Cervical Spine Biomechanics and Manual Therapy
there are ___ cervical vertebra, ___ nerve roots and _____ vertebral discs
7 8 6
following a lesion to one of the alar ligs, theere may be an increase of ____% rotation to the opposite side
30%
what are Kaltenhorn's treatment parameters?
Grades 1-3 sustained glides held for minimum of 7-10 seconds (upward of 30-60 sec) repeat 2-5 times
what direct movement does the unilateral L/R IMP facilitate?
IPSILATERAL side flexion and rotation
for the alar lig stress test, by moving the patient into RIGHT side flexion, you are testing the _____ alar lig and vice versa
LEFT
what would constitute a positive anterior shear (sagittal stress) test?
any S/S of cervical instability
what would constitute a positive lateral shear test?
any S/S of cervical instability
what would constitute a positive posterior stability tesT?
any S/S of cervical instability
what is longitudinal traction/distraction?
applying a gapping to vertebral bodies isolated to spinal motion segment C0 - T1
what is the joint made by C1 and occiput?
atlanto-occipital (C0 & C1)
what muscles make up the inner unit? (3)
deep neck flexors deep neck extensors suboccipitals
what is the lateral (transverse) shear test?
designed to test the integrity of the supporting lateral ligamentous and capsular tissues of c-spine
____ due to the compression of soft tissues against the bone during lateral shear test is common, and patient should be told beforehand
discomfort
what does atlanto-axial rotation (45 degrees) consist of? (2)
due to biconvex surfaces, there is... - ipsilateral posterior & inferior glide - contralateral anterior & inferior glide
what will be demonstrated on observation if the transverse ligament is torn?
during c-spine flexion, C1 will translate forward on C2 which may cause C2 to become more prominant
what are the middle neck extensors? (2)
erector spinae (cervicus group) scalenes posterior
performing a PPIVM on one side will facilitate that osteokinematic movement on the ____ side
ipsilateral (SAME) side
for side flexion and rotation of the lower c-spine, what glide occurs at the ipsilateral facet joint? at the contralateral facet joint?
ipsilateral: inferior-medio-posterior glide (IMP) contralateral superior-antero-lateral glide (SAL)
posterior atlanto-occipital & atlanto-axial membranes are a continuation of which ligament?
ligamentum flavum
the inner unit act as ____ ______, the middle unit acts as ____ ___ and the outer unit acts as ____ ___
local stabilizers (inner) global stabilizers (middle) global mobilizers (outer)
what is flexion of atlanto-occipital joint produced by? (2)
longus capitis rectus capitis anterior
what muscles produce lower C=spine flexion? (3)
longus colli scalenes SCM
what muscles make of the middle layer (2)?
middle neck flexors middle neck extensors
how are c-spine facets oriented?
midway between coronal and transverse planes at 45 degrees
if the alar ligament is intact, what will be the findings?
minimal side flexion with solid end feel
thicker discs allow for more _____
movement
middle layer unit muscles are global stabilizers and are _____
multisegmental (attaching to each segment)
what movement is made with atlanto-occipital joint?
nodding (yes) 10 degrees of flexion & 20 degrees extension
during flexion of atlanto-occipital joint, the ___ and ___ ___ of the atlas separate
occiput posterior arch
what is the side flexion range of the C-spine? overall? upper? lower?
overall 20-45 degrees each direction lower 20-40 degrees upper 5 degrees
what is the flexion ROM in c-spine? overall? upper? lower?
overall 45-50 degrees lower 35-40 degrees upper 10 degrees
what is the extension range of the C-spine? overall? upper? lower?
overall 70-90 degrees lower 50-70 degrees upper 20 degrees
what is the rotation range of the C-spine? overall? upper? lower?
overall 70-90 each direction lower 45 degrees upper 45 degrees
what are the 5 c-spine instability tests?
sharp-purser test alar ligament stress test anterior shear (sagittal stress test) posterior stability test lateral (transverse) shear test
there is a ____ and statistically significant improvement in function from manual therapy + exericse, vs exercise alone in the short term treatment of neck pain
small (0.22)
discs are ____ in the C-spine and are slightly thicker ____ causing a cervical ____
smallest anteriorly lordosis
how do you perform PAIVMs for C1-C2 for RIGHT rotation at RIGHT joint?
stabilize C2 and apply posterior force through RIGHT C1
what are the lower C-spine ligaments? (C2/3-T1) (6)
- ALL - PLL - ligamentum flavum - supraspinous - interspinous - intertransverse
what are the 4 additional upper C-spine (C0-C2) ligaments?
- anterior atlanto-occipital & atlanto-axial membranes - tectorial membrane - posterior atlanto-occipital & atlanto-axial membranes - ligamentum nuchae
what resists extension of atlanto-occipital joint? (2)
- anterior atlanto-occipital membrane - anterior joint capsule
what movements of the upper c-spine can be facilitated with PPIVMs?
- atlanto-occipital flexion & extension - atlanto-axial rotation (L & R)
what is lower c-spine extension resisted by? (4)
- bony impact of posterior arches, SP - impact of superior articular facet on inferior - ALL - anterior annulus of disc (tensile/distraction)
what are the deep neck extensors? (3)
- cervical multifidus - interspinalis - intertransversarii & rotatores
what is flexion of atlanto-occipital joint resisted by? (3)
- contact of anterior margin of foramen magnum with dens - posterior atlanto-occipital membrane and joint capsule - tectorial membrane and suboccipital muscles
what resists atlanto-axial rotation? (2)
- contralateral alar ligaments - joint capsule
local stabilizers do not cross many segments and they can be helpful in ... (2)
- controlling shear force - local stability
what are the functions of alar ligs? (2)
- craniovertebral stability - limits axial rotation and side flexion
what are the superficial neck extensors? (6)
- erector spinae - longissimus and spinalis - trapezius - levator scapula - splenius capitis and cervicis - semispinalis capitis and cervicis
what resists lower c-spine flexion? (4)
- facet joints & capsules - ligamentum flavum, ligamentum nuchae, PLL, interspinous lig - posterior (tensile) and anterior (compression) annulus - extensor muscles
what movements of the lower c-spine can be facilitated with PPIVMs?
- flexion - extension - side flexion & rotation
what resists side flexion and rotation in lower c-spine? (3)
- ipsilateral compression of U-joint - ipsilateral AND contralateral joint capsule - contralateral scalenes, UFT, SCM
what are the deep neck flexors? (4)
- longus colli & longus capitis - rectus capitis anterior & rectus capitis lateralis
what are characteristics of the atlas? (C1)
- no SP (instead has anterior and posterior arches) - no vertebral body - largest TP in C-spine - lateral masses articulate above with occipital condules
what produces rotation at atlanto-axial joint? (2)
- oblique capitis inferior - global neck rotators
what are s/s of cervical instability?
- patient doesn't want to move head (esp. flexion) - severe headacge - pupil changes - nausea/vomiting - soft end feel - severe muscle spasm - lump in throat - nystagmus - lip/facial paresthesia
how is the sharp-purser test performed?
- patient flexes neck - examiner places one hand over pt's forehead while thumb of other hand stabilizes C2 SP - patient asked to slowly flex the head while examiner blocks movement by pressing backwards on forehead
how do you proceed with mobilizing the neck?
- patient has limited/painful motion, assess for contraindications and precautions - perform stability testing - if safe to proceed, identify comparible sign and choose appropriate grade & Rx technique - after treatment, re-perform comparible sign to assess benefit
how is the cervical flexion-rotation test performed?
- patient supine - examiner fully flexes patient's c-spine and maintains full flexion (takes up movement in lower c-spine) - rotate patient's head left and right
how is the lateral (transverse) shear test performed?
- patient supine with head in neutral - examiner stabilizes INFERIOR vertebra by placing radial aspect of 2nd MCP joint of one hand against the TP of the inferior vertebra - examiner then places other hand against TP of SUPERIOR vertebra on the other side of the neck - examiner applies lateral directed force through SUPERIOR vertebra - switch hand position and assess both directions
how is the anterior shear (sagittal stress) test performed?
- patient supine with head neutral - examiner stabilizes INFERIOR vertebra by placing both thumbs on anterior aspect of TPs - examiner places both index fingers on posterior arch (lamina) of SUPERIOR vertebra - apply anteriorly directed force with index fingers while stabilizing with thumbs
How is the alar ligament stress test performed?
- patient supine, head in neutral - examiner stabilizes axis (C2) with wide pinch grip around SP and lamina - examiner attempts to side flex the head and atlas
What are the suboccipital muscles? (4)
- rectus capitis posterior major - rectus captious posterior minor - superior oblique - inferior oblique
what produces extension at atlanto-occipital joint? (2)
- rectus capitis posterior minor - superior oblique (suboccipitals)
what movements are facilitated with unilateral IMP?
- same side (MOBILIZED) facet extension - opposite side (STABILIZED) facet rotation and side flexion - opposite side (STABILIZED) facet flexion (SAL)
what movements are facilitated with unilateral SAL?
- same side (MOBILIZED) facet flexion - opposite side (STABILIZED) facet rotation and side flexion - opposite side (STABILIZED) facet extension (IMP)
what are characteristics of C2 (axis)?
- small bifid SP - small vertebral body - smaller TPs - odontoid process (dens) projecting upwards to articulate with axis
what muscles produce side flexion and rotation of lower c-spine? (4)
- splenius capitus - levator scapulae - longissimus capitis - ipsilateral scalenes
how do you perform a unilateral IMP? (e.g., on the left side, C3-C4)
- stabilize INFERIOR vertebra (C4) by applying IMP force on the RIGHT transverse process and lamina - mobilize SUPERIOR vertebra (C3) by applying an IMP glide on the LEFT transverse process and lamina
how do you perform a unilateral SAL? (e.g., on the right side, C3-C4)
- stabilize INFERIOR vertebra (C4) by applying a slight SAL force on LEFT transverse process and lamina - mobilize SUPERIOR vertebra (C3) by applying SAL glide on the RIGHT transverse process and lamina
what muscles produce lower c-spine extension? (3)
- traps - splenius capitis - semispinalis capitis
vertebral discs in c-spine are from ____ to ___
C2 T1
what direct movement does unilateral R/L SAL facilitate?
CONTRALATERAL side flexion and rotation
what is the superfical neck flexor?
SCM
what is the process for how uncovertebral joints work?
act like stacking of bowls (allow for movement - convex on concave)
there is a large ___ effect associated with manual therapy
analgesic
what does atlanto-occipital extension (20 degrees) consist of?
anterior glide of the convex occipital condyles on concave lateral masses of atlas
anterior atlanto-occipital & atlanto-axial membranes are a continuation of which ligament?
anterior longitudinal - blends with the facet joint capsules
lower c-spine flexion (35-40 degrees) consists of...
anterior sagittal rotation with anterior translation
what are the two upper cervical vertebra?
atlas (C1) axis (C2)
what are the alar ligaments?
attach from lateral margins of foramen magnum to lateral aspect of dens
the atlanto-occipital joint surfaces are like a ____ which limits what 2 movements?
bowl side flexion & rotation
what are 3 passive c-spine movements?
cervical flexion-rotation test PPIVMs PAIVMs
what are ligamentous stress tests?
combined movements (thinking about anatomy of lig and attempting to strain it)
occipital condyles are ____
concave
with side flexion, the occipital portion of the ____ alar ligament is palced under tensile stress and limits further motion
contralateral
both surfaces of the atlanto-axial joint are ____
convex
the superior facet of C2 is a planar surface but the articular cartilage makes it ______
convex (thick in center, thin periphery)
how do you perform a PAIVM for C0-C1 to facilitate extension? flexion?
extension: (stabilize C1, apply anterior force through occiput) flexion: (stabilize C1, apply posterior force through occiput)
Where does the ligamentum nuchae insert??
external occipital protuberance (inion)
what are uncovertebral joints (Joints of von Luschka)?
formed by the lateral edges of adjacent vertebral bodies (C3-T1)
what are maitland's treatment parameters?
grade 1-4 oscillatory 2 oscillations/sec (or 2Hz) 20-60 oscillations, repeated 2-5 times
the thickness of the disc relative to the thickness of the vertebral body is ____ at this region in the spine
highest
what would constitute a positive sharp-purser test?
if examiner feels the head slide backward during the isometric contraction (may be accompanied with a clunk)
what are the cervicus group of erector spinae? (3 muscles)
iliocostalis longissimus spinalis
what does lower c-spine side flexion (20-40 degrees) & rotation (45 degrees) consist of?
impure movements occurring simultaneously - ipsilateral side flexion and rotation
what is a unilateral R/L IMP?
inferior medial posterior pressure on left or right lamina (glide) isolated to spinal segments C2-T1
for extension, facet joints in lower c-spine glide ____-___
inferior-posterior
what are the 3 layers of the c-spine musculature?
inner unit middle layer outer unit
the atlanto-axial joint is a _____ ____ joint and is the most mobile articulation of the spine
pivot synovial
what does atlanto-occipital flexion (10 degrees) consist of?
posterior glide of convex occipital condyles on concave facets of atlas
tectorial membrane is a continuation of which ligament? what is its function?
posterior longitudinal limits atlanto-occipital and atlanto-axial flexion
what does lower cervical spine extension (50-70 degrees) consist of?
posterior sagittal rotation with posterior translation
out unit muscles are global mobilizers, whose function is to ....
prime movers of the head on the trunk (phasic)
what movement occurs at atlanto-axial joint?
rotation (50 degrees)
what is the transverse ligament?
runs posterior to dens, preventing anterior translation of the atlas on the axis
how is the posterior stability test performed?
same as anterior, however examiner is stabilizing SUPERIOR vertebra with thumbs on anterior TP and is applying anterior mobilization on INFERIOR vertebra with index fingers
what are the middle neck flexors? (2)
scalenes (anterior/medius) hyoids
how do you perform PAIVMs for C1-C2 for leftward rotation on right joint?
stabilize C2, apply anterior force through RIGHT C1 transverse process to facilitate LEFT rotation on RIGHT facet joint
what muscles make up the outer unit? (2)
superficial neck flexors superficial neck extensors
how are superior c-spine facets oriented? inferior?
superior - face back, up and medial (BUM) inferior - face forward, down, and lateral (FDL)
what is the unilateral R/L SAL?
superior anterior lateral pressure on the left or right lamina (glide) isolated to spinal segments C2-T1
where are uncinate processes?
superior aspect of the vertebral bodies
for flexion, facet joints of lower C-spine glide ____-_____
superior-anteriorly
ligamentum nuchae is an additional support to the _____ ligament and originates from C___- C___
supraspinous C6-C7
What is the Alar Ligament Stress Test?
tests the contralateral alar ligament
what is the anterior shear test? (aka sagittal stress test)
tests the integrity of the supporting anterior ligamentous and capsular tissues of the C-spine
what is the posterior stability test?
tests the integrity of the supporting posterior ligamentous and capsular tissues of the c-spine
what is a normal end feel with the lateral shear test?
tissue stretch with an abrupt stop
what is the function of global stabilizers?
to stabilize during movement
TPs in c-spine have....
transverse foramen
what ligament is being tested with the sharp-purser test?
transverse ligament
evidence is _____ if manipulation or medication is more beneficial for neck pain
unclear
what are the 3 PAIVMs of the lower c-spine?
unilateral R/L SAL unilateral R/L IMP Longitudinal traction/distraction
what are stability tests?
uniplaner movements (anterior, lateral, rotation, compression/distraction)
What is the sharp purser test?
used to determine a subluxation of the atlas on the axis
what is the cervical flexion-rotation test?
used to evaluate C1-C2 rotation
with the cervical flexion-rotation test, when is ROM considered limited?
when movement is reduced by 10% from expected 45 degrees rotation
