Therapeutic Exercise for Athletes with Nonspecific Neck Pain: A Current Concepts Review

Typically when we think of neck pain, we think of sedentary individuals with poor posture or with a recent traumatic incident. We don't usually think about athletes experiencing neck pain (other than football injuries of course). Neck pain can result from various mechanisms: posture, strains, sprains, etc. This review did not find exercise protocols based on specific sports, so it developed an impairment-based review for therapeutic exercises.

Mobility
Self-stretching was found to improve chronic neck pain if performed at least 5x/wk, especially for the upper trap, scalenes, levator scapulae, and pec minor/major. With excessive thoracic kyphosis, try using foam roller combined with thoracic extension for some self-mobilization. Two methods of improving rotation include cervical rotation on a partially inflated beach ball or using a strap/rope to stabilize an articular pillar, while the patient actively turns his/her head. The patient can use his/her fingers to stabilize one segment, while moving into extension in order to focus mobility on a specific segment. With neural signs such as radicular symptoms, be sure to consider McKenzie repeated movements (like retraction) and nerve glides.

Motor Recruitment
With many neck pain disorders, a common culprit is poor motor control of the deep neck musculature. One of our special tests can be used to teach muscle recruitment of the cervical spine: the Craniocervical Flexion Test. Teaching the patient an upper cervical head nod is crucial to preventing overuse of the superficial neck flexors. Protrusion of the head is seen with superficial muscle use. Once the head nod is mastered, flexion of the lower cervical spine in supine can be utilized (while maintaining head nod). To improve control of the deep neck extensors, use eccentric exercises for the lower cervical spine while maintaining the upper cervical spine in neutral (try performing in quadruped or prone on elbows). Of course, theraband can be used as well to improve motor control for a muscle group. An important consideration is to keep the intensity low, so as to take advantage of the pain-mediating effects. Higher levels of contraction may aggravate the patient's symptoms initially.

Muscle Strength/Endurance
When considering cervical muscle strength and endurance, remember to use exercises that are low load for endurance and high load for strength. The choice of focus between endurance and strength can be influenced by the sport of the patient (football - stength, swimming - endurance). With any cervical patient, we must also consider the shoulder and thoracic spine due to their proximity. Poor endurance/strength/motor control of the scapular musculature can lead to poor posturing and influence the positioning of the cervical spine, eventually producing pain. Therefore, it is important to focus part of the treatment on these muscles. Interestingly, this review found some studies that stated there was no difference between having the patient perform 1 set to exhaustion compared to performing 1 or 2 sets of 8-12 reps. Another study found no difference between 1 and 5 sets of repetitions. The American College of Sports Medicine supports the claim that 1 set of an exercise can be performed to exhaustion.

Repositioning Acuity, Oculomotor Control, or Postural Stability
As with any other joint, proprioception and kinesthesia can be impaired with pathology, but is more likely with traumatic pain. One method of treating this involves placing a light on the patient's head. A target is placed on the wall. The therapist passively places the patient's head in a specific position and the patient notes the position. The therapist then moves the patient's head around in various positions (with the eyes closed) and asks the patient to reposition his/her head to the starting position. The patient must rely on the mechanoreceptors to return to the starting position. Check out Table 2 for oculomotor control exercises and Table 3 for postural stability exercises in the review. All the exercises can be progressed by altering the stability of the surface the patient is standing on. It is especially important to adapt the exercises to being sport-specific to train the athlete for the forces their cervical spine will endure, when competing and practicing.

Reference:
Durall CJ. "Therapeutic exercise for athletes with nonspecific neck pain: a current concepts review." Sports Health. 2012 Jul;4(4):293-301. Print.