physical therpay protocols for conditions of neck region
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Red Flags for Potential Serious Conditions in Patients with Head and Neck Problems
Red Flags for the Head and Neck Region
Condition
Red Flag
Data obtained during
Interview/History
Red Flag
Data obtained during
Physical Exam
SubarachnoidHemorrhage
Ischemic Stroke1,2
Sudden onset of a severe headacheHistory of hypertension
Concurrent elevated blood pressureTrunk and extremity weakness, Aphasia
Altered mental status
Vertigo, Vomiting
Vertebrobasilar
Insufficiency3-5Dizziness
Headaches
Nausea
Loss of consciousness
Vertigo that lasts for minutes (not seconds)
Visual disturbances
Apprehension with end range neck movements
Unilateral hearing loss
Vestibular function abnormalities
Meningitis6,7 Headache
Fever
Gastrointestinal signs of vomiting and
symptoms of nausea
Positive slump sign
Photophobia
Confusion
Seizures
SleepinessPrimary Brain
Tumor8-11
Headache
Gastrointestinal signs of vomiting and
symptoms of nausea
Ataxia
Speech deficits
Sensory abnormalities
Visual changes
Altered mental status
Seizures
Mild Traumatic
Brain Injury
Post Concussion
Syndrome
Subdural
Hematoma12,13
Dangerous injury mechanism
Headache
Nausea/vomiting
Sensitivity to light and sounds
Loss of consciousness/dazed an initial Glaslow
Coma Scale of 13 to 15
Deficits in short term memory
Physical evidence of trauma above the clavicles
Drug or alcohol intoxication
Seizures
References:1. Hiroki O, Hidefumi T, Suzuki S, Islam S. Risk factors for aneurysmal subarachnoid hemorrhage in Aomori, Japan. Stroke.
2003;34:34-100.
2. Hong YH, Lee YS, Park S. Headache as a predictive factor of severe systolic hypertension in acute ischemic stroke. Can JNeurol Sci. 2003;30:210-214.
3. Grad A, Baloh RW. Vertigo of vascular origin. clinical and electronystagmographic features in 84 cases.Arch Neurology.46:281-4, 1989.
4. Szirmai A. Evidences of vascular origin of cochleovestibular dysfunction.Acta Neurol Scand. 2001;104:68-71.5. Silbert PT, Bahram M, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery
dissections. Neurology. 1995;45:1517-1522.
6. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of theliterature. Spine. 1996;21:1746-1760.
7. Bruce, M, Rosenstein N, Capparella J, et al. Risk factors for meningococcal disease in college students. JAMA. 2001;286:
688-693.
8. Berger JP. Buclin T. Haller E, et al. Does this adult patient have acute meningitis?JAMA. 1999;282:175-181.9. Snyder H, Robinson K Shah D, et al. Signs and symptoms of patients with brain tumors presenting in the emergencydepartment.J Emerg Med. 1993;11:253-258.
10. Zaki A. Patterns of presentation in brain tumors in the United States. J Surg Oncology 1993; 53:110-112.11. Forsyth PA, Posner JB. Headaches in patients with brain tumors: A study of 111 patients.Neurology. 1993; 43:1678-1683.12. Sobri M, Lamont AC, Alias NA, Win MN. Red flags in patients presenting with headache: clinical indication for
neuroimaging.Brit J Radiology 2003; 76:532-535.13. Borg J, Holm L, Cassidy JD, et al. Diagnostic procedures in mild traumatic brain injury: results of the WHO Collaborating
Centre Task Force on Mild Traumatic Brain Injury.J Rehabil Med. 2004; Suppl. 43: 61-75.
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HEAD AND NECK SCREENING QUESTIONNAIRE
NAME: __________________________________________ DATE: _____________
Medical Record #: _________________________
Yes No
1. Are you currently being treated for high blood pressure?
2. Have you recently had difficulty with speaking?
3. Have you noticed an increased clumsiness or weakness in your arms or
legs?
4. Do you frequently have headaches?
5. Have you noticed a recent decreased ability of concentrate?
6. Do you experience dizziness?
7. Have you noticed a recent change in your vision or ability to see?
8. Have you recently experienced a blow to the head or a whiplash injury?
9. Have you been experiencing nausea and/or vomiting?
10. Do you currently have a fever, or have you had a fever recently?
11. Have you recently been living in close quarters, such as in a dormitory?
12. Do you have a depressed immune system?
13. Are your eyes sensitivity to light?
14. Have you recently had a seizure?
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Cervical Spine Mobility Deficits
ICD-9-CM code: 723.1 Cervicalgia
ICF codes: Activities and Participation Domain code: d4108 Changing a basic
body position, other specified - specified as: rotating thehead and neck, such as in looking to the left or to the rightBody Structure code: s76000 Cervical vertebral column
Body Functions code: b7101 Mobility of several joints
Common Historical Findings:Neck pain, usually unilateral, pain referral from base of occiput to scapular region (location
of pain referral is dependent upon which segment or segments are involved)
Strain; awkward, unguarded movement; or prolonged period of time in strained position("Woke up with pain")
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:Increase in pain at end range of rotation left or rotation right
Symptoms reproduced with palpation of the involved facet
Motion limitation and pain at end range of either anterior/superior glide or
posterior/inferior glide of the involved spinal segment
Physical Examination Procedures:
Cervical Accessory Movement Test
Anterior/Superior Glide
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Cervical Accessory Movement TestAnterior/Superior Glide
Performance Cues:
Use DIP, PIP, or MCP for contactUse a "Flat Hand" - whole palm contacting side of neck and head
Slowly and predictably sink through the skin and myofascia until contact with "articularpillars" is made
Pull the top half of the "pea-sized" facet "toward the eyes" (ok to facilitate rotation to the
opposite side of facet being assessed)Assess mobility, resistance to movement, and symptom response of C2-3, C3-4, C4-5,
C5-6, and C6-7
Cervical Accessory Movement TestPosterior/Inferior Glide
Performance Cues:
Use PIP or MCP contact; flat, soft hand; predictable, uniform movement; sink throughsoft tissue
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Push the top half of the facet down and back (ok to facilitate side bending to same side offacet being assessed)
Assess mobility, resistance, and symptom response of each segment
Cervical Spine Mobility Deficits: Description, Etiology, Stages, and Intervention StrategiesThe below description is consistent with descriptions of clinical patterns associated with the vernacular termCervical Facet Syndrome
Description: Dysfunction of the movement of the one vertebrae of the cervical spine relative to
its adjacent vertebrae. This is usually a result of muscle imbalances, facet irregularities ortrauma. Patients with this condition commonly complain of unilateral neck and upper back pain
that increases at the end ranges of left or right sidebending or rotation. And, repeated flexion and
extension movements do not improve or worsen the patients baseline level of pain
Etiology: The cause of this dysfunction is believed to be a movement abnormality where a
segment of the spine is unable to either flex, extend, side bend or rotate normally in a pain free
manner on its adjacent vertebrae. This movement abnormality can be caused by either adisplacement of fibro-fatty tissue within the outer borders of the facet capsule or posttraumatic
fibrosis of the facet capsule. The cause of the movement abnormalities and the associated pain isthought to be a sudden, awkward, twisting or bending motion. This results in a potentially
reversible displacement of fibro-fatty tissue. The cause could also be a mild joint contracture
following the fibrotic healing of a posttraumatic facet capsule.
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints
Unilateral posterior-to-anterior pressures at the involved segment reproduce thepatients pain complaint
Motion restrictions are present at the involved segment Myofascia associated with the involved segment is usually hypertonic and painful
Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints
As above with the following differences:
The patients unilateral symptoms are reproduced only with overpressures at endranges of left or right sidebending
Note: Improved segmental mobility is commonly associated with improving
symptomatology
Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints
As above with the following differences:
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The patients unilateral symptoms are reproduced only with end range overpressuresin either a combined extension and sidebending motion or a combined flexion and
sidebending motion
Now when the patient is less acute examine for muscle flexibility and strength
deficits that may be a predisposing factor for future injury. For example:
Muscles that commonly exhibit flexibility deficits in patients with facet abnormalitiesare middle and posterior scaleni, SCM, upper trapezius, and the myofascia associated
with the involved cervical segment
Muscles that are commonly weak are the cervical neck flexors (i.e., longus colli),upper thoracic extensors and scapular retractors/adductors (i.e, middle and lower
trapezius)
Intervention Approaches / Strategies
Acute Stage / Severe Condition
Goal: Restore painfree active spinal mobility
Physical AgentsIce (or heat) to provide pain relief and reduce muscle guarding
Manual TherapySoft tissue mobilization to the myofascia associated with the involved cervical
segmentIsometric mobilization and contract/relax procedures to the involved segment to
reduce muscle guarding
Passive stretching procedures to restore normal cervical segmental mobility
Therapeutic ExercisesInstruction in exercise and functional movements to maintain the improvements in
mobility gained with the soft tissue and joint manipulations
Strengthening exercises for the neck flexors
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Re-injury Prevention InstructionInstruct the patient in efficient, painfree, motor performance of movements that
are related by the patient to be the cause of the current episode of neck pain
Sub Acute Stage / Moderate Condition:
Goal: Restore normal, painfree response to overpressures at end ranges of cervical rotation and
sidebending
Approaches / Strategies listed above focusing on: Manual Therapy
Soft tissue mobilization and joint mobilization/manipulation to normalize the
segmental mobility
Note: Performing upper cervical joint mobilization/manipulations with the
patients upper cervical spine at end ranges of extension or the end ranges of
combined of extension/rotation movements is contraindicated due the
potential disastrous effects that these manipulative procedures have been
reported to have on some individuals vertebral artery. Thus, all upper
cervical manipulations are performed with the head and neck in the neutral
or flexed position
Therapeutic ExercisesInstruction in exercise and functional movements to maintain the improvements in
mobility gained with the soft tissue and joint manipulations (e.g., towel SNAGs)
Settled Stage / Mild Condition:
Goals: Restore normal, pain free responses to overpressures of combined extension and
sidebending/rotation and/or combined flexion and sidebending/rotationNormalize cervical and upper thoracic flexibility and strength deficits
Approaches / Strategies listed above Therapeutic ExercisesStretching exercises to address the patients specific muscle flexibility deficits
Strengthening exercises to address the patients specific muscle strength deficits
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Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities
Approaches / Strategies listed above Therapeutic Exercises
Encourage participation in regular low stress aerobic activities as a means to
improve fitness, muscle strength and prevent recurrences
Ergonomic InstructionProvide body mechanics instructions and modify work area as indicated to
prevent symptoms. This typically emphasizes neutral cervical position for sitting,driving, traveling as a passenger in a car, bus, or airplane, reading, eating, and
resting/sleeping.
Selected References
Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999;79:50-65.
Jackson RP. The facet syndrome: myth or reality? Clin Orthop Rel Res. June, 1992.
Taimela S, Takala E, Asklof T, Seppala K, Parvianen S. Active treatment of chronic neck pain. a
prospective randomized intervention. Spine. 2000;25:1021-1027.
Jull G, Trott P, Potter H, Zito G, Niere K. Shirley D, Emberson J, Marschner I, Richardson C. Arandomized controlled trial of exercise and manipulative therapy for cervicogenic headache.
Spine. 2002;27:1835-1843.
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Posterior Cervical MyofasciaSoft Tissue Mobilization
Suboccipital Myofascia
Soft Tissue Mobilization
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Impairment: Limited and Painful Cervical Flexion, Right Rotation or Right Sidebending
Cervical NAG
Cues: Hug the patients head with your right forearm and anterior lateral trunkIt usually helps to be in front of the patients shoulder
The 5th finger of right hand is the dummy finger positioned on the spinous process or
articular pillarProvide traction or other combined movements by weight shifting to the backward (right)
legMobilize in the direction of the facet plane (superiorly more than anteriorly) using the left lateral
wrist/thenar eminence to provide the force
Generate the superior-anterior glide using left elbow flexion
Catch the skin with the dummy finger a segment of two below the involved
If the procedure is painful, stop. Consider naging in a slight different treatment plane oron a different cervical segment
The following reference provides additional information regarding this procedure:Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 12-15, 1995
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Impairment: Limited and Painful Cervical Right Rotation
Cervical SNAG
Cues: Use the right thumb as the dummy thumb over either the spinous process or thearticular pillar
The left thumb provides the SNAG
Sustain the NAG pressure in the plane of the facet think superiorly more than anteriorlyRemember: 1) NAG, 2) Sustain the NAG, 3) Overpressure end range, 4) Sustain the NAG during
left rotation back to neutral, 5) Release NAG
Use the ulnar aspect of the left hand or little finger, if possible, to limit thorax right rotation bymanually cuing the anterior aspect of the left clavicle
Remember: A SNAG is indicated if it permits (and improves) painfree motion
Alteration of the direction of the active cervical motion while performing this SNAG can also beused to treat limited and painful cervical sidebending, extension, or flexion
The following reference provides additional information regarding this procedure:
Brian Mulligan MNZSP, DipMT: Manual Therapy, p. 18-25, 1995
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Impairment: Limited Cervical Segmental Sidebending/Rotation
Cervical Superior/Anterior Glide
Cues: Contact the articular pillar of the superior vertebrae of the involved segment and glide it
toward the eyesStabilize the vertebrae below by contacting its spinous process (i.e., stablize the right side
of the spinous process of C6 with the left middle finger as the right middle finger
contacts the posterior aspect of the right C5 articular pillar and provides a
superior/anterior glide of C5)Utilize this procedure to address both the segmental myofascia and joint mobility deficits
The following reference provides additional information regarding this procedure:
Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 260, 1993
Impairment: Limited Cervical Segmental Rotation
Cervical Rotation in Neutral
Cues: Assess the amplitude (and end feel) of cervical rotation (using an anterior/superior glide)
of the involved segment in neutralAdd combined movements of cervical sidebending, side gliding, slight anterior (or
posterior) gliding, slight extension (or flexion), traction, and compression (firm
hug of the head and neck), until the anterior/superior glide motion barrier (i.e.,end feel) is as crisp as possible
Mobilize (or manipulate) with a low amplitude force into this barrier
The following reference provides additional information regarding this procedure:
Laurie Hartman DO: Handbook of Osteopathic Technique, p. 171-172, 1997
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Impairment: Limited Cervical Segmental Flexion, Right Sidebending, and Right Rotation
Cervical Spine Contract/Relax
(of segmental extensors and left sidebenders)
Cues: Slump the cervical spine as best as possible to create the maximal available posterior
translation of the involved segmentMaintaining the posterior slump, translate the involved segment to the left to obtain the
maximal available lateral translation
The intention is to create an apex of both posterior translation and left lateral translationat the involved segment, thus, placing the involved facet capsule and its
associated segmental myofascia at end range
Elicit contraction of the left sidebenders and/or left extensors relax take up slack
repeatUse a soft and flat manual contact to avoid painful pressure with the right hand
Utilize traction with the left hand to enhance the sidebending stretch to the left facet
joints and myofascia
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 260,1992
Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 191, 1996
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Impairment: Limited Cervical Segmental Flexion, Right Sidebending, and Right Rotation
Cervical Right Sidebending/Rotation in Flexion
Cues: At the end range of both posterior and lateral translation barriers - apply low amplitude
mobilizations or a low amplitude manipulation into the barrierThe direction of the mobilization force is laterally (to open the joint on the opposite
side)
Comfort and effectiveness is increased if: 1) the right hand maintains a broad surfacecontact, and 2) the left hand applies a traction force to maintain the stretch to
the left cervical facets and segmental myofascia
The following reference provides additional information regarding this procedure:Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 197, 199
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Impairment: Limited Cervical Segmental Extension, Right Sidebending, and Right Rotation
Cervical Spine Contract/Relax
(of segmental flexors and left sidebenders)
Cues: Use the index finger of the right hand to anterior glide, then, left laterally translate the
involved segmentElicit contraction of the left sidebenders and/or flexors of the involved segment - relax
take up slack in both barriers repeat
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 257-
259, 1992Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 189-190, 1996
Cervical Sidebending/Rotation in Extension
Cues: At the end range of both anterior and lateral translation barriers - apply low amplitudemobilizations or a low amplitude manipulation into the barrier
The direction of the mobilizing is primarily inferiorly (to close the joint on the same side)
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p.261, 1992Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 196, 1996
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Impairment: Limited C1/C2 Right Rotation
C1/C2 Contract/RelaxCues: Fully flex C2 through C7
Adding flexion at the occiput/C1/C2 areas assists in preventing rotation past C2 (i.e., it
helps create a firm C1/C2 rotation barrier)Rotate occiput and C1 to the right until the first barrier - be sure to 1) maintain the
cervical flexion, and 2) prevent cervical sidebending
Look with your eyes to the left Relax Take up the now available right rotation slackpassively (or gently look to the right) - relax - repeat contract/relax procedures
3 to 5 times
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 263-
264, 1992Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 192, 1996
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Impairment: Limited C1/C2 Right Rotation
C1/C2 Rotation
Cues: Stabilize the right lamina of C2 with your left thumb
Comfortably hug the patients head and rotate it (with C1) to the rightTilt the head to the left to allow some slack in the left alar ligament
Apply a passive stretch (or, a contract/relax stretch)
Be especially tuned into the patient with regards to VBI symptoms or signs whileperforming this technique
The following reference provides additional information regarding a similar procedure:
Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 279, 1995
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Impairment: Limited Occiput/C1 flexionLimited Occipital Posterior Glide (or C1 Anterior Glide) on the Left
Occipital Posterior Glide
Cues: Rest the right middle finger on the left thenar eminence
Position the patient (and your hands) so that the left lateral mass of C1 is contacted by the
dummy middle finger
Apply a posterior glide to the left occipital condyle via a posterior force on the patientsleft forehead (using flexion of your thorax with your left anterior
deltoid/clavipectoral area contacting the patients left forehead)
C1 Anterior Glide
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Impairment: Limited Upper Cervical Right SidebendingLimited C1 Right Lateral Translation
C1 Lateral Translation
Cue: Contact the left C1 lateral mass with 1) your left index or middle finger, or 2) the radialside of your left index finger MCP area
Stabilize the skull with your right hand
Apply right lateral translatory oscillations or stretching forces to C1Be kind and gentle - but effective
Dont be in a hurry
The following reference provides additional information regarding similar procedures:Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 243, 277,
1993
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Impairment: Limited Occipital Flexion and Right Sidebending
Occiput/C1 Contract/Relax
(of segmental extensors and left sidebenders)
Cue: Nod the occiput to take up the flexion barrier
Translate the nodded occiput to the left to first upper cervical barrier not mid cervicalbarrier
Keep the eyebrows parallel to the transverse plane when translating the occiput (to avoid
inadvertent left sidebending)
Elicited contraction of the segmental extensors (look to the left)Manually cue either the anterior aspect of the chin or the left zygoma (with your left
forearm) when providing the verbal commands
Maintain both the flexion and the left translation barriers during the contractionRelax
Take up available slack in both barriersRepeat
The following references provides additional information regarding this procedure:John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 267-
268, 1992
Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 194, 1996
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Impairment: Limited Occipital Flexion and Right Sidebending
Occipital Distraction in Flexion and Sidebending
Cues: Contact the right occipital condyle with the anterior surface of the index finger
metacarpal of the right handAs best as possible, align your right forearm parallel to the distraction force directionHug the right side of patients head with your left forearm
Position the patient at the barriers of both flexion and left translation - as he/she exhales
The distraction mobilization or manipulation force primarily comes from your indexfinger metacarpal using a weight shift from your trunk
If you are not moving the patients feet (positive toe sign) you are probably not
providing enough traction force to distract the patients occiput from C1
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 268-
269, 1992Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 202, 1996
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Impairment: Limited Occipital Extension and Right Sidebending
Occiput /C1 Contract/Relax
(of segmental flexors and left sidebenders)
Cues: Extend the head (not the cervical spine) to take up the extension barrier
Translate the extended head to the left to the first (upper cervical - not mid cervical) barrier
Translate left - not sidebend leftElicit contraction of the segmental flexors (look down toward your feet) or sidebenders
(look to the left)
Manually cue either under the chin or the left zygoma when providing the verbalcommands
Maintain both barriers during the contraction
Relax - take up slack repeat
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p. 266, 1992Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 193-194, 1996
Occipital Distraction in Extension and Sidebending
Cues: Contacts and force application is similar to the occipital distraction in flexionPosition the patient at the barriers of occipital extension (not cervical extension) and left
translation - as he/she exhales
Maintain these barriers apply the distraction mobilizations or manipulation
The following references provides additional information regarding this procedure:John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p.268, 1992
Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 201, 1996
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Cervical Spine Movement Coordination Deficits
ICD-9-CM code: 847.0 Neck ligament sprain
ICF codes: Activities and Participation Domain code: d4159 Maintaining a body position,
unspecifiedBody Structure code: s76000 Cervical vertebral columnBody Functions code: b7601 Control of complex voluntary movements
Common Historical Findings:
Significant trauma (e.g., MVA, fall, blow to head)Muscle tightness or spasm
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:Pain with mid-range motions - increases at end range of painful motion
Tender with palpation of area (ligamentum nuche, spinous process and interspinous
space) of the involved segment(s)Pain with central posterior-to-anterior PA pressures
If upper cervical ligament strain: laxity and/or symptom alteration with ligaments
stability exam
Physical Examination Procedures:
Palpation of Midline Soft Tissue
Central Posterior-to-Anterior Pressures
Performance Cues:May need to slightly flex head and neck to differentiate segments
Support head and neck to limit muscular contractionPalpate areas near ligamentum nuche, spinous processes, and interspinous spaces
determine symptom response
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Alar Ligament Integrity Test Alar Ligament Integrity Test
Performance Cues:
Keep head supported to limit muscle guarding
Place head and neck in midlinePinch C2 spinous between left thumb and index finger
Side bend skull 10-15 degrees to the right
Normal - lateral aspect of the C2 spinous immediately moves into thumb
Abnormal - the C2 spinous process does not move or the movement is noticeably delayedas the head is sidebent
Involuntary or voluntary muscle guarding may produce false negative results to these
examination procedures
Sharp-Purser Test for Ligamentus
Integrity for the Transverse Ligament
Performance Cues:
Flex skull slightly while sitting - about 25 degree or until the motion is taken up - do not take
up slack in tissues below C2.In the abnormal - head flexion allows the occiput and C1 vertebrae to translate anteriorly
relative to C2. Thus, this position may provoke symptoms.Posteriorly translate the skull-with the head in slight flexion - while stabilizing the spinous
process of C2 with an anteriorly directed force
In the abnormal - relative posterior translation of the skull in noted (approximately 5mm).This
position may alleviate the patients symptomsIn the normal - no symptoms are produced with head flexion and no translatory motion is
detected with occiput/C1 (posteriorly directed) translation (while C2 is stabilized)
The stabilization (anteriorly directed) force of C2 is firm
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Cervical Spine Stability Deficits: Description, Etiology, Stages, and Intervention StrategiesThe below description is consistent with descriptions of clinical patterns associated with the vernacular term
Cervical Instability or Cervical Ligament Strain
Description: A sudden jerky movement, whiplash to the neck, or blow to the head could lead
to cervical ligament sprain. Pain is usually felt in the back of the neck that gets worse with
movement. Muscle spasms and pain are the common complaint. The pain may be referred tothe upper back, shoulder girdle or upper extremity. The pain may be more noticable a day after
the injury. The pain symptoms worsen with movement. Headaches, increased fatigue,
irritability, and restless sleep are also associated with this disorder.
Etiology: The cause of this disorder could be due to significant trauma such as car crash, or
applying sudden brakes in which the head goes backward while the body stays back due to the
seat belt. This causes head and neck to extend and get overstretched causing stress on theligaments of the neck. Contact sports are also a common cause of cervical ligament sprains.
Individuals with a long history of a collagen vascular disease, such as rheumatoid arthritis, may
have upper cervical ligamentous instability as an unfortunate consequence of their disease.
Physical Examinations Findings (Key Impairments)
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7601.3 SEVERE impairment of motor control/coordination
of complex voluntary movements
Pain with end range cervical motion
May have swelling or bruising at the injury site
Muscle spasms at the associated spinal segment
Central or unilateral posterior-to-anterior pressures reproduce the reported symptoms
May exhibit laxity with ligamentous integrity tests (e.g., alar ligament integrity test or
the Sharp-Purser test)
Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7601.2 MODERATE impairment of motorcontrol/coordination of complex voluntary movements
As above the severity of the tenderness and muscle guarding may resolve at a slowrate if the injury was significant.
Be cautious of an underlying instability that is potentially dangerous to the patients
neural structures. Muscle guarding at the segment may mask this instability.
Weakness of neck musculature, especially the neck flexors
Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b7601.1 MILD impairment of motor control/coordination of
complex voluntary movements
As above with the following differences:
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Symptoms worsen or peripheralize with sustained end range positions or withrepeated movements into the patients available range
Intervention Approaches / Strategies
Acute Stage / Severe Condition
Goals: Allievate pain while in neutral cervical positionsPrevent further stress on injured tissues
Re-injury Prevention Instruction
Limit active and passive movement to painfree rangesInstruction is proper neutral positions for common activities such as sleeping,
sitting, reading, driving, and eating, as well as for movements such as moving
from supine to a sitting position
External Devices (Taping/Splinting/Orthotics)A rigid cervical collar is often indicated for acute cervical sprains to limit further
stress on the damaged tissues
A soft cervical collar may be useful in less severe strains to cue the patient to
maintain the neutral position
Physical AgentsIce packs applied with the neck in a neutral position may by applied for 15-30
minutes every few hours to reduce pain and inflammation
Sub Acute Stage / Moderate Condition
Goals: Prevent re-injury
Strengthening of neck musculature to improve dynamic stability
Improve mobility in areas superior or inferior to the injured, hypermobile segment
Approaches / Strategies listed above
Therapeutic Exercises
Initiate cervical stabilization/strengthening program with emphasis on the deepcervical neck flexors (i.e., longus colli)
Manual TherapySoft tissue and joint mobilization to restricted segments in the upper thoracic,
mid-cervical, or upper cervical region. Caution not to mobilize any segmentthat is potentially hypermobile or unstable.
Ergonomic Instruction
Promote efficient, painfree, motor control of the neck, scapulae and armModify activities to prevent overuse and re-injury
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Modify workstation to reduce risk of mounting pressure on the neck
Re-injury Prevention InstructionEmphasize the importance of neutral posture
Emphasize the importance of maintaining adequate stabilization through muscular
control of the unstable segment especially in individuals who participate incontact sports or other activities involving potential stress to the cervical spine.
Settled Stage / Mild Condition
Goal: Progress activity tolerance
Approaches/ Strategies listed above
Therapeutic Exercises
Provide endurance training to maximize muscle performance of the neck,
scapulae, and shoulder girdle muscles required to perform the desiredoccupational or recreational activities
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities
Approaches/ Strategies listed above
Ergonomic InstructionAdd job/sport specific training
Selected References
Donatelli, Robert. Orthopedic Physical Therapy. Georgia: Churchhill Livingstone Inc. 1994.
Gennis P, Miller L, Gallagher J, et al: The effect of soft cervical collars on persistent neck pain
in patients with whiplash injury. Acad Emerg Med3:568-573, 1996.
Magee, David. Orthopedic Physical Assessment. Pennsylvania: W.B. Saunders Co. 1997.
Meadows J: The Role of Mobilization and Manipulation in treatment of Spinal Instability. J
Orthop Phys Ther Clin N Am 8:519-34, 1999.
OGrady WH, Tollan MF: The role of exercise in the treatment of instabilities of hypermobilities
in the cervical spine. Orthop Phys Ther Clin N Am 10:3, 475-501, 2001.
Swinkles-RAH, Oostendorp-RAB: Upper cervical instability: fact or fiction?Journal of
Manipulative and Physiological Therapeutics 19:185-94, 1996.
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Neck and Headache Pain
ICD-9-CM code: 723.2 cervicocranial syndrome
ICF codes: Activities and Participation Domain code: d4158 Maintaining a body position,
other specified - specified as: maintaining the head in aflexed position, such as when reading a book; or,maintaining the head in an extended position, such as when
looking up at a computer screen or video monitor
Body Structure codes:s7103 Joints of head and neck region
Body Functions code: b28010 Pain in head and neck
Common Historical Findings:Unilateral neck pain with referral to occipital, temporal, parietal, frontal or orbital areas
Headache precipitated or aggravated by neck movements or sustained positions
Noncontinuous headaches (usually < 1 episode/day; < 2 episodes/week)
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:
Observable postural asymmetry of the head on neck (sidebent or extended)
Headache reproduced with provocation of the involved segmental myofascia and/or jointsO/C1, C1/C2, or C2/C3 restricted accessory motions with associated myofascial trigger
points
Physical Examination Procedures:
Palpation/Provocation of Suboccipital Myofascia
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O/C1, C1/C2, or C2/C3 accessory motion testingusing posterior-to-anterior pressures
0/C1 accessory motion testingusing C1 lateral translatoty pressures
C1 C2 Rotation ROM testing
with the C2 C7 segments in flexion
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Neck and Headache Pain: Description, Etiology, Stages, and Intervention StrategiesThe below description is consistent with descriptions of clinical patterns associated with the term
Cervicogenic Headache.
Description: Cervicogenic headache is a headache where the source of the ache is from a
structure in the cervical spine, such as a cervical facet, muscle, ligament, or dura. The pain isreferred to the occipital, temporal, parietal, frontal, and orbital areas. The characteristics of
cervicogenic headache are unilateral dominant side-consistent headache associated with neck
pain and aggravated by neck postures or movement, limited range of motion in the cervical spine
and joint tenderness in at least one of the upper three cervical joints as detected by manualpalpation. The aching is moderate-severe, without throbbing or lancinating pain, usually starting
in the neck. The episodes can be of varying duration (few hours to a few weeks). The initial
phase of cervicogenic headache is usually frequent and episodic. The occurrence among femalesis twice that of males.
Etiology: The headache is due to a musculoskeletal disorder in the upper cervical spine. Thus,
movement stresses of the upper cervical spine are associated with the headache complaint (e.g.,headache is worse at the end of a days work at a computer screen or talking on the phone).
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b28010.3 SEVERE pain in head and neck joints
Abnormal head on neck posture is commonly observed (e.g., the head is held in anexcessively extended position or an excessive sidebent position relative to the upper
cervical segments)
Limited O-C1 and/or C1-C2 and/or C2-C3 segmental mobility
Headache aggravated with certain head positions or sustained movements
Headaches reproduced with provocation of the involved segment at O/C1, C1/C2, C2/C3or with provocation of trigger points in the suboccipital myofascial or during slump
testing of the dural elements
Deep cervical flexor muscle control deficits (i.e., rectus capitus anterior and longus colli)
Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b2801.2 MODERAT pain in head and neck joints
As above the ability to reproduce the patients headache via palpatory provocation ofthe involved joints or myofascial lessens as the mobility of the involved upper cervical
segments
Settled / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions code: b2801.1 MILD pain in head and neck joints
Now when the patient is less acute examine for ergonomic factors, postural habits,muscle flexibility and strength deficits that may be predisposing factors for upper cervical
somatic disorders. For example:
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Ergonomic or postural paterns that involve excessive thoracic kyphosis and associatedexcessive cervical lordosis predisposes the head to be excessively extended on the neck
placing the upper cervical extensors on a chronically shortened position thus,
precipitating the above listed impairments.
Upper quarter muscle imbalances such as tightness of the scapular elevators (i.e., levatorscapulae and upper trapezius) muscles and weakness of the scapular adductors/stabilizing(i.e., lower and middle trapezius) muscles
Intervention Approaches / Strategies
Acute stage / Severe Condition
Goals: Reduce the frequency and severity of the headachesReduce the medication required to manage the symptoms
Re-injury Prevention Instruction
Avoid positions that reproduce or aggravate the headaches
Manual TherapySoft tissue mobilization to the involved suboccipital myofascial restrictions
(performed at an intensity that does not aggravating the patients condition)
Joint mobilization/manipulation to the involved upper cervical facet restrictions
(performed at an intensity or velocity that does not aggravating the patientscondition)
Note: Performing upper cervical joint mobilization/manipulations with thepatients upper cervical spine at end ranges of extension or the end ranges of
combined of extension/rotation movements is contraindicated due the
potential disaterous effects that these manipulative procedures have been
reported to have some individuals vertebral artery. Thus, all upper cervical
manipulations are performed with the head and neck in the neutral or flexed
position
Therapeutic Exercise:Instruct in exercise and functional movements to maintain the improvements in
mobility gained with the soft tissue and joint manipulations (Head nodding and
retraction/protraction for O-C1 and rotation for C1-C2)
Ergnomics Instructions
Postural re-education to limit excessive extended head postitions duringoccupational tasks, recreational activities and other daily activities
Sub Acute Stage / Moderate Condition
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Goals: As above
Normalize upper cervical segmental mobility
Approaches / Strategies listed above focusing on restoring normal, pain free
occipital and cervical spine mobility.
Therapeutic Exercise
Low load endurance exercises to train muscle control of the cervical and scapular
region, consists of exercises targeting deep neck flexor muscles and longuscapitus and colli, trapezius, and serratus anterior. For example, cervical flexion
exercises using a pressure biofeedback unit and isometric exercises using rotatoryresistance to train the cocontraction of the neck flexors and extensors
Settled Stage / Mild Condition
Goals: As above
Normalize cervical and upper thoracic flexibility and strength deficitsIncrease activity tolerance
Approaches / Strategies listed above
Therapeutic Exercises
Stretching exercises to address the patients specific muscle flexibility deficitsStrengthening exercises to address the patients specific muscle strength deficits
Dural mobiliy exercises to address the patients specific dural mobility deficits
Intervention for High Performance/High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities
Approaches / Strategies listed above
Therapeutic ExercisesMaximize muscle performance of the neck, scapulae, shoulder girdle muscles
perform the desired occupational or recreational activities.
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Selected References
Bansevicius D, Sjaastad O. Cervicogenic headache: The influence of mental load on pain leveland EMG of shoulder-neck and facial muscles.Headache. 1996;36:372-8.
Bovim G, Berg R, Dale LG. Cervicogenic headache: Anesthetic blockades of cervical nerves(C2-C5) and facet joint (C2-C3). Pain. 1992;49:315-20.
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A
randomized controlled trial of exercises and manipulative therapy for cervicogenic headache.
Spine. 2002;27:1835-43.
Mulligan BR.Manuel Therapy Nags, Snags, MWMs etc. 4th ed. Wellington: Plane ViewPress, 1995
Nilsson N. The prevalence of cervicogenic headache in a random population same of 29-to 59-year-olds. Spine. 1995;20:1884-8
Petersen S. Articular and Muscular Impairments in Cervicogenic Headache: A Case Report.
Journal of Orthopedic Sports Physical Therapy. 2003;33:21-32.
Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. Headache
1998;38:442-5.
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MANUAL EXAMINATION AND TREATMENT OF THE UPPER CERVICAL SPINE
Symptoms/Signs of Cerebral Anoxia:
Apprehension, anxiety, or panic with cervical movements
Vertigo and dizziness
Blurred vision
Nystagmus
NauseaSlowness of Response
Manual Examination:
If hypermobility is suspected, examine for instability:
Sharp-Purser Test
Odontoid-Alar Ligament Test
Hypermobile accessory movements
Central tenderness or pain with central posterior-to-anterior pressures
If vascular insufficiency is suspected:
Watch for signs of cerebral anoxia
Perform vertebral artery tests continually assessment of symptoms/signs of cerebral anoxia
Passive Movements:
Physiological Movement Testing:
Occiput-C1: Occiput FB/BB
Occiput SB
Occiput Lateral Translatory Movements in FB and BB
C1-C2: A/A Rotation in cervical flexion
Accessory Movement Testing:
Occiput-C1: C1 Anterior Glide
C1 Lateral Glide
Palpation:
Sub-occipital myofascia
Manual TreatmentSoft Tissue Mobilization:
Sub-occipital myofascia STM
Contract-Relax
Occiput-C1
C1-C2
Passive Joint Mobilization:
Occipital Distraction
C1 Anterior Glide
C1 Lateral Glide
C1-C2 Rotation (sitting)
Re-Education:
Neutral Head/Neck Cueing
Neck Flexor Therapeutic Exercises
Always remember: While performing all examination and treatment procedures, be alert for signs of cerebral anoxia
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Impairment: Limited C1/C2 Right Rotation
C1/C2 Contract/RelaxCues: Fully flex C2 through C7
Adding flexion at the occiput/C1/C2 areas assists in preventing rotation past C2 (i.e., it
helps create a firm C1/C2 rotation barrier)Rotate occiput and C1 to the right until the first barrier - be sure to 1) maintain the
cervical flexion, and 2) prevent cervical sidebending
Look with your eyes to the left Relax Take up the now available right rotation slackpassively (or gently look to the right) - relax - repeat contract/relax procedures
3 to 5 times
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 263-
264, 1992Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 192, 1996
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Impairment: Limited C1/C2 Right Rotation
C1/C2 Rotation
Cues: Stabilize the right lamina of C2 with your left thumb
Comfortably hug the patients head and rotate it (with C1) to the rightTilt the head to the left to allow some slack in the left alar ligament
Apply a passive stretch (or, a contract/relax stretch)
Be especially tuned into the patient with regards to VBI symptoms or signs whileperforming this technique
The following reference provides additional information regarding a similar procedure:
Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 279, 1995
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Impairment: Limited Occiput/C1 flexionLimited Occipital Posterior Glide (or C1 Anterior Glide) on the Left
Occipital Posterior Glide
Cues: Rest the right middle finger on the left thenar eminence
Position the patient (and your hands) so that the left lateral mass of C1 is contacted by the
dummy middle finger
Apply a posterior glide to the left occipital condyle via a posterior force on the patientsleft forehead (using flexion of your thorax with your left anterior
deltoid/clavipectoral area contacting the patients left forehead)
C1 Anterior Glide
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Impairment: Limited Upper Cervical Right SidebendingLimited C1 Right Lateral Translation
C1 Lateral Translation
Cue: Contact the left C1 lateral mass with 1) your left index or middle finger, or 2) the radial
side of your left index finger MCP area
Stabilize the skull with your right handApply right lateral translatory oscillations or stretching forces to C1
Be kind and gentle - but effective
Dont be in a hurry
The following reference provides additional information regarding similar procedures:Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 243, 277,
1993
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Impairment: Limited Occipital Flexion and Right Sidebending
Occiput/C1 Contract/Relax
(of segmental extensors and left sidebenders)
Cue: Nod the occiput to take up the flexion barrier
Translate the nodded occiput to the left to first upper cervical barrier not mid cervicalbarrier
Keep the eyebrows parallel to the transverse plane when translating the occiput (to avoid
inadvertent left sidebending)
Elicited contraction of the segmental extensors (look to the left)Manually cue either the anterior aspect of the chin or the left zygoma (with your left
forearm) when providing the verbal commands
Maintain both the flexion and the left translation barriers during the contractionRelax
Take up available slack in both barriersRepeat
The following references provides additional information regarding this procedure:John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 267-
268, 1992
Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 194, 1996
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Impairment: Limited Occipital Flexion and Right Sidebending
Occipital Distraction in Flexion and Sidebending
Cues: Contact the right occipital condyle with the anterior surface of the index finger
metacarpal of the right handAs best as possible, align your right forearm parallel to the distraction force direction
Hug the right side of patients head with your left forearmPosition the patient at the barriers of both flexion and left translation - as he/she exhales
The distraction mobilization or manipulation force primarily comes from your index
finger metacarpal using a weight shift from your trunk
If you are not moving the patients feet (positive toe sign) you are probably notproviding enough traction force to distract the patients occiput from C1
The following references provides additional information regarding this procedure:John Bourdillon FRCS, EA Day MD, and Mark Bookhout MS, PT: Spinal Manipulation, p. 268-
269, 1992Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 202, 1996
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Impairment: Limited Occipital Extension and Right Sidebending
Occiput /C1 Contract/Relax
(of segmental flexors and left sidebenders)
Cues: Extend the head (not the cervical spine) to take up the extension barrier
Translate the extended head to the left to the first (upper cervical - not mid cervical) barrier
Translate left - not sidebend leftElicit contraction of the segmental flexors (look down toward your feet) or sidebenders
(look to the left)
Manually cue either under the chin or the left zygoma when providing the verbalcommands
Maintain both barriers during the contraction
Relax - take up slack repeat
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p. 266, 1992
Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 193-194, 1996
Occipital Distraction in Extension and Sidebending
Cues: Contacts and force application is similar to the occipital distraction in flexion
Position the patient at the barriers of occipital extension (not cervical extension) and lefttranslation - as he/she exhales
Maintain these barriers apply the distraction mobilizations or manipulation
The following references provides additional information regarding this procedure:
John Bourdillon FRCS, EA Day MD, M Bookhout MS, PT: Spinal Manipulation, p.268, 1992Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 201, 1996
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Cervical Spine and Related Lower Extremity Radiating Pain
ICD-9-CM code: 724.4 cervical radiculitis
ICF codes: Activities and Participation Domain code: d4108 Changing a basic body
position, other specified - specified as: extending androtating the head and neck, such as in looking behindoneself to the left or to the right
Body Structure codes:s76000 Cervical vertebral column
s7309 Structure of the upper extremity, other specified
Body Functions code: b28010 Pain in head and neckb2803 Radiating pain in a dermatome
Common Historical Findings:Shooting, narrow band of pain - usually below the elbow
Paresthesias
NumbnessWeakness
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:
May adopt posture to relieve nerve tensionSymptoms reproduced with extension and sidebending toward the involved side
(extension quadrant or Spurlings test)
Symptoms reproduced with upper limb nerve tension testMay have sensation deficits and strength deficits in the upper extremity
Physical Examination Procedures:
Cervical Extension, Sidebending and
Rotation to the Same Side
Performance Cues:
This cervical Quadrant narrows the inter vertebral foramen (as well as approximates
the cervical facets)
Assess relation between movement and symptom reproduction
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Upper Limb Nerve Tension Test
Median Nerve Stretch Test
Performance Cues:
Determine baseline level of symptoms
Assess change in symptoms as each of the following components of the test are gradually
added - take up the slack only to the initial tissue resistance or report ofsymptomatology:
1. Scapular depression2. Humeral abduction (not past 90 degrees)
3. Humeral external rotation (not past 90 degrees)
4. Forearm supination5. Wrist, thumb, and finger extension
6. Elbow extension
Sensation Tension
Performance Cues:C5 - Lateral anticubital fossaC6 - Anterior distal aspect of thumb
C7 - Anterior distal aspect of middle finger
C8 - Anterior distal aspect of little fingerT1 - Medial aspect of arm, just proximal to elbow
Assess light touch and/or sharp-dull, comparing to uninvolved side
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C5 - Biceps Brachii MMT C6 - Extensor Carpi Radialis
Longus and Brevis MMT
C7 Triceps MMT
C8 - Flexor Digitorum Profundus MMT T1 - Abductor Digiti Minimi and First Dorsal
Interosseous MMT
Performance Cues:Assess motor involvement by using manual muscle tests to determine strength deficits
Compare strength to uninvolved side and with norm for age, gender, and activity levelManual muscle test norm is ability to move fully against gravity and take moderate-to-
maximal resistance without giving or fatiguing
Cervical Spine and Related Upper Extremity Radiating Pain
Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term
Cervical Radiculopathy
Description: Cervical radiculopathy is, by definition, a disease of the cervical spinal nerve root.It is most commonly caused by a cervical disc herniation or other space occupying lesion such as
a osteophytic encroachment associated with spondylosis or a tumor. This encroachment from a
space occupying lesion can result in nerve root impingement, inflammation, or both. The chiefsymptom is a narrow band of lancinating pain that radiates to the shoulder girdle and upper
extremity. The primary signs are unilateral paresthesias , sensory deficits, diminished muscle
stretch reflexes and motor deficits in the shoulder girdle and upper extremity.
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Etiology: Cervical radiculopathy is usually of non-traumatic origin and occurs spontaneously inthe majority of cases. In younger adults the most common cause of this disorder is disc
herniation, whereas cervical spondylosis is a more frequent cause in older patients. Peak
incidence of cervical radiculopathy is in the fourth or fifth decade of life.
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments)ICF Body Functions codes: b28010.3 SEVERE pain in head and neck; and b2803.3SEVERE radiating pain in a dermatome
Posture or positioning to relieve tension on the related nerve (e.g., cervical flexion orsidebending, elevated scapula, arm supported or held with wrist resting on head)
Positive Shoulder Abduction Test relieves symptions (i.e., the patient elevates armoverhead and places hand on head to bring on a relief of symptoms)
Decreased cervical rotation (cervical rotation < 60)
Positive Spurlings Test (i.e., cervical extension/sidebending/rotation toward theinvolved side with compression reproduces radicular symptoms)
Positive Manual Traction Test (i.e., axial manual traction to cervical spine relievessymptoms)
Peripheralization or centralization of symptoms with repeated movements
Positive Upper Limb Tension Test (i.e, tension or stretch of the involved nerve rootand its associated nerve reproduces the radicular symptoms)
Positive neurological signs (i.e., diminished sensation to the skin served by theinvolved nerve root and motor weakness of the muscles served by the involved nerve
root and diminished deep tendon reflexes associated with specific nerve roots)
Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions codes: b28010.2 MODERATE pain in head and neck; and b2803.2
MODERATE radiating pain in a dermatome
As above the severity of the radicular signs may resolve as the inflammation around
the involved nerve root diminishes
Now (when less acute) assess upper quarter postural alignment, muscle balance (i.e.,
muscle flexibility and strength deficits), and pertinent ergonomic factors contributingto the patients symptoms/functional limitations
Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments)
ICF Body Functions codes: b28010.1 MILD pain in head and neck; and b2803.1 MILD
radiating pain in a dermatome
As above with the following differences:
Radicular symptoms are reproduced only with end-range sustained positions of thecervical spine or sustained tension positions of the involved nerve root and itassociated upper extremity nerve
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Clinical Examination for Cervical Radiculopathy (Wainer)
If three of the four following tests are positive the probability of the condition
increases to 65%.
If all four of the following tests are positive the probability of the condition increasesto 90%.
If ULTTA is negative, the probability of the condition is 3%, essentially CervicalRadiculopathy can be ruled out.
1. ULTTA (Upper Limb Tension Test A)
2. Involved cervical rotation less than 60
Intervention Approaches / Strategies
Acute Stage / Severe Condition
Goals: Improve neurological status
Reduce radicular pain
Re-injury Prevention InstructionLimit movements or activities that aggravates the symptoms. For example, use of
1) a soft cervical collar, or 2) slight cervical flexion, sidebending opposite of
radiculopathy and retraction positions and motions increase neural foraminal size may be used to reduce further forminal aggravation during the inflammatory
stage.
Therapeutic ExercisesNerve mobility execises in painfree ranges
Manual Therapy
Manual cervical tractionSoft tissue mobilization to the myofascial restrictions in the areas of upper
extremity nerve entrapments associated the involved nerve root
Neuromuscular Reeducation
Facilitate cervical positions that optimally open the involved foramin typicallyby promoting neutral positions of the thoracic cage, scapular, neck and head
positions during daily activities.
Sub Acute Stage / Moderate Condition:
Goal: Prevent recurrence
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Approaches/ Strategies listed above
Therapeutic ExercisesStretching exercises to address the patients specific muscle flexibility deficits
Strengthening exercises to address the patients specific muscle strength deficits
Settled Stage / Mild Condition:
Goal: Progress activity tolerance
Approaches / Strategies listed above
Therapeutic ExercisesMaximize muscle performance of the relevant trunk, scapulae, shoulder girdle and
neck muscles required to perform the desired occupational or recreationalactivities
Ergonomic InstructionAdd job/sport specific training
Intervention for High Performance/High Demand Functioning in Workers or Athletes:
Goal: Return to desired occupational or leisure time activities
Approaches / Strategies listed above
Selected References
Abdulwahab SS, Sabbahi M., Neck retraction, cervical root decompression, and radicular pain. JOrtho Sports Phys Ther. 2000; 30: 4-8
Davidson RI., Dunn EJ., Metzmaker JN. The shoulder abduction test in the diagnosis of radicular
pain in cervical extradural compressive monoradiculopathies. Spine. 6:441-6, 1981.
Farmer JC., Wisneski RJ. Cervical spine nerve root compression. An analysis of neuroforaminal
pressures with varying head and arm positions. Spine. 19:1850-5, 1994.
Humphreys SC., Hodges SD., Patwardhan A., Eck JC., Covington LA., Sartori M. The natural
history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years
as measured by magnetic resonance imaging. A descriptive approach. Spine. 23:2180-4, 1998.
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Jordan A., Bendix T., Nielsen H., Hansen FR., Host D., Winkel A. Intensive training,physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-
blinded, randomized clinical trial. Spine. 23:311-8, 1998.
Lentell G., Kruse M., Chock B., Wilson K., Iwamoto M., Martin R. Dimensions of the cervical
neural foramina in resting and retracted positions using magnetic resonance imaging. J OrthopSports Phys Ther. 32:380-90, 2002
Muhle C., Resnick D., Ahn JM., Sudmeyer M., Heller M. In vivo changes in the neuroforaminal
size at flexion-extension and axial rotation of the cervical spine in healthy persons examined
using kinematic magnetic resonance imaging. Spine. 26(13):E287-93, 2001
Persson, Liselott CG. et al. Long-lasting cervical radicular pain managed with surgery,
physiotherapy, or a cervical collar. Spine. 1997; 22:751-758
Radhakrishnan K., Litchy WJ., O'Fallon WM., Kurland LT. Epidemiology of cervical
radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990.Brain.117 ( Pt 2):325-35, 1994.
Saal S, Yurth E.F. Nonoperative management of herniated cervical intervertebral disc with
radiculopathy. Spine. 1996; 21:1877-1883
Van der Heijden GJ., Beurskens AJ., Koes BW., Assendelft WJ., De Vet HC., Bouter LM. The
efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinicaltrial methods. Phys Ther. 75(2):93-104, 1995.
Viikari-Juntura E, Porras M., Laasonen E.M. Validity of clinical tests in the diagnosis of root
compression in cervical disc disease. Spine. 1989; 14:253-257.
Wainner RS., Gill H. Diagnosis and nonoperative management of cervical radiculopathy. JOrthop Sports Phys Ther. 2000;30:728-744.
Wainner RS., Fritz JM., Irrgang JJ., Boninger ML., Delitto A., Allison S. Reliability and
diagnostic accuracy of the clinical examination and patient self-report measures for cervical
radiculopathy. Spine. 28(1):52-62, 2003.
Wolff MW, Levine LA. Cervical radiculopathies: conservative approaches to management. PhysMed Rehabil Clin N Am. 2000, 13:589-608
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Cervical and Shoulder Examination
Algorithm #1
Yes
No
Yes If Negative
If Negative
Suspect 1) Fracture or Loss of Connective TissueIntegrity Due to Trauma or Disease, and/or 2)
Abnormal/Hypermobile Cervical Segmental Mobility
Cervical
Examination
Algorithm #2
Consultation with
Appropriate
Healthcare Provider
Screen for Potentially Serious
Non-Musculoskeletal
Pathology
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Cervical Examination and Intervention
Algorithm #2
Pain During Movement or Pain Does Not Limit Motion
Pain Limits Motion in Available in Available Ranges and/or
Ranges or Movement Produces Pain at End of Range Does Not
Peripheral Symptoms Produce Peripheral Symptoms
If Positive for Upper
Motor Neuron ProducesLesions Vertebro-
BasilarInsufficiency
Produces Peripheral Symptoms Signs
Does Not Produce
Peripheral Symptoms
If Segmental Instability
If Symptoms
Unresolved If Positive If Negative
NeurologicalStatus
Mobility Examination of
Upper Quarter Neural Elements
Peripheral Nerve Entrapment Sites
Nerve Entrapment
Reduction Procedures
Cervical StabilizationProcedures
If Symptoms Resolve to the Point Where Pain Does Not
Limit Motion in Available Range, Return to Single Plane
Active Mobility Examination
PainLimitedNerve
Mobilit
Consultation
with OtherHealthcare
Providers
Cervical Spine Side
Bending, and/or
Combined SideBending/Rotation
/ExtensionOver Pressures
Mobility Examination of:
Upper Thoracic and
Upper Quarter Neura
Mobilization of UpperQuarter Neural Elements
PainLimitedCervical
Mobilit
To Algori
Shoulder Ex
ResistanceLimitedNerve
Mobility
Cervical and UpperThoracic Single Plane
Active Mobility
Examination
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Shoulder Examination and Intervention Algorithm #3a
Active ROM Tests:
1) Elevation
2) 90/90 or Neutral External Rotation
3 Hand Behind Back
Passive ROM Tests:
1) Elevation with Over Pressure
2) Isolated Glenohumeral External Rotation\
3) Isolated Glenohumeral Internal Rotation
To Algorithm #3b
Palpatory Examination of
Suspected Enthesopathy
Resisted Tests:
1) External Rotation
2) Abduction Active Compression
3) Flexion Test
Passive Accessory Motion Tests:
1) Posterior Humeral Translation
2) Anterior Humeral Translation
3) Inferior Humeral Translation (sulcus sign)
4 Acromioclavicular Accessor Movements
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continuum
If Symptoms Unresolved
Algorithm #3b
Medical/Surgical
Consultation in
Addition to PT
Intervention
Pain Limits Active and
Passive Movements in
Mid Ranges
Normal or Excessive Active and Passive
Range of Motion
Painful and/or Excessive HumeralAccessory Motions
Positive Active Compression Tests
Pain with Active Motions
Pain with Passive Over Pressur
Weak and/or Painful Resisted T
Physical Agents and
Ergonomic Counseling
Shoulder Strengthening
Therapeutic Exercises
Shoulder
Strengthening
Therapeutic Exercises
If Symptoms Resolve, and Pain No
Longer Limits Active and Passive
Movements in Mid Ranges, Return to
Start of Algorithm #3
Associated Upper Quarter
Impairment Examination
Algorithm #4
Suspect
Rotator
Cuff Tear
Impingement
Instability
First Time Traumatic
Dislocation
Age 25 Years Old
SuspectGlenohumeral
Capsuloligamentous
Labral Tear
Dislocation
Over 40 Years o
Shoulder Elevati
degrees after 6 w
PainLimited
ShoulderMobility
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Associated Upper Quarter Impairment Examination
Algorithm #4
Physical
Agents and
ErgonomicInstructions
Shoulder
StrengtheningTherapeutic
Exercises
ShoulderStabilization
Procedures and
Therapeutic
Exercises
Nerve
EntrapmentReduction
Procedures
Cervical
Stabilization
Procedures
Mobilization of
Upper Quarter
Neural Elements
Strength/Motor Control/Endurance DeficitsDeep Neck Flexors Lower Trapezius Middle Trapezius Se
Shoul
Mobiliz
Proced
Postural Deficits
Excessive Capital Extension Protracted Scapulae Excessive Thoracic K
Flexibility Deficits
Levator Scapulae Pectoralis Major Pectoralis M
Upper Trapezius Latissimus Dorsi SubscapularSuboccipital Myofascia Teres Major Sternocleido
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SUMMARY OF CERVICAL SPINE DIAGNOSTIC CRITERIA AND PT MANAGEM
DISORDER HISTORY PHYSICAL EXAM
Cervical Facet
Syndrome
723.1 onov* = 4 or less
mnov** = 8
Unilateral neck pain commonly
with referral (from occiput to
scapula)
Strain, unguarded or awkward
movement or position
SR with: End range rotation left or
right
Palpation of involved facet
Restricted accessory movement of
the involved facet
CervicogenicHeadache
723.2 onov = 4 or less
mnov = 12
Unilateral neck pain with referral tooccipital, temporal, parietal,
frontal or orbital areas
HA precipitated/aggravated by neck
movements or sustained positions
Noncontinuous HA (usually < 1
episode/day, < 2 episodes/week)
Observable postural asymmetry ofthe head on neck (sidebent or
extended)
HA reproduced with provocation of
the involved segmental ST/Joints
O/C1, C1/C2, or C2/C3 restricted
accessory motions with associated
myofascial trigger points
Cervical
Radiculopathy
724.4 onov = 8 or less
mnov = 20
Lancinating pain to UE
Paresthesias
Numbness
Weakness
SR with: Ext/SB to same side
ULTT
May have neuro signs (UE sensory,
motor, and reflex deficits)
Cervical Ligament
Sprain
847.0 onov = 8 or less
mnov = 20
Trauma
Protective muscle spasm
Pain with motion worsens at end
range
SR with palpation or provocation (via
central PAs of the involved
ligament or segment)
May have laxity with ligamentous
stress tests
onov = optimal number of visits
mnov = maximal number of visits
SR = Symptom Reproduction
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Mid-Cervical Spine Fusion
Anatomical Considerations: The cervical spine consists of several joints. It is an area where
stability has been sacrificed for mobility, making the cervical spine particularly vulnerable to
injury. The superior apophyseal (aka facet) joints of each segment face upward, backward, andmedially. The inferior facets face downward, forward, and laterally. This facet orientation
facilitates flexion and extension, but it prevents isolated rotation or side flexion. Thus, rotation
and sidebending occur together (i.e., coupled) in the mid-cervical spine. These joints move
primarily by gliding and are classified as synovial (diarthrodial) joints. The greatest flexion-
extension of the facet joints occurs at C5 and C6; however, there is almost as much movement at
C4-C5 and C6-C7. Because of this mobility, degeneration is most likely to be seen at these
levels. The neutral or resting position of the cervical spine is slightly extended. The closed
packed position of the facet joints is complete extension. The intervertebral discs make up
approximately 25% of the height of the cervical spine.
Pathogenesis: The cervical spine can be structurally compromised by differing mechanisms,such as instability resulting from trauma or the degenerative processes associated with aging.
The degenerative process involving the cervical spine is also known as cervical spondylosis.
Disc degeneration and osteophyte formation are present on radiological studies in a majority of
the population by the age of 55, yet many people never develop symptoms. Cervical disc
degeneration occurs most commonly at the C5-C6 and the C6-C7 levels. The decreased water
content of the disc may result in a narrowing of the disc space and loss of disc height, which
increases the shearing motion at the affected disc space and further contributes to the
degenerative process. Many people develop osteophytes along the spine as a result of the
degenerative process. These osteophytes may compress or irritate the cervical nerve root at the
affected level or levels. Fissures may develop in the annulus, which can allow portions of the
nucleus to protrude through the annulus. Disc herniations may irritate or compress the spinalnerve roots exiting the spinal cord, causing pain or numbness along the distribution of the nerve.
The degenerative process can also cause narrowing of the spinal canal (spinal stenosis),
compression of the spinal cord, or compression of the vessels supplying the spinal cord, resulting
in cervical myelopathy. Cervical myelopathy may produce numbness and weakness in the upper
extremities (lower motor neuron signs) and can also cause long track (upper motor neuron) signs
affecting lower extremity function. Infections or tumors of the vertebral column can greatly
exaggerate the deleterious neurological changes and subsequent loss of function.
Epidemiology: Research into the epidemiology of cervical disc disease indicates that men are
affected more often than women by a small margin. Most people with symptomatic herniated
cervical discs are in their 40s and 50s. Cigarette smoking also is associated with increasedincidence of cervical disc disease. The most common symptoms seen in patients for treatment of
cervical degenerative disc disease are neck pain, occipital headaches, pain and numbness
radiating to one or both shoulders, the scapular region, or arms and hands.
Many patients have radicular symptoms, which are pain, paresthesias, motor and sensory deficits
due to disorders of the nerve roots, typically due to compression at the cervical lateral forminal
canal. Radicular pain can be aggravated or relieved by the patients neck and head position.
Neck flexion can relieve symptoms in some patients, and lateral flexion or rotating the head
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toward the affected arm may increase pain and numbness.
Diagnosis: A combination of plain radiographs and magnetic resonance imaging (MRI) with or
without computed topography (CT) myelograms often is used in the diagnosis of patients
presenting with symptoms of degenerative cervical disc disease. Plain x-ray films can be used to
determine whether cervical entophytes are present and whether a loss of disc height is present inthe cervical spine. The disc space and cervical nerve roots can be examined by MRI scan to
identify disc herniation. Compression of the spinal cord or nerve roots can be identified with CT
myelograms.
Non-operative versus Operative Management: Conservative treatment for patients with
symptomatic degenerative disc disease includes rest, pain medication, non-steroidal anti-
inflammatory medications, physical therapy including: intermittent cervical traction, positioning,
ice/heat, ultrasound/phonophoresis, electrical stimulation, soft tissue mobilization, joint
mobilization, nerve mobilization, exercises for flexibility, strength, coordination and overall
fitness; posture and ergonomics. Many patients benefit from conservative treatment and
experience a resolution of symptoms. Patients who continue to have pain, numbness, orweakness, despite conservative therapy for approximately 6 to12 months, may be candidates for
surgical intervention. However, host factors that have a negative impact on obtaining a fusion
play a role in determining whether a patient is a candidate for surgery. These factors include
cigarette smoking (nicotine is a bone toxin), osteoporosis, chronic steroid use, and malnutrition.
Surgical Procedures:
Anterior Cervical Discectomy and Fusion (ACDF): The patient is placed supine on the table.
Under general anesthesia, the neck is draped in sterile manner. The correct level is identified
under x-ray control. A transverse incision of approximately 1.8 cm is made at the desired level.
After the incision the sternocleidomastoid and the strap muscles are identified. The anteriorsurface of the cervical spine is exposed. The longus colli muscles are reflected laterally at the
C4-5 level and the level is once again identified under x-ray control. A self-retaining Cloward
retractor is placed and the disk space is identified.
Anterior Cervical Diskectomy: With the help of pituitary forceps and curettes, the disk is
removed as posteriorly as possible. The posterior longitudinal ligament is visualized. Further
disc is removed from the foramina on both sides. The foramen is probed with a nerve hook
and further decompression is carried out with the help of Kerrison rongeur.
Anterior Cervical Fusion: The end plates are lightly burred with a high-speed burr to expose
the bleeding subchondral bone. Sizing of the disc is performed. Appropriate allograft istaken and inserted in the disc space under tension. The graft fixation is checked for fit.
Cervical Plating: The appropriate sized cervical plate is selected. It is applied to the anterior
surfaces of the involved vertebra. Position is identified under x-ray control. This is fixed to
the vertebrae with the help of four 14mm screws. The fixation is checked. The wound is
irrigated and deeper tissues are closed with sutures and then, the skin is closed with sutures.
Marcaine is injected into the edges of the skin. A sterile dressing is applied and a cervical
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collar is given. The pati