Deep Neck Flexor Stabilisation Protocol

Strengthening

Evidence suggests that neck flexor motor control and strength are impaired in patients with neck pain disorders. Recent studies on the coordination of deep and superficial cervical muscles have shown that, during a low-load craniocervical flexion (CCF) task, the deep and the longus colli muscle are specifically targeted[1] This study showed that patients with neck pain exhibited increased EMG amplitudes of the sternocleidomastoid and anterior scalene muscles, activation of the deep neck flexors compared with patients with neck pain Decrease, CCF range of motion decreases For people without neck pain. A low-load craniocervical flexion exercise program that focuses on motor control of the deep neck flexors has been shown in clinical trials to reduce neck pain and headaches. This type of training has been shown to enhance depth and Superficial flexor activity in the CCF test compared with strength training. Furthermore, a higher proportion of patients showed improved temporal characteristics of deep neck flexor activation after CCF training. Comments below on Deep Neck Flexor Assessment and Exercise The protocol is described in detail in the peer-reviewed literature.

Edmondston et al. 2008[2]

[3]

Position: The test is performed with the subject lying bent on the base. The examiner places the subject’s left hand on the table just below the occipital bone, with the subject’s head slightly flexed by the upper neck.

Procedure: Subjects completed two tests on the first day of testing. Subjects rested for 3 minutes between tests. Subjects were reassessed 3 days after the initial session, but the test was only administered once a second time. Subjects were given a A detailed description of the test procedure is then placed at the start to aid in familiarization with the test. During the test, the subject receives verbal and tactile feedback to help maintain the correct test position. This feedback helps prevent the test from ending prematurely And help the subjects reach the end point of the test that truly reflects their muscular endurance. This feedback may also help reduce problems with kinesthetic awareness. If the subject’s discomfort increases to an unacceptable level, the test is terminated. after completing the first The test phase required the subjects to maintain normal levels of physical activity until the end of the second test.

Target Movement: The subject is asked to gently bend his or her upper neck and lift his or her head from the examiner’s hand while maintaining the upper neck flexed. Subjects were given verbal feedback (“put your jaw in” or “raise your head”) when their heads made contact Examiner’s left hand during the exam. If the subject is unable to maintain the head position of the examiner’s hand, the test is terminated.

Performance metrics measurement: Hold time is measured in seconds. (In this patient group, clinicians would need a change greater than 17 seconds (MDC) across repeated tests to be confident that the change was not measurement variability.) Video:

Jull et al. 2008[4]

Goal: Activation of endurance and isometric contractions of deep cervical flexors in progressive range positions.

Equipment: Inflatable cuff pressure sensor inflated to a baseline of 20 mmHg. This study used the StabilizerTM Chattanooga Group Inc. Chattanooga TN (bottom right). This is a standard pressure, enough to fill the space between the base and the neck without pushing it into the lordosis.

Position: Hook lying, neck neutral. Align the head and neck so they are straight: if there is a horizontal line between the eyes, the neck will be perpendicular to it. If necessary, place a towel under your head to achieve a neutral posture.

Procedure: Place the pressure sensor under the neck as shown on the left. Explain to the patient that the goal is not power but precision. Sternocleidomastoid replacement was monitored as shown on the left.

[5]

Target movement: Gently and slowly nodding as if to say “yes” so that the pressure sensor measures 2 mmHg above baseline, then 4 mmHg, then 6 mmHg, 8 mmHg, and 10 mmHg with no rest in between (the pressure sensor should read 30 mmHg at the end of the baseline exercise sequence). take each Increments of 2 seconds for a total of 10 seconds after all 5 increments. Repeat for the highest level achieved with proper form until you reach a total of 10 reps of 10-second holds.

Performance Indicator Measurement: Record the number of times the patient can maintain the pressure level. Multiply by the pressure increment. For example, if the patient is able to reach 4 mmHg without breaking form and can do 6 10-second holds without breaking form will be 24. The highest performance index possible is 100 (10mmHg x 10 repetitions).

Cagnie et al. 2008[6]

[7]

Craniocervical Flexion with Cervical Flexion: The head and neck flex together at the chest, and the head flexes at the cervical spine.

Purpose: To strengthen the deep neck flexors in addition to the superficial neck flexors.

Equipment: None

Position: supine

Procedure: Perform 3 isometric reps until fatigue, resting 1 minute in between.

Target movement: Begin craniocervical flexion first, then lift head off table (chin to chest) while continuing to maintain head in craniocervical flexion.

Cervical flexion with neutral craniocervical flexion: the head and neck flex together in the chest, while the head does not flex in the cervical spine.

Purpose: To train the deep neck flexors in addition to the superficial neck flexors.

Equipment: None

Position: supine

Procedure: Perform 3 isometric reps until fatigue, resting 1 minute in between.

Target Movement: Ask the patient to lift the head just off the base without tucking in or protruding the chin.

Craniocervical flexion: The bending of the head over the cervical spine.

Purpose: To retrain the deep neck flexors.

[8]

Equipment: Compression cuff manufactured by Chattanooga Group.

Procedure: Perform 3 isometric reps until fatigue, resting 1 minute in between.

Position: Lying on your back, place the pressure cuff under the occiput behind the cervical spine. Inflate the cuff to 20mmHg. The flattening of the lordosis is monitored by observing the increase in pressure using a pressure sensor as biofeedback. Monitor substitution by palpating the sternocleidomastoid muscle.

Targeted Movement: Perform a gentle nodding motion until full range is achieved. Hold for 10 seconds 10 times. Do not lift your head off the surface. The patient can stop after feeling that the contraction at the set intensity cannot be maintained.

Jull et al 2009[1]

Objective: To train the longus caputus and longus collius of the upper cervical spine with low load, and reduce the activation of the sternocleidomastoid muscle.

Phase1

Position: Supine

Equipment: None

Targeted Movement: Instruct the patient to focus on feeling the sagittal glide of the back of the head on the base while performing slow, controlled craniocervical flexion movements. Avoid holding back.

[9]

Phase 2

Position: Supine

Equipment: Inflatable pressure sensor. This study used the StabilizerTM Chattanooga Group Inc. Chattanooga TN

Procedure: Place the pressure transducer under the occiput on the lower neck. Monitor for sternocleidomastoid muscle replacement. The target level for the exercise is a level at which the subject can hold steady for 5 seconds while smoothly entering range and without retracting or using Neck bent skin.

Target movement: Gently and slowly nodding as if to say “yes” so that the pressure sensor measures 2 mmHg above baseline, then 4 mmHg, then 6 mmHg, 8 mmHg, and 10 mmHg mmHg with no breaks in between (the pressure sensor should read a 30 mmHg sequence at the end of the exercise). take each Increments by 5 seconds.

Dosage: Hold for 10 seconds at established target level for 10 repetitions, resting for 3 to 5 seconds in between. Train at the next target level with an end goal of 10mmHg (30mmHg) above baseline

O’Leary et al 2007[10]

[11]

Purpose: To improve the endurance of neck flexors.

Position: Supine

Equipment: Head weights

Procedure: Find the patient’s 12 rep max so that they fatigue at the end of 12 reps and begin to fatigue at the end. If the patient is unable to perform 12 repetitions against gravity without weights, tilt the head of the table to create a state of reduced gravity until 12 reach rep. Instruct patients to perform with proper form without weights. Ensure that the craniocervical rotation remains in a neutral position as the head is lifted from the base. Increase the weight in 0.5 kg increments until you find your new rep max of 12.

Target Movement: See Figure B on the right.

Dosage: Do 3 sets of 12 reps for the first two weeks, slowly increasing to 3 sets of 15 reps each. For the last 4 weeks, a 15 rep max was established and practiced until 3 sets of 20 reps were possible.

Chiu et al 2005[12]

Equipment: Pneumatic pressure transducers (Stablizer Chattanooga South Pacific Australia) were used to monitor the subtle flattening of cervical lordosis that is expected to occur with contraction of the deep cervical flexors.

Position: The patient is supine with the weight of the head and the cervical spine supported by a towel under the occipital bone in a neutral position. Ask the patient to place their tongue on the roof of the mouth, keep their lips together, and their teeth slightly apart to eliminate Activity of the depressor muscles.

Procedure: Place the transducer under the occipital bone at the back of the neck and inflate to 20 mm Hg, which is sufficient to fill the space between the test surface and the neck without pushing the neck into lordosis.

Targeted Movement: Under the guidance of an experienced physical therapist, patients are instructed to slowly nod their heads in a “yes” motion so that stress levels rise. The pressure that can be achieved and maintained stably for 10 seconds is called the activation fraction. This Ask the patient to practice 10-second holds for 10 minutes at this activation score, with a 15-second rest between each hold, or until the patient becomes tired and uncontrollable contractions, based on visual feedback from the pressure sensor. loss of control over contraction is Reflected in the pressure loss, as indicated by the inflation pressure sensor.

Falla et al 2003[13]

Equipment: Air-filled pressure sensor

Position: The subject is placed on the base in a supine flexed position. Standardize the starting position by placing the craniocervical and cervical vertebrae on an imaginary line at the subject’s forehead and chin level and parallel to the base And extends from the tragus and bisects the neck longitudinally.

Procedure: An inflation pressure transducer is positioned under the occipital bone at the back of the subject’s neck and set to a baseline pressure of 20 mmHg. Subjects were instructed on how to do CCF, they practiced nodding motions to gradually reach the incremental target and held 5 pressure A level between 22 mmHg and 30 mmHg lasts for 10 seconds. Examiners use visual inspection of the subject’s performance from the side to identify any substitutions such as neck constriction, and this is discouraged. The combined movement of CCF and cervical flexion (head up and chin down) is Also prepare for reference exercises.

Target Movement: The CCF test consists of 5 incremental movements that increase the CCF. During the CCF test, the test subject is required to perform a gentle nodding motion of the CCF, which is performed within a range to increase the pressure by 5 incremental levels, each increment representing 2 mmHg. starter The pressure is 22 mm Hg and the end pressure is 30 mm Hg. The examiner checks the pressure to make sure the subject is meeting each pressure target and keeping the pressure on the target stable. Instruct the subject to perform a combination exercise of CCF and cervical flexion. this The movement consists of a full CCF chin nod followed by cervical flexion to lift the head just off the base. Investigators observe this action to ensure proper execution. Hold this contraction for 10 seconds and repeat Between contractions, there is a 30-second rest period.

Subjects then performed 5 stages of the CCF test, from 22 mmHg to 30 mmHg, and held steady pressure on each target for 10 seconds. Take 30 seconds between contractions. Between contractions, the investigator checks the subject’s head and neck position to ensure The subject returns to his or her starting position.

Jull et al 1999[14]

Purpose: Craniocervical flexion is a low-load test that evaluates the subject’s ability to slowly execute and maintain precise upper cervical flexion movements in the absence of any voluntary flexion of the middle and lower cervical spine.

Equipment: Inflatable Inflatable Pressure Transducer (Stabilizer Chattanooga South Pacific)

Position: The test is performed with the patient lying supine with the weight of the head supported.

Procedure: Place the inflatable pressure transducer behind the neck and inflate to 20 mmHg. This is enough to fill the space between the test surface and the neck without pushing the neck into lordosis. Pressure transducers monitor slight flattening of cervical lordosis, Occurs when deep neck flexors contract and manifests as increased pressure.

Target Movement: Teach subjects to perform slow, gentle head-bending movements, like nodding for “yes” and holding the pose. Signs of improper performance, such as moving the jaw quickly or performing a jaw retraction to push the neck Errors on the sensor are corrected during the instruction phase. For the test, the increase in pressure that the subject could achieve and maintain with controlled upper cervical flexion maneuvers (activation score) was assessed. This pressure was then used as the target pressure the subject achieved over 10 days Repeat the lo-set hold test. Subjects look at the dial of the pressure sensor to target the specified pressure. Any unwanted head-up and general cervical flexion will take the weight of the neck off the transducer and cause pressure to drop. deep neck support Flexors were assessed by monitoring the subject’s ability to maintain the flexed position of the upper cervical spine under attainable pressure during a preset task that attempted 10 repetitions of low holds. A pressure loss of more than 20% of the target value is considered a failure, The number of repetitions up to this point is used to calculate capacity.

Performance Metric Measurement: Holding capacity was calculated by multiplying the achieved target pressure by the number of successful repetitions. For example, if a subject can increase the pressure by 10 mmHg with upper cervical flexion and repeat this 10 times His/her performance index is 100.

Jull et al 2008[15]

Indications: Patients with neck pain disorders; acute subacute and chronic manifestations.

Contraindications: The presence of neural tissue mechanical sensitivity that can cause pain with craniocervical flexion motion delays testing in its current form until this sensitivity is resolved. There should be no head or neck pain during this test. (The basic change is The clinical trial is being carried out in two phases. The first stage was a visual and palpable analysis of the movement and activity of the superficial cervical flexor muscles during five progressive stages of craniocervical flexion. Evaluation is still to determine which increment Test what the patient can achieve, but also include assessing any inappropriate compensatory movements (eg, retraction) or muscle strategies (eg, overuse of superficial neck flexors). Correct pattern of rehabilitation should be undertaken if abnormal movement patterns are present Further testing is prioritized at this time so that the endurance of the deep neck flexors can be tested with some degree of accuracy. Durability testing is of little value if left uncorrected. Phase 2 assesses the number of repetitions the patient is able to complete during the testing phase, while Execute and maintain correct craniocervical flexion. )

Phase 1: Objective: To analyze the performance of craniocervical flexion maneuvers

Equipment: Inflation pressure transducer (Chattanooga Stabilizer Group Inc. Hixson TN)

Position: Subject lies supine and flexed, pressure biofeedback is in place, and a dial is provided to guide test execution.

Procedure: A pneumatic pressure transducer is inserted between the test surface and the upper neck to monitor slight flattening of cervical lordosis associated with contraction of the deep cervical flexors.

Target Movement: Ask subjects to slowly feel the back of their head slide up the bed in a nodding motion, increase the target pressure from 20 mmHg to 22 mmHg, and hold this position for two to three seconds before relaxing and returning to their starting point. If the subject has Nod your head as you exhale. Repeat this process for every 2 mmHg increment through the test to 30 mmHg. Clinicians analyze head movement and superficial flexor muscle activity by observation or palpation. the motion should be During the five phases of the test, the range of head rotation gradually increases, and there should be negligible (if any) activity to be palpated or observed in the SCM or AS muscles until the last 1 or 2 phases of the test . Abnormal patterns or signs of poor activation of the deep neck flexors Include the following: the range of head rotation does not increase as the test progresses, and the movement strategy becomes more like a head-retraction maneuver; the patient raises the head to try to achieve the target pressure; the movement speed is fast; there is Activity of the superficial flexor or hyoid muscles is palpable during the first three phases of the test; the pressure dial does not return to the starting position and reads greater than 20 mmHg, indicating inability to relax the muscle after contraction – failure to relax the muscle This condition often touches the scalene muscle.

Performance Index Measurement: The patient can reach and maintain a 2 to 3 second test phase (increments of increasing pressure) with correct craniocervical flexion without significant activity of the surface flexor muscles, providing performance quantification for this phase test.

Phase II: This phase is performed when the patient is able to perform correct craniocervical flexion maneuvers even though all target pressures cannot be achieved. It is delayed when alternative movements are observed during phase 1 of the test.

OBJECTIVE: To test the isometric endurance of the deep neck flexors during the test phase that the patient can achieve with correct craniocervical flexion maneuvers.

Equipment: Inflation pressure transducer (Chattanooga Stabilizer Group Inc. Hixson TN)

Position: Patient lying supine flexed, pressure biofeedback in place, and a dial provided to guide test execution.

Procedure: A pneumatic pressure transducer is inserted between the test surface and the upper neck to monitor slight flattening of cervical lordosis associated with contraction of the deep cervical flexors.

Targeted movement: The patient performs a nodding motion to first aim at the lowest level (22 mmHg) and holds this position for 10 seconds. After assessing whether the patient can perform at least 3 repetitions of the 10-second hold without an alternate strategy, the test proceeds to the next pressure Target. Clinicians continue to observe the movement strategy used by the patient to ensure that it maintains craniocervical rotation. Signs of decreased endurance when testing increments include: patients are unable to hold pressure steady and pressure drops (although they seem keep the head in a flexed position); surface flexors are markedly recruited; and pressure levels remain constant, but movement is erratic, indicating that the patient is seeking another muscle to maintain pressure levels, which most likely indicates underlying muscle weakness or fatigue neck flexors. Performance Measures: Baseline assessment was documented as the patient’s ability to maintain a steady pressure level during repeated 10-second holds, with minimal surface muscle activity, and without any other alternative strategies.

Jull et al 2002[16]

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‘Equipment: Inflation pressure transducer (Stabilizer™ Chattanooga Group Inc. Chattanooga TN)

Position: Subject lies supine.

Procedure: Subjects are first taught to perform slow and controlled craniocervical flexion maneuvers. They were then trained to gradually increase the range of craniocervical flexion using feedback from an inflatable pressure transducer placed on the back of the neck.

Training of these neck muscles is also included in postural corrective exercises that are performed regularly throughout the day in a sitting position. Subject sits with natural lumbar lordosis while gently retracting and adducting the scapula and gently elongating the scapula The cervical spine favors the longus colli.

Targeted Movement: Slow and controlled craniocervical flexion movements maintain a gradually increasing range using feedback from pressure transducers.

Dosage: Subjects performed CCF exercises twice daily to increase endurance in the deep neck flexor muscles. Active treatment lasting more than 6 weeks includes a minimum of 8 and a maximum of 12 treatments. None of the sessions lasted longer than 30 minutes.

Falla et al 2007[17]

Purpose: To activate the deep neck flexors in a functional position.

Position: Sit with feet flat on the floor and hips fully supported by the ground. Set the height of the surface so that the patient’s thighs are tilted slightly downward and the hips are flexed approximately 100o to encourage an anterior tilt of the pelvis and a neutral lumbar spine. place marker On a wall within line of sight directly in front of the patient.

Procedure: Ask the patient to sit in a comfortable position and focus on marking. Patients are then asked to “sit upright the best way they know how.” The patient is then placed in a neutral position under verbal and manual guidance.

Target Movement: Gently roll the pelvis forward so that the patient sits directly on the ischial tuberosities. Instruct the patient to move the chest slightly up and forward to slightly elevate the sternum. Monitor for thoracolumbar hyperextension. lift gently and minimally The occiput positions the head in a neutral position away from any upper cervical extension. See left picture.

Dosage: Practice the entire procedure twice in the clinic.