Cervical Spine

What are the two primary assessments that you want to perform in a patient with neck pain and movement coordination impairment?

*CCFT and neck flexor endurance test. *In addition, assessing the isometric strength into flexion, extension, and right and left lateral flexion in chronic whiplash patients revealed that compared to published normal values, whiplash patients suffered a sharp reduction of about 90% in both genders in all directions. The interpretation is that in the absence of severe atrophy or grossly dysfunctional neurological control, the weakness may be associated with learned pain avoidance behavior that is typical among these patients.

Describe how to perform an upper cervical mobilization procedure to improve occupit-C1 mobility:

*Limited in segmental/accessory mobility at occiput- C1, painful capital flexion, and/or limited capital flexion are indicators that suggest this application's technique. There are two methods used. The first one is with the patient prone and the head and neck in the neutral rotation. The plinth height should be adjusted so that the physical therapist is in a comfortable position at the head of the patient with his elbows straight and the dorsal aspect of the thumbs approximating each other and contacting the articular pillar of C1. The physical therapist then gently pulls the lateral musculature posteriorly, creating some slack on the surrounding soft tissue, for the patient's comfort. With elbows straight, the physical therapist will apply a gentle, but firm, PA glide on the articular pillar (Figure 34). *The second position is with the patient supine. The physical therapist will come under the patient's occiput crossing midline and using the middle phalanx will stabilize the posterior aspect of the articular pillar of Cl. Stabilize that hand using the palm of the other hand to provide support for the hand and phalanx. Contact the patient's forehead on the involved side with the therapist's shoulder. Use the shoulder that is the same side as the involved side of the patient's neck (ie, if the patient has right-sided involvement, then the therapist will use his right shoulder to contact the right side of the patient's forehead). The physical therapist will apply a posterior glide with his shoulder on the patient's forehead while stabilizing C1 (Figure 35)

How can you assess flexion at C0-1?

*The therapist can ask the patient to nod his head while maintaining a neutral spine. *Another method to assess physiological motion of C0-1 is to have the patient rotate his head in one direction and then instruct him to perform a capital nod. The amount of capital nod is compared with the head and neck rotated in the opposite direction.

What treatments are commonly used to address spinal segmental accessory mobility?

*central PA *unilateral PA

What are the 3 categories of segmental motion (accessory motion)?

*decreased/hypomobile *normal *excessive/hypermobile

How do you test the dermatomal and myotomal portions of the C8 nerve root? What reflex is associated with this nerve root?

*dermatome: distal 5th digit *myotome: abductor pollicis brevis (thumb placed in abduction, resistance against proximal phalanx into abduction) *reflex: N/A

What do you assess after cervical AROM?

*segmental motion (accessory motion)

What is one intervention that can benefit a patient with neck pain and headaches?

*suboccipital muscle stretching *The patient is lying supine with knees bent. The patient is instructed to perform a head nod, much like he is nodding yes in a favorable response to a question. Once the patient nods yes, then he continues to increase the upper cervical flexion until he feels a stretch in the suboccipital area. The patient is then instructed to maintain this position for a period of time. Some evidence exists for a one-time stretch of 30 seconds. Although, these studies were related to hamstring length.

What is the Alar Ligament Test?

-Alar ligament: goes from the dens of C2 to the occiput -Symptoms of Alar Ligament insufficiency: metallic taste in their mouth, dizziness, nausea -Can be because of trauma, RA -Alar Ligament Test should be performed to increase or decrease the suspicion of the presence of ligamentous insufficiency. The purpose of this test is to assess the integrity of the alar ligaments that provide stability to the atlanto-occipital junction. -This test is performed with the patient in supine. The physical therapist will stabilize the spinous process of C2 using a pinch grip of one hand using the pad of the thumb and the pad of the index finger. Using the other hand, the examiner will grasp the patient's head and sidebend it opposite the thumb side of the spinous process of C2. -The physical therapist should feel the spinous process move immediately into the pad of his thumb. -Positive Test= a delay in the movement of the spinous process of C2 -The test is then repeated with sidebending to the other side. The physical therapist can switch hands or may keep the hands in place. lf the hands are kept in place, sidebend the head towards the thumb side of the spinous process. -A positive test is indicated by a delayed movement of C2 into the pad of the index finger as the head is side bent. -If this test is positive: traumatic and you don't get it very often, want to confirm and then call the doctor to let them know what is going on and ask them what they want you to do next.. don't want to finish the rest of the treatment -Open mouth x-ray will confirm this

What are the 4 ICF Classifications covered in this book?

1. Neck pain with mobility deficits 2. Neck Pain with Headaches 3. Neck pain with movement coordination impairments 4. Neck pain with radiating pain

What are 5 criteria that need to be met in order to classify a patient as having a low probability of injury?

1. no midline cervical tenderness 2. no focal neurologic deficit 3. normal alertness 4. no intoxication 5. no painful, distracting injury

What are the clinical predictor rules for patients who will likely respond favorably to thrust joint manipulation of the cervical spine?

1. symptom duration less than 38 days 2. a positive expectation that manipulation will help 3. side-to-side difference in cervical rotation ROM > or equal to 10 degrees 4. pain with posterioranteiror spring test of the middle cervical spine

What is another name for C1?

Atlas

What nerve roots innervate the UEs?

C5-T1

Describe how to perform a thoracic self-mobilization to improve extension, left side bending, and left rotation:

Figure 27 demonstrates the patient sitting upright in a chair with a medium high back. The patient is instructed to interlock his fingers behind his neck and to tuck his chin into his chest. The patient will make adjustments in the chair to approximate the involved level at the top of the chair's back. He is then instructed to bend backwards and to the left over the top of the chair while maintaining his capital flexion. The purpose of maintaining capital flexion is to promote thoracic extension and minimize cervical extension.

If there are no risk factors present then, according to the Canadian Cervical Spine Rules, what do you ask next?

Is the patient able to perform cervical AROM? IE do they have: (1) the ability to assume a sitting position in the emergency room (2) the ability to ambulate at any time (3) the onset of neck pain is not immediate, (4) the absence of midline tenderness in the cervical spine or (5) a motor vehicle accident that does not include being pushed into oncoming traffic, hit by a bus or large truck, hit by a high speed vehicle, or a rollover situation.

What is MCID? (relating to standardized questionnaires)

Minimal clinically important difference: represents the smallest amount of change in an outcome that might be considered important by the patient or clinician

Are there any clinical prediction rules or reliable criteria that can accurately identify which patients are at risk for VBI?

No. If there is a high suspicion of VBI based on the patient's history, then passive end range provocative testing should be avoided and the patient should be referred to the appropriate medical practitioner.2a Part of the patient's history that may help in the decision making is the mechanism of injury. The most common cause of sudden-onset VBl is trauma, specifically from high-velocity, flexion-distraction and rotational forces that may occur during a whiplash. As a result, if a patient presents with history of a high velocity trauma, proceed with a heightened suspicion of possible VBl.

What is the origin, insertion, and function of the rectus capitis anterior?

Origin: Anterior surface of the lateral mass of the atlas (C1 vertebra) and the root of its transverse process Insertion: The inferior surface of the occipital bone anterior to the foreamen magnum *Aids in flexion of the head and the neck

What is the origin, insertion and function of the semispinalis capitis?

Origin: LThe muscle originates on the articular processes of the C 5, 6, 7 and 8 as well as the transverse processes of T 1, 2 ,3 ,4 ,5 and 6 Insertion: The semispinalis capitis attaches onto the occiput inbetween the superior and inferior nuchal line. *The semispinalis capitis and cervicis muscles act with the splenius muscles to extend the head and cervical spine. The greater occipital nerve (C2) pierces this muscle. Entrapment of this nerve in the semispinalis cervicus can lead to greater occipital neuralgia.

What is the function of the sternocleidomastoid (SCM)?

Rotation of the head to the opposite side or obliquely rotate the head. It also flexes the neck. When acting together it flexes the neck and extends the head. When acting alone it rotates to the opposite side (contralaterally) and slightly (laterally) flexes to the same side. It also acts as an accessory muscle of inspiration.

What do upper limb tension tests (ULTT) look for?

The upper limb tension test is used to assess mobility of the neural elements of the upper limb while determining whether the patient's upper quarter symptoms are elicited during the test. There are test positions and sequences for the median, radial, and ulnar nerves.

Describe how to perform an upper thoracic manipulation to improve extension right side bending and right rotation:

Upper thoracic manipulation to improve extension right side bending and right rotation can be used for patients who typically present with right sided pain during extension and/or right side bending and right rotation. The patient is lying prone with the physical therapist standing at the head of the table near the patient's head. The therapist's left thumb will be at the right interspinous space of the involved segments. The therapist will then side bend the patient's head to the right until movement is felt in the superior vertebra. The therapist will then rotate the patient's head to the right until movement in the superior vertebra is felt. Keeping the right hand on the patient's head, the therapist will use the palm of his hand to apply a slight traction force superiorly from the occiput of the patient's head. As the patient exhales, the therapist will slide inferiorly on the patient's right side with the pisiform until it contacts the right transverse process of the lower vertebra of the involved segment. At the end of the exhalation, a HVLA anterior, slightly inferior force is applied.

What 4 examination items should you cluster when examining a patient who may have cervical radiculopathy?

When considering a cluster of examination items, the 4 to consider for a pattern of neck pain with radiating pain are: 1. cervical rotation less than 60 degrees to the involved side 2. upper limb tension test A (median nerve) 3. distraction test 4. Spurling Test. *lf all 4 tests are positive, then the sensitivity of the cluster is 24%, specificity is 99%, and positive likelihood ratio is 30.3. *Given the high specificity when 3 or 4 tests are positive, this cluster is an appropriate tool for the clinician to help with the clinical diagnosis of cervical radiculopathy and the associated ICF impairment-based classification of neck pain with radiating pain

When assessing cervical AROM, when is the right time to use overpressure?

When the patient's symptoms are not reproduced with any of the AROM assessments.

What is one thing to consider before working on improving the patient's cervical mobility?

whether or not the patient has cervical segmental hypermobility from a trauma or long term exposure to corticosteroids for systemic problems like RA, systemic lupus erythematosus or pulmonary conditions

In what positions can central PA pressures be performed on the cervical spine?

with the cervical spine in flexion or extension

According to the Canadian Cervical Spine Rules, if the patient cannot rotate the neck 45 degrees in both directions, are cervical spine radiographs required?

yes

Canadian Cervical Spine Rules, if cervical ROM cannot be assessed is a cervical radiograph required?

yes

What is the FRT Test?

* assesses dysfunction at the C1-2 segment. *To assess Cl -2 motion, the patient is supine with the therapist standing at the patient's head (Figure 2B). The physical therapist maximally flexes the patient's head and neck. While maintaining this flexion, the therapist passively rotates the patient's head and neck in each direction. Normal ROM would be close to 45 degrees each way. Less than 45 degrees would indicate some limitation of ROM at C1-2. The presence of either pain or resistance to the movement at less than 45 degrees may be the limiting factor. This test has also been indicated as a test for cervicogenic headaches. Average FRT ROM in healthy individuals is 44 degrees. In clinical practice, the test is deemed positive if there is a 10 degree reduction in the visually estimated range on either side and this method of test interpretation has been shown to be valid and reliable when compared with goniometry.

What are the clinical findings of a patient diagnosed with cervicalgia or pain in the neck and thoracic spine?

*<50 y.o. *duration <12 weeks *symptoms isolated to the neck *restricted cervical AROM typical symptoms: unilateral neck pain and neck motion limitations, onset of symptoms often linked to a recent unguarded/awkward movement or positoin and there can be associated (referred upper extremity pain)

Describe the characteristics of a patient diagnosed with neck pain with movement coordination impairments:

*Iong standing neck pain (> 12 weeks) *abnormal/substandard performance of the CCFI *abnormal/substandard performance of the deep flexor endurance test *coordination, strength, and endurance deficits of neck and upper quarter muscles (longus colli, middle trapezius, lower trapezius, serratus anterior) *flexibility deficits of upper quarter muscles (anterior/ middle/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, pectoralis major. *ergonomic inefficiencies with performing repetitive activities.

How do you test the dermatomal and myotomal portions of the C6 nerve root? What reflex is associated with this nerve root?

*dermatome: distal thumb *myotome: -Biceps brachii (elbow at 90" flexion with forearm supination, resistance against lower forearm into extension) -Extensor caroi radialis loneus/brevis (wrist extended and radially deviated with forearm pronation, resistance against dorsum of hand into flexion and ulnar deviation *brachioradialis: C5, C6

How do you test the dermatomal and myotomal portions of the C5 nerve root? What reflex is associated with this nerve root?

*dermatome: lateral forearm *myotome: deltoid (shoulder in 90" abduction, resistance against lateral upper arm into adduction) *biceps reflex: C5, C6

What are the 2 deep neck flexors?

-Longus capitis -Longus colli

What ROM deficit may be indicative of cervical radiculopathy?

A patient with less than 60" rotation to the involved side is displaying a sign that may be indicative of neck pain with radiating pain (cervical radiculopathy).

Describe how to perform a cervical manipulation to improve extension, right side bending/rotation?

Cervical manipulation to improve extension, right side bending/rotation (Figure 17) will be used on patients who typically present with pain on the right side with extension, and/or right side bending, and/or right rotation. This will treat closing dysfunctions on the right as described earlier. The patient is lying supine with his head at the edge of the table. The arms are at his side relaxed. The physical therapist sits or stands at the head of the patient. Using the middle and index fingers, the physical therapist will palpate the right and left articular pillars of the involved vertebra. He will then create an extension of the patient's neck with that vertebra at the apex of the extension arc. At that vertebra, apply a right to left translation with the right second MCP joint to create right side bending and right rotation in extension at the involved segment. A HVLA thrust is performed into a combined direction heading inferiorly and towards left translation using the right second MCP

What are the Canadian Cervical Spine Rules?

Helpful rules for making clinical decisions regarding the need for cervical spine radiographs in alert and stable patients.

What is the Hoffman's Test and describe how to perform it:

Hoffman reflex is performed with the patient sitting or standing. The middle finger, proximal to the distal interphalangeal joint, is stabilized while cradling the patient's hand. The physical therapist will flick the distal phalanx of the middle finger. The test is considered positive if flexion of the interphalangeal joint of the thumb occurs, with or without flexion of the index finger proximal or distal interphalangeal joints. A positive test may indicate intracranial pathology or spinal cord compression. This test is 94% sensitive. Referral to an appropriate specialist is recommended if either one or both of these tests are positive.

What should the physical therapist do if they encounter multiple dermatomal involvement?

Reports of multiple dermatomal involvements may indicate a more serious problem of cervical myelopathy or raise suspicion of increased psychosocial impairments. The dermatomes from C5 T1 should be assessed.

What 4 variables can predict which cervical radiculopathy patients are most likely to succeed with physical therapy interventions?

The authors used a 4 variable model that optimally identified patients who were most likely to achieve success with physical therapy interventions. The 4 variables were: 1. age < 54 years 2. dominant arm was not affected 3. symptoms did not worsen looking down 4. multimodal treatment included manual therapy, cervical traction, and deep neck flexor muscle strengthening for at least 50% of the visits. *Evidence has demonstrated interventions that included both cervical traction and manual therapy results in dramatic reductions in disability.

How do you test the length of the pectoralis major muscle?

The patient is lying supine with both knees flexed. The therapist stabilizes the proximal portion of the pectoralis major. For the upper fiber of the pectoralis major, the arm is horizontally abducted until a stretch is felt. The lower fibers are assessed with the patient in the same position, the pectoralis major muscle stabilized proximally in the same fashion. The arm is then flexed in approximately 135' of horizontal abduction. If the patient is able to Iay his arm flat on the table, then the muscle length is normal.

What is the Deep Neck Flexor Endurance Test (DNT) and how do you perform it?

The purpose of the neck flexor muscle endurance test is to assess the endurance of isolated muscles. With the patient in a supine hooklying position and the head and neck in mid-range neutral (Figure 30), the patient is instructed to maximally retract his chin and maintain that position isometrically as he lifts his head and neck approximately one inch off of the plinth. At this time, the examiner will place his hand under the patient's head (at the occipital bone) and focus his attention on the skin folds created by the patient's anterior neck. The patient is told to tuck the chin and keep the head up when the skin folds on the anterior neck begin to separate or the patient's occiput begins to touch the clinician's hand. The patient is given one cue to correct. Losing the skin fold or touching the therapist's hand for greater than one second will terminate the test. This test may represent a useful clinical tool for practitioners involved in treating and preventing neck pain. *mean hold time of 39 seconds for men and 29 seconds for women

What deficit is common in patient's with neck pain?

This demonstrates that neck pain sufferers have deficits in craniocervical flexion muscle strength, endurance at low and moderate intensity contractions, and contraction precision at low intensity.

Describe how to perform an upper cervical mobilization to improve C1-2 rotation:

This technique is used for patients with limited and/ or painful rotation. The patient is sitting in a chair. The physical therapist will hug the head with the anterior arm. The therapist will use the thumb of the other hand to stabilize the transverse process of C2 on the side of the rotational limitation. The therapist will apply an anterior force onto the transverse process of C2, slightly tilt the head away, and then use the anterior arm to create head and C1 rotation on a stable C2 segment

Describe how to perform a thoracic manipulation to improve cervical flexion, Ieft side bending and left rotation

Thoracic manipulation can be used for patients who typically present with right sided pain during flexion or left side bending. This will treat opening dysfunctions on the right as described previously. The patient is lying supine. The physical therapist stands on the patient's Ieft side. The patient's arms are crossed with the left arm inferior to the right. The physical therapist rolls the patient to the left and stabilizes the inferior vertebrae of the involved segment by ulnarly deviating to wind up the soft tissue. The thenar eminence will stabilize the right transverse process of the lower vertebrae while the middle phalanx of the third digit will stabilize the left transverse process. The patient is rolled back and the patient's elbows are placed in the therapist's xiphoid process area. The therapist will flex the patient up to the superior vertebrae of the involved segment and create left side bending to the segment along with slight left rotation. The patient will complete one breathing cycle. The therapist will lean on the patient's elbows and apply a posteriorly, slight cephalad force through the elbows.

What joints in the lower cervical spine (C3-C7) are known as potential areas for degenerative changes in cervical spondylosis?

Uncovertebral Joints (Luschka Joints)

Describe how to perform a an upper thoracic manipulation to improve right rotation:

Upper thoracic manipulation to improve right rotation can be used for patients who typically experience right-sided pain during right rotation, right side bending, right rotation, or extension. With this procedure, the patient's cervical and thoracic spine remain in a relatively neutral or mid-range position in the sagittal plane. The patient is lying prone with the physical therapist standing at the head of the table near the patient's head. The therapist's right thumb will be at the left interspinous space of the involved segments. The therapist will then side bend the patient's head to the left until movement is felt in the superior vertebrae. Then, the therapist will rotate the patient's head to the right until movement in the superior vertebrae is felt. Keeping the left thumb on the patient's head, the therapist will use the palm of his hand to apply a slight traction force superiorly from the occiput of the patient's head. As the patient exhales, the therapist will pivot on his right thumb placing the right pisiform on the right transverse process of the vertebra of the inferior segment. At the end of the exhalation a HVLA anterior, slightly inferior force is applied to this thoracic transverse process.

What is the purpose of assessing segmental motion (accessory motion)?

assess the amount of motion available at each individual spinal segment in relation to the segment above or below the reference segment

What is the structure and function of the Transverse Ligament?

attach from the Dens/Odontoid Process of C2 to C1 -It functions to prevent anterior displacement of the Odontoid process (into the spinal canal).

What is the structure and function of the Alar Ligaments?

attach from the Dens/odontoid process (C2) to the occipital condyles of the cranium. -taut in flexion, limit rotation and side flexion to the opposite side. -play a role in stabilizing C1 and C2, especially in rotation

If a patient requires a cervical radiograph according to the Canadian Cervical Spine Rules, what type of exercises should you focus on until then?

stabilization to address the potential presence of a cervical fracture or related instability until cleared otherwise

What is the purpose of providing overpressure?

stress the tissues sufficiently to rule out that the cervical spine is involved

How do you test the dermatomal and myotomal portions of the T1 nerve root? What reflex is associated with this nerve root?

*dermatome: medial forearm *myotome: First dorsal interossei (index and middle finger are separated, resistance against the medial aspect of proximal phalanx of the index finger into abduction *reflex: N/A

What are common signs associated with upper motor neuron pathology?

*hyperreflexia of the upper and/or lower extremities *more diffuse sensory changes (not following a dermatomal pattern) *clonus of the ankle *positive Hoffman and/or Babinski response *clumsiness of gait *generalized weakness below the level of the compression

What are common signs associated with lower motor neuron pathology?

*hyporeflexia or absent deep tendon reflexes (DTRs) *decreased sensation to Iight touch following a dermatomal pattern *muscle weakness that follows a myotomal pattern

List possible treatments for patients with cervical radiculopathy:

*intermittent cervical traction *deep neck flexor strengthening *thoracic manipulations *cervical lateral glides *scapulothoracic exercises (serratus anterior and middle and lower traps) *nerve glides

What are the body function impairments for a patient diagnosed with cervicalgia or pain in the neck and thoracic spine?

*limited cervical AROM *neck pain reproduced at end ranges of active and passive motions *restricted cervical and thoracic segmental mobility *neck and neck related upper extremity pain reproduced with provocation of the involved cervical or upper thoracic segments

How do you test the dermatomal and myotomal portions of the C7 nerve root? What reflex is associated with this nerve root?

*myotome: Distal middle finger *dermatome: -Triceps (arm is placed overhead with elbow slightly flexed, resistance against dorsum of hand into flexion and ulnar deviation) -Flexor carpi radialis (wrist flexed and radially deviated with forearm supinated, resistance against thenar eminence into extension and ulnar deviation) *triceps reflex: C7

What are the impairments of body function for patients with neck pain with radiating pain?

*neck and neck-related radiating pain reproduced with cervical extension, side bending, and rotation toward the involved side (Spurling test) and/or upper limb tension testing *neck and neck-related pain relieved with cervical distraction *or upper extremity sensory, strength, or reflex deficits associated with the involved nerve(s).

Describe how to perform the median nerve tension test. What indicates a positive test?

*scapular depression *shoulder abduction to between 90' and 1 10' with the elbow flexed *forearm supination, wrist and finger extension *shoulder lateral rotation *elbow extension *contralateral and/or ipsilateral cervical side bending. A test is considered positive when any of the following findings are present: *reproduction of all or part of the patient's symptoms, *side-to-side differences of greater than 10 degrees for ROM at the same sensitizing joint OR *determine the location on the symptomatic side. *In determining the location on the symptomatic side, choose a joint that is at least two segments away from the symptoms. Change the position of that joint to alter the tension along the entire path of the nerve without changing the muscle's length at the symptom's location. If the pain decreases, the physical therapist should suspect some nerve involvement.

In what positions can unilateral PA pressures be performed on the cervical spine?

*side bent to the involved side *side bent away from the involved side *directed medially, superiorly or inferiorly **there is no peer-reviewed evidence to support these variations in PA mobilizations *physical therapist may employ them for patients of lower irritability to improve specific segmental mobility or to improve pain free ROM.

Using the ICF terminology, impairments of body function associated with neck pain with movement coordination impairments would be:

*strength, endurance, and coordination deficits of the deep neck flexor muscles *neck pain with mid-range motion that worsens with end range movements or positions *neck and neck-related upper extremity pain reproduced with provocation of the involved cervical segment(s) *cervical instability may be present (note that muscle spasm adjacent to the involved cervical segment(s) may prohibit accurate testing).

What are some clinical findings that assist in classifying patients with cervicogenic headaches?

*unilateral headache asociated with neck/suboccipital area symptoms that are aggravated by neck movements or positions *headache produced or aggravated with provocation of the ipsilateral posterior cervical myofascia and joints *restricted cervical ROM *restricted cervical segmental mobility *abnormal/substandard performance on the CCFT

What are the clinical findings of a patient with neck pain with radiating pain?

*upper extremity symptoms, usually radicular or referred pain, that are produced or aggravated with Spurling maneuver and upper limb tension tests, and reduced with the neck distraction test *decreased cervical rotation (<60 degrees) toward the involved side *signs of nerve root compression *success with reducing upper extremity symptoms with initial examination and intervention procedures.

What are staple exercises for patient's with cervicogenic headaches?

-DNF strengthening (longis capitis and longis colli muscles) - rotational isometrics to coordinate co-contractions of cervical flexors and extensors

What special tests look for cervical spine ligamentous insufficiency?

-Sharp-Purser Test -Alar Ligament Test -central PA pressure assessing for midline tenderness and segmental mobility

What is the Sharp-Purser Test?

-Sharp-Purser Test is used to assess the integrity of the transverse or cruciform ligament of Cl-C2. -The test intends to identify excessive movement between, or a subluxation of, the atlas on the axis. -As originally described by Sharp and Purser, the patient is seated. The physical therapist will stabilize the spinous process of C2 (axis) with one hand while the other hand will be placed on the patient's forehead. The physical therapist will passively flex the patient's head and neck to between 20" and 30'. With C2 stabilized, the physical therapist will create a posteriorly directed force on the patient's forehead. The examiner must make sure that the force is a translation force and not one that creates capital extension. -A positive test would be if there is cranial movement with the posteriorly directed force on the forehead without the axis moving. This would indicate that C1 has subluxed anteriorly on C2 and the force created by the physical therapist has reduced the subluxation. -A negative test is indicated if the physical therapist feels C2 immediately move posteriorly as the translation force is applied to the patient's forehead. -Other indications of a positive test would be reproduction of myelopathic symptoms during flexion, or a decrease in symptoms during the posteriorly directed movement of the atlas on the axis. -This test was found to have a specificity of 0.96 and a sensitivity of 0.69. The reliability of this test has not been examined.

What is the structure and function of the Cruciform Ligament?

-also known as cruciate ligament -It is an important ligament that holds the posterior dens of C2 in articulation at the atlanto-axial joint (away from the spinal canal). -Longitudinal band: joins the body of the C2 (axis) to the foramen magnum -Transverse band: attaches to the inner margin of the C1 (atlas) lateral masses on both sides.

What are some common symptoms of a patient with neck pain with radiating pain?

-neck pain with associated radiating (narrow band of lancinating) pain in the involved upper extremity -upper extremity paresthesias -numbness -weakness

Describe the measuring scale for the deep tendon reflexes:

0: absent 1+: hypoactive 2+ normal 3+ hyperactive (within normal) 4+ hyperactive (could be indicative of an upper motor neuron lesion)

What percentage of cervical patient's suffer from facet-related pain and dysfunction?

50% *several studies report the presence of synovial folds, meniscoids, and fat pads within facet joints that may become entrapped during aberrant motions of the cervical spine and lead to the onset of neck pain. *This process would occur for each cervical segment from C2 through approximately T4 as the upper thoracic spine can contribute to neck pain.

How many vertebrae are in the cervical spine?

7 articulations: C0-1 C1-2 C3-7

What are the clinical prediction rules for a patient who would benefit from intermittent cervical traction?

A clinical prediction rule has been developed to help the physical therapist determine who would benefit from intermittent cervical traction. A clinical prediction rule was identified using the following 5 variables: 1. patient reported peripheralization with lower cervical spine (C4-7) mobility testing 2. positive shoulder abduction sign 3. age > 55 years 4. positive upper limb tension test (median nerve bias using shoulder abduction to 90 degrees 5. relief of symptoms with the manual distraction test.

Describe how to progress cervical flexor muscle training:

As the patient improves, a progression may be where the head is lifted off, then lowered down to the supporting surface, while maintaining the craniocervical region in mild flexion to train the inner range concentric and eccentric performance of all cervical flexor muscles. This exercise should be commenced carefully and within the capabilities of the patient, instructing him at first to only partially lift the weight of the head, progressing as able, to lifting the full weight of the head off the supporting surface. lf the patient has difficulty in performing this progression, an adjunct would be to allow the patient to self-assist by interlocking his fingers behind his head for support and assistance. A continued progression would be the patient in an upright position so that the outer range eccentric and concentric performance of the flexors can be trained, progressively training further towards the Iimits of range within the patient's capability.

What is another name for C2?

Axis

Describe how to perform a cervical manipulation to improve flexion, R side bending/rotation limitation:

Cervical manipulation to improve flexion, right side bending/ rotation limitation will be used on patients who typically present with pain on the left side with flexion , and/or right side bending, and/or right rotation. This will treat opening dysfunctions on the left as described earlier. The patient is lying supine with his head at the edge of the table. The arms are at his side relaxed. Create upper cervical flexion by applying a chin tuck. The physical therapist sits or stands at the head of the patient. Using the middle and index fingers, the physical therapist will palpate the articular pillars while creating flexion of the involved segment. Flex the cervical spine using both hands until the involved segment is reached. Apply a right to left (restricted side) translation with the right second MCP to create right side bending and right rotation in flexion. A high velocity, low amplitude thrust is performed into left translation using the right second MCP

Describe how to perform a cervical non-thrust for flexion, R side bending/ rotation limitation:

Cervical non-thrust for flexion right side bending/rotation limitation will be used on patients who typically present with pain on the left side with flexion, and/or right side bending, and/or right rotation. This will treat "opening dysfunctions" on the left as described earlier. The patient is lying supine with his head at the edge of the table. The arms are at his side relaxed. Create upper cervical flexion by applying a chin tuck. The physical therapist sits or stands at the head of the patient. Using the middle and index fingers, the physical therapist will palpate the articular pillar on the right while creating flexion of the involved segment. Support the patient's head with the left forearm. Flex the cervical spine using both hands until the involved segment is reached. Stand to the patient's right slightly. Maintain the cervical flexion and chin tuck as you create right rotation in flexion with the left forearm and a superiorly/anteriorly direct force at the articular pillar. This essentially creates an "upglide" on the left facet.

Describe how to perform a cervical self-mobilization to improve flexion, right sidebending, and right rotation:

Figure 24 demonstrates the patient sitting; with his right hand, he hooks the spinous process or the left articular pillar using his index or middle finger. The patient is instructed to look down and to the right. At the same time, the patient will pull anteriorly with the right hand assisting the segment into flexion and right rotation.

Describe how to perform a cervical self-mobilization to improve extension, right side bending, and right rotation:

Figure 25 demonstrates the patient sitting; using a towel that is wrapped around the neck, the edge of the towel is placed at the involved segment. The patient will grab each end of the towel and pull to the left and down. The patient is then instructed to look up to the right to facilitate extension, right side bending, and right rotation. The patient repeats this procedure several times keeping the pressure on the towel into the downward direction towards the left.

Describe how to perform a thoracic self-mobilization to improve flexion, Ieft side bending, and left rotation:

Figure 26 demonstrates the patient supine with a rolled up towel at the level of involvement of the thoracic spine. The patient is instructed to interlock his fingers behind his neck and to tuck his chin into his chest. The patient will roll up and with the chin maintained into flexion is instructed to push the area above the towel down towards the floor. This activity can also be performed with a foam roll in place of a towel. It is very difficult for the patient to induce segment specific rotation and side bending with this technique.

What should the physical therapist do if they encounter multiple myotomal involvement?

If there are reports of multiple myotomal involvement, the physical therapist should proceed with caution. This may indicate a more serious problem of cervical myelopathy or raise suspicion of increased psychosocial impairments

Cervical segmental mobility assessment in supine: When the patient's cervical spine is in extension, what does a limitation from R to L indicate?

Indicates a limitation with extension, right side bending, and right rotation at that segment, which is also described as a closing problem on the right

Cervical segmental mobility assessment in supine: When the patient's cervical spine is in flexion what does a limitation in R to L indicate?

Indicates a limitation with flexion, right side bending and right rotation, which is also described as an opening problem on the left.

What is the structure and function of the ligamentum nuchae?

Ligament that extends from the spinous process of C7 to the external occipital protuberance. This ligament increases the depth of the cervical spinous processes allowing for muscular attachment. This elastic Iigament helps limit cervical flexion.

Describe how to perform an upper cervical manipulation to improve occiput-C1 mobility:

Limited segmental/accessory mobility at occiput-C1, painful capital flexion, and/or limited capital flexion are indicators that suggest the technique's application. The patient is supine with his legs straight. The physical therapist stands towards the side of the patient at his head opposite the painful side. Use the second MCP joint to contact the patient's ipsilateral occipital condyle. Hug the patient's head into the therapist's chest by using the other arm with the forearm along the side of the patient's head. Take the patient to end range of capital flexion, and then translate the patient's head opposite the side the therapist is standing on. The physical therapist should be facing towards the patient's head and will take up the slack by shifting his weight in a cranial direction. An HVLA force is delivered through the second MCP using a quick weight shift of his body in a cranial direction.

According to the Canadian Cervical Spine Rules, if there are one or less high risk factors present, the patient's ROM can be assessed, and if it is greater than 45" in both directions are cervical radiographs required?

No

Is there a risk of vertebrobasilar stroke with cervical high-velocity, low amplitude (HVLA) thrust manipulations?

No, there has been no strong evidence Iinking the occurrence of serious adverse events with the use of cervical manipulation or mobilization in adults with neck pain. Although the risk of vertebrobasilar artery dissection has been reported to be very low, screening tools to identify patients who are at risk of adverse effects from the thrust manipulation have been proposed and their use recommended, despite a lack of evidence supporting their validity.

What is the origin, insertion and function of the longus colli cervicis?

Origin: C3 to T3 Insertion: -Anterior arch of atlas, anterior tubercles of C5-6, anterior surfaces of bodies of vertebrae C2-4 -Superior Oblique portion inserts into the tubercle on the anterior arch of the atlas -Inferior Oblique portion into the anterior tubercles of the transverse processes of the fifth and sixth cervical vertebræ -Verticle portion into the front of the bodies of the second, third, and fourth cervical vertebræ *Cervical flexion, ipsilateral side flexion and some cervical rotation

What is the origin, insertion and function of the middle scalene?

Origin: Posterior tubercles of the transverse processes of vertebrae C2-C7 Insertion: Upper surface of the first rib behind the subclavian artery **There is a dual action of this muscle. If the neck is fixed, the action is to elevate the 1st rib. lf the rib is fixed, the action is to laterally flex the neck to the same side and rotate the cervical column to the opposite side.

What is the origin, insertion and function of the posterior scalene?

Origin: Posterior tubercles of the transverse processes of vertebrae C5-C7 Insertion: Lateral surface of the second rib * lf the neck is fixed, the action is to elevate the 2nd rib. If the rib is fixed, the action is to laterally flex the neck to the same side.

What is the origin, insertion, and function of the rectus capitis lateralis?

Origin: Superior surfaces of the transverse processes of the atlas Insertion: Inferior surface of the jugular process of the occipital bone *Stabilizes the head *Weakly assists with lateral flexion of the head

What is the origin, insertion and function of the semispinalis cervicis?

Origin: Transverse processes of T1 to T6, articular processes of the 4th to 7th cervical vertebrae Insertion: Spinous processes of C2 to C5 **The semispinalis capitis and cervicis muscles act with the splenius muscles to extend the head and cervical spine. The greater occipital nerve (C2) pierces this muscle. Entrapment of this nerve in the semispinalis cervicis can lead to greater occipital neuralgia.

What is the origin, insertion and function of the anterior scalene?

Origin: anterior tubercles of the transverse processes of the C3 through C5 vertebrae Insertion: scalene tubercle of the 1st rib. *There is a dual action of this muscle. If the neck is fixed, the action is to elevate the 1st rib. lf the rib is fixed, the action is to laterally flex the neck to the same side and rotate the cervical column to the opposite side.

What is the origin, insertion and function of the longus capitis?

Origin: anterior tubercles of transverse processes of C3-C6 vertebrae Insertion: inferior surfaces of the basilar portion of the occipital bone *acting bilaterally: flexion of the cervical vertebrae and head *acting unilaterally: rotation and lateral flexion of the cervical vertebrae and head to the same side

What is the origin, insertion and function of the splenius capitis?

Origin: lower half of the ligamentum nuchae and the spinous processes of C7-T3 Insertion: lateral superior nuchal line and mastoid process. *extend the cervical spine (along with the splenius cervicus) *when acting unilaterally it laterally flexes and rotates the head to the same side

What is the origin, insertion and function of the splenius cervicus?

Origin: spinous processes of T3-6 Insertion: posterior tubercles of the transverse processes of C1-3 immediately anterior to the attachment of levator scapulae *extend the cervical spine (along with the splenius capitis) *when acting unilaterally it laterally flexes and rotates the head to the same side

Describe how to perform upper cervical contract relax procedure to improve C1-2 joint rotation:

Patients who lack cervical rotation atCl-2 can benefit from this technique. The patient is supine while the physical therapist will create full passive cervical and capital flexion (Figure 31). The patient's head is then passively rotated to the end of the available range into the restricted rotation. When this position is reached, the patient is instructed to look or turn gently into the opposite direction and hold that position for 3 to 5 seconds. At the end of the contraction, the patient relaxes and the physical therapist will take the head and neck further into the restricted rotation. Repeat the isometric contraction 3 to 5 times. After completion, the therapist should consider an additional contraction actively into the direction of the restriction to help maintain and train the muscles into the new range.

Describe how to perform a cervical manipulation to improve flexion, L side bending/rotation:

The cervical manipulation to improve flexion, left sidebending/rotation technique will be used on patients who typically present with pain on the right side with flexion, and/or Ieft sidebending, and/or left rotation. This intervention will treat opening dysfunctions on the right as described earlier. The patient is lying supine with his head at the edge of the table. The arms are at his side relaxed. Create upper cervical flexion by applying a chin tuck. The physical therapist sits or stands at the head of the patient. The physical therapist's right metacarpophalangeal joint (MCP) of the index finger is placed on the patient's right facet joint of the involved joint to create a fulcrum point. The left second MCP is placed over the articular pillar of C5 when treating the C5-6 joint. Flex the cervical spine until motion is palpated at the involved segment. Establish the fulcrum and take up the barrier into left rotation and left sidebending. While maintaining this barrier, apply a high velocity, small amplitude left rotational force with the right extremity.

Describe how to perform the general thoracic distraction technique. What is it used for?

The general thoracic distraction technique is used for patients with general thoracic spine area pain. The patient is seated and the physical therapist is behind the patient. The therapist's chest is placed at the levels of the segment that is to be manipulated. The patient clasps his hands behind the neck. The therapist will pull the patient's elbows towards the patient's lower ribs until the spine is firmly positioned against the therapist's chest and adjust the patient's position to help localize the force. An HVLA thrust is applied in an upward direction

Should you perform premanipulative cervical artery testing?

The most recent literature suggests that premanipulative cervical artery testing may be unable to identify individuals at risk of vascular complications from cervical HVLA thrust manipulation and that any symptoms detected during premanipulative testing may be unrelated to changes in blood flow in the vertebral artery. This means that a negative test may neither predict the absence of arterial pathology nor the propensity of the artery to be injured during cervical HVLA thrust manipulation, with testing being neither sensitive or specific.

Describe an exercise to improve capital flexion endurance/strengthening and motor control:

The patient is Iying supine in the hooklying position. A small pillow, folded towel, or nothing is placed under the patient's head. The patient who has excessive thoracic kyphosis may need larger pillows to provide head support. The patient is instructed to nod yes with his head. The head should not lift up off the plinth or supportive structure. Instruct the patient to maintain the nod for 5 seconds to start and progress to 10 seconds as the patient develops control. The patient should be instructed not to use large muscles and that this is a very subtle movement.

Describe how to perform the craniocervical head nod exercise with a blood pressure cuff: (for a patient with neck pain and movement coordination deficits)

The patient is in a supine hooklying position with the head and neck in mid-range neutral. lf the patient has difficulty attaining this neutral position towels can be used. In the clinic, a pneumatic pressure feedback device, such as a pressure biofeedback unit, can be inflated to 20 mmHg to fill the space between the cervical lordotic curve and the surface of the table. The patient is instructed to keep the posterior head/occiput stationary (do not lift, do not push down). The patient performs craniocervical flexion, or a head nod as in saying yes nonverbally, in a graded manner in 5 increments (22, 24,26,28, and 30 mmHg). The goal is to hold each position for 10 seconds, with 10 seconds rest in between each stage. To perform the craniocervical flexion, the patient is instructed to nod the head as if he was saying yes with the upper neck. This motion will flatten the cervical lordosis, creating a change in the pressure reading of the pressure feedback unit. Instruct the patient to palpate the neck to monitor for undesired activation of the superficial cervical muscle, such as the sternocleidomastoid. To decrease the activation of the platysma or hyoid, instruct the patient to place his tongue on the roof of his mouth, lips together, and teeth slightly separated. For the home exercise program, the pneumatic device is not used and the patient is instructed to maintain the craniocervical flexion while palpating the superficial neck flexors for increased, undesired activity

How do you test the length of the levator scapulae and posterior scalene muscles?

The patient is supine on the plinth (Figure 12). The therapist will (1) grasp the right superior proximal scapula with his right hand, (2) depress the scapula from this position, (3) cradle the occiput with the left hand and stabilize the forehead as previously described in the anterior and middle scalene stretch (4) flex and sidebend the cervical spine to the left with left rotation, and (5) assess the ROM and symptoms at end range.

How do you test the length of the upper trap muscle?

The patient is supine on the plinth. The therapist will (1) grasp the right superior proximal scapula with his right hand, (2) depress the scapula from this position, (3) cradle the occiput with the left hand and stabilize the forehead as previously described in the anterior and middle scalene stretch, (4) flex and sidebend the cervical spine to the left with right rotation, and (5) assess the ROM and symptoms at end range. The physical therapist may take note of the static position of the scapula prior to assessing the length of the upper trapezius. lf the patient presents with a depressed or downwardly rotated scapula, patients may develop symptom reproduction during the test. This is a false positive finding. The symptom reproduction is caused by stretching an already elongated muscle. Stretching the upper trapezius in this situation is not the treatment of choice. Normalizing scapular position should be the primary focus for this type of patient.

Describe how to perform a muscle length provocation test for suboccipital muscles/upper cervical muscles:

The patient is supine with his arms at his side. The physical therapist will stabilize C2 posteriorly using the second phalange (Figure 29). The patient's head is stabilized between the therapist's other hand and the ipsilateral shoulder on the patient's forehead. The therapist will create upper cervical flexion while stabilizing C2 posteriorly. The physical therapist can rotate the patient's head to the right approximately 20' to 30' to better assess the length of the right suboccipitals and to the left for the Ieft suboccipitals. The examiner should be comparing side to side for ROM and symptom reproduction.

How do you test the length of the pectoralis minor muscle?

The patient is supine with his arms at the side. A negative test would demonstrate that the patient's shoulders align symmetrically in the frontal plane. A positive test would demonstrate that the shoulder of the shortened pectoralis minor muscle would lie more anterior than the other (Figure 10). The pectoralis major muscle may also have some associated shortness. The examiner should differentiate between pectorals minor shortness and restricted glenohumeral capsular mobility using glenohumeral ROM and accessory motion tests.

How do you test the length of the anterior and middle scalene muscles?

The patient is supine with the head and neck on the edge of the plinth. The occiput is supported by the physical therapist's left hand and secured by the physical therapist's left shoulder on the forehead. The examiner stabilizes the patient's superior-medial clavicle and first rib with the right hand. The therapist then extends the Iower cervical spine while maintaining a neutral position of the upper cervical spine. Finally, the cervical spine is taken into left sidebending and right rotation until a stretch is felt in the area of the scalenes.

What is the Cranial Cervical Flexion Test (CCFT) and how to you perform it?

The purpose of the CCFT is to measure the control of simple voluntary movements and the endurance of isolated muscles. The patient is in a supine hooklying position with the head and neck in mid-range neutral. If the patient has difficulty attaining this neutral position, towels can be used. A pneumatic pressure feedback device, such as a pressure biofeedback unit, is inflated to 20 mmHg to fill the space between the cervical lordotic curve and the surface of the table. The patient is instructed to keep the posterior head/occiput stationary (do not lift, do not push down); the patient performs cranial cervical flexion in a graded manner in 5 increments (22, 24,26,28, and 30 mmHg). The goal is to hold each position for 10 seconds with 10 seconds rest in between each stage. To perform the CCFT, the patient is instructed to nod the head as if he was saying "yes" with the upper neck. This motion will flatten the cervical lordosis, creating a change in the pressure of the feedback unit. During the test, the physical therapist palpates the neck to monitor for undesired activation of the superficial cervical muscle, such as the sternocleidomastoid. To decrease the activation of the platysma or hyoid, instruct the patient to place his tongue on the roof of his mouth, Iips together, and teeth slightly separated. The test is graded based on the pressure Ievel the patient can achieve with concentric contractions and accurately sustain isometrically. The test is ended after the patient experiences a drop in pressure by more than 20% or when he is unable to perform proper cranial cervical flexion movement without substitution strategies. A normal response is for the pressure to increase between 26 mmHg to 30 mmHg and be maintained for 10 seconds without using superficial cervical muscle substitution patterns. An abnormal response is where the patient is unable to *generate an increase in pressure of at least 6 mmHg *is unable to hold the generated pressure for 10 seconds *uses superficial neck muscles to accomplish the cervical spine flexion motion *uses a sudden movement of the chin or pushing (extending) the neck forcefully against the pressure device. The test is recorded with an activation score: pressure achieved and held for 10 seconds with units of mmHg and a performance index: increase in pressure multiplied by the number of repetitions.

Describe how to perform an upper cervical spine contract-relax procedure to improve occiput-C1 flexion:

This technique is applied for patients who demonstrate limited and/or painful capital flexion. The patient is lying supine with his head at the edge of the plinth. The physical therapist will create capital flexion. Maintaining the capital flexion, the physical therapist will translate the patient's head to the most limited side, keeping the eyes on a horizontal line. At the end range of capital flexion and translation, the therapist will stabilize the head there. Place the index finger of the hand that the head was translated to on the patient's chin. Maintaining a horizontal eye position, instruct the patient to look up over to the side he is translated to; the therapist will resist this motion and hold for 5 seconds. At the end of the contraction, take the head into slightly more capital flexion and lateral translation and repeat the contraction. Repeat this process 3 to 5 times.

Describe how to perform thoracic manipulation to improve extension left side bending and left rotation:

Thoracic manipulation to improve extension left side bending and left rotation (Figure 20) can be used for patients who typically present with left-sided pain during extension or left side bending. This will treat closing dysfunctions on the left as described earlier. The patient is lying prone with the therapist standing on the patient's left side. The patient's head is turned to the left. The physical therapist's left hand will start 1 to 2 vertebrae above the involved segment to "catch" some skin and slide down to the left transverse process of the superior vertebra of the involved segment. The therapist's right pisiform is placed on the right transverse process of the superior vertebra of the involved segment. The therapist will then internally rotate the right arm while applying a downward force to wind up the soft tissue. The patient takes a deep breath as the patient exhales, the therapist leans on the patient. At the end of the exhalation, the therapist applies a HVLA force inferior and anteriorly directed with the left hand and an anteriorly directed force with the right hand

Describe how to perform lower cervical extensor muscle training:

Training of the deep lower cervical extensor muscles can be performed with the patient prone on his elbows. Alternative positions include the patient on his hands and knees, or sitting. The patient is instructed to let the head and neck move into flexion, and then to return to the starting position to train the eccentric/ concentric function of the cervical extensors. During the exercise, the patient is encouraged to maintain a neutral craniocervical position. A flexion/extension motion is encouraged at the lower cervical spine versus the upper cervical spine. Based on anatomical configurations of the extensor muscles, this maneuver is proposed to encourage training of the deep lower cervical extensors while minimizing activity of the more superficial extensors, ie, the semispinalis capitis muscles that attach to the occiput.

What do unilateral PAs test for?

Unilateral PA pressures and are intended to assess the mobility of the articular structures of a particular side (left versus right) of a segment. The physical therapist should keep in mind that applying a PA force to one segment will create movement of the entire cervical spine.

What is the Babinski test and describe how to perform it:

Upper motor neuron lesions may be further validated by tests such as the Babinski and/or the Hoffman reflex tests. The Babinski reflex test is performed with the patient supine and the foot in a relatively neutral position. The blunt end of a reflex hammer is pressed on the plantar aspect of the foot medial to lateral from heel to metatarsal heads. A negative finding is slight toe flexion with the smaller digits greater than the great toe. The intertester reliability of this test is 98% agreement.

Describe how to perform an upper thoracic manipulation to improve flexion left side bending and Ieft rotation:

Upper thoracic manipulation to improve flexion left sidebending and left rotation (Figure 21) can be used for patients who typically present with right-sided pain during flexion or left sidebending. This will treat opening dysfunctions on the right as described earlier. The patient is lying supine. The physical therapist stands by the patient's left side. The patient's arms are crossed with the left arm inferior to the right. Rolled up towels are used to ensure that the elbows are positioned above the level of the involved segment. The physical therapist rolls the patient to the left and stabilizes the inferior vertebra of the involved segment by ulnarly deviating to wind up the soft tissue. The thenar eminence will stabilize the right transverse process of the lower vertebra while the middle phalanx of the third digit will stabilize the left transverse process. The patient is rolled back and the patient's elbows are positioned just below the therapist's xiphoid process area. The therapist will flex the patient up to the superior vertetrrae of the involved segment as well as adding left sidebending and slight left rotation to that segment. The patient is instructed to take a breath in, and on the way out, the physical therapist will lean on the patient's elbows, and at the end of the exhalation, will apply a posteriorly and slightly cephalad force through the elbows.

How should you proceed with testing VBI involvement (if you choose to do so)?

When conducting a physical examination assessing for possible VBI involvement, proceed with the intent to minimize the challenges placed on vertebral artery complex. The author of this monograph begins with an active approach, instructing the sitting patient to look up and over your shoulder (extension, rotation, and sidebending to one side). If the patient moves through full ROM with no complaints that are typically associated with VBl, the author then proceeds to the next step, a premanipulative hold. This consists of maintaining the patient's head in the position that the procedure will be performed for a period of 10 to 15 seconds prior to imparting the force, assessing signs and symptoms consistent with VBl. lf any of the signs and/or symptoms described earlier in this text are observed, the hold should be terminated. The intended manual therapy intervention is contraindicated and consideration for further medical evaluation may be warranted. lf the patient is unable to actively move through full range and stops short, an inquiry is made of the patient. "What stops you from going further?" lf the response is similar to a VBI sign or symptoms like, "l will get dizzy if I go further," or "l feel like I will pass out if I go further," then the examination is stopped and no intervention is attempted beyond the patient's choice of active ROM. lf the patient stops short of full ROM, an inquiry is made of the patient. "What stops you from going further?" lf the reply is something Iike, "l just can't Bo any further, it is stiff;" the author will then apply a gentle passive ROM in an attempt to take the patient further into the range (extension, rotation, and sidebending). The above physical examination procedures described has no supporting peer reviewed evidence, but the method represents a cautionary but progressive approach to physical examination of the vertebral artery complex. ln the clinic, if there is any uncertainty, there is certainly no harm in proceeding down a conservative path when managing a patient with possible VBI involvement.

In the cases of extreme degenerative changes, should a patient still be able to bring their chin to their chest?

Yes.

Can a thoracic spine manipulation be beneficial in patients with mechanical neck pain?

Yes. *A growing body of evidence exists demonstrating the beneficial effects of thoracic spine manipulation for patients with mechanical neck pain. Studies have reported an improvement in cervical ROM following manual therapy that have applied a thoracic thrust manipulation and reported changes in ROM at longer follow-up periods. *with mechanical neck pain who do not exhibit any contraindications to manipulation exhibit statistically significant improvements in disability in both the short- and long-term follow-up periods. *The published clinical practice guidelines for neck pain recommends that thoracic spine manipulation can be used for patients with primary complaints of neck pain. In addition, it can reduce pain and disability in patients with neck and neck-related arm pain. *The results of a systematic review indicate that thoracic spine thrust manipulation may be used in the management of acute or subacute mechanical neck pain to reduce pain, improve cervical ROM, and improve function. Positive effects were shown to occur immediately following the first intervention and continued up to 5 months after participants were discharged from a 3-week program with repeated thoracic spine thrust manipulations. *There are some holes in the research. Thoracic spine thrust manipulation should be considered when treating patients with mechanical neck pain, especially if cervical spine thrust manipulation is contraindicated or the patient is averse to cervical spine thrust manipulation. Future research should establish treatment parameters that include short- and long-term effects, as well as compare treatment effectiveness to interventions directed at the cervical spine

Can a physical therapist determine the location of symptomatic zygapophyseal joints using manual techniques?

Yes. Manual diagnosis by a trained manipulative therapist can be as accurate as radiologically controlled diagnostic blocks in the diagnosis of cervical zygapophyseal syndromes. However, before generalized claims about the reliability of manual diagnosis can be made, further studies of this nature are required to validate intertherapist reliability and the ability of manual techniques to diagnose other spinal pain syndromes.

Can you perform segmental mobilization on C1-2?

Yes. Segmental (accessory) mobility examination is performed in much the same way as performed for the lower cervical spine. Unilateral PA pressures can be performed on the articular pillars of Cl. Assessing C2 segmental mobility can be examined using a central PA pressure over the spinous process of C2 and unilateral PA pressures over the transverse processes of C2. One study found 100% for both specificity and sensitivity. The reliability for upper cervical spine assessment using PA pressures is generally poor with upper cervical tenderness having a kappa value of 0.1 4 in relation to pain replication. When comparing cervicogenic headache patients to those who get migraines, the cervicogenic headache patients have less ROM into cervical flexion and extension. This group also had significantly higher instances of painful upper cervical joint dysfunction assessed by manual examination and muscle tightness.

What motion should you look at when assessing a patient with neck pain and headaches?

cervical rotation: The primary motion of C1-2 is rotation; in fact, up to half (50%) of the normal ROM of cervical rotation occurs at C1-C2. The C1-2 articulation has been found to have a high frequency of symptomatic involvement in patients with neck pain and headaches. lf the rotation is less than 45', then the physical therapist can suspect that there is a problem likely at C1-2. |f greater than 45", then the FRT Test needs to be performed to differentiate a C1-2 limitation versus lower cervical spine.

What is unique about C2 (Axis)?

contains an elongated superior projection called the Dens (Odontoid Process)

What is vertebrobasilar vascular insufficiency (VBI)?

inadequate blood flow through the posterior circulation of the brain, supplied by the 2 vertebral arteries that merge to form the basilar artery.

What is the best tool for measuring physiologic cervical AROM?

inclinometer

Which deep tendon reflex is most important when diagnosing a cervical radiculopathy?

lf the biceps reflex is diminished or absent, the chance of having a cervical radiculopathy increases from 23% to 59%.

What cervical segments are generally the concern in regards to neck pain with mobility deficits?

lower cervical spine (C2-C7)

When positive, shat ULTT is most associated with cervical radiculopathy?

median nerve tension test

What is MDC? (relating to standardized questionnaires)

minimal detectable change: amount of change that must be observed before the change can be considered to exceed the measurement of error

What are common symptoms of a person diagnosed with neck pain with movement coordination impairments?

neck pain and associated (referred) UE pain. *Symptoms are often Iinked to a precipitating trauma/whiplash and may be present for an extended period of time.

What is unique about C1 (Atlas)?

no vertebral body or spinous process

What are the risk factors in the Canadian Cervical Spine Rules? How many risk factors have to be present to require cervical radiographs?

o >65y.o. o Paresthesias in the extremities o Dangerous mechanism of injury that includes: -fall from a height of over 1 meter -MVA at > than 100 kilometers per hour -MVA that involves a rollover or ejection -bicycle collision -motorized recreational vehicle accident o ***If 2 or more high risk factors are present then radiographs are required.

What are the 4 suboccipital muscles and their functions?

o Rectus capitis posterior major -Extension and rotation of the head to the same side as the muscle o Rectus capitis posterior minor -Extend the head at the atlanto-occipital joint (C0-C1) o Obliquus capitis inferior - Rotate the atlas (C1) and skull around the odontoid process of the axis (C2) to the same side as the muscle o Obliquus capitis superior - Extension and lateral flexion of the head to the same side as the muscle

What is the most common symptom in patients suggestive of vertebral artery dissection?

pain on the head and neck (almost 90% of cases), often unilateral and suboccipital. Be aware of the VBI risk in patients who report these symptoms!!

What repeated motion is important for the patient with neck pain and movement coordination impairment?

repeated rotation -other important treatments= -postural education -craniocervical flexion exercises -neck stabilization exercises -rotational isometrics -endurance and strength training -proprioceptive training -manual therapy

What is the significance of pain located at a particular cervical segment during PA mobilization?

symptom reproduction with PA pressures increases the likelihood that the segment is related to the patient's reported pain-related limitations

What cervical segments are generally the concern in regards to neck pain with headaches?

upper cervical spine (occiput-C2)

Describe the anatomy of the vertebral artery:

vertebral artery originates from the subclavian artery then passes through the foramen formed in the C1-C7 transverse processes then it passes through the foramen magnum where it becomes the basilar artery