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Can Neck Exercises Enhance The Activation Of The Semispinalis Cervicis Relative To The Splenius Capitus At Specific Spinal Levels?

Schomacher, J. et al., Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.04.010.

Abstracted by: Russell Hanks, PT, COMT, Anchorage, AK — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.

Exercise has been shown to be an effective treatment for people with chronic neck pain but the neuromuscular changes in response to training are typically specific to the mode of exercise performed (Miller et al., 2010; Jull et al., 2008; Falla et al., 2012).  Patients with neck pain often display increased sternocleidomastoid activity and decreased deep cervical flexor activation (Jull et al., 2009).  Therefore, exercises to increase deep cervical flexors activity are often employed (Falla et al., 2004; O’Leary et al., 2011b).  It has also been shown that the deep cervical extensor, semispinalis cervicis, is relatively inactive in individuals with chronic neck pain while showing increased activation of the superficial extensor muscles including the splenius capitis (Schomacher et al., 2012b, 2013; Schomacher and Falla, 2013). This study attempted to demonstrate a method to activate the deep cervical extensor muscle, semispinalis cervicis, while relatively inhibiting the superficial cervical extensor, splenius capitis, as is done with deep cervical flexor exercises.


Using intramuscular electromyography (EMG), this study investigated the activity of the deep semispinalis cervicis and the superficial splenius capitis muscle at two spinal levels (C2 and C5) in ten healthy volunteers during a series of neck exercises:

  1. Traction and compression
  2. Resistance applied in either flexion or extension at the occiput, at the level of the vertebral arch of C1 and of C4.  
  3. Maintaining the neck in neutral while inclined prone on the elbows, with and without resistance at C4.

The ratio between semispinalis cervicis and the splenius capitis EMG amplitude was quantified as an indication of whether the exercise could emphasize the activation of the semispinalis cervicis muscle relative to the splenius capitis. Manual resistance applied in extension over the vertebral arch emphasized the activation of the semispinalis cervicis relative to the splenius capitis at the spinal level directly caudal to the site of resistance (ratio: 2.0 ± 1.1 measured at C5 with resistance at C4 and 2.1 ± 1.2 measured at C2 with resistance at C1).


Ten healthy volunteers (3 men and 7 women; age 30.7+/-7.4 years; height 170+/- 8.8 cm; weight 67.6+/-24.8 kg) without neck pain participated.  Intramuscular EMG, guided by ultrasound, was acquired from the semispinalis cervicis and splenius capitis muscles at the level of the 2nd and 5th spinous processes on the right side.  The subjects were placed in a prone position with the head slightly flexed.  The deep cervical artery, which lies in the fascia separating the semispinalis cervicis from the splenius capitis muscle, was visualized with Doppler sonography prior to the insertion of the needle.  The needle was inserted at the spinal levels of C2 and C5 vertically into the semispinalis cervicis and at a 45 degree angle into the splenius capitis.  Once the target muscles were identified by ultrasound, the needle was removed leaving the wire in the muscle belly for the duration of the experiment.  A reference surface electrode for each wire was placed adjacently (mastoid process, spinous process C7, and for the levels of C2 and C5) and a further common reference electrode was placed around the wrist.

The participants were then seated in a device to measure neck muscle force (Cervical-Multi unit, BTE technologies, USA).  Three maximum voluntary neck extension contractions were measured and the highest value of force was selected as the maximal force.  The subjects then performed isometric exercises against manual resistance in sitting resisting axial traction and compression (Figures 7, 8), extension and flexion (Figures 1-4), and standing in front of a table propped up on both forearms in extension (Figures 5, 6).  Each exercise was repeated twice for approximately 10 seconds during which EMG activity was recorded.  The intensity of the resistance was applied with the maximal force that each subject could counteract without discomfort from the investigators hands/fingers over the neck.  Manual resistance could not be standardized so the ratio between normalized root mean square (RMS – estimated amplitude of the EMG signal) of the semispinalis cervicis and splenius capitis was calculated and compared across conditions.

Figure 1: Subject retracts head and neck against the extension resistance at the occiput

Figure 2: Subject retracts head and neck against the extension resistance at C1.


Figure 3: Subject protracts head against the flexion resistance at the occiput.

Figure 4: Subject protracts head against the flexion resistance at C4

Fig 5: Propping on elbows with head aligned.

Figure 6: Propping on elbows with resistance in extension at the level of C4.

Figure 7

Figure 8

Figures 7-8: Compression and traction respectively while asking the patient to resist the downward or push upwards.

A three-way ANOVA (Analysis of Variance) was conducted on the normalized RMS values for semispinalis cervicis and splenius capitis, both at C2 and C5, with direction (flexion and extension), location of resistance (occiput, C1 and C4) and muscle (semispinalis cervicis and splenius capitis) as factors.  


This study evaluated and confirmed, for the first time, the ability to enhance the activation of the semispinalis cervicis muscle relative to the splenius capitis at different spinal levels with targeted exercise interventions.  

Resistance in cervical Flexion and Extension:

    • The activation of both muscles at both spinal levels was greatest when resistance was applied to the head, for flexion and extension, compared to resistance over the vertebral arches.
    • Resistance at C1 produced higher muscle activity at C2 compared to resistance at C4 which has no direct lever at the level of C2.
    • Resistance at C1 had the same level of muscle activity at C2 as it did at C5 indicating the other factors influence muscle activation.
    • The ratio between the semispinalis cervicis and splenius capitis recorded at C2 was highest when resistance was applied in extension at the level of C1 compared to resistance applied at the occiput or the level of C4.
    • The ratio of muscle activity at C5 was highest with resistance in extension at C4 compared to the occiput or C1.
  • Manual resistance applied over the vertebral arch can emphasize the activation of the semispinalis cervicis relative to the splenius capitis directly caudal to the location of the resistance compared to resistance applied at other locations.  
  • These concepts might be clinically relevant when movement dysfunction or structural changes are identified at specific segments.

Prone extension on elbows:

  • The aim of this exercise was to emphasize the lower cervical extensor muscles, so resistance was only applied at C4.  This may be helpful for patients presenting with a forward head posture.
    • As previously confirmed, resistance over the vertebral arch of C4 further increased the activity of both muscles at both levels but more so at C5 compared to C2.
  • The ratio between the deep and superficial muscles did not differ with this exercise, however the muscle activity recorded at C5 was higher compared to the exercises when the resistance was applied in flexion which suggests that extension on elbows is still an effective way to activate the semispinalis cervicis in the lower cervical spine.

Seated cervical traction and compression:

  • Higher muscle activity was recorded for both muscles at both levels during traction versus compression.
  • Cervical lordosis flattened during traction and increased during compression.  Flattening of the cervical lordosis occurs during traction (Panjabi et al., 1978) which may prompt activation of all extensor muscles.  Compression tends to increase cervical lordosis which cannot be limited by extensor muscle contraction.  The activation of both the semispinalis cervicis and splenius capitis during compression may reflect coactivation with the cervical flexor muscles which are likely more activated (Falla et al., 2007b).

Methodological considerations and limitations of the study:

    • The invasive nature of the experiment limited the sample size of the study but it is consistent with other invasive EMG studies.
    • The electrode wires may have moved during the exercise because the size of the wire and the inability to confirm its location once the needle was removed.  The hook at the end of the wire did limit its movement.
    • Pressure on the tissue near the wires may have caused EMG artifact but this was monitored continuously throughout the experiment.
    • The validity and reliability of the exercises selected have not been previously evaluated.
  • Both muscles were activated in all of the exercises.  Exclusive activation of the semispinalis cervicis was not found, however resistance applied over the vertebral arch did activate the semispinalis cervicis relative to the splenius capitis directly caudal to the site of resistance.  
  • The study was performed on pain-free subjects and the results may differ if performed on subjects with neck pain however previous studies have concluded a difference in semispinalis cervicis relative to splenius capitis in people with chronic neck pain when resistance was applied locally to the neck.


Since resistance applied over the vertebral arch was found to activate the semispinalis cervicis relative to the splenius capitis directly caudal to the site where the resistance was applied, this concept may prove to be useful if applied to people with neck pain who have shown to suffer from impairment to this muscle during clinical testing.

IAOM Comment:

What do we know about the semispinalis cervicis?  The fibers of semispinalis cervicis originate from the transverse processes of T1 to T5/T6 and insert on the spinous processes of C2 to C5 (Leonhard et al., 2003) respectively down to C7 (Schünke et al., 2006; Drake et al., 2010).  The deep semispinalis cervicis muscle is active predominately in extension with a small ipsilateral component (Schomacher et al., 2012b).  The activity of the semispinalis cervicis increases with increasing contraction intensity (Schomacher et al., 2012b), confirming observations for other neck muscles, such as the sternocleidomastoid, semispinalis capitis, splenius capitis and upper trapezius (Blouin et al., 2007; Falla et al., 2010; Lindstrøm et al., 2011).  This finding suggests that multiple muscles can be recruited at lower loads to generate a required force in a desired direction, while at higher loads the primary muscles are predominately recruited (Blouin et al., 2007).

Schomacher and Falla, in 2013, found structural changes in the deep cervical extensors of patients with neck pain compared to healthy controls such as a higher concentration of fat within the muscle, variable cross-sectional area and higher proportions of type II fibers.  They postulated that these findings suggest that the behavior of the deep extensors may be altered in patients with neck pain.  On the contrary, fatty infiltration of muscle tissue has not been observed consistently in patients with insidious-onset neck pain (Elliott et al., 2008b).  The superficial cervical extensors typically show increased activation in patients with neck pain (Szeto et al., 2005; Kumar et al., 2007; Johnston et al., 2008; Lindstrøm et al., 2011) as well as delayed offset (relaxation) after activity (Johnston et al., 2008).  On the contrary, recent studies show that patients with neck pain display reduced activation of the deep extensor muscles, semispinalis cervicis and multifidus when assessed with muscle functional magnetic resonance imaging (mfMRI) (O’Leary et al., 2011a).

So, a good question to ask at this point is how do you know in clinical practice when the semispinalis cervicis is weak and is it weaker in patients with chronic neck pain?  The answers to these questions were alluded to in this abstracted study but no testing was performed to measure weakness because the test subjects in this study had no neck pain.  Can we make the assumption that weakness is occurring in muscles showing a higher concentration of fat, variable cross-sectional area and higher proportions of type II fibers?  I think we can, but is there a clinical test to show it?  Not that was shown in this study.

Quote from the previous IAOM CTL-Safe course: “The musculoskeletal system of the cervical spine is among the most complex of the human body.  Cervical muscles demonstrate marked morphological diversity to permit and control the wide variety of head movements that are possible.  Untrained individuals are unable to maximally activate cervical muscles (Conley ’97).”

With this in mind, it is important that we include appropriate stabilization training that encompasses the complete cervical spine.  This is the attempt of the Sensoimotor Control and Rehabilitation of the CT Spine (SenMoCOR) course taught Phil Sizer Jr., PT, PhD, OCS, FAAOMPT with the IAOM-US.  The information contained in this article is an effective precursor to the SenMoCOR program.  Emphasis in this article is placed on the semispinalis cervicis, a deep cervical postural stabilizing muscle, similar to the multifidus.  When used as a neuromuscular re-education (NMR) tool post cervical mobilization, it can be an effective means to keep the newly gained range of motion in addition to activating the appropriate deep cervical extensors that are important in the stability of the cervical spine.  This article studied the C2 and C5 levels but I believe that activation of the semispinalis cervicis could be emphasized at all cervical levels, especially as a NMR tool.  For activation of the semispinalis cervicis after mobilization, have the patient push gently retract (2-3 lbs. of force) while you are providing resistance at the vertebral arch.  A light force of resistance is recommended because as previously mentioned above, in the study by Blouin et al. 2007, multiple muscles can be recruited at lower loads to generate a required force in a desired direction, while at higher loads the primary muscles are predominately recruited.

Since resistance applied over the vertebral arch was found to activate the semispinalis cervicis relative to the splenius capitis directly caudal to the site where the resistance was applied, it is important that surface anatomy for the cervical spine be emphasized.  The IAOM recommends beginning with the Frankfurter position, which is performed when the dorsal-most part of the occiput is in line with the dorsal-most aspect of the thoracic spine and the lower part of the orbit is in line with the external auditory meatus.  C1 is then found between the mastoid and the posterior angle of the mandible, anterior and deep to the sternocleidomastoid muscle.  C2 is the first spinous process caudal to the external occipital protuberance, C3 is found at the level of the hyoid bone, C4 at the level of the v-notch of the thyroid cartilage, C5 is found at the 3plates of the thyroid cartilage and C6 is located at the level of the 1st ring of the cricoid cartilage.

While not mentioned in this article, a home exercise program could be used to apply these principles for strengthening the semispinalis cervicis.  A Mulligan strap or similar strap could be used as pictured below (figures 9 and 10).  I recommend an isometric resistance of 2-3 lbs. into extension against the strap for a 3-second hold for a total of 3 sets of 25 repetitions or as symptoms will allow (72 repetitions over a 15 minute period for 7 consecutive days was shown to improve long-term motor learning – Boudreau et al. 2010).  All cervical levels can be treated in this manner.  You can also implement proprioceptive training using guided imagery with “thinking” looking up and “thinking” looking right or left while maintaining the resistance to add an additional component to the exercises.


Blouin JS, Siegmund GP, Carpenter MG, Inglis JT, Neural control of superficial and deep neck muscles in humans. Journal Neurophysiology 2007; 98:920-8.

Boudreau SA, Hennings K, Svensson P, Sessle BJ, Arendt-Nielsen L.  The effects of training time, sensory loss and pain on human motor learning.  Journal of Oral Rehabilitation 2010; 37(9):704-18.

Conley MS, Stone MH, Nimmons M, Dudley GA.  Resistance training and human cervical muscle recruitment plasticity. Journal of Applied Physiology 1997; 83(6):2105-11.

Drake RI, Vogl WA, Mitchell AWM. Gray’s Anatomy. Philadelphia, PA: Churchhill Livingston Elsevier, 2010.

Elliott J, Sterling M, Noteboom JT, Darnell R, Galloway G, Jull G. Fatty infiltrate in the cervical extensor muscles is not a feature of chronic, insidious-onset neck pain. Clinical Radiology 2008b; 63(6):681-7.

Falla D, Jull G, Hodges PW.  Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test.  Spine 2004; 29:2108-14.

Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain.  Physical Therapy 2007a; 87:408-17.

Falla D, Lindstrøm R, Rechter L, Farina D.  Effect of pain on the modulation in discharge rate of sternocleidomastoid motor units with force direction.  Clinical Neurophysiology 2010; 121:744-53.

Falla D, O’Leary S, Farina D, Jull G.  The change in deep cervical flexor activity after training is associated with the degree of pain reduction in patients with chronic neck pain. Clinical Journal of Pain 2012; 28:628-34.

Johnston V, Jull G, Souvlis T, Jimmieson N. Neck movement and muscle activity characteristics in female office workers with neck pain. Spine 2008; 33 (5): 555-63.

Jull G, Falla D, Vicenzino B, Hodges PW.  The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain.  Manual Therapy 2009; 14:696-701.

Jull G, Sterling M. Falla D, Treleaven J, O’Leary S.  Whiplash, headache and neck pain: research-based directions for physical therapies.  Edinburgh: Elsevier, Churchhill Livingston; 2008.

Kumar S, Narayan Y, Prasad N. Shuaib A, Siddiqui ZA.  Cervical electromyogram profile differences between patients of neck pain and control.  Spine 2007; 32 (8):E246-53.

Leonhard H, Tillmann B, Tondury G, Zilles K. Rauber/Kopsch. Anatomie des Menschen, Lehrbuch und Atlas. In: Tillmann B, editor. Bewegungsapparat, Band I. Stuttgart – New York: Georg Thieme Verlag: 2003.

Lindstrøm R, Schomacher J, Farina D, Rechter L, Falla D.  Association between neck muscle coactivation, pain, and strength in women with neck pain.  Manual Therapy 2011; 16 (1): 80-6.

Miller I, Gross A, D’Sylva J, Burnie SI, Goldsmith CH, Graham N, et al.  Manual therapy and exercise for neck pain: a systematic review.  Manual Therapy 2010; 15:334-54.

O’Leary S, Cagnie B, Reeve A, Jull G, Elliott JM.  Is there altered activity of the extensor muscles in chronic mechanical neck pain? A functional magnetic resonance imaging study. Archives of Physical Medicine and Rehabilitation 2011; 92(6): 929-34.

O’Leary S, Falla D, Jull G.  the relationship between superficial muscle activity during the craniocervical flexion test and clinical features in patients with chronic neck pain.  Manual Therapy 2011b; 16:452-5.

Panjabi MM, White III AA, Keller D, Southwick WO, Friedlaender G.  Stability of the cervical spine under tension. Journal of Biomechanics 1978; 11:189-97.

Schomacher J, Falla D.  Function and structure of the deep cervical extensor muscles in patients with neck pain. Manual Therapy 2013; 18:360-8.

Schomacher J, Farina D, Lindstroem R, Falla D.  Chronic trauma-induced neck pain impairs the neural control of the deep semispinalis cervicis muscle.  Clinical Neurophysiology 2012b; 123:1403-8.

Schomacher J, Petzke F, Falla D.  Localised resistance selectively activates the semispinalis cervicis muscle in patients with neck pain.  Manual Therapy 2012c; 17:544-8.

Schuenke M, Schulte E, Schumacher U. Thieme Atlas of Anatomy, General Anatomy and Musculoskeletal System. Stuttgart, Germany: Thieme, 2006.

Szeto GPY, Straker LM, O’Sullivan PB. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work – 1: neck and shoulder muscle recruitment patterns.  Manual Therapy 2005; 10:270-80.

Fibular Malalignment in Individuals with Chronic Ankle Instability

Kobayashi T, Suzuki E, Yamazaki N, et al. Fibular malalignment in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2014;44(11):872-878.

Abstracted by:  Rebecca Sherwin, PT, COMT, West Monroe, LA – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, IAOM-US Fellowship Program Director

Chronic ankle instability can be associated with ankle sprains and changes that occur at the distal tibiofibular joint (DTFJ) with injuries.  When there is increased movement at the DTFJ, there is naturally an increase in talar movement, which affects the mechanics of the entire foot.  This change also affects the load distribution that occurs at the ankle during weight-bearing and has been shown to lead to osteoarthritis of the ankle joint.1  This increased motion at the ankle is commonly assessed with radiography; however, computed tomography (CT) is superior to radiography.2,3

Many different fibular positions have been indicated with chronic ankle instability in 2-D studies; however, none of the studies are in full agreement with their findings. According to Kobayashi et al, studies utilizing CT scans found a posterior placement of the fibula while many radiographic studies found that there was an anterior placement of the fibula.  

This study was performed to analyze the 3-D position variations of the ankle with computed tomography in a non-weight bearing position in subjects with chronic ankle instability.  The study hypothesis was that the fibula of an ankle with chronic ankle instability would exhibit a posterior and lateral position in relation to the tibia.  The inclusion criteria were:  healthy male, at least 2 episodes of unilateral ankle sprain in the year prior to the study, multiple episodes of giving way unilaterally especially during sporting events, side-to-side differences on figure 8 hop test and side hop test and a contralateral ankle without dysfunction.  The exclusion criteria were: ankle sprain within the past 3 months on the lateral side, any history of a neurological deficit (CVA, neuropathy) or lower extremity injury, and any history of using medication that could affect balance. 

Seventeen participants were chosen for this study that exhibited unilateral chronic ankle instability (CAI).  All participants were tested with stress radiography bilaterally in order to screen for any type of mechanical instability that could be present.  The stress radiography included an Anterior Drawer test (Figure 1) and a Talar Tilt test (Figure 2).  The study’s definition of mechanical instability was equal to or greater than 3 mm difference with the anterior drawer test between affected and non-affected side as well as a talar tilt of 3 degrees or greater.

The participants had non-weight bearing CT scans performed in 1 mm slices from the distal 10 cm of the lower leg to the distal end of the calcaneus.  The ankles were held in a neutral position during the scanning.  From the CT imaging, bone models were formulated and measurements were taken 10 cm proximal from the lateral malleolus, 5cm proximal from the lateral malleolus and at the most prominent part of the lateral malleolus.  In this study, there was not a significant difference in the affected and non-affected ankle in anterior and posterior positioning of the fibula.  However, there was a significant difference in lateral positioning of the fibula as well as a slight difference in external rotation of the fibula when looking at the affected versus the non-affected limb at all three of the markers that were measured as previously mentioned.

Figure 1: Positive anterior drawer test on lateral radiographic view


Figure 2: Positive talar tilt test (image on left side of picture) on AP radiographic view

IAOM Commentary: The imaging in this study was performed in a non-weight bearing positioning where the widening of the distal tibiofibular joint is lessened in comparison to what would occur in a weight-bearing position.4  A disruption of the interosseous membrane that can occur with some lateral ankle instability dysfunctions will allow changed segmental mechanics, decreased weight distribution through the lower leg and resultant stability deficits4, which can occur up to 6 months post-injury.5  Many studies have shown that improvements in chronic ankle instability and postural sway can be made through strengthening, balance challenges as well as with ankle stabilization training.6,7,8  A study performed by Matsusaka et al reported that the addition of lateral ankle taping increases the joint awareness during ankle stabilization exercises.9  They also found that there was a reduction in recovery time and return to peak performance within 4 weeks versus 6 weeks.  Other studies discuss the effectiveness of challenging the brain’s ability to focus on a task in order to improve balance and reaction times.10  The following are examples of exercises to challenge balance, concentration on tasks as well as improve ankle stabilization.  One would want to progress their patient in training from a bilateral activity to a unilateral activity, progress from a static to a dynamic activity, from a firm surface to a softer, more unstable support.7

Figure 3: Taping a 1 cm strip of tape anterior and posterior to the malleolus with the addition of disc training has shown quicker improvement times.9


Figure 4: Bilateral balance exercise on dynadisc.6


Figure 5: Single leg stance balance exercise with dynamic activity with contralateral LE.


Figure 6: Single leg stance with rebounder activity to distract the brain and increase automatic responses in the ankle/foot complex.10


  1. Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone. 1984;66(4):490-503.
  2. Harley JD, Mack LA, Winquist RA. CT of acetabular fractures: comparison with conventional radiography. Am J Roentgenol. 1982;138(3):413–417.
  3. Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma. 2012;26(7):433–438.
  4. Wang Q, Whittle M, Cunningham J, Kenwright J. Fibula and Its Ligaments in Load Transmission and Ankle Joint Stability. Clin Orth Rel Res. 1996;330:261-270.
  5. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent Disability Associated with Ankle Sprains: A Prospective Examination of an Athletic Population. Foot Ankle Int. 1998;19(10):653-660.
  6. Eils E, Rosenbaum D. A multi-station proprioceptive exercise program in patients with ankle instability. Med Sci Sports Exerc. 33(12):1991-1998.
  7. Rozzi SL, Lephart SM, Sterner R, Kuligowski L. Balance training for persons with functionally unstable ankles. J Orthop Sports Phys Ther. 1999;29(8):478-486.
  8. Sekir U, Yildiz Y, Hazneci B, Ors F, Aydin T. Effect of isokinetic training on strength, functionality and proprioception in athletes with functional ankle instability. Knee Surg Sports Traumatol Arthrosc. 2007;15(5):654-664.
  9. Matsusaka N, Yokoyama S, Tsurusaki T, Inokuchi S, Okita M. Effect of ankle disk training combined with tactile stimulation to the leg and foot on functional instability of the ankle. Am J Sports Med. 2001;29(1):25–30.
  10. Ashton-Miller JA, Wojtys EM, Huston LJ, Fry-Welch D. Can proprioception really be improved by exercises? Knee Surg Sports Traumatol Arthrosc. 2001;9(3):128-136.

Daily Exercises and Education for Preventing Low Back Pain in Children: Cluster Randomized Controlled Trial

Hill JJ, Keating JL, Physical Therapy Journal, 95 (2015) 507–516.

Abstracted by: Russell Hanks, PT, COMT, Anchorage, AK — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.

This prospective multicenter cluster randomized controlled trial (RCT) compared education and regular specific back exercises with education alone on the incidence of low back pain (LBP) in children aged 8 to 11 years.  The research available1 appears to indicate that regular specific back exercises when combined with education may reduce episodes of LBP and lifetime first episodes of LBP when compared with education alone. This paper attempted to examine how children stay compliant to an exercise routine and whether or not they would make it an ongoing part of their daily practice. This study also examined the factors that lead to exercise compliance.

The prevalence of LBP increases with age, starting as young as 9 years of age and reaching similar prevalence as reported for adults by 15 years of age.2, 3  LBP in adolescence predicts LBP in adulthood, 4, 5 signaling a role for primary prevention of the lifetime first episode of LBP.3, 6  The only risk factor for LBP that has been validated in independent studies in adults is a history of previous LBP.3, 7-11 Exercise appears to be helpful in reducing the recurrence of LBP in adults,12 and may influence future spine health of young people with a history of LBP.13,14 Reviews of interventions to improve spinal knowledge, change movement behavior and reduce the prevalence of LBP in children showed potential benefits, but evidence to support their effects is limited.15, 16


This was an observational study of compliance to exercise. It was embedded in a prospective RCT comparing education and daily exercise with education alone on LBP in children (aged 8 to 11 years) in primary schools in New Zealand for 270 days between April and December 2011.  Schools were enrolled in the MySpine program and were allocated using randomization with concealment to an exercise and education group (intervention) or to education alone (control).

The children in the study ranged in age from 8 to 11 years and were able to follow simple instructions, complete a child-friendly survey and whose parents gave their informed consent. Children were excluded if they were not able to do the exercises due to spinal pathologies, neurological disorders, injuries, or physical disabilities for which movement was a contraindication or prevented standing unilaterally safely and independently.

The primary researcher, a physical therapist, visited each group in the study (intervention or control) seven times over the 270-day period.  A randomization officer assigned the students to each of the groups.  Figure 1 summarizes the intervention (MySpine program) and control conditions, along with the 4 exercises shown to the intervention group.  Back awareness and taking responsibility for “MySpine” were taught and reinforced at each session within each of the control and intervention groups.  The range of motion exercises encouraged movement, could be performed without supervision, were meant to be easy to remember and could be added to any existing exercise routine.  Students were encouraged to perform the exercises three times per day.  Instruction was also provided to encourage compliance to the exercise program.

Children were given surveys to determine a history of low back pain (day 1) or episode of low back pain when the researcher visited the schools on days 7, 21, 49, 105, 161, and 270.  The duration of low back pain was tracked and categorized in shorter episodes (1-2 days) and longer episodes (> 3 days).  They were also asked about their compliance to the exercise, the frequency of performance and their reasons for non-adherence.  

MySpine Program

Both Groups:

  1. Introduction to the MySpine program (15 minutes)
  2. Baseline Survey
  3. Back awareness education session. “Taking responsibility for your spine.” (15 minutes)
  • Anatomy of the spine
  • What is low back pain?
  • Movement versus static postures
  • Taking responsibility for your spine – “It’s about what you can do.”
  • Handy hints – advise children to “stand tall, shoulders square, chin in, keep moving, don’t slouch.”
  1. Question time (5 minutes)

Intervention Group:

  1. Demonstrate 4 back exercises (see below)
  2. Emphasize moving the back through the full range of flexion, extension, and lateral flexion movements, repetition, and awareness of back movement.  Advise to repeat 3x/day.
  3. Children demonstrate exercises
  4. Exercises checked
  5. Performance difficulties addressed using feedback and demonstration

Figure 1: MySpine Program (may be used without permission by the authors)


There were 764 children in 7 participating schools meeting the criteria for the study.  There were no significant differences between the groups in regards to age, episodes of LBP, or response attrition.  During the trial, 35% of the intervention group and 28% of the control group reported on LBP episodes.  Children with a history of LBP had greater odds of reporting pain during the study.  Short duration LBP (1-2 days) occurred in 72% in the control groups and 62% in the intervention groups.  There were no significant differences between groups for LBP episode durations and there was no significant effect on the frequency of exercises performed for episodes of LBP.


Children in the exercise group reported fewer episodes of LBP and fewer lifetime first episodes of LBP than those in the control group.  At the start of the study, 47% of the children reported a previous episode of LBP. The researchers observed a decrease of 23% at day 7 in episodes of LBP to 13% at day 270 in the intervention group and 33% to 24% in the control group, respectively.  Children in the exercise group were also less likely to report a lifetime first episode of LBP and experience a longer time to onset of a first episode when one did occur.

It has been suggested that it may be inappropriate to apply adult definitions of LBP when assessing children17 and that children may conceptualize pain in ways that differ from adults.18  A reduction in LBP was reported across both groups in spite of compliance to the exercises declining across the study.  The researchers could not confidently attribute the results to exercise participation.  They stated that likely there was not a physiological effect from the four exercises but felt that paying attention to the children, educating them about the spine and LBP and talking about the importance of movement had a therapeutic effect on the children.

In conclusion, the program presented in this study may reduce episodes of LBP in children ages 8-11 years, however it is unlikely the results can be attributed to the exercises alone but also the education provided.  Additional studies are needed to validate these findings.


IAOM Comment:

Low back pain in children is becoming more common and as indicated in the references of this study, it is often a predictor of LBP in adulthood.4,5  I think the important point made in this study was that it wasn’t either exercise or education that made the difference, it was both.  I don’t think it comes as a surprise to anyone with children that compliance to the exercises declined over time.  In fact, I think we could safely assume that happens with all age groups.  We don’t need a study to prove what most of us have seen in our practices.  

Increasing activity levels in children is important.  It is disturbing that LBP is becoming more common but not surprising given the trends seen with children spending more time in front of screens.19  I think it is important to note that any exercise will become routine for most people over time.  Regardless of the effectiveness of the 4 exercises in this program, asking a child to be compliant over a 6-month period, especially if they didn’t have back pain, seems unlikely.  I think it is a challenge for physical therapists to have our patients stay compliant with their home exercise programs.  In this study, education was also an important component in the success of reducing the onset of back pain.  I try to ask myself the following four questions when prescribing a home program: (1) What does the patient need to know?  (2) Why do they need to know it? (3)   What do they need to do?; and (4) Why do they need to do it?

Education is important, but ultimately, what does the patient need to know about what is going on with their body?  This will be dependent on what the patient wants to know.20  Some patients want to know everything and others, not so much.  Once you have determined what they need to know, it is important to help them understand why.  This makes the information relevant.  It the information stays irrelevant, then it is not a felt need and will be ignored.  Next, what do they need to do?  This is the exercise, or whatever else makes up your home program.  Is it easy to follow?  Have you included a picture, or video from their phone, or handout of some kind?  This helps with compliance.21  Lastly, why do they need to do it?  Assisting patients with understanding why they are doing a home program helps them understand the relevance of the exercise.  It also helps them engage in what problem is being addressed and how to measure their improvement.  Compliance is a challenge but I’ve found asking these four questions helps my patients be more successful.



1 Hill JJ, Keating JL. Daily exercises and education for preventing low back pain in children: cluster randomized controlled trial. Phys Ther 2015; 95:507–16.

2 Hill JJ, Keating JL. A systematic review of the incidence and prevalence of low back pain in children. Phys Ther Rev 2009; 14:272–84.

3 Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, et al. How to prevent low back pain. Best Pract Res Clin Rheumatol 2005; 19:541–55.

4 Hestbaek L, Leboeuf-Yde C, Kyvik KO, Manniche C. The course of low back pain from adolescence to adulthood: eight-year follow-up of9600 twins. Spine 2006; 31:468–72.

5 Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine 2007; 32:2630–7.

6 Cardon G, Balague F. Low back pain prevention’s effects in school children. What is the evidence. Eur Spine J 2004; 13:663–79.

7 Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 2003; 12:149–65.

8 Jones GT, Macfarlane GJ. Epidemiology of low back pain in children and adolescents. Arch Dis Child 2005; 90:312–6.

9 Hestbaek L, Leboeuf-Yde C, Kyvik KO, Hestbaek L, Leboeuf-Yde C,Kyvik KO. Is comorbidity in adolescence a predictor for adult low backpain? A prospective study of a young population. BMC Musculoskel Dis 2006; 7:29.

10 Harreby M, Neergaard K, Hesselsoe G, Kjer J, Harreby M, Neergaard K, et al. Are radiologic changes in the thoracic and lumbar spine of adolescents’ risk factors for low back pain in adults? A 25-year prospective cohort study of 640 school children. Spine 1995; 20:2298–302.

11 Hill JJ, Keating JL. Risk factors for the first episode of low back pain in children are infrequently validated across samples and conditions: a systematic review. J Physiother 2010; 56:237–44.

12 Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. [Summary for patients in Ann Intern Med 2005;142: I71]. Ann Intern Med 2005; 142:765–75.

13 Jones M, Stratton G, Reilly T, Unnithan V. The efficacy of exercise as an intervention to treat recurrent nonspecific low back pain in adolescents. Pediatr Exerc Sci 2007;19:349–59.

14 Fanucchi GL, Stewart A, Jordaan R, Becker P. Exercise reduces the intensity and prevalence of low back pain in 12–13-year-old children: a randomized trial. Aust J Physiother 2009; 55:97–104.

15 Steele EJMPHB, Dawson APGB, Hiller JEP. School-based interventions for spinal pain: a systematic review. Spine 2006; 31:226–33.

16 Cardon G, Balague F. Low back pain prevention’s effects in school children. What is the evidence? Eur Spine J 2004; 13:663–79.

17 Balague´ F, Dudler J, Nordin M. Low-back pain in children. Lancet. 2003; 361:1403–1404.

18 Burton AK, Mu¨ller G, Balague´ F, et al; on behalf of the COST B13 Working Group on Guidelines for Prevention in Low Back Pain. European guidelines for prevention in low back pain. November 2004. Available at: http://www.backpaineurope.org/web/files/WG3_Guidelines.pdf. Accessed September 2014.

19 American Academy of Pediatrics. Children, adolescents, and television. Pediatrics 2001; 107:423–426 [PubMed]

20 Shekhawat L et.al. Does the cancer patient want to know? Results from a study in an Indian tertiary cancer center. South Asian J Cancer 2013; 2:57-61.

21 Zhabenko O. et.al. Supporting Homework Compliance in Cognitive Behavioral Therapy: Essential Features of Mobile Apps. JMIR Ment Health 2017 4:e20. 10.2196/mental.5283

The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography

Abstracted by: Dale Gerke, PT, ScD, COMT, Mequon, Wisconsin — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship Program.

Lawrence CR, East B, Rashid A, Tytherleigh-Strong GM. The prevalence of osteoarthritis of the sternoclavicular joint on computed tomography. J Shoulder Elbow Surg. 2017; 26:e18-e22.

The shoulder girdle is comprised of 3 synovial joints with the sternoclavicular joint (SCJ) likely the least commonly involved (Figure 1). The authors acknowledged that the most common pathology of the SCJ is osteoarthritis (OA) as previously determined through cadaveric observation. Therefore, the dual purpose of this study was to determine if there was a similar pattern of OA severity and prevalence in the SCJ.

Figure 1. Sternoclavicular Joint (source: Wikipedia)

The investigators retrospectively viewed CT scans from patients who underwent imaging for adjacent trauma or systemic pathologies such as cancer. None of the scans were ordered to evaluate the SCJ, but the image was reconstructed to use a minimum of 18 slices. This is significant because the scans were not ordered secondary to a painful SCJ. The authors acquired at least 20 patients in each decade of adult life. A total of 232 patients and 464 SCJ scans were used in the study. Definitive signs of OA were used to grade the joints including obvious presence of an osteophyte, subchondral cyst or cortical sclerosis. Each finding was given one point with the greatest severity receiving a score of 3 points per joint. Three separate reviewers reviewed the images to eliminate a deadlocked decision.

OA was identified in 137 (59%) patients and 107 (46%) patients had bilateral involvement.  Interestingly, a majority of the signs occurred on the clavicular side of the joint with less than 2% having isolated OA on the sternal side of the joint. The average age without any signs of OA was 41.4 years. Conversely, the average age for those patients with OA of the SCJ being 73.1 years of age. Eighty-nine percent of patients who were older than 70 years of age had at least 3 signs of OA in one joint. The presence of OA in the SCJ was not different between genders or hand dominance. Furthermore, there was an open physis in the younger patients between the ages of 20-25 years of age and an absence of OA.

The presence of OA in the SCJ appears to be a normal degeneration of the joint beginning as early is the mid 30’s. By age 50, nearly 90% of individuals will have some sign of OA. It is also important to remember that OA could be a normal variant as none of these subjects were scanned for discomfort in the SCJ.

IAOM Comment:

According to the information from the authors, the SCJ is prone to typical degeneration especially as we age. It would be easy to consider this information as inconsequential, but this is beneficial for several reasons. It is important to remember that we do not treat imaging alone. Identifying OA in the SCJ coupled with the results from the examination would be more meaningful. If the SCJ is symptomatic, the IAOM advocates pain would be present in the C4 distribution1. It is also possible to see signs of degeneration such as osteophytes on the medial aspect of the clavicle with observation. Some authors have also advocated that a common characteristic of SCJ arthritis is a larger prominence with possible subtle anterior dislocation5.The basic examination includes an assessment of shoulder girdle motions.  This may allow the clinician to compare sides for pain provocation or subtle hypomobility. Similarly, the capsular pattern for the SCJ is pain at the end of shoulder elevation requiring end range shoulder girdle motion to be evaluated as well. In summary, a cluster of pain in the C4 region, provocation or hypomobility with shoulder girdle motions, anteromedial clavicular prominence and pain at the end of shoulder elevation should warrant a local investigation of the SCJ. The IAOM advocates specific joint play testing to determine if the joint is hypermobile or hypomobile (Figure 2).to direct the appropriate intervention. If it is determined that the SCJ is a pain generator, traction mobilizations up to tissue resistance can be used for pain relief with acute injury (Figure 3).

Figure 2. The examiner grasps the lateral aspect of the shoulder with the lateral clavicle. While stabilizing the thorax, the examiner will pull the right shoulder girdle in a direction of retraction. The examiner will simultaneously monitor the ipsilateral SCJ play with the index finger of the contralateral hand.

Figure 3. To perform traction, the patient is positioned supine with a towel medial to the involved scapula to allow for slight retraction. Another towel is placed over the middle sternum of the patient prior to the clinician stabilizing the sternum with their forearm. Failure to stabilize the sternum will create a rocking or tipping of the trunk during the mobilization technique. Then the clinician will apply a traction up to tissue resistance for acute pain in the SCJ or a manipulative thrust through tissue resistance for a non-painful SCJ. The direction of force is in line with the clavicle.

Moreover, a hypomobility may warrant joint specific mobilization (Figure 4) to improve mobility. The clinician may identify the hypomobility as part of an active arthritis in the SCJ. However, it may also be important to consider mobilizations through tissue resistance to improve end range limits with overhead elevation for pathologies such as external impingement3. In a study of 18-60 year old asymptomatic and symptomatic adults, the authors found that SCJ elevation and posterior rotation were decreased in the symptomatic population2. Identifying pain or limitations is important for the orthopedic manual physical therapist as there is evidence suggesting SCJ mobilizations can help decrease shoulder pain2,3. Furthermore, dysfunction in the SCJ may also warrant additional screening of the ACJ and scapular kinematics during humeral elevation2.

Figure 4. Caudal glide of the SCJ can be performed to address end range shoulder girdle limitations identified in the SCJ. The clinician will first pre-position the shoulder at or near the end range humeral elevation (4a). The clinician will then orient themselves in a position lateral and inferior to the side being treated in a position ready to pull the clavicle in a caudal, ventral and slightly lateral direction (4b). The examiner will position the head in ipsilateral sidebending and contralateral rotation to allow muscular relaxation and maximal purchase on the clavicle (4c). The opposite hand can be used to reinforce the mobilizing hand or to provide a more diffuse grip. An alternative position for the clinician is to push the clavicle in the same direction (4d) whereby the clinician will orient themselves in a position cranial to the involved SCJ. The direction of the mobilization is the same. In each scenario, the mobilization force will be performed to a point of tissue resistance.


  1. Hasset G, Barnsley L. Pain referral from the sternoclavicular joint: a study in normal volunteers. Rheumatology. 2001;40(8):859-62.
  2. Lawrence RL, Braman JP, LaPrade RF, Ludewig PM. (2014). Comparison of 3-Dimensional shoulder  complex Kinematics in Individuals with and without shoulder pain, part I: SCJ, ACJ and STJ. JOSPT; 44(9):636-645.
  3. Mischke JJ, Emerson-Kavchak AJ, Courtney CA. Effect of sternoclavicular mobilization on pain and function in a patient with massive supraspinatus tear. Physiother Theory Pract. 2016;32(2):153-8.
  4. Van Tongel A, MacDonald P, Leiter J, Pouliart N, Peeler J. A cadaveric study of the structural anatomy of the sternoclavicular joint. Clin Anat. 2012;25(7):903-10.
  5. Van Tongel A, Valcke J, Piepers I, Verschueren T, DeWilde L. Relationship of the medial clavicular head to the manubrium in normal and symptomatic degenerated sternoclavicular joints. J Bone Joint Surg Am. 2014;96(13):e109.

Evaluation of Hip Internal and External Rotation Range of Motion as an Injury Risk Factor for Hip, Abdominal and Groin Injuries in Professional Baseball Players

Abstracted by:  Jacob Hangen, SPT at Missouri State University, Springfield, Missouri

Li, X., Ma, R., Zhou, H., Thompson, M., Dawson, C., Nguyen, J., & Coleman, S. (2015, October 1).  Orthopedic Reviews, 7(6142), 111-115. doi:10.4081/or.2015.6142

The authors of the study evaluated the internal and external rotation range of motion of the hips of 201 professional baseball players in an attempt to correlate range of motion with risk of injury to the hamstrings, abdominals, and hips.  The players were sorted by age and position in anticipation of different findings by position.  The researchers then measured both the internal and external rotation of each player in supine and recorded the results.  

Pitchers and catchers demonstrated the lowest values of both hip internal rotation and total range of motion of the hip.  In general, pitchers exhibited greater range of motion of internal rotation, which the authors of the study hypothesized was due to the fact that the majority of players throw right handed, and the right leg is the trail leg in the delivery of a pitch.  As previously stated, catchers were also found to have reduced hip internal rotation and total range of motion, which the authors attributed to the prolonged deep squat required to play this position.  Position players on average demonstrated the greatest amount of internal rotation and total range of motion likely due to their need to sprint most frequently.  Both internal and total rotation were associated with the previously specified injuries, and surprisingly, younger age of the athlete was actually associated with higher incidence of injury.  Another surprising finding was that position players were more likely sustain an injury of the hip, hamstrings, or abdominals over the course of the season.  This could possibly be due to the sheer volume of position players versus pitchers and catchers.

Personal Commentary:

I chose to review this article because of my interest in baseball and my desire to work with athletes.  The information presented in this study may be helpful in clinical practice because it suggests the risk of hip, hamstring, and groin injuries in baseball players can be reduced and preventative measures can be taken.  Additionally, it provides biomechanical information that would be helpful in designing a treatment regimen to help improve performance in the athletic population; specifically, baseball players.  

It follows logic that reduced range of motion at the hip or asymmetry from limb to limb may lead to injury, but one thing this study was not able to do was outline the mechanism of injury for each player.  If there were groin, hip, and hamstring injuries experienced by the subjects of this study, it is likely that one would be able to draw conclusions based on the injury and the requirements of playing specific positions.  For example, hamstring injuries are common among athletes participating in sports which require a significant amount of running; especially in the latter half of the game or late in the season.  In baseball, outfielders run far more than any other position player, so it would be likely that the three outfield positions represented the greatest number of hamstring injuries in this study, but this is unable to be determined because the position players are all grouped together.  Conversely, pitchers rarely have to run over the course of a game, but have to repetitively generate extremely high torques to deliver a pitch, specifically at the hip and shoulder.  A pitching motion consists of a single leg stance phase, then transitions into rapid rotation and push off with the trail leg, placing a tremendous amount of torque on and compression of the acetabular labrum.  Each pitch thrown could result in microtrauma to the acetabular labrum, eventually resulting in a tear after thousands of repetitions over the course of a season.  Future studies in this area should document specific injuries and correlate each to the position of the player injured to provide insight into which structures are most vulnerable to injury.

There are many tools already in existence which help to screen athletes for risk of injury, but measuring hip internal rotation, external rotation, and total arc of motion may be a simpler, more effective tool to predict lower extremity injury than something such as the Functional Movement Screen.  A study conducted by Dossa et. al involving the use of the Functional Movement Screen with hockey players found no significant difference between one group which had high scores on the FMS and another which had low scores (2014).  In addition, measuring range of motion of the hip with a standard goniometer is a free method of assessment versus others which require a therapist to attend a seated course which costs a substantial amount of money and detracts from their time providing patient care.  As previously stated, however, this would only identify players at risk of any number of lower extremity injuries, so it may not provide the clinician with specific enough information as to which muscle groups are functioning deficiently, so clinical judgement would be vital.

In evaluating the kinematics of baseball players, the shoulder is often thought of as the most important articulation in the body.  However, as the authors of the study suggested, the mechanics of both throwing a ball and swinging a bat are bottom-up movements; meaning that extremely high amounts of torque are generated through contact with the ground and translated up the biomechanical chain ultimately through the shoulder to the elbow and finally, the hand (Li et. al, 2015).  It is interesting that the authors suggested great similarities in the shoulder and hip; hopefully in the near future literature is published which confirms or refutes the idea that GIRD can also occur in the hip.  Future publications which use radiological assessment would be essential to furthering our understanding of the structural adaptations occurring at the hip to allow for comparison to the shoulder.


Dossa, K., Cashman, G., Howitt, S., West, B., & Murray, N. (2014). Can injury in major junior hockey players be predicted by a pre-season functional movement screen – a prospective cohort study. Journal Of The Canadian Chiropractic Association, 58(4), 421-427.

Li, X., Ma, R., Zhou, H., Thompson, M., Dawson, C., Nguyen, J., & Coleman, S. (2015, October 1). Evaluation of hip internal and external rotation range of motion as an injury risk factor for hip, abdominal and groin injuries in professional baseball players [Electronic version]. Orthopedic Reviews7(6142), 111-115. doi:10.4081/or.2015.6142

Clinical Pearl – Use a stabilization belt to help mobilize a stiff elbow


Mischke, J., Emerson Kaychak, A., & Courtney, C. (2016).  Physiotherapy Theory & Practice, 32(2), 153-158.

Abstracted by: Erica Campbell, SPT, Missouri State University, Springfield, Missouri

Rotator cuff tears are a common and debilitating injury which are frequently treated with surgical interventions.  Some conservative treatment interventions, specifically directed toward the cervical and thoracic spine, have been shown to be successful in patients with rotator cuff pathologies, but little research has been done on those with full thickness tears.  

This aim of this study is to investigate conservative treatment of a full thickness supraspinatus tear using mobilization of the sternoclavicular joint (SCJ) in a patient with several co-morbidities.  A 57-year-old female with chronic right shoulder pain and dysfunction was referred to physical therapy after an MRI confirmed a full thickness supraspinatus tear.  The patient was deemed a nonsurgical candidate due to her high body mass index of 59 and the presence of multiple co-morbidities known to affect tendon healing (hypercholesterolemia, hypertension, diabetes mellitus, depression, and hypothyroidism).  

The patient presented initially with significant upper extremity weakness, 0–80° of active shoulder flexion range of motion (ROM), a 7/10 on the numeric pain rating scale (NPRS), and a QuickDASH score of 65.9%.  After six treatment sessions using a multimodal approach of glenohumeral and thoracic mobilizations, rotator cuff and scapulothoracic strengthening exercises, and posterior shoulder stretching, the patient reached a plateau in her functional improvements and pain reduction.  Upon reevaluation, SCJ hypomobility was noted while the glenohumeral joint, ribs, cervical and thoracic spine all demonstrated normal mobility.  

After a single treatment session including Grade III caudal mobilizations to the SCJ, the patient demonstrated an increase in active shoulder flexion ROM, and reported a reduction in pain.  Following six more visits using a multimodal approach including SCJ mobilizations, the patient was discharged with increased active shoulder flexion ROM from 0-170°, pain reduction to 1/10 on the NPRS, and a reduction on the QuickDASH to 31.8%.  

This study clearly demonstrates that conservative treatment using a multimodal approach, including SCJ mobilizations, is successful even in patients with irreparable rotator cuff tears and multiple co-morbidities.  

Personal Commentary:

This article was of particular interest to me because until this semester, the sternoclavicular joint was a joint I had not examined nor considered in my overall assessment of a patient.  After reviewing the articles and cases provided to us regarding this joint, I further understand the importance of its mobility in the proper mobility of the shoulder complex, including the acromioclavicular joint, glenohumeral joint, and scapulothoracic joint.  The proper biomechanics of these joints is dependent upon clavicular motion at both ends (Ludewig and Braman, 2011). In the case in this study, the SCJ was quickly screened during the initial evaluation, but after progress plateaued and a more thorough re-evaluation was performed, the presence of ipsilateral SCJ hypomobility was noted and treated using mobilization techniques.  Once proper mobility was restored to the shoulder complex, as well as, the cervical and thoracic spine, in conjunction with strengthening of the rotator cuff and scapulothoracic muscles, significant improvements in function and pain were achieved in a case where little improvement was predicted (Mischke, Emerson Kaychak, & Courtney, 2016). Just as in this case, the SCJ is often overlooked due to the presence of higher ranking and more obvious impairments.  This is why it is important that we perform a detailed subjective and objective assessment with joint specific testing and continuously re-evaluate our patients and update our plan of care as necessary.  I will make sure to employ these principles in my own PT practice and not be afraid to take a second look at my patients or make adjustments as progress may plateau or certain interventions may not prove effective in achieving the patient’s functional goals.  


Ludewig, P., and Braman, J. (2011).  Shoulder impingment: biomechanical considerations in rehabilitation.  Manual Therapy, 16(1), 33-39.  doi: 10.1016/j.math.2010.08.004

Mischke, J., Emerson Kaychak, A., & Courtney, C. (2016).  Effect of sternoclavicular joint mobilization on pain and function in a patient with massive supraspinatus tear.  Physiotherapy Theory & Practice, 32(2), 153-158.  doi:10.3109/09593985.2015.1114691

The Effectiveness of Cupping Therapy on Relieving Chronic Neck and Shoulder Pain: A Randomized Controlled Trial

Lee-Mei Chi, Li-Mei Lin, Chien-Lin Chen, Shu-Fang Wang, Hui-Ling Lai, and Tai-Chu Peng. (2016). Evidence-Based Complementary and Alternative Medicine, 1-7.

Article Summary by Isaac Ervin, MS, SPT from Missouri State University, Springfield, MO

The goal of this single-blind, randomized controlled trial is to assess the effects cupping therapy has on improving chronic neck and shoulder pain in full-time members of the work force.  The cupping therapy was specifically utilized on three sites commonly treated in acupuncture therapy to relieve neck and shoulder pain.  These three sites are SI 15, GB 21, and LI 15.  SI 15 is located 3-4 cm lateral to the 7th cervical vertebrae on the upper trapezius musculature.  GB 21 is located midway between the SI 15 location and the acromion on the upper trapezius musculature.  LI 15 is located laterally on the middle deltoid musculature.  

The study included 62 participants.  The inclusion criteria for the study was 1) had to work at least 40 hours per week and 2) had to have work-related neck 2) shoulder pain continuously for at least the previous three consecutive months and 3) a pain intensity of at least a 3 on the VAS.  The exclusion criteria for the study included 1) infection, injury, or bleeding surrounding the cupping area, 2) cervical neuropathy, 3) analgesic ingestion 4 hours or less before treatment, 4) had ingested coffee, tea, or any caffeinated beverage 4 hours or less before treatment, and 5) no tobacco products smoked 30 minutes or less before treatment.  The subjects were broken up into a resting or cupping group, and the subjects received a 10-minute treatment to both the right and left sites independently.  

Skin surface temperatures were measured at each cupping site pre-treatment, 5 minutes into treatment, post-treatment, and 5 minutes post-treatment using the FLIR infrared camera.  The results indicated that there were significant temperature differences between both groups during treatment and at both post-treatment measures, with the cupping group having higher skin surface temperatures.  The VAS was recorded pre-treatment and post-treatment.  When comparing the two groups, the cupping group’s average pain measures significantly decreased (8.5 to 2.6) compared to the resting group (8.5 to 7.9).  Overall, the authors concluded that cupping therapy could be used to treat chronic neck and shoulder pain with minimal side effects.

Personal Commentary:

Cupping is a treatment method utilized by physical therapists to alleviate musculoskeletal pain by relieving trigger points and acupuncture sites as well as increasing blood flow to the affected area (Kim et al, 2011).  In the above study by Chi et al, there was a significant decrease in pain after one cupping treatment.  One of the issues with this trial is there were no follow-up measurements to assess the long lasting effects of treatment.  While cupping may have a short-term effect on pain modulation, this treatment may not fully address the primary issue.  In this case, I would expect the pain to increase in intensity post-treatment if the underlying issue is not addressed and cupping is not continued.

Another issue with this article is the absence of a clinical examination to identify the pain generator.  Through performance of the basic physical therapy examination, we would be able to narrow our potential diagnoses and identify the primary issues causing pain generation.  Identifying and treating the primary cause of neck and shoulder pain will not only allow us to improve the patient’s symptoms, but also allows physical therapists to provide them with the education and a specific treatment protocol that could potentially prevent pain from reoccurring.  While there is clinical evidence to support the use of cupping therapy for neck and shoulder pain in these specific sites, it would be best to first identify the primary issue and then utilize cupping therapy, when it is indicated, as a beneficial tool in an individualized, holistic treatment approach.


  • Lee-Mei Chi, Li-Mei Lin, Chien-Lin Chen, Shu-Fang Wang, Hui-Ling Lai, and Tai-Chu Peng, “The Effectiveness of Cupping Therapy on Relieving Chronic Neck and Shoulder Pain: A Randomized Controlled Trial,” Evidence-Based Complementary and Alternative Medicine, vol. 2016, Article ID 7358918, 7 pages, 2016. doi:10.1155/2016/7358918
  • Jong-IN Kim, Myeong Soo Lee, Dong-Hyo Lee, Kate Boddy, and Edzard Ernst. “Cupping for Treating Pain: A Systematic Review.” Evidence-Based Complementary and Alternative Medicine, vol. 2011, Article ID 467014, 7 pages, 2011, doi: 10.1093/ecam/nep035.

CLINICAL PEARL Dizziness with Neck Pain

Becky Sherwin MPT, COMT

The vast majority of my caseload consists of patients with spinal impairments, and most of these are patients with neck pain.  Many of these people have been in motor vehicle accidents and  have complaints of headaches and dizziness.  Kristjansson states that “cervical induced dizziness is characterized by subjective complaints of unsteadiness, insecurity and lightheadedness. Some patients also complain about a feeling of … ‘spinning in their head.’”1,2,3  This is a question that I have begun asking my patients that are dizzy:  Do they experience spinning in their head? (indicating a cervicogenic origin) or is the room spinning? (indicating more of a vestibular impairment).2,4

Oculomotor disturbances can also occur with neck pain.  Patients can present with complaints of “symptoms relating to the visual system such as blurred vision, reduced visual field, grey spots appearing in the visual field, temporary blinding, photophobia, and disordered fusion.” 1,5,6  However, “diplopia, which is common in patients with vertebrobasilar insufficiency, is rare in somatic neck dysfunctions.” 5

I have found that I can gain useful information that guides my treatment in cases of chronic pain or patients who have been in an MVA by utilizing the following tests.

Smooth Pursuit — The patient is asked to smoothly follow a slow-moving target with the eyes while keeping the head still.  Kristjansson suggests moving the object horizontally; however, I usually test horizontal, vertical, and diagonal directions.1  According to their deficits, I use this information in developing a HEP for the patient. Quick saccadic eye movements to catch up to the target rather than smooth eye movement, especially during midrange eye movement, are an indication of impairment in the task.7 Reproduction of dizziness and blurred vision may also occur.  Deterioration of eye follow (increase in catch-up saccades), when the patient’s trunk is subsequently turned to 45 degrees (in either direction), while the head is kept still, suggests a cervical afferent component to the deficits as seen on the Smooth-Pursuit Neck Torsion Test (SPNTT).8 If a poor performance is noted when the head is in neutral, and is unchanged by adding neck torsion by rotating the trunk 45 degrees, this would imply CNS disorder.9

Gaze Stability — The patient is asked to focus on a point directly in front of them and then moves the head horizontally, vertically, and in diagonal directions.  I will take note of the patient’s deficits and where they are in the ROM when deficits occur.  This provides information that can be compared at a reassessment.  I am also looking at their ability to perform the ROM correctly.

Per the article:  Patients may “deviate into cervical lateral flexion.  Reproduction of dizziness and / or blurred vision may occur.  This is similar to the dynamic visual acuity test used for those with vestibular disorders; however, head movement is performed actively and slowly rather than passively and quickly.  This approach is better suited to cervical-related gaze disorders, as the cervical afferents are stimulated at lower movement frequencies compared to fast movements that stimulate the vestibular afferents (references).”9

Saccadic Eye Movement — Two targets are placed in front of a patient.  The patient is then asked to move their eyes quickly between the targets.  Take note of deficits.  Again, I test horizontally, vertically, and in diagonal directions.  I have noted clinically that my patients with deficits in the upper cervical area will have difficulty with the upward diagonal patterns on the side of their dysfunction.  “Inability to fixate on target, overshooting the target, and taking more than 2 eye movements to reach to the target might indicate a poor performance.  Again, reproduction of dizziness and or blurred vision may also occur.”9

Eye-Head Coordination — Using the same two targets used with saccadic eye movement,  the patient will look at a target first moving their eyes, then move the head even with the target.  Again, I test in all directions:  horizontal, vertical, and all diagonal directions.  “Often, patients with neck pain are unable to keep their head still while their eyes move or lose focus during the head movement.”10 Clinically, this will also reproduce the patient’s dizziness and / or blurred vision.

I incorporate these tests during my upper cervical evaluation in order to gather more data and in order to reproduce my patients’ symptoms.  These tests assist me in educating my patients on their symptoms, which in turn, helps to decrease their anxiety about them.


  1. Kristjansson E, Trelevan J. Sensorimotor Function and Dizziness in Neck Pain: Implicationsfor Assessment and Management. JOSPT. 2009;39(5):364-377.
  2. Hülse M, Holzl M. [Vestibulospinals reactions in cervicogenic disequilibrium. Cervicogenic imbalances].  HNO. 2000; 48:295-301.
  3. Karlberg M. The Neck and Human Balance:  A Clinical and Experimental Approach to “Cervical Vertigo”  [dissertation].  Lund, Sweden:  University Hospital of Lund; 1995.

The Reliability of the Cervical Relocation Test on People with and Without a History of Neck Pain

Burke S, Lynch K, Moghul Z, Young C, Saviola K, Schenk R. The reliability of the cervical relocation test on people with and without a history of neck pain. J Man Manip Ther. 2016;24(4):210-214.

Abstracted by:  Rebecca Sherwin, PT, COMT, West Monroe, LA – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, IAOM-US Fellowship Program Director

Neck pain is a common disorder in the United States.  This complaint affects millions of people per year with costs equaling billions of dollars in the United States alone.1  Neck pain can be present due to a chronic problem as well as acute dysfunction from whiplash.  With neck pain, a dysfunction in the proprioceptive sense of the neck and errors in repositioning of the head on the neck can occur.2,3  According to Manchikanti et al, “54-60% of people present with chronic neck pain following a whiplash injury.”4 Changes in position sense of the head and neck is clearly evident in whiplash injury patients as well as other dysfunctions.5  While people seek treatment for the pain, the position sense may remain an untreated condition.  

One test that is utilized to assess position sense in the cervical spine is the Cervical Relocation Test (CRT).3,6  Many studies have been performed to assess position sense with the ability to return the head to a neutral position; however, none have looked at the utilization of a CROM device with this test.  Studies have shown the ability of utilizing the cervical relocation test with various instruments in assessing position sense.  There are many studies that have shown the differences between the position sense of subjects with and without symptoms when utilizing the cervical relocation test (CRT).  One study was performed with the use of a CROM in order to assess cervical position sense and found that relocation accuracy differed between symptomatic and asymptomatic subjects.7  Another study found that a relative head on trunk rotation, which activated cervical proprioceptors without activating the vestibular afferents, produced more position errors for those with symptoms versus the asymptomatic subjects with use of the laser and Fastrak measurement tools.8  Treatment for the neck for not only pain relief but for improving the proprioceptive system seems to be indicated due to the increase in joint position sense in those with neck pain.  Much research has been done on the laser, Fastrak and US measurement tools; however, there is limited research on the reliability of the use of CROM with the cervical relocation test with either intertester or intratester reliability.  

This study was performed to determine the intertester and intratester reliability of utilization of the CROM device in comparison with a laser for measuring cervical relocation in those with and without neck pain. The CROM is an inexpensive and easily accessible tool in the clinic.  

This study included two groups of 25 subjects.  The groups were split into two groups based on convenience.  Each group was paired with each tester to perform the following tests utilizing the CROM and a laser. The 25 subjects in each group were analyzed independently of the other subjects.  The exclusion criteria were:  1) being under the age of 18; 2) previous spinal surgery; 3) pregnant currently; 4) receiving care for neck pathology.  The groups were split and tested with 2 testers where one tester utilized a laser and the other tester utilized the CROM.  The subject was blindfolded (not in picture – subject is with her eyes closed) to inhibit visual input thereby forcing the subject to utilize their proprioception system in the cervical spine.  The test began with the utilization of the CROM.  The subject was asked to turn the head to the right (figure 1), pause at end-range (to allow documentation of the ROM) then return to their perceived neutral head position (NHP) and a recording of this rotation ROM was documented.  Three trials were documented to the right then performed and documented to the left.

The same test was repeated with a laser system.  The subject was blindfolded (not in picture – subject is with her eyes closed) then the laser was placed on the subject’s head with the light at the forehead (figure 2). The subject was placed 3 feet from a wall with a target placed in front of the them.  The return to perceived neutral position was recorded based on the laser projection on the target. This was done with 3 trials to the right and then 3 trials to the left with a brief pause at end-range and then returning to NHP.  

The reliability of the CRT to assess position sense has been established throughout the literature as previously discussed.  This study determined that the interrater reliability using the CROM to measure CRT had ICC values > 0.75 showing a good reliability between testers with the same instrument.  The intertester reliability with the laser was not as good as the CROM with an ICC value of 0.67.  This could possibly be due to the challenging equipment fit of the laser as it was attached in the study with a one-sized bike helmet.   A paired t-test showed no difference in the accuracy to relocate using the CROM in subjects with and without a history of neck pain.  The CROM is a relatively inexpensive and accurate tool to utilize in the clinic to measure a patient’s proprioceptive sense in the cervical spine after trauma.

IAOM Commentary:

Many patients present to the clinic with neck pain after various types of injuries whether traumatic or non-traumatic events.  These patients will usually present with changes in their cervical position sense due to these painful events.  When there is a dysfunction of the position sense in the cervical spine, there will be dysfunction up and down the chain, which can lend to multiple dysfunctions ranging from stiffness, headaches, ROM deficits, muscular tightness and dizziness to name a few.  There are many exercises that can improve position sense in the cervical spine.  Peterson et al report that position sense can be improved through DNF activity, coordination exercises, including eye-head-neck exercises, as well as manual therapy techniques for improving segmental mobilization with the coordination exercises producing the largest effects on position sense.9  The following pages give various exercises as examples of what will improve these different areas previously mentioned.

Figure : Deep Neck Flexion with Beach Ball Roll – Instructions are to perform DNF then rotate the head left and right.


Figure : Deep Neck Flexion with Inclinometers – Pt head is rotated in 10˚, 20˚ and 30˚ degree increments in one direction and patient is asked to replicate this motion. The move is then increased to a full arc from left to right.


Figure: Laser with Figure 8 motion — moving in a clockwise and counterclockwise direction.


Figure: Laser with Clover with a clockwise and counterclockwise movement.


Figure: Laser with horizontal movement; and with vertical movement


Progression with utilization of various surfaces:

Figure: Challenges with various surfaces or positions — from left to right. Top row: single leg stance with rows, squat with rows, wedge surface with rows. Bottom row: theradisc with rows, theradisc squat with rows, BOSU with lats


Segmental Mobilization:

Figure: Segmental Extension Gliding — Lock the caudal segment by stabilizing it (pushing it in a ventral direction), then bring cranial segment into rotation and side-bending away from the treating clinician. Mobilization force through the cranial hand is in a caudal and dorsal direction with rotation away from the treating clinician.


Figure: Segmental Flexion Gliding — Lock the caudal segment with a 90˚ angle from the line of the zygapophyseal joint (pushing in a ventral and caudal direction), then bring cranial segment into rotation and side-bending towards the treating clinician. Mobilization force through the cranial hand is in a cranial and ventral and rotation towards the treating clinician.


  1. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain Off J Am Pain Soc. 2012;13(8):715-724.
  2. Armstrong BS, McNair PJ, Williams M. Head and neck position sense in whiplash patients and healthy individuals and the effect of the cranio-cervical flexion action. Clin Biomech. 2005;20(7):675-684.
  3. Pinsault N, Vuillerme N, Pavan P. Cervicocephalic Relocation Test to the Neutral Head Position: Assessment in Bilateral Labyrinthine-Defective and Chronic, Nontraumatic Neck Pain Patients. Arch Phys Med Rehabil. 2008;89(12):2375-2378.
  4. Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician. 2002;5(3):243–249.
  5. Sizer PS, Poorbaugh K, Phelps V. Whiplash associated disorders: pathomechanics, diagnosis, and management. Pain Pract. 2004;4(3):249–266.
  6. Pinsault N, Vuillerme N. Degradation of cervical joint position sense following muscular fatigue in humans. Spine. 2010;35(3):294–297.
  7. Wibault J, Vaillant J, Vuillerme N, Dedering Å, Peolsson A. Using the cervical range of motion (CROM) device to assess head repositioning accuracy in individuals with cervical radiculopathy in comparison to neck- healthy individuals. Man Ther. 2013;18(5):403-409.
  8. Chen X, Treleaven J. The effect of neck torsion on joint position error in subjects with chronic neck pain. Man Ther. 2013;18(6):562-567.
  9. Petersen CM, Zimmermann CL, Tang R. Proprioception interventions to improve cervical position sense in cervical pathology. Int J Ther Rehabil. 2013;20(3):154-163.
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