Cervical Spine Interventions

• Adam Squires is a physical therapist with certifications in Spinal Manipulation Therapy (SMT) and Dry Needling (DN).
• He is also board certified as an orthopedic physical therapy specialist.

Objectives of Cervical Spine Interventions

• Understand rationale and demonstrate joint mobilization and HVLAT techniques in the cervical spine.
• Understand the rationale and demonstrate soft tissue mobilization techniques.
• Understand the rationale, demonstrate performance, and coach for exercise interventions for cervical spine pain.

Overview of Cervical Spine Interventions

• Cervical spine joint mobilization includes CPA, UPA, and lateral glide techniques.
• Cervical spine HVLAT is performed in the upper cervical, mid cervical, and cervicothoracic regions.
• Exercise interventions include mobility, motor control, and strengthening exercises.

Intervention Considerations

• Determine the most relevant impairment to address and what patients' goals are.
• Impairments include mobility, pain, motor control, and strength.
• Patient goals and impairments guide the choice of interventions.

Interventions by Issue Type

• For a mobility issue, interventions include mobilization/HVLAT, mobility exercises, and eccentric strengthening.
• For a pain issue, interventions include mobilization/HVLAT, soft tissue mobilization, graded exposure exercises, and direction-specific exercises including traction.
• For motor control issues like instability and WAD, motor control exercises, graded exposure, and strength training are employed.
• For strength/endurance issues linked to instability, WAD, and mechanical problems, strength and endurance training are used.
• A combination of interventions is often the most effective approach.

Joint Mobilization Techniques

• Central Posterior-Anterior Glide:
  • The patient is prone, with the therapist at the head of the table.
  • Thumbs are stacked with MCPs flexed, DIPs and PIPs straight, elbows straight
  • Contact is made on the spinous process.
  • The force is directed straight down to the table.
  • Start the process at C2 and move down to C7.
• Unilateral Posterior-Anterior:
  • The patient is prone, with the therapist at the head of the patient.
  • The hand position is the same.
  • Contact is approximately one thumb width lateral to spinous process on the articular pillar.
  • The direction of force is straight down to the table.
  • Start at C2 and move toward C7, one side at a time.
• Lateral Glide:
  • The patient is side-lying, with the therapist at the head of the patient.
  • The hand position is the same.
  • Contact is made between the spinous process and transverse process on the articular pillar.
  • The direction of force is straight down to the table.
  • Start at C2 and move toward C7.
• OA Glide:
  • The patient is supine, with the therapist at the head of the patient.
  • Both hands hold the patient’s head with thumbs along the zygomatic arch.
  • Contact the patient’s forehead with the deltopectoral groove using a small towel or pillowcase.
  • Force is applied into capital flexion and down to the table.
  • Bias one side through contralateral lateral flexion and slight ipsilateral rotation.
• C1/2 Rotation:
  • The patient is supine, and the therapist is seated at the head.
  • A hand is placed opposite the direction of rotation under the patient's occiput, with the 2nd or 3rd digit contacting the C2 spinous process laterally.
  • To improve left rotation, the right 2nd or 3rd digit contacts lateral to the left C2 spinous process.
  • The other hand grasps the forehead while force from the underside hand is directed anteriorly.
  • Force from the top hand is into the desired direction of rotation.

Soft Tissue Mobilization Techniques

• Suboccipital Release:
  • The patient is supine, with the therapist seated at the head.
  • Hands cup the patient’s head with the 1st-4th digits contacting suboccipital muscles.
  • Apply force up toward the ceiling with slight traction using hooking fingers on occiput.
  • Hold for 30-60 seconds, then release and repeat as needed.
• Pin and Stretch:
  • It can be used for the upper trapezius, scalenes, levator scapulae, and SCM muscles.
  • The patient is supine, with the therapist seated at the head.
  • Find the desired muscle and apply tolerable compressive force and use the opposite hand to move the head opposite the selected muscle’s line of force.
  • Hold for 5-10 seconds, slightly release, and repeat 5-10 times.

HVLAT: High-Velocity, Low Amplitude Thrust Manipulation

• Clinical Prediction Rule criteria includes:
  • Symptom duration less than 38 days
  • Positive expectation that manipulation will help
  • A difference in motion side to side of >10 degrees
  • Pain with CPA testing of the mid cervical spine
• HVLAT should be a high-velocity, low-amplitude thrust and quick enough that the patient cannot stop it.
• Use “Iron fists in velvet gloves" with Fryette’s 3rd law.
• Always respect if a patient does not want to be manipulated.
• Mid-cervical HVLAT is ideally for C2/3-C5/6.
• It requires patient supine, with head even with the end of the table and therapist at the head of the patient.
• With table height level with MCPs with hand at your side, elbows tucked in at your side and diagonal stance, weight shifting can occur.
• To manipulate the right cervical spine, start with about 30 degrees of contralateral rotation.
• Place the left hand on temporal bone with web space surrounding ear, and the right 2nd digit PIP contacts articular pillar of desired level.
• The right thumb is along the mandible while you take up slack by ipsilateral sidebending and a contralateral side shift.
• The direction of thrust is toward contralateral eye with rapid pronation/supination.
• Upper Cervical C1/2 HVLAT has the same patient and therapist position, but with exceptions.
• The "Applicator" finger should be in the sulcus immediately inferior to the occiput.
• The thumb is now perpendicular to the face along the zygomatic arch with the elbow abducted to point the forearm at a 90-degree angle to the body.
• Cervicothoracic Junction (CTJ) HVLAT:
  • The patient is prone with head turned to the side of manipulation, ipsilateral arm up, contralateral arm down at patient’s side, and close to the plinth's edge.
  • The table height should be low enough to get your chest over the patient's thoracic spine and ensure your body is directly over area.
  • Use the "Tie rule" in a staggered stance with weight shifted to the front foot.
  • The MCP of lower hand/lever contacts the lateral aspect of T1, with the elbow flared pointing a line of force across to the opposite shoulder.
  • The palm of the upper hand/lever contacts the temporal region of the head.

Exercise Interventions for Cervical Spine

• Mobility interventions improve ROM in the deficit direction.
• They can have pain modulating effects and primarily target muscle/connective tissue.
• Examples include upper trapezius stretch, levator scapulae stretch, scalene stretch, SCM stretch, and suboccipital stretch.
• Primarily joint stiffness needs cervical self-SNAGs.
• Nerve Glides
  • Decrease nerve mechanosensitivity via manual or patient-performed methods.
  • Perform gently and frequently, starting with 5-10 reps 3-5 times daily, and adjust up to hourly until symptoms begin.
  • Manual nerve glides have ULLT repeated on/off with head movement.
• Motor Control Interventions:
  • Motor control interventions are generally small, controlled movements with graded exposure.
  • Target deep spine muscles like suboccipitals, cervical multifidi, and deep neck flexors for improving motor coordination impairments.
  • Perform 3 sets of 15-30 reps, examples include Supine chin tuck, Cranio-cervical flexion with cuff, Prone chin tuck and head lift, Quadruped retraction with and without arm movements, and laser pointer tracing.
• Strengthening Interventions:
  • Focus on specific cervical muscles or cervicothoracic and scapulothoracic musculature.
  • Increased intensity is the most important factor is improving strength.
  • Utilize higher loads and lower reps or many reps where effort is still high, perform 3-5 sets of 5-12 reps and "Hippie bands”, Prone Ts and Ys, Rows, Overhead Press, Serratus push-up.
• Clinical Prediction Rule (CPR) - Traction + Exercise criteria:
  • Age > or = 55
  • Positive shoulder abduction test
  • Positive ULTT A
  • Peripheralization with CPA at lower c-spine
  • Positive neck distraction