Core Muscles of Neck and Exercises

Everyone talks about strengthening of "CORE MUSCLES" to prevent back pain but, we rarely hear or talk about the core muscles of neck.
Research shows that 70% people experience neck pain at some point in their life.The cause of injury may range from accident to use of wrong pillow causing strain in their neck. Any injury has shown to inhibit recruitment and strength of muscles in neck. And these muscles are your DEEP NECK FLEXORS or Core muscles.
Similar to lumbar spine, cervical spine uses these deep muscles to ensure the intersegmental spinal control.

DEEP FLEXOR MUSCLES

Small stabilizing muscles are located in anterior and antero-lateral part of cervical spine. They are located deep to sternocleidomastoid.

LONGUS COLLI
ORIGIN and INSERTION
Superior oblique arises from anterior tubercle of transverse process of third fourth and fifth cervical vertebra and inserted into narrow arch of the tubercle of atlas.
Inferior fibres originate from first 2 or 3 bodies of thoracic vertebrae and is inserted intoanterior tubercle of the transverse process of 5th and 6th cervical vertebra.
It is the most common muscle injured during whiplash injuries.
Longus colli with other muscles forms a sleeve to stabilize the neck in antigravity positions.

LONGUS CAPITIS
ORIGIN and INSERTION
It arises from four tendinous slips from the transverse processes of third, fourth, fifth and sixth cervical vertebra and is inserted into inferior surface of basilar part of occipital bone.

Both the muscles together perform following role:

• Responsible for initiating or starting neck flexion movement.
• reduce shearing force across cervical facet joint and disc.
• maintain neck posture.

Patients with neck pain exibit an increased EMG amplitude of superficial sternocleidomastoid and scalene muscles and decreased activation of deep flexors which causes a decrease in range of motion.
A low load program for craniocervical flexion exercise focusing especially on motor control of deep neck flexors have shown to reduce neck pain and headaches.

chin tuck in

EXERCISES TO ACTIVATE CORE MUSCLES


1) CHIN TUCK IN EXERCISE:
Lie on the floor with neck supported.Tuck your chin in or push your head on the floor without bending your neck. Repeat the exercise for 12 counts for 2 sets. Gradually try to hold each count for 5sec.

2)HEAD LIFT EXERCISE
Lie on the floor. Tuck your chin in and lift the head just 3-4 inches above the floor and return.

3)NECK FLEXION
Ask the patient to lie on the floor with knees bent and feet on floor. Put finger at base of the skull and lift about 1/8th inch off the floor. Make sure the neck is not liftitng off the floor. Remember core exercises are slow movements. Feel down  for a bony bump (7th cervical vertebra). Now ask patient to lift the neck till this bump and the skull but not the rest of the neck. Now gradually ask to release it.

4)BIOFEEDBACK
You can also keep a pressure sensor or pressure cuff beneath patients neck and ask him to slowly nod as if saying yes.Ask him to hold the position 2mmHg above the baseline and gradually increase the baseline to 4,6,8 10 mm Hg and 10 Sec hold. Highest level acheived in 10 repetitions 10 seconds hold.

PERFORMANCE INDEX MEASURE
Number of times patient can hold pressure level, multiply  it by pressure increment. For example: if patient can achieve 4mmHg and could do 6 repetitions of 10 sec hold without breaking the form then the performance is 24. The highest is 100 that is 10 mmHg and 10repetitions.


5) CRANIOCERVICAL FLEXION WITH CERVICAL FLEXION
It works on deep as well as superficial muscles.
Tuck in the chin and lift the head off  so that chin touches the chest.

PROGRESSION
a) Using resistance with help of theraband or manually applied resistance.
Patient is supine. The resistance is applied manually  and the patient is asked to do 12 repetitions of craniocervical and cervical flexion.
 Perform 3 sets of 12 repetitions for 2 weeks then by 4th week perform 15 repetitions.

 b) In quadruped position
Ask patient to assume quadruped (on all four) position and perform chin tuck in or nods without bending the neck.

EXERCISE IN FUNCTIONAL POSITION


a) Sit with feet flat n buttock supported.Gently roll the pelvis forward on ischial tuberosity.
Instruct the patient to move thorax slightly up and forward for slight lift.Gently and minimally lift the occiput to position the head in neutral position away from cervical extension.

b) Also, Patient must be taught to maintain optimal neck position while performing upper extremity task.

Shoulder blade stabilization is integral part of stabilization of neck and hence shoulder blade exercises should also be performed.


Also a heat pad can help to relax the muscles and the perform the exercises, make sure that mild stretches are done after the exercises are over.
While performing all exercises breathing is very very important. Make sure during the course of exercise you donot hold your breath and perform the exercise.

Thus, training these muscles along with the treatment commonly practiced by the physiotherapists will serve to prevent the later complications or recurrence of any chronic dysfunction.


 DISCLAIMER: The above given program is a general guideline to introduce the importance of the concept of core muscles of neck. Do thoroughly assess your patient before attempting any of the exercises.

Aquatic Cardiac Rehabilitation

Aquatic exercises are popular because of the buoyancy afforded by water which lowers joint stress and resistance created by moving one's limb through water.

Recently water based activity is also becoming popular in cardiac rehabilitation. But it’s still controversial because of the safety concerns put forth by many doctors.

SAFETY CONCERNS:

Physiological changes after immersion could jeopardize diseased myocardium.

Possible problems	Physiological changes	Possible clinical outcomes
Increase in central blood volume	Increase stroke volume and cardiac output and left ventricular   volume. Decrease in heart rate	Increase in left ventricular wall stress, angina, ST depression.
Cold Water exposure	Increase in PaCO2 and decrease in heart rate	Increase in ventricular irregularity Increase in arrhythmia

PRACTICAL CONCERNS:

Heart Rate:  As its difficult to monitor it, there might be a problem in deciding intensity for exercise prescription

Monitoring: ECG and Blood pressure monitoring also becomes difficult.

PATIENT SELECTION:

Exercise is most beneficial for LOW-MODERATE RISK cardiac patients who either like swimming or have orthopedic or arthritis problems which may increase by land based exercise.

Water based exercises are particularly beneficial for individuals with peripheral vascular diseases. Particularly if temperature is 30-33 degree Celsius.Warmer water facilitates vasodilation and added buoyancy afforded by water decreases lower limb stress, allowing longer exercise duration.

EXERCISE PRESCRIPTION CONSIDERATIONS:

Water temperature: 26- 33degrees

Temperature at lower end is better for heat dissipation while upper end temperature is comfortable for most of the patients. If patient has orthopedic or PVD better is upper end temperature. Temperature should never be less than 15 degrees.

INTENSITY:

40-85% of the functional capacity. Start with a 40-50% of the functional capacity.

FREQUENCY AND DURATION:

Perform exercise at least 3 days per week

Aerobic portion: 20-30min. If you are performing Swimming: 1000 yards (500-2000) and Walking: 400-700 yards/workout

Warm up and cool down is very important. Warm up can be done for 3-5 min of stretches and light calisthenics on pool deck And Cool down in water3-5 min free standing and wall stretches.

MONITORING:

Frequent monitoring of Blood pressure and heart rate.

ECG should be done during early stages

EMERGENCY PROCEDURES: The staff should be well trained for CPR and defibrillator should also be present.

AQUATIC ACTIVITIES /EXERCISES:

1) WATER WALKING

It’s one of the safest and easiest activity. Energy cost is determined by depth, speed, and degree of arm involvement.The depth of the water should be between thighs and chest so as to have a greater energy cost. Going deeper may decreased the cost as buoyant forces affordable by water offsets the increased resistance that comes from having water coverage over greater body surface area. Energy cost increases with increase in speed. To increase intensity involve arms. Arms can be used in simulated swimming motion either above (front crawl)or below breast stroke.

2) GAIT TRAINING

Gait training and submerged interval training help you gain benefits of jogging or running without added impact on joints.

Similarly stretching and extensions help in flexibility with help of underwater leg movements such as kicks, bicycling maneuver and lateral rises.

THE PLOW

It’s a type of gait exercises .Once you are comfortable walking and jogging in water try using a wide hand held exercise tool called plow to increase resistance of your gait.

According to study in Journal of Athletic training: plow exercise mimics physical demands of aerobic sports like football and should be completed in shallow water sprints of 6 to 10 sec interval.

3) BUOYANCY RESISTED STERTCHES

Basic stretches: recovering joint .more intense variety can be used to create aerobic effect

Begin with underwater kicks.

Added effect: stretch your leg as much possible during end of each kick and gradually increase power and speed. If it’s difficult perform lunge/lateral raise in shallow water.

3) SWIMMING

Variants of strokes. For modified backstrokes, side strokes and breast strokes intensity can be controlled by most of the patients.

Front crawl not recommended by many people.

4) SWIMNASTICS/ WATER AEROBICS

These are Upright group water exercises, essentially aerobic dance conducted in water

5-10 min warm up in water then a 15-20 min of aerobic arm and leg exercise and 5 min cool down, resistive movements can also be done with help of  water dumbbells, floats/paddles.

Aqua stepping: step aerobics using weighted steps can also be done.

5) WATER VOLLEYBALL

Fun alternative: Played in shallow end. Water level: waist to nipple level. It should not be replaced to aerobics.

RECENT EVIDENCE:

Training induced increase in NO metabolites in CHF and CAD : an extra benefit of water based exercise. (European Journal of cardiovascular prevention rehabilitation Aug 2009)

CONCLUSION OF THE STUDY:

The cardio respiratory capacity of patients was significantly improved after rehabilitation.Water based exercise seemed to effectively increase the basal level of plasma nitrates. Such changes may not be related to an enhancement of endothelial function and may be important for health of patient.

DISCLAIMER: Please consult your doctor before attempting any of the above exercises.