Features Practice Technique
Therapeutic Exercise For The Cervical Spine

Any traumatic incident can produce a sprain or strain of the cervical spine. The most common incident is the acceleration-deceleration injury after a motor vehicle accident.

Therapeutic exercises are crucial in the rehabilitation of any cervical spine disorder, particularly those of a recurrent or chronic nature. However, exercise programs designed for the treatment of the cervical spine cannot stand alone. Because of the close relationship between the neck, thoracic spine, shoulder girdle and temporomandibular joint, a complete and successful exercise program must also deal with impairments found in these regions.

Any comprehensive therapeutic exercise program for the cervical spine must address various physiological impairments.

This article suggests modalities for impairments of cervical function, mobility (hypermobility, hypomobility), and posture. Appropriate modifications may be necessary for some patients, depending on their signs and symptoms.

Acute Stage
During this stage, treatment is aimed at reducing inflammation and promoting optimal healing. Educating about proper resting position, the proper application of ice, and limiting activity can assist in reaching these goals.
Exercise at this time involves breathing exercises and active range of motion exercises within the pain free range. The supine position is often best tolerated at this stage, because it unloads the weight of the head. Cervical rotation movements performed in a supine position in conjunction with breathing can increase mobility and assist vascular flow.

Subacute stage
During this stage, it is important to continue to protect the injured structures and to introduce stresses that encourage healing. The treatment goal in the subacute phase is to restore flexibility to the cervical muscle groups and facet joints, if they are involved. Joint mobilization treatment is most effective in the subacute phase because muscle guarding has subsided, and stretching and mobilization will be somewhat comfortable, but adhesions between muscle and joint fibers will not have solidified into scars.

The cervical facet joints are very small and delicate. The mechanical forces that the facet joints undergo in an acceleration injury are severe. Grade I and II mobilization techniques are effective in pain relief, and grade III and IV mobilizations can help restore motion of the involved segments.

Mobilization or stretching that causes an increase in swelling will be harmful to the joint, because the presence
of edema contributes to scarring. It is possible that overstretching or mobilization of swollen joints may lead to degenerative joint disease. Loss of mobility may continue to be the primary dysfunction. Mobility exercises may be progressed into larger movements, more specific to the articular restrictions found on mobility testing. It is also reasonable to begin postural re-education at this time.

Here are helpful guidelines in treating the facet joints:

• During the acute phase, the patient should be instructed in active rotation within limits of pain to be done every hour;
• Joint mobilizations in the subacute phase should not be painful or cause lingering discomfort after treatment;
• Hypermobile areas should be identified and mobilization  should be avoided;
• Gross passive stretching of the head and neck should be avoided because of the possibility of overstretching; hypermobile segments. Range of motion should be restored by segmental joint mobilizations.

Chronic stage
During this stage, other impairments can be addressed. There is a close relationship between the neck, thoracic spine, shoulder girdle and temporomandibular joint (TMJ). A complete and successful exercise program must deal with impairments found in these regions. 

The muscles strained at the time of injury often show weakness. A specific strengthening program can be designed to improve muscle function. Depending on the degree of ligamentous or disc injury, there may be hypermobility.

Postural imbalances continue to be a concern, and treatment should include dynamic exercises that encourage movement patterns.
 
The following principles will make treatment of the muscles of the cervical spine more effective:

• Stretch sternocleidomastoid
• Stretch longus colli to increase cervical lordosis
• Strengthen multifidi to increase cervical lordosis
• Strengthen large posterior neck musculature

Although massage is a valuable tool in relieving tension in muscle, it is imperative that the patient be taught how to relax their muscles in order to achieve prolonged good results. This requires a learning process like that for any skill we have learned – riding a bike, tying shoes etc., it is essentially muscle re-education.

To teach relaxation we must develop muscle awareness in the patient. Combined with head, neck and shoulder motion abdominal breathing is helpful to release physical and mental tension in a simple and effective manner.

• Assume a comfortable position lying on your back on the floor
• Place your hands on your stomach just below the ribs
• Relax your shoulders and belly as much as possible
• Breathe in slowly and deeply through the nose
• Allow the belly to rise
• Next, the air should move into the middle portion of the lungs, causing the area of the lower and middle ribs to expand
• Hold the breath for 1 or 2 seconds
• Let the air out of the mouth in a controlled manner