Physical Therpay Protocols for Conditions of Neck Region

8/8/2019 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.

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency


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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?

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency


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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

Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency1


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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




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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


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


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


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)


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



264, 1992Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 192, 1996



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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:




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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


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




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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



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


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


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




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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


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)


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)


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




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Symptoms worsen or peripheralize with sustained end range positions or withrepeated movements into the patients available range



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


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



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


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).


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)


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


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



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



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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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



264, 1992Philip Greenman DO, FAAO: Principles on Manual Medicine, p. 192, 1996



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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:




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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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Occiput/C1 Contract/Relax


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


268, 1992




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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


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


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


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


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


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)


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


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



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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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


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:



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

Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS KP So Cal


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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


Shoulder

Strengthening


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

Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS


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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

Emmanuel Yung PT, MA, OCS Skulpan Asavasopon MPT, OCS Joe Godges DPT, MA, OCS


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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


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


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

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs Joe Godges DPT, MA, OCS


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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

Physical Therpay Protocols for Conditions of Neck Region

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