Rehabilitation of Cervical Spine
A Patient's Guide to Rehabilitation of the Cervical Spine
Your doctor may have you see a physical therapist who will design a neck-care
program just for you. Your physical therapist will evaluate your condition to
determine the best way to help ease your pain and help your neck move better.
You will also be given ways to take care of your neck so you can avoid pain
and prevent further injury to your neck.
Your First visit to Physical Therapy
On your first visit, your physical therapist will want to gather some more
information about the history of your neck problem. You may be given a questionnaire
that helps you tell about the day to day problems you are having with your neck.
The information you give will help measure the success of your treatment. You
may also be asked to rate your pain on a scale of one to ten. This will help
your physical therapist gauge how much pain you have now and how your pain changes
once you've had treatment. Your physical therapist will probably ask some more
questions about your neck problem to begin zeroing in on the source of your
pain and to know what will be needed to help relieve it. Here are some questions
your therapist may ask you:
- How long have you had neck pain?
- Where do you feel the pain?
- What makes the pain better or worse?
- How does your pain affect your daily activities?
- Do you have headaches?
- Do you have pain in your shoulder, arm, or hand?
- Do you have any numbness or tingling?
Physical Therapy Evaluation
Once all this information has been gathered, your neck condition will be evaluated.
Posture/observation: Your physical therapist will begin by checking
your posture to see if your soreness is coming from changes in posture. Imbalances
in the position of your spine can put pressure on sore joints, nerves, and muscles.
Postures used for a long time at school, with hobbies, or when working can change
the balance of muscle strength and flexibility. Muscles that have been stretched
over time tend to be weaker, while muscles that are put in shortened positions
can begin to overpower the weaker ones. This can put added strain on areas around
the neck that can cause a problem or make a sore area worse. Helping you improve
your posture can oftentimes make a big difference in easing pain.
Range of motion (ROM): Next, your physical therapist will check the
ROM in your neck. This is a measurement of how far you can move your neck in
different directions. Neck movements include bending the neck forward and backward
(flexion and extension), bending to either side (side bending), and turning
the neck to one side and the other (rotation). Measurements may also be taken
of upper back and/or shoulder movements. Your ROM is written down to compare
how much improvement you are making with the treatments.
Neurological screen: Your physical therapist may need to do some tests
to check the nerves of your neck. This part of the evaluation looks at your
reflexes, sensation, and strength in your neck, shoulders, and arms. The results
of these tests can help your physical therapist know which area of the neck
may be causing problems for you and can guide the type of treatment to help
Manual examination: You may be given a manual examination of the muscles
and joints of the neck. Your physical therapist will carefully move your neck
in different positions to make sure that the joints are moving smoothly at each
level of the neck. This will help guide treatment to the joint that is tight
(called a hypomobility) or where a joint may have been injured and is moving
too much (called a hypermobility). Some of the movements you'll feel are where
your physical therapist is looking at the flexibility of the muscles around
your neck. This type of examination can help guide your therapist to know where
your soreness is coming from and which type of treatment will help you the most.
Special tests: Other special tests may be done if your physical therapist
thinks your neck pain is coming from other areas or causes. Other areas that
may need to be looked at include:
- Thoracic outlet: This is where a group of nerves and vessels make their
way out of the chest cavity and travel down the arm. Problems in this area
can cause numbness, pain, or even coldness in the arm and hands.
- Temporomandibular joint (jaw): Problems here can cause headaches, pain in
your upper neck, and even spasm in muscles of the neck.
- Thoracic spine: Problems beginning in the upper back can include joints
and muscles of the thorax or even in the alignment of one or more ribs, which
can cause pain to radiate toward the neck and shoulder.
- Nerve tension: Nerves of the mid and lower neck travel down the arm to service
the arm and hand. Irritation or scarring around the covering of these nerves
can cause pain that radiates from the neck to the upper back or even into
the arm. By locating scarred or irritated areas along the nerve, a treatment
called "neural mobilization" can be used to free up movement in the nerve
and to ease the soreness you feel.
- Ergonomics: Ergonomics is a way to look at where and how you do your work
or hobby activities. Your physical therapist may want to understand your ergonomics
to figure out if the way you do your activities is making your condition worse.
Sometimes even simple corrections of your hobby or work station can make a
big difference in easing neck symptoms.
Palpation: The evaluation usually ends with palpation. Palpation is
when your physical therapist feels the soft tissues around the neck. This is
done to check the skin for changes in temperature or texture, which could tell
if you have inflammation or nerve irritation. Palpation is also done to find
whether there are tender points or spasm in the muscles around the neck and
upper back. This too can give your therapist a good idea about which treatments
will help you the most.
Treatment plan: Once the examination is done, your therapist will put
together a treatment plan. The treatment plan lists the types of treatments
that will be used for your condition. It gives an indication of how many visits
you will need and how long you may need therapy. It also includes the goals
that you and your therapist think will be the most helpful for getting your
activities done safely and with the least amount of soreness. Finally, it will
include a prognosis, which is how your therapist feels the treatment will help
Physical Therapy Treatment
Controlling your pain and symptoms
Easing pain: Your therapist may choose from one or more of the following
tools, or modalities, to help control the symptoms you are having:
Rest: Resting the painful joints and muscles helps calm soreness, giving
your neck time to heal. If you are having pain with an activity or movement,
it should be a signal that there is still irritation going on. You should try
to avoid all movements and activities that increase your pain. In the early
stages of your problem, your doctor or therapist may want you to use a soft
or hard neck collar to limit neck movement nearly completely.
Specific Rest: Specific rest encourages safe movement of the joints
and muscles on either side of a painful area, while protecting the sore spot
during the initial healing phase. Select exercises can be given to encourage
safe movement of the shoulders and upper back. If you've been prescribed a collar,
you will likely be instructed to take it off a few times a day so you can do
some gentle and controlled exercises.
Positioning: The results of the evaluation will give your therapist
a clear picture of ways you can position your neck for the greatest comfort.
A special pillow, called a contour pillow, may be suggested to help get your
neck in the most comfortable position while sleeping or resting. A commercial
neck roll, or even a rolled towel, can be slid inside your pillow case so that
when you lie back, the roll fills in and supports the curve in your neck. Other
special ways to rest your head and neck may be given by your therapist to help
take away arm pain that is coming from your neck.
Ice: Ice makes the blood vessels in the sore area become narrower,
called vasoconstriction. This helps control inflammation that is causing pain.
Some ways to put ice on include cold packs, ice bags, or ice massage. Cold packs
or ice bags are generally put on the sore area for 10 to 15 minutes. Ice massage
is done by rubbing an ice cube or ice cup on a sore spot or tender point. It's
as easy as freezing a small paper cup full of water. Once the water freezes,
simply tear off the top inch of the cup and rub the exposed ice on the sore
spot for three to five minutes, or until it feels numb.
Heat: Heat makes blood vessels get larger, called vasodilation. This
action helps to flush away chemicals that are making your neck hurt. It also
helps to bring in nutrients and oxygen which help the area heal. True heat in
the form of a moist hot pack, a heating pad, or warm shower or bath is more
beneficial than creams that merely give the feeling of heat. Hot packs are usually
placed on the sore area for 15 to 20 minutes. Special care must be taken to
make sure your skin doesn't overheat and burn. It's also not a good idea to
sleep with an electric hot pad at night.
Ultrasound: An ultrasound machine produces high frequency sound waves
that are directed toward the sore area. Passing through the body's tissues,
these waves vibrate molecules. This causes friction and warmth as the sound
passes through the tissue. The rest of the sound changes to heat in the deeper
tissues of the body. This heating effect helps flush the sore area and brings
in a new supply of nutrient and oxygen-rich blood. Ultrasound treatments are
a way for your therapist to reach tissues that are over two inches below the
surface of your skin.
Phoresis: This means to "carry or transmit." There are two methods that
therapists can use to transmit substances across the skin. Phonophoresis uses
the high frequency sound waves of ultrasound to "push" a steroid medication
(cortisone) through the skin. Iontophoresis uses a small machine that produces
a mild electrical charge, which is used to carry medicine, usually a steroid,
through the skin. The steroid is a very strong anti-inflammatory medication that
actually stops the pain-causing chemical reaction within the cells of the sore
tissue in your body. Either type of phoresis may be used in place of a cortisone
Electrical Stimulation: This treatment stimulates nerves by sending
an electrical current gently through your skin. Some people say it feels like
sort of like a massage on their skin. Electrical stimulation can ease pain by
sending impulses that are felt instead of pain. Two respected scientists discovered
a theory, called the Gait Theory. This theory says that when you feel a sensation
other than pain, like rubbing, massage, or even a mild electrical impulse, your
spinal column will actually "close the gate" and not let pain impulses pass
to the brain. In the case of electrical stimulation, the electrical impulses
speed their way across the skin and on to the central nervous system much faster
than pain. By getting there first, the electrical information "closes the gate"
to pain, blocking its passage to the brain. Once the pain eases, muscles that
are in spasm begin to relax, letting you move and exercise with less discomfort.
Other settings on the machine can be used to help your body release endorphins.
These are natural chemicals formed within your body that behave like a strong
drug in reducing the perception of pain for up to eight hours at a time.
Soft tissue mobilization/massage: Physical therapists are trained in
many different forms of massage and mobilization when treating the neck. Massage
has been shown to calm pain and spasm by helping muscles relax, by bringing
in a fresh supply of oxygen and nutrient-rich blood, and by flushing the area
of chemical irritants that come from inflammation. Soft tissue treatments can
help tight muscles relax, getting them back to a normal length. This will help
you begin to move with less pain and greater ease. Physical therapists have
special training in a variety of different ways to mobilize or massage. These
can include gentle strokes, called effleurage. Myofascial release techniques
help restore better movement by getting the thick layer of fascia below the
skin and around muscles to "give". Strain-counter-strain is a type of therapy
that is especially helpful when tender points are causing muscles to restrict
movement. The treatment is usually done in a way that the muscle is put in a
special position, usually where the muscle is shortest. The position is held
long enough to "reset" the nerve input to the muscle. Another way to help soft
tissues "move" is by the use of muscle energy technique. Your therapist will
place your muscle in a certain position and then direct you to use your muscles
against the therapist's force. As you relax, your therapist will gradually "take
up the slack", giving a stretch on the muscle.
Joint mobilization: These are graded pressures and movements that are
done by skilled physical therapists. Gentle graded pressures help lubricate
joint surfaces, easing stiffness and helping you begin moving with less pain.
Pain that is left unchecked can quickly escalate to an uncomfortable "cycle
of pain and muscle guarding." In other words, the pain can make your muscles
go into spasm, in which your muscles try to guard the sore joints, keeping you
from wanting to move your neck at all. When movement stops, your brain gets
an uninterrupted flow of pain sensation. Ouch! This leads to a cycle of even
more muscle spasm and pain because your muscles try to "protect" you from painful
movement. By applying gentle pressures, or mobilizations, your therapist will
begin to halt the flow of pain information, which helps muscles relax. Once
your muscles begin to relax, you will begin to feel other sensations than pain.
As your pain eases, more vigorous grades of mobilization may be used to lengthen
tissues around the joint helping restore better movement in your neck.
Traction: Sore joints and muscles in the neck often feel better when
a traction "pull" is used. Your therapist will test at first to see if you can
get relief with this type of treatment. Traction can be done in a variety of
ways. There are traction machines that allow you to relax comfortably with either
a halter or cushion behind your neck. The machine is set to pull on this halter
or cushion for a certain amount of time and pressure. Manual traction is another
way for your therapist to put a graded pull on your neck. There are also traction
devices that can be issued for you to use at home. The amount of pull that is
used will depend on your condition. A gentle on/off pressure may be better early
on to help control pain or if there is pain from arthritis. More vigorous traction
can help take away pain if a joint is mildly sore or tight.
Strengthening your neck
Exercise is important during all stages of recovery from neck pain. Different
types of exercises will be used by your physical therapist as you get better.
In the early stages, when your neck is still quite painful, specific exercises
may be suggested to help reduce your pain. Supporting your neck in certain positions
as suggested by your therapist can take pressure off sore or injured areas.
These positions are sometimes easier to get into by using a pillow, rolled towel,
or commercial neck roll. You may need to relax back on a recliner or mattress
for best results. In cases of significant pain, you may be given a set of breathing
exercises. Deep, diaphragmatic breathing helps air to reach even the lower
lobes of your lungs. Combining deep breathing to a slow relaxing count can help
muscles relax, while bringing much needed oxygen to sore tissues. Neck pain
can be physically and emotionally draining. Relaxation exercises may not correct
your problem, but they can help control pain and its accompanying stress.
Movement is also important, even when your neck is still painful. Careful movements
suggested by your therapist can safely ease pain by providing nutrition and
lubrication to injured and sore areas. Movement of joints and muscles also signals
the nervous system to block incoming pain. Common movement exercises include
active range of motion, in which you are encouraged to move your neck toward
directions that don't hurt. Your therapist will evaluate which movements will
be safest and best for you. In some cases, pain will ease with the addition
of pressure into one or another direction. Again, your therapist will need to
determine which movements are best for your condition. Avoid movements that
hurt or seem to irritate the soreness in your neck.
As your neck becomes less painful, the exercises will be changed to focus on
improving the overall health of your neck. These changes will focus on exercises
- Aerobic conditioning
Exercises that increase flexibility help to reduce pain and make it easier
to keep your neck and spine in a healthy position. Tight muscles cause imbalances
in spinal movements. This can make injury of these structures more likely. Flexibility
exercises for the neck, chest, and upper shoulders can be helpful in establishing
safe movement. A slow progression of stretching exercises can increase flexibility
in these areas, ease pain, and reduce the chance of reinjury.
The next stage of exercise focuses on the strength of the muscles that support
the neck. These muscles help bring the spine into a safe position--and keep
it there! Trained muscles can keep your neck healthy by getting it into better
posture. A series of strengthening exercises, called stabilization training,
is a way to get better balance in the muscles around your neck, chest, and upper
back. These stabilization exercises are helpful in supporting your neck in safe
positions while you are working or when you are doing other daily activities.
Strengthening and stabilization exercises are simple to do at home and don't
have to require any expensive equipment. By practicing these exercises often,
you will become comfortable keeping your neck in healthy positions and postures
with all your activities.
Strong muscles need to be coordinated. As the strength of the spinal muscles
increases, it becomes important to train those muscles to work together. Learning
any physical activity takes practice. Muscles must be trained so that the physical
activity is under control. Muscles that are trained to control safe movement
of the spine help reduce the chance of injury. You will be taught exercises
to help train your neck, chest, and upper back muscles to work together in protecting
Finally, attention will be directed to increasing your overall fitness. The
word aerobic means "with oxygen". By using oxygen as they work, muscles are
better able to move continuously, rather than in spurts. Fitness training allows
the muscles to become more efficient at obtaining nutrients and oxygen from
the blood. As the muscles use up the nutrients and oxygen, chemical waste products
are created that can cause pain. Training also increases the ability of muscles
to get rid of these waste products.
Exercise has other benefits as well. Vigorous exercise can cause chemicals
called endorphins to be released into the blood. These chemical hormones act
as natural pain relievers in reducing your pain. It will be important that you
pick an aerobic activity you can enjoy and stick with it!
Once your pain is controlled, your range of motion is improved, and your strength
is returning, you will be progressed to a final home program. Your therapist
will give you some ideas to help take care of any more soreness at home. You'll
be given some ways to keep working on the range of motion and strength too.
Before you are done with physical therapy, more measurements will be taken to
see how well you're doing now compared to when you first started in therapy.
Prevention and long term self care for the neck
Is this is your first experience with a neck problem? Maybe you've had ongoing
problems for many years. In either case, your best bet for avoiding neck problems
in the future is to get a handle on ways you can prevent further neck pain and/or
injury. It is also helpful to know how to take care of your neck if pain strikes
Posture: Using healthy posture is like holding a defense shield against
future neck problems. Pain and injury CAN be prevented. When your joints are
positioned in their safe—or neutral posture—the body works like an elegant
machine. It works safely and even more productively. When unbalanced postures
are used, problems are more likely to happen. Prevention of neck pain and injury
has a lot to do with keeping a balanced position of the spine and extremities.
When standing, this balance follows a plumb line from ear to ankle. In a seated
position, this line descends from the ear to the hip. A rule of thumb for the
extremities is to keep them in their relaxed positions.
There are three natural curves in the spine. From a side view, the neck (cervical
spine) curves slightly inward. The mid-back (thoracic spine) curves slightly
outward. The low back (lumbar spine) curves slightly inward. Keeping this relationship
while standing, sitting, or moving is the basis for healthy posture. When moving,
bend at the hips to avoid rounding or straightening the spine. This keeps the
spine safe during activities like lifting and walking.
For better sitting posture, sit with a good upright alignment of the spine
by using a comfortable chair designed to support correct posture. Avoid slouching
by keeping your low back against the back of the chair. Bending the head forward
strains the neck and affects the nerves and arteries leading to the arms. Your
shoulders should be relaxed, and the elbows, hips, and knees should be bent
at right angles (ninety degrees). Avoid pressure to the back of the knees. Your
feet should be kept flat on the floor or supported by a foot rest.
Awkward posture places stress on the body that can lead to neck pain. Slouching
with the spine or leaning the head forward puts the body out of alignment, causing
the limbs to be stretched and bent. Too much bending (flexion) or straightening
(extension) in the spine increases the risk of injury. Symptoms of pain, tingling,
or numbness in the arm or hand may also come from poor neck posture. The slight
inward curve of the neck balances the head on the spine. Avoid extreme postures,
like gazing up at the stars, or bending your head down for long periods when
reading a book. Keeping balanced posture is a measure you can use to prevent
further injury and pain in your neck.
Ergonomics: Ergonomics is a look at the way people do work. What does
ergonomics have to do with the ache in your neck? It could have a lot to do with
it. It's possible that even minor changes in the way you do your work or hobby
activities could ease the pain you feel now while preventing further neck injury
In some cases, it is best to have someone trained in ergonomics, like a physical
or occupational therapist, check your work station and the way you do your work.
The first step will be for them to ask you some questions about your work, which
makes good sense. Since you're the one doing the job, you will have an expert
opinion about what seems to be working, what could be done differently, and
what tasks seem to be causing the most problems for you. Once these questions
are covered, the evaluator will want to watch you do the work tasks. Areas that
will be noted include the postures you use, repetitions to complete the task,
rest time between tasks, and the amounts of weight you are dealing with. For
office workers, the examiner will look at alignment of the computer monitors,
chairs, desk heights, etc. Other areas that may be evaluated include work heights,
tools of the trade, lighting, and temperature. It's also helpful to look at
your work postures and work tasks to see if what you are doing can be done with
less stress and strain on your body.
When the work site evaluation is over, you or your supervisor will probably
be given some recommendations—some of these may even be ones you came up with!
Ergonomics doesn't always have to involve expensive changes. Even minor adjustments
can make a huge difference in easing your pain and preventing further problems.
Work Place Strategies: These strategies are ideas of how to work with
greater safety and even better productivity. Have you ever felt stress or tension
at work? Chances are good that you wouldn't have a pain or worry if you didn't.
The reality is that people are often called on to do even more with less resources.
They are faced with more responsibility and more deadlines to get their tasks
done. The health of your neck may be at risk with these mounting pressures.
But scientists have helped us learn that there is a defense in the face of these
mounting pressures. They have shown the importance of using the "Three R's"
to help ease tension and reduce neck pain at work:
Rest: This includes taking frequent breaks during the work hour. It
also means choosing alternate activities to get your mind ready for a new job
task. Activities include deep breathing, walking, napping, or exercising.
Relaxation: Take a load off. Lie back. Turn down the lights, and listen
to your favorite tape or CD. Attempt to breath slowly and deeply, allowing your
abdomen to rise and fall rhythmically. Using visual imagery can also aid in relaxation.
Try to visualize each muscle relaxing one after another.
Recovery: Our bodies need a chance to heal. Repeated and prolonged activities
can take their toll if the body doesn't get a chance to recover. Recovery helps
repair these sore and achy tissues along the way, keeping them healthy.
Whether at work or at home, you can use these ideas to help prevent neck pain
and injury. Here are some additional tips to use at work to avoid tension and
keep your neck healthy:
Be Relaxed. Try to work with your muscles relaxed. To stay relaxed, look relaxed.
Pace Yourself. Keep an even keel. Avoid sudden changes in your workload.
Try to avoid last minute "panics" to meet deadlines.
Take a Break. Take a thirty second "microbreak" every twenty to thirty
minutes to do some deep breathing and a few exercises. Take a few minutes each
hour to do some exercises, get a drink, or go bug a coworker. Use your lunch
break to take a nap or a walk.
Change Positions. Avoid holding your neck, trunk, or limbs still for
a long time. Plan ways to get the job done using different positions. Sit for
a bit—then stand for a bit. Or simply readjust your approach to the task.
Rotate Duties. Rotating or sharing your tasks can be fun by offering
a new work setting, while giving your body a chance to recover.
Avoid Caffeine and Tobacco. These can heighten stress, reduce blood
flow, and elevate the awareness of neck pain.
Taking Care of Your Neck
If you've had neck pain once, there's a fair chance you'll have it in one form
or another in the future. When pain comes back again and again, it is called
recurrent pain. Even though you may have been treated for neck pain or problems
in the past, it's not a guarantee you won't have pain again. The question, then,
is whether you can take care of your neck if soreness does return.
Your therapist will probably give you a thorough home program when you get
done with your treatments. Some of the exercises will be helpful to keep up
with as a way to keep your neck healthy over time. You may also be given ways
to help control pain or symptoms if they don't go completely away, or if they
return in the future. Although there are many good "home remedies", you will
want to visit your family doctor if these symptoms appear:
- Pain with no apparent injury that doesn't go away within a week to 10 days
- Pain that doesn't ease or change with movement
- Pain that actually wakes you up at night
- Pain that shoots from your neck down into your arm when you cough or sneeze
- "Visceral" symptoms of nausea, diarrhea, dizziness, blurred vision, ringing in the ears, etc.
- Numbness, tingling, or weakness in your arms or legs
If you feel achiness or pain that is not associated with the red flags listed
above, here are some home treatment ideas you may be given to ease your symptoms:
Rest: When neck pain strikes, don't do activities that make your pain
worse. Remember the benefits of rest (see above).
Ice: For the first two to three days, you may get help by applying a
homemade cold pack. Simply place two parts crushed ice in a plastic bag with
one part rubbing alcohol. This lets you reuse the bag without having it freeze
solid between uses. When you're ready to use the cold pack, wrap it in a wet
washcloth. Then place it on the sore area for up to fifteen minutes a few times
Contrast: On day three, you may find more relief by using a "contrast"
of ice and heat. This is where you begin by placing a cold pack on the sore
area for 10 minutes. Then place a heating pad on for another 10 minutes. You
can repeat the process a couple times, finishing with the heat.
Heat: Once the acute symptoms are controlled (two to three days), you
may get good relief using a heating pad. Remember to turn off the pad before
going to sleep. Check your skin regularly to make sure you are not getting too
Traction: In some cases, your therapist may have found out that you
get good relief with neck traction. That can be good news. There are a number
of traction units that can be used at home. Some of these work by giving a traction
pull as water is added to a bag. Others work by pumping air pressure into a
neck cushion. A simple way to do traction at home is to place two tennis balls
in a sock. Lay down with the sock sideways just below the back of your head.
The two tennis balls will give a gentle traction, and the pressure of the balls
can help relieve headaches, neck pain, and upper back discomfort.
TENS: This stands for transcutaneous electrical nerve stimulation. If
you've been treated in the clinic with electrical stimulation, your therapist
will have a good idea if this kind of treatment helps you. If so, there are
small, pocket-sized electrical stimulation units that can be used up to 24 hours
a day if needed to keep pain at bay. Your therapist may choose to issue one
of these, but only if you can't get good pain relief in other ways. Also, a
prescription from your doctor is required for you to use one on your own.
Exercise: Some exercises are designed to help take pain away. After
you have completed your physical therapy visits, your therapist will have gotten
a good idea what types of exercise help you control your pain. Your therapist
will go over the exercises that will give you the best relief if you get sore
again. Remember to only do the exercises in the way your therapist has instructed.
Overdoing them could make your pain worsen.
Long-term strategies: The best way to treat neck pain is to avoid it
all together. A good exercise regimen can help. Also, remember the benefits
of good posture, ergonomics, and work habits—and use them. If you are trying
to take care of your neck but you're not getting adequate relief, you may need
to revisit your physical therapist for additional help.
Home program: Once your pain is controlled, your range of motion is
improved, and your strength is returning, you will be progressed to a final
home program. Your therapist will review some of the ideas listed above to help
take care of any more soreness at home. You'll be given some ways to keep working
on the range of motion and strength too. Before you are done with therapy, more
measurements will be taken to see how well you're doing now compared to when
you first started in therapy.
Copyright © 2003 DePuy Acromed.
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