Final Mobilization of the Cervical Spine PDF

Mobilization of the Cervical Spine Mobilization of the Cervical Spine Cervical mobilization permits early treatment by means of gentle oscillatory movements which have the effect of decreasing muscle spasm and pain and thus gradually improving mobility. While there is a risk o...

Mobilization of the Cervical Spine Mobilization of the Cervical Spine Cervical mobilization permits early treatment by means of gentle oscillatory movements which have the effect of decreasing muscle spasm and pain and thus gradually improving mobility. While there is a risk of complications with cervical manipulation, cervical mobilization is safe as it is not a past end range technique. Furthermore, a lesser degree of skill is required for mobilization than for manipulation. 2  The Mobile Segment A three joint complex composed of the intervertebral disc joint and two facet joints As well as the muscles, ligaments, and neurovascular structures surrounding, between, and connecting adjacent vertebrae  Intervertebral Disks (Joints) Discs form the main connection between vertebrae. They bear loading during axial compression and allow movement between the vertebrae. :Consists of Central nucleus pulposus Annulus fibrosus which surround the nucleus pulposus.  Facet Joints -Formed by articulation of inferior and superior processes of subsequent vertebrae -Provide movement and helps to prevent anterior movement of superior vertebra on inferior one. Mobilization can be given over three stages of the joint ROM ( Mainly used in the spinal Mobilization). Mobilization) o Stage (1): refers to the small amplitude rhythmic oscillating movement at or near the beginning of ROM. o Stage (2): refers to a large amplitude rhythmic oscillating movement spanning the mid range. o Stage (3): represent a small amplitude rhythmic oscillating movement at or near the end of range  Stages of Mobilization Stage (1) Stage (2) Stage (3) Range Start of Mid Range End of Range Range Amplitude Small Large Small Indication Acute Pain and Stiffness and painful stiffness pain Hypomobile joints  Mobilization Techniques for Spine The techniques may be direct or indirect, depending on whether body lever is used. o Direct technique are those where a direct pressure or force is applied to the affected area and hence are generally specific to that area. o Indirect technique use body lever to produce the effect and are non specific, producing movement not only at the affected level but also over wide area of the spine. NB: it is appropriate to use the indirect technique when the affected part is too painful to withstand direct pressure and also when where a wide region is affected rather than one level Mobilization Techniques for the Cervical Spine Technique Type Indication Anterior directed central gliding Direct Bilateral or central pain Anterior directed unilateral Direct Unilateral Pain gliding Anterior directed unilateral Direct Unilateral pain c1/c2 gliding with head rotation Accessory rotation Indirect Unilateral pain Central or bilateral pain Acute pain Lateral flexion Indirect Unilateral pain Acute pain Longitudinal distraction gliding Indirect Central or bilateral pain =gliding traction Unilateral pain 9  1-Anterior directed central gliding The tips of the thumbs must be used and the technique has to be delicate. It is suitable for the levels from C2 to C6. It can be used as an early, mid or end range technique (that is, all three grades). Indication Bilateral or central symptoms (pain). 10  1-Anterior directed central gliding Position of the patient The patient lies prone. The head rests in a flexed position, with the forehead in the palms or on the back of the hands. The chin is slightly tucked in. Position of the therapist The therapist stands at the patient's head, facing the patient, The tips of both thumbs (with nails back to back) are placed on the tip of the spinous process at the affected level. The other fingers are spread to each side of the patient's neck in order to stabilize the hands Method Holding the thumbs in apposition, direct the longitudinal axis of the thumbs in a direct postero-anterior direction. Pressure is transmitted through the therapist's thumbs by movement of the trunk and arms Initially the oscillations are gentle and rhythmic (about one or two per second). Ask the patient what he or she is feeling. The depth and amplitude of the mobilization can be increased according to the response. At all times it is important to maintain constant rhythm and depth. 11  2-Anterior directed unilateral gliding This is a very effective technique which is often used. As there is considerable movement over the apophyseal joint it can be highly effective through all three stages. Indication Unilateral cervical pain. especially for the common dysfunction of C2-C3 - the 'headache' joint. It is used for the lateral joints from C2-C3 to C6-C7. Position of the patient and therapist As for technique 1. 12  2-Anterior directed unilateral gliding Method The thumbs are placed over the tender level behind the articular pillar about two to three centimeters from the midline. This varies slightly from patient to patient Application of pressure at the C4 level mobilizes the C4-C5 joint. The rhythmical oscillatory movement is transmitted to the thumbs in the usual way. 13  3-Anterior unilateral gliding with head rotation This is a specific method for treatment of the important C1-C2 joint which, like the C2-C3 joint, is often responsible for headache. The method is similar to technique 2 but the head is rotated towards the painful side. 14  3-Anterior unilateral gliding with head rotation Indication Unilateral painful C1-C2 apophyseal joint. Position of the patient and therapist This is similar to technique 2 except that the patient's head is rotated approximately 30 degrees towards the painful side. Method The long axis of the therapist's thumbs is postero-anterior directed but tilted slightly towards the head. 15  4-Rotation The accessory movement is an extremely important technique for treatment of unilateral or bilateral cervical pain. For unilateral pain the head should be rotated away from the painful side. 16  4-Rotation Position of the patient: The patient lies supine lying with the head at the edge of the couch and arms by the side. Position of the therapist: The therapist crouches at the end of the couch over the patient. The patient's head is gently cradled in the therapist's hands with the right forearm and hand snugly embracing the right side of the patient's head and the fingers supporting the chin without pressing against the throat. Method Rotation of the cervical spine is achieved by equal and rhythmic movements of both hands working in union to produce a smooth oscillatory movement around a constant axis of direction. 17  4-Rotation Achieving some specificity for an indirect technique Variations to the accessory rotation technique can be applied to give more specificity for example: - the lower the cervical area to be mobilized, the greater the degree of neck flexion. -For the upper cervical spine the patient's neck is held on the same plane as the body, -For the mid cervical spine the neck is flexed to about 30 degrees. -For the lower cervical spine the neck is flexed to about 45 degrees. -Localization is achieved by placing the hand over the appropriate level. 18  5- Lateral flexion Mobilization in lateral flexion is often underrated, but it can be a very effective technique. It can be used effectively when rotation is painful and restricted because this means that lateral flexion is also restricted and limiting rotation. Lateral flexion mobilization can be used as a general or as a specific technique, depending on whether the objective is to mobilize the entire cervical spine or only one or two levels. 19  5- Lateral flexion To achieve specificity at a given level, the proximal aspect of the lateral border of the index finger of the near hand applies pressure on the neck against the affected level of the articular pillar. Indications for use Unilateral pain in neck and referred pain. Rotation decreased and, or painful. Lateral flexion decreased and/or painful. Rules of procedure In lateral flexion it is the opposite side that is being handled – for example, if the left side is the side requiring treatment, the neck is flexed to the right because this affects gapping of the stiff joints on the left. Lateral flexion is therefore away from the painful side. The head is used as a body lever. Lateral flexion is most effective as a stage 2 or 3 procedure. 20  5- Lateral flexion Position of the patient The patient lies supine with the head resting on the couch (the head can be taken over the end of the couch for the procedure but it is not necessary). Position of the therapist The therapist stands above the patient and to the side, that is, alongside the shoulder opposite to the painful side. Note: this method is shown for a painful left side. The patient's head is cradled in a neutral position mid-way between flexion and extension (for the upper cervical spine) and slightly flexed for treating the lower cervical spine. One hand cradles the occiput while the other is placed at the base of the neck (or at a specific level) with the thumb resting anteriorly and to the side and the four fingers curled posteriorly around the neck with the palmar surface of the index finger wedged against the articular pillar. 21  5- Lateral flexion Method The patient's head is laterally flexed away from the painful side and firmly held against the therapist's body. The lateral flexion mobilization is produced by an oscillatory movement between the therapist's hands assisted by rocking the therapist's hips from side to side with a combined forward and side movement of the right side of the pelvis (for this particular patient). During this procedure the near hand on the neck acts as a fulcrum against the articular pillar and thus achieves gapping on the opposite side of the spine. 22  6- Longitudinal distraction gliding (traction) Traction, which is an excellent and safe method, can be administered by machines but can also be applied manually, including by the use of a belt. It is an underrated technique and is often most effective when used manually. Indications include: Nerve root irritation Irritable spine Headache Wry neck Severe degenerative changes 23  6- Longitudinal distraction gliding (traction) Position of the patient The patient lies supine, relaxed with arms by the side. The head can be supported at the end of the couch or just over the couch. Position of the therapist The therapist stands at the head of the couch facing the patient. One hand clasps the occiput just above the atlanto-occipital joint with the thumb wedged under the mastoid process of one side and the middle finger under the opposite mastoid process. The other hand holds the chin (it may be necessary to use the lower three fingers only, to avoid undue pressure on the upper throat) with the forearm resting alongside the patient's face Method Traction is achieved by using body weight, and not the arms, which quickly fatigue. This implies placing the feet to take a firm and comfortable stance, and leaning back during the traction. The steady controlled traction stretches the cervical spine. 24  6- Longitudinal distraction gliding (traction) Precautions Avoid traction to an extended neck Note: The traction force should be taken up slowly and released gently never suddenly. Sudden release will exacerbate an irritable condition. -The upper cervical spine ( occiput to C2-C3): the head should be in a neutral position for traction -The mid cervical spine (C3-C4 and C4-C5): the head should be lifted off the couch at an angle of 30 degree -The lower cervical spine(C5-C6 and C7-T1): the angle of the neck to the couch should be about 45 degree 25  Summary Cervical mobilization is a vital basic skill for the beginner in manual therapy to master. If a therapist does not wish to use – cervical manipulation, then mobilization alone will be very effective It can be rendered more specific by placement of the therapist's hand at the affected level or by placing the neck in varying degrees of flexion. As for the other techniques, it is essential to rotate or flex away from the painful side and not to aggravate the patient's pain Anterior directed (postero-anterior) gliding techniques give excellent results and are very specific but may not be possible in the acutely tender neck. Rotation mobilization is the appropriate first line treatment in these cases. 26  THANK YOU November 4, 2024 Prof.Dr:Amir Saleh Ph.D,P.T 27