Original articleImmediate effects of active cranio-cervical flexion exercise versus passive mobilisation of the upper cervical spine on pain and performance on the cranio-cervical flexion test
Introduction
Neck pain is a long-standing problem (Holmberg and Thelin, 2006; Kjellman et al., 2001) and costly for society (Korthals de Bos et al., 2003). Pain is only a single, non-recurrent event in 6.3% of patients experiencing neck pain (Picavet and Schouten, 2003). Between half and three quarters of people with current neck pain will experience recurrence within 1–5 years (Carroll et al., 2009). A contributing mechanical cause of recurrent neck pain can be disturbances in motor control of the cervical spine which may increase the risk of micro-/macrotrauma of cervical structures (Bogduk and McGuirk, 2006; Pearson et al., 2004). Restoration of muscle function is therefore considered fundamental for the treatment of cervical spine disorders (Jull et al., 2008).
Reduced activation of the deep cervical flexors muscles has been observed directly (Falla et al., 2004) and indirectly (Amiri et al., 2007; Chiu et al., 2005; Jull, 2000; Jull et al., 1999; Jull et al., 2004; Jull et al., 2007) when people with neck pain perform the cranio-cervical flexion test (CCFT). Reduced activation of the deep cervical flexor muscles during performance of this task is concomitant with increased activation of the superficial muscles (e.g. the sternocleidomastoid and anterior scalenes), indicating a reorganization of the motor strategy to perform the task (Falla et al., 2004). Used as an exercise, cranio-cervical flexion succeeds in both immediate (O'Leary et al., 2007) and long term pain relief (Jull et al., 2002; O'Leary et al., 2012) and leads to improved coordination between the deep and superficial cervical flexors (Jull et al., 2009).
Passive joint mobilisation might be a useful technique to promote improved neck muscle activation when painful or limited joint mobility makes the movement difficult. However, the efficacy of passive mobilisation and manipulation has been questioned (Gross et al., 2007) and both techniques have shown equal pain relief (Leaver et al., 2010), though only in the short-term (Gross et al., 2010). Their efficacy may be improved when combined with active exercise as recommended by guidelines for the treatment of mechanical neck pain (Childs et al., 2008).
A study which applied a postero-anterior grade III Maitland oscillatory mobilisation to the articular pillars of the C5-6 segment in patients with chronic neck pain, showed decreased activity of the superficial neck flexors post intervention. In this study, ultrasonography was utilised and changes in muscle thickness were calculated to infer muscle recruitment (Jesus-Moraleida et al., 2011). In an earlier study, reduced electromyography (EMG) amplitude of the sternocleidomastoid muscle was observed during the lower stages of the CCFT following passive mobilisation of the cervical spine (Sterling et al., 2001). However, no studies have directly compared the immediate benefit of active versus passive interventions on motor control of the cervical spine.
This study compared the immediate effects of assisted plus active cranio-cervical flexion (exercise group) versus passive mobilisation plus assisted cranio-cervical flexion (mobilisation group) on performance on the CCFT, cervical range of motion and pain in patients with chronic idiopathic neck pain.
Section snippets
Methods
The outcome measures for the study were patient reported levels of pain rated on a numerical rating scale (NRS), cervical range of motion (ROM), pressure pain threshold (PPT) and surface electromyography (EMG) of the sternocleidomastoid, anterior scalene and splenius capitis muscles during performance of the CCFT. All measures were conducted before and immediately after an intervention to the cranio-cervical region in patients with chronic idiopathic neck pain.
Results
The patients' demographic characteristics are presented in Table 1. No significant differences were observed between groups for age, weight or height (all P > 0.05).
Discussion
A reduction in resting pain and PPT measured over cervical sites was observed immediately following an active exercise or mobilisation of the upper cervical spine in patients with neck pain. However, improvement in performance on a motor task (CCFT) was only observed for the group of patients that performed 3 min of active exercise. These results confirm that both passive and active interventions lead to immediate relief of pain (Aquino et al., 2009; Jull et al., 2002; O'Leary et al., 2007;
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