Spine - ICF Neck Pain with Movement Coordination Impairments: Cervical Spine Instability

ICF classification: Movement with movement coordination impairments

• Clinical instability: the inability of the spine under physiologic loads to maintain its pattern of displacement so that no neurologic damage or irritation, no development of deformity, and no incapacitating pain occur

Zone/systems review

• Neutral zone: motion that occurs in and around the neutral mid position of the spine and is produced against minimal passive resistance

• Elastic zone: motion that occurs near the end range of spinal motion that is produced against increased passive resistance

• Stabilizing systems:

  • Passive: vertebral bodies, joints, joint capsules, ligs, passive tension from muscles/tendons - stabilizes elastic zone and limits size of neutral zone

  • Active: spinal muscles and tendons, generates force in response to changing loads to maintain size of neutral zone

  • Neural: peripheral nerves and CNS, receives information from passive and active systems and uses them to act on muscles to produce required stabilization forces

• Clinical instability occurs when the neural zone increases and the stabilizing systems are unable to compensate for this increase, causing poorly coordinated movement

Causes

• Breakdown/damage of the passive stabilizing subsystem

  • Commonly caused by

    • RA

    • Down syndrome

    • Post traumatic event (i.e. MVA)

Symptoms & Impairments

• Symptoms:

  • Neck pain and associated UE pain

  • Remote hx of trauma

  • Intolerance to static WB postures

  • Fatigue and inability to hold the head up

  • Symptoms relieved w NWB postures

  • Sharp pain w sudden movements

  • Aberrant movements

  • Bilateral foot and hand dysesthesia

  • Feeling of a lump in the throat

  • Taste of metallic in the mouth (CN VII)

  • Arm and leg weakness

  • Lack of bilateral extremity coordination

• Impairments:

  • Hypermobility with loose feel of cervical segments

  • Deficits in strength, endurance, and coordination of deep cervical flexor/extensor muscles

  • Aberrant motion with cervical AROM

  • Greater cervical AROM in supine (NWB) position compared to standing (WB) position

  • Neck and neck related UE pain reproduced with provocation of the involved cervical segment

• Interventions

• Neck and postural muscles coordination, strengthening, and endurance exercises

  • Enhance the function of the active subsystem

  • Improves the quality of control of movement within the neutral zone

• Stretching

• Mobilization and manipulation at segments above and below hypermobile segments

  • Decrease stress on the passive subsystem

  • Allows spinal movement to be more evenly distributed across several segments

• Ergonomic corrections

  • Reduces the load placed on the spinal segments at end ranges

  • Returns the spine to a biomechanically efficient position

• If therapeutic interventions do not work

  • Surgical spinal fusion may be necessary

Musculature

• Cervical multifidus

  • Provides posterior stability via attachments to cervical vertebrae

  • Strengthening allows these muscles to improve control over movements

• Longus colli/longus capitis

  • Provide ant stabilization to cervical vertebrae

  • Pts with neck pain disorders showed decreased muscle synergy of deep neck flexors and overuse of the SCM

• Deep neck extensors

  • Pts w neck pain often shows lack of muscle synergy in the semispinalis cervicis, with overuse of the splenius capitis, which often causes decreased neuromuscular control in the middle and lower cervical spine and increased tone in the suboccipitals

• Combined training of the deep neck flexors and extensors has been shown to increase strength and reduce neck pain