Exercise Therapy Following Motor Vehicle Trauma (Pt. 3)

Editor's Note: Part 1 of this article ran in the November 2018 issue; part 2 ran in December.

Exercise Progressions for Whiplash-Related Injuries (Cont.)

4. Have your patient maintain the neck position (retracted to optimal posture) described in part 2 with the head hanging off the table. Patients don't always like this exercise, but I at least try it out and hope they will perform it as part of the program. It has three components:

• Attempt in prone
• Attempt in supine
• Attempt in side-lying

Keep the neck in retraction by pulling the chin back toward the spine. Some rehab instructors used to refer to this as "packing the neck." I really emphasize decompressing the head away. Some patients I see from other practices interpret "packing" as compressing the head. I'm really trying to get the message out to decompress the cervical spine. Pause for 2-3 seconds and release by resting the head with your hands or the patient's hands. Perform 1-3 sets of 5-10 quality repetitions, building up to 10-second hold times.

If the patient struggles in one of the above positions, consider starting back in the seated position and cue the movement by placing a finger on the chin and directing the proper pattern and/or allowing them to view the exercise in a mirror. I recommend that the patient supports their elbows in the seated position to reduce tension from the upper trap / levator and encourage a more upright posture.

After a few days, go back to the exercise in supine, focusing on a chin nod maneuver with the head off the table. My only caution with the head-off position is to ensure the patient does not tilt the chin or look downward instead of retracting the neck.

5. For the next exercise sequence, the patient is standing. You will need either a soft stability ball or a regular stability ball. The patient stands the width of the ball away from a wall. For each standing pose, always review optimal posture of the feet (hip-width apart), including short foot, soft knees, slight posterior pelvic tilt to reduce an excessive lordosis / anterior pelvic tilt), lumbar spine, ribs and thoracic spine in position, and cervical spine tall. Make sure the head stays centered.

• With the stability ball behind the patient's head, this automatically forces them to press and hold the stability ball in place against the wall (activation). Next, ask the patient to press with retraction against the ball. The ball should have a little "give'"and reinforces the isometric contraction (strength) of the deep neck flexors. Just holding the ball increases the stabilization demands on these muscles. You as the doctor can provide small amounts of perturbations to the ball throughout the rehabilitation process. The goal is increased endurance of the deep neck flexors; I aim for five sets of 45-second holds. In practice, the duration of the hold will be dictated by many factors; an entry level may be 10 seconds while breathing. Maintaining this position without compensation is a challenging progression (pay careful attention to SCM and scalene activation).
• Have the patient maintain the position described above while performing integration of the Brugger's position. Once the patient maintains the head-against-the-ball-against-the-wall position, introduce a band.
• This is also the point that I might add scaption to the routine. Scaption can be added as a stand-alone cervical exercise or with the standing, head-against-ball maneuver. I really like the last two exercise progressions, as they include scapular stabilizers.

6. Another transition is to the quadruped (on-all-fours) position. The patient contacts the forehead on a stability ball, and I usually place the ball against a wall.

Note: I never want a compression force on the cervical spine. I am very aware to cue the patient to decompress the cervical spine in all of these exercises. This takes a little practice and constant cuing. The patient will need the retraction and sense of give the stability ball offers. In the quadruped position, we can add hand movements like upper extremity external rotation, scaption, rows, alternating opposite arm / leg raises, and other core stability movements.

You have permission to be creative. Just allow adequate time for tissue remodeling by respecting a two- to three-day response to a new load.

Final Thoughts

Every patient going through cervical rehab needs to have a range-of-motion evaluation. Optimal healing includes posture lessons (ergonomics) at home and work. Have your patient perform restricted range of motion in poor posture and in good posture. Make them aware of the exercises that improve limitations of motion. In addition to the above, I ask patients to practice cervical flexion, extension, lateral bending and rotation throughout the day.

Resources

• Falla D, et al. Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual Ther, 2007;12(2):139-143.
• Jull GA, et al. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Ther, 2002;14:696-701.
• Jull G, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 2002;27(17):1835-1843.
• Van Ettekoven H, Lucas C. Efficacy of physiotherapy including a craniocervical training program for tension-type headache: a randomized clinical trial. Cephalalgia, 2006;26(8):983-91.