Editor's Note: . Part 1 of this article appeared in the April issue.
These patients may need more frequent monitoring, not less. I need patient engagement in doing the prescribed exercises, although I also use my version of the biopsychosocial approach that addresses the biological, psychological and social factors that may be playing contributory roles.
Step 1: Posture
This past year, I have noticed that some of the things I've been implementing are definitely making changes I did not previously see with these difficult and chronic neck pain patients. I am making sure the patient has brain awareness, meaning better proprioception of improved overall posture. It appears these postural releases are influencing the fascial chains. My patients are learning semi-static hold positions to increase physical ability, body awareness and sensory feedback – all rolled into one.
The current exercise treatment principle: I always start with static postural alignment education. (You can read all my previous articles on this subject on my columnist page.) Every patient learns a "best position for you" (in sitting and standing), which teaches the patient the beginning of being their own best therapist.
Step 2: Lengthen
I've learned to work with extreme range and fascial stretching. I teach the patient to lengthen the spine, especially the neck, creating space for the disc and rehydrating the disc. Patients learn what a fixed point is, and then elongate longitudinally from the sacrum and top of the head while stretching and strengthening. These exercises feel like isometrics, and there are many reasons for using isometrics in your cervical spine dysfunction rehab.
These exercises are called ELDOA [a French acronym: Entirements Longitudinaux avec Decoaptation Osteo-Articulaire.] They help "create space," improve joint mechanics, increase blood flow, reduce pressure on the discs, decrease pain, improve disc hydration, create better muscle tone, improve posture, and offer a sense of well-being and awareness.
I also couple band exercises with ELDOA, especially if the muscles are weak. Bands will allow patients to do exercises more effectively and as a result, get greater facilitation, strength, muscle mass and more functional movement.
ELDOA exercises as the main treatment intervention for lengthening: Have your patient supine on the ground. Ensure that the posture of the cervical, thoracic, lumbar spine, pelvis and lower extremities are in a straight line. This may require you to position the patient.
Have your patient bend the knees to about 90-100 degrees with the feet off the floor and the little toes to the shins. The iliac crest and sacral base remain on the floor, but the lower sacrum and coccyx are off the floor.
Cue the patient to retract and extend the head and sacrum against the floor, but keep the chin strongly tucked in. This tenses the dura mater, posterior cervical muscles and ligaments. The arms are held straight up in the air at 90 degrees, in maximal external rotation and wrist extension.
Instruct the patient to keep looking down at the thighs to keep the dura tight. Keep everything aligned and breathe for 60 seconds. Tell them to think of lengthening, especially the cervical spine.
Step 3: Strengthen
Band exercises are my main treatment intervention for strengthening (e.g., activation for the deep cervical flexors. To start, have your patient stand facing a mirror. Ensure optimal posture of the thoracic and lumbar spine, pelvis and lower extremity. This may require cuing "chest up" (thoracic extension), "tucking the pelvis under" (posterior pelvic tilt to reduce an excessive lordosis / anterior pelvic tilt), and feet parallel and hip width (2nd toe pointing forward in line with the anterior superior iliac spine). Cue "tall spine and neck" the entire time.
Instruct the patient to wrap a loop band (choose appropriate tension depending on patient size and strength) around their hands, with the hands holding the end loops of the band (metacarpals 2-5). The middle loops should be positioned against the posterior lower skull and possibly upper cervical segment.
The resistance of the band will start with the patient in a pose similar to a "T-Rex" impression. Test the tension of the band and ensure the scapular retractors are on. The arms may need to be moved into the 90 degree position again.
Start each repetition by cuing cervical retractions with a strong chin tuck. Have your patient perform a 10-second chin tuck with retraction against the band, maintaining optimal cervical elongation and retraction. Perform this task on an unstable surface to create a rapid increase in tension from extending the arms that forces the deep cervical flexors to "react" and stabilize the spine during rapid movement.
Combining these stretching and strengthening exercises with hands-on therapy and modalities has helped my difficult cervical cases. Try them and see how your patients respond.
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