In a 32-Year-Old Woman With Chronic Neck Pain and Headaches, Will an Exercise Regimen Be Beneficial for Reducing Her Reports of Neck Pain and Headaches?

Can an exercise program help this patient?

Mrs. Jones is a 32-year-old, self-employed computer programmer who was seen by her physical therapist for a 7-month history of neck pain. She reported that her symptoms started while working on a project in which she sat at her computer work station for up to 12 hours per day, for a period of 3 weeks. She stated that she felt like she did not have the strength to maintain good posture at her work station and that after about 30 minutes of computer work her neck would begin to hurt. By the end of the day, she would frequently experience a right-sided headache. Her Neck Disability Index (NDI) score was 26% out of 100%, where 100% indicates total disability.¹⁹ Her pain ratings at rest before work were 0/10 on the Numeric Pain Rating Scale (NPRS),²⁰ and her pain ratings progressed to 3/10 by midmorning and to 5/10 by the end of the day. She reported that her neck felt considerably better on the weekends, when she did not work. She had no previous history of trauma, and no “red flags” were noted on her intake questionnaire or in her subjective history.^21,22 A systems review revealed that she was generally in good health; however, the musculoskeletal system required further review.²¹ An upper-quarter screen was negative for neurological impairments.^22,23 She had a forward head posture, and impaired muscular strength and endurance were identified in her deep neck flexor, middle and lower trapezius, serratus anterior, and posterior rotator cuff muscles. She had an altered pattern of muscle activation, including reduced deep cervical flexor muscle activity during the craniocervical flexion test (CCFT), and she had increased activity of the superficial cervical flexor muscles during both cognitive tasks and functional activities.¹⁴ Based on assessment of active and passive range of motion along with passive accessory motions, she had mobility impairments in the upper 3 cervical vertebrae into flexion and impaired mobility of the thoracic spine, specifically into extension.^24,25 Decreased length also was identified in the pectoralis minor, suboccipital, and latissimus dorsi muscles.²⁴

How do we apply the results of the Cochrane Review to Mrs. Jones?

Mrs. Jones' physical therapist questioned whether she would be a good candidate for an exercise program for her mechanical neck pain and headaches. Using the PICO (Patient, Intervention, Comparison, Outcome) format, he asked the question: In a 32-year-old woman with chronic neck pain and headaches, will an exercise regimen (as compared with no exercise regimen) be beneficial for reducing her reports of neck pain and headaches? Her physical therapist determined that the systematic review by Kay et al¹² provided relevant information that would allow him to answer this question. The systematic review included studies of patients with ages similar to Mrs. Jones' age. Additionally, numerous studies reported in the review included patients with chronic mechanical neck pain and headache and examined a variety of exercise programs. In the systematic review, exercise was most often compared with another intervention or “multimodal” care, including manual therapy. Reliable and valid self-report outcome measures, including pain and disability measures, were used by the studies in the systematic review.

Based on the physical therapist's critical appraisal of the systematic review,¹² an exercise program that included interventions to address impaired strength, endurance, and muscle activation patterns for the cervical and periscapular musculature along with stretching exercises was recommended for the patient.^18,26–31 This program would be performed at home and progressed in the clinic and would be multimodal to include manual therapy to improve mobility impairments in the cervical and thoracic spine, as well as patient education and counseling on posture and ergonomics. Mrs. Jones agreed to participate in the treatment plan and began an individualized physical therapy program, tailored to her specific impairments, in which she would perform a daily home program and come to the clinic for 45 minutes, 2 times a week, for 8 weeks. Each session included a 10-minute warm-up on an upper-body ergometer followed by low-load endurance exercises to train muscle control of the cervicoscapular region.^{18,26,27,32,33} The exercise program then would be progressed to high-intensity strength training of the neck and shoulder muscles based on the work of Ylinen and colleagues.^28–31

The first stage consisted of specific exercises to address the impairment in the deep neck flexors commonly found in patients with neck pain and cervicogenic headache. Craniocervical flexion exercises were performed in a supine position and targeted the deep neck flexor muscles. Mrs. Jones was taught to perform a slow and controlled craniocervical flexion motion. She then was trained to hold progressively increasing ranges of craniocervical flexion using 10-second holds with a goal of 10 repetitions per session without substitution. The scapular muscles, including the lower trapezius and serratus anterior muscles, were trained using end-range holding exercises of scapular posterior tilt with retraction, practiced initially in the prone position. She was instructed to perform these 2 exercises twice daily with 10-second holds, working up to 10 repetitions to increase the endurance capacity of the muscles.^18,26,27

These movements also were incorporated into postural correction exercises performed hourly throughout the day while she was at work sitting at her computer. She was instructed to sit with a natural lumbar lordosis while gently retracting and adducting the scapulae and gently elongating her cervical spine to facilitate the deep neck flexors. In the clinic, the cervical flexor muscle performance was progressed in a supine position where the patient was encouraged to maintain craniocervical flexion while gently lifting and lowering the head to train inner-range concentric and eccentric performance. Retraining of the deep cervical extensor muscles was added, starting in a prone position on elbows, followed by the quadruped position. She was asked to maintain scapular protraction and a neutral craniocervical position while moving the lower cervical spine into flexion and extension. This movement can be facilitated by tactile feedback from the therapist's fingers.¹⁸ This movement then was progressed to flexion and extension in a sitting position to train outer-range eccentric and concentric performance of the flexors and extensors.^18,34 Once the therapist determined that the altered pattern of muscle activation had resolved (as assessed using the CCFT),^14,35 he progressed the rehabilitation program to the second stage.

For the second stage of the exercise program, Mrs. Jones' therapist chose to progress strengthening to include the protocol used by Ylinen and colleagues,^28–31 which was included in the review by Kay et al¹² as well as in several subsequent clinical trials. The strengthening exercises included specific neck exercises with use of an elastic band (Thera-Band, Hygenic Corporation, Akron, Ohio) for resistance. The patient, in a sitting position, performed 1 set of 15 repetitions into flexion, extension, and flexion into a diagonal pattern to the left and the right. She was instructed to keep her head and neck stable in relation to her trunk. The participants in the study by Ylinen²⁸ also performed dynamic strengthening exercises for the upper quarter using a dumbbell, including shrugs, bench presses, flyes, curls, bent-over rows, and pullovers. They were told to start with a weight at which they could safely perform up to 15 repetitions of each exercise. Once 15 repetitions were achieved, they were instructed to increase the weight by 1 to 2 kg. Ylinen et al²⁹ reported that this exercise program resulted in improvements in maximal isometric neck strength (as measured with a handheld dynamometer) of 110% in flexion, 76% in rotation, and 69% in extension. Home and clinic sessions concluded with a stretching program for length impairments in the pectoralis minor, suboccipital, and the latissimus dorsi muscles.

How well do the outcomes of the intervention provided to Mrs. Jones match those suggested by the systematic review?

Mrs. Jones completed 15 of 16 physical therapy sessions. Her NDI score was reduced at the end of the program to 8%. The minimal clinically important difference has been reported to range from 7% to 18% in patients with mechanical neck pain.^20,36 Therefore, the magnitude of Mrs. Jones' reduction in disability (18 points) may be considered clinically important. Her pain ratings on the NPRS had decreased to 0/10 at most times, and at worst were 2/10 at the end of the day. The 15-point global rating scale described by Jaeschke et al³⁷ also was used at the end of treatment. The scale ranges from −7 (“a very great deal worse”) to 0 (“about the same”) to +7 (“a very great deal better”). She rated her condition as +6 (“a great deal better”). It has been reported that scores of +6 and +7 indicate large changes in patient status.³⁷ The patient did not report any side effects or worsening of symptoms with the prescribed exercise regimen.

Can you apply the results of the systematic review to your patients?

The findings of this systematic review apply to patients over the age of 18 years with various types of mechanical neck pain, with or without arm pain or headaches, who are receiving exercise interventions. The results appear to apply to patients in both supervised and home-based exercise programs. It is interesting to note that the systematic review by Kay et al¹² included “low-load endurance exercises to train muscle control” under strengthening. This finding needs to be interpreted with caution, as there is evidence that this type of training does not have a significant impact on strength.³³

What can be advised based on the results of the systematic review?

Patients with a clinical presentation similar to that described above are likely to benefit from an exercise program of approximately 8 weeks in duration. The studies cited in the review by Kay et al¹² used multiple modes of exercise with a wide variety of frequencies, intensities, and durations of exercise. Impairments in muscle performance and motor control are common in patients with neck pain.^{14,32,34,38–41} Patients with MNDs frequently have underlying neuromuscular impairments, including altered muscle activation patterns between superficial and deep neck flexors, greater fatigue of cervical musculature under low load, and deficits in kinesthetic perception.²⁷ Although changes have been found in patterns of cervical muscle activation in cognitive, functional, and automatic tasks, patients with neck pain also frequently have impairments in the postural control system, which may implicate the musculature and joints of the cervicothoracic and periscapular regions.⁴² In the systematic review, Kay et al¹² recommended that exercise programs for patients with acute or chronic MNDs should consist of stretching and strengthening exercises targeting the musculature of the cervical region, scapulothoracic region, or both. This review revealed that exercise programs consisting of stretching and strengthening exercises for the cervical region or for both the cervical and scapulothoracic regions resulted in reductions in pain and improvement in function in patients with MNDs. Some trials included in the review suggested benefit for various exercise modalities, but there was not a clear demonstration of the superiority of any one approach. Additionally, outcomes for patients with neck pain seem to improve when exercise interventions are combined with manual therapy in a multimodal approach.¹²