Astri - Neck Cailliet Exercise

Neck Cailliet ExercisePresentan : Setia Wati Astri Arifin Pembimbing : Prof. Dr. dr. Angela B.M. Tulaar, SpKFR-K

Introduction

Vertebra CervicalForamen transversumProcessus articularis pendekForamen vertebra segitiga, lebih besar dari corpusProcessus spinosus pendek dan bercabang

Cervical Vertebral ColumnNeumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p

C1= AtlasBagian superior ada faset luas, (berartikulasi dengan occipital)Tidak memiliki corpus & processus spinosusGerakan rocking YES Joint (fleksi ekstensi)

C2= AxisBentuk seperti gigi proc.odontoid (dens)Bersendi dengan atlasGerak : rotasi = NO JointRotasi terbesar mencapai 50% (total rotasi leher)

Tidak terdapat diskus antara C1 - occiput & antara C1 C2Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Sendi Atlanto OccipitalSendi antara faset superior atlas dan condilus occipitalDisebut YES JointsRocking motionSendi Atlanto AxialRotasi pada bidang longitudinalDisebut NO JointsRotasi 50% (total rotasi leher)

Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

C 7 Vertebra ProminensProcessus spinosus : panjang, tebal, hampir horizontal, tidak bifidaProcessus transversus lebih luasForamen transverum lebih kecilReyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Membentuk 5 persendian :Vertebra-diskus (true joint)Sepasang Sendi Luschka (false joint)Sepasang articulasi posterior faset (true joint)Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Arunachalam Kumar VK. UNCO VERTEBRAL JOINTS OF LUSCHKA: AN OSTEOLOGICAL STUDY. Nitte Univ J Health Sci. 2012;2(4):579

A paired of Luschka Joints (unco-vertebral joints) important in the pathology of neck painReyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.

Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p

Muscles of The NeckReyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p

http://www.slideshare.net/ananthatiger/muscles-of-the-neck-1Superficial

SuperficialLippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company

FlexorsSCMScalenusLippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company

FlexorsLippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company

ExtensorsLippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company

SpinalisExtensorsLippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company

Kinesiologi Faset pada prosesus articularis cervikal berorientasi pada :Bidang oblique 45Arah kemiringan dari atas depan ke bawah-belakangMembentuk sadel joint

GerakanFleksiEkstensiLateral fleksiRotasi

karena posisi persendian yang khas, trauma (dislokasi) tanpa fraktur tulang sering terjadi

WHIPLASH INJURY

C4 s/d C6Paling aktif bergerak fleksi dan ekstensiPaling sering mengalami kondisi patologis


FORAMEN INTERVERTEBRALISFleksi membukaEkstensi menyempitLateral fleksi Foramina ipsilateral mengecil & foramina kontralateral membesar dan sebaliknyaCANALIS CERVICALISFleksi MemanjangEkstensi MemendekTetapi syaraf/medulla spinalis tidak memanjang/memendekReyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p

Cervical ROM

MovementDegree ()TotalAOJAAJC2-C7Flexion6010545Extension80251045Rotation (each side)75-4530Lateral flexion (each side)4551030

www.healthtap.com

Movements of The DiscSumber :Diunduh dari http://www.coreconcepts.com.sg/mcr/wp-content/uploads/2008/06/stretched-disc.jpg

Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p

MusclesFlexionExtensionLateral FlexionAxial RotationSternocleidomastoideus XXXX (upper)XXXXXX (CL)Scalenus anteriorXX-XXXX (CL)Scalenus mediusX-XXX-Scalenus posterior--XX-Longus colliXX-XX-Longus capitisXX-XX-Rectus capitis anteriorXX (AOJ)-X (AOJ)-Rectus capitis lateralis--XX (AOJ)-Splenius capitis -XXXXXXXX (IL)Splenius cervicis-XXXXXXXX (IL)Rectus capitis posterior mayor-XXX (AOJ & AAJ)XX (AOJ)XX (IL) (AAJ)Rectus capitis posterior minor-XX (AOJ)X (AOJ)-Oblikus capitis inferior-XX (AAJ)-XXX (IL) (AAJ)Oblikus capitis superior-XXX (AOJ)XXX (AOJ)-Keterangan: AOJ : atlanto-oksipital joint AA J : atlanto-aksial joint CL : contralateralIL : ipsilateral

Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p

NECK PAIN

Epidemiology

Classification by Onset

Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.Tulaar ABM. Nyeri leher dan punggung. Maj Kedokt Indon 2008; 58(5): 169-180

The most common neck pain is non-specific mechanical neck pain caused by muscle strain, ligament sprain, spasm, or a combination No specific lesions, or findingsUsually caused by daily activitiesPhilip D. Sloan, Essentials of the family medicine , Chapter 37 Introduction , Wolters Kluwer , 6th edition

PatophysiologyIrritation or inflammation on cervical tissue can produce pain The nociceptive sites on cervical area are:Anterior & Posterior Longitudinal LigamentOuter Annulus Fibrosus DuramaterSpinal Nerve Root Facet Joint Capsule Muscles Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

PatophysiologyTwo major mechanisms of neck pain are trauma and arthritisTrauma:External traumaPostural traumaTension traumaArthritis: Degenerative arthritis Sequelae of acute inflammation arthritisCaillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

PatophysiologyExternal Trauma: The neck received external forces that cause abnormal cervical vertebrae position or movement that leading to injury and painCaillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

PatophysiologyPostural Trauma:Wrong posture can cause various trauma to the musculoskeletal system, especially the vertebral column:Forward head postureDropping shoulder

Image Source: Quora.comCaillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

PatophysiologyTension Trauma: Emotional factor hypothalamic limbic system physiologic & neuromuscular system Tension within the neuromuscular system manifest as a sustained isometric muscular contraction No period of relaxation blood flow Ischemic pain lymphatic flow nutrient & O2 metabolic waste, lactic acidCaillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

Penyebab Nyeri Leher

Clinical ManifestationPain on neck or pain from neck, with or without radiation to the head, back, shoulder and upper extremityFatigueSleep disturbanceHeadache Pain with movementLimited ROMPalpated trigger pointRadicular pain: Sharp or dull, burning sensation or shocking pain depend on ventral or dorsal nerve root involvementDistributes according to the dermatomal or myotomal areaNeurologic symptoms such as tingling sensation, paresthesia, numb or weakness Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.

PM & R Jackson C. TanDifferential Diagnoses

Neck Cailliet Exercises

Kontraindikasi

Isometric Neck Exercise

Thank You

Flynn TW, Cleland JA, Whitman JM. Users Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008.

Axial (C2)Odontoid Process / Dens, Tooth-like projectionArticulates with anterior arch of atlas rotation in longitudinal plane Act as a PIVOTCalled NO JointsGreatest motion of neck rotation 50% total neck rotation

NO joint

MotionAtlanto AxialFlexion5Extension10Rotation (each side)45Lateral flexion (each side)10

Atlas (C1)No vertebral body2 large concave facets on upper surface occipital condyles

YES joint

MotionAtlanto - OccipitalFlexion10Extension25Rotation (each side)-Lateral flexion (each side)5

Atlanto Occipital JointArticulates between facets superior Atlas and occipital condylesCalled YES JointsRocking motion; Flexion & Extension

KontraindikasiMyelopathyFracture DislocationAcute InjuryVascular injuryInfectionMalignancyLigamentous instabilityJoint InstabilityDiseases Affecting the Tissues Being StretchedExcessive Pain When StretchingInflammation or Joint EffusionSevere degenerative changesVertebrobasilar insufficiency

Flynn TW, Cleland JA, Whitman JM. Users Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion. 2008.

Cervical Movement Major movement in range and amplitude occurs between skull C3. Movement of C4 C7 depend upon ligament laxity, distortion and compressibility of intervertebral discFacet joints in coronal plane, slanted backward 45Flexion cervical canal lengthens, intervertebral foramina openExtension cervical canal shortens, intervertebral foramina narrowedLateral bending close on the side the head turns and vice versa

Lower Cervical Movement Most active and most mobile C4-C6C 4-6 maximum stress most wear and tear and degenerative diseaseGreatest degree of flexion C 4-5 and C 5-6Maximal extension C 4-5

Cervical Movement

MotionAtlanto OccipitalAtlanto AxialC2 C7Total cervicalFlexion1054560Extension25104580Rotation (each side)-453075Lateral flexion (each side)5103045

Vertebra ServikalMempunyai foramen tranversumProsesus artikularis pendekMembentuk 5 persendian dengan vertebra terdekat:Sisi akhir vertebra dengan diskus (true joint)Sepasang joint of luschka (false joint)Sepasang artikulasi posterior faset (true joint)C4-C6 paling aktif bergerak fleksi dan ekstensi, paling sering mengalami kondisi patologisReyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Joint of Luschka / Uncovertables jointdibentuk oleh proyeksi tulang( prosessus uncinatus)Faset pada prosesus artikularis cervikalOrientasi pada bidang oblik: miring dari atas depan ke bawah belakangMembentuk saddle joints, 3th degree freedom of motionGerakan: fleksi, ekstensi, lateral fleksiTrauma tanpa fraktur sering terjadi: whiplash injury


C1 = atlasNo bodyBagian superior ada faset luas, bersendi dengan occipitalGerakan rocking=YES jointC2 = axisBentuk seperti gigi = prosesus odontoidBersendi dengan arkusGerak=rotasi=NO jointReyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

C7 = ProminensProcessus spinosus : panjang, tebal, hampir horizontal, tidak bifidaProcessus transversus lebih luasForamen transversum lebih kecilReyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Deep Cervical Lymph NodesJugular TrunkRetroauricularNodesSuperficial Cervical Lymph Nodes

Cervical Spinal Nerves

Classification by ICD-10

Classification by ICF

1. Trunk or lower extremity neurologic symptoms, especially long-tract signs. 2. Bilateral upper extremity pain. 3. Remote symptoms with neck movements (lower extremity). 4. Signs of sphincter dysfunction, bowel or bladder dysfunction or incontinence. 5. Fever, unrelenting nocturnal pain, weight loss, chronic fatigue. 6. Recent infection or surgery. 7. Polyarthralgia. 8. Dysphagia. 9. Nuchal flexion or extension rigidity, especially in the absence of trauma. 10. Cranial neurologic deficit or central nervous system symptoms. 11. Cervical pain related to general exertion (i.e., after climbing stairs). 12. Symptoms unchanged or progressive, despite previous functional management. 13. Onset of cervical pain associated with direct head trauma, loss of consciousness. 14. Sudden onset of cervical pain without trauma or incident. 15. Neck or occipital pain with a sharp quality and severe intensity, or severe and persistent headache, which is sudden and unlike any previously experienced pain or headachePrecautions Symptoms that Should Raise Suspicion That The Presenting Cervical Pain Is Not Of Mechanical Origin (McMillin)

The Scientic Evidence Strongly Supports the Use of: Screening protocols in emergency care in low risk patient with blunt trauma to the neckCT-scanning in emergency care for high-risk patients with blunt trauma to the neckFor non-emergency neck pain:Manual provocation tests in patients with neck pain and suspected radiculopathyThe combination of history, physical examination, modern imaging techniques, and needle EMG to diagnose the cause and site of cervical radiculopathySelf-reported patient assessment to evaluate perceived pain, function, disability, and psychosocial statusNordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of Neck Pain and Its Associated Disorders. Eur Spine J. 2008 Feb 29;17(1):10122.

EvaluationPhysical Examination:Palpation of trigger point & tendernessCervical Range of Movement (CROM)Manual Muscle Testing (MMT)Pain Perception:Visual Analog Scale (VAS)Functional Assessment:Neck Disability Index (NDI)46,47

Cervical ROM ExaminationImage Source: http://www.slideshare.net/ssuser33ed1c/neck-trunk-rom-measurement

Image Source: annals.orgImage Source: womenhealth.us

Vernon H, Mior S. The neck disability index: a study of reliability and validity. J Manip Physiol Ther 1991; 14:407-415.

INTERVERTEBRAL DISKS

Intervertebral DisksThe chief structural unit between adjacent vertebral bodies 25% of the total length of the spinal columnFunction:To bind vertebrae together & allow motionContributes to the formation of spinal curves (cervical & lumbar)A self-contained fluid elastic system that absorbs shock during vertical loading & permits transient compression

Intervertebral DisksAllowing fluid displacements within its elastic container, distributes pressure equally The compressive force is not concentrated on the edge of the vertebral body toward which the spine bendsPermits movement, equalizes pressure and forces on the column & disperses the forces.

Sumber diunduh dari http://classconnection.s3.amazonaws.com/704/flashcards/586704/png/intervertebral_disk1309215048088.png

Intervertebral DisksThe cartilaginous plateHyaline cartilage Covers the bony surfaces of the opposed vertebral bodiesAct as semipermeable membraneAnchors the attachment of the annulus fibrosus

The Disk is made up of two parts:Nucleus pulposus Annulus fibrosus

Nucleus pulposus 40% of cross sectionBetween middle & posterior third of the disk 80% waterPascals Law of fluid under pressureThe external forces that applied to any point is transmitted to every unit area of the interior of the containing vessel

Karakter DiskusGambar diunduh dari http://www.corpshumain.ca/en/images/Squelette_colonne_(FF)_en.jpg

Area ServikalisUkuran besar : diskus > korpus vetebraKetebalan : bagian anterior > bagian posterior (membentuk kurva lordosis)Lebar diskus sedikit lebih kecil dibandingkan korpus vertebraLokasi nukleus lebih anterior dibandingkan dengan di area lainArea ThorakalisKetebalan : bagian anterior = bagian posterior (bentuk kurva kifosis lebih dikarenakan struktur korpus vertebra dibandingkan diskus intervertebralisnya)Ukuran diskus lebih tipis dibandingkan pada area lainnyaUkuran lebih kecil dibandingkan dengan korpus vertebraArea LumbalisKetebalan : bagian anterior > bagian posterior (membentuk kurva lordosis)Paling terlihat pada intervertebralis L5

Vasular Supply & Innervationn. rekuren meningealLigamentum longitudinal posterior Posterior annulus fibrosusNot innervates nucleus pulposus insensitive structureBlood supply of the disk dissappears about the second decade of lifeNutrition depends upon the osmotic properties of cartilagenous plate Alternate compression & relaxation of the elastic container resembles a sponge being squeezed & relaxed

The Load on L3 Disk for Subject Weighing 70kgs (Nachemson)Sumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.

PosisiBeban (Kg)Standing100 Sitting140Sitting with forward tilting 20190Sitting with forward tilting 20 with 20 kg weight270Reclining70Supine 16Tilting forward from a standing position carrying 50 kg300

Weak Area & ProtrusionTremendous amounts of pressure the disks are constantly under, making it very prone to being dislocated or rupturedRuptured disks or herniated nucleus pulposus most commonly occurs in the lumbar region (L5-S1 , L4-L5) occasionally thoracic areaProtrusion of the disk occurs posterolaterally , because:The stresses usually generated by lifting a load with the trunk in flexion greatest stretch given to posterior aspect of annulusThe annulus is thinner posteriorly No ligament at the posterolateral aspectAnterior ALLPosteromedial PLLSumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.

When the disk protrudesSumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.Rule of Thumb:When the disk protruded is small, it will usually affects the spinal nerve below correspondent vertebra.If there are symptoms of sensory motor loss as referred to spinal involvement, the disk number is one above the vertebra

No.OrganSensitifResisten Ligamentum longitudinalis posterior2.Ligamentum longitudinalis anterior3.Ligamentum flavum4.Serabut saraf5.Anulus fibrosus6.Kartilago facet artikularis 7.Korpus vertebra8.Ligamentum interspinosus9.Otot-otot trunkus

Normal DehydrationDehydration during days activity loss of 2cm height in an adultDuring the rest in bed & sleep pressure

Aging Decreased ability to absorbs water

LigamenLigamen Longitudinal anterior& posteriorLigamen transversumLigamen FlavumLig. Atlanto-occipitalLig. Cruciate proc. odontoid & occiputLig. Alar proc odontoid & anterior atlasLigamentum nuchae

Longitudinal Intersegmental Ligament Anterior Longitudinal LigamentPosterior Longitudinal LigamentSupraspinous LigamentLongitudinal Intrasegmental Ligament Interspinous LigamentIntertransverse LigamentsLigamentum FlavumReinforcing ligaments of atlanto-occipital and atlanto-axial jointsThe reinforcing ligaments of SIJ

LIGAMENTS

Tulaar ABM. Nyeri leher dan punggung. Maj Kedokt Indon 2008; 58(5): 169-180Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 pReyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.

First I will review about the neck, which including *There are 7 cervical vertebral column The 3rd - 6th vertebrae is a typical cervical vertebraeThe 1st, 2nd, and 7th are atypical cervical vertebraeTypical cervical vertebrae hasrectangular bodies with articular uncinate processes on their lateral aspectstriangular vertebral foraminabifid spinous processes and transverse foramen*These are the ligaments in the cervical area*These are the veins in the neck regionThe important superficial veins are External Jugular Vein that close to the SCM muscle*And now the muscles of the neck divided into 3 parts*This is platysma muscle **Normal movement of cervical area includes flexion, extension, rotation and lateral flexionThe total movement of cervical area is consist of combination movement from AOJ, AAJ, and 2nd to 7th cervical vertebral columns

*Struktur diskus akan berbentuk baji (wedge-shaped) dengan bagian terluas merupakan bagian cembung dari kurva

Gerak FleksiKompresi pada jaringan ikat bagian anterior dan relaksasi pada bagian posterior

Gerak EkstensiKompresi pada jaringan ikat bagian posterior dan relaksasi pada bagian Anterior

*This is the summary The muscle involved *Jangan lebih dari 1 slide**(eg, disk bulging or degeneration, osteophytes, spondylolysis, congenital facet abnormalities) *Jadiin 2 slide*Postural cause of neck pain is frequently found and leading to disabilityNormal cervical postur is defined by cervical lordosis that maintained to keep the head in line with gravity line, where the head is slightly anterior to the gravity line Upper point of gravity line is on the outer ear cavity

*Jadiin 2 slide*in shoulder, arm and hand, with the most frequent site in interscapula area with or without radiation to the occiput, shoulder or arm

*fleksibilitas spina servikal, re-edukasi postur dan penguatanpartisipasi aktif pasien*The lymphatic vessels from thead, face and neck will drain into the superficial & deep cervical lymph nodesAnd then to the right and left jugular lymphatic trunkThe right jugular lymphatic trunk will drain directly into right venous angleBut the left jugular lymphatic trunk will drain into the left venous angle through the thoracic duct

Arahnya kemana Pijatan Otot origo insersio*There are 8 cervical spinal nerves come out from foramen intervertebralis, despite of 7 cervical vertebral columnsThe 1st cervical spinal nerve comes out from above atlas/C1/1st cervical vertebral columnthe 8th cervical spinal nerve comes out from foramen intervertebralis between C7-T1*Motoric component cervical spinal nerves innervate variuous muscle according to the levelSensoric component cervical spinal nerves has segmental area of innervation known as dermatomes*There are two plexus that arise from cervical spinal nerves root*The VAS is best at detecting change in patients who improve in pain. *The NDI, a neck-specic functional status questionnaire, 10 items including pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping and recreation.the NDI has proofed to be a valid tool for functional assessment of neck disability. & the most commonly used self-report measurefor neck painThe NDI can be used to evaluate the patients status at present and to evaluate the evolution during the therapy**Nukleus pulposus hanya dapat menahan tekanan / beban yang terbatas.

Pada beberapa posisi, beban yang diterima tubuh meningkat lebih tinggi.

Mekanisme lain yang membantu menahan beban / tekanan :

Gaya beban / tekanan akan dikurangi sebanyak 30% oleh otot-otot trunkus yang membentuk dinding rongga dada dan rongga perut.

*

Astri - Neck Cailliet Exercise

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