Rehabilitation of the Cervical Spine

Introduction

Your doctor may have you see a physical therapist who will design a neck-care program just for you. Your physical therapist will evaluate your condition to determine the best way to help ease your pain and help your neck move better. You will also be given ways to take care of your neck so you can avoid pain and prevent further injury to your neck.

Your First visit to Physical Therapy

On your first visit, your physical therapist will want to gather some more information about the history of your neck problem. You may be given a questionnaire that helps you tell about the day to day problems you are having with your neck. The information you give will help measure the success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This will help your physical therapist gauge how much pain you have now and how your pain changes once you've had treatment. Your physical therapist will probably ask some more questions about your neck problem to begin zeroing in on the source of your pain and to know what will be needed to help relieve it. Here are some questions your therapist may ask you:

How long have you had neck pain?
Where do you feel the pain?
What makes the pain better or worse?
How does your pain affect your daily activities?
Do you have headaches?
Do you have pain in your shoulder, arm, or hand?
Do you have any numbness or tingling?

Physical Therapy Evaluation

Once all this information has been gathered, your neck condition will be evaluated.

Posture/observation: Your physical therapist will begin by checking your posture to see if your soreness is coming from changes in posture. Imbalances in the position of your spine can put pressure on sore joints, nerves, and muscles. Postures used for a long time at school, with hobbies, or when working can change the balance of muscle strength and flexibility. Muscles that have been stretched over time tend to be weaker, while muscles that are put in shortened positions can begin to overpower the weaker ones. This can put added strain on areas around the neck that can cause a problem or make a sore area worse. Helping you improve your posture can oftentimes make a big difference in easing pain.

Range of motion (ROM): Next, your physical therapist will check the ROM in your neck. This is a measurement of how far you can move your neck in different directions. Neck movements include bending the neck forward and backward (flexion and extension), bending to either side (side bending), and turning the neck to one side and the other (rotation). Measurements may also be taken of upper back and/or shoulder movements. Your ROM is written down to compare how much improvement you are making with the treatments.

Neurological screen: Your physical therapist may need to do some tests to check the nerves of your neck. This part of the evaluation looks at your reflexes, sensation, and strength in your neck, shoulders, and arms. The results of these tests can help your physical therapist know which area of the neck may be causing problems for you and can guide the type of treatment to help your condition.

Manual examination: You may be given a manual examination of the muscles and joints of the neck. Your physical therapist will carefully move your neck in different positions to make sure that the joints are moving smoothly at each level of the neck. This will help guide treatment to the joint that is tight (called a hypomobility) or where a joint may have been injured and is moving too much (called a hypermobility). Some of the movements you'll feel are where your physical therapist is looking at the flexibility of the muscles around your neck. This type of examination can help guide your therapist to know where your soreness is coming from and which type of treatment will help you the most.

Special tests: Other special tests may be done if your physical therapist thinks your neck pain is coming from other areas or causes. Other areas that may need to be looked at include:

* Thoracic outlet: This is where a group of nerves and vessels make their way out of the chest cavity and travel down the arm. Problems in this area can cause numbness, pain, or even coldness in the arm and hands.

* Temporomandibular joint (jaw): Problems here can cause headaches, pain in your upper neck, and even spasm in muscles of the neck.

* Thoracic spine: Problems beginning in the upper back can include joints and muscles of the thorax or even in the alignment of one or more ribs, which can cause pain to radiate toward the neck and shoulder.

* Nerve tension: Nerves of the mid and lower neck travel down the arm to service the arm and hand. Irritation or scarring around the covering of these nerves can cause pain that radiates from the neck to the upper back or even into the arm. By locating scarred or irritated areas along the nerve, a treatment called "neural mobilization" can be used to free up movement in the nerve and to ease the soreness you feel.

* Ergonomics: Ergonomics is a way to look at where and how you do your work or hobby activities. Your physical therapist may want to understand your ergonomics to figure out if the way you do your activities is making your condition worse. Sometimes even simple corrections of your hobby or work station can make a big difference in easing neck sypmtoms.

Palpation: The evaluation usually ends with palpation. Palpation is when your physical therapist feels the soft tissues around the neck. This is done to check the skin for changes in temperature or texture, which could tell if you have inflammation or nerve irritation. Palpation is also done to find whether there are tender points or spasm in the muscles around the neck and upper back. This too can give your therapist a good idea about which treatments will help you the most.

Treatment plan: Once the examination is done, your therapist will put together a treatment plan. The treatment plan lists the types of treatments that will be used for your condition. It gives an indication of how many visits you will need and how long you may need therapy. It also includes the goals that you and your therapist think will be the most helpful for getting your activities done safely and with the least amount of soreness. Finally, it will include a prognosis, which is how your therapist feels the treatment will help you improve.

 

Physical Therapy Treatment

Controlling your pain and symptoms

Easing pain: Your therapist may choose from one or more of the following tools, or modalities, to help control the symptoms you are having:

Rest: Resting the painful joints and muscles helps calm soreness, giving your neck time to heal. If you are having pain with an activity or movement, it should be a signal that there is still irritation going on. You should try to avoid all movements and activities that increase your pain. In the early stages of your problem, your doctor or therapist may want you to use a soft or hard neck collar to limit neck movement nearly completely.

Specific Rest: Specific rest encourages safe movement of the joints and muscles on either side of a painful area, while protecting the sore spot during the initial healing phase. Select exercises can be given to encourage safe movement of the shoulders and upper back. If you've been prescribed a collar, you will likely be instructed to take it off a few times a day so you can do some gentle and controlled exercises.

Positioning: The results of the evaluation will give your therapist a clear picture of ways you can position your neck for the greatest comfort. A special pillow, called a contour pillow, may be suggested to help get your neck in the most comfortable position while sleeping or resting. A commercial neck roll, or even a rolled towel, can be slid inside your pillow case so that when you lie back, the roll fills in and supports the curve in your neck. Other special ways to rest your head and neck may be given by your therapist to help take away arm pain that is coming from your neck.

Ice: Ice makes the blood vessels in the sore area become more narrow, called vasoconstriction. This helps control inflammation that is causing pain. Some ways to put ice on include cold packs, ice bags, or ice massage. Cold packs or ice bags are generally put on the sore area for 10 to 15 minutes. Ice massage is done by rubbing an ice cube or ice cup on a sore spot or tender point. It's as easy as freezing a small paper cup full of water. Once the water freezes, simply tear off the top inch of the cup and rub the exposed ice on the sore spot for three to five minutes, or until it feels numb.

Heat: Heat makes blood vessels get larger, called vasodilation. This action helps to flush away chemicals that are making your neck hurt. It also helps to bring in nutrients and oxygen which help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm shower or bath is more beneficial than creams that merely give the feeling of heat. Hot packs are usually placed on the sore area for 15 to 20 minutes. Special care must be taken to make sure your skin doesn't overheat and burn. It's also not a good idea to sleep with an electric hot pad at night.

Ultrasound: An ultrasound machine produces high frequency sound waves that are directed toward the sore area. Passing through the body's tissues, these waves vibrate molecules. This causes friction and warmth as the sound passes through the tissue. The rest of the sound changes to heat in the deeper tissues of the body. This heating effect helps flush the sore area and brings in a new supply of nutrient and oxygen-rich blood. Ultrasound treatments are a way for your therapist to reach tissues that are over two inches below the surface of your skin.

Phoresis: This means to "carry or transmit." There are two methods that therapists can use to transmit substances across the skin. Phonophoresis uses the high frequency sound waves of ultrasound to "push" a steroid medication (cortisone) through the skin. Iontophoresis uses a small machine that produces a mild electrical charge, which is used to carry medicine, usually a steriod, through the skin. The steroid is a very strong antiinflammatory medication that actually stops the pain-causing chemical reaction within the cells of the sore tissue in your body. Either type of phoresis may be used in place of a cortisone injection.

Electrical Stimulation: This treatmemt stimulates nerves by sending an electrical current gently through your skin. Some people say it feels like sort of like a massage on their skin. Electrical stimulation can ease pain by sending impulses that are felt instead of pain. Two respected scientists discovered a theory, called the Gait Theory. This theory says that when you feel a sensation other than pain, like rubbing, massage, or even a mild electrical impulse, your spinal column will actually "close the gate" and not let pain impulses pass to the brain. In the case of electrical stimulation, the electrical impulses speed their way across the skin and on to the central nervous system much faster than pain. By getting there first, the electrical information "closes the gate" to pain, blocking its passage to the brain. Once the pain eases, muscles that are in spasm begin to relax, letting you move and exercise with less discomfort. Other settings on the machine can be used to help your body release endorphins. These are natural chemicals formed within your body that behave like a strong drug in reducing the perception of pain for up to eight hours at a time.

Soft tissue mobilization/massage: Physical therapists are trained in many different forms of massage and mobilization when treating the neck. Massage has been shown to calm pain and spasm by helping muscles relax, by bringing in a fresh supply of oxygen and nutrient-rich blood, and by flushing the area of chemical irritants that come from inflammation. Soft tissue treatments can help tight muscles relax, getting them back to a normal length. This will help you begin to move with less pain and greater ease. Physical therapists have special training in a variety of different ways to mobilize or massage. These can include gentle strokes, called effleurage. Myofascial release techniques help restore better movement by getting the thick layer of fascia below the skin and around muscles to "give". Strain-counter-strain is a type of therapy that is especially helpful when tender points are causing muscles to restrict movement. The treatment is usually done in a way that the muscle is put in a special position, usually where the muscle is shortest. The position is held long enough to "reset" the nerve input to the muscle. Another way to help soft tissues "move" is by the use of muscle energy technique. Your therapist will place your muscle in a certain position and then direct you to use your muscles against the therapist's force. As you relax, your therapist will gradually "take up the slack", giving a stretch on the muscle.

Joint mobilization: These are graded pressures and movements that are done by skilled physical therapists. Gentle graded pressures help lubricate joint surfaces, easing stiffness and helping you begin moving with less pain. Pain that is left unchecked can quickly escalate to an uncomfortable "cycle of pain and muscle guarding." In other words, the pain can make your muscles go into spasm, in which your muscles try to guard the sore joints, keeping you from wanting to move your neck at all. When movement stops, your brain gets an uninterupted flow of pain sensation. Ouch! This leads to a cycle of even more muscle spasm and pain because your muscles try to "protect" you from painful movement. By applying gentle pressures, or mobilizations, your therapist will begin to halt the flow of pain information, which helps muscles relax. Once your muscles begin to relax, you will begin to feel other sensations than pain. As your pain eases, more vigorous grades of mobilization may be used to lengthen tissues around the joint helping restore better movement in your neck.

Traction: Sore joints and muscles in the neck often feel better when a traction "pull" is used. Your therapist will test at first to see if you can get relief with this type of treatment. Traction can be done in a variety of ways. There are traction machines that allow you to relax comfortably with either a halter or cusion behind your neck. The machine is set to pull on this halter or cushion for a certain amount of time and pressure. Manual traction is another way for your therapist to put a graded pull on your neck. There are also traction devices that can be issued for you to use at home. The amount of pull that is used will depend on your condition. A gentle on/off pressure may be better early on to help control pain or if there is pain from arthritis. More vigorous traction can help take away pain if a joint is mildly sore or tight.

Exercises

Strengthening your neck

Exercise is important during all stages of recovery from neck pain. Different types of exercises will be used by your physical therapist as you get better. In the early stages, when your neck is still quite painful, specific exercises may be suggested to help reduce your pain. Supporting your neck in certain positions as suggested by your therapist can take pressure off sore or injured areas. These positions are sometimes easier to get into by using a pillow, rolled towel, or commercial neck roll. You may need to relax back on a recliner or matress for best results. In cases of significant pain, you may be given a set of breathing exercises. Deep, diaphragmatic breathing, helps air to reach even the lower lobes of your lungs. Combining deep breathing to a slow relaxing count can help muscles relax, while bringing much needed oxygen to sore tissues. Neck pain can be physically and emotionally draining. Relaxation exercises may not correct your problem, but they can help control pain and its accompanying stress.

Movement is also important, even when your neck is still painful. Careful movements suggested by your therapist can safely ease pain by providing nutrition and lubrication to injured and sore areas. Movement of joints and muscles also signals the nervous system to block incoming pain. Common movement exercises include active range of motion, in which you are encouraged to move your neck toward directions that don't hurt. Your therapist will evaluate which movements will be safest and best for you. In some cases, pain will ease with the addition of pressure into one or another direction. Again, your therapist will need to determine which movements are best for your condition. Avoid movements that hurt or seem to irritate the soreness in your neck.

As your neck becomes less painful, the exercises will be changed to focus on improving the overall health of your neck. These changes will focus on exercises for:

 

• Flexibility

• Strength

• Coordination

• Aerobic conditioning

Exercises that increase flexibility help to reduce pain and make it easier to keep your neck and spine in a healthy position. Tight muscles cause imbalances in spinal movements. This can make injury of these structures more likely. Flexibility exercises for the neck, chest, and upper shoulders can be helpful in establishing safe movement. A slow progression of stretching exercises can increase flexibility in these areas, ease pain, and reduce the chance of reinjury.

The next stage of exercise focuses on the strength of the muscles that support the neck. These muscles help bring the spine into a safe position--and keep it there! Trained muscles can keep your neck healthy by getting it into better posture. A series of strengthening exercises, called stabilization training, is a way to get better balance in the muscles around your neck, chest, and upper back. These stabilization exercises are helpful in supporting your neck in safe positions while you are working or when you are doing other daily activities. Strengthening and stabilization exercises are simple to do at home and don't have to require any expensive equipment. By practicing these exercises often, you will become comfortable keeping your neck in healthy positions and postures with all your activities.

Strong muscles need to be coordinated. As the strength of the spinal muscles increases, it becomes important to train those muscles to work together. Learning any physical activity takes practice. Muscles must be trained so that the physical activity is under control. Muscles that are trained to control safe movement of the spine help reduce the chance of injury. You will be taught exercises to help train your neck, chest, and upper back muscles to work together in protecting your spine.

Finally, attention will be directed to increasing your overall fitness. The word aerobic means "with oxygen". By using oxygen as they work, muscles are better able to move continuously, rather than in spurts. Fitness training allows the muscles to become more efficient at obtaining nutrients and oxygen from the blood. As the muscles use up the nutrients and oxygen, chemical waste products are created that can cause pain. Training also increases the ability of muscles to get rid of these waste products.

Exercise has other benefits as well. Vigorous exercise can cause chemicals called endorphins to be released into the blood. These chemical hormones act as natural pain relievers in reducing your pain. It will be important that you pick an aerobic activity you can enjoy and stick with it!

Once your pain is controlled, your range of motion is improved, and your strength is returning, you will be progressed to a final home program. Your therapist will give you some ideas to help take care of any more soreness at home. You'll be given some ways to keep working on the range of motion and strength too. Before you are done with physical therapy, more measurements will be taken to see how well you're doing now compared to when you first started in therapy.

 

Prevention and long term self care for the neck

Is this is your first experience with a neck problem? Maybe you've had ongoing problems for many years. In either case, your best bet for avoiding neck problems in the future is to get a handle on ways you can prevent further neck pain and/or injury. It is also helpful to know how to take care of your neck if pain strikes again.

Posture: Using healthy posture is like holding a defense shield against future neck problems. Pain and injury CAN be prevented. When your joints are positioned in their safe--or neutral posture--the body works like an elegant machine. It works safely and even more productively. When unbalanced postures are used, problems are more likely to happen. Prevention of neck pain and injury has alot to do with keeping a balanced position of the spine and extremities. When standing, this balance follows a plumb line from ear to ankle. In a seated position, this line descends from the ear to the hip. A rule of thumb for the extremities is to keep them in thier relaxed positions.

There are three natural curves in the spine. From a side view, the neck (cervical spine) curves slightly inward. The midback (thoracic spine) curves slightly outward. The low back (lumbar spine) curves slightly inward. Keeping this relationship while standing, sitting, or moving is the basis for healthy posture. When moving, bend at the hips to avoid rounding or straightening the spine. This keeps the spine safe during activities like lifting and walking.

For better sitting posture, sit with a good upright alignment of the spine by using a comfortable chair designed to support correct posture. Avoid slouching by keeping your low back against the back of the chair. Bending the head forward strains the neck and affects the nerves and arteries leading to the arms. Your shoulders should be relaxed, and the elbows, hips, and knees should be bent at right angles (ninety degrees). Avoid pressure to the back of the knees. Your feet should be kept flat on the floor or supported by a foot rest.

Akward posture places stress on the body that can lead to neck pain. Slouching with the spine or leaning the head forward puts the body out of alignment, causing the limbs to be stretched and bent. Too much bending (flexion) or straightening (extension) in the spine increases the risk of injury. Symptoms of pain, tingling, or numbness in the arm or hand may also come from poor neck posture. The slight inward curve of the neck balances the head on the spine. Avoid extreme postures, like gazing up at the stars, or bending your head down for long periods when reading a book. Keeping balanced posture is a measure you can use to prevent further injury and pain in your neck.

Ergonomics: Ergonomics is a look at the way people do work. What does ergonomics have to do with the ache in your neck? It could have alot to do with it. It's possible that even minor changes in the way you do your work or hobby activities could ease the pain you feel now while preventing further neck injury or pain.

In some cases, it is best to have someone trained in ergonomics, like a physical or occupational therapist, check your work station and the way you do your work. The first step will be for them to ask you some questions about your work, which makes good sense. Since you're the one doing the job, you will have an expert opinion about what seems to be working, what could be done differently, and what tasks seem to be causing the most problems for you. Once these questions are covered, the evaluator will want to watch you do the work tasks. Areas that will be noted include the postures you use, repetitions to complete the task, rest time between tasks, and the amounts of weight you are dealing with. For office workers, the examiner will look at alignment of the computer monitors, chairs, desk heights, etc. Other areas that may be evaluated include work heights, tools of the trade, lighting, and temperature. It's also helpful to look at your work postures and work tasks to see if what you are doing can be done with less stress and strain on your body.

When the work site evaluation is over, you or your supervisor will probably be given some recommendations--some of these may even be ones you came up with! Ergonomics doesn't always have to involve expensive changes. Even minor adjustments can make a huge difference in easing your pain and preventing further problems.

Work Place Strategies: These strategies are ideas of how to work with greater safety and even better productivity. Have you ever felt stress or tension at work? Chances are good that you wouldn't have a pain or worry if you didn't. The reality is that people are often called on to do even more with less resources. They are faced with more responsibility and more deadlines to get their tasks done. The health of your neck may be at risk with these mounting pressures. But scientists have helped us learn that there is a defence in the face of these mounting pressures. They have shown the importance of using the "Three R's" to help ease tension and reduce neck pain at work. Here are the three Rs:

Rest: This includes taking frequent breaks during the work hour. It also means choosing alternate activities to get your mind ready for a new job task. Activities include deep breathing, walking, napping, or exercising.

Relaxation: Take a load off. Lie back. Turn down the lights, and listen to your favorite tape or CD. Attempt to breath slowly and deeply, allowing your abdomen to rise and fall rythmically. Using visual imagery can also aid in relaxation. Try to visualize each muscle relaxing one after another.

Recovery: Our bodies need a chance to heal. Repeated and prolonged activities can take their toll if the body doesn't get a chance to recover. Recovery helps repair these sore and achy tissues along the way, keeping them healthy.

Whether at work or at home you can use these ideas to help prevent neck pain and injury. Here are some additional tips to use at work to avoid tension and keep your neck healthy:

Be Relaxed. Try to work with your muscles relaxed. To stay relaxed, look relaxed.

Pace Yourself.Keep an even keel. Avoid sudden changes in your workload. Try to avoid last minute "panics" to meet deadlines.

Take a Break.Take a thirty second "microbreak" every twenty to thirty minutes to do some deep breathing and a few exercises. Take a few minutes each hour to do some exercises, get a drink, or go bug a coworker. Use your lunch break to take a nap or a walk.

Change Positions. Avoid holding your neck, trunk, or limbs still for a long time. Plan ways to get the job done using different positions. Sit for a bit--then stand for a bit. Or simply readjust your approach to the task.

Rotate Duties. Rotating or sharing your tasks can be fun by offering a new worksetting, while giving your body a chance to recover.

Avoid Caffeine and Tobacco. These can heighten stress, reduce blood flow, and elevate the awareness of neck pain.

 

Taking Care of Your Neck

If you've had neck pain once, there's a fair chance you'll have it in one form or another in the future. When pain comes back again and again, it is called recurrent pain. Even though you may have been treated for neck pain or problems in the past, it's not a guarantee you won't have pain again. The question, then, is whether you can take care of your neck if soreness does return.

Your therapist will probably give you a thorough home program when you get done with your treatments. Some of the exercises will be helpful to keep up with as a way to keep your neck healthy over time. You may also be given ways to help control pain or symptoms if they don't go completely away, or if they return in the future. Although there are many good "home remedies", you will want to visit your family doctor if these symptoms appear:

* Pain with no apparent injury that doesn't go away within a week to 10 days
* Pain that doesn't ease or change with movement
* Pain that actually wakes you up at night
* Pain that shoots from your neck down into your arm when you cough or sneeze
* "Visceral" symptoms of nausea, diarrhea, dizziness, blurred vision, ringing in the ears, etc.
* Numbness, tingling, or weakness in your arms or legs

If you feel achiness or pain that is not associated with the red flags listed above, here are some home treatment ideas you may be given to ease your symptoms:

Rest: When neck pain strikes, don't do activities that make your pain worse. Remember the benefits of rest (see above).

Ice: For the first two to three days, you may get help by appling a home-made cold pack. Simply place two parts crushed ice in a plastic bag with one part rubbing alcohol. This lets you reuse the bag without having it freeze solid between uses. When you're ready to use the cold pack, wrap it in a wet washcloth. Then place it on the sore area for up to fifteen minutes a few times a day.

Contrast: On day three, you may find more relief by using a "contrast" of ice and heat. This is where you begin by placing a cold pack on the sore area for 10 minutes. Then place a heating pad on for another 10 minutes. You can repeat the process a couple times, finishing with the heat.

Heat: Once the acute symptoms are controlled (two to three days), you may get good relief using a heating pad. Remember to turn off the pad before going to sleep. Check your skin regularly to make sure you are not getting too much heat.

Traction: In some cases, your therapist may have found out that you get good relief with neck traction. That can be good news. There are a number of traction units that can be used at home. Some of these work by giving a traction pull as water is added to a bag. Others work by pumping air pressure into a neck cushion. A simple way to do traction at home is to place two tennis balls in a sock. Lay down with the sock sideways just below the back of your head. The two tennis balls will give a gentle traction, and the pressure of the balls can help relieve headaches, neck pain, and upper back discomfort.

TENS: This stands for transcutaneous electrical nerve stimulation. If you've been treated in the clinic with electrical stimulation, your therapist will have a good idea if this kind of treatment helps you. If so, there are small, pocket-sized electrical stimulation units that can be used up to 24 hours a day if needed to keep pain at bay. Your therapist may choose to issue one of these, but only if you can't get good pain relief in other ways. Also, a prescription from your doctor is required for you to use one on your own.

Exercise: Some exercises are designed to help take pain away. After you have completed your physical therapy visits, your therapist will have gotten a good idea what types of exercise help you control your pain. Your therapist will go over the exercises that will give you the best relief if you get sore again. Remember to only do the exercises in the way your therapist has instructed. Overdoing them could make your pain worsen.

Long-term strategies: The best way to treat neck pain is to avoid it all together. A good exercise regimen can help. Also, remember the benefits of good posture, ergonomics, and work habits--and use them. If you are trying to take care of your neck but you're not getting adequate relief, you may need to revisit your physical therapist for additional help.

Home program: Once your pain is controlled, your range of motion is improved, and your strength is returning, you will be progressed to a final home program. Your therapist will review some of the ideas listed above to help take care of any more soreness at home. You'll be given some ways to keep working on the range of motion and strength too. Before you are done with therapy, more measurements will be taken to see how well you're doing now compared to when you first started in therapy.