In the absence of acute trauma, a usual strength-building session includes concentric, eccentric and isometric exercises. Popular exercise programs typically include concentric movements as the major muscle contraction and should constitute approximately 70-75 percent of the workout time. Eccentrics should be done for approximately 15-20 percent of the time and isometrics about 10-15 percent of the time. This approximate 70/15/15 ratio stimulates muscle strength and provides enough variety in a workout program to prevent staleness.
Patients can easily be taught to stretch these muscles. Motor vehicle accident patients may need to target the deep neck flexors for motor control / activation; cervical retraction exercises elicit good patient participation and higher muscle activation to accomplish this.1-3
Research: Stand-Alone Value of Exercise Therapy Following MVA
In a 2017 article, Fredin and Lorasdiscuss how neck pain is common and often disabling. They assessed whether combined treatment consisting of manual therapy (MT) and exercise therapy (ET) is more effective than either therapy alone in relieving pain and improving function in adult patients with grade I-II neck pain. In a meta-analysis of 1,169 articles screened, seven studies were included, all of which investigated the addition of ET to MT.
Only very small and nonsignificant between-group differences were found on pain intensity at rest, neck disability, and quality of life at immediate post-treatment, six-month and 12-month follow-up. The quality of evidence was moderate for pain-at-rest outcomes, and moderate too low for neck disability and quality-of-life outcomes.
Based on these findings, Fredin and Loras concluded that combined treatment consisting of MT and ET does not seem to be more effective than ET alone in reducing neck pain intensity at rest or neck disability, or improving quality of life in adult patients with grade I-II neck pain.4
I have also noticed that after an MVA (especially a rear-end collision), the deep neck flexors (DNF) predictively become underactive and the superficial flexors become overactive (e.g., sternocleidomastoid and anterior scalenes). This combination has been correlated with loss of cervical spine ROM, chronic neck pain, acute neck injury and cervicogenic headache.5-10
Assessment Tests / Exercises Following Motor Vehicle Trauma
As part of my overall examination and as soon as the patient is capable of performing a series of isometric stability tests without pain, I test them. The isometric stability tests are called the Bunkie tests and include planks, side planks and bridge isometric holds with the feet elevated approximately 12 inches.
These tests can also develop strength needed to stabilize the entire body during exercise. Remember, we can take any exercise and duplicate the positions in which you hold your body and turn it into an isometric, but this series of exercises has become a mainstay in my practice.
For more detailed evaluation of the deep neck flexors, we can use two tests: Janda's supine neck flexion test (the name really says it all) and the deep cervical flexor endurance test (a provocative test).
Supine Neck Flexion Test
- Patient position: Supine, knees bent.
- Instruction: Ask patient to raise head off the table as if to look at their toes.
- Pass: The patient's chin should tuck first, then the head should smoothly roll off the table while the neck is flexing.
- Fail: If the SCM and suboccipitals are dominating and the DNFs are inhibited, the chin will poke out at the beginning of the movement and will remain protruded throughout.
- The visible dysfunctional point is usually found upon initiation of movement into neck flexion or below the halfway up to the chin-to-chest position (with the patient in the supine position).
Deep Cervical Flexor Endurance Test
- Patient position: Supine.
- Instruction: Passively preposition the head in the neutral position with the chin slightly tucked. Tell the patient you are going to let go of their head and that they should continue to hold it in this exact position.
- Let go of the head suddenly and observe to see if the chin pokes, or if the patient flexes the entire neck, or if there is excessive shaking. Any of these constitutes a positive test.
- This test helps determine optimal function of the deep cervical flexors. The test demonstrates the ability to maintain unsupported cervical retraction without protraction or pain for a minimum of 30 seconds.2
In both tests, we are looking for the benchmark (pass) motion or the ability to hold versus dysfunction (compensation / fail). Generally, the compensation is flexion of the lower cervical spine and atlanto-occipital extension; a combination of motions commonly referred to as protraction of the cervical spine (forward head). This is often caused by synergistic dominance of the sternocleidomastoid, scalenes, levator scapulae and cervical extensors (superficial neck flexors), and poor motor control or strength of the deep cervical flexors.
A Great Exercise to Develop the Deep Stabilizing Neck Muscles
To develop the deep stabilizing muscles in the neck, instruct the patient to hold a band or a stretch strap around the occiput (they will need a band with three loops), with the ends of the loops in each hand. Instruct the patient to extend their arms away from the head at approximately eye level. Take the head into retraction against the band, take two deep breaths in and out. Release the hand and repeat, building up the isometric hold time for 10 seconds per rep. I like a total of 2-3 minutes of time-under-tension (TUT) twice a day.
I never ask the patient to casually hold the band in the hands. I want them to grip the band. I also teach my patient to grip the ground with the feet and be intentional in stiffening the whole body. When you grip, you create a chain reaction from the hand to the arm, shoulder and core!
This isn't magic, but what is known as the Law of Irradiation. We use tension to build a chain reaction throughout the body. Similar to the glutes being turned off by spraining your ankle, we use the short foot gripping to activate the glutes. Hand gripping influences your rotator cuff and beyond.
Editor's Note: In part 2 of this article, Dr. Tucker will outline how you can teach your patient to perform one cervical exercise per visit and build a progression over 12 visits.
References
- Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing and Function With Posture and Pain, 5th Edition. Lippincott Williams & Wilkins, 2005.
- Page P, et al. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Benchmark Physical Therapy, Inc., 2010.
- Sahrmann S, and associates. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine. Mosby, Inc., 2011.
- Fredin K, Loras H. Manual therapy, exercise therapy or combined treatment in the management of adult neck pain - a systematic review and meta-analysis. Musculoskel Sci Pract, 2017 Oct;31:62-71.
- Peolsson AL, Peolsson MN, Jull GA. Cervical muscle activity during loaded arm lifts in patients 10 years post surgery for cervical disc disease. JMPT, 2013;36(5):292-299.
- Falla D, Jull G, Hodges PW. Feedforward activity of the cervical flexor muscles during voluntary arm movements is delayed in chronic neck pain. Experimental Brain Res, 2004;157(1):43-48.
- Jull JA. Deep cervical flexor muscle dysfunction in whiplash. J Musculoskel Pain, 2000;8(1-2):143-154.
- Jull G, Barrett C, Magee R, Hodges P. Further clinical clarification of the muscle dysfunction in cervical headache. Cephalalgia, 1999;19(3):179-185.
- Jull G, Kristjansson E, Dall'Alba P. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Manual Ther, 2004;9(2):89-94.
- Falla D, O'Leary S, Farina D, Jull G. Association between intensity of pain and impairment in onset and activation of the deep cervical flexors in patients with persistent neck pain. Clinical J Pain, 2011;27(4):309-314.
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