Cervical Spine Rehabilitation Protocol Based on Neck Disability Index (NDI) Scores

This rehabilitation protocol is designed for patients experiencing neck pain and dysfunction, guided by their Neck Disability Index (NDI) score. The NDI is a self-reported questionnaire assessing the impact of neck pain on various aspects of daily life. This protocol is divided into three phases: Protection (acute), Loading (sub-acute), and Return to Function (chronic). Treatment progressions are based on symptom presentation and patient tolerance. This is a general guideline and should be tailored to the individual patient's needs and clinical presentation.

Pathophysiology of Neck Pain

Neck pain can arise from a variety of sources, including:

• Muscle Strain/Spasm: Often due to poor posture, repetitive movements, or sudden trauma.
• Facet Joint Dysfunction: Inflammation or restriction of movement in the facet joints of the cervical spine.
• Disc Herniation/Degeneration: Protrusion of the intervertebral disc, potentially compressing nerve roots.
• Nerve Root Compression: Pressure on nerve roots due to disc herniation, bony spurs, or inflammation. This can cause radicular symptoms (pain radiating down the arm).
• Cervical Spondylosis: Degenerative changes in the cervical spine, including disc degeneration, bone spurs, and ligament thickening.
• Whiplash Associated Disorders (WAD): Injuries resulting from rapid acceleration-deceleration forces, often in motor vehicle accidents.
• Postural Dysfunction: Prolonged periods of poor posture, such as forward head posture, can contribute to neck pain.

Common Special Tests

These tests should be performed during the initial evaluation to help identify the source of the patient's symptoms.

• Spurling's Test: To assess for cervical radiculopathy (nerve root compression).
• Distraction Test: To relieve pressure on nerve roots and assess pain reduction.
• Upper Limb Tension Tests (ULTT): To assess for neural tension in the upper extremities. Specifically ULTT1/Median Nerve Bias, ULTT2a/Median, Axillary, Musculocutaneous Nerve Bias, ULTT2b/Radial Nerve Bias, ULTT3/Ulnar Nerve Bias
• Vertebral Artery Test (VBI): To assess for vertebral artery insufficiency (contraindicated in certain cases).
• Cervical Compression Test: To assess for pain provoked by cervical spine compression
• Shoulder Abduction Test (Bakody's sign): To assess for cervical radiculopathy; pain relief with arm abduction is a positive finding.

Phase I: Protection (Acute Phase - High NDI Score)

Goals: Reduce pain and inflammation, protect injured tissues, and promote early healing.

• Pain Management:
  • Patient education on pain management strategies (e.g., pacing activities, proper posture).
  • Modalities: Ice/heat therapy (as appropriate), electrical stimulation (TENS), manual therapy (gentle cervical traction, soft tissue mobilization - addressing muscles such as upper trapezius, levator scapulae, sternocleidomastoid).
• Cervical ROM (Range of Motion):
  • Gentle active ROM exercises within pain-free limits (e.g., chin tucks, cervical rotation, lateral flexion).
  • Avoid provocative movements that increase pain.
• Postural Correction:
  • Education on proper posture and ergonomics.
  • Chin tuck exercises to improve cervical lordosis and reduce forward head posture.
• Isometric Strengthening:
  • Gentle isometric exercises for cervical flexors, extensors, and lateral flexors. Hold each contraction for 5-10 seconds.

Phase II: Loading (Sub-Acute Phase - Moderate NDI Score)

Goals: Restore ROM, improve muscle strength and endurance, and begin functional activities.

• ROM Progression:
  • Progress to more challenging active ROM exercises.
  • Introduce gentle cervical joint mobilization techniques (grade I-II) to address joint restrictions if appropriate.
• Strengthening Progression:
  • Progress from isometric to isotonic exercises (e.g., using resistance bands or light weights).
  • Focus on strengthening deep neck flexors, scapular stabilizers (rhomboids, middle/lower trapezius), and upper back muscles.
  • Examples: Chin tucks with resistance band, rows, scapular retractions, Y-raises, T-raises, I-raises.
• Endurance Training:
  • Increase the repetitions and duration of strengthening exercises.
  • Introduce postural endurance exercises (e.g., maintaining proper posture for extended periods).
• Proprioception Training:
  • Exercises to improve balance and coordination (e.g., head control exercises with eyes closed, balance board activities).
• Functional Activities:
  • Gradually introduce activities that simulate daily tasks, such as reaching, lifting light objects, and turning the head while driving.

Phase III: Return to Function (Chronic Phase - Low NDI Score)

Goals: Optimize strength, endurance, and functional capacity. Prevent recurrence of symptoms.

• Advanced Strengthening:
  • Progress to more challenging resistance exercises using heavier weights or resistance bands.
  • Incorporate exercises that mimic sport-specific or work-related activities.
• Plyometric Training:
  • Introduce plyometric exercises (e.g., medicine ball throws) to improve power and explosiveness (if appropriate).
• Sport-Specific/Work-Related Training:
  • Simulate activities specific to the patient's sport or job (e.g., throwing, lifting heavy objects, repetitive movements).
• Postural Maintenance:
  • Continue to emphasize proper posture and ergonomics.
  • Implement strategies to maintain good posture throughout the day (e.g., setting reminders, using ergonomic equipment).
• Self-Management Strategies:
  • Educate the patient on self-management techniques to prevent future episodes of neck pain (e.g., stretching exercises, activity modification).
  • Develop a home exercise program to maintain strength, endurance, and flexibility.

Progression Criteria: Progression through each phase is dependent on the patient's ability to tolerate the exercises and activities without an increase in pain or other symptoms. A decrease in NDI score indicates improvement. If symptoms worsen, the patient should be regressed to the previous phase or exercise. Frequent communication and monitoring are essential for successful rehabilitation.