PMC7787856_01
Lateral view of the patient's neck (a) and her cervical lateral radiograph (b) at the first visit. (a) Dropped head syndrome (DHS) was evident. Remarkable bulging was seen over her trapezius and levator scapulae muscles (a, arrow). (b) The patient's cervical spine inclined forward, and kyphotic deformity was present at C5-C6.
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At the first visit, her DHS posture was evident, and her neck extension was severely restricted (Figure 1(a)). Remarkable bulging was seen over her trapezius and levator scapulae muscles (Figure 1(a), arrow). Cervical lateral radiographs showed that her cervical spine inclined forward, and kyphotic deformity was present at C5-C6 (Figure 1(b)).
T2-weighted magnetic resonance (MR) sagittal image (a) and axial image at C5-C6 (b) of the patient's cervical spine at the first visit. (a) Cervical alignment was slightly kyphotic, and the C5-C6 intervertebral disc protruded posteriorly (arrow). (b) The cervical extensor muscles were atrophic. The trapezius muscles showed a stretched morphology (arrowhead).   : deep layers of the cervical extensor muscles (semispinalis cervicis and multifidus).   : lateral-dorsal layers of the cervical extensor muscles (splenius capitis, splenius cervicis, and longissimus).   : trapezius.  : C5-C6 disc.
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Cervical magnetic resonance (MR) images showed that her cervical alignment was slightly kyphotic, and the C5-C6 intervertebral disc protruded posteriorly (Figure 2(a), arrow). An axial view MRI at C5-C6 showed atrophy of cervical extensor muscles (Figure 2(b)). The cross-sectional area of the trapezius muscles was 182.5 mm2 (Table 1), and morphologically, her trapezius muscles were stretched (Figure 2(b), arrowhead).
The principle of our approach to cervical disorders in athletes.
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According to our approach to cervical disorders in athletes (Figure 3), we provided her with our AR-PT (Figure 4). As an initial treatment, we applied phase I programs for relieving her severe symptoms.
The program of athletic rehabilitation-based physical therapy (AR-PT) for the present patient and the change of her symptoms. Programs applied for this patient are shown. The circled numbers at phase I, phase II, and phase III are the programs described in Figure 3. NRS: Numerical Rating Scale; JOA-CMEQ: Japanese Orthopaedic Association-Cervical Myelopathy Evaluation Questionnaire; m: month.
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According to our approach to cervical disorders in athletes (Figure 3), we provided her with our AR-PT (Figure 4). As an initial treatment, we applied phase I programs for relieving her severe symptoms. At the third AR-PT, the patient's neck pain was relieved with only slight pain and stiffness on the left side of her neck (NRS: Rt = 0, Lt = 2) (Figure 4). At the 12th AR-PT, the patient's neck pain was relieved completely (NRS: Rt = 0, Lt = 0) (Figure 4).
Representative exercises of our AR-PT (phase II) for the present patient. (a) Scapular retraction with a foam roller. As the patient was able to lean back on the sofa only with head support, scapular retraction was introduced for her to become aware of her habitual control of posture. This exercise corresponded to the phase II     programs. (b) Ball roll-out exercise for shoulder flexion and trunk flexion. Kinesthetic awareness of craniospinal balance needed to be learned initially, and proprioception and coordination training of her posture were taught such as shoulder flexion, trunk flexion, and anterior pelvic tilt. This exercise corresponded to the phase II     programs.
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The details of representative exercises of our AR-PT for this patient are shown in Figures 5 and 6.
Representative exercises of our AR-PT (phase III) for the present patient. (a) Thoracic extension with head resting on a foam roller. The goal of this exercise was to mobilize and control the cervical and upper thoracic regions while her head was stabilized. The lower thoracic and lumber regions also were consciously controlled with anterior pelvic tilting so that the desired sitting position was under the patient's own control. This exercise corresponded to the phase III     programs. (b) Spinal extension within the submaximal active range of motion. The goal of this exercise was to activate cervical and upper thoracic regions while her head was stabilized under her own control. Both suboccipital flexion and pelvic anterior tilt were controlled throughout this movement. This exercise corresponded to the phase III     programs.
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The details of representative exercises of our AR-PT for this patient are shown in Figures 5 and 6.
Lateral view of the patient's neck at the 3rd AR-PT. DHS was improved. The bulged muscles were still seen at this point (arrow).
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Her cervical extension was improved, and she was able to use a cup to drink and gargle (Figure 7). However, the bulged muscles were still seen at this point (Figure 7, arrow).
Lateral view of the patient's neck (a) and her cervical lateral radiograph (b) seven months after the 1st AR-PT. (a) The patient's neck posture was normal, and the muscle bulging had disappeared. (b) Forward inclination of her cervical spine was improved.
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Seven months after the first AR-PT, her cervical posture became normal, and the muscle bulging disappeared (Figure 8(a)). Cervical radiographs showed that forward inclination of her cervical spine was improved (Figure 8(b)).
T2-weighted MR sagittal image (a) and axial image at C5-C6 (b) of the patient's cervical spine eight months after the first AR-PT. (a) Alignment of her cervical spine became normal. (b) Atrophy of her cervical extensor muscles was improved. Muscle tonus of the trapezius was restored (arrowhead).   : deep layers of cervical extensor muscles (semispinalis cervicis and multifidus).   : lateral-dorsal layers of cervical extensor muscles (splenius capitis, splenius cervicis, and longissimus).   : trapezius.  : C5-C6 disc.
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AR-PT showed that alignment of her cervical spine had become normal and atrophy of her cervical extensor muscles was improved (Figure 9(b)). At the C5-C6 level, the cross-sectional area of the deep layers of cervical extensor muscles was 324.6 mm2 and that of the lateral-dorsal layers of the cervical extensor muscles was 615.9 mm2, both of which were greater than those before AR-PT. However, their morphology indicated that muscle tonus was restored after AR-PT (Figure 9(b), arrowhead).