MANUAL THERAPY

DPT 6TH SEMESTER

“Common pathologies & Treatment of the Cervical Spine”
MUJEEB UR RAHMAN
ASSISTANT PROFESSOR
IPM&R KMU
Common Cervical Pathologies
Objectives

• Recognize the more prevalent cervical pathologies seen in

musculoskeletal practice

• Understand the etiology behind each of the pathologies

Most Common Problems

• Cervical Disc Disorders

 Herniated disc
• Cervical Degenerative Disorders
 Spondylosis/ Spondylolysis
 Stenosis (Myelopathy and Radiculopathy)
• Headaches
 Cervicogenic headache
• Cervical Neck Injuries
 Whiplash Associated Disorder
Cervical Herniated Disc

• Usually C6-7
• May see sensory, muscle, and reflex changes
• Generally sharp pain with extension
• Usually young
• Often will hold their head in
opposite SB, Rot, and flexion
• “Flattened” neck posture
Posterolateral  called?
Posterior/central ?
Lateral  ?
Causes-Herniated Disc

• Excessive force on a cervical IV disc  car accident or a traumatic fall

• Classified into 3 categories:
• 1) soft herniation of nucleus material  younger population
Rx RESPONSE?
• 2) mixed soft-calcified herniation of disc material and calcified
structures  Response ?
• 3) calcified disc herniation
• 2&3 degenerative process
Cervical Spondylosis

• Common over the age of 40 years.

• Levels most affected include C5-C6

& C6-C7  Reason?
• C2-C3 least affected
Cervical Spondylosis is Related to Instability

• Degeneration  desiccation of the cervical disc (Arana et al., 2004) 

reductions in disc height and capsular laxity.

• Disc degeneration is a ubiquitous condition with mild to no reported

symptoms (Rao 2003).

• Disc degeneration concurrent with zygopophyseal and uncovertebral

degeneration.
 Clinical Cervical Instability

• Clinical cervical instability is the failure of:

• Active structures (longus coli and capitus) and
• Passive structures (disc, ligaments, facets, uncovertebral joints)

“of the neck to appropriately stabilize structures

during static positions and dynamic movement”.
Clinical Instability

• Clinical cervical Instability is one element of cervical pain, and may

contribute to the clinical presentation of various conditions, including:
• – 1. Cervicogenic headaches
• – 2. Chronic whiplash dysfunction
• – 3. Rheumatoid arthritis
• – 4. Osteoarthritis and segmental degeneration
• – 5. Situations involving trauma
• – 6. Genetic predisposition
• – 7. Disc degeneration
• – 8. Surgery
Radiographic Instability Parameters
Symptoms
• Stiffness • Usually younger
• Diffuse Pain • Women > Men
• Headaches (occasionally) • Usually associated with some
• Frequent need of manipulation trauma or long term postural
disorder
• Rarely complain of neurological
signs
Leads to Degeneration

• Degenerative process can lead to reduced disc height and bulging of

the posterior aspect of the disc into the spinal canal.

• Surrounding bones and ligaments of the spinal joints thicken and

enlarge, collectively pushing into the spinal canal or nerve roots.

• Stenotic changes may cause radiculopathy in isolation but will often

coincide with a disc herniation or degradation
Stenosis, Radiculopathy, and Myelopathy
Cervical Stenosis

• Stenosis stands for narrowing.

• This dysfunction can lead to myelopathy or radiculopathy (can be

lateral or central or both)

• Can be caused from herniated disc, degeneration, or other factors

associated with range loss
Cervical Myelopathy

• Cervical-Spondylotic-Myelopathy is the most common cause of spinal

cord dysfunction in older persons.
• Signs and Symptoms: Sx  leg stiffness, hand weakness, Motor
problems occurring sooner than sensory)
• Characteristic signs (hyper-reflexia, atrophy of hands)
• MRI or CT (showing spinal stenosis and cord compression as a result
of osteophyte overgrowth, disc herniation, ligamentum hypertrophy)
Cervical Radiculopathy
• Cervical radiculopathy is a pathological consequence in the cervical
region associated with degenerative changes, a herniated disc, or
other less common phenomena  nerve root should be chemically
activated  tension or compression on NR
• Prevalence of 3.3 cases per 1,000 people and predominantly occurs in
the fourth or fifth decade of life.
• Symptoms associated with this disorder include pain that radiates
from the neck to the extremities or body.
• Generally, these symptoms are represented by pain, numbness
and/or weakness.
Cervicogenic Headache
Cervicogenic Headache
• The World Cervicogenic Headache Society defines cervicogenic
headache (CGH) as “referred pain perceived in any part of the head
caused by primary nociceptive source in the musculoskeletal tissues
innervated by cervical nerves.”
Identification of Cervicogenic Pain

• Head pain that spreads below the occiput is likely to originate from
the atlantoaxial joint and can be distinguished from other types of
headaches.

• Structures may include muscles, facet joint, capsule, ligament, nerves,

dura mater, spinal cord, or vertebral artery.

• Usually C0-1, 1-2, 2-3, Rarely C-6

Location of Symptoms

• Common locations of the head pain

– C6-  Frontal,
– C0-1  Retro-orbital,
– C1-2  Temporal
– Tension occipital areas.
– C2-3  Parietal
• Pain is usually unilateral (can be bilateral) and does not change sides
like a migraine (Dreyfuss et al., 1994; Heikkila et al., 1996)
• Not triggered by smell or other triggers like migraine
• Stress
Precipitating Events

• Pain has been described as an ache with a deep boring quality and
may be accompanied by dizziness, light-headedness, nausea, visual
disturbances and tinnitus.
• Cervical headache is commonly continuous and can occur daily or two
to three times during a week with fluctuating intensity.
• Pain is often present upon waking that increase throughout the day
and is commonly precipitated by neck movement or a sustained neck
posture (Grant, 1988).
Differentiation
• Cervical headaches are not confined to bouts or attacks (fluctuate
according to circumstance)
• – Most have 2 or more headaches a week
• – 58% will awake with their headache
• – Emotional tension is a precipitating factor
• – Cervical tender points can significantly influence the headache
Range of Motion Loss

• Rotation deficit (26 degrees)

• Side Flexion deficit (6 degrees)

• Flexion/Extension deficit (23 degrees)

• Modified from Zwart (1997) Headache.

Whiplash Associated Disorder
Signs and Symptoms
• Pain and aching to the neck and back, referred pain, to the shoulders,
sensory disturbance (such as pins and needles) to the arms and legs,
and headaches.

• Symptoms can appear directly after the injury, but often are not felt
until days afterwards
Specifically
• Suboccipital, neck and yoke, shoulders or scapulae, back, unilateral, or
bilateral
• Frontal Headache-may be periodic or transient, dull or background
constant ache
• Retro-orbital pain-sometimes parasthesia in the eye
• Facial and/or anterio-lateral throat pain, otalgia
Clinical Symptoms
• Upper pectoral area and axillary pain
• Subjective laryngeal disturbances, with compulsive clearing of the
throat or dysphagia
• Numbness or parathesia in either or both upper extremities, patchy
or dermatomal
• VBI symptoms
Etiology
• May involve tearing of the anterior or posterior muscles; rupture or
tear of Alar ligament; rupture or tear of Transverse ligament;
hypermobility of the upper or mid cervical segments.
Hyper Sensitive
• Patients with chronic WAD displayed lower pain/reflex thresholds
than healthy subjects.

• These findings provide objective electrophysiological evidence for

generalized spinal cord hyper-excitability.
Prognosis
• Expect symptoms to persist at least 6 months, 25% for years
• Common to see postural changes
• Origin of lengthy prognosis
– Alar and Transverse ligament instability – Transverse ligament
– Anterior local muscle group tears
Postural Syndrome
Mechanism (Origin of Pain)
• Maintaining a postural preference the patient puts normal tissue
under abnormal mechanical stress by hanging their spinal joints at
end range in certain positions (Some tissues are getting unduly
stretched while others are unduly shortened).

• Repeated undue stretching probably leads to many of the

dysfunctions and derangements people over thirty experience.
Common Postural Conditions

• Upper Crossed Syndrome (Janda 1972, Sahrmann 1990)

• Cervical headache is commonly precipitated or aggravated by
sustained neck posturing or neck movements (Watson & Trott, 1993).
• Truck drivers are prone to long term sitting and subsequent primary
disc dysfunctions
THANK YOU 
Treatment By Classification
Objectives

• Recognize the proposed benefit to classifying cervical conditions by

similarity

• Understand that classifications do not need to be mutually exclusive

Cervical Spine Guidelines

• Usually used for clearing spine

• Imaging guidelines

• Guidelines for trauma

Physical Therapist?
• JOSPT guidelines

• Single discipline based, somewhat weighted toward the author’s

preferences

• Suggests the following:

– Manipulation
– Exercise and Conditioning – Advise to Stay Active
what seems to Work?

• Multi-modal (exercise + manual therapy)

• Exercises
• Manual Therapy (Manipulation and Mobilization)
• These have the largest “effect”
• May be patient specific
Exercise and Manual Therapy
• Endurance over strengthening

• Include thoracic and shoulder musculature too

• Mob or Manip, it doesn’t matter

• Ex + MT > MT alone
• Effect for both 0.40 (~66% did better than comparison)
Classification for Conservative
Treatment (after triage)

• Pain Control-Stabilize and Palliative

• Mobility-Mobilization or Manipulation
• Exercise and Conditioning (non- mobilization)
• Headache-Mobilization and Postural Treatment
• Centralization-Traction Group & repetitive movts
Pain control

• Whiplash Associated Disorder

• Severe pain from sprain and strain

• Treatments include modalities, general strengthening exercises, and

general manual therapy procedures
Mobility

• HNP
• Spondylosis
• Neck Strain/Sprain
• (occasionally) Whiplash Associated disorder

• Treatments would be active movement, HEP, Combined,

Mobilization and Manipulation
Exercise and Conditioning

• Spondylosis
• Whiplash Associated Disorder
• Neck Strain/Sprain
• Headache (Tension)
• Postural problems

• Treatments will include general conditioning exercises and

stretching
Headache

• Cervicogenic Headache

• Tension Type Headache

• Treatments will include focused strengthening exercises and

mobilization/manipulation. Also massage/stretching.
Centralization

• HNP
• Stenosis
• Spondylosis
• Postural syndrome  repeated movts

• Treatments will include selected manual techniques, traction, and

positional based active and passive exercises
Interventions to Relieve Concordant Sign or Priority Impairment
Objectives

• Review the concordant techniques used to target the primary

impairment

• Analyze the effectiveness of each technique for treatment within the

classifications
Neck Classification
• Pain Control-Stabilize and Palliative
• Mobility-Mobilization or Manipulation
• Exercise and Conditioning (non- mobilization)
• Headache-Mobilization and Postural Treatment
• Centralization-Traction Group
PAIN CONTROL GROUP
Pain Control
• physical medicine modalities for mechanical neck pain little
evidence

• Exercise, mobilization, and manipulation have the best evidence in

the literature

• Little evidence for use of TENS, ultrasound, thermal agents, and

electrical agents (other than transient effect)
Mobilization has best Evidence for
Acute Whiplash
• Light mobilizations demonstrate
the most evidence in treatment
of acute whiplash
• Limited evidence for
manipulations
• Transient evidence for
modalities
Chin Retractions In Supine
• Passively retract the chin of the patient

• Stabilize the head posteriorly

• Slowly, bring the head into extension

during passive movements

• Keep the chin retraction

Anterior Neck Flexion Exercises (motor control excs)

• Analgesic in nature
• Low Load retraining is needed
• Show short term effectiveness
Mobilization

• Manipulation and/or mobilization alone not beneficial;

• when compared to one another, neither was superior.”

• “Mobilization and/or manipulation + exercise are beneficial for

persistent mechanical neck disorders with or without headache
MOBILIZATION GROUP
CPA’s
1. Baseline
2. Move to First point
Of pain
3. Move past First point
Of pain to end range
4. Assess if concordant
UPA’s
1. Baseline
2. Move to First point
Of pain
3. Move past First point
Of pain to end range
4. Assess if concordant
5. Repeat on Opposite
Side
 Unilateral pain
Unilateral Anterior Posterior
Opening Technique

• Thrust Involves a Rotation and

Side Flexion

• Pain in flexion
• Side flexion
• Rotation away
1st step lift in flexion (further unlock facet)
Blocking area below the affected segment
Side flex towards

Rotate away

Side flexion and rotation at the same time

Closing Technique
• Thrust Involves Side Flexion and
Extension
A

Extension
Side-flexion
Rotation
Thrust to opposite hip
Manipulation vs. Mobilization C-
Spine
• Similar results (no conclusive difference) (long term)
• – Hurwitz et al. Am J Public Health. 2002;92:1634-41.
• – Leaver et al. Arch Phys Med Rehabil. 2010 Sep;91(9):1313-8.
Cervicogenic Headache
C0-1 Mobilization
Retro-orbital pain? +ve

3 sets of 30, check symptoms in sitting

C1-2/C2-3 Differentiation

• Palpate the C2 Facet and mobilize straight down toward the patients
throat. This assesses the C2-3 segment.
• Rotate the head 30 degrees to the same side then perform the same
mobilization, this time aiming at the patient’s mouth. This assesses
C1- 2.
• • When rotated, the Alar ligament stabilizes the C2-3 segment,
• Allowing more movement in the C1-2.
C2-3 Assessment (parietal)

• Mobilize the C2-3 facet pushing

downward vertically toward the
table.
• • Look for the comparable sign
of the patient.
• • Don’t get hung up on
joint direction
C1-2 Assessment
• Thumb remains on the C2-3
process
• Turn the head 30 degrees to the
same side
• Mobilize toward the patient’s
mouth
• Look for the comparable sign
Specific Exercise
Examination Drives the Response

• Do repeated movements centralize the pain of the patient?

• Centralization:
“The process by which pain radiating from the spine is sequentially
abolished, distally to proximally, in response to therapeutic positions or
movements; and includes reduction and abolition of spinal pain”.

Centralization is prognostic
Active Mobilization: Chin Retraction (Upper C-Spine
Flexion)

• After the repeated movements,

no statistically significant
difference was found in neck
retraction range of motion, but a
statistically significant change in
the resting neck posture and
pain was detected.
Clinical Prediction Rule
Radiculopathy
• +ULTT test
• <60 cervical rotation
• +Spurling’s Test
• +Distraction Test

• 2 of 4 positive is a LR+ of 0.80

• 3 of 4 positive is a LR+ of 6.1
• 4 of 4 positive is a LR+ of 30.3
Benefit of Cervical Traction

• Intermittent better than continuous (for pain reduction)

• Only one quality study
• Actually demonstrated more benefit for mechanical neck pain
• Halter traction and neck brace may be helpful (caution cohort study)
Mechanical Traction
• A CPR with five variables was • 3 of 5 predictors was +LR equal to
identified: 4.81 (95% CI = 2.17-11.4),
• (1) patient reported increasing the likelihood of
peripheralization with lower success with cervical traction
cervical spine (C4-7) mobility from 44 to 79.2%.
testing; • 4 of 5 variables, the +LR was
• (2) positive shoulder abduction test; equal to 23.1 (2.5-
• (3) age > or =55; • 227.9), increasing the post-test
• (4) positive upper limb tension test probability of having
A; and • improvement with cervical
• (5) positive neck distraction test. traction to 94.8%.
Pain Relief-Home Traction
• Fear-Avoidance Beliefs Work Subscale score < 13,
• pre-intervention pain intensity ≥ 7/10,
• positive cervical distraction test and pain below shoulder).
• With satisfaction of at least three out of four variables (positive
likelihood ratio = 4.77 for use of traction). the intervention's success
rate increased from 45.6% to over 80%.
Traction Progression
• 1. Distraction (light force, patient response)
• 2. Rotation Away
• 3. Rotate back
• 4. Release Distraction
• Continue process slowly working toward rotation to the same side as
the pain.
• Thank You 