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05 Dynamic Stability of the
Cervical Spine
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05
Anatomical Considerations
Bony configuration (biomechanics)Bony configuration (biomechanics)Muscles (neuromuscular)Muscles (neuromuscular)
Accompanying structures (kinetic chain) Accompanying structures (kinetic chain)
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05 Cervical Vertebrae
C1
C2
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05 Spinal Vertebrae
Lumbar Spine
Thoracic Spine
Cervical Spine
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05Neurological Considerations
Extensive WiringExtensive Mechanoreceptor and
proprioceptive networkingMultiple sources for PAIN
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05 Neurological Connections
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05
Musculature
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05Anterior Cervical Spine
Deep Cervical Flexors = Vertebral Flexors (local)vs.
Cervical Spine Flexors (global)
Longus Colli
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05Anterior Cervical Spine
Deep Cervical Flexor MusclesLongus Colli & Capitis (intervertebral) Superficial Flexor Muscles
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05Posterior Spine
U. Trapezius & Levator Scauplae “tether”
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05Kinetic Chain Implications
Interfacing with: Rib CageScapula
GHJ Function
Anterior LoadingOf
C-Spine withShoulder Girdle
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05Shoulder Girdle Dyskinesis
Scapulo-humeral RhythmRib CageGHJ Function
Link to:Upper ExtremitiesThe Lumbar Spine
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05 Force Closure
Spinal StabilityCore StabilityLower Extremity Influences
Vleeming, et al. Spine20 (7), 1995
Janda’s Pelvic Crossed Syndrome
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05
Spinal Stability
Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders, 5(4), 383-389
Panjabi, M. M. (1992). The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders, 5(4), 390-397
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05Spine Stabilization
Neural SubNeural Sub--SystemSystemControls active & passive subControls active & passive sub--systemssystems
Feedback mechanismsFeedback mechanisms““Force transducersForce transducers”” in ligaments, muscles, in ligaments, muscles, tendons & neural control centerstendons & neural control centers
Compensates to maintain stability Compensates to maintain stability ……..of the ..of the systemsystem
May compromise locally for global stabilityMay compromise locally for global stabilityResultant tissue and joint degeneration, Resultant tissue and joint degeneration, abnormal muscle loads, fatigue, etc.abnormal muscle loads, fatigue, etc.
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05 Spine Stabilization - cont
Passive SubPassive Sub--SystemSystemVertebraeVertebraeFacet articulationsFacet articulationsIntervertebralIntervertebral discsdiscsSpinal ligamentsSpinal ligamentsJoint capsulesJoint capsulesPassive mechanical Passive mechanical properties of the properties of the musclesmuscles
Active SubActive Sub--SystemSystemMuscles & tendonsMuscles & tendonsSurrounding spinal Surrounding spinal columncolumn
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05 Neutral Spine
““the posture of the spine in which thethe posture of the spine in which theoverall internal stresses in the spinal overall internal stresses in the spinal column andcolumn andthe muscular effort to hold the posture arethe muscular effort to hold the posture areminimalminimal””
What does that look like clinically??What does that look like clinically??
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05 Functional Zones
Neutral ZoneNeutral ZoneMinimal internal resistanceMinimal internal resistance
Elastic ZoneElastic ZoneEnd of the neutral zone up to the End of the neutral zone up to the physiological limitphysiological limit
Note: repeated physiological loadingNote: repeated physiological loadingResidual displacement of tissueResidual displacement of tissue
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05Clinical Implications
Displacement beyond the neutral zone due to Displacement beyond the neutral zone due to compensation would result in damage, compensation would result in damage, degeneration, abnormal muscle loads and muscle degeneration, abnormal muscle loads and muscle fatigue fatigue Spinal ROM that is typically measured clinically, Spinal ROM that is typically measured clinically, encompasses the available displacement from both encompasses the available displacement from both the neural & elastic zonesthe neural & elastic zonesThe current The current clinicalclinical model is insensitive to onmodel is insensitive to on--going physiological adaptation & damage and that going physiological adaptation & damage and that when changes in spinal ROM are seen clinically, when changes in spinal ROM are seen clinically, irreparable damage may already be done, irreparable damage may already be done, precluding prevention intervention strategiesprecluding prevention intervention strategies
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05Putting It All Together:
The Game PlanLocal Intervention: Cervical Spine Local Intervention: Cervical Spine
Deep cervical flexor activationDeep cervical flexor activationSuboccipitalSuboccipital mobilitymobility
Global InterventionGlobal InterventionPosturePostureThoracic SpineThoracic SpineShoulder GirdleShoulder Girdle
Scapula stabilizationScapula stabilizationCore StabilityCore Stability
LocalLocalGlobalGlobalForm & Force closureForm & Force closure
Secondary considerations of the Lower ExtremitySecondary considerations of the Lower ExtremityPelvic InclinationPelvic InclinationFoot MechanicsFoot Mechanics
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05 Muscle Impairment
Diminished Deep Cervical Flexor ActivityDiminished Deep Cervical Flexor ActivityDelayed onset of neck muscle contraction with Delayed onset of neck muscle contraction with associated movement of the upper limbassociated movement of the upper limbIncreased superficial cervical flexor muscles Increased superficial cervical flexor muscles during functional activitiesduring functional activitiesIncreased fatigability of cervical flexors in neck Increased fatigability of cervical flexors in neck pain patientspain patients
Falla, D. ,Manual Therapy, 9:125-133, 2004Falla, et al, Clinical Neurophysiology 114:488 – 495, 2003
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05Feedforward Activation with Upper Extremity Movement
SCM & Cervical ExtensorSCM & Cervical ExtensorCoCo--contractioncontractionWithin 50 ms of Within 50 ms of Deltoid OnsetDeltoid OnsetAutomatic Automatic feedforwardfeedforwardresponse delayed in response delayed in chronic neck pain chronic neck pain subjectssubjects
TransversusTransversus AbdominisAbdominisFeedforwardFeedforward activation activation with all GHJ motionswith all GHJ motions
Hodges and Richardson, Hodges and Richardson, Exp Brain Exp Brain ResRes, 114:362, 114:362--370, 1997370, 1997
Falla, et alJ. Of Electromyography & Kinesiology
14: 463-474, 2004
Falla, et al, Exp Brain Res, 157:43-48, 2004
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05 Cervical Spine Intervention
Joint Mobilization as Joint Mobilization as NeededNeededDeep Flexor Deep Flexor ActivationActivation
LongusLongus ColliColliLongusLongus CapitisCapitis
(EMG) Falla, D. et al, Physical Therapy, 8 (10) 2003.
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05
Clinical Application and Intervention
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05 Deep Cervical Flexors
Upright Head Nod
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05 Deep Cervical Flexors
Palpate for SCMto AVOID recruitment
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05Deep Cervical Flexors:
supine to startHead Weighs ~ 10 lbs.
Initiate Deep Cervical Flexor Work in SupineMotor Learning: New Task
Motor Control: Automaticity
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05 Deep Cervical Flexors
Support as Needed Palpate for SCM
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05 Functional Cervical Flexion
C - Spine Thoracic Spine
Limited mobilityLimited mobility
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05 Sub-Occipital Mobility
2 - tennis balls in a sock 2 - potatoes in a sock
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05Postural Intervention and Education
Belly button to spineSqueeze cheeks togetherEqual weight both feet
Feet straight ahead
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05 Postural Intervention and Education
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05 Thoracic Spine: Joint Mobilization
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05Thoracic Spine: Functional
Mobilization
Kneeling Thoracic Rotation
Lumbar flexion
Thoracic rotation
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05 Shoulder Girdle InterventionGHJ MobilityGHJ Mobility
WallWallFoam rollersFoam rollers
Scapula StabilityScapula StabilityWallWallProneProne
GHJ ExtensionGHJ ExtensionQuadrupedQuadruped
TTIIYY
Modified QuadrupedModified QuadrupedPlankingPlankingScapula RetractionScapula Retraction
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05Glenohumeral Joint Mobility:
Foam RollerGHJ Flexion and Extension
GHJ: Abduction/Adduction
Lengthening of anterior thorax musculaturePectoralis major and minor stretch
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05Glenohumeral Joint Mobility:
Wall Exercises
Watch for Compensations
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05Glenohumeral Joint Mobility:
Wall Exercises
Incorporate Vision
Watch for Compensations
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05Scapula Stability:
Prone GHJ ExtensionBelly Button to SpineStiff Thoracic Spine
Watch for C-Spine
Compensation
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05 Scapula Stability: Prone
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05Scapula Stability: Quadruped
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05Scapula Stability: Quadruped
D2 PNF Pattern
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05Modified Quadruped
Planking
Co-contractiontricepsbiceps
Scapula StabilizersSpine Stabilizers
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05 Modified Quadruped
Serratus AnteriorPush Up Plus
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05Scapula Stability:
Wall Exercises
Combines GHJ ROM/S-H Rhythm Add Resistance/Long Lever Arm
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05 Accompanying Structures
The CoreThe CoreCore StabilityCore Stability
The PelvisThe PelvisPelvic InclinationPelvic InclinationPelvoPelvo--femoral femoral considerationsconsiderations
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05Core Stability
LocalLocalTransverse mm Transverse mm fiber orientationfiber orientation
TrTr AbAb**MultifidusMultifidusLower IOLower IOPiriformisPiriformisPelvic floor mms Pelvic floor mms
GlobalGlobalVertical mm fiber Vertical mm fiber orientationorientation
EO EO Erector Erector SpinaeSpinaeRARA
Form and Force Closure
Diaphragm
Other Considerations:
* * FeedforwardFeedforward activation with all GHJ motionsactivation with all GHJ motionsHodges and Richardson, Exp Brain Hodges and Richardson, Exp Brain ResRes, 114:362, 114:362--370, 1997370, 1997
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05Core Stability
Foam Roller:Postural Alignment
Transverse AbdominisExternal Oblique
Pelvic Floor Muscles:Kegel Exercises
Diaphramatic Breathing
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05Force Closure: Bird Dog
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05 Force Closure: BW Walking
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05 Pelvic Inclination: Neutral PelvisActivation of lumbar Activation of lumbar multifidusmultifidus
Small and gentle Small and gentle lumbar curvelumbar curve
Activation of Activation of errectorerrectorspinaespinae
Long and accentuated Long and accentuated lumbar curvelumbar curveResultant thoracic and Resultant thoracic and cervical adaptationscervical adaptations Foot
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05Summary
Local Intervention: Cervical Spine Local Intervention: Cervical Spine Deep cervical flexor activationDeep cervical flexor activationOO--A mobilityA mobility
Global InterventionGlobal InterventionPosturePostureThoracic SpineThoracic SpineShoulder GirdleShoulder Girdle
Scapula stabilizationScapula stabilizationCore StabilityCore Stability
LocalLocalGlobalGlobalForm & Force closureForm & Force closure
Secondary considerations of the Lower ExtremitySecondary considerations of the Lower ExtremityPelvic InclinationPelvic InclinationFoot MechanicsFoot Mechanics
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05 Clinical ReferencesTherapeutic Intervention
Beazell & MagrumClinics in Sports Medicine, 22: 523-557, 2003
Case Study (HA’s)McDonnell, MK, et alJ Ortho Spts Phy Ther, 35: 3-15, 2005
Therapeutic InterventionKennedy, CN (chapter 24)Therapeutic Exercises : Moving Towards Function (2nd Ed), Carrie Hall & Lori T. BrodyLippincott Williams & Wilkins 2005
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05
Marjorie A. King, PhD, ATC, PTDirector of Graduate Athletic Training Education
Plymouth State [email protected]