l nnua 5 h a 2 dynamic stability t of the -...

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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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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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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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Wall Exercises

Watch for Compensations

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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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Marjorie A. King, PhD, ATC, PTDirector of Graduate Athletic Training Education

Plymouth State [email protected]

l nnua 5 h a 2 dynamic stability t of the -...

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