Movement System Syndromes of the Cervical Spine (Devasya Dodia)

Title: Movement System Syndromes of the Cervical Spine

Summary:

- The cervical spine is prone to degenerative changes due to everyday movements, prolonged
postures, and aging.

- This chapter focuses on normal cervical spine anatomy and kinesiology, recognizing abnormal
motion patterns, and rehabilitation for movement system syndromes.

- Good posture and optimal movement patterns are essential to slow degeneration associated with
arthrokinematic hypermobility.

- Daily activities like head and neck movements, maintaining alignment with the thoracic spine, and
supporting head weight affect the cervical spine.

- Forward-head posture and thoracic kyphosis are common alignment issues, increasing compressive
load on cervical tissues, especially facet joints.

- Faulty extension and rotation patterns in the cervical region can lead to pain and limited range of
motion.

- Correcting alignment issues in the cervical, thoracic, and scapular regions is crucial before
addressing faulty cervical movements.

- Precise cervical rotation exercises, focusing on proper alignment, alleviate pain and improve range
of motion.

Please let me know if you need more specific information or further summarization of this text.

Title: Maintaining Precise Movement in the Cervical Region

Summary:

- Maintaining precise movement in the cervical region is challenging due to factors like the number
of segments, degrees of freedom, and the influence of thoracic spine alignment and shoulder muscle
involvement.

- Effective treatment for cervical issues involves addressing trunk, shoulder girdle, and cervical spine
alignment, intrinsic muscle length and recruitment, and proper movement patterns.

- Supporting the upper extremities while sitting with armrests at the right height reduces
compressive forces on cervical structures and tension from cervicoscapular muscles.

- Ideal cervical alignment includes an inward lordotic curve with slight extension in both upper and
lower cervical regions.

- Forward-head posture is a common alignment problem, characterized by lower cervical forward

translation, cervical hyperextension, and increased thoracic kyphosis.

- Patients with chronic neck pain struggle to maintain correct alignment when distracted.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- Forward-head posture leads to muscular adaptations, including cervical extensor shortening and
intrinsic flexor lengthening, along with increased extensor muscle activity to counter gravity effects.

- This posture increases compressive forces on articular facets and may impact the ligamentum
nuchae and upper trapezius.

- Patients with tension headaches and migraines often exhibit forward-head posture and other
alignment issues.

- Communication habits, such as excessive cervical extension and forward translation during talking
or computer use, can worsen alignment problems, especially in patients with eyeglasses or bifocals.

- Sight or hearing deficits can lead to prolonged cervical rotation and sidebending in one direction,
causing asymmetrical muscle adaptations and facet joint compression.

- Therapists should educate patients about these habits and provide exercises to offset their effects.

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Title: Motions and Muscle Actions of the Cervical Spine

Summary:

- The cervical spine consists of two regions: upper (occiput, C1, C2) and lower (C3 to C7).

- Available cervical motion varies with significant intersubject variability.

- Precise cervical movements depend on optimal arthrokinematics, osteokinematics, muscle length,

strength, and recruitment patterns.

- Cervical motions involve coupled motions, where movement in one plane accompanies motion in
another.

- Cervical flexion/extension involves translation and sagittal plane rotation, with translation motion
often exceeding sagittal rotation.

- Rotation motion includes coupled motions of lateral flexion and rotation, gradually decreasing as it
progresses from superior to inferior.

- Lateral flexion motion also involves coupled lateral flexion and rotation.

- Age and degenerative changes reduce cervical range of motion, with a 5-degree decrease every 10
years.

- Muscle actions are crucial for precise cervical motion, with intrinsic muscles providing control and
extrinsic muscles providing power.

- Cervical flexors include intrinsic (rectus capitis anterior, rectus capitis lateralis in the upper region,
and longus capitis, longus colli in the lower region) and extrinsic (sternocleidomastoids, anterior and
medial scalenes).

- Intrinsic flexors produce sagittal plane rotation, while extrinsic flexors contribute to translatory
motion and forward translation of the cervical spine.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- Faulty patterns can lead to excessive anterior translation and reduced anterior sagittal plane
rotation.

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Title: Cervical Extensors, Rotators, and Muscle Actions

Summary:

- Intrinsic cervical extensors produce posterior sagittal rotation of cervical vertebrae.

- Intrinsic extensors in the upper region include rectus capitis posterior major and minor, oblique
capitis inferior and superior, semispinalis capitis, splenius capitis, and longissimus capitis.

- Lower cervical region intrinsic extensors are semispinalis cervicis, splenius cervicis, and longissimus
cervicis.

- Cervical multifidus spinae muscles, while contributing to extension, rotation, and lateral bending,
have limited moment-generating capacity.

- Extrinsic cervical extensors (upper trapezius and levator scapulae) produce extension with posterior
translation of cervical vertebrae.

- Incorrect recruitment patterns may lead to greater extrinsic extensor use during cervical extension.

- Cervical rotators include intrinsic (rectus capitis posterior major, oblique capitis inferior, oblique
capitis superior, splenius) and extrinsic (sternocleidomastoids, scalenes, upper trapezii, levator
scapulae).

- Extrinsic rotators often produce both rotation and lateral flexion, compromising precision.

- Dominance of extensor muscles can result in rotation with extension, while anterior scalenes,
middle scalenes, and sternocleidomastoids can lead to rotation with flexion or forward translation.

- Proper guidance and encouragement of easy, minimal effort movements are often needed to
correct faulty rotation patterns.

- Upper trapezius and levator scapulae muscles, with attachments to the cervical spine region and
scapula/clavicle, play a role in compensatory cervical motion.

- Passive support of the upper extremities can reduce passive stretch of upper trapezius and levator
scapulae, potentially decreasing cervical spine load and improving motion.

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Title: Movement System Syndromes of the Cervical Spine

Summary:
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- Movement system syndromes in the cervical spine result from deviations in alignment and
movement patterns.

- Cervical spine syndromes, in order of frequency, include cervical forward head with asymmetrical
extension, cervical extension translation, cervical flexion-rotation, and cervical flexion.

- Cervical extension syndrome involves imprecise cervical extension, often painful, and associated
with imbalances in cervical extensors and flexors, influenced by upper extremity weight, thoracic
spine alignment, and scapula alignment.

- Symptoms typically include posterior cervical pain, radicular symptoms along cervical nerve root
dermatomes, scapular pain along the vertebral border, and suboccipital headaches.

- Key alignment faults include a forward-head position with increased cervical lordosis and anterior
translation.

- Movement impairments involve pain during active cervical extension, limited and painful flexion,
and faster upper cervical extension compared to lower cervical extension.

- Correcting alignment and movement faults can alleviate symptoms and increase ROM.

- Passive support of the upper extremities and passive elevation of the ribcage may reduce pain and
improve cervical ROM in some cases.

Title: Movement System Syndromes of the Cervical Spine

Summary:

- Movement system syndromes in the cervical spine result from deviations in alignment and
movement patterns.

- Cervical spine syndromes, in order of frequency, include cervical forward head with asymmetrical
extension, cervical extension translation, cervical flexion-rotation, and cervical flexion.

- Cervical extension syndrome involves imprecise cervical extension, often painful, and associated
with imbalances in cervical extensors and flexors, influenced by upper extremity weight, thoracic
spine alignment, and scapula alignment.

- Symptoms typically include posterior cervical pain, radicular symptoms along cervical nerve root
dermatomes, scapular pain along the vertebral border, and suboccipital headaches.

- Key alignment faults include a forward-head position with increased cervical lordosis and anterior
translation.

- Movement impairments involve pain during active cervical extension, limited and painful flexion,
and faster upper cervical extension compared to lower cervical extension.

- Correcting alignment and movement faults can alleviate symptoms and increase ROM.

- Passive support of the upper extremities and passive elevation of the ribcage may reduce pain and
improve cervical ROM in some cases.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

If you need more specific information or details on any part of this passage, please let me know.

This passage provides a detailed description of exercises aimed at strengthening the intrinsic cervical
spine flexors and extensors in various positions. These exercises are designed to improve cervical
spine alignment and reduce symptoms related to movement system syndromes. Here's a summary
of the exercises:

Strengthening the Intrinsic Cervical Spine Flexors in Supine:

- Begin with correcting thoracic spine and shoulder alignment.

- Activate lower abdominal muscles to maintain a neutral lumbar spine.

- Correct scapular alignment (depression, downward rotation, and abduction).

- Support the arms on pillows with hips and knees flexed.

- Use a towel roll under the head as needed.

- Perform a progression of exercises:

1. Capital flexion without head lift (roll the chin toward the front of the cervical spine).

2. Capital flexion with head lift (roll the chin and head off the supporting surface).

3. Add head lift for a greater challenge.

- Maintain the chin's position at the anterior cervical spine.

Strengthening the Intrinsic Cervical Spine Extensors:

- Prone Position: Position the forehead on the palms of the hands and roll the head back.

- Quadruped Position: Align the head and cervical spine with the thoracic and lumbar spine, then roll
the head back.

- Emphasize posterior sagittal rotation and diminish recruitment of extrinsic cervical spine muscles.

Sitting with Back to Wall - Shoulder Abduction Lateral Rotation:

- Assume a position with correct spinal alignment.

- Perform bilateral shoulder abduction and lateral rotation, keeping the arms against the wall.

- Slide the arms up the wall, maintaining proper spinal alignment.

Sitting with Back to Wall - Shoulder Flexion:

- Similar to the previous exercise but with shoulder flexion to 90 degrees.

 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- Keep elbows flexed and palms facing up.

- Maintain lumbar and cervical spine alignment.

- Avoid lumbar extension and cervical extension.

- Monitor elbow position to prevent compensatory medial rotation.

Wall Slides Facing the Wall - Shoulder Flexion:

- Face the wall with the ulnar side of the hands against it.

- Keep the shoulders in flexion and the chin down.

- Slide the arms up the wall while maintaining cervical spine position.

- Avoid cervical extension during the shoulder flexion movement.

These exercises focus on improving cervical spine alignment and muscle recruitment to address
movement system syndromes. Proper form and alignment are crucial for the effectiveness of these
exercises. Modifications and progressions are provided to suit individual needs and abilities.

This passage provides functional instructions for individuals with cervical extension syndrome,
aiming to help them reduce cervical extension and forward translation movements during daily
activities, especially when sitting at a computer or using eyeglasses, including multifocal lenses. Here
are the key points of these instructions:

Prolonged Sitting at the Computer:

- Use a supportive chair that promotes good thoracic alignment and reduces thoracic flexion.

- Support the forearms on the desk or an extended tray for the keyboard, ensuring that the arms are
well-supported without slouching.

- Adjust the desk or tray height to prevent the need for slouching.

- If necessary, raise the supporting surface or add armrests for improved support.

Using Eyeglasses, Especially Multifocal Lenses:

- Observe the patient's alignment when wearing eyeglasses.

- Correct alignment sequentially, starting with the lumbar, thoracic, and scapular alignment, and
then adjusting neck and head position.

- Ensure that wearing glasses doesn't lead to a forward-head position or increased upper cervical
extension.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

Next, the passage introduces the concept of the cervical extension-rotation syndrome. This
syndrome is characterized by pain associated with cervical extension and rotation. The primary
movement impairment involves imprecise cervical rotation, often accompanied by extension and/or
side bending, leading to pain, limited range of motion, and altered distribution of rotation across the
cervical region. Muscle imbalances between the cervical rotator muscles and extrinsic muscles
contribute to multiplanar movements instead of precise uniplanar motion.

Factors contributing to this syndrome include the weight of the upper extremities, alignment of the
thoracic spine, and scapular alignment. Asymmetries in the appearance of the cervical spine,
thoracic spine, and scapular regions may also be present.

Symptoms and history of individuals with cervical extension-rotation syndrome may be similar to
those of cervical extension syndrome, including pain with cervical extension and rotation.
Additionally, patients may have a history of vision or hearing deficits that require frequent cervical
rotation or sustained postures to compensate for these deficits. Symptom location is typically
unilateral in this syndrome.

These functional instructions and descriptions are intended to help individuals manage their
symptoms and promote better cervical spine alignment during daily activities.

This section discusses key tests and signs associated with the cervical extension-rotation syndrome.
This syndrome is characterized by pain during cervical extension and rotation, with movement
impairments such as imprecise cervical rotation, associated compensatory cervical extension, and/or
lateral flexion, often leading to pain and limited range of motion (ROM).

Alignment Analysis:

- Alignment faults are similar to those in cervical extension syndrome but may include an asymmetry
in muscle size of the cervical extensors.

- Asymmetry can be associated with vision or hearing deficits or repetitive one-arm activities that
lead to postural asymmetry.

- Patients may unknowingly maintain a position of slight rotation due to habit, and using a mirror can
help correct this.

- Alignment faults in adjacent regions, thoracic and scapulothoracic regions, may also be observed.

Movement Impairment Analysis:

- Movement impairments include pain and limited motion during active cervical rotation.

- Active rotation may involve imprecise cervical rotation, concurrent cervical extension, or lateral
flexion.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- Tests in the sitting position are similar to those for cervical extension syndrome, with a focus on
adjacent regions and movement precision.

- Passive elevation of the shoulder girdle or supporting the weight of the upper extremities can
increase rotation ROM and decrease pain.

- Correction of thoracic kyphosis and forward-head posture before active rotation can improve ROM
and reduce symptoms.

- Correction of compensatory movements (extension and lateral flexion) during rotation helps
improve ROM and symptoms.

- Additional tests involve monitoring cervical spinous processes during single-arm flexion and
addressing any rotation or sidebending impairments.

- In the supine position, active cervical rotation is limited and painful, but correction and assistance
of movement, including precise guidance, can reduce symptoms.

- In the quadruped position, active cervical rotation is limited and painful, but correcting alignment,
providing verbal and manual cues, and guiding the motion can increase pain-free ROM and reduce
symptoms.

These tests and analyses help clinicians assess and address movement impairments and alignment
faults associated with cervical extension-rotation syndrome, with the goal of improving range of
motion and reducing pain during cervical rotation.

The treatment for cervical rotation-extension syndrome aims to reduce compensatory cervical
extension and lateral flexion during active cervical rotation, correct movement patterns during daily
activities, and improve the strength and motor control of the intrinsic cervical spine rotators. Here
are some key strategies and exercises for managing this syndrome:

Exercise Program:

1. Sitting with Back to Wall Performing Cervical Rotation:

- Start with the patient sitting with their back against the wall, arms supported on pillows to reduce
cervical loading.

- Correct alignment faults in the lumbar, thoracic, and scapulothoracic regions before proceeding.

- Instruct the patient to perform cervical rotation about a "vertical axis" while avoiding
compensatory movements such as extension and side bending.

- Encourage minimal effort during rotation to reduce recruitment of extrinsic cervical rotators (e.g.,
scalene and sternocleidomastoid).

2. Supine Active Cervical Rotation:

 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- If sitting cervical rotation is too difficult or painful, the patient can perform this exercise in a
supine position.

- Correct alignment issues in the lumbar, thoracic, and scapulothoracic regions first.

- Instruct the patient to perform cervical rotation without movements of cervical extension and
side bending.

3. Facing Wall, Arms Supported-Active Cervical Rotation:

- Instruct the patient to face a wall and rest their forearms on it, allowing the wall to support the
upper extremities.

- This exercise helps relax the upper trapezius muscles and promotes precise cervical rotation
without extension or side bending.

4. Quadruped Active Cervical Rotation:

- In the quadruped position, the patient flattens the spine like a "tabletop" and aligns the head and
cervical spine with the thoracic and lumbar spine.

- Instruct the patient to perform cervical rotation without extension or side bending.

Functional Instructions:

- For daily activities, such as sitting at a computer, ensure that the patient uses a supportive chair
with armrests to maintain good thoracic alignment and support their forearms. The computer or
work station should be centered to avoid prolonged postures of rotation or side bending.

- Counsel the patient to avoid prolonged positions of rotation or side bending during activities like
watching TV, playing video games, and using the telephone. Suggest the use of a headset or "blue
tooth" device to reduce cervical side bending during phone calls.

- Caution against repetitive and resistive one-arm activities, as they can impose asymmetrical
stresses on the cervical spine. If such activities are necessary, advise the patient to maintain proper
alignment of the thoracic and cervical spines, avoiding cervical extension and forward-head posture.
Instruct them to "keep the chin and nose down" to engage the intrinsic cervical neck flexors during
these activities.

These strategies and exercises aim to improve cervical rotation while minimizing compensatory
movements, reduce pain, and enhance the patient's ability to maintain proper cervical alignment
during daily activities.

Case Presentation - Cervical Extension-Rotation Syndrome:

 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

Symptoms and History:

- A 24-year-old female student complains of neck pain in the bilateral upper cervical region, right
lower cervical region, and right upper trapezius muscle.

- Occasional numbness and tingling in the right forearm and hand.

- Daily pain rated at 4/10 but increases to 7/10 with prolonged sitting, computer use, and studying.

- Neck Disability Index (NDI) score of 23, indicating moderate disability.

- History of chronic migraines since age 16, increasing in frequency to 2-3 per month in the last 4
months.

Alignment Analysis:

- Forward head posture with upper cervical extension, increased flexion at the upper thoracic region,
flat thoracic spine below, and lumbar lordosis.

- Scapulae positioned in abduction and slight depression.

- Hypomobility and tenderness in C5/6 and C6/7 spinous processes and articular pillars.

- Active shoulder movements reveal decreased upward scapular rotation during shoulder flexion.

- Supine shoulder flexion shows limited motion with compensatory rib cage elevation, lumbar
extension, and cervical extension.

- Shortened latissimus dorsi and pectoralis minor muscles.

- Weak lower abdominal muscles and deep neck flexors.

- Middle trapezius strength graded at 3/5.

Diagnosis and Staging:

- Diagnosis: Cervical extension-rotation syndrome with scapula abduction.

- Stage: Stage 2.

- Prognosis: Good to excellent, with positive and negative moderators affecting the outcome.

Treatment:

- Treatment consisted of a 4-week initial phase with weekly sessions followed by 4 weeks of sessions
every other week.

- Each session lasted approximately 30 minutes and included a specific home exercise program and
functional instructions.

- Home exercise program included:

1. Capital flexion in sitting.

 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

2. Cervical rotation in sitting.

3. Sitting-shoulder abduction with lateral rotation.

4. Sitting-shoulder flexion.

5. Supine capital flexion without head lift.

6. Supine neck flexor strengthening with assisted head lift.

These exercises focused on improving cervical spine function, scapular alignment, and intrinsic
muscle strength while minimizing compensatory movements. Functional instructions aimed to
reduce excessive forces on the cervical spine during daily activities, such as computer use and
studying.

The patient reported improvements, including decreased neck pain, increased cervical mobility, and
reduced headache frequency, during the treatment period.

(Note: Figures mentioned in the case presentation are not available in the provided text.)

In this case presentation, the treatment plan for cervical extension-rotation syndrome and
associated headache was described. Here's a summary of the key points:

Trapezius Exercises in Sidelying:

- The patient is positioned in sidelying with her head supported on a towel roll, and her arm
overhead.

- The therapist supports the arm while guiding the scapula into adduction, external rotation, and
posterior tilt.

- The patient is asked to adduct the scapula while keeping it adducted and avoiding neck extension
to recruit the trapezius muscle.

Wall Slides - Shoulder Flexion:

- The patient faces the wall and places the ulnar side of her hands on the wall in the flexion plane.

- Correct scapular position and chin tuck are emphasized.

- The patient slides her arms up the wall, recruiting the serratus anterior while maintaining cervical
spine position.

Facing Wall, Arms Supported - Active Cervical Rotation:

- The patient faces the wall with arms overhead and supported on the wall.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- The forearms rest on the wall to relax the upper trapezius muscles.

- The patient rolls the chin down slightly and performs precise cervical rotation without extension or
side-bending.

Quadruped Rocking Back without Extension:

- The patient assumes the quadruped position, keeping the spine flat like a "tabletop."

- The head and cervical spine are aligned with the thoracic and lumbar spine.

- The patient rocks back on her heels while maintaining a "flat spine" and avoiding cervical extension.

Functional Instructions:

- During sitting activities, the patient is encouraged to support her arms and engage abdominal and
scapular muscles while maintaining neutral neck position with the chin slightly down.

- Proper chair use to support thoracic spine alignment is emphasized.

- Proper use of eyeglasses during computer work to maintain a neutral neck position is taught.

- The patient is educated about daily movement habits and postures that contribute to cervical
extension, with an emphasis on reducing these habits.

After four weeks of treatment, the patient reported reduced numbness and tingling in her forearm
and hand, a decrease in migraine frequency, and a daily pain rating of 2/10. Her Neck Disability Index
(NDI) score improved to 14, indicating minimal disability. By the end of eight weeks of treatment,
her daily pain rating remained at 2/10, even during extended computer use.

This case highlights the importance of addressing adjacent regions (shoulders and thoracic spine)
and patient awareness of daily movement habits in the management of cervical extension-rotation
syndrome and associated symptoms. Strengthening and proper alignment of scapular muscles and
cervical spine, along with patient education, were key components of the successful outcome.

Cervical Flexion Syndrome is characterized by imprecise cervical flexion, often associated with pain
and limited range of motion (ROM). This condition is typically seen in younger patients who have a
history of activities that require repetitive positioning in an extreme cervical flexion posture, such as
maintaining a "military posture" or ballet positions.

Key Signs and Symptoms:

1. Decreased cervical inward curve, resulting in a flat appearance of the cervical spine.

2. Reduced thoracic curve, associated with loss of thoracic flexion ROM.

3. Scapular alignment faults, including scapular depression and downward rotation.

 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

4. Pain with cervical flexion.

5. Excessive recruitment of neck flexors, particularly the anterior and middle scalene muscles, during
arm movements and daily activities.

6. Poor recruitment of intrinsic cervical extensors during cervical extension.

Treatment for Cervical Flexion Syndrome focuses on restoring a normal cervical curve, improving the
function of intrinsic cervical extensors, and avoiding positions and movements that encourage
excessive cervical flexion. Here are some exercise programs that can be beneficial:

1. Prone Active Cervical Extension:

- The patient lies in a prone position (face down).

- Instruct the patient to "roll" the head and neck back in the direction of extension.

- Encourage recruitment of intrinsic neck extensors and reduce recruitment of extrinsic neck
extensors.

- Avoid reaching full end-range extension to prevent excessive compression on cervical facets and
discs.

2. Quadruped Active Cervical Extension:

- The patient assumes a quadruped position (on hands and knees).

- Perform cervical extension in the middle third of the range of motion.

- This exercise challenges axioscapular muscle function while bearing weight through the upper
extremities.

These exercises help improve cervical extension while minimizing the recruitment of extrinsic neck
extensors. Additionally, patients may be instructed to increase thoracic flexion or assume a
"slumped" position to address any thoracic alignment faults.

The key to successful treatment lies in patient education, postural awareness, and targeted exercises
that promote proper alignment and muscle recruitment. Scapular movement impairments should
also be considered and managed as part of the treatment plan. A thorough examination and
classification of associated scapular movement impairments are essential for effective management.

It's important to note that this information is based on the provided case presentation and may not
cover all aspects of individual patient care. A comprehensive assessment and tailored treatment plan
should be developed by a qualified healthcare professional based on the specific needs of the
patient.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

Cervical Flexion-Rotation Syndrome is characterized by imprecise cervical rotation, often

accompanied by compensatory cervical flexion, resulting in pain and limited range of motion (ROM).
The syndrome can also involve an imbalance in muscle performance among the cervical rotator
muscles, leading to multiplanar movements instead of precise uniplanar motion produced by
intrinsic rotators.

Symptoms and History:

- Symptoms and history may overlap with those of cervical flexion syndrome, with additional
complaints of pain during rotation movements.

- Patients may also report discomfort related to asymmetrical alignment of the neck and scapulae,
potentially linked to hearing or vision impairments.

Alignment Analysis:

- The cervical spine may exhibit sidebending and/or rotation, along with any alignment faults
observed in cervical flexion syndrome.

- Scapular asymmetry may be present as well.

- Verbal cueing, manual assistance, and the use of a mirror can help correct cervical spine and
scapular alignment issues, potentially reducing symptoms.

Movement Impairment Analysis:

- Patients with cervical flexion-rotation syndrome often demonstrate pain during rotation and
exhibit associated cervical flexion and sidebending movements.

- Secondary tests may involve repeating active rotation without associated flexion or sidebending,
instructing the patient to "slump" before rotation to improve cervical alignment, or passive support
of the upper extremities during rotation.

- During single-arm flexion, palpable rotation of single or multiple cervical vertebrae may occur,
without significant pain. Compensatory sidebending or rotation of the cervical spine can also be
observed during this movement.

Correction Strategies:

1. Correct Cervical Alignment:

- Instruct the patient to correct cervical alignment by lifting the nose and chin to assume a normal
inward curve, reducing the recruitment of cervical flexors.

- Encourage the patient to actively maintain this corrected alignment during single-arm flexion.

2. Correct Scapular Movement Impairment:

 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- Assist the patient in correcting associated scapular movement impairments during single-arm
shoulder flexion.

- Have the patient perform bilateral shoulder flexion to assess if the movement impairment
improves.

These strategies aim to improve cervical alignment and reduce compensatory movements during
cervical rotation. Patient education, awareness of posture and alignment, and targeted exercises
play crucial roles in managing cervical flexion-rotation syndrome effectively.

As with any musculoskeletal condition, a comprehensive assessment by a qualified healthcare

professional is essential to tailor treatment strategies to the individual patient's needs and address
any specific contributing factors.

The primary goals of treatment for cervical flexion-rotation syndrome are to restore a normal
cervical inward curve, instruct the patient in strategies to avoid excessive cervical flexion, encourage
increased flexion movements in adjacent regions, and restore precise motion during active cervical
rotation. Here are some specific treatment strategies and exercises:

Sitting Cervical Rotation:

- Patients can sit in a chair with good thoracic spine support to encourage a normal thoracic
alignment.

- The upper extremities should be supported on pillows to reduce compressive loading on the
cervical spine.

- Patients should be assessed for individual alignment impairments in the lumbar and thoracic spine
and scapulothoracic region and instructed on how to correct them.

- Instruct the patient to perform cervical rotation about a "vertical axis," avoiding movements of
flexion and sidebending.

- Verbal cues include "raise the chin up slightly" to prevent compensatory flexion during rotation and
"do not lean the head and neck toward the side to which you are rotating."

Supine Active Cervical Rotation:

- Patients can assume a supine position with the arms supported on pillows.

- A towel roll under the cervical spine may be necessary to support a normal cervical curve.

- Similar instructions for addressing adjacent region impairments and precise cervical rotation apply.

- Verbal cues are consistent with those used in sitting exercises.

Quadruped Active Cervical Rotation:

 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

- In the quadruped position, patients allow the thoracic spine to be slightly flexed.

- They should raise the head and chin slightly to avoid excessive cervical flexion.

- Instruct patients to rotate the head and neck about an axis of motion while avoiding cervical flexion
and sidebending.

Facing Wall, Arms Supported-Active Cervical Rotation:

- Patients can face a wall with their arms overhead, supported on the wall.

- Forearms rest on the wall, and the upper trapezius muscles should be relaxed.

- Similar instructions for cervical alignment and precise rotation apply.

- Verbal cues include raising the head and chin slightly and avoiding cervical flexion and sidebending.

Functional Instructions:

- Encourage flexion in adjacent regions, particularly the thoracic spine, to reduce the demand for
cervical flexion during daily activities.

- Minimize asymmetrical stress on the cervical spine by reducing repetitive one-arm activities and
avoiding prolonged positioning in sidebend or rotation.

It's crucial to tailor treatment and exercises to each patient's specific needs and alignment
impairments. Patient education, posture awareness, and adherence to correct movement patterns
during daily activities are essential components of managing cervical flexion-rotation syndrome
effectively. Additionally, addressing any scapular movement impairments as described in Sahrmann's
work is important for comprehensive care.

Based on the case presentation and the diagnosis of cervical flexion-rotation syndrome with scapula
depression, the treatment plan appears to include the following key components:

1. Active Cervical Range of Motion Exercises: The patient is instructed to perform specific cervical
range of motion exercises to improve cervical spine function. These exercises include active cervical
rotation while maintaining good alignment, emphasizing minimal effort to reduce recruitment of
extrinsic neck muscles.

2. Prone Cervical Extension: Prone cervical extension exercises are used to strengthen and recruit
intrinsic cervical extensor muscles. The patient is positioned face-down with the forehead resting on
the palms of their hands. They are then guided to perform active cervical extension by rolling the
head and neck back towards extension, imagining an "axial running through the middle of the
cervical spine." Proper recruitment of intrinsic neck extensors is encouraged while avoiding
excessive activation of extrinsic muscles like the levator scapulae and upper trapezius.
 Movement System Syndromes of the Cervical Spine (Devasya Dodia)

3. Quadruped Active Cervical Extension: This exercise is an alternative to the prone position for
improving cervical extensor function. In a quadruped position, the patient avoids excessive thoracic
extension and performs active cervical extension by rolling the head and neck back while
maintaining proper recruitment of intrinsic neck extensors.

4. Facing the Wall - Shoulder Flexion with Scapula Elevation: This exercise targets the upper
trapezius and serratus anterior muscles. The patient faces a wall and places their hands on the wall
just above shoulder level. As they slide their hands up the wall, they are instructed to elevate the
scapulae/acromion toward their ears. Maintaining proper alignment of the cervical spine by keeping
the nose and chin slightly up is emphasized during this exercise.

5. Functional Instructions: Functional instructions are given to help the patient avoid excessive forces
on the cervical spine during daily activities. These instructions may include maintaining proper
alignment, minimizing cervical flexion, and avoiding asymmetrical stress on the cervical spine.

The treatment plan seems to focus on restoring proper cervical alignment and function,
strengthening intrinsic neck muscles, and promoting scapular stability. It also involves educating the
patient on how to maintain correct posture and movement patterns during their daily activities to
prevent exacerbation of symptoms. The patient's prognosis is described as excellent, given their
young age, good health, minimal duration of symptoms, and low disability score. The treatment is
likely to help alleviate the patient's neck pain and improve their overall function.