MOVEMENT SYSTEM SYNDROMES of the Cervical Spine

Sitting tests

Sitting tests should be performed in active cervical ROM and flexion, extension, and rotation.

Supine tests

Manual muscle test of cervical flexion

The cervical intrinsic flexor muscles will test weak.⁸ The patient will be unable to maintain a position of a “neck curl” and will assume an extended forward-head position that is characteristically associated with dominance of the sternocleidomastoid and anterior and middle scalenes and weakness of the deep neck flexors^8,35,45 (Figure 3-20).

Figure 3-20 Faulty supine neck flexion.

Prone and quadruped tests

Active cervical extension in prone or quadruped: Active cervical extension can be performed in both the prone and quadruped positions and is characterized by a greater degree of posterior translation as compared to posterior sagittal rotation. During this movement, the examiner will typically observe an increase recruitment of levator scapulae muscles that contribute to posterior translation and diminished recruitment of the intrinsic cervical extensors that produce posterior sagittal rotation (see Figure 3-10).

Quadruped test

Active cervical extension in quadruped: During the quadruped rocking back, the examiner will often observe a compensatory motion of cervical extension. Typically, this movement impairment is not associated with the complaint of pain (Figure 3-21).

Figure 3-21 A, Compensatory cervical extension during quadruped rocking back. B, Correction of compensatory cervical extension.

The cervical extension during rocking back is believed to be the result of the lengthening or stretching of the levator scapulae, a downward rotator, as the scapula upwardly rotates during the motion of rocking back. The passive lengthening of the levator scapulae muscle causes extension of the cervical spine, which is also associated with posterior translation.

Sitting with back to the wall—capital flexion

The upper extremities are supported on pillows to diminish the compressive loading of the cervical spine from the transfer of the weight of the upper extremities to the cervical region through the cervicoscapular muscle attachment.⁹,¹⁵ Each patient needs to be assessed for specific alignment impairments at the lumbar and thoracic spines and scapulothoracic region. The patient is then instructed in strategies to precisely correct alignment faults in these regions before proceeding with cervical movements (Figure 3-22, A). These instructions include recruiting the lower abdominal muscles to maintain a neutral lumbar spine alignment and patient-specific instructions to correct scapulae alignment. This will typically include correction of scapular alignment of depression, downward rotation, and/or abduction (internal rotation). The key instruction for faulty alignment of scapulae depression is to “elevate the acromions toward the ears,” and the key instruction for the position of the scapulae downward rotation is to “elevate the acromions toward the ears and then slightly adduct the scapulae.” Instruction for faulty position of excessive abduction (>3 inches from the spine) would be to “squeeze the shoulder blades together.” The ideal position of the scapulae would be (1) the vertebral borders of the scapulae oriented in a vertical position or slight upward rotation, (2) the scapulae positioned 2.5 to 3 inches from the vertebral spine, (3) the scapulae positioned between T2 and T7, (4) 10 degrees of anterior tilt, and (5) 30 to 40 degrees of internal rotation.^1,8,19,43,49

Figure 3-22 A, Sitting against the wall, arms supported, correct scapulae position. B, Performing capital flexion.

The patient is instructed to place his or her head close to the wall and perform capital head flexion. The patient is encouraged to “roll” the head and chin toward the base of the anterior neck while trying to maintain the head close to the wall (Figure 3-22, B). The verbal cue to “roll” the head is to encourage recruitment of the intrinsic cervical muscle to perform sagittal rotation rather than anterior translation. Many patients report a “tightening” in the front of the cervical spine region while performing this exercise. This sensation is most likely the muscles in the front of the neck being appropriately recruited, and specifically, the muscles are being recruited in a shortened position rather than the lengthened position. In addition, patients also report a “stretch or pull” down the proximal posterior cervical region that can extend into the central upper thoracic region. Again, this is an appropriate stretch to the posterior structures. There should be no pain along the vertebral border of the scapula.

The patient is encouraged to maintain appropriate alignment of the adjacent regions during the movement of the cervical spine. This exercise can best be performed in sitting, but if the patient has difficulty maintaining the correct postural alignment during the cervical motion, the exercise can be performed in supine. The supine position will not be as challenging on the trunk musculature to maintain the alignment of the adjacent regions, although the demands on the deep neck flexors are greater in the supine position than in sitting.

Any radiation of symptoms to the vertebral border of the scapulae and away from the proximal spine would be considered a possible sign of cervical radiculopathy and an inappropriate response to the movement. If radiation of symptoms occurs, the therapist should reassess whether this exercise in this position is appropriate for the patient. Radiation of symptoms indicate that the exercise should be made easier by performing the same movement in a supine position with support of the arms with pillows or using the hands to assist with movement of the head and neck.

Strengthening the intrinsic cervical spine flexors in supine

Strengthening the intrinsic cervical spine flexors in supine begins with correcting the alignment of the thoracic spine and shoulders, as well as similar instructions as noted in the previous exercise. Patients are instructed to recruit the lower abdominal muscle to maintain a neutral lumbar spine alignment. Patient-specific instructions are provided to correct the scapulae alignment, typically including correction of scapular alignment of depression, downward rotation, and/or abduction (internal rotation).

The arms should be supported on pillows with the hips and knees in flexion. The patient may require a towel roll under the head. The thickness of the towel roll depends on the patient’s thoracic alignment and severity of the forward-head alignment. The greater the kyphosis and forward-head posture the greater the thickness of the towel roll. The following is a progression of exercises from the easiest to the hardest.

Capital flexion with head lift—with and without assistance

The patient is instructed to roll the chin toward the front of the cervical spine and then continue to roll the cervical spine and head off the supporting surface while maintaining the chin positioned at the anterior cervical spine. Adding the lift of the head is more challenging, and the patient may have trouble maintaining the chin in contact with the anterior cervical spine region.⁴⁶,⁴⁷ Forward translation of the chin or the chin “jutting forward” indicates poor performance of the intrinsic cervical spine flexors and a dominance of the extrinsic cervical spine flexors⁸ (see Figure 3-19). If a patient is unable to maintain the head position, he or she can use the hands to lift the head to minimize the load on the cervical spine muscles (Figure 3-23). Patients are encouraged to allow only enough support to permit the appropriate “curl up” position of the head and cervical spine. Progression of the exercise would be to provide less support.

Figure 3-23 Supine: Strengthening of deep cervical flexors with assistance.

Strengthening the intrinsic cervical spine extensors in prone or quadruped

Prone position

To strengthen the intrinsic cervical spine extensors in prone, the patient is positioned with the forehead on the palms of the hands (Figure 3-24). The patient is then instructed to “roll” the head back in a pain-free range. The instruction of rolling the head back is to encourage recruitment of intrinsic cervical spine muscles (splenius/semispinalis) to produce posterior sagittal rotation and diminish recruitment of the extrinsic cervical spine muscles (levator scapulae/upper trapezius) and the movement of the posterior translation. The therapist should observe the appropriate muscle recruitment of the intrinsic cervical spine muscles and diminished recruitment of the extrinsic muscles.

Figure 3-24 Prone cervical extension with emphasis of sagittal rotation.

Quadruped position

To strengthen the intrinsic cervical spine extensors in quadruped, the patient is instructed to flatten the thoracic spine like a “table top” and align the head and cervical spine with the thoracic and lumbar spine. The patient is instructed to “roll” the head down and then roll the head back while imagining that there is a rod running through the middle of the neck and rotating about the rod. The instruction of rolling the head back encourages recruitment of intrinsic cervical spine muscles (suboccipitals, semispinalis, and splenius) to produce posterior sagittal rotation and diminish recruitment of the extrinsic cervical spine muscles (levator scapulae/upper trapezius) and posterior translation. The patient should be instructed to perform the movement in the “middle-third” of the range to avoid end-ranges. The therapist should observe the appropriate muscle recruitment of the intrinsic cervical spine muscles and diminished recruitment of the extrinsic muscles. Performing this movement in the quadruped position is a greater challenge because the patient must maintain proper trunk and scapulothoracic position in an upper extremity weight-bearing position during the movement of the cervical spine (Figure 3-25).

Figure 3-25 Quadruped cervical extension with emphasis of sagittal rotation in midrange.

Sitting with back to wall—shoulder abduction lateral rotation

Sitting with back to wall—shoulder abduction lateral rotation exercise is a progression of the back to wall—capital flexion exercise. The patient assumes the position as described in the first exercise, which includes correct positioning of the lumbar spine, thoracic spine, scapulae, and cervical capital flexion. The patient then performs bilateral shoulder abduction and lateral rotation so that the arms are against the wall without compensatory thoracic, lumbar, or cervical extension. The patient slides the arms up the wall, maintaining spinal alignment, especially capital flexion. A typical response from the patient is a report of increased muscle activity in the midthoracic region, indicating increased recruitment of trapezius, rhomboid, and thoracic spinal musculature (Figure 3-26).

Figure 3-26 Sitting back to wall, shoulder abduction lateral rotation.

Modification: The arms do not make full contact with the wall. The arms can be parallel to the wall.

Modification: The fingertips can be placed on the wall with the elbows away from the wall.

Progression: When adding resistance with free weights or resistance bands, the patient is instructed to position the trunk, neck, and arms as described previously, then move through shoulder abduction with resistance. The patient continues to maintain the lumbar spine against the wall and capital cervical flexion during the shoulder movement.

Sitting with back to wall performing shoulder flexion

Sitting with the back to the wall performing shoulder flexion exercise is a progression of the back to wall—capital flexion exercise program. The patient assumes the same head and trunk alignment, as described, of correct positioning of the lumbar spine, scapulae, and cervical capital flexion. The patient performs shoulder flexion and lateral rotation to 90 degrees with the elbows flexed and the “palms facing you.” The patient is then instructed to perform shoulder flexion by “reaching up toward the ceiling.” The patient should maintain the lumbar spine against the wall and the cervical spine in the position of capital flexion. Since the movement of shoulder flexion is increased, there is a stretch to the latissimus dorsi and avoiding lumbar extension will be difficult if the muscle is short or stiffer than the abdominal muscles. In addition, during shoulder flexion, maintaining the humeral position of lateral rotation will also be difficult and the therapist should monitor the elbow position for indication of compensatory medial rotation. A verbal cue of “elbows in” can assist in preventing medial rotation. Also, as shoulder flexion motion increases, there often is associated cervical extension because of the stretch of the levator scapulae as the scapula upwardly rotate. Again, the patient should be encouraged to maintain capital cervical flexion and avoid compensatory cervical extension. Maintaining the position of cervical flexion during the movement of the arms encourages recruitment of the intrinsic cervical flexors to maintain cervical alignment (Figure 3-27).

Figure 3-27 Back to wall sitting, shoulder flexion with lateral rotation. A, Start position. B, Shoulder flexion.

Modification: Position the humeri/arms in the scapular plane: 30 degrees of horizontal abduction.

Modification: Position the humeri in less lateral rotation: “Palms face each other, elbows in.”

Progression: When adding resistance with free weights or resistance bands, the patient is instructed to position the trunk, neck and arms as described previously then move through movement of shoulder flexion with resistance. The patient continues to maintain the lumbar spine against the wall and will find it a challenge to maintain capital cervical flexion and avoid cervical extension during the shoulder movement (Figure 3-28).

Figure 3-28 Progression of wall exercises with resistance bands and free weights.

Wall slides: facing the wall—shoulder flexion

The patient is instructed to face the wall and place the ulnar side of the hands on the wall with the shoulders in flexion. The patient is instructed in the correct scapulae position and to bring the chin down toward the front of the neck. The patient is then instructed to slide the arms up the wall while maintaining the cervical spine position, avoiding any compensatory cervical extension during the movement of shoulder flexion and returning to the starting position (Figure 3-29).

Figure 3-29 Wall slide without resistance.

Modification: Position the shoulders in the scapular plane.

Progression: When adding resistance with resistance bands, the patient is instructed to maintain the cervical position and to avoid any compensatory cervical extension during the movement of the shoulder flexion wall slide (Figure 3-30).

Figure 3-30 Progression of wall slide facing the wall exercise with scapula elevation adding resistance with elastic band. Patient instructed to look down and avoid any compensatory cervical extension.

Sitting tests

Secondary tests

Correction of alignment and observed compensatory motions are key to diminishing pain and improving ROM. Passive elevation of the shoulder girdle and/or supporting the weight of the upper extremities results in an increase in rotation ROM and a decrease in pain¹⁴,¹⁵ (Figure 3-33).

Figure 3-33 Passive elevation of the shoulder girdle test.

Supine test

Supine active cervical flexion: In supine, active cervical rotation is limited and painful.

Quadruped test

Active cervical rotation: In the quadruped position, active cervical rotation is limited and painful.

Sitting with back to wall performing cervical rotation

The initial positioning for the sitting with back to wall performing cervical rotation exercise is the same as the first exercise described in the section on cervical extension syndrome. The initial instructions address impairments in adjacent regions. The upper extremities are supported on pillows to diminish the compressive loading of the cervical spine from the transfer of the weight of the upper extremities to the cervical region through the cervicoscapular muscle attachment.⁹,¹⁵ Each patient needs to be assessed for specific alignment impairments at the lumbar and thoracic spines and scapulothoracic region. The patient is then instructed in strategies to precisely correct individual alignment faults in these regions before proceeding with the exercise (see Figure 3-22).

The patient is then instructed to perform cervical rotation about a “vertical axis” and to avoid the compensatory movements of extension and sidebending. The therapist should encourage the patient to “easily” turn the head and neck to minimize the recruitment of the extrinsic cervical rotators. Specific instructions include “keep the chin down” and “do not lean the head and neck toward the side you are rotating toward.” Additional instructions to sidebend in the opposite direction that the patient is rotating the head, typically result in a vertical position of the head and neck and diminished ipsilateral sidebending. Maintaining the precise motion of rotation without compensatory sidebending or extension promotes an increased use of the intrinsic rotators and diminished use of the extrinsic rotators, thus reducing shear forces on the cervical spine.

As described in cervical extension syndrome, the patient is encouraged to maintain appropriate alignment of the adjacent regions during this movement of the cervical spine. This exercise can be ideally performed in sitting, but if the patient has difficulty maintaining the correct postural alignment during the cervical motion, the exercise can be performed in supine. The supine position will not be as challenging on the trunk musculature to maintain the alignment of the adjacent regions.

Supine active cervical rotation

Performance of precise cervical rotation in supine can be performed if sitting cervical rotation is too difficult or painful. The patient assumes a hook lying position with the arms supported on pillows (Figure 3-34). The patient may require a towel roll under the head. The thickness of the towel roll depends on the patient’s thoracic alignment and severity of the forward-head alignment. The greater the kyphosis and forward-head posture the greater the thickness of the towel roll. The same initial instructions to address the adjacent regions impairments as explained in the sitting exercises. The patient is then instructed in strategies to precisely correct individual alignment faults in the adjacent regions—lumbar and thoracic spines and scapulothoracic region—before proceeding with the exercise. The patient is then instructed to perform cervical rotation about a “vertical axis” and to avoid the movements of cervical extension and sidebending.

Figure 3-34 Patient in supine, arms supported on pillows, and head on folded towel.

Facing wall, arms supported—active cervical rotation

An additional position of facing the wall with the arms overhead supported on the wall can be used to perform precise cervical rotation with support to the upper extremities. The patient is instructed to rest his or her forearms on the wall, allowing the wall to support the upper extremities and relaxing the upper trapezius muscles (Figure 3-35). The patient is instructed to roll the chin down slightly and then perform precise cervical rotation about a vertical axis and to avoid movements of cervical extension and sidebending.

Figure 3-35 Facing wall, arms overhead and supported on the wall.

Quadruped active cervical rotation

The alternative position of quadruped can be used to perform precise cervical rotation if the previously described positions of sitting or supine are too difficult or painful with cervical rotation motion (Figure 3-36). The patient is instructed to flatten the spine like a “table top,” align the head and cervical spine with thoracic and lumbar spine and then rotate the head and neck about an axis of motion. The patient is instructed to avoid movements of cervical extension and sidebending.

Figure 3-36 Corrected quadruped (A) and quadruped cervical rotation (B).

Symptoms and History

A 24-year-old female student presents with a complaint of neck pain that has worsened in the last 4 months. Pain is located in the bilateral upper cervical region, right lower cervical region, and right upper trapezius muscle. She also complains of occasional numbness and tingling in the right forearm and hand. She rates her average daily pain 4/10. Pain can increase to 7/10 with prolonged sitting, working on the computer, and studying. Her neck disability index (NDI) score = 23 indicating moderate disability.⁵⁰ Radiographs of the cervical spine were unremarkable.

She reports a history of chronic migraines since she was 16 years old. She averages about one migraine a month and manages the migraines with Imitrex and rest. In the last 4 months, as her neck pain has worsened, she has noted an increase frequency of migraines to 2 to 3 per month.

Alignment Analysis

In standing, she presents with a position of forward head with upper cervical extension, increased flexion at the upper thoracic region with a flat thoracic spine below and lumbar lordosis (Figure 3-37). The scapulae are positioned in abduction and slight depression. The right scapula is positioned 4 inches lateral from the spine, and the left scapula is positioned 3.5 inches lateral from the spine.

Figure 3-37 Alignment side view.

Movement Analysis and Active Range of Motion Findings

Active shoulder movements

Shoulder flexion demonstrated a decreased upward rotation of scapulae: <60 degrees.⁴⁹ Patient also demonstrates compensatory cervical extension and complaint of cervical pain (Figure 3-38).

Figure 3-38 Standing shoulder flexion.

Secondary Tests

The therapist corrects the starting alignment of the abducted scapulae and cervical spine extension position, then during active shoulder flexion, the therapist manually assists the scapulae into the greater upward rotation and instructs the patient to avoid compensatory cervical extension. The corrections resulted in greater scapular upward rotation and no complaint of neck pain.

Additional impairments

Supine shoulder flexion demonstrates limited shoulder motion with compensatory rib cage elevation, lumbar extension, and cervical extension (Figure 3-39).

Figure 3-39 A, Supine shoulder flexion with rib cage elevation. B, Supine shoulder flexion with correction.

Secondary Tests

The patient was then instructed to correct the starting scapular alignment by actively adducting the scapulae; to recruit lower abdominals to maintain lumbar spine alignment, and to avoid rib cage elevation and cervical extension. The patient was then instructed to actively perform shoulder flexion without compensatory motions. Shoulder flexion ROM is decreased, but she able to perform movement without compensatory motion. Passive length assessment of the latissimus dorsi bilaterally was determined to be short.⁸

Length test of the pectoralis minor: Passive length assessment of the pectoralis minor was determined to be short bilaterally with the right shorter than the left.⁸ Also noted was compensatory cervical rotation in the direction of the muscle being tested.

Manual muscle testing (MMT): The lower abdominal muscles were weak at a 2/5 level, with compensatory rib cage elevation and cervical extension during testing.¹ The deep neck flexors were 2/5 muscle grade.⁸ The strength of the middle trapezius was determined to be 3/5 on both right and left.⁸

Diagnosis and Staging

The patient’s diagnosis is cervical extension-rotation syndrome with scapula abduction.¹ The stage for rehabilitation is Stage 2. Her prognosis is good to excellent. Her positive moderators include her young age, overall good health, and moderate duration of symptoms. Her negative moderators include her reports of radiculopathy and long history of migraines.

AROM, Active range of motion; ROM, range of motion.

Treatment

The patient was seen once a week for 4 weeks and then once every other week for 4 weeks. Each treatment session lasted approximately 30 minutes. The treatment included instruction in a specific home exercise program to improve cervical spine function and functional instructions to diminish excessive forces on the cervical spine during her daily activities.

Exercise program

Initially, the patient was instructed in active cervical ROM exercises. The initial “set up” for the patient was sitting in a chair with the back against the wall and the arms supported on pillows. This type of positioning diminished thoracic flexion and provided the patient with tactile feedback of “correct alignment.” The pillows allow support of the weight of the upper extremity and diminish the downward pull on the cervical spine via the attachment of the cervicoscapular muscles.⁹ The patient was then instructed in the following cervical exercises:

Capital flexion in sitting (see Figure 3-40): The patient was instructed to recruit the lower abdominal muscles to maintain a neutral lumbar spine alignment then correct her faulty scapular position of scapula depression and abduction. She was instructed to slightly elevate the shoulders toward the ears and then adduct the scapulae. Once she had corrected her starting alignment of her lumbar spine, thoracic spine, cervical spine, and scapulae, she was instructed to place her head close to the wall and perform capital head flexion. The patient was encouraged to “roll” the head and chin toward the base of the anterior neck while trying to maintain the head close to the wall. The verbal cue to “roll” the head is to encourage recruitment of the intrinsic cervical muscle to perform sagittal rotation rather than anterior translation. The patient reported a “tightening feeling” in the front of the neck and stretching in the back of the neck. She did not have complaints of reproduction of cervical spine pain or any complaints of peripheralization of symptoms into her arm. She was instructed to repeat the movement five times. At the completion of the repetitions, the patient reported that the exercise was difficult, but there was no increase or peripheralization of her symptoms. She reported that her neck felt “looser,” and she felt a decrease in her headache pain. She was instructed to repeat the exercise an additional five repetitions. She again reported a positive response.

Figure 3-40 A and B, Sitting capital flexion arms supported.

Cervical rotation in sitting: The patient was instructed to position herself in the same position as in the previous exercise. This incorporated support of the upper extremities and correction of spinal and scapulae alignment, including rolling the head and chin down to the correct cervical spinal extension position. Once positioned, the patient was instructed to perform rotation. The patient was then instructed to perform cervical rotation about a “vertical axis” and to avoid the movements of extension and sidebending. Specific instructions included “keep the chin down” and “do not lean the head and neck toward the side of rotation.” Additional instructions included to sidebend in the opposite direction of the rotation, which results in a vertical position of the head and neck and diminished ipsilateral sidebending. Maintaining the precise motion of rotation without compensatory sidebending or extension promotes increased use of the intrinsic rotators and diminished use of the extrinsic rotators, thus diminishing shear and translatory forces on the cervical spine. Initially, the patient was able to perform approximately 60 degrees of pain-free rotation without compensatory cervical extension. She was reminded to keep her “nose down” during the rotation movement. Practice during the first session resulted in approximately 70 degrees of pain-free rotation without compensatory extension.

Sitting—shoulder abduction lateral rotation (see Figure 3-41, A): The patient was instructed to position herself in the same position as the previous exercises. She correctly positioned her lumbar spine, scapulae and cervical spine (capital flexion). The patient then performed shoulder abduction and lateral rotation and maintained the position by placing her arms against the wall. The patient then slid the arms up the wall (abduction-elevation), maintaining spinal alignment, especially capital flexion. The patient reported and increased muscle activity in the midthoracic region, indicating increased recruitment of trapezius, rhomboid, and thoracic spinal musculature.

Figure 3-41 A, Sitting-shoulder abduction with lateral rotation. B, Sitting-shoulder flexion with lateral rotation.

Sitting—shoulder flexion (see Figure 3-41, B): The patient was instructed to position herself as noted in the first two exercises. The patient then performed 90 degrees of shoulder flexion and lateral rotation of the humerus “palms facing each other.” The patient was then instructed to perform shoulder flexion: “reach up toward the ceiling.” The patient was instructed to “keep elbows in” to prevent humeral medial rotation, and to maintain the lumbar spine against the wall and the cervical spine in the position of capital flexion.

Supine capital flexion without head lift: In a supine position with the arms supported on pillows, the patient was instructed to recruit the lower abdominals to maintain the lumbar spine position, adduct the scapula to properly align the scapulae, and then perform capital cervical flexion without a head lift. The patient was instructed to maintain the lumbar spine and scapulae alignment during the movement of the neck. The patient should feel a stretch in the posterior neck region and a recruitment of the intrinsic cervical flexor muscles.

Supine neck flexor strengthening—with assisted head lift (Figure 3-42): The patient was instructed to roll the chin toward the front of the cervical spine and assist with her hand to roll the cervical spine off the supporting surface while maintaining the chin positioned at the anterior cervical spine. The assisting hand should be placed at the back of the head to help direct the movement of capital flexion and assist in lifting the weight of the head. The patient was encouraged to only allow enough support that permits the appropriate “curl up” position of the head and cervical spine. Progression of the exercise would be to provide less support.

Figure 3-42 Assisted neck flexion.

Trapezius exercises in sidelying (Figure 3-43): The patient is positioned in sidelying with her head supported on a towel roll and her arm overhead. The therapist supports the arm with one hand and guides the scapula into adduction, external rotation and posterior tilt with the other hand. The patient is asked to adduct the scapula, and at the end of the scapula adduction ROM, the therapist instructs the patient to hold the weight of the arm while keeping the scapula adducted and avoiding any position of neck extension. The therapist should observe appropriate recruitment of the trapezius muscle. The patient can perform this exercise at home with her arms supported on pillows.

Figure 3-43 A Starting position for trapezius exercises. B, Final position.

Wall slides: Facing the wall—shoulder flexion: The patient is instructed to face the wall and place the ulnar side of the hands on the wall with the shoulders in the flexion plane. The patient is instructed how to use correct scapulae position and bring the chin down toward the front of the neck. The patient is then instructed to slide the arms up the wall and gently push into the wall to recruit the serratus anterior while maintaining the cervical spine position. The patient should avoid any compensatory cervical extension during the movement of shoulder flexion and return from shoulder flexion.

Facing wall, arms supported—active cervical rotation (Figure 3-44): An additional position of facing the wall with the arms overhead and supported on the wall can be used to perform precise cervical rotation with support to the upper extremities. The patient is instructed to rest the forearms on the wall, allow the wall to support the upper extremities, and relax the upper trapezius muscles. The patient is instructed to roll the chin down slightly, perform precise cervical rotation about a vertical axis, and avoid movements of cervical extension and sidebending. These instructions are similar to the instructions used in cervical rotation in sitting.

Figure 3-44 Arms supported on wall; capital flexion and rotation.

Quadruped rocking back without associated extension (Figure 3-45): The patient was instructed to assume the quadruped position, flatten the spine like a “table top,” and align the head and cervical spine with thoracic and lumbar spine. She was then instructed to rock back on to her heels while maintaining a “flat spine” and “chin rolled in toward the front of the neck.” She was instructed to avoid cervical extension during the movement of rocking back. The patient had difficulty maintaining the thoracic and cervical spine position as she rocked back. Her rocking back range was limited to the range in which there was no spinal movement.

Figure 3-45 A, Rocking back with compensatory extension. B, Correctional exercise—rocking back without associated extension.

Functional Instruction

The patient was encouraged during sitting activities to support the arms and periodically recruit abdominals and scapular posterior tilt and external rotation muscles, while maintaining neutral neck position with the chin and nose slightly down.⁵ She was encouraged to use a chair that would support her thoracic spine and not allow thoracic flexion.¹¹ She was instructed in proper use of eyeglasses to allow a neutral neck position during computer use. The instructions were directed to diminish upper cervical extension and forward translation.² She was also instructed in the typical “gestures” and “habits” of cervical extension that she demonstrated during the examination while she was communicating and expressing herself. She was instructed in strategies to diminish these habits during her day.

At the end of 4 weeks of treatment (4 treatment sessions), the patient reported no episodes of numbness/tingling in her forearm or hand. She reported only 1 migraine headache during the 4-week period (previously 2 to 3 a month). She rated her daily average pain 2/10 and also 2/10 with prolonged sitting at a computer. Her NDI score was 14, indicating minimum disability. At the end of 8 weeks of treatment (6 treatment sessions), she reported her daily average pain 0/10 and occasional pain (2/10) if she sat more than 2 hours at the computer without a break or did not support her arms during the sitting activity. Her headache behavior was now typical of what she experienced before the recent neck pain flare-up, or one migraine a month. She reported that she was using her eyeglasses properly while working on her computer and had become more “aware” of her gestures and habits that contribute to stress on her cervical spine. She was making an effort to diminish cervical extension movements during her daily activities. She continued to remind herself to keep her “nose down” to avoid excessive extension.

This case is a useful illustration of the importance of addressing the adjacent regions, shoulders and thoracic spine, when treating a patient with cervical extension-rotation syndrome and associated headache. Alignment, length, and strength of muscles in the adjacent region are critical to address before attending to the cervical movement impairments. In addition, demonstrating to the patient that she had a tendency to frequently move in the direction of extension rotation and teaching her that this movement needed to be reduced during her daily activities helped alleviate her pain. Patient awareness of her daily movement habits and postures is essential in managing her symptoms and possible future flare-ups. Essential components for management of her problem included (1) improving the strength of her scapula posterior tilt and external rotator muscles, serratus anterior, rhomboids, and middle trapezius to maintain appropriate alignment of her scapula. Improving the participation of the serratus anterior muscle reduces the loading from the cervicoscapular muscles on the cervical spine and increases the support from the axioscapular muscle for the weight of her upper extremities. Proper support of her upper extremities is necessary for decreasing the compressive load on the cervical spine structures and allows pain-free motion of the cervical spine.⁴⁴ Improving the strength and recruitment of her abdominal muscles supports the appropriate alignment of her lumbar spine and rib cage during movements of the extremities and neck. Education in the patient’s preferred daily habits and postures contribute to stress on cervical spine structures. All of these components contributed to a successful outcome and enabled her to manage her symptoms.

Prone active cervical extension

In prone or in quadruped, the patient is instructed to “roll” head and neck back in the direction of extension (Figure 3-48). The verbal cue of rolling is to facilitate the recruitment of the intrinsic neck extensors and reduce recruitment of the extrinsic neck extensors. The patient is encouraged not to reach full end-range extension to avoid excessive compression on the cervical facets and discs.

Figure 3-48 Prone position.

Quadruped active cervical extension

The quadruped position can be a more difficult exercise because the exercise requires good axioscapular muscle function while weight bearing through the upper extremities (Figure 3-49). When performing the cervical extension exercise in the quadruped, the patient is encourage to perform the movement in the middle third of the ROM to avoid end-range extension or flexion.

Figure 3-49 Quadruped position for cervical extension exercise.

The description of treatment for the previous diagnoses indicates that examination and classification of associated scapular movement impairments is critical in the management of the patients with cervical pain. Strategies to examine, classify, and manage scapular movement impairments are clearly described in Sahrmann.¹

Secondary tests

Secondary follow-up tests can include several strategies, including repeating active rotation without associated flexion and/or sidebending movement. In addition, instructing the patient to “slump” before performing active rotation can promote an improved starting alignment of the cervical spine with reduced cervical flexion. Other corrections include passive support of the upper extremities during performance of active rotation and/or the therapist can passively assist the cervical vertebrae and guide precise rotation motion.

During active single arm flexion, rotation of a single or multiple vertebrae are noted via palpation of the cervical spinous process. The patient does not typically complain of pain. An alternative finding during single-arm flexion is compensatory sidebending or rotation of the cervical spine.¹⁰

Correction of this rotation movement impairment can be difficult. Several strategies can be attempted, as follows:

Sitting Cervical Rotation

The patient may not need to assume the position of sitting with the back to the wall as has been previously described for the cervical extension syndrome. Sitting in a chair with good thoracic spine support may be appropriate and may encourage a normal thoracic alignment of slight flexion and discourage a flat thoracic spine. As described in cervical flexion syndrome, an exaggerated straightening or reduced flexion of the thoracic spine may result in compensatory flexion of the cervical spine. Initial instructions address the impairments of adjacent regions, which were previously described. The upper extremities are supported on pillows to diminish the compressive loading of the cervical spine from the transfer of the weight of the upper extremities to the cervical region through the cervicoscapular muscle attachment.⁹,¹⁵ Each patient needs to be assessed for his or her specific alignment impairments at the lumbar and thoracic spines and scapulothoracic region. The patient is then instructed in strategies to precisely correct his or her individual alignment faults in these regions before proceeding with the exercise.

The patient is then instructed to perform cervical rotation about a “vertical axis” and to avoid the movements of flexion and sidebending. Specific instructions include “raise the chin up slightly” to avoid compensatory flexion during rotation and “do not lean the head and neck toward the side to which you are rotating.” Additional instructions to sidebend in the opposite direction that the patient is rotating his or her head typically result in a vertical position of the head and neck and diminished ipsilateral sidebending. Maintaining the precise motion of rotation without compensatory sidebending or flexion promotes increased use of the intrinsic rotators and diminished use of the extrinsic rotators, thus diminishing shear and translatory forces on the cervical spine.

The patient is encouraged to maintain appropriate alignment of the adjacent regions during this movement of the cervical spine. This exercise can be ideally performed in sitting, but if the patient has difficulty maintaining the correct postural alignment during the cervical motion, the exercise can be performed in supine. The supine position will not be as challenging as control by the trunk musculature in maintaining alignment of the adjacent regions.

History and Symptoms

A 26-year-old male complains of lower cervical neck and right upper trapezius pain that is increased with sustained sitting postures working at the computer. He rates his pain 2/10 at rest and 4/10 with neck movements. His NDI score = 14, indicating mild disability. He reports that in high school he was a competitive swimmer and presently enjoys surfing.

Alignment

In standing, he has a swayback posture, with the thoracic region swayed posterior.⁸ The spinal alignment was remarkable for a reduced curve in the cervical region and also a reduced curve or “flat” thoracic spine (Figure 3-50, A). The clavicular alignment appears horizontal with a diminished upward slope of the distal end of the clavicle. The scapulae were in a position of depression with the superior angle of scapula positioned below T2⁸ (see Figure 3-50, B).

Figure 3-50 A, Reduced cervical curve from thoracic spine. B, Depressed shoulders.

Reduced muscle bulk was noted in the cervical paraspinal musculature. He also complained of pain on palpation of right upper trapezius and levator scapulae muscles.

Movement Analysis and Active Range of Motion Findings

Active ROM test results are given in the following table.

Diagnosis and Staging

The patient’s diagnosis is cervical flexion rotation with scapula depression and the stage for rehabilitation is Stage 3. His prognosis is excellent. His positive moderators include young age, good health, minimal duration of symptoms, and low NDI score.

AROM, Active range of motion; ROM, range of motion.

Treatment

The patient was seen once a week for 2 weeks and then once every other week for 4 weeks. Each treatment session lasted approximately 30 minutes. The treatment included instruction in a specific home exercise program to improve cervical spine function and functional instructions to diminish excessive forces on the cervical spine during daily activities.

Additional exercises

Additional exercises to improve intrinsic cervical extensor muscle function include the following:

Prone cervical extension to improve the strength and recruitment of the intrinsic cervical extensors (see Figure 3-48): The patient is positioned prone with his forehead resting in the palm of his hands. The patient is to perform active cervical extension by “rolling” the head and neck back in the direction of extension but not to end-range. The patient is instructed to imagine an “axial running through the middle of his cervical spine” and rotate about the axial as he performs active extension. The therapist should observe if the patient is properly recruiting the intrinsic neck extensors and not excessively recruiting the extrinsic muscles (levator scapulae and upper trapezius).

Quadruped active cervical extension (see Figure 3-49): An alternative exercise that can improve cervical extensor function is to perform the previously described motion in the quadruped position. The patient is encouraged to avoid excessive thoracic extension and assume slight thoracic flexion. The patient is to perform active cervical extension by “rolling” the head and neck back in the direction of extension but not to end-range. The patient is instructed to imagine an “axial running through the middle of his cervical spine” and rotate about the axial as he performs active extension. The therapist should observe if the patient is properly recruiting the intrinsic neck extensors and not excessively recruiting the extrinsic muscles (levator scapulae and upper trapezius). The patient is also instructed to “roll” his head and neck forward as he returns from cervical extension. The patient is instructed to perform the movement of flexion and extension with precision and in the middle-third of the range, avoiding end-range extension or flexion.

Facing the wall—shoulder flexion with scapula elevation (Figure 3-51): This exercise improves strength and length of the upper trapezius and serratus anterior muscles.⁵¹ The patient’s scapulae position was determined to be in a position of depression, which results in a lengthened upper trapezius muscle. The objective of the exercise is to strengthen the upper trapezius muscle in a shortened position. The patient is instructed to face the wall and rest his hands on the wall just above shoulder level. As he slides his hands up the wall, he is instructed to elevate the scapula/acromion toward his ears. He is instructed to “keep his nose and chin slightly up” to avoid cervical flexion. In addition, he can return from flexion, slide his hands down while maintaining the scapulae in an elevated position and not allow excessive depression while returning from the flexion position.

Figure 3-51 Facing the wall, shoulder flexion with scapula elevation.

Functional Instruction

During sitting activities, the patient is encouraged to “Slump!” He is encouraged not to attempt to have a very straight thoracic spine and to relax the neck position. He is encouraged to allow the chin and nose to be slightly up. The patient may feel that he is excessively slumped because he is accustomed to being very straight. A mirror can provide visual feedback that the correction does not result in excessive slumping but rather appropriate alignment of thoracic and cervical spines. In addition, the patient is encouraged to support the arms on pillows or the desk to minimize the downward pull on the upper trapezius and levator scapulae muscles. The patient is instructed in a strategy of allowing the thoracic spine to flex, which will also minimize excessive flexion in the cervical spine.

The patient was also instructed in the appropriate cervical and head positions when using his eyeglasses. The patient is to position his eyeglasses to allow a neutral neck position during computer use and should exaggerate a flexed cervical position.

The patient was also instructed to minimize one-arm activities with the left arm to avoid compensatory lower cervical rotation. When possible, he should consider using the right arm or both arms with functional activities.

At end of 6 weeks of treatment (4 treatment sessions), the patient reported 0/10 pain at rest and with movements of the neck. His neck disability index score = 4, indicating no disability. He also reported that he was doing his exercises several times a week, but he found that the functional instructions were the most helpful in managing his symptoms. He found that supporting his arms during the day, relaxing his upper back, and trying not to sit up too straight decreased the stress through his neck region.

This case is an illustration of how excessive motion in one region of the spine and lack of motion in adjacent regions can increase stress on the spinal tissue that demonstrates excessive motion. This patient’s attempts for “correct” posture were exaggerated. The flat thoracic spine and loss of a normal thoracic curve did not permit proper neck alignment. Relaxing the upper back to allow some flexion also allows the cervical spine to acquire a normal lordotic curve of the cervical spine. It was important that the patient avoid excessive flexion and encourage extension or a normal inward curve of the cervical spine. This acquired posture allows appropriate distribution of stresses across the spine. In addition, support of the upper extremities and improving the alignment of the scapulae into an elevation out of a depressed position also decreased the compressive load on the cervical spine structures.