Now for the fun part: treatment!
The treatment strategies fall into 5 categories: general therex, head-neck awareness exercises, oculomotor exercises, movement control exercises and postural stability-balance training. Here is where those types of intervention fall on a temporal treatment plan.
Let’s start from the beginning.
The basis throughout the treatment plan is “physical therapy/exercises including postural corrections and dissociation between body parts.” The article doesn’t really go into what that is too much. What I could gather was manual interventions (take your pick on your favorite theory/application, although the article specifically mentions manips several times), pain management (“acupressure on trigger points” Is specifically mention), therex, and PNF. The therex seems to focus on postural corrective activities– facilitating deep neck flexors, inhibiting neck extensors, facilitating shoulder retractors– and the proper coordination of these muscle groups during functional activities.
Along with those are the head-neck awareness exercises. I’ll just take a long quote section from the article, as they are very succinct and precise.
“… [C]ervical joint position sense can be retrained using a laser pointer mounted onto a headband with the light projected onto a wall, as described in the section on assessment. Patients practice relocating the head to a neutral position (guided by the laser beam) from their most difficult movement directions.”
This is progressed by closing the eyes and using the laser position to “check” the accuracy of the movement once completed and returning to a slightly off neutral location rather than neutral. Accuracy is of utmost importance, so if that breaks down, back off.
For these, I taped my cat’s toy laser onto a hat that I had the patient wear. I like my cat’s laser best, because it has an on/off switch that I don’t have to keep depressed to have it stay on. I’ve used it for several other feedback interventions as well. The cat does miss her toy when I borrow it though.
Oculomotor training is also involved. Smooth pursuit involves following a moving target with eye balls only. I use a Christmas laser light show for this. Gaze stability involves VOR x 1: focus on point and move head in all planes. Then for eye-head coordination you move your eyeballs to a focus point, then move your head to where you are facing the focus point. And finally saccades where you move the eyeballs quickly between points. These can all be progressed by increasing speed, more intricate focus point (like from a dot to some words), a more complex background behind the focus point (I like wrapping paper sheets), increasing the range of motion, restricting peripheral vision, changing from sitting to standing.
Once the head-neck awareness exercises are mastered, they can be phased out and movement control exercises added in. These include using the same laser to trace patterns or follow mazes. Again, accuracy is the name of the game here, so progressions would challenge the accuracy, but not completely destroy it.
Finally, when the oculomotor exercises are going well, those can be phased out and more traditional balance exercises or postural stability can be addressed. The articles recommends starting with static standing for 30 second intervals varying stance position, eyes open/closed, pliability of the surface, adding cognitive tasks, adding functional tasks to some of the activities from the oculomotor, movement awareness and head-neck awareness sections, like walking while turning the head. The article cautions, “care and slow progression without extremes is vital for successful treatment in patients with whiplash and those with equilibrium disorders of cervical origin.”
I didn’t get beyond the basic manual treatments, oculomotor and head-neck awareness exercises with my case with Polly Patient as she was ready to discharge before I could advance her further. But I did have fun with this case!