A Multimodal Approach

Active care and exercise therapy have become complementary approaches
to spinal manipulation in the treatment of musculoskeletal disorders.
Active care refers to patient self-empowerment in his/her treatment,
under the guidance of the health-care practitioner.

Figure 1	Advertisement

Active care and exercise therapy have become complementary approaches
to spinal manipulation in the treatment of musculoskeletal disorders.
Active care refers to patient self-empowerment in his/her treatment,
under the guidance of the health-care practitioner. Several benefits could be associated with the active care model in the rehabilitation process¹. Active care could include pain management, education and home exercises. Exercise therapy comprises specific movements practiced by the patient under the direct supervision of the therapist.

Neck pain is a prevalent musculoskeletal condition seen in chiropractic practice. Lifetime neck pain prevalence is more than 60 per cent.² In the general working population, the annual prevalence ranges between 27 and 49 per cent³ and recurrent pain, or episodes lasting more than six months, have been reported in 10 per cent of the general working population⁴ and 14 per cent of the adult population⁵. Although no clear evidence has materialized, active modalities, such as mobilization and exercises, seem to provide more benefits than treatment based on immobilization and passive modalities such as rest, soft collar, etc⁶. On the other hand, there is strong evidence favouring a multimodal care approach of exercises combined with mobilizations or manipulations for chronic mechanical neck disorders⁷. This article will discuss exercise therapy, and the exercised-based active care approaches, that could complement your chiropractic management of chronic neck pain (CNP) patients.

Figure 2a
Figure 2b
Figure 3a
Figure 3b

Sensorimotor Impairments in Chronic Neck Pain
Recent studies have implicated sensorimotor impairments in CNP patients. After pain, unsteadiness and balance problems are among the most frequent symptoms reported by these subjects⁸. Quantitative posturography studies have discerned increased postural sway in CNP, compared to healthy controls. Cervicocephalic kinesthesia, or cervical proprioception deficits, are also observed in CNP subjects^9,10,11. Pathomechanical features of neck pain development – that is, whether they are traumatic or idiopathic – influence sensorimotor evaluation outcomes. Generally speaking, trauma-induced neck pain patients present greater sensorimotor impairments than idiopathic neck pain patients.

The control of upright stance relies on the integration of several afferent inputs. It is well known that visual, vestibular and proprioceptive afferents contribute to the control of upright stance. More specifically, cervical proprioceptive afferents play an important role in postural control¹² by providing information regarding head position, in space, as well as head position relative to the trunk. They also are involved in the cervico-collic reflex, the cervico-ocular reflexes, and the tonic neck reflex, all of which are important in regulating head and eye movement co-ordination and postural stability.¹³ In CNP patients, such disturbances are believed to be a consequence of aberrant cervical proprioceptive inputs or changes in sensorimotor integration. Modulation of cervical sensorimotor control in neck pain is thought to occur via several mechanisms, including variations in fusimotor drive impacting muscle spindle sensitivity and modifying cortical representation of cervical afferent input^14,15,16 as a result of pain, muscle dysfunction (for example, increased fatiguability and muscle fibre adaptation) and inflammation.

Rehabilitation For CNP With Unsteadiness
In a recent case study involving a CNP trauma patient with unsteadiness, we tested the effect of a rehabilitation program combining spinal manipulation with strengthening and proprioceptive exercises, on postural steadiness improvement¹⁷. The proposed exercise regimen focused on the cervical region, as well as on global sensorimotor function through postural stability training. Although great care should be taken with regard to generalizing from a single case, we believe that the combination of strengthening and proprioceptive exercises should be considered during exercise therapy targeted to CNP patients with neurophysiological deficits. More extensive research is needed to define the optimal exercise strategies for management of CNP with sensorimotor deficits. The following guidelines are based on the available evidence to date, as well as clinical experience.

Preferably, isometric strengthening exercises should be performed to improve endurance and reduce neck muscle fatiguability (Figure 1). Static stretching exercise should not be prescribed systematically – but only if stiffness is present – whereas dynamic proprioceptive exercises involving head and eyes movements should be favoured. Examples of proprioceptive exercises are presented in Figures 2a and 2b. During therapy sessions, strengthening and proprioceptive exercises can be undertaken in sequence, in an alternating pattern or in combination. At the beginning of the treatment protocol, proprioceptive exercises should be conducted first to avoid the potential negative influence of fatigue. As the patient progresses, static strengthening exercises could be performed before proprioceptive exercises to increase the challenge associated with muscle fatigue accumulation. Exercises under unstable conditions favourably increase the role of proprioceptive afferent inputs and optimize the co-ordination challenge between trunk and head acceleration. Exercise regimens could also include overall postural activities for the patient, such as beginning in a sitting position and progressing to standing position. Proprioceptive and isometric strengthening exercises could be performed on a Swiss ball and in upright stance with several feet positions  (Figure 3a and b) or with the feet on an unstable support base (for example; wobble board or foams).

Article references:

1. Greenstein JS. Active Care – The future of your practice. Canadian Chiropractor, Volume 3, No. 2, April 2008. 11 and 32.
2. Côté P, Cassidy JD, Carroll L. (2000). The factors associated with neck pain and its related disability in the Saskatchewan population. Spine, 25(9):1109-1117.
3. Côté P, van der Velde G, Cassidy JD, Carroll LJ, Hogg-Johnson S, Holm LW, Carragee EJ, Haldeman S, Nordin M, Hurwitz EL, Guzman J, Peloso PM (2008). Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 33(4 Suppl):S60-74.
4. Cassou B, Derriennic F, Monfort C, et al. (2002). Chronic neck and shoulder pain, age, working conditions: longitudinal results from a large random sample in France. Occupational & Environ Med, 59:537–44.
5.  Fejer R, Kyvik KO, Hartvigsen J. (2006). The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J, 15(6):834-848.
6. Verhagen AP, Scholten-Peeters GG, van Wijngaarden S, de Bie RA,Bierma-Zeinstra SM. (2007). Conservative treatments for whiplash. Cochrane Database Syst Rev. Apr 8;(2):CD003338.
7. Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G. (2005). Cervical Overview Group. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. Jul 20;(3):CD004250.
8. Rubin AM, Woolley SM, Dailey VM, Goebel JA. (1995). Postural stability following mild head or whiplash injuries. Am J Otol, 16(2):216-221.
9. Field S, Treleaven J, Jull G. (2008). Standing balance: a comparison between idiopathic and whiplash-induced neck pain. Man Ther, 13(3):183-191.
10. Karlberg M, Persson L, Magnusson M: Impaired postural control in patients with cervico-brachial pain. Acta Otolaryngol 1995, 115(S520):440-442.
11. Treleaven J, Jull G, Lowchoy N. (2005). Standing balance in persistent whiplash: a comparison between subjects with and without dizziness. J Rehabil Med, 37(4):224-229.
12. Humphreys, K. (2008). Cervical outcome measures: testing for postural stability and balance. J Manipulative Physiol Ther 31:540-546.
13. Morningstar MW, Pettibon BR, Schlappi H, Schlappi M, Ireland TV. (2005). Reflex control of the spine and posture: a review of the literature from a chiropractic perspective. Chiropr Osteopat. 13:16.
14. Le Pera D, Graven-Nielsen T, Valeriani M, Oliviero A, Di Lazzaro V, Tonali PA, Arendt-Nielsen L. (2001). Inhibition of motor system excitability at cortical and spinal level by tonic muscle pain. ClinNeurophysiol, 112(9):1633-1641.
15. Flor H (2003). Cortical reorganisation and chronic pain: implications for rehabilitation. J Rehabil Med, 66-72.
16. Capra NF, Ro JY. (2000) Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles. Pain, 86(1-2):151-162.
17. Lafond D, Champagne A, Cadieux R, Descarreaux M. (2008). Rehabilitation program for traumatic chronic cervical pain associated with unsteadiness: a single case study. Chiropr Osteopat. 16:15.