Chronic Injury Rehab Exercise Management

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Chronic Injury RehabExercise Management

• Alistair Wilson
• BSPE, BSc.P.T, CAT(C)

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Chronic Neck Pain

• Definitions vary within the literature.
• Generally defined as persistent neck pain which
  lasts greater than three(3) to six (6) months.
• Long standing intermittent neck pain following
  injury to the neck, lasting greater than twelve
  (12) weeks.

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Incidence of Chronic Neck Pain

• Incidence of chronic neck pain in the general
  population ranges from 16-48
• Incidence of chronic neck pain increases with age
  to as high as 1 in 3 persons 60 years of age and
  older. (Gureje 2007)
• Up to 18 of reported chronic neck pain cases
  are reported as continuous and lasting greater
  than six (6) months. (Guez 2003)

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Neck Pain in Sport

• Contact Sports
• Auto Sports
• Equestrian
• Multi Sport
• Cycling
• Others

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Sources of Chronic Neck Pain

• Facet Dysfunction
• Discogenic
• Myofascial
• Instability
• Postural Dysfunction

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What do we look for?
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Impairment of Muscle PerformanceThe Spinal
Stability System (Panjabi 1992)

• PASSIVE
• Musculoskeletal osteoligamentous column
• ACTIVE
• Musculoskeletal muscle tendon unit
• CONTROL
• Neural feedback system
• The Active and Control systems may be enhanced
  with exercise programming

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Impairment of Mobility

• Articular
• -Restriction of joint mobility
• Myofascial
• -Restriction of extensibility
• Neuromeningeal
• -Restriction of neural mobility
• Mobility restrictions may be improved with
  mobilization/manipulation and stretching

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Impairment of posture

• Evaluation of postural impairments should include
  evaluation of
• Cervical spine
• Thoracic spine
• Shoulder Girdle
• Pelvis
• Postural impairments may be corrected through the
  use of postural correction exercises and
  restoration of muscle imbalances

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The Active and Control systems may be enhanced
with exercise programming

• Deep segmental muscles (inner unit)
• local stabilizers, tend to become weak
• Middle layer global stabilizers
• tend to become overactive
• Superficial layer global mobilizers (outer unit)
• tend to tighten, become overactive and inhibit
  deeper muscle groups
• 
  (CKennedy 2003)

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What is the evidence?

• A Cochrane review of manipulation and
  mobilization for mechanical neck disorders.
  (Spine 2005)
• There was strong evidence of benefit favoring
  multimodal care (mobilization and/or manipulation
  plus exercise) over a waiting list control for
  pain reduction, improvement in function and
  global perceived effect for subacute/chronic
  mechanical neck disorders with or without
  headache.
• Done alone, manipulation and/or mobilization
  were not beneficial when compared to one
  another, neither was superior.

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What works best?

• A randomized clinical trial of exercise and
  spinal manipulation for patients with chronic
  neck pain. (Bronfort G, 2001)
• Except for patient satisfaction, where
  spinal manipulative therapy and exercise were
  superior, the group differences in patient-rated
  outcomes after 11 weeks of treatment were not
  statistically significant. However, the spinal
  manipulative therapy and exercise group showed
  greater gains in all measures of strength,
  endurance, and range of motion than the spinal
  manipulation and exercise groups alone.

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Long term effectiveness

• Physical exercises and functional rehabilitation
  for the management of chronic neck pain. (Ylinen.
  2007)
• Findings revealed moderate evidence supporting
  the effectiveness of both long-term dynamic as
  well as isometric resistance exercises of the
  neck and shoulder musculature for chronic or
  frequent neck disorders. Findings revealed no
  evidence supporting the long-term effectiveness
  of postural and proprioceptive exercises or other
  very low intensity exercises.

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It works!

• A randomized controlled trial on the efficacy of
  exercise for patients with chronic neck pain.
• Chiu TT, Lam TH, Hedley AJ. 2005
• At week 6, patients with chronic neck pain can
  benefit from the neck exercise program with
  significant improvement in disability (?28.8),
  pain (? 34.9), and isometric neck muscle
  strength (? 26.1 - 45.7) in different
  directions. However, the effect of exercise was
  less favorable at 6 months.

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Continued improvement

• Cervical resistance training effects on
  isometric and dynamic strength. (Taylor M et al,
  2006)
• This study was designed to investigate the
  effects of 12 wks of cervical strength training
  on isometric strength, dynamic strength, and
  hypertrophy in a sample of military men. Results
  indicated significant improvements in isometric
  strength and dynamic strength, typically
  occurring as early as 4 wks and improving
  throughout the 12-wk period. Modest increases in
  neck circumference were also noted.

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How long?

• Neck muscle training in the treatment of chronic
  neck pain a three-year follow-up study. (Ylinen
  2007)
• At the 3-year follow-up, neck pain and
  disability indices showed no statistically
  discernible change compared to the situation at
  the 12-month follow-up. The improvements achieved
  through long-term training were maintained at the
  3-year follow-up.

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Who is likely to respond?

• Predicting Short-Term Response and Non-Response
  to Neck Strengthening Exercise for Chronic Neck
  Pain (Keating et al, 2005)
• Changes in NDI scores of 14 points or greater
  were considered to be significant.
• Initial NDI scores gt30 were more likely to
  respond to a strengthening program. (69)
• Lifting and Reading scores gt1 were more likely to
  respond. (66)
• Greater negative predictive value (those who
  would not respond)

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Inner Unit Strengthening

• Goal to isolate the DNF DNE.
• Improve control of a neutral spine posture with
  emphasis on co-contraction.
• Progress
• recruitment
• strength
• endurance
• direction
• Avoid pain, substitution and fatigue.

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Outer Unit Strengthening

• Maintaining neutral spine posture while
  activating scapular stabilizers, thoracic
  extensors and imposing upper extremity movement.
• Add active neck motion sequences while
  maintaining deep segmental muscle control.
• Incorporate a global conditioning program and
  functional activities.

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Exercise Prescription

• Inner Unit
• CKennedy2003

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Inner Unit Isometric

• Progress from 5 to 10 second holds.
• Progress from 5 to 10 repetitions once daily.
• Allow for adequate rest between contractions (2-3
  min.) and sessions 2-3 per week.

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Inner Unit Isotonic

• Progress from 5 repetitions per set to 10
  repetitions per set.
• Progress from 1 set to 2-3 sets per session.
• Progress up to 2 sessions per day.

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Outer Unit IsotonicGeneral Strengthening
Principles

• Select mode
• Load intensity
• Repetition intensity
• Set intensity
• Rest interval
• Frequency

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Strength Protocol

• Little research to date on specific
  strengthening protocols.
• Predicting Short-Term Response and Non-Response
  to Neck Strengthening Exercise for Chronic Neck
  Pain (Keating et al, 2005)
• Used a protocol for MedX equipment. Protocol
  has come to be known as the Melbourne Protocol.

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Melbourne Protocol

• 6-8 exercises
• 3 sets of 10 repetitions
• 2-3 sessions per week
• Flexion
• Extension
• LSF/RSF
• Flex _at_ 25/45 degrees
• Ext _at_ 25/45 degrees

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Melbourne Protocol Progression

• Based upon RPE following first three reps of each
  exercise. Nine point visual analog scale
• 1-3 increase 1 lb.
• 4-6 increase ½ lb.
• 7-8 no change in weight
• 9 reduce ½ lb

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Strength vs. Endurance

• Isometric cervical extension strength of
  recreational and experienced cyclists. (Jacobs,
  1995)
• Found no significant difference between extensor
  muscle strength of recreational vs. experienced
  cyclists.
• Conclude cyclists neck pain due to fatigue due
  non adaptation to activity requirements.

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Conclusions.

• Evaluate the whole system
• Identify impairments
• Multimodal treatment
• Progress inner to outer unit

• Inner unit exercise must be specific
• Progress exercise specific to sport specific
• Consider exercise duration
• More research is needed