22nd February 2012
CASE REVIEW: CERVICAL SPINE
Let's set the scene.
An office worker presents with right sided upper cervical neck pain and occipital headaches following a fall on a slippery pavement 3 months ago where she “jarred” her neck. She has a ‘head forward – chin poke’ and dropped shoulder posture. She complains of deep constant ache in the upper neck (right > left) with a sharp catch of right upper cervical pain when she turns her heads to the right, which limits neck rotation to ½ range. The deep ache and headache are aggravated by driving and static positions such as working at a computer. The right sided sharp catch is particularly aggravated by rotation to the right and by extension or looking up. She gets significant relief of her symptoms if she lies down or if she supports her right shoulder in upward rotation.
In managing this person’s pain and dysfunction we need to be able to answer some important questions.
Question 1: Where does the pain come from? What structures are injured?
Manual therapy assessment involving assessment of provocative movements, palpation of pain sensitive tissues and structural testing implicates a right C1-2 facet joint sprain and myofascial trigger point pain from the levator scapulae, sterno-cleido mastoid and splenius cervicus muscles contributing to the headache and neck pain.
Question 2: How do movement faults or uncontrolled movement (UCM) contribute to this pain and injury?
This woman demonstrates an aberrant movement pattern when she performs functional movements into cervical extension. She has a pattern of initiating neck extension and looking up by lifting her chin and pivoting at the base of the skull, with lower cervical movement contributing late. The cervico-thoracic junction has reduced extension. If the deep cervical flexor muscles (longus colli) and the deep posterior cervico-thoracic extensor muscles (semispinalis & cervical multifidus) lack appropriate co-ordination or are functionally inefficient, then, there is a lack of ability to maintain control of the upper cervical extension initiating the functional movement of looking up
She also initiates head rotation with a chin poke (upper cervical extension) movement and uses cervical sidebending to the right towards the end of her pain limited range. The dropped and downwardly rotated scapula significantly reduces the functional range of available neck rotation. When the scapula is passively supported in full upward rotation, which results in myofascial unloading of the neck-shoulder girdle muscles, then head rotation increases to almost full range with significant pain reduction. Inefficient recruitment of the scapulo-thoracic upward rotator muscles (serratus anterior and trapezius) contribute to poor scapular stability, which consequently mechanically limits neck rotation.
This person demonstrates uncontrolled right C0-1 extension & rotation.
Question 3: How do we test for and identify uncontrolled movement that is related to pain and dysfunction?
The evaluation of uncontrolled movement involves a process of assessing cognitive motor control abilities. In this case, both extension and rotation control abilities need evaluation.
Testing extension control involves instructing the patient to initiate neck extension in such a way that the lower cervical spine initiates the movement and moves independently of the upper neck and thoracic spine. That is, lift the head up using specific segmental lower cervical extension while at the same time preventing any upper cervical extension or chin lift. The inability to control or prevent chin lift (upper neck extension) during the initiation of a movement of looking up, demonstrates a movement control dysfunction that is related to the patient’s pain mechanism and pain behaviour.
Testing rotation control involves instructing the patient to perform head rotation without the compensatory movements of chin poke (upper cervical extension) or sidebending, while maintaining the scapula (on the same side) in upward rotation. That is, turn the head to the side (keeping the eyes horizontal), while at the same time preventing any upper cervical extension (chin lift), or sidebending of the head or depression / downward rotation of the shoulder. The inability to control or prevent chin poke, sidebending or shoulder dropping during head rotation, demonstrates a movement control dysfunction that is related to the patient’s pain mechanism and pain behaviour.
Question 4: What movement control strategies can be used to recover this dysfunction?
There are a variety of movement control options to deal with this dysfunction.
Use movement control dissociation to train the patient to control or prevent upper cervical extension or chin lift during independent low cervical extension activities and end range arm movements
Use movement control dissociation to train the patient to control or prevent upper cervical extension, head sidebending and scapular depression during independent head rotation activities.
Perform recruitment efficiency training of the specific anterior cervical stabiliser muscles that can protect against extension at the upper cervical spine. In this case, retraining inner range holding efficiency of the longus colli and capitis muscles would be effective.
Perform recruitment efficiency training of the specific scapula stabiliser muscles that can protect against scapula depression or downward rotation. In this case, retraining inner range holding efficiency of the serratus anterior and trapezius.
The Movement Solution course provides these answers and solutions to enhance and integrate your manual therapy skills into contemporary movement control theory and practice. Our aim is to develop a diagnostic framework of movement function so that for each patient you make a diagnosis of:
1) The injured or pain generating tissues (e.g. right C1-2 facet joint and its peri-articular soft tissues)
2) The site and direction of uncontrolled movements that causes the tissue stress and strain (e.g. uncontrolled upper cervical extension and uncontrolled scapula downward rotation)
3) The pain mechanisms involved in the pain experience (e.g. a peripheral inflammatory nociceptive mechanism at the R C1-2 joint and a peripheral neurogenic mechanism associated with myofascial tripper point pain headache referral)
Contextual factors, such as environment and ergonomics are also considered (e.g. working at computer with the head in a sustained head forward – chin poke posture and added repetitive head rotation to right to read from notes for data entry. This is compounded with the right shoulder dropped in sustained downward rotation while using a mouse with the right hand).