1. Cervical Spine Muscular Weakness; Diagnosis & Correction Marc Weinberg, D.C. June 2011 South Carolina Chiropractic Association Summer Convention

2. Marc Weinberg, D.C. Marc Weinberg, D.C. Member, Florida Chiropractic Society Member, Foundation for Chiropractic Education and Research Member, National Academy of MUA Physicians Past Founding Member, ICA Council of Chiropractic Pediatrics Board of Directors American Thoracic Outlet Syndrome Association- Director of Alternative Medicine Research and Development 561.262.4724 www.weinbergchiro.com

3. Goals Defining Cervical Muscular Weakness. Creating awareness of the importance of diagnosis and treatment of CMW. Exploring a reliable, valid andaccurate method of diagnosis and treatment. Creating a marketing niche for your practice. Revealing a method to improve service and clinical results with your patients. Creating a valuable income stream for your practice …All while remaining evidence based

4. What’s all the fuss about “Evidence Based Chiropractic” Is it important? My history as a chiropractor My recent experiences Wouldn’t it be nice if ….

5. FAQ’s about Cervical Muscular Weakness What is Cervical Muscular Weakness (CMW)?

6. 3 Integral Components of Movement

7. ANATOMY:Cervical Flexors

8. Superficial Deep

9. Sternocleidomastoid Hyoids

10. Longus Capitis C1 C6 Longus Colli

11. Cranio-Cervical Flexion Neutral Cervico-Thoracic Flexion

12. ANATOMY: Cervical Extensors

13. Superficial Deep C2 C2

14. Upper Trapezius C2

15. Splenius C2

16. Semispinalis Capitis C2

17. Semispinalis Cervicis & Multifidus C2

18. Rectus Capitus Posterior Minor Rectus Capitus Posterior Major Obliquus Capitus Superior C2 Obliquus Capitus Inferior

19. Cranio-Cervical Extension Neutral Cervico-Thoracic Extension

21. Lifestyle / Posture

22. Work Place Injuries

23. Sports Injuries

24. Diving InjuriesClick on video to play

25. Rear End Collision Video:Actual Speed of Occupant Motion The average rear-end collision occurs in about 250 milliseconds or ¼ second. The injury causing portion of the collision occurs in the first 75 milliseconds, or in the blink of an eye. Click on image to start or pause video

26. Rear End Collision Video:Occupant Motion in Slow Motion Click on image to start or pause video

27. Live Occupant Video This video clearly shows the dramatic forces that occur during a low speed collision. This was a 6 mph test crash. Click on image to start or pause video Video footage copyright information

28. US National Safety Council / Research 12 Million Car Accidents / Year 1 Car Crash every 2.5 secs  > 46,000 Fatalities 2.5 Million Rear End Collisions / Year 1.99 Million Reported Whiplash Injuries WAD’s all the Fuss About?

29. The WAD Epidemic Up to 60% of those who are “Rear-ended” are symptomatic after 6 months. 25 – 40% are symptomatic for 2 years. 10% of all who are “rear-ended” will become chronically disabled. 5 - 6 Million Current MVA Victims in U.S. $30-40 billion is spent in the US each year on WAD rehabilitation and litigation.

30. Normal Facet Motion The cervical vertebrae are designed for smooth, even motion. The facet joints stabilize the spine and allow this forward and backward movement. Click on image to start or pause video

31. Normal vs. Abnormal Motion Normal Flexion/Extension: Smooth, even motion of all spinal segments Abnormal S-Shaped Curve: Dramatic movement in just a few spinal segments Click on image to start or pause video

32. Vertebral Motion During Impact Instead of a smooth motion, the cervical spine experiences simultaneous compression and shear. This can cause tearing in the front portion of the spine and pinching in the facet joints. Click on image to start or pause video

33. Nerves of the Facet Joint The pain from inflamed facet joints is transmitted by the medial branch of the dorsal ramus. Stimulation of the facet nerves often results in referred pain. Spinal Cord Facet Joints Medial Branch Dorsal Ramus Spinous Process

34. Referred Pain Patterns "... the prevalence of cervical zygapophysial joint pain was 60%." The most common facets to be injured were at C2/C3 and C5/C6. C2/3, C3 C2/3, C3/4, C3 C3/4, C4/5, C4 C4/5, C5/6, C4, C5 C4/5, C5/6, C4 C6/7, C6, C7 Wallis BJ, Lord SM, Bogduk N. 1997 C7/T1, C7

35. Neck Weakness and Imbalance

36. Home and recreational involvement

38. Occupational Involvement

39. Fighter Pilot Training RCT of 10 Naval Fighter Pilots 12 week strength training 2x/wk Results: Indicated significant improvements in isometric strength and dynamic strength, typically occurring as early as 4 wks and improving throughout 12-wk period. Conclusion: “These findings have implications for military personnel at risk of neck injury in their occupational activities” Dr. Marcus Taylor, 2006

40. Research What Are You Doing About Muscle Weakness? Pt. 2: Cervical Spine Cuthbert SC, DYNAMIC CHIRO 2009JUL1; 27(14) The most significant of the anatomic structures providing stability to the cervical spine are the musculature and the firm bond between the bodies formed by the intervertebral discs.“ The role of the muscles becomes even more important to chiropractors because of their integral control of spinal dynamics. the evidence now shows with greater clarity than ever that inflammation or injury produces specifically identified inhibited muscles. Controlled clinical studies have shown that dysfunction and pain specifically in the cervical spine will produce inhibited muscles. These data indicate that the body's reaction to injury and pain is not increased muscular tension and stiffness; muscle inhibition is often more significant, as measured by several different methods of testing Overall studies indicate that compared to normal subjects, patients suffering from neck-related disorders present with significant reduction in cervical strength

41. Research What Are You Doing About Muscle Weakness? Pt. 2: Cervical Spine Cuthbert SC, DYNAMIC CHIRO 2009JUL1; 27(14) Prushansky and others have shown consistently cervical muscle weakness in chronic whiplash patients. Barton, et al., measured the strength deficits in patients with neck pain and showed that all force values were significantly lower in the neck pain population. Falla has similarly reported that both the sternocleidomastoid and anterior scalene muscles' strength was significantly reduced in patients with neck pain at 25 percent of maximum voluntary contraction (p<0.05). Edgerton, et al., showed altered muscle activation ratios of synergist spinal muscles during a variety of motor tasks in whiplash patients. Recent studies by Nederhand, et al., have confirmed that cervical muscle dysfunction appears to be a general sign in diverse chronic neck pain syndromes, especially related to whiplash injuries. To summarize: In patients with neck pain, the research has shown that muscle weakness is a very common causative factor. To fail to diagnose and specifically treat this component in your patients with neck pain will impede your therapeutic efforts.

42. FAQ’s about Cervical Muscular Weakness What is Cervical Muscular Weakness (CMW)? Is neck pain related to CMW?

43. Research Association of manual muscle tests and mechanical neck pain: results from a prospective pilot study. Cuthbert SC, Rosner AL, McDowall D.J Bodyw Mov Ther. 2011 Apr;15(2):192-200. Epub 2010 Dec 15. RESULTS: In group 1, 139 of 148 patients reporting neck pain also showed neck weakness . In group 2, 30 of the 100 patients without MNP showed neck weakness CONCLUSIONS: A symptomatic group of patients with MNP demonstrated significantly increased MMT findings in the form of reduced strength levels compared to a control group. This evidence suggests that the MMT is potentially a sensitive and specific test for evaluating cervical spine muscular impairments in patients with MNP.

44. Research Cervical muscles strength testing: methods and clinical implications. Dvir Z, Prushansky T, Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. zdvir@post.tau.ac.il J MANIPULATIVE PHYSIOL THER 2008SEP; 31(7) pp. 518 - 24 SUMMARY: Overall studies indicate that compared to normal subjects patients suffering from neck-related disorders present with significant reduction in CS, whereas women are weaker than men by about 40%. Noteworthy a significant drop in CS in both sexes is delayed until the seventh decade. In terms of its reproducibility, CS findings have been investigated using primarily relative parameters, and hence, the associated error is not yet established. Therefore, application of CS as a clinical outcome measure, particularly for assessing change due to intervention, should be critically conducted.

45. Research A review of functional outcome measures for cervical spine disorders: literature review Bussieres A, J CAN CHIRO ASSOC 1994MAR; 38(1) pp. 32 - 40 Evidence suggested that neck pain sufferers have weaker neck flexors than normal subjects.

46. Research Quantitative cervical flexor strength in healthy subjects and in subjects with mechanical neck pain ARCH PHYS MED REHABIL 1991AUG; 72(9) pp. 679 - 81 Silverman J, Rodriquez A, Agre J, Alta Bates-Herrick Hospital, Berkeley, CA [Anterior cervical muscle] weakness and its role in persistent neck pain should be recognized. The efficiency and effect of cervical muscle strengthening in treatment of chronic neck pain should be further defined.

47. FAQ’s about Cervical Muscular Weakness What is Cervical Muscular Weakness (CMW)? Is neck pain related to CMW? Doesn’t regular exercise keep our necks strong?

48. Research Muscle strength of the cervical and lumbar spine in triathletes Miltner O, Siebert CH, Müller-Rath R, Kieffer O. Z Orthop Unfall. 2010 Dec;148(6):657-61. Epub 2010 Mar 8 CONCLUSION: In conclusion, in the triathlon there is a specific stress that is obviously not an adequate stimulus for the muscles of the cervical spine in order to achieve a balanced musculature and the athletes should be advised to practice a preventive approach with regard to these areas. The triathletes have a significant imbalance in the lateral flexion of the cervical spine compared to the reference group

49. Research University of Connecticut's freshman football team. The purpose of this study was to identify weaknesses in the neck musculature and note any relationships between strength differences and cervical spine stability CONCLUSIONS: The data recorded indicates that there are significant differences between the neck muscle strength of the two groups, as well as differences in neck muscle strength of individuals between their right and left sides. Looking at these muscular differences and their relationship to cervical vertebrae alignment during lateral flexion, the author contends that blocking or tackling with the head in a laterally flexed position, to supposedly hit with the shoulder, places the cervical spine in a structurally weak position lacking muscular support, and predisposes the athlete to cervical spine injuries. A Comparative Assessment of Neck Muscle Strength and Vertebral Stability Franco J, Herzog A, J ORTHOP SPORTS PHYS THER 1987; 8 pp. 351 - 5

50. Research Conditioning Provides Protection. Helping Athletes Avoid Neck Injuries Bland JH, J MUSCULOSKEL MED 1996MAY; 13(5) pp. 30 - 8 Conclusion: During sports participation, the exceptional mobility of the neck can expose its structures to levels of flexion and compression that can cause injury and sometimes death. Yet even athletes involved in contact sports. who are especially vulnerable to cervical spine injury, seldom receive adequate neck conditioning in their training. Exercises such as weight lifting and pulling against gravity are most effective for developing strength and endurance, Both anterior and posterior muscle groups must be trained. Developing optimal proprioception is also important for cervical spine protection.

51. FAQ’s about Cervical Muscular Weakness What is Cervical Muscular Weakness (CMW)? Is neck pain related to CMW? Doesn’t regular exercise keep our necks strong? Are there other conditions that can develop from CMW?

52. Research Is maximal strength of the cervical flexor muscles reduced in patients with temporomandibular disorders? ARCH PHYS MED REHABIL 2010AUG; 91(8) pp. 1236 - 42 Armijo-Olivo SL, Fuentes JP, Major PW, Warren S, Thie NM, Magee DJ, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada CONCLUSIONS: These results indicated that strength evaluation is one of several assessment factors that need to be addressed when evaluating musculoskeletal painful conditions such as TMD and neck disorders, but strength evaluation cannot be considered as a direct measure of disability. Future studies should explore evaluation of strength in other muscular groups such as cervical extensors, rotators, and lateral flexors, and also under different conditions such as rapid movements, and in patients with more severe jaw disability.

53. Research The treatment of neck and low back pain: who seeks care? who goes where? Côté P, Cassidy JD, Carroll L. Med Care. 2001 Sep;39(9):956-67. RESULTS: Twenty-five percent of individuals with neck or low back pain visited a health care provider. Seeking health care was associated with disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning. CONCLUSIONS: Individuals seeking care for neck or back pain have worse health status than those who do not seek care. Patients consulting chiropractors alone report fewer co-morbidities and are less limited in their activities than those consulting medical doctors.

54. Current Chiropractic Treatment of Neck Pain Lasers Modalities Chiropractic Adjustments Devices

55. “Missing Link” in Neck Rehabilitation

56. Neck Strengthening

57. Research Maximal Isometric Strength of the Cervical Musculature in 100 Healthy Volunteers Jordan A, Mehlsen J, Bulow PM, Ostergaard K, Danneskiold-Samsoe B SPINE 1999JUL1; 24(13) pp. 1343 - 8 Conclusions: Men and women demonstrate impressive levels of muscular strength in the flexors and extensors of the cervical spine and can maintain these values until the seventh decade of life. Successful rehabilitation of the cervical musculature will require considerable resistance for sufficient stimulation of the cervical musculature.

58. Research Decreased isometric neck strength in women with chronic neck pain and the repeatability of neck strength measurements. Ylinen J, Salo P, Nykänen M, Kautiainen H, Häkkinen A, Department of Physical and Rehabilitation Medicine, Jyväskylä Central Hospital, Jyväskylä, Finland. ARCH PHYS MED REHABIL 2004AUG; 85(8) pp. 1303 - 8 CONCLUSIONS: The group with neck pain had lower neck muscle strength in all the directions tested than the control group. This factor should be considered when planning rehabilitation programs. Strength tests may be useful in monitoring training progress in clinical settings, but training programs should be planned so that the improvement in results is well above biologic variation, measurement error, and learning effect because of repeated testing..

59. Research Exercise therapy for office workers with nonspecific neck pain: a systematic review. Sihawong R, Janwantanakul P, Sitthipornvorakul E, Pensri P, PhD Candidate, Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand. J MANIPULATIVE PHYSIOL THER 2011JAN; 34(1) pp. 62 - 71 RESULTS: Strong evidence was found for the effectiveness of muscle strengthening and endurance exercises in treating neck pain. Moderate evidence supported the use of muscle endurance exercise in reducing disability attributed to neck pain. CONCLUSION: Literature investigating the efficacy of exercise in office workers with nonspecific neck pain was heterogeneous. Within the limitations, for treatment of neck pain, either muscle strengthening or endurance exercise is recommended, whereas for reduction of pain-related disability, muscle endurance exercise is suggested

60. Research Monitoring the change: current trends in outcome measure usage in physiotherapy. Abrams D, Davidson M, Harrick J, Harcourt P, Zylinski M, Clancy J, Lifecare Ashwood Sports Medicine Centre; Physiotherapy Consultant, Transport Accident Commission, 222 Exhibition St, Melbourne 3000, Australia. MANUAL THERAPY 2006FEB; 11(1) pp. 46 - 53 The trend towards greater objectivity in measuring the progress of rehabilitation can enable physiotherapists to develop improved treatment plans with the patients' needs at the centre of the equation.

61. Research Isometric strength of the cervical flexor, extensor, and rotator muscles in 220 healthy females aged 20 to 59 years. Salo PK, Ylinen JJ, Mälkiä EA, Kautiainen H, Häkkinen AH, Department of Physical and Rehabilitation Medicine, Central Finland Health Care District, Jyväskylä. Petri.Salo@ksshp.fi J ORTHOP SPORTS PHYS THER 2006JUL; 36(7) pp. 495 - 502 CONCLUSIONS: Women aged 20 to 59 years appear to have similar absolute isometric neck muscle strength levels. Thus these values can be used as reference for the working-age female population.

62. Research Rehab of CAD Injury Christensen KD, AMER CHIROP 2004SEP-OCT; 26(6) pp. 50 - 1 Doctors of chiropractic who incorporate rehab exercises can provide "multimodal care" to whiplash patients, in order to minimize the risk of long-term problems. This has been defined in the previously referenced study as care that applies manual procedures (spinal manipulation, mobilization, and massage), along with physical training to improve muscle strength and endurance, including sport activities. Multimodal care has been found to be effective in preventing many of the persisting symptoms of "late whiplash syndrome."

63. Research A specific exercise program and modification of postural alignment for treatment of cervicogenic headache: a case report. McDonnell MK, Sahrmann SA, Van Dillen L, J ORTHOP SPORTS PHYS THER 2005JAN; 35(1) pp. 3 - 15 CONCLUSIONS: Interventions that included modification of alignment in the cervical, scapulothoracic, and lumbar region, along with instruction in a specific active-exercise program to address movement impairments in these 3 regions, appeared to have been successful in relieving headaches and improving function in this patient.

64. Research Strength and Endurance Measurements of the Cervical Musculature in 100 Health Subjects 1996OCT; pp. 186 - 7 Jordan A, Mehlsen J, Bulow PM, Danneskiold-Samsoe B, CONCLUSIONS: Strength levels are maintained until late in life in both groups. Measured strength levels are high and the restoration of normal strength values in patient populations will require considerable resistance in order to provide the cervical musculature with sufficient stimulus. This is in contrast with the lumbar muscles where simple anti-gravity training is sufficient. Rehabilitative program dosage need not be age dependent until the 6th decade of life.

65. Use of Technology for Neck Strengthening

66. Initial Evaluation Protocols

67. Origins of Muscle Testing Manual muscle testing (MMT) was born in the 1950s with the work of two physical therapists (Kendall and Kendall) and their historic text, Muscles: Testing and Function.

68. Limitations of MMT Questionable inter-rater reliability. Jain M, 2006 Testers required repeated training. Esclolar DM, 2001 Limited ability to detect discrete differences in strength. Aitkens S, 1989 Difficult to stabilize the patients. Surburg PR, 1992

69. Did MMT stand the test of time? “Diagnostic accuracy of Manual Muscle Testing was never greater than 78% casting doubt on the suitability of manual muscle testing as a screening test for strength impairments.” Bohannon RW, 2005 “MMT method does not seem to be sufficiently sensitive to assess muscle strength or to detect small or moderate increases of strength over the course of rehabilitation. Since outcome measures is an important issue in rehabilitation, objective measurements of strength should be used in clinical settings.” Noreau L, 1998

70. Strength gains Chronic Neck Pain 31-41% improvement with 3 wk isometric training program. n=56 Ylinen J, 1994 Dynamic strength training program yielded 69%-110% strength gains when measured isometrically. n=180 Ylinen J, 2003 88-113% increase in isometric neck strength following dynamic strength program. n=371 DeNardis RJ, 2005

71. Multi – Cervical Unit Orientation of the unit ROM testing Isometric testing

72. Multi-Cervical Unit (MCU) MCU (1997-2004) MCU (2005-present) 35 sq. ft. / 3.25 m2 30 sq. ft. / 2.79 m2

73. MCU History The Melbourne Whiplash Centre (MWC), established 1997. Baseline protocol Hong Kong Polytechnic University research began, 2000. validity Clinical Applications developed and published, 2002, 2004, 2005 MCU II released, 2005 MCU Radar Graph, 2007

75. Research A comparison of training methods to increase neck muscle strength Burnett AF, Naumann FL, Price RS, Sanders RH WORK 2005; 25(3) pp. 205 - 210 Background: Neck injury in pilots flying high performance aircraft is a concern in aviation medicine. Strength training may be an effective means to strengthen the neck and decrease injury risk. Conclusions: This study demonstrated that the MCU was the most effective training modality to increase isometric cervical muscle strength. NB. Thera-Band tubing did however, produce moderate gains in isometric neck strength.

76. Research Cervical muscle strength measurement is dependent on the location of thoracic support Rezasoltani A, Ylinen J, Bakhtiary AH, Norozi M, Montazeri M, University of Shahid Beheshti (Medical Sciences), Faculty of Rehabilitation, Department of Physiotherapy, Damavand Avenue, 16169 Tehran, Iran. BR J SPORTS MED 2008MAY; 42(5) pp. 379 - 82 CONCLUSION: Maximum isometric force and maximum isometric torque measurements of the neck extensor muscles vary with the length of the lever arm. It is recommended that a specific level of thoracic support should be used in follow-up and intervention studies. Setting the level of thoracic support at a specific level will make it possible to compare the strength of the neck extensor muscles in different studies. Measurements at the level of the spine of the scapula were easier and less time consuming.

77. What would you do?

78. MCU Clinical Outcomes

79. Goals of Rehabilitation The primary goal is to regain the strength and symmetry of the cervical musculature. We also aim to improve the active ROM of the cervical spine where restriction has been identified. Secondary goals will be to decrease pain and improve overall function

80. MCU vs. Heat Therapy RCT of 145 Subjects with neck pain Exercise and Infrared/Neck care instruction Pre-Post measures after 6 weeks of intervention. Results: Exercise group had a significantly better improvement in disability score, pain rating, and isometric strength after 6 weeks. Conclusion: “Chronic neck pain can benefit from the neck exercise program” –Dr TT Chiu, 2004

81. Analysis of Published Outcomes Note: Stratford’s findings of MDC of 14 NDI % Points

82. Reassessment: Re-assess symptoms each treatment session Re-evaluate on the MCU after 9 treatment sessions Adjust treatment plan and MCU training as indicated.

83. S/P Cervical Fusion Do not begin until 6 months post fusion. This patient population is extremely weak. ROM will be limited due to the fusion. Begin with neutral planes with very low resistance, within mid-ranges. Progress slowly Monitor symptoms continually

84. Chronic WAD Case Study Referring diagnosis: Neck pain/ C-4 HNP /DDD C6-7. History: 58 yo female with chronic neck pain for the past 5 years after being involved in a MVA. Pain location: neck, bilateral trap and scapular area, with pain radiating up the back of her head. Neck pain rated as 9/10 and constant in nature. NDI score = 54% Mechanical assessment: non-responder

85. WAD Case Study Patient began treatment on the MCU ~2x/wk. Between 7/31/08 and 10/14/08 Refer to exercise sheet

86. WAD Case Study Results: Strength and ROM improved in all planes NDI scores decreased from 52% - 26%-14%. SIR scores decreased from 49% - 15% - 8%.

87. Other Case Studies: Chronic WAD Acute WAD Cervical DDD/ Stenosis S/P Cervical Fusion HNP

88. Marketing Initiatives 2 Key Areas General Public - Media and Advertising Referrers - GP’s, Health Professionals

90. Newspaper

91. Direct Mail

92. Newsletter

94. Referrers Prospective Referrers should be invited to an Information Session Focus on Research, Outcome Data, Case Studies & Publications Highlight Objective Data Regular Feedback

95. Referrers Industry Transport - Truck or Bus Drivers Sporting Teams Pre-season Injury Screening e.g. Rugby Union, NFL, Divers, Gymnasts

96. Advertising Coordinated Radio and Print Campaign Include Specialization in Neck Pain Successful Outcomes Scientifically Proven Free Information Evenings

97. In Summary… Objective Evaluation and Treatment with simple reporting functions that save time in documentation. Financial and Clinical rewards through rehabilitating a patient population that is typically a high cost of care. Unique Marketing Opportunities to Establish aNeck Care Center of Excellence.

98. For More Information on the MCU Don Garrison Regional Sales Manager BTE Technologies, Inc. 7455-L New Ridge Rd Hanover, MD 21076 Tel: 410.850.0333 Fax: 410.850.5244 Mobile: 301.908.3966 www.btetech.com James Jordan Precise Medical 1.800.849.7846 803.360.6920 - Cell jamesprecisemed@sc.rr.com