so I count myself lucky that I found my way to work today.
:)
Barrett, always an interesting discussion, thanks for challenging me to rethink my practice. It has helped me grow.
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 - April 1, 2005 6:51:00 AM
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january
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Jason,
[QUOTE]sorry, didn't mean to mis-characterize your technique, I misunderstood.[/QUOTE]No problem!
It is not "my" technique but only some findings based upon neurosciences. A matrix is a strong neural network and a painful movement is a strong network with some weak ones that parasite the previous one.
If you use force, you cut the "speech" to C fibers and CNS is removing the faulty associated programs and then you find again the original pain free movement.
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Re: Deep Neck Flexor Endurance - April 1, 2005 9:57:00 AM
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Barrett
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Jason,
I’ll take a few of your comments and questions in turn.
You say: “I'm not really sure there is always available an "unconsciously-generated resolution".
Sure there is-it’s the instinctive movement that moves us toward comfort, it is seen as the shifting about we do while in any prolonged position-it’s called ideomotor activity (which, by the way, doesn’t just express our thoughts as they might become manifest in words and actions, but also our continual rumination toward comfort) and I didn’t just recently make it up. We use it when released from a hammerlock for instance. It’s inherent to life, and only becomes “unavailable” upon death-barring paralysis or profound weakness. This is not the problem we normally see, of course. Consider this: Wall recognized an instinctive motor response to painful sensation and he called the third and final stage “resolution” Patrick Wall, for heaven’s sake. It doesn’t make much sense to disagree with him.
And you’re right, recognizing its presence and purpose and using it to resolve the pain secondary to mechanical deformation would revolutionize care. Check out “Where’s the Revolution?” in the Bullypit.
You say: “I think that pain states are very difficult to understand and that our current understanding of them leaves much to be desired.”
Well, centrally mediated pain mechanisms perhaps, but not the origins of pain. There are just two of those and they can be sorted out on history. If mechanical deformation is the problem we then decide whether there’s a relevant pathology and look to the physiologic and mechanical signatures to determine which tissue.
You say: “I think an impairment-based model of approach to the problem has the most evidence to support it and seems the most common-sense to me.”
This is where we truly diverge. I’m of the opinion that we need to follow the path of evolutionary or ultimate reasoning in order to understand what we’re seeing in our patients with pain and unconsciously generated muscular activity. Here’s a paragraph from “Asking Why: Evolutionary Reasoning and Manual Care” on my site:
“Evolutionary reasoning is not commonly used in clinical science but here I want to point out what effect it may have on the provision of manual care. It suggests we divide bodily response to trauma or disease into one of two categories-defects and defenses. Defects are those processes or behaviors that reveal the body’s weaknesses; they are the result of the disease process and are present without any particular utility. Defenses serve a purpose. They promote a change toward health and homeostasis. If we categorize our findings upon exam in this way, we are guided toward care that seeks to reduce the manifestation of the defect and leave the defense to do its job, that is, preserve our species. If we mistake one for the other care will be ineffective, and clearly runs the risk of becoming counter-productive.”
In short, you see the muscular activity as a defect and thus work to get rid of it. I see it as a defense and work manually to enhance its expression isotonically in any direction it wishes to go. This interpretation changes everything, and what you see as an “impairment” simply disappears as movement toward resolution emerges. I don’t take the patient there, I follow them.
You say: “Why do half of your attendees have pain? Not sure. I thought that was a condition of being human, but also maybe we in health care tend to be more sensitized to things like that.”
This I must disagree with. I’m human (pretty much) and I’m not young (54 this year) and I’m in health care (well, okay, sensitivity isn’t my strong suit). I have no symptoms. Might it have to do with my physiologic state and its relation to the amount of mechanical deformation in my system? How many therapists are aware of the critical nature of this relationship and how to go about controlling it? In my experience, the ones who hurt aren’t very clear on this.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Deep Neck Flexor Endurance - April 1, 2005 10:27:00 AM
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JLS_PT_OCS
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Seems like a conversation we should be having over in the Bullypit, I admit I haven't been there much.
I can appreciate your point of view, and what you say seems to make sense, which is why I like discussing/arguing things here.
For neck pain patients who are demonstrating this sort of muscular activity we were talking about, can you give me some idea of how you approach it, specifically? I think that would help me understand your perspective better.
I take it you don't subscribe to the deep neck flexor retraining idea, but I would like to see what you might suggest, as I think it would clear things up for me.
Thanks for your interest.
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 - April 1, 2005 12:02:00 PM
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Barrett
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I swear I'm not trying to hide what I do in hopes that people will attend my workshop in order to get that. Having said that, I don't think this thread is exactly the place for yet another explanation of Simple Contact.
Try looking at "Do Nothing" on my site. Keep an eye on the new thread "Movement and Unseen Influence" in the Bullypit. I think that might help. Maybe not.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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