By Dr. Jeffrey Tucker
My personal in-office experience of patients that present with pain after a motor vehicle injury is consistent with a 2010 study by Hincapié CA, et al. I find most patients report pain in multiple body areas and that isolated neck pain is extremely rare. Hincapié CA, et al report 86 percent of 6481 Saskatchewan residents that responded reported posterior neck pain, 72 percent indicated head pain, and 60 percent noted lumbar back pain. Ninety-five percent of claimants reported some pain within the posterior trunk region, comprising the posterior neck, shoulder, midback, lumbar, and buttock areas.
Regarding cervical rehab for these patients, in the past I’ve used everything from bodyweight isometrics and elastic Thera-Bands to strengthen the neck; dumbbells and kettlebells to strengthen the upper body; low load exercises for strength and motor control concepts performing 10 repetitions of deep neck flexor activation against an inflatable blood pressure cuff and a whole lot more.
All of these are effective at reducing acute and chronic neck pain. Oh, I can’t forget teaching patients all the foam rolling, stretching, warm-ups and cool downs I can get them to do. I can probably do an entire seminar on rehab compliance at this point.
My treatment choice has always depended on the individual patient, whether they are young or old, active or inactive, conditioned or deconditioned. Truthfully I don’t see a significant difference between the different treatment modalities. Most patients obtain clinically important improvements at 6 weeks after the beginning of treatment and exercise programs. I think that is in line with what most practitioners were taught to expect. However, I still see that 10% (plus or minus) or so of clients take a lot longer than 6 weeks to resolve and have on-going residual complaints and problems. On the other hand, I love treating chronic pain patients that come into my office that were not originally treated by me – those who had previous chiropractic care, acupuncture, medical care or physical therapy without active rehab (they just received passive modalities). With some new tweeks on rehab, I expect good results with these individuals. My hands-on treatment over the past few years seems to include more cervical mobilization (stair-stepping technique), lower cervical manipulation (rather than upper cervical manipulation), thoracic manipulation, and I continue to do a lot of specialized deep soft tissue therapy for pain reduction. The deep tissue work is especially valuable to the upper cervical region. Over the last few years, I’ve added warm laser, but it is so unpredictable who will benefit and change and who doesn’t, I’m losing interest in the whole “laser” thing for the cervical region.
One of the most helpful things I’ve learned in the last five to six years is Dr. Kim Christensen’s Neuromobilization technique. If you have a patient with radiculitis, this technique can produce some clinically important reduction of pain immediately posttreatment. The biggest changes in my cervical treatment come in my rehab. Helpful strategies in the past several years include using the NASM protocol for the ‘overhead squat’ as a diagnostic tool and treatment guide, and using the Functional Movement Screen (FMS) as a predictor of risk for injury.
My latest rehab management strategies for MVA & cervical spine patients:
Manual therapy: lot of personal thought and patient time figuring out manual maneuvers and stretches to influence the fascia – that thin fibrous layer consisting of longitudinal and transverse connective tissue fibers. Restrictions seem to show up everywhere. Along the sacrotuberous ligament, the thoracolumbar fascia, the latissimus dorsi muscle, the spinous processes of all of the thoracic vertebrae, the angles of ribs, the serratus muscle, the splenius capitis muscles and the deep fascia of the neck.
Balancing (sensorimotor training) exercises as early as possible. I start patients standing with a narrow stance, progressing to tandem stance and single leg stance. The progression includes the use of foam under each foot to augment postural instability. Manipulate visual inputs (focusing on a point 2 meters away on the wall at eye level and under, with eyes open (EO) plus eyes closed (EC) conditions). I use 30 second bouts.
Stretching exercises is still part of many cervical rehab programs but dynamic stretching and mobility of the thoracic spine to influence the cervical spine is enhancing rehab routines. Mobility needs to be taught before stability. We have to reduce neck/shoulder stiffness and enhance neck range of motion. The static stretches for the levator scapulae, suboccipitals, SCM, pectoralis minor, and scalenes continue to be at the top of the list. I am enjoying using the stretch strap from Theraband.
Strengthening exercises after the deep neck flexors (DNF): Sometimes I begin with the head positioned against gravity to enhance isometric strength of the neck extensor muscles. I still do typical strengthening exercises for the paraspinal muscles and shoulder girdle muscles (upper and middle trapezius, rhombo-serratus). These exercises help increase the sustained isometric effort tolerance of the neck muscles. Progression includes unstable surface
and escalating resistance and movement pattern improvement. I begin my corrective exercise strategy with bodyweight, progress to Therabands resistance, then progress to free weights and kettlebells.
Oculomotor and head/eye exercises
: In the upright, sitting and supine positions I teach patients eye tracking while moving the head. This involves coordination exercises and re-establishing proper movement patterns.
The progression includes increasing neck rotation amplitude, instability on a stability ball and augmenting neck muscle activity with the head in a weight-dependent position. For the past few years I’ve been using the overhead squat for cervical evaluation. Dr. Christensen and I wrote a chapter on the cervical spine in Mike Clark’s new book. In the past we used the overhead squat as a movement pattern to evaluate the ankles, knees, and lumbopelvic-hip complex. Now we use it to evaluate the cervical spine as well. Just think of it as closely rel ated to the supine cervical flexion movement pattern. Have the patient perform the overhead squat. Observe them from the front and side. The normal pattern would be for them to lead with the posterosuperiour aspect of head. If the SCM’s and subocciptals are dominating, they will lead with their chin. This is a faulty pattern. Remember these muscle actions:
Antomical action of longus capitus and colli (cranio-cervical flexion) nods the chin.
SCM extends the cranio-cervical region and flexes the neck.
Scalenes are neck flexors.
During the overhead squat I seem to find a lot of overactive SCM, anterior scalene, and suboccipital muscles.
Here are a couple of corrective exercises:
Scalenes and hyoids can be short, limiting cervical extension. Hyoid stretch: teeth touching – extend the neck – open mouth and your head extends further. The stretch is close the mouth = fascial stretch of hyoids. To find out if it‘s articular, perform the chin tuck and extend the cervical spine over the upper thoracic region.
4 Point Kneeling: The head and neck are passively positioned in neutral alignment, then the patient actively moves (turning side to side, looking up and down) and attempts to return to neutral position. Perform this procedure twice. Notice if they can come back to the neutral position. Score: Good = the patient accurately and confidently returns to the neutral position both times without making adjustments. Average = the patient returns to neutral position with reasonable accuracy but lacks confidence – may need to make several adjusting movements or is “not quite sure.” Poor
= the patient cannot return to the neutral position and is often very unsure of the correct position as evidenced by the vacant facial expression that frequently is associated with performing this test.
I’m sure there are dozens of specific treatments, exercises, and natural remedies out there for our patients. I’d be interested to know about them, but if you’re following the rehab model in all its facets – manipulation/mobilization, modalities, diet, activity, exercise, leisure, sleep, stress prevention – I think you’ll find we do so much good!
I have new material to share with you.
Dr. Jeffrey Tucker can be contacted at:
11600 Wilshire Blvd. #412, Los Angeles,
CA 90025, phone 310.473.2911
and on the web at www.DrJeffrey-
1. J Occup Environ Med. 2010 Mar 30. Whiplash
Injury is More Than Neck Pain: A Population-
Based Study of Pain Localization After
Traffic Injury. Hincapié CA, Cassidy JD, Côté P,
Carroll LJ, Guzmán J.
2. Comerford lecture notes 2009.
Dr. Tucker completed Chiropractic training at Los Angeles College of Chiropractic.
He has a post graduate Diplomate degree in Rehabilitation and is certified in
chiropractic spinal trauma. He is a past-president of the Santa Monica Chiropractic
Society. Dr. Tucker served on the Chiropractic Rehabilitation board. He is a
member of the California Chiropractic Association and the American Chiropractic
Ankle sprains can easily get reinjured – which is especially common during the first year – and this can result in chronic pain or disability. My article offers a home–based proprioceptive training program shown to significantly reduce the risk of recurrent ankle sprain.
California Chiropractic Journal article and photos:
I am a patient of Dr. S (chiropractor) and have had chronic
achilles tendonitis for at least 10 yrs. Recently icing and stretching
has not been effective to decrease inflamation in the L foot in
particular. I have been going to PT for the past month receiving
iontophoresis with dexamethasone treatments. I do get some burning on the skin and it has taken about 6 treatments to see and feel about a 60% improvement. However , as soon as I do even mild use of the left foot with weight bearing, it flares up to previous levels.
I am curious as to whether hot or cold laser therapy would help this
condition. Do you think laser therapy would help and what type…hot
or cold? Any advise, information, opinions are welcome from you.
THANK YOU very much for your time.
RESPONSE FROM DR. TUCKER
It is a challenge managing chronic Achilles tendon injuries. The warm laser can help heal the in-growth of new nerves and blood vessels which are known to be sensitive to pain chemicals. As part of my rehab protocol for Achilles problems I use the following:
•Alfredson’s heel-drop exercise
In 1998 a Swedish orthopaedic surgeon published excellent results for a group of patients with Achilles tendinosis who undertook a specific 12-week eccentric calf loading rehabilitation program. The subjects all experienced a dramatic reduction in pain, a significant increase in calf strength and returned to full running.
The client stands on the bottom step of a staircase, facing inwards, hands lightly supporting at either side. The forefoot of the affected leg is placed on the edge of the step. The client lowers their body down by dropping the heel of the affected leg over the edge, with control; then places the foot of the non-affected leg on the step to raise the body back up to the starting point. If this proves too difficult, or if both Achilles are affected, it is possible to raise back up on two legs (thereby sharing the concentric load) and coming down on a single leg (this is the “2 up, 1 down” concept).
•Perform 3 x 15 eccentric heel drops with the knee straight and 3 x 15 repetitions with the knee bent, repeated twice daily.
More recent studies have found that eccentric loading increases collagen deposition in tendinotic tendons, suggesting a healing response. Perhaps of greater significance is the apparent disappearance of the vascular in-growth in people who respond favourably to loading and it is possible that the effectiveness of the program is due to the direct effect on pain rather than tendon healing or an increase in calf muscle strength.
Balance training programs are essential as part of the rehab for Achilles.
Regarding the warm laser, I think it would be very helpful & effective.
This article appeared in the California Chiropractic Journal
In-Office Rehab and Balance Training by Dr. Jeffrey Tucker, DC
The doctors that I get to teach, and those that I meet who include exercise therapy in their practice appear to create better client satisfaction and experience better patient retention. Patients enjoy the participation in their care that exercise therapy provides.
More than thirty-five years ago, when I was a teenager, going to the gym and working out was for kids and parents who already had an active lifestyle. The typical ‘old school’ gym program included a ten minute bike or treadmill warm up, a 40-50 minute strength training regime—usually in a muscle group split, and then on “off-days,” 20-30 minutes of cardio.
Today’s ‘new school’ exercise programs consists of foam roll therapy (self myofascial release) for 10 minutes, stretching of overactive muscles for 5-10 minutes, core stability exercises for 5-10 minutes, balance training for 5 minutes, reactive training and speed, agility and quickness training for 5-10 minutes, intense strength training for 20-25 minutes, metabolic/cardiovascular training for 10-15 minutes and 5 minutes for cooling down.
Many clients that come to us may already be doing any or all of these exercise strategies on their own at home or in the gym. My role as a rehab specialist is to write corrective exercise programs, teach clients how to perform the exercises and guide them into progressions that help eliminate pain.
Additional therapeutic goals may include injury prevention, decreased body fat, increased lean muscle mass, increased strength, increased endurance, increased flexibility, and enhanced performance.
You can have a very successful exercise practice in your office using Therabands, especially the ones with handles, a barbell, dumbbells, kettlebells, a sturdy exercise bench that inclines, a swiss ball, a wobble board, or rocker board, or bosu.
I break up each of the “new school” categories of exercise in my in-office treatment sessions. After the acute care phase, I start by training clients in the use of the 3-foot-by-6-inchwide foam roll. This method of self myofascial release is used to inhibit overactive muscles. Holding pressure on the tender areas of tissue (trigger points) for a sustained period of time, usually 30 seconds per tender point,can diminish trigger point activity. Patients are expected to use the foam roll at home on their own. This is followed by a session where I teach clients how to stretch.
Following use of the foam roll, the application of a lengthening technique (static stretching) resets the muscle lengths and provides for optimal length-tension relationships. Once patients are foam rolling and stretching at home, the subsequent in-office session is used to teach isolated strengthening exercises. This session time is used to teach clients how to isolate and exercise a particular muscle. For example, a common underactive muscle is the gluteus medius. The side lying hip abduction exercise would be taught to increase the force production capabilities through concentric-eccentric muscle actions.
Isolated exercises focus on the muscles of the body that have synergistic function of the stabilization and mobilization system.
Additional sessions are required to train clients in integrated dynamic strengthening exercises. This will ensure an increase in intra- and intermuscular coordination, endurance strength and optimal force-couple relationships that will produce proper arthrokinematics.
An important exercise therapy often overlooked by clinicians, is that prior to resistance training, balance training should be performed, because it has preconditioning effects
on strength training. Our everyday clients face the challenges of keeping balance to perform activities such as playing with their children or grandchildren, walking on uneven surfaces or even taking a walk in their neighborhood.
‘New school’ exercise programs realize balance is a skill-related component of physical fitness. It is important to incorporate balance training in every client’s corrective exercise program as an integrated component to a comprehensive training regimen.
Balance can be influenced by many factors. As we age, our ability to balance or maintain postural control decreases. Watch seniors maneuver steps and stairs. Those who lack the ability to decelerate and control their center of gravity have a significant risk potential of a devastating fall. Prior injuries, especially after ankle sprains, ligamentous injuries to the knee, and low back pain can also decrease an individual’s ability to balance.
A joint dysfunction in the ankle, knee, shoulder, or low back can lead to muscle inhibition. An acute joint injury may cause joint swelling, which results in an interruption in the internal communication process of the body–sensory input from receptors such as articular, ligamentous, and muscular mechanoreceptors to the central nervous system. In turn, this changes our proprioceptive capabilities. When sensory input to the central nervous system is altered, our movement system may become imbalanced.
Repetitive recruitment of the wrong muscle fibers, in the same ROM/Plane of motion and at the same speed, creates tissue overload and eventual injury. Consequentially, this can lead to neuromuscular inefficiency, resulting in decreased balance and postural instability.
Recovery from injury needs to include repairing faulty movement patterns (alterations in stability) and correcting inefficient neuromuscular control. Through balance training,
the central nervous system can be exercised to change and improve a lack of joint stabilization that is causing functional instability.
Don’t forget to address balance as a component of a training program. Balance training may be used not only for reconditioning clients post injury, but also as a preventative measure to increase postural stability and reduce the chances of injury.
Dr. Jeffrey Tucker, D.C., D.A.C.R.B, is
a rehabilitation specialist, author,
lecturer, and healer best known
for his holistic approach in supporting
the body’s inherent healing
mechanisms and for integrating
the art and science of chiropractic,
exercise, nutrition and attitudinal
health. He instructs for the National
Academy of Sports Medicine and
the Chiropractic Rehabilitation Association.
He practices in West Los
Arch Up (Prone)
Lying on your stomach with hands along your side, palms facing up. Lift head and torso off the floor as high as possible and look up toward the ceiling. After holding for two breaths rotate head so looking toward the floor again and release the pose.
Hold for 2 breaths.
Repeat 10 times per session.
Two sets per session.
Complete 1 session per day.
Opposite Arm/Opposite Leg (On All Fours)
Tighten stomach and raise right leg and opposite arm. Keep hips level and stomach very tight and drawn in.
Hold for two breaths.
Repeat 20 times per side, per set.
One set per session.
Complete 1 session per day.
With or without weights, raise both arms in the “I” position, “Y”position and “T” position.
Repeat 10 times per set.
Two sets per session.
Complete 1 session per day.
Stand with feet shoulder/hip width apart. Squat deeply trying to keep heels on the floor. Keep head and chest up.
Build up to 50 squats per set.
One set per session.
Complete 1 session per day.