Background:

• Neck pain is the third most commonly reported type of pain
• There is a higher prevalence in women than men
• Chronic neck pain often leads to impaired movement coordination, endurance, and strength

 

Clinical Case and PICO:

• 59 y.o. retired female seamstress with insidious onset of neck pain that has lasted over 5 yrs.
• Current pain level of 4/10 and 8/10 at worst on NPRS| NDI: 30%
• Denies any numbness, tingling, and headaches
• Relief with lying down and NSAIDs
• Family physician advised that general exercise would ↓ pain
• Primary Impairments: ↓neck ROM (flexion, b/l rotation), ↓ endurance (per CCFT)
• Functional Limitations: reading, crossing the street, care-taking grandson

PICO: For individuals with chronic neck pain, is general exercise as effective for reducing pain and improving function as specific exercise targeting deep neck flexors?

 

Figure 1: Deep Cervical Flexors – Longus Capitis and Longus Colli

 

Search Strategy:

• 59 articles identified
• via PubMed, CINAHL, and PEDro
• 9 duplicates removed
• 50 articles screened
• 42 articles not relevant
• 8 full-text articles screened
• 3 articles excluded
• 5 articles included

 

Key Results:

Author, Date, Country	Patient Population	Study Type, Evidence	Outcomes	Key Results
O’Leary, 2011, Australia	N = 60 Pain > 6 mos., score btw. 10/50 – 15/50 on NDI	RCT Level II	Pain (VAS) Disability (NDI)	Specific exercises targeting endurance, strength, coordination, and ROM improved these respective motor performances with minor carry-over in performance in other motor domains. Pain: Meaningful from baseline to 10 wks. for coordination group (↓19.2 mm) Disability: All groups had similar reductions in disability
Ludvigsson, 2015, Sweden	N = 216 Pain > 6 mos., > 10/50 on NDI,  > 20/100mm on VAS, post-WAD.	RCT Level II	Pain (VAS) Disability (NDI)	Neck-specific group resulted in better outcomes in pain and disability than general exercise group. Pain: Significant ↓ over time in all three groups Disability: Significant ↓ from baseline to 6 mos. for neck-specific group. No improvement for general exercise.
Izquierdo, 2015, Spain	N = 28 Pain > 3 mos., < 15/50 on NDI	RCT Level II	Pain (VAS) Disability (NDI)	Both CCF and proprioceptive groups  improved in pain and disability as well as positive outcomes for deep neck flexor neuromuscular control. Pain: Meaningful for current pain from baseline to post 2 mos. (↓3.45mm in CCF and ↓4.00mm in proprioception). Resulted in no current pain. Disability: Significant from baseline to post 2 mos. (↓3.25pts. for CCF and ↓3.28pts. for proprioception)
Borisut 2013, Thailand	N = 100 Pain > 6 mos., > 30/100 mm on VAS	Clinical Trial Level III	Pain (VAS) Disability (NDI)	Pain and disability improved for strength-endurance, CCF, and combined group. Pain: Meaningful from baseline to 12 wks. in combined group (↓44.6mm) Disability: Meaningful from baseline to 12 wks. in strength-endurance (↓13.51pts.), CCF (↓15.55pts.), combo (↓13.52pts.)
Kim, 2016, South Korea	N = 28 Pain > 3 mos., NDI < 15 pts.	Clinical Trial Level III	Pain (NPRS) Disability (NDI)	DCF group had better outcomes in pain and disability than general exercise group. Pain: Meaningful at 8 wks. for DCF (↓3.5pts.) Disability: Significant at 8 wks. for DCF (↓3.8 pts.)

Legend: CCF = craniocervical flexion  | VAS = Visual Analog Scale | CCFT = craniocervical flexion test

DCF = deep cervical flexor  | NDI = Neck Disability Index | NPRS = Numeric Pain Rating Scale

 

Clinical Bottom Line:

Upon review of moderate level evidence comparing general exercise to deep neck flexor exercise in treating chronic neck pain, general exercise is not as effective as deep neck flexor exercise but more specifically, the evidence suggests that any neck-specific exercise can improve pain and disability.

 

Limitations:

• No long-term follow-up past 6 months
• Only studied patients with mild neck pain and disability
• Subjects and therapists were not blinded
• Impairments were not targeted for patient interventions

 

Application:

As with most conditions, it is imperative to identify the key impairments related to the individual and to prescribe exercises that target that impairment.  The specific neck exercise that targets the impairment will address the impairment and also improve pain and disability.

Plan of Care –

Patient Education:

– Ergonomic modifications

– Discuss chronic pain

– Reassurance

Manual Therapy:

– Cervical Traction

– Atlantoaxial Joint Mobilization

Therapeutic Exercise:

– Endurance – CCF

– Mobility – cervical rotation and flexion

Figure 2: Craniocervical Flexion Exercise using objective measurement

 

Acknowledgements:

Bill Egan, PT, DPT, OCS, FAAOMPT & Temple DPT Class of 2017

 

References:

1. O’Leary S, Jull G, Kim M, Uthaikhup S, Vicenzino B. Training mode-dependent changes in motor performance in neck pain. Arch Phys Med Rehabil. 2012;93(7):1225-1233. doi: 10.1016/j.apmr.2012.02.018 [doi].

2. Ludvigsson ML, Peterson G, O’Leary S, Dedering A, Peolsson A. The effect of neck-specific exercise with, or without a behavioral approach, on pain, disability, and self-efficacy in chronic whiplash-associated disorders: A randomized clinical trial. Clin J Pain. 2015;31(4):294-303. doi: 10.1097/AJP.0000000000000123 [doi].

3. Gallego Izquierdo T, Pecos-Martin D, Lluch Girbés E, et al. Comparison of cranio-cervical flexion training versus cervical proprioception training in patients with chronic neck pain: A randomized controlled clinical trial. J REHABIL MED (16501977). 2016;48(1):48-55. http://libproxy.temple.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=112739640&site=ehost-live&scope=site. doi: 10.2340/16501977-2034.

4. Borisut S, Vongsirinavarat M, Vachalathiti R, Sakulsriprasert P. Effects of strength and endurance training of superficial and deep neck muscles on muscle activities and pain levels of females with chronic neck pain. J PHYS THER SCI. 2013;25(9):1157-1162. http://libproxy.temple.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=104154602&site=ehost-live&scope=site. doi: 10.1589/jpts.25.1157.

5. Kim JY, Kwag KI. Clinical effects of deep cervical flexor muscle activation in patients with chronic neck pain. J Phys Ther Sci. 2016;28(1):269-273. doi: 10.1589/jpts.28.269 [doi].

 

Contact Information:

georgechau@gmail.com