There are three phases of specific rehabilitation that can be viewed as a continuum for prescribing exercises(1)
Phase 1: Focus on low-load precision to activate deep cervical and axioscapular muscles.
Phase 2: Coordination of muscles during postural movements and functional tasks.
Phase 3: Strength and endurance.
PHASE 1: PRECISION & LOW LOAD EXERCISES
In this first stage the focus is on training deep cervical neck flexor control in supine, scapula setting in sitting and 4PK and deep neck extensor and suboccipital muscle activity in 4PK. The aim with each exercise is to achieve the correct pattern of movement without substitution from other muscle synergies and the starting positions are going to be the same as the assessment positions for each of the muscle groups.
Cervical flexion exercises (4 weeks):
Longus colli and longus capitus activation is trained in supine in the same position as the CCFT (1).
Deep Cervical Neck Flexors (DCNF) need be correctly activated to perform Cranio-Cervical Flexion (CCF) in the correct manner.
It is an activation movement and therefore should be performed slowly.
It is better not to use the stabilizer in this phase of training but to use other external feedback cues.
The aim is to perform the correct exercise 2-3 times a day and building up to 10 x 10 second holds.
One important note about phase 1 exercises for both the flexor and extensor group is that they can be commenced very early in rehabilitation and are often performed in a pain-free manner (2)
PHASE 2: RETRAINING COORDINATION AND POSTURE
The role of endurance training.
Falla discuss how research has demonstrated greater fatigability in SCM and AS between 25-50% maximal voluntary contraction in patients with neck pain. This suggests that addressing fatigability during rehabilitation is an important focus (3). We have to progress our rehabilitation to incorporate strengthening of the global muscles as they work synergistically with the local stabilisers. This is an important component of treatment progression.
Cervical flexion endurance capacity is trained with a head lifting task but the emphasis is placed on maintaining craniocervical flexion (4).
PHASE 3: HIGH LOAD & FUNCTIONAL TRAINING
Their exercises consisted of postural correction with CCF into the resistance of a blue theraband. The exercise was performed twice a day for about 10 minute sessions over the course of 6 weeks and then twice a week for 6 months (5).
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1. Jull G, Sterling M, Falla D, Treleaven J, O´Leary S. Whiplash, headache, and neck pain: research-based directions for physical therapies. 1st Editio. Elsevier Health Sciences; 2008. 208 p.
2. O’Leary S, Falla D, Jull G. The relationship between superficial muscle activity during the cranio-cervical flexion test and clinical features in patients with chronic neck pain. Man Ther. 2011 Oct;16(5):452–5.
3. Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. Man Ther. 2004 Aug;9(3):125–33.
4. Selvaratnam P, Niere K, Zuluaga M, Oddy P. Headache, Orofacial Pain and Bruxism. 1st editio. Elsevier Health Sciences; 2009. 400 p.
5. van Ettekoven H, Lucas C. Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial. Cephalalgia. 2006 Aug;26(8):983–91.
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