Neck Exercises Guide

Neck Cailliet
Exercise
Presentan :
Setia Wati Astri Arifin
Pembimbing :
Prof. Dr. dr. Angela B.M. Tulaar, SpKFR-K
Introduction
Vertebra
Cervical
Foramen transversum
Processus articularis
pendek
Foramen vertebra
segitiga, lebih besar dari
corpus
Processus spinosus pendek
dan bercabang
Cervical
Vertebral
Column
Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby; 2009. 725 p
C1= Atlas
Bagian superior ada
faset luas,
(berartikulasi dengan
occipital)
Tidak memiliki corpus
& processus spinosus
Gerakan rocking
YES Joint (fleksi
ekstensi)
C2= Axis
Bentuk seperti gigi
proc.
odontoid (dens)
Bersendi dengan
atlas
Tidak terdapat diskus antara

C1 - occiput & antara C1 C2
Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office
Sendi Atlanto Occipital

Sendi antara faset
superior atlas dan
condilus occipital
Disebut YES Joints
Rocking motion
Sendi Atlanto Axial

Rotasi pada bidang
longitudinal
Disebut NO Joints
Rotasi 50% (total
rotasi leher)
C 7 Vertebra Prominens
Processus spinosus : panjang, tebal,
hampir horizontal, tidak bifida
Processus transversus lebih luas
Foramen transverum lebih kecil
Membentuk 5 persendian :
Vertebra-diskus (true joint)
Sepasang Sendi Luschka (false
joint)
Sepasang articulasi posterior faset
Arunachalam Kumar VK. UNCO VERTEBRAL JOINTS OF LUSCHKA: AN OSTEOLOGICAL STUDY. Nitte Univ J Health Sci. 2012;2(4):579
A paired of
Luschka
Joints (uncovertebral
joints)
important in
the
pathology of
neck pain
Reyes MT, Reyes OBL. Kinesiology, Volume Four of The Philippine Physical Therapy. U.S.T. Printing Office, Manila, Phillipines; 1978. (2) 27-31.
Caillet R. Neck and Arm Pain, 3rd ed., Philadelphia: F.A.Davis, 1991.
Neumann DA. Kinesiology of the Musculoskeletal System:

Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby;
2009. 725 p
Neumann DA. Kinesiology of the Musculoskeletal System:

Foundations for Rehabilitation, 2e. 2 edition. St. Louis, Mo: Mosby;
2009. 725 p
Muscles of The Neck
Superficia
l
http://www.slideshare.net/ananthatiger/muscles-of-the-neck-1
Superficia
l
Lippert, S. Lynn. Clinical Kinesiology and Anatomy. 4th Ed. Philadelphia; F.A Davis Company
Flexors
Scalenus
SCM
Flexors
Extensors
Extensors
Extensors
Spinalis
Kinesiologi
Faset pada prosesus articularis cervikal
berorientasi pada :
Bidang oblique 45
Arah kemiringan dari atas depan ke
bawah-belakang
Membentuk sadel joint
Gerakan
Fleksi
Ekstensi
Lateral fleksi
Rotasi
C4 s/d C6
Paling aktif bergerak

fleksi dan ekstensi
Paling sering mengalami
kondisi patologis
WHIPLASH
karena posisi persendian yang khas,

trauma (dislokasi) tanpa fraktur tulangINJURY
Reyes,
Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office
sering
terjadi
FORAMEN
INTERVERTEBRALIS
Fleksi
membuka
Ekstensi menyempit
Lateral fleksi Foramina
ipsilateral mengecil &
foramina kontralateral
membesar dan sebaliknya
CANALIS
CERVICALIS
Fleksi
Memanjang
Ekstensi
Memendek
Tetapi
syaraf/medulla
spinalis tidak
memanjang/meme
ndek
Cervical
ROM
Degree ()
Movement
Tota
l
AOJ
AAJ
C2C7
Flexion
60
10
45
Extension
80
25
10
45
Rotation (each side)
75
45
30
Lateral flexion (each

side)
45
10
30
www.healthtap.com
Movements of The Disc
Sumber :
Diunduh dari http://www.coreconcepts.com.sg/mcr/wp-content/uploads/2008/06/stretched-disc.jpg
Flexion
Extension
Lateral
Flexion
XXX
X (upper)
XXX
XXX (CL)
Scalenus anterior
XX
XXX
X (CL)
Scalenus medius
XXX
Scalenus posterior
XX
Longus colli
XX
XX
Longus capitis
XX
XX
Rectus capitis anterior
XX (AOJ)
X (AOJ)
Rectus capitis lateralis
XX (AOJ)
Splenius capitis
XXX
XX
XXX (IL)
Splenius cervicis
XXX
XX
XXX (IL)
Rectus capitis posterior mayor
XXX (AOJ & AAJ)
XX (AOJ)
XX (IL) (AAJ)
Rectus capitis posterior minor
XX (AOJ)
X (AOJ)
Oblikus capitis inferior
XX (AAJ)
XXX (IL) (AAJ)
Oblikus capitis superior
XXX (AOJ)
XXX (AOJ)
Muscles
Sternocleidomastoideus
Keterangan:
AOJ : atlanto-oksipital joint
AA J : atlanto-aksial joint
Axial
Rotation
CL : contralateral
IL : ipsilateral
NECK PAIN
Definition
Epidemiolog
y
Classification by
Onset
Tulaar ABM. Nyeri leher dan punggung. Maj Kedokt Indon 2008; 58(5): 169-180
Mechanic
al
Etiology
The most common neck pain is
non-specific mechanical neck
pain caused by muscle strain,
ligament sprain, spasm, or a
combination
No specific lesions, or findings
Usually caused by daily activities
Philip D. Sloan, Essentials of the family medicine , Chapter 37 Introduction , Wolters Kluwer , 6th edition
Patophysiology
The nociceptive sites on
cervical area are:
1. Anterior & Posterior
Longitudinal Ligament
2. Outer Annulus
Fibrosus
3. Duramater
4. Spinal Nerve Root
5. Facet Joint Capsule
6. Muscles
Irritation or
inflammation
on cervical
tissue can
produce pain
Patophysiology
Two major mechanisms of neck pain
are trauma and arthritis
Trauma:
1.External
trauma
2.Postural
trauma
3.Tension
Arthritis:
1.Degenerative
arthritis
2.Sequelae of
acute
inflammation
arthritis
Patophysiology
External Trauma:
The neck received external forces that cause
abnormal cervical vertebrae position or
movement that leading to injury and pain
Patophysiology
Postural
Trauma:
Wrong posture
can cause
various trauma
to the
musculoskeletal
system,
especially the
vertebral
column:
1.Forward head
Image Source: Quora.com
Patophysiology
Tension Trauma:
Emotional factor hypothalamic
limbic system physiologic &
neuromuscular system
Tension within the neuromuscular
system manifest as a sustained
isometric muscular contraction No
period of relaxation
blood flow Ischemic pain

lymphatic flow
nutrient & O2
metabolic waste, lactic acid
Penyebab Nyeri Leher
Clinical Manifestation
Pain on neck or pain
from neck, with or
without radiation to
the head, back,
shoulder and upper
extremity
Fatigue
Sleep disturbance
Headache
Pain with movement
Limited ROM
Palpated trigger point
Radicular pain:
Sharp or dull,
burning sensation
or shocking pain
depend on ventral
or dorsal nerve
root involvement
Distributes
according to the
dermatomal or
myotomal area
Neurologic
symptoms such as
tingling sensation,
paresthesia, numb
Differential Diagnoses
PM & R Jackson C. Tan
Neck Cailliet
Exercises
Kontraindikas
i
Isometric Neck Exercise
Isometric Neck Exercise
Tha
nk
You
Flynn TW, Cleland JA, Whitman JM. Users Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion.
Axial (C2)
Odontoid Process / Dens, Tooth-like projection
Articulates with anterior arch of atlas
rotation in longitudinal plane Act as a
PIVOT
Called NO Joints
Greatest motion of neck rotation 50% total
neck rotation
Motion
Atlanto
Axial
Flexion
Extension
10
Rotation (each
side)
45
Lateral flexion
(each side)
10
NO joint
Atlas (C1)
No vertebral body
2 large concave facets
on upper surface
occipital condyles
Motion
Atlanto Occipital
Flexion
10
Extension
25
Rotation (each side)
Lateral flexion
(each side)
YES joint
Atlanto Occipital Joint

Articulates between facets superior
Atlas and occipital condyles
Called YES Joints
Rocking motion; Flexion &
Extension
Kontraindikasi
Myelopathy
Fracture
Dislocation
Acute Injury
Vascular injury
Infection
Malignancy
Ligamentous
instability
Joint Instability
Diseases Affecting
the Tissues Being
Stretched
Excessive Pain
When Stretching
Inflammation or
Joint Effusion
Severe
degenerative
changes
Vertebrobasilar
insufficiency
Flynn TW, Cleland JA, Whitman JM. Users Guide to the Musculoskeletal Examination: Fundamentals for the Evidence Based Clinician. Evidence in Motion.
Cervical Movement
Major movement in range and amplitude occurs
between skull C3.
Movement of C4 C7 depend upon ligament
laxity, distortion and compressibility of
intervertebral disc
Facet joints in coronal plane, slanted backward
45
Flexion cervical canal lengthens,
intervertebral foramina open
Extension cervical canal shortens,
intervertebral foramina narrowed
Lateral bending close on the side the head
turns and vice versa
Lower Cervical Movement

Most active and most mobile C4C6
C 4-6 maximum stress most
wear and tear and degenerative
disease
Greatest degree of flexion C 4-5 and
C 5-6
Maximal extension C 4-5
Cervical Movement
Motion
Flexion
Extension
Rotation
(each
side)
Lateral
flexion
Atlant
Atlanto
o
Occipital
Axial
C2
C7
Total
cervic
al
10
25
5
10
45 60
45 80
45
30 75
Vertebra Servikal
Mempunyai foramen
tranversum
Prosesus artikularis pendek
Membentuk 5 persendian
dengan vertebra terdekat:
Sisi akhir vertebra dengan
diskus (true joint)
Sepasang joint of luschka (false
joint)
Sepasang artikulasi posterior
faset (true joint)
C4-C6 paling aktif bergerak

fleksi dan ekstensi, paling
sering mengalami kondisi
patologis
Joint of Luschka /
Uncovertables joint
dibentuk oleh proyeksi
tulang
( prosessus uncinatus)
Faset pada prosesus
artikularis cervikal
Orientasi pada bidang oblik:
miring dari atas depan ke
bawah belakang
Membentuk saddle joints,
3th degree freedom of motion
Gerakan: fleksi, ekstensi,
lateral fleksi
Trauma tanpa fraktur sering
terjadi: whiplash injury
C1 = atlas
No body
Bagian superior ada
faset luas, bersendi
dengan occipital
Gerakan rocking=YES
joint
C2 = axis
Bentuk seperti gigi =
prosesus odontoid
Bersendi dengan arkus
Gerak=rotasi=NO joint
C7 = Prominens
Processus
spinosus :
panjang, tebal,
hampir
horizontal, tidak
bifida
Processus
transversus lebih
luas
Foramen
Reyes,
Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office
transversum
Retroauricula
rNodes
Superficial
Cervical
Lymph
Nodes
Deep
Cervical
Lymph
Jugular
Trunk
Cervical Spinal
Nerves
Cervical Spinal
Nerves
Classification by
ICD-10
Classification by
ICF
1. Trunk or lower extremity

10. Cranial neurologic deficit or
neurologic symptoms,
central nervous system
symptoms.
especially long-tract signs.
11. Cervical pain related to
2. Bilateral upper extremity
general exertion (i.e., after
pain.
climbing stairs).
3. Remote symptoms with neck
12. Symptoms unchanged or
movements (lower
progressive, despite previous
extremity).
functional management.
4. Signs of sphincter
13. OnsetSuspicion
of cervical painThat
dysfunction, bowel
or bladder
Symptoms
that
Should Raise
associated with direct head
dysfunction or incontinence.
The
Presenting
Pain
Not Of
trauma,
lossIs
of consciousness.
5. Fever,
unrelenting
nocturnalCervical
Sudden onset of cervical pain
pain, weight loss, chronic
Mechanical14.Origin
without trauma or incident.
fatigue.
15. Neck or occipital pain with a
6. Recent infection or surgery.
sharp quality and severe
7. Polyarthralgia.
intensity, or severe and
8. Dysphagia.
persistent headache, which is
9. Nuchal flexion or extension
sudden and unlike any
rigidity, especially in the
previously experienced pain or
absence of trauma.
headache
Precautions
(McMillin)
The Scientific Evidence

Strongly Supports the Use of:
Screening
protocols in
emergency care
in low risk
patient with
blunt trauma to
the neck
CT-scanning in
emergency care
for high-risk
patients with
blunt trauma to
the neck
For non-emergency neck pain:

Manual provocation tests in
patients with neck pain and
suspected radiculopathy
The combination of history,
physical examination, modern
imaging techniques, and needle
EMG to diagnose the cause and site
of cervical radiculopathy
Self-reported patient
assessment to evaluate perceived
pain, function, disability, and
psychosocial status
Nordin M, Carragee EJ, Hogg-Johnson S, Weiner SS, Hurwitz EL, Peloso PM, et al. Assessment of Neck Pain and Its Associated Disorders. Eur
Spine J. 2008 Feb 29;17(1):10122.
Evaluation
Physical Examination:
Palpation of trigger point & tenderness
Cervical Range of Movement (CROM)
Manual Muscle Testing (MMT)
Pain Perception:
Visual Analog Scale (VAS)
Functional Assessment:
Neck Disability Index (NDI)46,47
Cervical
ROM
Examinatio
n
Image Source: http://www.slideshare.net/ssuser33ed1c/neck-trunk-rom-measurement
Image Source: annals.org
Image Source:
Vernon H, Mior S. The neck disability index:

a study of reliability and validity. J Manip
Physiol Ther 1991; 14:407-415.
INTERVERTEBRAL DISKS
Intervertebral Disks
The chief structural unit between adjacent
vertebral bodies
25% of the total length of the spinal
column
Function:
To bind vertebrae together & allow motion
Contributes to the formation of spinal curves
(cervical & lumbar)
A self-contained fluid elastic system that
absorbs shock during vertical loading &
permits transient compression
Allowing fluid displacements within its
elastic container, distributes pressure
equally
The compressive force is not
concentrated on the edge of the vertebral
body toward which the spine bends
Permits movement, equalizes pressure
and forces on the column & disperses the
forces.
Sumber diunduh dari http://classconnection.s3.amazonaws.com/704/flashcards/586704/png/intervertebral_disk1309215048088.png
The cartilaginous plate
Hyaline cartilage
Covers the bony
surfaces of the
opposed vertebral
bodies
Act as semipermeable
membrane
Anchors the
attachment of the
annulus fibrosus
The Disk is made

up of two parts:
Nucleus pulposus
Annulus fibrosus
Nucleus pulposus
40% of cross section
Between middle &
posterior third of the
disk
80% water
Pascals Law of fluid
under pressure
The external forces
that applied to any
point is transmitted
to every unit area of
the interior of the
containing vessel
Karakter Diskus
Area Servikalis
Ukuran besar : diskus > korpus vetebra
Ketebalan : bagian anterior > bagian posterior
(membentuk kurva lordosis)
Lebar diskus sedikit lebih kecil dibandingkan korpus vertebra
Lokasi nukleus lebih anterior dibandingkan dengan di area lain
Area Thorakalis
Ketebalan : bagian anterior = bagian posterior
(bentuk kurva kifosis lebih dikarenakan struktur korpus vertebra
dibandingkan diskus intervertebralisnya)
Ukuran diskus lebih tipis dibandingkan pada area lainnya
Ukuran lebih kecil dibandingkan dengan korpus vertebra
Area Lumbalis
Ketebalan : bagian anterior > bagian posterior
(membentuk kurva lordosis)
Paling terlihat pada intervertebralis L5
Gambar diunduh dari http://www.corpshumain.ca/en/images/Squelette_colonne_(FF )_en.jpg
Vasular Supply &

Innervation
n. rekuren meningeal
Ligamentum longitudinal posterior

Posterior annulus fibrosus
Not innervates nucleus pulposus
insensitive structure
Blood supply of the disk dissappears about

the second decade of life
Nutrition depends upon the osmotic
properties of cartilagenous plate
Alternate compression & relaxation of the
elastic container resembles a sponge being
squeezed & relaxed
The Load on L3 Disk for Subject

Weighing 70kgs (Nachemson)
Posisi
Beban
(Kg)
Standing
100
Sitting
140
Sitting with forward tilting 20
190
Sitting with forward tilting 20 with 20 kg weight
270
Reclining
70
Supine
16
Tilting forward from a standing position carrying 50 kg
300
Sumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.
Weak Area & Protrusion
Tremendous amounts of pressure the disks are

constantly under, making it very prone to being
dislocated or ruptured
Ruptured disks or herniated nucleus pulposus most
commonly occurs in the lumbar region (L5-S1 , L4-L5)
occasionally thoracic area
Protrusion of the disk occurs posterolaterally , because:
The stresses usually generated by lifting a load with the trunk in

flexion greatest stretch given to posterior aspect of annulus
The annulus is thinner posteriorly
No ligament at the posterolateral aspect
Anterior ALL
Posteromedial PLL
When the disk protrudes

No.
Organ
Sensitif
1.
Ligamentum longitudinalis posterior
2.
Ligamentum longitudinalis anterior
3.
Ligamentum flavum
4.
Serabut saraf
5.
Anulus fibrosus
6.
Kartilago facet artikularis
7.
Korpus vertebra
8.
Ligamentum interspinosus
9.
Otot-otot trunkus
Resisten
Rule of Thumb:
When the disk protruded is small, it will usually affects the spinal nerve
below correspondent vertebra.
If there are symptoms of sensory motor loss as referred to spinal
involvement, the disk number is one above the vertebra
Normal Dehydration
Dehydration during days activity
loss of 2cm height in an adult
During the rest in bed & sleep
pressure << water absorbed from
blood by the disk original height is
regained
Aging
Decreased ability to
absorbs water << 20%
fluid deability of the
disk to trasmit the
pressure prone to
rupture
Calcification of
cartilagenous plate & gel
part of the nucleus
pulposus
nonproductive collagen
tissue space between
vertebrae narrows & the
annulus bulges new
collagen tissues
proliferate on the lips &
vertebral bodies
ossification & osteophytes
Ligamen
Ligamen Longitudinal
anterior
& posterior
Ligamen transversum
Ligamen Flavum
Lig. Atlanto-occipital
Lig. Cruciate proc.
odontoid & occiput
Lig. Alar proc
odontoid & anterior
atlas
Ligamentum nuchae
LIGAMENTS
1. Longitudinal Intersegmental Ligament
a) Anterior Longitudinal Ligament
b) Posterior Longitudinal Ligament
c) Supraspinous Ligament
2. Longitudinal Intrasegmental Ligament

a)
b)
c)
d)
Interspinous Ligament
Intertransverse Ligaments
Ligamentum Flavum
Reinforcing ligaments of atlanto-occipital
and atlanto-axial joints
3. The reinforcing ligaments of SIJ
LIGAMENTS
1. Longitudinal Intersegmental Ligament
a) Anterior Longitudinal Ligament
b) Posterior Longitudinal Ligament
c) Supraspinous Ligament
2. Longitudinal Intrasegmental Ligament

a)
b)
c)
d)
Interspinous Ligament
Intertransverse Ligaments
Ligamentum Flavum
Reinforcing ligaments of atlanto-occipital
and atlanto-axial joints
3. The reinforcing ligaments of SIJ

Neck Exercises Guide

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Neck Cailliet

Tidak terdapat diskus antara

Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Sendi Atlanto Occipital

Sendi Atlanto Axial

Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Reyes, Tyrone M. Kinesiology. Vol 4. Manila; U.S.T Printing Office

Neumann DA. Kinesiology of the Musculoskeletal System:

Neumann DA. Kinesiology of the Musculoskeletal System:

Muscles of The Neck

Paling aktif bergerak

karena posisi persendian yang khas,

Rotation (each side)

Lateral flexion (each

Movements of The Disc

Rectus capitis anterior

Rectus capitis lateralis

Rectus capitis posterior mayor

XXX (AOJ & AAJ)

Rectus capitis posterior minor

Oblikus capitis inferior

XXX (IL) (AAJ)

Oblikus capitis superior

Image Source: Quora.com

blood flow Ischemic pain

Penyebab Nyeri Leher

PM & R Jackson C. Tan

Isometric Neck Exercise

Isometric Neck Exercise

Rotation (each side)

Atlanto Occipital Joint

Lower Cervical Movement

C4-C6 paling aktif bergerak

1. Trunk or lower extremity

The Scientific Evidence

For non-emergency neck pain:

Image Source: http://www.slideshare.net/ssuser33ed1c/neck-trunk-rom-measurement

Image Source: annals.org

Vernon H, Mior S. The neck disability index:

Sumber diunduh dari http://classconnection.s3.amazonaws.com/704/flashcards/586704/png/intervertebral_disk1309215048088.png

The Disk is made

Vasular Supply &

Ligamentum longitudinal posterior

Blood supply of the disk dissappears about

The Load on L3 Disk for Subject

Sitting with forward tilting 20

Sitting with forward tilting 20 with 20 kg weight

Tilting forward from a standing position carrying 50 kg

Sumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.

Weak Area & Protrusion

Tremendous amounts of pressure the disks are

The stresses usually generated by lifting a load with the trunk in

Sumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.

When the disk protrudes

Ligamentum longitudinalis posterior

Ligamentum longitudinalis anterior

Kartilago facet artikularis

Sumber : Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.

2. Longitudinal Intrasegmental Ligament

3. The reinforcing ligaments of SIJ

2. Longitudinal Intrasegmental Ligament

3. The reinforcing ligaments of SIJ

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