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Techniques to improve range of movement can consist of manual therapy to the cervi- cal spine, to open the intervertebral fora- men and allow more space for the nerve roots to move. Similarly techniques to close down the intervertebral foramen must be tested to ensure there is no ‘pincer‘ mecha- nism present within the cervical spine.

As recovery is occurring it is important to ensure the neural structures have regained their flexibility. Mobility of the neural tis- sue is required particularly due to the arm position in a tackle situation.

Cervical spinal stenosis has been shown to increase the risk of permanent neurological injury (3).The nerve roots occupy between 25-33% of the foramina space, hence the effect of canal narrowing acts like a ‘pincer’ mechanism in hyperextension (see Fig.1b).

Recent research compared control subjects of the same age with French rugby players who played in ‘the front row’ of the scrum. Results showed that out of forty seven players, 52% had abnormal cervical spinal canal ratios based on the Torg index.

The findings showed that younger players did not have cervical spine canal stenosis. Thus the stenosis developed as a result of degeneration of the cervical spine due to the stresses placed on the spine during ‘front row’ forward play in rugby union.

Rugby players who receive recurrent ‘stinger’ injuries should be investigated by MRI and x-ray for the possibility of cervi- cal spine canal stenosis. This assists the medical team in identifying the extent of injury or if there is a congenital abnor- mality present.

Torg’s recommendations for evaluating collision sport participation by an athlete with developmental narrowing of the cer- vical spine is as follows: 1. Canal/vertebral body ratio less than 0.8 in asymptomatic individuals - no con- traindication to playing collision sports 2. Ratio of less than 0.8 with one episode of cervical cord neuropraxia - relative con- traindication to playing collision sports 3. Documented episodes of cervical cord neuropraxia associated with intervertebral disc disease and or/degenerative changes - relative contraindication to playing col- lision sports

14 SportEX

4. Documented episodes of cervical cord neuropraxia associated with MRI, evi- dence of cord defect or cord oedema - rel- ative/absolute contraindication to play- ing collision sports 5. Documented evidence of cervical cord neuropraxia associated with ligamentous instability, symptoms of neurological find- ings lasting more than 36 hours and or multiple episodes - absolute contraindica- tion to playing collision sports

2. Increase flexibility of the cervical spine and surrounding soft tissue In the cervical spine it is important to regain full functional range of movement of joint and soft tissue. Lack of flexibility may lead to poor technique putting the cervical spine at risk. In the ‘stinger’ a full assessment of the cervical spine move- ment, neurological examination including neural tissue provocation tests to radial, median and ulnar nerve pathways must be carried out. As the cervical spine under- goes coupled motion during normal move- ment it is important that the joints and soft tissues can move with the demands placed on the tissues.

3. Increase functional strength of the stabilising muscles of the respective joints In collision sports the cervical spine can be subjected to large forces similar to the hyperextension ‘whiplash‘ injury in road traffic accidents. Muscle conditioning in rehabilitation should be function-specific.

The role of the cervical spine muscles is two-fold, firstly to provide stability and secondly to produce functional movement of the cervical spine. Injury to the soft tissues such as those of a ‘stinger’ to the cervical spine, may lead to local instabili- ty at a particular joint level.

A model of spinal stability by Panjabi (6) states that spinal stability is controlled by three systems: a) a control subsystem – neural b) a passive subsystem - the spinal column c) an active subsystem – the spinal muscles

These systems work in harmony to allow normal function. Panjabi indicates that muscles require programming in response to feedback from receptors which allow activation of the muscles to required loads. Research has shown that the sta- bility of the spine is controlled by the activity of the local muscles by low-load tonic, continuous activity in the antigrav- ity muscles and decreasing the activity of the global muscles (7).

Figure 2: Manual therapy to mobilise the cervical spine to regain range of movement

Studies by Johansson (8) linked muscle stiffness as a controlling factor in joint stability. They described two components of muscle stiffness: intrinsic and reflex- mediated. Intrinsic they described being related to the visco-elastic properties of the muscle and reflex-mediated being dependent upon motor neurone pool

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