Cervical Spine Rehabilitation

Joseph C. Gianoni

Cervical spine pain is a common musculoskeletal impairment that may affect 10% of the general population.¹ Two of the main sources of cervical pain can be broadly broken down into traumatic and nontraumatic sources. One particular contributing factor to cervical spine problems can be from improper posture, particularly poor sitting posture (Fig. 69-1), where loads on the lower cervical spine can increase as much as 300% when the head is in a protruded position.² Today’s increasing reliance on computers and smart phones in the workplace, in schools, and at home tends to promote forward head posture.

The functional unit of the spine is made of two vertebral bodies and the intervertebral disk. The cervical region comprises seven cervical and one thoracic vertebrae along with a fibrocartilaginous disk between the vertebrae (with the exception of C1-2). The spine is surrounded by a full complement of stabilizing ligaments and supportive musculature. The cervical spine must provide protection for the vulnerable spinal cord and support the head yet allow functional mobility. The hydraulic nature of the disk allows for shock absorption. As the disk ages, its ability to distribute compressive forces becomes decreased. Posteriorly, the articular processes and facet joints guide the movement of the cervical spine. The facet joints are synovial articulations like any peripheral joint and as such respond to trauma and overuse and are susceptible to degenerative changes similar to the knee, shoulder, elbow, and such. Therefore, the timehonored strategies that are used with extremity joints apply to the spine as well. There are patients who, based on their level of tissue reactivity, may benefit from unloading (i.e., lying supine or side lying) for a prescribed period of time, just as crutches are utilized in the management of a lower extremity injury, before they are ready to engage in active movement exercises.

The posterior curve or lordosis of the cervical spine increases the ability of the cervical spine to resist compressive forces up to 10 times than that of a straight spine.³ Loss of cervical lordosis therefore decreases the spine’s ability to withstand the compressive force encountered in daily living and can significantly increase intradiskal pressure.

When the cervical spine is subjected to severe traumatic forces such as in motor vehicle accidents, it is not uncommon for the patient to experience complaints of pain, stiffness, and decreased range of motion (ROM). Straightening of the cervical spine may be noted on radiographic studies. The patient may also complain of headaches. These types of injuries are typically referred to as whiplash injuries or cervical sprain/strain. With cervical whiplash, there may be an accompanying injury to one or more of the cervical disks and/or the surrounding cervical musculature. The disks can become herniated and place pressure on the sensitive surrounding nociceptive tissues. The nociceptive receptors are sensitive to mechanical pressure. If this receptor system is stimulated by the application of sufficient mechanical forces to stress, deform, or damage it, then mechanical pain is produced.⁴

THERAPEUTIC EXERCISE

Cervical Retraction

Cervical retraction is an exercise designed to reduce symptoms, restore cervical lordosis, and improve posture. Therefore, it can be used for degenerative disk disease, a herniated disk, or whiplash. The exercise is theorized to reduce pressure on the posterior annulus, thereby decreasing pressure on pain-producing nerves. The cervical retraction exercise is performed with the patient sitting in a firm-back chair for good thoracic support (Fig. 69-2); with the patient lying supine with zero, one, or two pillows for head support; or with the patient standing. The position that produces the greatest symptom reduction is chosen. The exercise is performed in two to three sets of 10 repetitions every 2 to 4 hours. When patients perform this exercise, it is important that they do not flex or extend their neck and maintain a neutral head position. The exercise is done at intervals of 25%, 50%, 75%, or 100% of the patient’s available range. It is critical that the patient experiences a lessening or an abolishment of the most distal symptom from the cervical spine (i.e., if the patient is experiencing symptoms down to the elbow, the symptoms at the elbow should begin to lessen or abolish). The range of retraction that produces maximum distal symptom reduction is utilized. As the distal symptom decreases during the retraction exercise, the patient may also experience a temporary increase in proximal symptoms (i.e., toward cervical region). While this may cause some discomfort proximally, this is an acceptable outcome when performing this exercise.

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