MRAT 211

Lecture
CERVICAL REHABILITATION
Moriones, Adrienne Joi A. || BSPT 2 A-1
Causes - Failure in treating the underlying pathologic
lesion
- Osteoarthritis - Persistent pain or tightness resulting from MTrP
- Discogenic disorders even after complete elimination of the
- Trauma underlying pathology
- Tumors - Intolerable pain resulting from MTrP
- Infection - Pain or discomfort interfering with functional
- Myofascial pain syndrome activity
- Torticollis
- Whiplash Fibromyalgia
- Congetinal deformities
“chronic condition characterized by widespread pain
Cervical Cervical Cervical that covers half of the body (right or left half, upper or
Spondylosis Spinal Disc lower half and has lasted for more than 3 months)”
Stenosis Herniation
May be May be - Noninflammatory condition
Pain Unilateral unilateral or unilateral (MC)
bilateral or bilateral o Generalized musculoskeletal pain
Usually several o Tenderness to touch in a large number
Distribution of Into affected Into affected
dermatomes of specific areas of the body
pain dermatomes dermatomes
affected
Pain on May increase
o Wide array of associated symptoms
Increases Increase
extension (MC)
May increase Primary Fibromyalgia
Pain of flexion Decreases Decreases or decrease
(MC) - “Pure” FMS having no association with any
Pain relieved other medical condition
No Yes No
by rest
Age group 60% of >45yr 11-70 yr Secondary Fibromyalgia
17-60yr
affected 85% of >65yr MC: 30-60yr
Instability Possible No No
Levels
- Associated with another medical condition
commonly C5-C6, C6-C7 Varies C5-C6 o Ex. RA, SLE, hyperthyroidism
affected
Slow (may be Co-Morbidities
combined with
Onset Slow spondylosis or sudden - Depression - Chronic Fatigue
disc
hermniation) - Anxiety - Endocrinopathies
- Insomnia - irritable bowel syndrome
- Cognitive dysfunction
Myofascial Pain Syndromes - Dysfunction of the autonomic system
Signs & Symptoms Clinical Signs & Symptoms
- Motor aspect - Widespread pain lasting more than 3 months
o Disturbed motor function - Widespread local tenderness
o Muscle weakness
o Stiffness Primary musculoskeletal Symptoms
o LOM
- Aches and pains
- Sensory aspect
- Stiffness
o Referred pain
- Swelling in soft
o Local tenderness
tissue
o Peripheral & central sensitization
- Tender points
▪ Allodynia
- Muscle spasms
▪ Hyperalgesia
or nodules
Myofascial Trigger Points

- Minimum criteria
o Taut band
o Trigger point in that taut band

Indications for inactivation of myofascial trigger points

- Unable to identify the underlying pathology of

MTrP activation
Aggravating Factors o Associated with injury to cranial nerves
VI-XII and neurapraxia of the
- Cold suboccipital and greater occipital
- Stress nerves
- Excessive or no exercise o Neck pain or a feeling of “instability”
- Physical activity (overstretching) - Jefferson fracture: a 4-part fracture of the
Relieved by atlas
- MC injuries – 2-part and 3-part
- Warmth or heat
- Rest C2 Pars Interarticularis
- Exercise (gentle stretching) - AKA hangman’s Fracture
Clinical Signs & symptoms - MOI: hyperextension and axial load
- Manifestations:
- Temperature dysregulation o Pain, instability, or both are present
o Raynaud’s Phenomenon; cold-induces o Patient may have neurologic
vasospasm (hypersensitivity to cold) compromise
o Hypothermia (mild decrease in core o May be associated with cranial nerve,
body temperature) vertebral artery, or craniofacial injuries
- Dyspnea, dizziness, syncope o Disruption of the C2-C3 disk causes
- Headache (throbbing occipital pain) marked instability
Differentiating MPS from FMS C2 Odontoid Process FRacture

MPS FMS
Trigger points Tender points

Localized musculoskeletal
Systemic Condition
condition

No associated sign and Wide array of associated

symptoms signs and symptoms
Symptoms
Etilogy: overuse, repetitive Etiology: neurohormonal
motions; reduced muscle imbalance; autonomic - Pain
activity nervous system dysfunction o May refer to the shoulders and arm
- Stiffness
- Deformity
Cervical Strains & Sprains (Whiplash Injury)
o Wry neck or excessive flexion or
- Manifestations extension
o Pain is the chief complaint - Numbness, tingling, & weakness
o Local tenderness o Nerve root impingement
o Decreased ROM - Headache
o Headaches, typically occipital - Tension
o Blurred or double vision
Signs
o Dysphagia, hoarseness, jaw pain,
difficulty with balance, vertigo - No examination of the neck is complete without
examination of the upper trunk, both upper
Cervical Features
limbs, and sho8ulder joints
- Occipital condyle fracture
Signs & symptoms arising from cervical spine
- Occipito-cervical dislocation Pathology
- C1 ring fracture Signs Sypmtoms
- C2 pars interarticularis Anesthesia (lack of Arms and leg pain and
- C2 odontoid process fracture sensation) ache
- Wedge compression fracture Ataxia Auditory disturbance
Atrophy Cough
- Burst and compression-flexion (tear-drop)
Asymmetry Depressed mood
fracture Drop attack Diarrhea
Dysesthesia (abnormal Diplopia
C1 ring Fracture sensation) Dizziness
Falling Fatigue
- MOI: axial compression with elements of
Fasciculation Gait disturbance
hyperextension and asymmetric loading of Hyperesthesia Headache
condyles (increased sensitivity) Insomnia
- Manifestations: Nystagmus Muscle twitch
o Vertebral artery injuries may cause Pathologic gait Paresthesia
basilar insufficiency: vertigo blurred Sweating or lack of Poor balance
sweating “restless arms & Legs”
vision, and nystagmus Tender bones Sneeze
 Tender muscles Speech disturbance
Tender scalp Stiff neck
Transient loss of Threatened faint Palpation
hearing, consciousness, Tinnitus
sight Torticollis
Upper Extremity Vertigo
weakness Visual Disturbance

Look

- Search for deformities

o Wryneck
o Stiffness Anterior Muscles of the Neck

Mylohyoid
Suprahyoid
Stylohyoid
Muscles
Hyoid bone

Omogyoid
Thyroid Cartilage
Infrahyoid
Sternohyoid
Muscles
Cricothyroid

Sternocleidomastoid

Observation Trapezius

Omohyoid
- Head and neck (inferior belly)

Digastric (ant. Belly) Suprahyoid

Observation Digastric (post. Belly) Muscles
- Shoulder levels Levator Scapulae
- Muscle spasm or any asymmetry Longus Capitis
- Facial expression Scalenes
- Boney and soft-tissue contours
- Evidence of ischemia in either upper limb Thyrohyoid Infrahyoid
Sternothyroid Muscles
- Normal sitting

Feel
Thyroid Gland
- Anterior Cervical Muscles
o Longus capitis and longus colli muscles Clavicle
o Scaleneus anterior, medius, and
posterior muscles
o Sternocleidomastoid muscles
- Posterior Cervical Muscles
o Suboccipital muscles
o Transversospinal Muscles
o Erector Spinae Muscles
 than extension and left side
bending
Flexion & right-side bending
restriction equal to extension *
left-side flexion
Semispinalis Capitis Side bending in neutral,
flexion, and extension
Left subluxation
Left capsular pattern (arthritis)
Left arthrofibrosis (very hard
capsular end feel)
Uncovertebral hypomobility or
anomaly

Splenius Capitis
Cervical Myotomes

- Neck flexion: C1 to C2
Levator Scapulae
- Neck side flexion: C3 and Cranial nerve XI
Splenius Cervicis - Shoulder elevation: C4 and CN XI
- Shoulder abd/shoulder LR: C5
Serratus Posterior - Elbow Flexion and wrist extension: C6
Superior
- Elbow extension and wrist flexion: C7
Rhomboideus - Thumb extension and ulnar deviation: C8
Minor - Abduction and adduction of hand intrinsics: T1

Rhomboideus Functional Assessment of the Cervical Spine

Major
- Breathing
o Normal. Unlabored breathing should be
seen with the mouth closed
o No gulping or gasping
- Swallowing
Rectus Capitis Posterior minor
o A complex movement involving
Rectus Capitis Posterior major muscles of the lips, tongue, jaw, soft
Oblique Capitis Superior palate, pharynx, and larynx as well as
the suprahyoid and infrahyoid muscles
Oblique Capitis Inferior
- Looking up at the ceiling
Longissimus Capitis o At least 40deg to 50deg of neck
Splenius Cervicis extension is usually necessary for
Levator Scapulae everyday activities
Scolenus Medius ▪ If this range is not available,
the patient will bend the back
Scolenus Posterior or the knees, or both, to obtain
the desired range
- Looking down at belt buckle or shoe laces
Longissimus Cervicis o At least 60deg to 70deg of neck flexion
Iliocostalis Cervicis is necessary
▪ If this range is not available,
Longissimus the patient will flex the back to
Thoracis complete the task
- Shoulder check
Examination o At least 60deg to 70deg of cervical
rotation is necessary
- Active movements
▪ If this range is not available.
o Flexion
The patient will rotate the trunk
o Extension
to accomplish this task
o Side flexion left and right
- Tuck Chin In
o Rotation left & right
o This action produces upper cervical
o Combined movements
flexion with lower cervical extension
o Repetitive movements
- Poke chin Out
o Sustained positions
o This action produces upper cervical
Movement restriction & Possible causes extension with lower cervical flexion
Movement restrictions Possible Causes - Neck Strength
Extension & right-side Right extension hypomobility o In athletes, neck strength should be
bending Left flexor muscle tightness approximately 30% of body weight of
Anterior capsular adhesions decrease chance of injury
Right subluxation
- Paresthesia
Right small disc protrusion
Flexion & right-side bending Left flexion hypomobility o Referred to the hands, may make
Left extensor muscle tightness cooking and handling utensils
Extension & right-side Left posterior capsular particularly difficult or even dangerous
bending restriction greater adhesions
 Starting Action Functional Test - With the chin maximally retracted and
Position
maintained isometrically
6-8 rep: Functional
Lift head keeping - Patient lifts head and neck until head is ~ 1 inch
Supine 3-5 rep: functionally fair
chin tucked in
Lying
(neck Flexion)
1-2 rep: functionally poor above plinth keeping chin retracted to the chest
0 rep: Nonfunctional
Hold 20-25 secs: functional Special Tests
Lift head backward Hold 10-19 secs: Functionally fair
Prone lying
(neck extension) Hold 1-9 secs: Functionally poor
Hold 0 secs: Nonfunctional
- Foraminal Compression (Spurling’s) Test
Side lying - Upper Limb Tension Test (ULTT)
Lift head sideways
(pillows
away from pillow
Hold 20-25 secs: functional - Jackson compression Test
under head Hold 10-19 secs: Functionally fair
so head is
(neck side flexion)
Hold 1-9 secs: Functionally poor
- Distraction test
(must be repeated - Shoulder abduction Relief Test
not side Hold 0 secs: Nonfunctional
for other side)
flexed) - Valsalva Test
Lift head off bed
and rotate to one
- Tinel’s for Brachial Plexus
Hold 20-25 secs: functional - Romberg’s test
side keeping head
Supine Hold 10-19 secs: Functionally fair
off bed or pillow - Tinel’s for Brachial Plexus
lying Hold 1-9 secs: Functionally poor
(neck rotation)
(must be repeated
Hold 0 secs: Nonfunctional - Lhermitte’s Sign
both ways) - Vertebral Artery (Cervical Quadrant) Test
- Hautant’s Test
- Naffziger’s Test
Outcome Measures - Sharp-Purser Test
- Neck Disability Index (NDI) - Transverse Ligament stress Test
o Capture perceived disability in patients Physical Therapy Intervention
with neck pain
- Patient-specific functional scale (PSFC) - Cervical manipulation/mobilization
o Alternative or supplement to generic o SHOULD be performed as an adjunct
condition-specific measures to exercise
- Thoracic mobilization/manipulation
Cervical Active Range of Motion - Stretching
- The amount of active neck flexion, extension, o Anterior, medial, posterior scalenes;
rotation, and side bending motion measured upper trapezius; levator scapulae;
using an inclinomenter pectoralis minor; and pectoralis major
- Coordination, strengthening, and Endurance
Cervical and Thoracic Segmental Mobility Exercises
- With the patient in prone, cervical and thoracic Physical Therapy Intervention
pine segmental movement and pain response
are assessed - Voluntary contraction and release methods
- Assess the mobility of each joint using the o Muscle energy technique
thumb o Reciprocal inhibition
- (cervical) and hypothenar (thoracic) to check o Post-isometric relaxation
each joint - Upper Quarter and Neck Mobilization
- Traction
Cranial Cervical Flexion Test

- Using pressure biofeedback inflated to

20mmHg
- Give pressure (22, 24, 26, 28 and 30 mmHg)
- Should maintain to 10 secs each stage
- Abnormal response
o Is unable to generate an increase in
pressure of at least 6 mmHg
o Is unable to hold the generated
pressure for 10 secs
o Uses superficial neck muscles to
accomplish the cervical flexion
o Uses a sudden movement of the chin
or pushing the neck forcefully against
the pressure device

Neck Flexor Muscle Endurance Test

- In supine, the ability to lift the head and neck

against gravity for an extended period
- Supine, hook-lying position