Cervical Spine Intervention Techniques

• Objectives of Cervical Spine Interventions
• Demonstrate Joint mobilization and HVLAT techniques in the cervical spine
• Demonstrate Soft tissue mobilization techniques in the cervical spine
• Demonstrate exercise interventions for cervical spine pain

Cervical spine interventions overview

• Joint mobilization includes CPA, UPA, and Lateral glide
• HVLAT includes upper cervical, mid cervical, and cervicothoracic region
• Exercise intervention includes Mobility, Motor control and Strengthening

Interventions

• To address relevant impairments, determine the most relevant impairment
• The most relevant impairments include mobility, pain, motor control, strength
• The patient’s goals will guide which interventions to choose

Mobility issues

• Use mobilization/HVLAT
• Include mobility exercises
• Include eccentric strengthening

Pain issues

• Use Mobilization/HVLAT
• Use Soft tissue mobilization
• Use Graded exposure exercises
• Use Direction-specific techniques including traction

Motor control issues

• Include motor control exercises
• Use graded exposure
• Use strength training

Strength/endurance issue

• Include strength training
• Use endurance training
• A combination approach is most likely needed

Central Posterior-Anterior Glide

• Patient position is prone
• Therapist stands at the head of the patient
• Stack the thumbs
• Flex MCPs of the fingers.
• Keep the DIP and PIP straight, elbows straight
• Adjust table height as needed
• Contact on spinous process
• Apply directional force straight down to the table
• Start at C2 and work down to C7

Unilateral Posterior-Anterior

• Place the Patient in prone position
• Stand at the head of the patient.
• Maintain the same hand position
• Contact 1 thumb width lateral to spinous process or on the articular pillar
• Direction of force applies straight down to the table
• Start at C2 and move to C7
• One can do all on one side then switch, or alternate each level

Lateral Glide

• Patient is in side-lying position
• Therapist stands at the head of the patient
• Maintain the same hand position
• Contact between the spinous process and transverse process or on the articular pillar
• Apply a directional force straight down to the table
• Start at C2 and move to C7

OA glide

• Place the Patient in supine position
• Therapist stands at the head of the patient
• Hold patient’s head with thumbs along zygomatic arch
• Contact patient’s forehead with deltopectoral groove
• Use a small towel or pillowcase for comfort and protection
• Apply force into capital flexion and down to the table
• Bias one side through contralateral lateral flexion and slight ipsilateral rotation

C1/2 Rotation

• Place the Patient in supine position
• Therapist should be seated at head of the patient
• Place the hand opposite to the direction of rotation rests under patients occiput
• The 2nd or 3rd digit contacts lateral to the C2 spinous process on the side of rotation
• For example, to improve left rotation, the right 2nd or 3rd digit contacts lateral to the left C2 spinous process
• The other hand grasps the forehead
• The Force from the underside hand is directly anterior
• The Force from the top hand is into the desired direction of rotation

Suboccipital "Release"

• Place the Patient in supine position
• Therapist should be seated at head of the patient
• Place the Hands cupping patient's head with 1st-4th digits contacting suboccipital muscles
• Apply force upward toward ceiling with slight traction
• Hook the fingers on occiput
• Hold it between 30 to 60 seconds then release and repeat multiple times as needed

Pin and Stretch

• Can be used on multiple muscles of the neck and shoulder region: e.g., upper trapezius, scalenes, levator scapulae, SCM
• Place the Patient in supine position
• Therapist should be seated at head of the patient
• Find the desired muscle and apply a tolerable compressive force
• The Exercise can be uncomfortable, but must be tolerable.
• Use the opposite hand to move the head in a direction opposite the line of force of the selected muscle
• Hold for 5-10 seconds, slight release, and repeat 5-10 times

Clinical Prediction Rule for HVLAT

• Created by Puentedura et al (2012)
• The patient should have Symptom duration less than 38 days
• The patient should have Positive expectation that manipulation helps
• There should be a Difference in motion side to side of greater than 10 degrees
• Pain with CPA testing of the mid cervical spine

Principles Review

• HVLAT is safe
• Use high-velocity, with low amplitude thrust
• The Movement has to be quick enough that the patient cannot stop it
• Use the “Iron fists in velvet gloves” technique
• Go through Fryette’s 3rd law
• Use multiple cervical motions to “take up the slack” to increase comfort
• Do NOT manipulate if the patient does not want you to

Mid-cervical HVLAT

• Best for C2/3-C5/6
• Place the Patient in supine position, with the head even with the end of the table
• Therapist stands at head of the patient
• Adjust the Table height to level with MCPs with hand at the side
• Assume a Diagonal stance to allow weight shifting
• Keep the Elbows tucked in at your side

Right cervical spine manipulation

• Start with slight (~30 deg) contralateral rotation
• Place the Left hand on temporal bone with web space surrounding ear
• Place the right 2nd digit PIP contacting articular pillar of the desired level
• Place the Right thumb along the mandible
• Take up slack by ipsilateral (right) sidebending and contralateral (left) side shift
• Apply Direction of thrust toward contralateral eye with rapid pronation/supination

Upper Cervical C1/2 HVLAT

• There is same patient and therapist position as previously
• The Movement should be set up with significant exceptions
• The Applicator” finger should be in the sulcus immediately inferior to the occiput
• The Applicator finger should be on the posterior arch of the atlas C1
• Thumb is now perpendicular to the face along the zygomatic arch
• Keep the Elbow abducted away from the body to point the forearm at a 90 deg angle to the body

Cervicothoracic Junction (CTJ) HVLAT

• Place the Patient prone and turn the head to the side of manipulation.
• Place the Ipsilateral arm up and contralateral arm down at patient’s side, near the plinth edge
• Adjust the Table height so you are able to getchest over patient’s thoracic spine
• The Body should be directly over the area you are manipulating to follow the ‘Tie Rule’
• Maintain a Staggered stance with weight shifted to the front foot

CTJ HVLAT

• The MCP of the lower hand/lever should contact the lateral aspect of T1
• The Elbow should be flared out and point to a line of force across to the opposite shoulder
• The Palm of the upper hand/lever contacts the temporal region of the head
• The Thrust delivers a side-shifting translation motion toward your body
• Both hands take part in the thrust, but 60 % of the motion comes from the lower hand

CTJ HVLAT Seated

• Have Patient seated and scooted to the back edge of the plinth
• Therapist should be standing behind the Patient
• The Table height should place patient’s CTJ region in line with therapist’s mid sternum
• Have the Patient place his hands interlocked behind his neck, NOT on the head: this tends to induce forward flexion
• Therapist is to come under patient’s arms, through triangle made by the Patient’s elbow with his wrists and forearms

CTJ HVLAT forces

• Can use a rolled towel to focus forces along the spine
• Lean back to pull patient toward you into upper thoracic flexion with slight to moderate cervical flexion
• Use a High-velocity thrust is applied in the superior and posterior direction

Mobility Interventions

• This is a Comprehensive list to include Neuromusculoskeletal effects, but not elasticity changes
• Is this a contractile/connective tissue limitation or a joint limitation?
• Generally, start gentle and short duration
• Increase intensity or duration as patient improves
• Never both at the same time

Range of Motion mobility interventions

• To improve ROM in direction of deficit
• Can have pain modulating effects
• Primarily muscle/connective tissue
• Upper trapezius stretch
• Levator scapulae stretch
• Scalene stretch
• SCM stretch
• Suboccipital stretch

Joint Stiffness Mobility Interventions

• Use cervical self-SNAG

Nerve Glides

• Used To decrease nerve mechanosensitivity
• The glide can be Manual or performed by patient
• Use a gentle but frequent approach
  • Start with 5-10 reps, 3-5x/day and titrate up to hourly
  • Work up to point of symptoms then back off

Nerve Glides: Manual and Self

• Movement can be performed ULLT repeatedly on/off with head movement
• Slider/Glides -Tensioner

Motor Control Interventions

• Include Generally small, controlled movements
• Use Graded exposure to build tolerance
• To Improve motor coordination impairments
• Target deep spine muscles -Suboccipitals -Deep neck flexors -Cervical multifidi
• Use 3 sets of 15-30 reps

Specific Motor Control Interventions

• Supine chin tuck
• Cranio-cervical flexion with cuff
• Prone chin tuck and head lift
• Quadruped retraction -With and without arm movements
• Laser pointer tracing

Strengthening Interventions

• Can target specific cervical or cervicothoracic musculature
• Use Increased intensity -Effort is the most important factor
• Use Higher loads
  • Use lower reps for high effect
• Perform reps in 3-5 sets of 5-12

Specific Strengthening Interventions

• “Hippie bands” – cervical isometrics with theraband
• Prone Ts and Ys
• Rows -Bent Over Row -Low Row
• Seated Row
• Overhead Press
• Serratus push-up

CPR – Traction+Exercise

• Use For patients Age > or = 55
• Those who present with Positive shoulder abduction test
• Show a Positive ULTT A
• Show a Peripheralization with CPA at lower c-spine
• Those show a Positive neck distraction
• Success has been determined at 44% with treatment to traction