Exercise for Neck Pain · exercise intervention had up to 5.3 times higher odds of disability reduction, and 3.9 times higher odds of pain reduction compared to those in the physical

Deborah Falla

Centre of Precision Rehabilitation for Spinal Pain School of Sport, Exercise and Rehabilitation SciencesCollege of Life and Environmental SciencesUniversity of Birmingham, United Kingdom

@Deb_Falla

Exercise for Neck

Pain

http://www.google.co.uk/url?url=http://plus.google.com/u/0/%2Bunibirmingham&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjC5e70qdLMAhWjOsAKHQNcATcQ_B0IcTAR&usg=AFQjCNHFFSX0JP2TV7DXJa8rFlzPu-fgjA

The enormous burden of neck pain

Neck pain is one of the most common

musculoskeletal disorders with an annual

prevalence up to 50% and a lifetime prevalence

up to 70%

In the main it is not a catastrophic condition, but it

can have a significant impact on a person’s work,

recreation and quality of life

Neck pain spares no age group, gender or culture

Global Burden Disease 2015. Lancet. 2016

The enormous burden of neck pain

Following a first episode of neck pain, there is a

high chance of repeated episodes, which may

extend over a lifetime

Up to 85% of people can expect some degree of

ongoing pain for many years after their first

episode

30% of patients develop chronic pain

Haldeman et al. J Occup Environ Med 2010

Hush et al. Arch Phys Med Rehabil 2011

Systematic reviews and meta-analyses confirm

the effectiveness of exercise for relieving neck

pain and also for the prevention of pain

Kay et al. Cochrane Database Syst Rev. 2012

Bertozzi et al. Phys Ther. 2013

Yamoto et al. Br J Sports Med. 2015

Gross et al. Man Ther. 2016

Fredin et al. Musculoskelet Sci Pract. 2017

de Campos et al. J Physiother. 2018

Effective and early management of pain via

exercise is promoted as a critical element of

management for neck pain, recommended by

clinical practice guidelines internationally

When considering the analgesic effect of

exercise, multiple forms of exercise have

been proposed to relieve neck pain

Currently there is little

evidence of

superiority of one

exercise approach

over another

Geneen et al. Cochrane Database Syst Rev. 2017

Cranio-cervical Flexion Training

Motor Control

General Neck Flexion Training

Strength

Falla et al. Clin Neurophysiol. 2006

Falla et al. Phys Ther. 2007

O’Leary, Falla et al. J Pain. 2007

Falla et al. Man Ther. 2008

Jull, Falla et al. Man Ther. 2009

Chronic idiopathic neck pain

Mild to moderate disability

6 week intervention

Practising daily

CCF training

Strength training

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ck P

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Falla et al. Clin Neurophysiol. 2006 Falla et al. Phys Ther. 2007

Comparable reduction of pain and disability

between groups

O’Leary et al. Arch Phys Med Rehab. 2012

CCF Training

Motor ControlCCF Training

Endurance

Range of Motion Training

Flexibility

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Ne

ck P

ain

Dis

ab

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(N

DI)


between groups

Baseline 10 wk 26 wk Baseline 10 wk 26 wk Baseline 10 wk 26 wk

Mechanical neck pain


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**

**

Progressive Resistance Exercise

Elastic bands

Physical Activity

General activity and Resistance

Iversen et al. J Rehab Med. 2018

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Baseline 3 wk 12 wk Baseline 3 wk 12 wk

Chronic non-specific neck pain



between groups

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ck P

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ctio

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ck P

ain

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Re

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Systematic reviews indicate little

evidence of superiority of one exercise approach over another

Decision on the type of exercise to use should be dictated by

clinician preference

The same exercise does not achieve the same

effect in different neck pain disorders

Perceived pain and disability is not the only

relevant outcome measure

Specificity of exercise is critical to modify

neuromuscular function

Exercise for Neck Pain








Effect of cranio-cervical flexion exercise in

cervicogenic headache

Jull et al. Spine. 2002

Visual feedback display

Pressure Biofeedback Unit

Cranio-cervical

flexion

>50% reduction in

Headache Frequency

100% reduction in

Headache Frequency

6 weeks 76% 31%

12 months ~40%

Cervicogenic headache

Average 6 years duration

6 week intervention

12 month follow up

Symptomatic relief following a neck-specific

exercise in various neck pain disorders


MILDIDIOPATHIC

Falla et al. Eur J Pain. 2013 Jull et al. Pain. 2007

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Resistance

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% R

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25%

MODERATE SEVEREIDIOPATHIC

COLD HYPERALGESIAWHIPLASH

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% R

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ck P

ain

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Predicting response to neck-specific exercise

interventions in chronic whiplashChronic Whiplash (n=205)

Predictors Average pain intensity

Catastrophizing

Post-traumatic stressQuality of life

Pain extent

Pain extent significantly

associated with

changes in the NDI at

one year and two year

follow-up

Alalawi et al. 2018

Participation in a neck-specific exercise

intervention, in contrast to general physical

activity, was the only factor that consistently

indicated higher odds of treatment success

At 12 months patients in the neck-specific

exercise intervention had up to 5.3 times higher

odds of disability reduction, and 3.9 times higher

odds of pain reduction compared to those in the

physical activity group

Landén Ludvigsson et al., Eur J Pain, 2015

Superiority of long term efficacy of neck-specific

exercise over general physical activity for

Chronic Whiplash Associated Disorders








Reductions in pain and disability are often

the main outcome measure in randomised

controlled trials for various types of exercise

programmes in patients with neck pain

As pain is multifactorial, a single subjective

method of measuring pain as the sole

outcome to evaluate the superiority of a

particular exercise protocol for chronic

neck pain is insufficient


Motor Control

General Neck Flexion Training

Strength

CCF training

Strength training

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Falla et al. Clin Neurophysiol. 2006 Falla et al. Phys Ther. 2007


between groups

Pre-Intervention Post-Intervention100

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PP

T (k

P)

mo

st s

ym

pto

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rvic

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otio

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eg

me

nt

Cranio-cervical

Flexion

Cervical Flexion

O’Leary, Falla, Hodges, Jull, Vicenzino. J Pain 2007

Cranio-cervical flexion exercise induces a

superior immediate hypoalgesic effect

*significant reduction in pain during

active movement post-exercise

following the craniocervical flexion

exercise only

Qualitative research: Patients articulated

that the immediate demonstration that

exercise could help their pain gave them

hope and motivated them to continue

Rebbeck et al. 2015, Sterling et al. 2011

Landén Ludvigsson et al., Clin J Pain, 2015

Neck-specific exercise with or without a behavioural

approach achieves the same reduction in perceived

pain and disability in Chronic Whiplash Associated

Disorders Motor control exercises progressed to resistance

training - 12 weeks

NSEB: Patients were encouraged not to focus on

temporary increases in neck pain

-10 -8 -6 -4 -2 0

3 months

12 months

Physical activity

NSEB

NSE

Neck Pain Disability Reduction

*

*

*

*

Monitoring changes in the size of the painful area

over time

Baseline Post Treatment 6 months

22% 8.5% 3.2%

16% 3.9% 3.4%

Do

rsa

lFro

nta

l

Falla et al. 2018

Neck-specific exercise with

a behavioural approach

Neck-specific exercise

Me

dia

n p

ain

exte

nt

(%)

Me

dia

n p

ain

exte

nt

(%)

Falla et al. 2018

Neck-specific exercise with or without a behavioural

approach achieves a different effect on the size of the

painful area

Significant changes in

Kinesiophobia

Anxiety

Self-efficacy Overmeer et al. Medicine. 2016

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Baseline 3

months

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PAIN is an important consideration and

patients usually seek pain relief as a

primary goal of treatment

The challenge is not only to resolve an

episode of pain, but to prevent or limit its

recurrence for future quality of life

EXERCISE should also be prescribed with

the aim of restoring NEUROMUSCULAR

FUNCTION

Motor adaptations to pain

Exercise to restore neuromuscular function is a logical component of the

management programme

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Left Sternocleidomastoid Right Sternocleidomastoid

Left Splenius Capitis Right Splenius Capitis

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°

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°

15 N contraction , 0-360°

EMG Tuning Curves

mean resultant vector

(preferred direction)


Left Sternocleidomastoid Right Sternocleidomastoid

Left Splenius Capitis Right Splenius Capitis

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0 0° °


EMG Tuning Curves

mean resultant vector

(preferred direction)


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Directional specificity of muscle activity is

reduced in persons with neck pain


Relative muscle specificity to direction

Neck Pain

Controls

Left SCM

Right SCM

Left SCap

Right SCap


Effectiveness of an 8-week exercise programme

on specificity of neck muscle activity

Patients with chronic idiopathic neck pain – NDI:

18.2(7.4)/50

Randomised into 1 of 2 groups

program of neck-specific exercise Jull et al 2008; Jull et al 2018

control: treatment as usual including general exercise

8 week exercise intervention

Measures baseline and week 9

Outcome: Directional specificity of neck muscle

activityFalla et al. Eur J Pain. 2013

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Pre Post

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ck

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ec

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Ex

erc

ise

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tme

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usu

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(R) SCM(L) SCM

(R) SCap(L) SCap

(R) SCM(L) SCM

(R) SCap(L) SCap

(R) SCM(L) SCM

(R) SCap(L) SCap

(R) SCM(L) SCM

(R) SCap(L) SCap

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Falla, et al. Eur J Pain. 2013

Neck-Specific Exercise


Relative muscle specificity to direction, RSD (%)

Treatment as usual


Relative muscle specificity to direction, RSD (%)

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PrePost

Left SCM

Right SCM

Left SCap

Right SCap

Falla, et al. Eur J Pain. 2013


Motor Control

Global Neck Flexion Training

Strength


Falla et al. Phys Ther. 2007

O’Leary, Falla et al. J Pain. 2007

Falla et al. Man Ther. 2008


Chronic idiopathic neck pain


6 week intervention

Practising daily

Falla et al. Spine; 2004


Pressure Biofeedback Unit

Cranio-cervical

flexion

Altered co-ordination between the deep

and superficial neck flexor muscles in

patients with neck pain Control

Neck pain

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Stage of C-CFT (mmHg)

DN

F n

orm

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(%)

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CCF training Strength training

****

*


Increased activation of the deep neck flexors following training

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Decreased activation of the superficial neck flexors following training


Pre

Post


Cervical

angle

Neck Pain Controls

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an

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in C

erv

ica

l An

gle

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Time Time

T0-T2 T0-T4 T0-T6 T0-T8 T0-T10 T0-T2 T0-T4 T0-T6 T0-T8 T0-T10

20

Falla et al; Phys Ther 2007

People with neck pain drift into a forward

head posture during prolonged sitting

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T0-T2 T0-T4 T0-T6 T0-T8 T0-T10 T0-T2 T0-T4 T0-T6 T0-T8 T0-T10

Ch

an

ge

in C

erv

ica

l An

gle

()

Falla et al; Phys Ther 2007

Improved postural endurance following

training



Direction of

neck effort

Neck Flexion Strength

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Ma

xim

al N

ec

k F

lexi

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Fo

rce

(N

)

Pre

Post

*

Falla et al, Clin Neurophysiol 2006

Increased neck flexor strength following

training

CCF trainingStrength training

RCTs –Neuromuscular adaptations are specific to

the type of exercise

Falla et al. 2007 Increased neck muscle strength

Increased neck muscle endurance

Falla et al. 2006 Reduced neck muscle fatigability

Falla et al. 2006 Increased postural endurance

Jull et al. 2007 Improved neck proprioception

Jull et al. 2009 Increased activation of the deep neck flexors

Reduced activation of the superficial neck flexors

Faster onset of deep neck flexor activity

O’Leary et al. 2009 Reduced fatty tissue content

Falla et al. 2013 Enhanced specificity of neck muscle activity

Decreased muscle co-contraction

Brage et al. 2015 Reduced activation of the superficial neck flexors

Exercises should be

selected to target deficits

in neuromuscular function

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am

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Average normalized EMG amplitude of DNF

over CCFT at baseline

The baseline neuromuscular features determine

the extent of neuromuscular adaptations to

exercise

Falla et al. Clin J Pain. 2011

Chronic neck pain

6 weeks of CCF

exercise

-20 0 20 40 60 80

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-4

-2

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2

Change normalised DNF EMG amplitude on CCFT

Ch

an

ge

av

era

ge

pa

in in

ten

sity

(V

AS)

The baseline neuromuscular features are an

important determinant for symptomatic relief

with exerciseHighlighted the need for

assessment driven

targeted exercise interventions

Yet…….

Participant inclusion

criteria in clinical trials

usually do not include

measures of muscle

function that link to the

intervention

Falla et al. Clin J Pain. 2011

Is exercise A better than

exercise B at reducing pain?

What are the causal mechanisms of recovery

for an individual patient?

Has the mechanism(s) changed to warrant a

change in outcome?

Which exercise is better at altering the

mechanism(s)?

Landén Ludvigsson et al., Clin J Pain, 2015

Neck-specific exercise is superior to physical activity in

Chronic Whiplash Associated Disorders

NSE: Motor control exercises progressed to resistance

training - 12 weeks

PA: Increase overall physical activity, either with

home exercise or activities in gym

-10 -8 -6 -4 -2 0

3 months

12 months

Physical activity (PA)

Neck-Specific Exercise (NSE)

Neck Pain Reduction

NSE = PA

Evaluating the mechanisms underlying the

effectiveness of neck specific exercises

Group

Dynamic Bayesian Networks –

a probabilistic graphical

modelling approach, to

understand the causal

mechanisms underpinning

treatmentΔ WAIΔ Neck Endurance

Δ Pain

Δ HAD

Δ PCS

Δ SES

Δ NDI

Liew et al, 2018

NSE > PA

2 pathways by

which exercise

reduces pain

Rather than the type of exercise being

dictated by clinician preference

Decision must be based on

knowledge/skills and informed by a

comprehensive assessment and clinical

reasoning

What mechanism(s) should I intervene,

rather than what approach should I

choose?

Pathology driven

Red flags

Pathoanatomical disorders

• Spinal stenosis with radicular pain

• Neurological deficits

• Inflammatory pain

Psycho-socially driven

Anxiety, fear, anger

Depression

Negative beliefs

Poor coping strategies

Negative social and interpersonal

circumstances

Movement driven

Painful aberrant movement

patterns

Altered muscle activation

Suboptimal muscle use

Biologically driven

Central hypersensitivity

Inflammatory system response

What are the key drivers?

Adapted from Glasgow. PhysioFirst. 2017

Pe

rsis

ten

t o

r re

cu

rre

nt

ne

ck

pa

in

Physical factors that load tissues suboptimally leading to on-going

nociceptive input that continues to drive and maintain their chronic pain

disorder

Social factors such as poor support or high job demands with low

reward that amplify the patient’s perceived pain

Biological factors (e.g. central sensitization, inflammatory system

response) that contribute to maintenance of pain

Psychological features (e.g. pain catastrophizing, fear avoidance,

anxiety, depression or stress) which contribute to pain experience and interact with biological processes

Multisystem assessment Individualised exercise interventions

Development of individualised package

of exercise interventions targeted to the patient’s

unique mix of presenting features for

more effective management of neck

pain

Modified motor control (muscle activation, posture/alignment,

and movement) to optimise tissue loading to reduce

nociceptive input

Exposure to movement to reduce threat

Graded activity using cognitive behavioural principles to

enhance function and overcome disability

Selection of exercise components

Change exercise beliefs and attitudes

Improve strength and endurance to enhance function

Exercise for analgesic effects

Exercise to enhance physical fitness

Assessment-driven targeted interventions to

achieve meaningful and long-lasting change

Falla & Hodges. Exerc Sport Sci Rev. 2017

Patient-specific, tailored interventions

Reduced pain, improved function, less recurrance

and improved quality of life

Perceived pain and disability are relevant but

pain is multifactorial and other features should

also be considered

Whilst pain is important there should be an

equal focus on exercise prescription for

“rehabilitation”

Neuromuscular adaptations are specific to the

mode of training

Targeting mechanisms and functional

impairments

SPECIFICITY OF EXERCISE IS RELEVANT

To conclude…..

Exercise for Neck Pain · exercise intervention had up to 5.3 times higher odds of disability reduction, and 3.9 times higher odds of pain reduction compared to those in the physical

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