MAGDALENA, AIREN MARGARET

CERVICAL SPINE & TMJ ⎯ With herniation, when the nuclear content bulges out,
the spinal nerve may be impinged.
⎯ Neck Pain ⎯ Patient will have neck pain that is referred distally
⎯ Faulty Neck Postures (depending on the nerve root affected.
⎯ Temporomandibular Joint (TMJ) Dysfunction o Sensory loss (numbness and tingling) for
o Any postural deviations of the spine will affect the dermatomal affectation.
mandible o Muscle weakness for myotomal affectation.

NECK PAIN OTHER CAUSES

PAIN SENSTITIVE STRUCTURES: Facet Joint May be d/t tightening of the capsule of
⎯ Anterior dura matter and dural sleeves Dysfunction the superior facet and the inferior facet
⎯ Epidural areolar tissue which may limit the gliding.
⎯ Facet joint capsule
⎯ Ligaments This can lead to pain muscle
guarding LOM.
⎯ Muscles
periosteum of the vertebrae Cervical OA or Thinning of IV Disc which leads to the
Spondylosis approximation of the vertebral bodies.
⎯ Walls of blood vessels
Cervical RA Affects the synovial joints specially for
C1-C2
May lead to secondary impairments such as LOM.
For chronic conditions there may be
MPS
subluxation.
⎯ If this happens, this could lead
⎯ Very common syndrome
to spinal cord injuries
⎯ A chronic regional pain syndrome that affects the
⎯ Important to properly stabilize.
muscle. Localized.
⎯ Characterized by the presence of myofascial trigger
points. PRACTICE DOCUMENTATION:
PT Dx:
⎯ Referred pain.
Inability to perform deskwork d/t pain & LOM in the neck.
⎯ Not limited to neck.
- Focus is activity restriction
⎯ Different from fibromyalgia.
⎯ No swelling. Diff. rotating the neck to the R in isolation c trunk motion
⎯ D/t: d/t pain & muscle guarding.
o Poor posture - Focus is functional limitation.
o Chronic repetitive minor strain
LTG:
Pt will resume work as an office clerk c normal & pain
8 POSSIBLE OBJECTIVE FINDINGS free cervical ROM p 4 wks. of PT sessions.
• Pain in specific part or region of the body - Duration is dependent on the condition and
• Referred pain or altered sensation in an MDDx.
expected body area from a trigger point
• (+) spot tenderness along the length of a STG:
taut band Pt will report dec neck pain from 8/10 – 4/10 p 2 wks. of
5 Major
o Taut band: Adhesion of muscle PT sessions to be able to turn head side-to-side c more
fibers ease.
• Limitation of cervical range of motion
• Taut band palpable in an accessible MANAGEMENT OF NECK PAIN
muscle
• (+) jump sign on the tender spot PROTECTION PHASE
o When you glide a finger over the Intervention Scenario: Restore
nodule, there is the sensation of REHAB INTERVENTIONS
“jumping” GOALS
3 Minor
• Reproduction of symptoms by applying 1. Control ⎯ Pain modulation
pressure on the tender spot pain, spasm, ⎯ Rest, collar, modalities
• Decreased pain when stretching the swelling, o May be cryo/ US/ heating
affected muscle and modalities
To be considered and MPS: 5/5 Major + atleast 1/3 Minor inflammation ⎯ Massage, ischemic compression
(if present) o If RA, be cautious
TORTICOLLIS ⎯ Stretching, traction
2. Improve ⎯ Kinesthetic training, Neutral Spine
⎯ Contraction of the SCM. posture and o Kinesthetic training: Pt should be
⎯ May be congenital or acquired. workstation more aware of safer and pain
o Acquired may be d/t trauma, infection, ergonomics free motions of the spine. Similar
disease process or dystonia to AROM but the focus is the
⎯ Ipsilateral side flexion + Contralateral rotation awareness of the motions.
⎯ Intervention: Stretching, positioning, postural correction, (Hinahanap yung position na
neck brace etc. walang sakit)
⎯ Postural training
WHIPLASH o Chin tucking, proper breathing,
proper positions
⎯ Sudden jolting towards hyperflexion/extension 3. Maintain ⎯ Core stabilization/ Calliet Neck
⎯ Often during vehicular accidents soft tissue Exercise
⎯ Strained posterior and anterior muscles, Ligaments may and joint o Targeting the inner muscles
be sprained integrity and (those closer to the vertebrae)
⎯ Decreased control of neck motion mobility o Relaxed SCM and scalenes
⎯ There may be dizziness, headaches, tinnitus. ⎯ Non-Destructive movements in pain
⎯ Does not usually lead to fracture. free range
o Resolved by 2-3 mos. o Eg. Side flexion: PT stabilizes
o Fairly good prognosis (excellent) while giving isometric resistance.
⎯ Intervention: Collar 4. Maintain ⎯ Basic function training maneuvers.
integrity and o Shoulders, trunk, UE, lower
CERVICAL RADICULOPATHY function of trunk, lumbar spine, pelvis
MAGDALENA, AIREN MARGARET
associated Self-stretching of neck muscles in all planes x 3 reps c 15
areas secs hold each in sitting to maintain or inc neck flexibility.
5. Patient ⎯ Body mechanics, rest, avoid trauma
education

PRACTICE DOCUMENATTION:
P:
ICT in supine c neck flexed 25º X 5kg max force; 2kg min
force x 8s pull release x 20 mins to dec muscle spasm

Massage using effleurage, kneading, picking up, wringing,

friction and pulling x 15 mins on (B) upper traps in sitting
to loosen adhesions and dec trigger points.

Kinesthetic training on all motions of the cervical spine x

10 reps x 1 set each to identify neutral sine & development
awareness of safe neck motions

Calliet neck exercises on all planes x 10 reps x 6 secs hold

to maintain muscle integrity.

CONTROLLED MOTION PHASE

Intervention Scenario: Restore
REHAB GOALS INTERVENTIONS
1. Continue to ⎯ Pain modulation
reduce pain and ⎯ Awareness, ergonomics
tenderness ⎯ Ischemic compression,
stretching

Decreased dependence on the

modalities
INTERVENTIONS: NECK PAIN WITH MOBILITY
2. Improve muscle ⎯ Kinesthetic training DEFICITS
performance ⎯ Dynamic stabilizations ACUTE (protection stage)
o May progress to manual For patients with acute neck pain with mobility deficits:
resistance (isotonic) B. Clinicians should provide thoracic manipulation, a
⎯ Extremity strengthening program of neck ROM exercises, and
o Consider shoulder, UE, scapulothoracic and upper extremity strengthening
and trunk to enhance program adherence.
3. Increase range of ⎯ Stretching and mobilization C. Clinicians may provide cervical manipulation and/or
motion, joint play and mobilization.
soft tissue mobility
4. Improve function ⎯ Functional retraining SUBACUTE (controlled motion)
⎯ Evaluation of the pt For patients with subacute neck pain with mobility deficits:
occupation and then try to
simulate the activities B. Clinicians should provide neck and shoulder girdle
o Aerobic conditioning endurance exercises.
⎯ Sitting and standing postural C. Clinicians may provide thoracic manipulation and
exercises cervical manipulation and/or mobilization.
5. Patient education o Postural stress management
and relaxation CHRONIC (return to function)
For patients with chronic neck pain with mobility deficits:
PRACTICE DOCUMENATTION: B. Clinicians should provide a multimodal approach of
P: the following:
Kinesthetic training on all motions of the cervical spine x o Thoracic manipulation and cervical
10 reps x 1 set each to identify neutral spine & develop manipulation or mobilization
awareness of safe neck motions o Mixed exercise for cervical/scapulothoracic
regions: neuromuscular exercise (eg,
Hold-relax stretching on all major muscle groups of the coordination, proprioception, and postural
neck x 3 reps x 15 secs hold to inc. cervical ROM training), stretching, strengthening, endurance
training, aerobic conditioning, and cognitive
Jacobson’s relaxation exercise x 20 mins of (B) UE, head affective elements
& trunk in supine to promote relaxation. o Dry needling, laser, or intermittent
mechanical/manual traction
RETURN TO FUNCTION PHASE C. Clinicians may provide neck, shoulder girdle, and
Intervention Scenario: Restore trunk endurance exercise approaches and patient
REHAB GOALS INTERVENTIONS education and counseling strategies that promote
1. Further improve o Progress exercise an active lifestyle and address cognitive and
muscle performance (endurance, speed, timing) affective factors.
o Aerobic fitness
2. Return to functional o Activity specific training INTERVENTIONS: NECK PAIN WITH MOVEMENT
activities o Work hardening COORDINATION IMPAIRMENTS
3. Increase range of o Maintain fitness level and ACUTE
motion, joint play and safe body mechanics For patients with acute neck pain with movement
coordination impairments (including WAD):
soft tissue mobility
B. Clinicians should provide the following:
PRACTICE DOCUMENATTION:
o Education of the patient to
P:
o Return to normal, nonprovocative preaccident
Aerobic dance exercise c emphasis on head, trunk & UE
activities as soon as possible
motions x 30 mins at 13-25 RPE x 3x per week to maintain
o Minimize use of a cervical collar
or inc. endurance.
o Perform postural and mobility exercises to
decrease pain and increase ROM
(RPE: Rate of perceived exertion)
o Reassurance to the patient that recovery is
expected to occur within the first 2 to 3 months.
MAGDALENA, AIREN MARGARET
B. Clinicians should provide a multimodal intervention FAULTY NECK POSTURES
approach including manual mobilization techniques
plus exercise (eg, strengthening, endurance,
flexibility, postural, coordination, aerobic, and
functional exercises) for those patients expected to FORWARD HEAD FLAT NECK
experience a moderate to slow recovery with POSTURE POSTURE
persistent impairments.
C. Clinicians may provide the following for patients In forward head In flat neck posture,
whose condition is perceived to be at low risk of posture, there is there is an observed
progressing toward chronicity: increased lower decrease in thoracic
o A single session consisting of early advice, cervical and upper curve, scapular and
exercise instruction, and education A thoracic flexion, clavicular depression,
comprehensive exercise program (including increased or excessive and a decrease in

Illustration/ Drawing
strength and/or endurance with/without extension of occiput on cervical lordosis with

Description
coordination exercises) C1 vertebra and upper increased flexion of the
o Transcutaneous electrical nerve stimulation cervical vertebrae occiput on the atlas
(TENS) (Kisner & Colby, 2012). (Kisner & Colby, 2012).
F. Clinicians should monitor recovery status in an The ears are positioned
attempt to identify those patients experiencing anterior to the body with
delayed recovery who may need more intensive observed poking out of (Kisner & Colby, 2012)
rehabilitation and an early pain education program. the chin.
CHRONIC
For patients with chronic neck pain with movement (PhysioPedia, 2021)
coordination impairments (including WAD): Scalenes Anterior neck muscles
C. Clinicians may provide the following: Levator Scapulae • Platysma
o Patient education and advice focusing on Subscapularis • Scalenes
assurance, encouragement, prognosis, and Pectoralis Minor
pain management • Sternocleidomastoid
Pectoralis Major • Suprahyoid muscles
Tight Muscles

o Mobilization combined with an individualized,

progressive submaximal exercise program • Infrahyoid muscles
including cervicothoracic strengthening, Erector Spinae
endurance, flexibility, and coordination, using Scapular retractors
principles of cognitive behavioral therapy • Middle trapezius
o TENS (Kisner & Colby, 2012) • Rhomboids

INTERVENTIONS: NECK PAIN WITH HEADACHES (Kisner & Colby, 2012)

ACUTE Lower cervical muscles Scapular protractors
For patients with acute neck pain with headache: Upper thoracic erector Intercostal muscles of
B. Clinicians should provide supervised instruction in spinae anterior thorax
active mobility exercise. Scapular retractor (Kisner, 2012)
C. Clinicians may provide C1-2 self-sustained natural muscles
apophyseal glide (self-SNAG) exercise. • rhomboids Anterior and posterior
• middle trapezius paraspinal muscles
Lengthened Muscles

SUBACUTE Anterior throat muscles Suboccipital muscles

For patients with subacute neck pain with headache: • suprahyoid (Asher, 2020)
B. Clinicians should provide cervical manipulation and
• Infrahyoid
mobilization.
Capital flexors
C. Clinicians may provide C1-2 self-SNAG exercise.
• rectus capitis
CHRONIC anterior and
For patients with chronic neck pain with headache: lateralis
B. Clinicians should provide cervical or cervicothoracic • Superior oblique
manipulation or mobilizations combined with longus colli
shoulder girdle and neck stretching, strengthening, • longus capitis
and endurance exercise.
(Kisner & Colby, 2012)
INTERVENTIONS: NECK PAIN WITH RADIATING PAIN
ACUTE
For patients with acute neck pain with radiating pain:
C. Clinicians may provide mobilizing and stabilizing
exercises, laser, and short-term use of a cervical
collar.

CHRONIC
For patients with chronic neck pain with radiating pain:
B. Clinicians should provide mechanical intermittent
cervical traction, combined with other interventions
such as stretching and strengthening exercise plus
cervical and thoracic mobilization/ manipulation.
B. Clinicians should provide education and counseling
to encourage participation in occupational and
exercise activities.
MAGDALENA, AIREN MARGARET
Kisner • fatigue of muscles TEMPOROMANDIBULAR JOINT (TMJ)
• stress to anterior • compression of DYSFUNCTION
longitudinal neurovascular Intervention Scenario: Restore
ligament in the bundles in the
upper C spine thoracic outlet 3 CARDINAL SIGNS:
• stress to the • TMJ pain due to 1. Pain
posterior occlusion 2. Clicking noise during movement
longitudinal decrease in shock 3. LOM
ligament and absorbing function of the
ligamentum flavum spinal curvatures MANAGEMENT OF TMJ DYSFUNCTION
in the lower cervical REHAB GOALS INTERVENTIONS
and thoracic spine 1. Decrease pain and ⎯ Modalities, massage, and
• fatigue of thoracic muscle guarding relaxation exercises
erector spinae and o US, IRR, Ice massage
scapular retractors 2. Increase facial ⎯ Tip of tongue on hard palate
• irritation of joint muscle relaxation, and exercise
Potential Sources of Symptoms

facets in the upper tongue proprioception ⎯ Air puffing

C spine and control o For relaxation
• narrowing of ⎯ Tongue clicking
intervertebral 3. Improve strength ⎯ Opening and closing of the
foramina and control of jaw mouth in front of the mirror
• impingement mucles (for visual feedback)
and/or strain of the ⎯ Lateral movement opposite
neurovascular the deviation; pain free
bundle in the ⎯ Progress with resistance
thoracic outlet 4. Increase mobility of ⎯ Passive stretching
• impingement of the jaw ⎯ Joint mb techniques
cervical plexus 5. Reduce upper ⎯ Stretching and relaxation
from muscle quarter muscle ⎯ Postural re-education
tightness (levator imbalances and
scapulae) improve posture
• impingement of the 6. Patient education ⎯ Eat soft food
greater occipital ⎯ Avoid too much jaw opening
nerves from a tight and firm biting
trapezius ⎯ Avoid jaw clenching,
• joint compression chewing gum, clenching
of the TMJ from pipe or cigar, nail biting,
joint malalignment chewing pencil or leaning
• lower cervical disc on the jaw
lesions
• Effects of gravity Not a common postural PRACTICE DOCUMENATTION:
• Slouching deviation, but may occur PT Dx:
• Poor ergonomic due to exaggeration of Limited jaw opening d/t R TMJ pain.
alignment in the the military posture
work or home (Kisner & Colby, 2012). Diff. eating d/t pain & LOM on (L) TMJ (better(
Common Causes

environment.
• Continued LTG:
slouching and Pt will be able to eat a quarter pounder burger s pain & diff
overemphasis on p 5 wks of PT sessions
flexion exercises in
general exercise STG:
programs. Pt will demonstrate in AROM in jaw opening from 2mm to
4 mm p 3 wks of PT sessions to be able to take in a
(Kisner & Colby, 2012) spoonful amount if food
(1)HMP x 20 mins on (1)Cervical HMP x 20
the upper back in prone min on posterior neck x INTERVENTIONS:
position to promote in short sitting & neck in Cont. US using small head x 1 MHz X 1.5 W/cm2 X 5 mins
relaxation & inc. tissue end-range flexion to inc. using direct method on R TMJ in (L) side-lying to dec. pain
extensibility. tissue extensibility.
Massage using light effleurage on B side of the fce x 5
(2)Hold-relax stretching (2)Manual Stretching x mins in supine to promote relaxation of facial &
x 3 reps x 15secs hold 10 reps x 15 secs hold mastication muscles.
towards cervical on neck extension in
extension & lateral sitting to dec. tightness AROM ex towards jaw opening, protrusion & B excursion
Therapeutic Interventions

flexion in sitting to inc. of anterior neck x 10 reps x 2 sets each in short sitting facing a mirror to
ROM. muscles. improve control of jaw motions.

(3)Postural training in (3)Kinesthetic training on PATIENT EDUCATION FOR TMJ DYSFUNCTION

sitting by doing axial all motions of the cervical
extension (cervical spine X 10 reps X 1 set
retraction) x 5 reps x 2 each to identify neutral
sets to correct forward spine
head posture.
(4)Manual Resistance x
(4)Manual Resistance x 10 reps x 2 sets towards
10 reps x 2 sets towards scapular protraction
capital flexion in sitting while pt. in T-position in
position to inc. muscle sitting to strengthen
strength. scapular protractors.
Mnemonic RTTPB
R Relax completely
T Teeth apart (say “Emma”)
Tongue on palate (“cluck tongue on palate and leave
T
on roof of mouth)
Posture (imagine strings from back of head and front
P
of sternum pulling to ceiling)
B Breathing (nasodiaphtagmatic not mouth breathing)
Performed hourly and indefinitely to check aggravating
behaviors

To remember:
“Relaxation Techniques Teach Proper Breathing”
MAGDALENA, AIREN MARGARET

SUMMARY

NECK PAIN
⎯ MPS
⎯ Torticollis
⎯ Whiplash
⎯ Radiculopathy
⎯ Others

FAULTY NECK POSTURES

⎯ Forward head
⎯ Flat Neck

TMJ DYSFUNCTION
⎯ TMJ
⎯ Dysfunction