Cervical Spine Special Tests/Mobilizations/Interventions

Positional Cervical Distraction

- Supine - Neck flexed to invovled side and supported on a firm stack or other comfortable material (use towel) - Side flex and rotate to contralaterally from the pain Dose: 3-5 minutes Do at home.

Thoracic Manipulation for Cervical Patients CPR (not validated)

- Symptoms < 30 days - No symptoms distal to shoulder - Not feeling worse with extension - FABQ activity less than or equal to 11 - Decreased upper thoracic kyphosis - Cervical extension < 30

Look at Medications!

Just do it now!

Sharp-Purser Test

Purpose: Upper Cervical Instability (transverse ligament not intact so dens could compress the spinal cord posterior) - Sitting - Cradle the head with the arm/elbow on the forehead - Thumb of opposite hand stabilize the spinous process of axis (do not apply glide!) - Slowly flex head and glide forehead backwards Positive: head slides backward with an audible clunk (dens reduced into arch of C1) Do before mobilization or manipulation to make sure not ligament laxity.

Cervical Spine Red Flags to Manipulation

- Previous diagnosis of vertebrobasilar insufficiency - Facial/intra-oral anesthesia or paresthesias - Visual disturbances - Dizziness/vertigo - Blurred vision - Diplopia - Nausea - Tinnitus - Drop attacks - Dysarthria - Dysphagia - Any symptoms listed above aggravated by position or movement of the neck - No change or worsening of symptoms after multiple manipulations

Segmental Mobility Testing: Mid to Lower Cervical Spine: Unilateral P/A

- Prone - Stand on same side - Thumbs on posterior articulate pillar (just lateral to S.P.) - Force applied in P/A direction - Unilateral P/A (or normal P/A) can be as accurate as radiologically controlled diagnostic blocks to diagnosis facet joint disorders: pain and hypomobility P/A on left side: Right rotation Right side bend Treatment: Start with grade 1 or grade 2 M, but progress to grade 4 M

Middle Trapezius

- Prone with chest over edge - Shoulders abducted to 90 degrees while retracting the cervical spine Dose: Hold 10 sec 12 reps Progress: longer holds (this is usually goal), higher reps, and loads Individuals with weakness may have cervical extension, cervical protraction, or trunk extension with this exercise

Lower Trapezius

- Prone with chest over edge (may use pillows under chest so not off table) - Shoulders abducted to 130 degrees while retracting the cervical spine (forehead parallel to floor still) Dose: Hold 10 sec 12 reps Progress: longer holds (this is usually goal), higher reps, and loads Individuals with weakness may have cervical extension, cervical protraction, or trunk extension with this exercise

Lower Cervical Extensor Endurance test (Modified Biering-Sorensen test)

- Prone with neck off table - Maintain retraction in horizontal position parallel to floor - Strap upper thoracic spine with arms at side - Mean: 10 minute hold

Deep Cervical Extensors

- Prone with neck off table, arms at sides, and scapula at mid position - Maintain retraction (jaw fully towards the spine) in horizontal position parallel to floor (do not extend the spine) Dose: 10 sec hold for 12 reps Progress: increase duration of hold, increase reps, perform in quadruped Quadruped: arms first, then legs, then arms and legs while holding cervical retraction and scapular mid position

AA Rotation in Sitting Treatment

- Seated - Standing on right side of patient - Left thumb blocks against right lamina of axis with the thumb - Head is comfortably cradled and against your chest/abdomen - Rotate your head to the right - Monitor signs of VAI Treatment: 15 sec 3 times *Know by rotation with flexion or ipsilateral rotation with side bend

Scalenes

- Seated with good posture - Ipsilateral arm holds side of chair to anchor - Cervical spine flexed away and extended Dose: hold 15-30 sec 3-5 reps Make sure first rib doesn't elevate: use towel on trap and wrap around then AROM side bend away (reciprocal inhibition: muscles will relax with active side bend, could switch and do passive if wanted though)

Sternocleidomastoid

- Seated with good posture - Ipsilateral arm holds side of chair to anchor - Cervical spine flexed away, extended, and ipsilateral rotation Dose: hold 15-30 sec 3-5 reps

Levator Scapulae

- Seated with good posture - Ipsilateral arm holds side of chair to anchor - Cervical spine flexed away, forward flexed, and contralateral rotation Dose: hold 15-30 sec 3-5 reps

Upper Trapezius

- Seated with good posture - Ipsilateral arm holds side of chair to anchor - Cervical spine flexed away, forward flexion, and ipsilateral rotation Dose: hold 15-30 seconds 3-5 reps

Multifidus-Isometric Facet Impingement

- Sitting arms fully supported - Stand opposite to side being mobilized - Grasp patient head and hold to chest while flex, rotate, and side flex to opposite side to be released - Stabilize involved shoulder - Instruct patient to hold isometric contraction Dose: 6-10 sec 50% 1-RM 3-5 reps - Reassess ipsilateral rotation and side bend - PA or UPA right after

Cervical Manual Traction Technique 2

- Sitting with clinician behind - Thenar eminences support occiput and mastoid - Therapist forearms rest on scapula (elbows tight and forearms against the shoulders) - Patient lean back 45 degree angle - Weight of patient with therapist contact points creates distraction Easy to do this after repetitive motion Ask if any pain? (Do not lead with questions!)

Cervical Manual Traction Technique 1

- Supine - Hands grasp head and mandible (you can stand, staggered stance with table higher or sit) - Long axis pull applied to cervical spine Dose: 3-5 minutes Precaution: TMD (hold occipital region with both hands; Stenosis (flex then distract); Disc (neutral or retract unless large disc protrusion) Check with this before do mechanical traction

Vertebral Artery Insufficiency test

- Supine lying with head supported over the edge of the table (T2-T3 off the table) - Passive neck extension - Passive neck rotation and hold for 30 seconds (Rotation performed in both directions, but the contralateral side is being tested) Look out for five D's and N's: Drop attack, dizziness, dysphasia, dysarthria, diplopia or Nystagmus, numbness, nausea Validity of test in question.

Pectoral Stretch

- Supine on foam roll with shoulders abducted and elbows flexed to 90 degrees (high-five) - Allow the arms to horizontally abduct as far as possible until stretch is felt Can also be done with arms in 150 degrees of scaption Dose: hold 15-30 sec 3 reps at least

Segmental Mobility Testing: Mid to Lower Cervical Spine: Cervical inferior glide

- Supine with head supported (rotate head away to move SCM then back to neutral) - Force applied in a medial, posterior, and slight inferior direction through base of index finger (palmar MCP) at the lateral articulate pillar - All levels Hypomobility and pain shows facet stuck open ipsilateral. Right inferior glide: Right rotation Right side flexion Extension Right facet stuck open: AROM extension contralateral deviation AROM flexion no deviation Treatment: 1 Hz oscillation at end range 3 or 4M Progress: side bend to that level ipsilateral then do grade 3 or 4 M oscillations 1 Hz

Cervical C2-C7 Manipulation

- Supine, you send at corner - Proximal phalanx on posterior lateral pillar - Underneath hand on posterior lateral occiput above ear - Rotate head to right - SB left - Side glide right - Slight segmental extension (PA shift) - Pre-manipulative hold: hold position 10 seconds (check for VAI, check tolerance of combined movement so symptoms) - Thrust into rotation in an arch to posited underside eye

Cervical Manipulation CPR

- Symptoms duration less than 38 days - Positive expectation that manipulation will help - Cervical rotation difference 10 degrees or greater - Pain with PA lower cervical spine 3/4 has 90% chance of success Keep eye on 3 N's and 5 D's

Deep Cervical Flexor (BP cuff)

Works endurance and coordination of deep cervical flexors - Instability (ligamentous hyperlaxity and disc dessication so rely on muscles to keep in neutral zone) - Disc herniation because no disc in upper cervical spine! Make sure able to do chin tuck actively first (posterior glide limitation will not be able) Make sure EAM in line with acromion - Hook lying - BP cuff under cervical spine behind the suboccipital region not lower cervical spine - Inflate to 20 mmHg to fill lordotic curve - Patient "nods" the head with chin tuck (upper cervical flexion) - Patient targets 2 mmHg increases and hold 10 seconds (20,22,24,26,28,30) Dose: 10 sec on/10 sec off - Cue by hand on chin and under head to help - Keep eye on SCM! Progress: Deep Cervical Flexor Lift

Cervical Traction CPR

Patients who benefit from cervical traction: Age greater than or equal to 55 Positive shoulder abduction test Positive ULTT Symptom peripheralization with central P/A motion testing at lower cervical spine C4-C7 Positive neck distraction test

Neural Mobility/Tension (Elvey tests)

Purpose: Assess cervical radiculopathy - Shirt off, hook lying, explain procedure before, do bilateral ULTT 1: Median nerve, C5-C7 nerve root 1. Scapular depression 2. Shoulder abduction to 90-110 degrees 3. Forearm supination, wrist and finger extension 4. Shoulder lateral rotation 5. Elbow extension 6. Contralateral/ipsilateral cervical bending Positive: concordat symptoms (radiculopathy)

Timed Supine Capital Flexion test

Purpose: Test the endurance of deep cervical flexors: longus coli and capitus (primarily type one fibers) - Do for any neck pain, headache, bad posture (not just instability) - Supine with neutral spine - Patient slowly raise head 2 inches off table with chin tuck - minimal contraction of SCM - Time stopped if cannot hold head up or lose upper cervical flexion (may lose chin tuck d/t discomfort) - Normal: 38-49 seconds

Alar Ligament test

Purpose: Upper Cervical Instability (Laxity of Alar Ligament) - Supine - Palpate spinous process of C2 with one hand - Laterally flex or rotate the head to one side Positive: The C2 S.P. does not move as soon as the head begins to side bend or rotate (side bend to left makes ligament on the right taut so if laxity, then the S.P. Will not move) Do before mobilization or manipulation to make sure not ligament laxity.

Cervical Rotation Lateral Flexion test

Purpose: assess for 1st rib hypomobility - Sitting - Cervical spine passively rotated away (max rotation) from the side being tested - While maintaining position, the cervical spine is passively and gently lateral flexed as far as possible by moving the ear toward the chest Positive: unable to lateral flex (with an abrupt or bony end feel) (The transverse process on left moves right with right rotation and when side flex it hits the 1st rib: the ear that is going to chest is the side that has the hypomobile rib)

Segmental Mobility Testing Cervical A/A Joint

Purpose: assess for decreased ROM at the A/A Joint - Supine - Apply full cervical flexion to "lock" all the segments below and isolate C1-C2 then apply full cervical rotation Treatment: 15 sec 3 times at end range MET: resist opposite rotation 6 sec 50% 1-RM then move into end range Normal ROM: 43 degrees Cervicogenic Headaches: unilateral 20 degrees Migraine with aura and asymptomatic patients: 39 degrees

Segmental Mobility testing of O/A (Side flexion)

Purpose: assess for hypomobility at the O/A (cervicogenic headaches) - Supine - Hold the patients head by grasping the occipital and temporal regions - Side flexion left and right with the nose as the axis of rotation - Avoid side flexion of cervical spine, only O/A! - Assess and compare movement and end-feel Treatment: 15 sec 3 times at end range Monitor for VAI MET: resist against contralateral side flexion 6 sec 50% 1-RM (oblique superior capitus) then move to end range Right side flexion: Right condyle anterior Left condyle posterior (usually this is side of pain) Both condyle go left

Examination Segmental Mobility testing of O/A

Purpose: assess for hypomobility at the O/A (cervicogenic headaches) - Supine - Hold the patients head by grasping the occipital and temporal regions (Use stomach to support) - Flex or extend the occiput - Assess side flexion while maintaining flexion or extension (Make sure EAM and nose stay still!) - Assess and compare movement and end-feel Treatment: 15 sec 3 times at end range Monitor for VAI and check patient tolerance to combined movements Hands should be "loose"

Segmental Mobility testing of O/A (Flexion and Extension)

Purpose: assess for hypomobility at the O/A (cervicogenic headaches) - Supine - Hold the patients head by grasping the frontal and occipital regions - Flex and extend the head with the ear as the axis of rotation (external auditory meats level with acromion) - Avoid extension and flexion of the cervical spine - Assess and compare for movement and end feel Treatment: 15 sec 3 times at end range Monitor for signs of VAI MET for suboccipital mm guard: Flex upper cervical spine then ask patient to look up 6 sec hold 50% 1-RM, move into further end range Hold-relax: excite golgi tendon which relax suboccipital mm. Stick to posterior glide with OA flexion Right rotation: Right condyle anterior Left condyle posterior

Depression of First Rib

Purpose: assess mobility of first rib (T.O.S.) - Supine with head supported and in neutral - MCP of index finger against the first rib (full inhalation and ipsilateral side flexion (scalenes on slack)) - Force in medial and inferior direction - Exert pressure when patient breathes out Treatment: 3 times 15 sec stretch 6 sec hold 50% 1-RM (upper traps?) or grade 3 (large-amp) M, 1 Hz

Spurling

Purpose: confirm nerve root involvement (narrows the canal or irritates the nerve root) - Sitting (with good posture! 10%) - Side flex to uninvolved side first followed by involved side (30-45 degrees) - Carefully compress head down and hold a few seconds Positive: Pain radiates down the arm with compression (radiculopathy) (Neck pain without radiation down shoulder or arm is NOT positive)

Distraction

Purpose: confirm nerve root involvement (radiculopathy) - Sitting - Both hands around occiput then slowly lift the head (hypothenar eminences on occipital condyles with at least 25 pound lift - may lean patient toward you to help) Positive: pain is relieved or decreased with distraction (radiculopathy gone)

Bakody

Purpose: confirm nerve root involvement (radiculopathy): usually discogenic pathology because stenosis has a narrowed canal whether or not the arm is in abduction - Sitting - Patient asked to actively elevate or abduct the arm so it rests on the head Positive: Position relieves or decreases symptoms Increased symptoms: shoulder or interscalene triangle pathology

Soft Tissue Mobilization: Suboccipital Release

Purpose: forward head posture causes suboccipital tightness (and decreased posterior glide OA) (this can lead to compression at suboccipital triangle, compression of greater occipital nerve and pain in temporal-occipital region - headaches) - Supine, hook-lying on a soft pillow - Sit behind with 2nd, 3rd, 4th gainers along unchallenged line on base on occiput , elbows tight Dose: 3-5 minutes

Segmental Mobility Testing P/A Glide

Purpose: mobility of C2-C7 vertebrae - Prone with hand under forehand or hole in bed - Thumb - thumb application to apply downward force to end range - Slow force so don't activate paraspinals (may manually move the paraspinals out of the way) - Assess all segments P/A glide (or unilateral P/A glide) can be as accurate as radiologically controlled diagnostic blocks to diagnosis facet joint disorders Diagnostic for facet joint disorder: pain with hypomobility Treatment: Grade 3 M 1 Hz, 30-60 sec, 3-5 times May not see increase in motion, but may have decrease in pain May do to treat pain!

Cranial Cervical Flexion test

Purpose: test the endurance of deep cervical flexors: longus coli and capitus - Instability (ligamentous hyperlaxity and disc dessication so rely on muscles to keep in neutral zone) Make sure able to do chin tuck actively first (posterior glide limitation will not be able) Make sure EAM in line with acromion Watch SCM - Hook lying - BP cuff under cervical spine behind the suboccipital region not lower cervical spine - Inflate to 20 mmHg to fill lordotic curve - Patient "nods" the head with chin tuck (upper cervical flexion) - Patient targets 2 mmHg increases and hold 10 seconds (20,22,24,26,28,30): 10 sec on/10 sec off - Normal: Able to hold 10 seconds 26-30 mmHg Usually can't do 26 mmHg d/t muscle weakness

Serratus Anterior

Push-up plus: Push-up position, protract the shoulders (push scapulae as far as possible from spine) at the top of the push-up position hold for 10 seconds 12 reps - go to full retract then protract Progress: increase the reps, sets, and elastic bands Regress (if does not have strength to perform or has pain): perform on hands and knees or against the wall Quadruped: knees under hips, elbows under shoulder, no elbow hyperextension, no elbow flare, no IR/ER of shoulder, don't point the hands in > max scap recruitment; min UE stress

Palpation Slide 2

Supine: - TMJ - Mastoid Process - Occipital Protuberance - C2 S.P. - Articular Pillars - Cervical paraspinals - SCM - Suboccipital muscles Prone: - C2 S.P. - C7 S.P. - Trapezius - Levator scapulae muscle - Rhomboid

Palpation

Temperature Muscle state: spasm, guarding, chemical stasis, tenderness, trigger points Position: supine, prone, seated Scratch test

Stretches

Upper trapezius SCM Scalenes Levator scapulae HEP: 2-3x/week Muscles tight because over recruited

Cervical Traction

Types: manual, mechanical, self or autotraction, positional Force: 25-45 lbs max Time: Disc - 5-10 minutes; Non-disc - 10-20 minutes (disc can do 10-12 minutes but start with 10 minutes) Intermittent: DDD intermittent with short rest period Constant: Disc sustained (better) or intermittent (60 sec hold 20 sec rest) - use traction for disc when repetitive motion does work

Soft Tissue Mobilization: Cervical Laminar Release

- One hand cradles the head and occiput to bring the cervical spine into a forward bent position - Other hand makes contact with cervical paravertebral muscles bilateral using PIP joints of 2nd/3rd digit at CT junction - Stroke from the CT junction up to the occiput using the PIP of digits 2nd and 3rd joints

Cervical Spine Absolute Contraindications to Manipulation

- Acute fracture - Dislocation - Ligamentous rupture - Instability - Tumor - Infection - Acute myelopathy - Recent surgery - Acute soft tissue injury - Osteoporosis - Ankylosing spondylitis - RA - Vascular disease - Vertebral artery abnormalities - Connective tissues disease - Anticoagulant therapy - Lack of patient consen

Gym Exercises

- Avoid protrusion - Avoid tricep dumbbell dips, reverse lat pull down, crunches with protrusion (maintain neck retraction) - Strengthen the cervical and scapular muscles to improve posture - Proper form to avoid flexion and forward flexed posture - Focus on endurance training with high reps, long holds, lower loads, and short rests - DOMS w/i 24-48 hours - Caution if on Rx may not know doing damage to muscles! - Don't hold breath - 3x/week wit hon day of rest b/w to allow tissue to recover

Soft Tissue Mobilization: Ischemic compression to the trigger point

- Before trigger point, stroke parallel to the fibers of the muscle: trap, LS, SCM, scalenes - Sustain pressure using thumb to apply pressure for 10 sec for 3 times for each trigger point - Dormant gives only local pain, not referred - do not compress!

Deep Cervical Flexor (Lift)

- Do for any neck pain, headache, bad posture (not just instability) - Explore this 48-72 hours after cessation of pain - Supine with neutral spine - Patient slowly raise head 2-3 inches off table with maximal chin tuck - minimal contraction of SCM (make sure don't protract or have excessive neck flexion) Dose: 10 seconds for 12 reps Regress (if cannot hold 10 sec): Incline the table

Posture and Neuro Re-Ed

1. Have patient sit in a slouched posture and in an overcorrected posture then back off 10% (legs on floor, tuck the chin to get EAM in line with acromion) 2. Perform 5 times - Provide visual, tactile, or verbal cues as needed - Manually correct posture if needed: hand on chest and hand on thoracic spine - At home: 10x every other hour

Special Tests

1. State purpose, let me know if you have pain at any time, adjust the bed, and take off shirt/shoes 2. Test unaffected first then affected 3. Ask how the pain feels or if there is any discomfort? 4. State a positive test

Mobilizations

1. State you are going to assess mobility of joint, let me know if there is pain at any time, adjust bed, take off shirt/shoes, assess AROM 2. Ask how the pain is before start? 3. Test unaffected first 4. Test affected, ask how the pain is? 5. Assess R1, R2 6. Determine hypomobile, normal, hypermobile 7. Ask how the pain is after? 8. Reassess AROM

Home Exercise Program

Upper Cervical Flexion Upper Cervical Rotation Cervical Extension Neurodynamic Mobility