Recuperare Coloana

Original Article:http://www.mayoclinic.
com/health/spinal-cord-injury/DS00460/
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Spinal cord injury

Overview
In 1995, actor Christopher Reeve fell off a horse and severely damaged his spinal cord, leaving him paralyzed
from the neck down. From then until his death in 2004, the silver screen Superman became the most famous face
of spinal cord injury. But he was not alone. Every year, about 11,000 Americans experience a traumatic spinal
cord injury. Many other people develop nontraumatic spinal cord injuries, due to infection or chronic conditions.
A diagnosis of spinal cord injury can be devastating. The sudden presence of disability can be frightening,
frustrating and confusing to those affected and their families and friends. They naturally wonder how spinal cord
injury will affect their everyday activities, their jobs, their relationships, their dreams and their long-term happiness.
Most trauma to the spinal cord causes permanent disability or loss of movement (paralysis) and sensation below
the site of the injury. Paralysis can involve all four extremities, a condition called quadriplegia or tetraplegia, or
only the lower body, a condition called paraplegia.
But there is good news. Christopher Reeve's celebrity and advocacy raised national interest, awareness and
research funding for spinal cord injury. Many scientists are optimistic that important advances will restore some
function in people with a spinal cord injury within the next 10 to 25 years. In the meantime, medications,
rehabilitation and counseling allow many people with spinal cord injury to lead happy, active, independent lives.
Signs and symptoms
The signs and symptoms of a spinal cord injury depend on two factors:
 The location of the injury. In general, injuries that are higher in the spinal
cord produce more paralysis. For example, a spinal cord injury at the neck level
may cause paralysis in both arms and legs and make it impossible to breathe
without a respirator, while a lower injury may affect only the legs and lower parts
of the body.
 The severity of the injury. Spinal cord injuries are classified as partial or
complete, depending on how much of the cord width is damaged. In a partial
spinal cord injury, which may also be called an incomplete injury, the spinal cord
is able to convey some messages to or from the brain. So people with partial
spinal cord injury retain some sensation and possibly some motor function
below the affected area. A complete injury is defined by complete loss of motor
function and sensation below the area of injury. However, even in a complete
injury, the spinal cord is almost never completely cut in half. Doctors use the
term "complete" to describe a large amount of damage to the spinal cord. It's a
key distinction because many people with partial spinal cord injuries are able to
experience significant recovery, while those with complete injuries are not.
Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:
 Pain or an intense stinging sensation caused by damage to the nerve fibers

in the spinal cord
 Loss of movement
 Loss of sensation, including the ability to feel heat, cold and touch
 Loss of bowel or bladder control
 Exaggerated reflex activities or spasms
 Changes in sexual function, sexual sensitivity and fertility
 Difficulty breathing, coughing or clearing secretions from the lungs
Emergency signs and symptoms

Emergency signs and symptoms of spinal cord injury after a head injury or accident may include:
 Fading in and out of consciousness

 Extreme back pain or pressure in the neck, head or back
 Weakness, incoordination or paralysis in any part of the body
 Numbness, tingling or loss of sensation in the hands, fingers, feet or toes
 Loss of bladder or bowel control
 Difficulty with balance and walking
 Impaired breathing after injury
 An oddly positioned or twisted neck or back
Causes
Together, your spinal cord and your brain make up your central nervous system, which controls most of the
functions of your body. Your spinal cord runs approximately 15 to 17 inches from the base of your brain to your
waist and is composed of long nerve fibers that carry messages to and from your brain. These nerve fibers feed
into nerve roots that emerge between your vertebrae — the 33 bones that surround your spinal cord and make up
your backbone. There, the nerve fibers organize into peripheral nerves that extend to the rest of your body.
Injury may be traumatic or nontraumatic

A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine that fractures, dislocates,
crushes or compresses one or more of your vertebrae. It may also result from a gunshot or knife wound that
penetrates and cuts your spinal cord. Additional damage usually occurs over days or weeks because of bleeding,
swelling, inflammation and fluid accumulation in and around your spinal cord. Nontraumatic spinal cord injury may
be caused by arthritis, cancer, blood vessel problems or bleeding, inflammation or infections, or disk degeneration
of the spine.
Whether the cause is traumatic or nontraumatic, the damage affects the nerve fibers passing through the injured
area and may impair part or all of your corresponding muscles and nerves below the injury site. Spinal injuries
occur most frequently in the neck (cervical) and lower back (thoracic and lumbar) areas. A thoracic or lumbar
injury can affect leg, bowel and bladder control, and sexual function. A cervical injury may affect breathing as well
as movements of your upper and lower limbs.
The spinal cord ends at the lower border of the first vertebra in your lower back — known as a lumbar vertebra.
So injuries below this vertebra actually don't involve the spinal cord. However, an injury to this part of your back or
pelvis may damage nerve roots in the area and may cause some loss of function in the legs, as well as difficulty
with bowel and bladder control and sexual function.
Common causes of spinal cord injury

The most common causes of spinal cord injury in the United States are:
 Motor vehicle accidents. Auto and motorcycle accidents are the leading
cause of spinal cord injuries, accounting for approximately 50 percent of new
spinal cord injuries each year.
 Acts of violence. Since 2000, 11 percent of spinal cord injuries have
resulted from violent encounters, primarily involving gunshot wounds.
 Falls. Spinal cord injury after age 65 is often caused by a fall. Overall, falls
make up approximately 24 percent of spinal cord injuries.
 Sports and recreation injuries. Athletic activities such as impact sports and
diving in shallow water cause about 9 percent of spinal cord injuries.
 Diseases. Cancer, infections, arthritis and inflammation of the spinal cord
also cause spinal cord injuries each year. The exact number isn't known, but
some estimates suggest that the number could equal or exceed the number of
people with traumatic spinal cord injuries each year.
Risk factors
Although a spinal cord injury is usually the result of an unexpected accident that can happen to anyone, some
groups of people have a higher risk of sustaining a spinal cord injury. These include:
 Men. Spinal cord injury affects a disproportionate amount of men. In fact,

women account for only about 20 percent of spinal cord injuries in the United
States.
 Young adults and seniors. People are most often injured between ages 16
and 35. But there is another peak in people older than 60. Motor vehicle
crashes are the leading cause of spinal cord injury for young people, while falls
cause most injuries in older adults. However, in some cities, acts of violence —
such as gunshot wounds, stabbings and assaults — are a major cause of spinal
cord injury.
 People who are active in sports. Sports and recreational activities cause up
to 9 percent of the 11,000 spinal cord injuries in the United States each year.
High-risk athletic activities include football, rugby, wrestling, gymnastics, diving,
surfing, ice hockey and downhill skiing.
 People with predisposing conditions. A relatively minor injury can cause
spinal cord injury in people with conditions that affect their bones or joints, such
as arthritis or osteoporosis.
When to seek medical advice
Spinal cord injury isn't always obvious. Numbness or paralysis may result immediately after a spinal cord injury or
gradually as bleeding or swelling occurs in or around the spinal cord. In either case, the time between injury and
treatment is a critical factor that can determine the extent of complications and the level of recovery.
Anyone who has experienced significant trauma to the head or neck needs immediate medical evaluation for the
possibility of spinal cord injury. In fact, it's safest to assume that trauma victims have a spinal cord injury until
proved otherwise.
If you suspect that someone has a back or neck injury, don't move the injured person. Permanent paralysis and
other serious complications may result. Instead, take these steps:
 Dial 911 or call for emergency medical assistance.

 Keep the person still.
 Place heavy towels on both sides of the neck to prevent it from moving, until
emergency care arrives.
 Provide basic first aid, such as stopping any bleeding and making the person
comfortable, without moving the head or neck.
Screening and diagnosis
Paramedics and emergency workers are trained to treat people who have suffered a traumatic head or neck injury
as if they have a spinal cord injury or an unstable spinal column, until a thorough screening and diagnosis can be
completed. A key step in the initial treatment is immobilizing the spine.
Immobilizing the spine can prevent injury to the spine or prevent worsening of any injury that is already present.
For this reason, emergency personnel receive training in handling an injured person without moving the neck and
back. They use rigid collars around the injured person's neck and place the injured person on a rigid board, until a
complete evaluation can take place.
In the emergency room, a doctor may be able to rule out spinal cord injury by carefully inspecting an injured
person, testing for sensory function and movement, and asking some questions about the accident. But if the
injured person complains of neck pain, isn't fully awake, or has obvious signs of weakness or neurological injury,
emergency diagnostic tests may be needed.
These tests may include:
 X-rays. Medical personnel typically order these tests on all trauma victims
suspected of having a spinal cord injury. X-rays can reveal vertebral problems,
tumors, fractures or degenerative changes in your spine.
 Computerized tomography (CT) scan. A CT scan may provide a better look
at abnormalities seen on an X-ray. This scan uses computers to form a series of
cross-sectional images that can define bone, disk and other problems.
 Magnetic resonance imaging (MRI). MRI uses a strong magnetic force and
radio waves to produce computer-generated images. This test is extremely
helpful for looking at the spinal cord and identifying herniated disks, blood clots
or other masses that may be compressing the spinal cord. But MRI can't be
used on people with pacemakers or on trauma victims who need certain life-
support machines or cervical traction devices.
 Myelography. Myelography allows your doctor to visualize your spinal
nerves more clearly. After a special dye is injected into your spinal canal, X-rays
or CT scans of your vertebrae can suggest a herniated disk or other lesions.
This test is used when MRI isn't possible or when it may yield important
additional information that isn't provided by other tests.
If your doctor suspects a spinal cord injury, he or she may prescribe traction to immobilize your spine, as well as
high doses of the corticosteroid drug methylprednisolone (Medrol). There is some controversy about the use of
this medication due to the small benefits noted in research studies and the possible risks. However, there are no
other medications available at this time. So, methylprednisolone is generally given as soon as possible, and it
must be given within eight hours of injury.
Diagnosis doesn't stop there, though. A few days after injury, your doctor will conduct a neurological exam to
determine the severity of the injury and to predict the likely extent of recovery. This may involve more X-rays,
MRIs or more advanced imaging techniques.
It's often impossible for your doctor to make a precise prognosis right away. Recovery typically starts between a
week and six months after injury, if it occurs, with the majority of recovery taking place within one year. Doctors
generally regard any impairment remaining after 12 to 24 months as likely to be permanent.
However, some people experience small improvements for up to two years or longer. At one point, Christopher
Reeve made national headlines when he regained the ability to move his fingers and wrists and feel sensations
more than five years after he was paralyzed in a horse accident. But many not-so-famous folks with a spinal cord
injury have made similar strides away from the media spotlight. And doctors are researching ways to improve late
recovery.
Complications
If you recently experienced a spinal cord injury, it might seem like every aspect of life just became a lot more
complicated. After all, adapting to life with a disability — often in a wheelchair — is no easy task.
You'll likely experience many thoughts and emotions after the injury. And you'll likely have concerns about how
your injury will affect your lifestyle, your financial situation and your personal relationships. Grieving and emotional
stress are normal and common. However, if your grief and sadness are affecting your personal care, causing you
to isolate yourself from others, or prompting you to abuse alcohol or other drugs, it's time to seek help.
Depression and alcohol abuse can be common.
Other complications of a spinal cord injury may include:
 Urinary tract problems. A spinal cord injury that affects nerves that run to
the bladder can cause urinary incontinence — the inability to control the release
of urine from your bladder. Loss of bladder control increases your risk of urinary
tract infections. It may also cause kidney infection and kidney or bladder stones.
Drinking plenty of clear fluids and using a catheter — a thin, soft tube that you
insert into your urethra and bladder to drain your urine — several times a day
may help.
 Bowel management difficulties. After a spinal cord injury, voluntary control
of the bowels may be lost or impaired. This can make it difficult for stool to
move through your intestines, or it can result in fecal incontinence — the
inability to control your bowel movements. Eating a high-fiber diet can help
regulate your bowels. Medications and other products are also available to
manage waste elimination.
 Pressure sores. Sitting or lying in the same position for a long period of time
can cause pressure sores, which are also called decubitus ulcers or bedsores.
People with a spinal cord injury are particularly susceptible to pressure sores
because the injury reduces or eliminates sensations, making it difficult to know
when a sore is developing. Changing positions frequently — with help, if
needed — is the best way to prevent these sores.
 Deep vein thrombosis and pulmonary embolism. Sitting for long periods
of time can also decrease blood flow through the veins and cause blood clots to
form. These blood clots can develop in a vein deep within a muscle (deep vein
thrombosis), and they can lead to a blocked pulmonary artery in the lungs
(pulmonary embolism). Large clots that block blood flow can be fatal, so people
with spinal cord injury may need devices or medications to try to prevent
clotting.
 Lung and breathing problems. It's more difficult to breathe and cough with
weakened abdominal and chest muscles, so people with cervical and thoracic
spinal cord injury may develop pneumonia, asthma or other lung problems.
Medications and therapy can treat these problems. In some instances, people
with spinal cord injury may also need a yearly flu shot or other immunizations.
 Autonomic dysreflexia. Spinal cord injury above the middle of the chest
may cause a condition called autonomic dysreflexia. This dangerous condition
occurs when an irritation or pain below the level of the injury sends a signal that
fails to reach the brain, producing a reflex action that can constrict blood
vessels. The result is a rise in blood pressure and a drop in heart rate that can
result in stroke or seizure. Changing positions or eliminating the cause of the
irritation — which can be something as simple as a full bladder or tight clothes
— can help.
 Spasticity. Some people with spinal cord injury develop muscle spasms and
jumping of their arms and legs. Unfortunately, this doesn't mean that they're
recovering. These exaggerated reflexes occur because some of the nerves in
the lower spinal cord become more sensitive after injury and cause muscle
contractions. However, because of the spinal cord injury, the brain can no
longer send signals to the lower nerves to regulate the contractions. Medical
treatments may be needed if spasms become severe.
 Weight control issues. After a spinal cord injury, weight loss and muscle
atrophy are common. But the change in lifestyle and activities may eventually
cause weight gain, which can make it difficult for you to lift yourself — or be
lifted — from place to place and put you at risk of heart disease and other
problems. It's a good idea to develop an exercise and diet plan with assistance
from a dietitian and rehabilitation therapist.
 Sexual dysfunction. Many men with a spinal cord injury still have erections,
even men with little sensation in the genital area. But the erections may not be
firm enough or last long enough for sexual activity. Fertility also can be affected.
Ninety percent of men with a spinal cord injury aren't able to ejaculate during
intercourse. However, this doesn't mean that men with a spinal cord injury can't
be sexually active or father a child. Doctors, urologists and fertility specialists
who specialize in spinal cord injury can offer options for better sexual
functioning and fertility. Women with a spinal cord injury also may benefit from
seeing a doctor about changes in their sexuality and fertility. There's usually no
physical change in women with a spinal cord injury that inhibits sexual
intercourse or pregnancy. But women may lose the ability to produce vaginal
lubrication or control the vaginal muscles, and many experience changes in
body image that affect sexuality. In addition, any pregnancy will likely be
considered high risk. It's important to talk with a doctor before becoming
pregnant.
 Pain. You may experience pain as a result of damage to your spinal cord or
other parts of your body during your accident. It's possible to feel pain in areas
of your body where there's little or no sensation. You may also experience pain
from overusing muscles in one part of the body. For example, many people
develop shoulder tendinitis from manually operating a wheelchair for a long
period of time. Any kind of pain can have a negative impact on daily living.
Medications and modified activities can help manage pain.
 New injuries. People with a spinal cord injury are susceptible to injury of any
part of the body that has impaired sensation. Someone with a spinal cord injury
may even receive a burn or cut without realizing it. Take steps to prevent new
injuries and to inspect your body for any cuts or sores that need medical
attention.
Treatment
Fifty years ago, a spinal cord injury was usually fatal. At that time, most injuries were severe, complete injuries
and little treatment was available.
Today, there's still no way to reverse damage to the spinal cord. But modern injuries are usually less severe,
partial spinal cord injuries. And advances in recent years have improved the recovery of patients with a spinal
cord injury and halved the amount of time survivors must spend in the hospital. Researchers are working on new
treatments, including innovative treatments, prostheses and medications that may promote nerve cell
regeneration or improve the function of the nerves that remain after a spinal cord injury.
In the meantime, treatment focuses on preventing further injury and enabling people with a spinal cord injury to
return to an active and productive life within the limits of their disability. This requires urgent emergency attention
and ongoing care.
Emergency actions
Urgent medical attention is critical to minimizing the long-term effects of any head or neck trauma. So treatment
for a spinal cord injury often begins at the scene of the accident.
If you suffer a head or neck injury, you'll likely be treated by paramedics and emergency workers who will attend
to three immediate concerns — maintaining your ability to breathe, keeping you from going into shock and
immobilizing your neck to prevent further spinal cord damage. Emergency personnel typically immobilize the
spine as gently and quickly as possible using a rigid neck collar and a rigid carrying board, which they'll use to
transport you to the hospital.
In the emergency room, doctors focus on maintaining your blood pressure, breathing and neck stabilization and
avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular difficulty, and
formation of deep vein blood clots in the extremities. You may be sedated so that you don't move and cause more
damage while undergoing diagnostic tests for spinal cord injury.
If you do have a spinal cord injury, you'll usually be admitted to the intensive care unit for treatment. You may
even be transferred to a regional spine injury center that has a team of neurosurgeons, orthopedic surgeons,
spinal cord medicine specialists, psychologists, nurses, therapists and social workers with expertise in spinal cord
injury.
In the early stages of paraplegia or quadriplegia, your doctor will treat the injury or disease that caused the loss of
function. Immediate treatment may include:
 Medications. Methylprednisolone (Medrol) is a treatment option for acute

spinal cord injury. This corticosteroid seems to cause some recovery in people
with a spinal cord injury if given within eight hours of injury. Methylprednisolone
works by reducing damage to nerve cells and decreasing inflammation near the
site of injury.
 Immobilization. You may need traction to stabilize your spine and bring the
spine into proper alignment during healing. Sometimes, traction is accomplished
by placing metal braces, attached to weights or a body harness, into your skull
to hold it in place. In some cases, a rigid neck collar also may work.
 Surgery. Occasionally, emergency surgery is necessary to remove
fragments of bones, foreign objects, herniated disks or fractured vertebrae that
appear to be compressing the spine. Surgery may also be needed to stabilize
the spine to prevent future pain or deformity. However, some surgeons believe
it's safer to wait for several days before attempting any surgery.
Ongoing care
After the initial injury or disease stabilizes, doctors turn their attention to problems that may arise from
immobilization, such as deconditioning, muscle contractures, bedsores, urinary infection and blood clots. Early
care will likely include range-of-motion exercises for paralyzed limbs, help with your bladder and bowel functions,
applications of skin lotion, and use of soft bed coverings or flotation mattresses, as well as frequently changing
your position. Hospitalization can last from several days to several weeks, depending on the cause and extent of
the paralysis and the progress of your therapy. But treatment doesn't stop when you check out of the hospital.
Here are some of the ongoing treatments you can expect.
Rehabilitation. During your hospital stay, a rehabilitation team will work with you to improve your remaining
muscle strength and to give you the greatest possible mobility and independence. Your team may include a
physical therapist, occupational therapist, rehabilitation nurse, rehabilitation psychologist, social worker, dietitian
recreation therapist and a doctor who specializes in physical medicine (physiatrist) or spinal cord injury.
During the initial stages of rehabilitation, therapists usually emphasize regaining leg and arm strength,
redeveloping fine-motor skills and learning adaptive techniques to accomplish day-to-day tasks. A program
typically includes exercise, as well as training on the medical devices you'll need to assist you, such as a
wheelchair or equipment that can make it easier to fasten buttons or dial a telephone.
Therapy often begins in the hospital and continues for several weeks in a rehabilitation facility. As therapy
continues, you and your family members will receive counseling and assistance on a wide range of topics, from
dealing with urinary tract infections and skin care to modifying your home and car to accommodate your disability.
Therapists will encourage you to resume your favorite hobbies, participate in athletic activities and return to the
workplace, if possible. They'll even help determine what type of assistive equipment you'll need for these
vocational and recreational activities and teach you how to use it.
Medications. You may benefit from medications that manage the signs, symptoms and complications of spinal
cord injury. These include medications to control pain and muscle spasticity, as well as medications that can
improve bladder control, bowel control and sexual functioning. You may also need short-term medications from
time to time, such as antibiotics for urinary tract infections.
New technologies. Inventive medical devices can help people with a spinal cord injury become more
independent and more mobile. Some apparatuses may also restore function. These include:
 Modern wheelchairs. Improved, lighter weight wheelchairs are making

people with spinal cord injury more mobile and more comfortable. The Food and
Drug Administration has even approved a wheelchair that can climb stairs and
elevate a seated passenger to eye level to reach high places without help.
 Computer devices. Computer-driven tools and gadgets can help with daily
routines. You can use voice-activated computer technologies to answer and dial
a phone, or to use a computer and pay bills. Computer-controlled technologies
can also help with bathing, dressing, grooming, cleaning and reading.
 Electrical stimulation devices and neural prostheses. These
sophisticated devices use electrical stimulation to produce actions. Some are
implanted under the skin and connect with the nervous system to supplement or
replace lost motor and sensory functions. Others are outside the body. They are
often called functional electrical stimulation (FES) systems, and they use
electrical stimulators to control arm and leg muscles to allow people with a
spinal cord injury to stand, walk, reach and grip. These systems are composed
of computer-controlled electrodes that are taped to the skin or implanted under
the skin by a needle and controlled by the user. One of the systems allows
someone with a spinal cord injury to trigger hand and arm movements. These
devices require more research, but they've gained a great deal of attention, in
part because the actor Christopher Reeve was able to rely primarily on an FES
bicycle that used computer-controlled electrodes to stimulate his legs to cycle.
He also had a system implanted to stimulate his breathing.
Prevention
Following this advice may reduce your risk of a spinal cord injury:
 Drive safely. Motor vehicle accidents are the leading cause of spinal cord
injuries. Wear a seat belt every time you drive. Make sure that your children
wear a seat belt or, if they're very young, use a child safety seat. Don't drive
while intoxicated.
 Be safe with firearms. Lock up firearms and ammunition in a safe place to
prevent accidental discharge of weapons. Store guns and ammunition
separately.
 Prevent falls. Use a stool or stepladder to reach objects in high places. Add
handrails along stairways. Place nonslip mats on your bathroom and shower
floor. For young children, use safety gates to block stairs and consider installing
window guards.
 Take precautions when playing sports. Always wear recommended safety
gear. Avoid headfirst moves, such as diving into shallow water, spear tackling in
football, sliding headfirst in baseball and skating headfirst into the boards in ice
hockey. Use a spotter in gymnastics.
Coping skills
An accident that results in paralysis is a life-changing event, whether you've lost movement in your legs and lower
body or all four extremities. Recovery from such an event takes time, but many people who are paralyzed move
on to lead productive and fulfilling lives. The will to live in humans is amazingly strong, and the creativity with
which many affected people lead their lives is great. It's essential to stay motivated and get the support you need.
Grieving
If you're newly injured, you and your family will likely experience a period of mourning and grief that's similar to
the period after the death of a loved one. Although the grieving process is different for everyone, it's common to
experience denial or disbelief, then sadness, anger, bargaining, and, finally, acceptance. However, it may take up
to a year to accept the reality of your disability.
The grieving process is a common, healthy part of your recovery. It's natural — and important — to grieve the loss
of the way you were. But it's also necessary to set new goals and find a way to move forward with your life.
Taking control
One of the best ways to regain control of your life is to educate yourself about your injury and your options for
reclaiming an independent life. A wide range of driving equipment and vehicle modifications is available today.
The same is true of home modification products. Ramps, wider doors, special sinks, grab bars and easy-to-turn
doorknobs make it possible for you to assert your autonomy.
Because the costs of a spinal cord injury can be overwhelming, you may want to find out if you are eligible for
economic assistance or support services from the state or federal government or from charitable organizations.
Your rehabilitation team can help you identify resources in your area.
Talking about your disability

Your friends and family may respond to your disability in different ways. Some may be unfazed by your injury.
Others may be uncomfortable and unsure if they are saying or doing the right thing. And some may have a
difficult time adjusting to the change. They may grieve for the loss of the way your life was before the accident.
They may be scared about the financial challenges and stress that are sure to arise. Or they may be nervous
about their new role as caregiver.
Educating people about your disability is often the best solution. Children are naturally curious and sometimes
adjust rather quickly if their questions are answered in a clear, straightforward way. Adults can also benefit from
learning the facts. Explain the effects of your injury and what your family and friends can do to help. At the same
time, don't hesitate to tell friends and loved ones when they're helping too much. Although it may be
uncomfortable at first, talking about your injury often strengthens your relationships with family and friends.
Dealing with intimacy

Many men and women with a spinal cord injury wonder if they can maintain a romantic, intimate relationship with
a partner. The answer is yes.
However, people with a spinal cord injury often need to address physical and emotional changes that can affect
sexuality. You may need medical treatments or medications to have sexual intercourse. In some cases,
intercourse may not be possible and you and your partner may need to explore and experiment with different
ways to be romantic and intimate. A professional counselor can help couples communicate their needs and
feelings so that they are more comfortable talking about sex and discovering what is fulfilling for both of them.
Taking care of yourself

As you adjust to your disability, allow yourself time to rest and time to process your thoughts and feelings about
your disability. This is also a good time to concentrate on eating a healthy diet and reducing stress.
Good nutrition will help you build enough strength to fully participate in daily activities. A balanced diet will also
help you fight infections and maintain proper body weight. Plus, it will help maintain regular bladder and bowel
functioning and assist in preventing pressure ulcers.
Looking ahead
By nature, a spinal cord injury has a sudden impact on your life and the lives of those closest to you. When you
first hear your diagnosis, you may start making a mental list of all of the things you can't do anymore. However, as
you learn more about your injury and your treatment options, you may be surprised at all of the things you can do.
Thanks to new technologies, treatments and devices, people with a spinal cord injury play basketball and
participate in track meets. They paint and take photographs. They get married, raise children and have rewarding
jobs.
Today, advances in stem cell research and nerve cell regeneration give hope for a greater recovery for people
with a spinal cord injury. Several experimental treatments are being tested around the world. At the same time,
new medications are being developed for people with long-standing spinal cord injuries. No one knows exactly
when new treatments will become available, but you can remain hopeful about the future of spinal cord research,
while living your life to the fullest today.
Aug 22, 2005

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A Typical Day for Spinal Cord Rehabilitation

7:30 a.m. Morning hygiene activities
Skin inspection and care
8:00 a.m. Breakfast
8:30 a.m. Dressing with assistance of Occupational Therapy
9:00 a.m. Activities to improve mobility and function with
Occupational Therapy
10:00 a.m. Activities to improve mobility and function with
Physical Therapy
Transfer techniques
11:00 a.m. Bladder care
Noon Lunch
1:00 p.m. Rest
Skin inspection
2:00 p.m. Lower extremity therapy with Physical Therapy
3:00 p.m. Free time
4:00 p.m. Upper extremity therapy with Occupational Therapy
5:00 p.m. Bladder care
6:00 p.m. Dinner
7:00 p.m. Free time/ Social Activities with Recreational Therapy
8:30 p.m. Bowel care
9:00 p.m. Bath/Shower
9:30 p.m. Skin Inspection and care
10:00 p.m. To bed
Patient education, respiratory care, tracheotomy care, surgical-incision care and medication
administration are incorporated into the day. Throughout the rehab stay, times are also arranged for
meeting with the social worker and psychologist. Daily schedules vary to meet the needs of each patient.

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Spinal Cord Injury Rehabilitation
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Managed by a team of experienced professionals, Good Shepherd's Spinal Cord Injury

Rehabilitation Program is an aggressive, holistic approach to rehabilitation designed to restore
individuals to their highest potential physically, socially, and emotionally. Our Spinal Cord Injury Rehabilitation
Program is directed and monitored by a physician specializing in physical and medical rehabilitation, also known
as a physiatrist.
Throughout the course of treatment, both patient and family become an integral part of the rehabilitation process
and help to identify individual needs and goals. As Good Shepherd's team meets on a regular basis, patient
progress is assessed and treatment goals are developed and adjusted as needed. For more information on the
Good Shepherd Spinal Cord Injury Rehabilitation Program, e-mail us today or call 1-877-734-2247 (8 a.m.-4:30
p.m., Monday-Friday).
Spinal Cord Injury Rehabilitation Program
 Home and work evaluations

 Sexuality counseling
 Community re-integration
 Driver training
 Sports training
 Comprehensive follow-up clinic
 Community resource referrals
 Ongoing consultation with treatment team
 Long-term acute care
 Urodynamic testing
 Ventilator weaning
 Wheelchair clinic
Program Specialties Include:
 Medical management
 Rehabilitation nursing
 Pain rehabilitation
 Continence training
 Physical therapy
 Wheelchair skills training
 Skin care management
 Occupational therapy
 Dysphagia program
 Social work services
 Psychology
 Vocational counseling
 Substance abuse counseling
 Patient/family education
 Recreational therapy
 Pastoral care
Rehabilitation Nursing
Rehabilitation nursing, a specialty of professional nursing, provides care to persons of all ages in order to facilitate
recovery of functional abilities, prevent complications, and restore optimal wellness. Comprehensive rehabilitative
care is provided to patients with a broad spectrum of medical diagnoses and acuity in a collaborative,
interdisciplinary, healthcare model.
Rehabilitation nurses at Good Shepherd vigilantly assess, plan, perform, evaluate, and coordinate rehabilitative
and medical care—around the clock—with a particular emphasis on the dignity and value of each person we
serve. Our average daily ratio is one registered nurse to five patients. This enables us to provide clinical
excellence and compassionate care—the foundation of Good Shepherd’s reputation.
Rehabilitation Nursing Program
 Transfer skills
 Ambulation
 Application of splints, pylons, and CPM machines
 Bed mobility
 Daily living activities
 Dysphagia eating techniques
 Memory improvement techniques
 Communication with aphasic patients
 Safety awareness and fall prevention
 Continence training
 Cognitive/linguistic treatment
 Behavior management
 Crisis prevention and intervention
 Health maintenance
 Complex wound management

 Burn care
 Enterostomal care
 Decubitis care
 Respiratory support services
 Tracheotomy management
 Oxygen therapy
 Chest physiotherapy
 Energy conservation techniques
 Infection prevention and management
 Management of metabolically compromised patients receiving renal dialysis and CAPD
 Management of cancer patients receiving chemotherapy and radiation
 Intravenous therapy: Central and peripheral
 Continuous heparin
 Blood products
 Intermittent antibiotics
 TPN
 Emergency medical support
 Cardiorespiratory emergency protocols
 Management of autonomic dysreflexia
 Nutrition management
 NG tubes
 Peg tubes
 Medication management
 Patient and family education
 Group and individual teaching sessions
 Multimedia instructional methods: video, audio, models, demonstrations
 Patient education literature
 Individual home reference information
Wound Care Program

 Professional skin care and clinical wound management
 Electrical stimulation, ultrasound, and whirlpool therapy
 Manual lymph drainage
 Aquatherapy
 Nutritional counseling
 Family conferences and education
 Physical medicine and rehabilitation

 Psychology
Complex Wound Rehabilitation

| Links |
Good Shepherd's Complex Wound Rehabilitation Program is an integrated system of professional, clinical, and
technical resources designed for the individualized treatment of a variety of wound conditions including ostomies,
wound dehiscence, diabetic arterial/venous ulcers, pressure ulcers, burns, and pre- and post-flap surgery.
Treatment plans are based solely on patient needs, and the patient is treated as a participating team member
throughout all treatment phases.
What is a complex wound?

Program Locations
A complex wound is often the result of the treatment of any
number of other conditions, including cardiac, pulmonary,
neuromuscular, and renal diseases. A wound that doesn't heal
Inpatient complex wound rehabilitations:
properly can pose serious health problems. Diabetics must be
Good Shepherd Rehabilitation Hospital—Allentown
particularly vigilant about wounds and proper healing as neglect
Good Shepherd Rehabilitation Hospital—Easton
may result in amputation or other chronic conditions. Even wounds
Good Shepherd Specialty Hospital
that are properly cared for are still at risk for infection and should
be followed closely by medical professionals. Complex wounds can also extend hospitalization, prolonging
rehabilitation.
Age, malnutrition, mobility, incontinence, diabetes, and peripheral vascular disease can all play a part in
preventing proper wound healing. If you notice any of the following signs when examining your wounds, you
should see a doctor immediately:
 Chills or fever
 Redness, swelling, or tenderness in the wound area
 Throbbing pain in the wound area
 Red streaks in the skin around the wound
 Pus that collects beneath the skin
 Any lumps or swelling in your armpit, groin, or neck (take note whether these lumps are tender)
 An unpleasant odor from the wound
For more information on the Good Shepherd Complex Wound Care Program, e-mail us today or call 1-877-734-
2247 (8 a.m.-4:30 p.m., Monday-Friday).
Complex Wound Rehabilitation Program

 Professional skin care and clinical wound management and therapy experience
 Electrical stimulation, ultrasound, and whirlpool therapy
 Discharge planning
 Family conferences and education
 Patient-specific seating protocols
 IV therapy (TPN, antibiotics)

 Physical therapy designed to increase strength and mobility and enhance wound healing
 Clinical nursing
 Psychology
 Care management
 Infectious diseases
Burn Care Program
 Skin care and scar tissue management including garment prescription and fitting
 Adaptations and training for daily living and everyday tasks
 Mobility training, including ambulation and functional transfers
 Hand therapy
 Thorough exercise regimen designed to improve motion and strength
 Community re-integration through therapeutic recreation and outings
 Emotional support and counseling
 Infection control (IV antibiotics)
 Pulmonary management (tracheotomy care, pulmonary rehabilitation)
 Nutritional therapy (TPN, PEG/tube feeding)
 Aquatherapy
 Family education
 Outpatient therapy available after inpatient discharge
 Evaluation, prescription, and provision of equipment
 Family conferences
 Home visits

 Psychology
 Nutritional education
 Pastoral care
Pain Rehabilitation
| Program Admission | Our Approach | FAQs | Links |
Good Shepherd's Pain Rehabilitation Program is a comprehensive outpatient rehabilitation program designed
for persons who have had ongoing pain for at least a three-month period. Program participants also suffer from
severely decreased activity levels and have been unable to find a medical cure for their pain. By working with an
interdisciplinary team to increase their activity and function, individuals undergoing pain rehabilitation develop the
coping skills needed to resume vocational and/or avocational pursuits.
Pain Rehabilitation Program participants undergo evaluation by all team members prior to the establishment of
their respective treatment plans. Treatment is then usually conducted three days a week for eight weeks. During
the treatment day, persons served by the program are involved with a number of therapies and educational
programs to develop physical mobility, strength, stamina, and valuable coping skills. For more information on the
Good Shepherd Pain Rehabilitation Program, please call 610-778-9234 (8 a.m.-4:30 p.m., Monday-Friday).
 Rehabilitation Medicine
 Clinical Psychology
 Care management
Additional Pain Rehabilitation Services Include:
 Cognitive assessment and rehabilitation

 Aquatherapy
 Biofeedback and self-regulation training
 Complementary/alternative therapies (yoga, etc.)
 Hand therapy
 Nutritional education
 Therapeutic massage
 Liaison with the State Office of Vocational Rehabilitation
Occupational Therapy
Occupational Therapy Program
 Daily skills
o Dressing/feeding skills
o Writing, shopping, banking
o Functional transfers (bed, toilet, tub)
o Wheelchair skills
o Durable medical equipment (DME) training (commodes, tub seats, etc.)
o Splinting/casting
o Energy conservation/joint protection
 Work simplification
 Patient/family education
 Home evaluation/management
 Cognitive/perceptual/motor training
 Driver training
 Home exercise
 Visual retraining
 Endurance and strength training
 Sensory stimulation
Areas of Occupational Therapy Treatment Include:
 Spinal cord injury

 Brain injury
 Stroke rehab
 Joint fracture/replacement
 Amputee rehab
 Arthritis rehab
 Burn care
 Neuromuscular disorders (MS, MD, Guillain-Barre Syndrome, ALS/Lou Gehrig's disease)
 Multi-trauma rehab
 Chronic obstructive pulmonary disease
 Generalized weakness
 Work injuries
 Parkinson's disease
Dysphagia Program
As part of an integrated approach to rehabilitation, Good Shepherd's speech and language therapy department
provides a Dysphagia Program for any inpatient or outpatient experiencing swallowing disorders. Master's-level
speech and language pathologists design and implement the program.
Dysphagia Program referral diagnoses include spinal cord injury, brain injury, stroke, neuromusculature disorders
(Multiple Sclerosis, muscular dystrophy, ALS, Parkinson's disease), and pediatric swallowing disorders. For more
information on the Good Shepherd Dysphagia Program, e-mail us today or call 1-877-734-2247 (8 a.m.-4:30
p.m., Monday-Friday).
Dysphagia Program Components
 Modified barium swallow study (radiographic/x-ray assessment of the anatomy and physiology of the
oral, pharyngeal, and esophageal musculature to allow analysis of the structure and function of the
swallow)
 VitalStim® Therapy (electrical stimulation therapy for adults who suffer from chronic oral/pharyngeal
dysphagia; used to maximize swallowing, speech, and vocal functioning). For more information on
VitalStim Therapy, visit www.vitalstimtherapy.com.
 Neuromuscular electrical stimulation used in the facial muscle exercise program
 DPNS—Deep Pharyngeal Neuromuscular Stimulation
 Therapeutic exercise program
 Modified diet levels
 Therapeutic compensatory strategy instruction
 Ongoing patient/family education
 Comprehensive evaluation

 Otolaryngology
 Gastroenterology
 Radiology
 Respiratory therapy
Recreational Therapy
Good Shepherd’s Recreational Therapy Program involves the use of recreation and leisure activities to improve
an individual’s functional skills and his or her ability to get the most out of life.
Recreational therapy at Good Shepherd improves physical, cognitive, emotional, and social functioning in order to
facilitate personal growth and development. The goals of our Recreational Therapy Program are related to a
patient’s overall rehabilitation goals, many of which can be addresses directly through recreational therapy
services.
 Recreational therapy is utilized as a major method of treatment intervention for specific physical,
emotional, social, and cognitive goals.
 Recreational therapy addresses the effect of illness and disability on an individual’s personality and on
his or her family life. The patient’s family is encouraged to participate in all leisure and recreational
programs in order to increase the patient’s support base and to provide the resources needed to make a
smooth discharge transition.
 Recreational therapy includes community reintegration treatment outings which enable patients to
practice mobility, cognitive, social, and emotional skills in an interactive setting.
 One-on-one treatment sessions

 Leisure education and counseling
 Recreation and leisure activities
 Community reintegration treatment outings
 Assistive technology
 Aquatherapy
 Social group programs
 Patient/family education sessions
 Sports clinics
 Co-treatment groups: Cooking, mobility, cognitive
 Wheelchair tennis tournaments
Monograph 22
Cervical Spine Trauma

R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1999
Copied by Chiro.Org with permission from ACAPress.com
TOPICS
Flexion Strain/Sprain
Background Mechanisms
Common Injuries and Effects
Disorders of the Case Management
Cervical Spine Lateral Flexion
Prevalence Strain/Sprain
Emergency Care Occipital and Cervical
Initial Assessment Subluxation
Posttraumatic Syndromes
Roentgenographic Clues Functional Anatomy
Injury of the Cervical Nerve Relative to
Roots Cervical Subluxations
Contributing and Further Clinical
Complicating Factors Implications
Motor Aberrations Cervical Spondylosis
Interpreting Sensory Clinical Implications
Irregularities Etiology
Subluxation-Induced Reflex Clinical Findings
Syndromes Case Management and
Neurovascular Implications Prognosis
of Upper Reversal of the Normal
Cervical Subluxations Cervical Curve
The Vertebral Arteries Clinical Findings
The Vertebral and Deep Case Management and
Cervical Veins Prognosis
Cerebrospinal Circulation Traumatic Brachial Plexus
The Medulla Oblongata Traction
The Vital Vagus Bikele's Test
Classic Effects of Severe Supine Tension Test
Cervical Trauma Case Management
Planes of Force and Their The Stinger Syndrome
Consequences Clinical Findings
Fractures and Dislocations Complications
of the Atlas Subluxation Induced
Fractures and Dislocations Torticollis
of the Axis Clinical Findings
Severe C3--C7 Injuries Effects of Cervical Area
Spinal Cord Injury Hypertonicity
Vertebral Artery Trigger-Point Syndromes
Abnormalities Management
Cervicothoracic Tunnel Barre-Lieou Syndrome
Compression Clinical Findings
Syndromes Barre-Lieou Test
Origin Cervical Disc Disorders
Clinical Features Disc Encroachment
Clinical Maneuvers and Disc Degeneration
Tests Clinical Findings
Vertebrobasilar System Case Management
Patency Tests Traumatic Cervical
Maigne's Test Scoliosis
DeKleyn's Test Effect of a Flattening
Hautant's Test Curve
Arthrokinematics The Self-Stabilization
Structural Characteristics of Factor
the Cervical Disc Reactions in
Region Cervical Scoliosis
The Upper Cervical Spine Effect of Lateral Tilt in
The Occipitocervical Cervical
ligaments Scoliosis
The Lower Cervical Area Cervical Rib Syndromes
Kinematics Differentiation
The Upper Cervical Area Case Management
The Lower Cervical Area Posttraumatic Headaches
The Transitional of Cervical
Cervicothoracic Area Origin
Applied Anatomy of the Posttraumatic
Cervical Plexus Rehabilitation Goals
The Brachial Plexus Postural Strength and
The Cervicothoracic Balance
Junction Area Dynamic and Static
Clinical Management Proprioception
Electives In Cervical Cervical Receptor Input
Strain/Sprain/IVD Lesion Normal Cervical Righting
Commentary
Extension Strain/Sprain Mechanisms
(Whiplash Cervical Strength
Syndrome) Development
Mechanisms Rehabilitation Therapy
Kinematics Following
Effects Cervical Trauma
Case Management
The cervical spine provides structural stability and support for the
cranium, and a flexible and protective column for movement and balance
adaptation, along with housing of the spinal cord and vertebral arteries.
It also allows for directional orientation of the eyes and ears. Nowhere in
the spine is the relationship between the osseous structures and the
surrounding neurologic and vascular beds as intimate or subject to
disturbance as it is in the cervical region.
BACKGROUND
Whether induced by trauma or not, cervical subluxation syndromes may

be reflected in total body habitus. IVF insults, and the effects of articular
fixations can manifest throughout the motor, sensory, and autonomic
nervous systems. Many peripheral nerve symptoms in the shoulder, arm,
and hand will find their origin in the cervical spine, as may numerous
brainstem disorders.
Common Injuries and Disorders of the Cervical Spine
Cervical spine injuries can be classified as (1) mild (eg, contusions,

strains); (2) moderate (eg, subluxations, sprains, occult fractures, nerve
contusions, neurapraxias); (3) severe (eg, axonotmesis, dislocation,
stable fracture without neurologic deficit); and (4) dangerous (eg,
unstable fracture-dislocation, spinal cord or nerve root injury).
Spasm of the sternocleidomastoideus and trapezius can be due to strain

or irritation of the sensory fibers of the spinal accessory nerves as they
exit with the C2--C4 spinal nerves. The C1 and C2 nerves are especially
vulnerable because they do not have the protection of an IVF. Radicular
symptoms are rarely evident unless an IVD protrusion or rupture is
present.
PREVALENCE
Because of its great mobility, relatively small structures, and weight-

bearing role, the cervical spine is a frequent site of severe spinal nerve
injury and subluxation/fixations. A large variety of cervical contusions,
Grade 1--3 strains and sprains, subluxations, disc syndromes,
dislocations, and fractures will be seen as the result of trauma.
The most vulnerable segments to injury are the axis and C5--C6
according to accident statistics. Surprisingly, the atlas is the least
involved of all cervical vertebrae. In terms of segmental structure, the
vertebral arch (50%), vertebral body (30%), and IVD (30%) are most
commonly involved in severe cervical trauma. While the anterior
ligaments are only involved in 2% of injuries, the posterior ligaments are
involved in 16% of injuries.
EMERGENCY CARE
In the emergency-care situation, the patient with spinal cord injury must
be treated as if the spinal column were fractured, even when there is no
external evidence. Immediate and obvious symptom of spinal cord injury
parallel those of fractures of the spinal column. The establishment of an
adequate airway takes priority over all other concerns except for spurting
hemorrhage.
In general, trauma anteriorly to the neck implies soft-tissue damage and

possible airway obstruction; trauma posteriorly suggests cervical spine
and cord damage; and lateral trauma indicates possible vascular and
musculature damage. Due to relative head weight to neck strength and
other anatomic differences, neck injury is more critical in the very young.
INITIAL ASSESSMENT
If there are no severe complaints or recognizable signs of major
disability, ask the patient to conduct mild slow active movements if able
to do so without discomfort. If slight straight axial compression on the
head produces unilateral or bilateral radiating root pain, deep injury
must be suspected and precautions taken immediately. After the neck
has been evaluated, check possible injury to other parts of the body.
Knee and ankle reflexes can be tested, but the neck should not be moved.
Stabilize the neck before assessment of severity. A collapsed patient
should never be asked to sit or stand until major disability has been ruled
out. The first point in accurate analysis is knowing the mechanism of
injury. Without moving the patient, check vital signs and palpate for
swelling, deep tenderness, deformity, and throat cartilage stability. When
logical, another person should apply gentle bilateral traction on the
cervical area via the skull during palpation.
Are there bleeding, spasm, pain, motion restrictions, sensory changes,

signs of shock? Limb weakness or dysesthesia indicates nerve root
compression. Injuries of the upper airway or alimentary canal feature
ventilation abnormalities, stridor, a bubbling wound, subcutaneous
emphysema, hoarseness and dysphagia, bloody sputum, nosebleed,
bloody vomitus, or unexplained wound tenderness. Injuries to the
cervical nerves are suggested by deviation of the tongue, drooping mouth
corner, sensory deficits, and Horner's syndrome. Cervical fractures are
commonly associated with severe pain, spasm, and joint stiffness.
Vascular injuries feature vigorous bleeding, absent superficial artery

pulsations, an enlarging or pulsatile hematoma, and stroke signs. If there
is any suggestion of injury to the carotid artery, palpation should be
avoided. Such an injury should be suspected if there is a diagonal
erythematous contusion on the side of the neck. Palpation may
encourage complete carotid occlusion.
POSTTRAUMATIC ROENTGENOGRAPHIC CLUES
On standard lateral and A-P views, the anterior and posterior soft tissues
deserve unusually detailed inspection. Signs of widened retrotracheal
space, widened retropharyngeal space, displacement of the prevertebral
fat stripe, laryngeal dislocation, or tracheal displacement should be
sought. Abnormal vertebral alignment may be shown by a loss of the
normal lordotic curve or even an acute kyphotic hyperangulation,
vertebral body displacement, abnormal dens position, widened
interspinous space, or rotation of the vertebral bodies. Abnormal joints
may portray unusual IVD-space symmetry or widening of an apophyseal
joint space. It is easy to miss lower cervical fractures because they are
often obscured on lateral views by the subject's shoulders if proper
precautions are not taken.
INJURY OF THE CERVICAL NERVE ROOTS
Neural dysfunction associated with either acute or chronic subluxation

syndromes basically manifest as abnormalities in sensory interpretations
and/or motor activities. These disturbances may be through one of two
primary mechanisms: direct nerve or nerve root disorders or of a reflex
nature.
Contributing and Complicating Factors
The common subluxation picture is rarely pure. It is often superimposed

on subclinical processes in the mature patient such as weak or scarred
tissue, vertebral instability, osteochondrophytic ridges at the
uncovertebral joints, apophyseal thickening and exostosis. Canal
encroachment can occur by a buckling ligamentum flavum, spinal
stenosis, posterior vertebral body spurs, disc protrusions, dura and
dentate thickening, arachnoid cysts, dura and arachnoid adhesions, and
ossification of the posterior longitudinal ligament.
Loss of disc space, especially in the lower cervical area, may contribute as
a source of chronic irritation to an already inflamed root by altering the
angulation of involved IVF tunnels. The sequence of inflammation,
granulation, fibrosis, adhesion formation, and nerve root stricture may
follow, along with a loss in root mobility and elasticity. Fortunately for
children, these degenerative changes are not as pronounced during
youth.
Motor Aberrations
Nerve root insults from subluxations may manifest as disturbances in

motor reflexes and/or muscular strength. Examples include the deep
tendon reflexes such as seen in the reduced biceps reflex when
involvement occurs between C5 and C6; or the reduced triceps reflex
when involvement occurs between C6 and C7. These reflexes must be
compared bilaterally to judge whether hyporeflexia is unilateral.
Unilateral hyperreflexia is pathognomonic of an upper motor neuron
lesion. Prolonged and/or severe nerve root irritation may also produce
trophic changes in the tissues supplied.
Interpreting Sensory Irregularities
When direct nerve root involvement occurs on the posterior root of a

specific neuromere, it manifests as an increase or a decrease in sensitivity
over the dermatome. A typical example is foraminal occlusion or
irritating factors exhibited clinically as hyperesthesia, particularly on the
dorsal and lateral aspects of the thumb and radial side of the hand, when
involvement occurs between C5 and C6. Another example is on the
dorsum of the hand, the index and middle fingers, and the ventroradial
side of the forearm, thumb, index and middle fingers, when involvement
occurs between C6 and C7.
In other instances, nerve root involvement may cause hypertonicity and

the sensation of deep pain in the muscles supplied by the neuromere. For
example, in C6 involvement, there is deep pain in the biceps. In C7
lesions, there is deep pain in the triceps and supinators of the forearm.
Direct pressure near the nerve root or along its distribution may be
particularly painful. The pioneer chiropractic art of nerve tracing would
be well to acquire.
SUBLUXATION-INDUCED REFLEX SYNDROMES
It is generally accepted that certain spinosomatic and spinovisceral

syndromes may result from cervical subluxation complexes. For example,
if the involvement is in the C1--C4 area, the cervical portion of the
sympathetic chain or the 9th--12th cranial nerves (as they exit from the
base of the skull and pass into their compartments within deep cervical
fascia) may be involved. The syndrome may include (1) suboccipital or
postocular migraine; (2) greater occipital nerve extension neuralgia; (3)
mandibular, cervical, auricular, pectoral, or precordial neuralgia; (4)
paroxysmal torticollis; (5) congestion of the upper respiratory mucosa,
paranasal sinuses, or eustachian tube with hearing loss; (6)
cardiorespiratory attacks; (7) ocular muscle malfunction; (8) pathologic
hiccups; (9) scalenus anticus syndrome; or (10) painful spasm in the
suboccipital area.
Phillips describes that if a subluxation produces a stretching of the

paravertebral musculature, there is a continuous barrage of afferent
impulses in the Group Ia fibers. "These afferent impulses
monosynaptically bombard the alpha motor neurons causing the
paravertebral musculature to go into tetany. There is a cessation of this
afferent barrage when the stretch is released. The muscle stretching also
initiates afferent impulses in the Group II afferents from flower spray
endings, which may reinforce the spastic muscle condition." He explains
that trauma to facet joints, disturbed articular relationships, spasms of
closely related muscles, and overlying trigger points --all the result of a
subluxation-- inaugurate a barrage of flexor-reflex afferent impulses via
the Group II--IV fibers that converge on the internuncial pool in lamina 7
of the spinal cord. "This abundant supply of flexor-reflex afferent
impulses excites the alpha motor neurons through multisynaptic
connections causing an excess of excitation of paravertebral muscles
resulting in spasm."
NEUROVASCULAR IMPLICATIONS OF UPPER CERVICAL

SUBLUXATIONS
Aside from nerve root dysfunction, subluxation complexes in the cervical

spine, especially the upper region, can have serious neurovascular
consequences. Function of the vertebral arteries, the vertebral veins and
deep cervical veins, cerebrospinal circulation, the caudad medulla
oblongata, and the vital vagus nerve may be disturbed.
The artery and vein supplying a spinal nerve course within the IVF
between the nerve and the fibrous tissue in the anterior portion of the
foramen. Deprived mobility of any one or more segments of the spine
correspondingly influences area circulation, and the partial anoxia
effected is likely to have a harmful influence on nerve function. Because
of the vessels' position, it is unlikely that circulation to the nerve would
be disrupted without first irritating or compressing the nerve because the
arteries and veins are much smaller, the blood pressure within their
lumen makes them somewhat resistant to compression, and nerve tissue
is much more responsive to encroachment irritation.
The Vertebral Arteries
Janse explains that any cervical subluxation (particularly atlantal, axial,

or occipital) producing muscle spasm may produce unilateral or bilateral
constriction of the vertebral arteries resulting in circulatory impairment.
A large number of equilibrium, cardiac, respiratory, cranial nerve,
extrapyramidal, vagal, visual, and auditory symptoms may follow.
The vertebral nerve (sympathetic) courses along the vertebral artery

within the arterial foramen of the cervical transverse processes. Irritation
to this nerve can occur from mechanical irritation to the vertebral artery
anywhere along its course producing symptoms of a vasomotor nature;
eg, headache, vertigo, tinnitus, nasal disturbances, facial pain, facial
flushing, and pharyngeal paresthesias. Cailliet points out that although
sympathetic fibers have not been found along the cervical roots, surgical
decompression of an entrapped nerve root relieves symptoms attributed
to the sympathetics. The mechanism for this effect is unclear.
The Vertebral and Deep Cervical Veins
Spasm of suboccipital muscles may cause a decided impediment of

venous drainage from the suboccipital area via vertebral and deep
cervical veins. The result is passive congestion with consequent pressure
on the sensory nerves in the area. This is often perceived by the patient as
unilateral or bilateral pain and a throbbing discomfort. The site may be
palpated as knotty lumps within suboccipital muscles. The condition
appears to be of a reflex nature that is more common among people
under mental tension or those who work closely with their eyes over long
periods.
Cerebrospinal Circulation
Constriction in the connecting area between the cerebral subarachnoid

space and the vertebral canal can impair the escape of cerebrospinal fluid
into the inferior vertebral canal. This results in increased intracranial
pressure. An atlanto-occipital subluxation may cause the dura mater of
the cisterna cerebellaris to press against the posterior medullary velum
and partially occlude the foramina of Luschka and Magendie and thus
interfere with flow from the 4th ventricle. The increased intraventricular
fluid accumulation can thus produce a variety of symptoms such as deep-
seated stubborn "internal pressure" headaches, nausea, a tendency
toward projectile vomiting, bizarre and unusual visual disturbances, and
protopathic ataxia.
The Medulla Oblongata
The medulla extends well into the lower reaches of the foramen magnum
and the ligament ring connecting it with the atlas, thus any type of
occipital or atlantal subluxation may potentially affect this portion of the
brain stem. Bilateral posterior shifting of the occiput or atlas can induce
pressure in the pyramids or adjacent olivary bodies producing a
syndrome of upper-motor-neuron involvement characterized by a degree
of spastic paralysis or ataxia. A lateral shift of the occiput may cause
pressure on the tubercle of Rolando producing pain in trigeminal nerve
distribution, headache, sinus discomforts, ocular neuralgia, and aches in
the jaw.
The Vital Vagus

As the vagus lies almost in immediate contact with the transverse process
of the atlas, rotary subluxation of the atlas may induce pressure that can
produce a broad range of symptoms. The syndrome may include nasal
and sinus congestion, swallowing and speech difficulties, cardiac
arrhythmias, functional coronary artery spasm, gastric and intestinal
colic, and/or other symptoms of vagal disturbance.
CLASSIC EFFECTS OF SEVERE CERVICAL TRAUMA
Planes of Force and Their Consequences
It was briefly brought out earlier that knowing the mechanism of injury is
important to accurate diagnosis. This section will confirm this truth.
Compression Forces. Excessive compression forces on the neck

commonly lead to facet jamming and fixation, isolated or multiple
fractures of the atlantal ring, or vertical, oblique, and/or bursting
fractures of the lower cervical bodies.
Hyperextension Forces. The effects of forceful posterior bending may

include sprain of the anterior ligaments, wedging of the posterior anulus
and vertebral body, posterior subluxation, horizontal fracture of the
anterior arch of the atlas, fracture of the anteroinferior margin of a
vertebral body, compression of the posterior arch and associated
structures, posterior bilateral or unilateral dislocation, spinous process
fracture, and/or traumatic spondylolisthesis.
Hyperflexion Forces. Excessive anterior bending may produce sprain of

the posterior ligaments, compressive wedging of the anterior anulus and
vertebral body, anterior subluxation, anterior bilateral or unilateral
dislocation with locked facets, and/or spinous process avulsion.
Abnormal widening of a spinous interspace on a lateral roentgenograph
should arouse suspicion of ruptured posterior ligaments.
Lateral Hyperflexion Forces. The effects of excessive lateral bending

include transverse process fracture, uncinate process failure, lateral
dislocation-fracture of the odontoid process, lateral wedging of the
anulus and vertebral body, and/or brachial plexus injury.
Hyperrotary Forces. Exorbitant segmental rotation about the

longitudinal axis produces anterior or posterior ligament torsion
overstress, rotary subluxation, spiral loosening of the nucleus pulposus,
and/or unilateral or bilateral atlas-axis dislocation. The traumatic stress
involved invariably include shear forces.
Shear Forces. Flagrant shearing forces can disrupt the anterior or
posterior ligaments, displace the end-plates, produce anterior or
posterior subluxation or dislocation, create anterior or posterior fracture
displacement of the dens, and/or cause anterior compressive fracture of
the anterior ring of the atlas or vertebral body.
Fractures and Dislocations of the Atlas
Atlanto-occipital dislocations, often bilateral, are usually quickly

incompatible with life. Any severe subluxation in the upper cervical area
can lead to quadriplegia or death, often with little warning and few
symptoms to differentiate it initially from a mild strain/sprain. Thus, it is
always better to be especially cautious (and be accused of being too
concerned in mild injuries) to insure against a possible disaster. Signs
and symptoms vary from subtle to severe pain and gross motor
involvement. Tenderness may be acute over the posterior atlas,
aggravated by mild rotation and extension.
Fractures and Dislocations of the Axis
Odontoid fractures are often produced by severe forces directed to the

head, and the direction of force usually determines the direction of
displacement. Suboccipital tenderness may be present. A severe
extension force may fracture the odontoid at its base, with possible
odontoid posterior displacement. The danger of cord pressure is great.
Open-mouth views, flexion-extension x-ray views, or tomography may be
necessary for accurate determination.
Severe C3--C7 Injuries
Cervical fractures and dislocations are often the result of a severe fall, an
automobile accident, a football pile-up, or a trampoline or gymnastic
mishap. Bruises on the face, occiput, and shoulders may offer clues to the
mechanism of injury. Seek signs of vertebral tenderness, limitation in
movement, muscle spasm, and neurologic deficits. As in upper-cervical
damage, careful emergency management is necessary to avoid paralysis
and death. Severe fracture or dislocation of any cervical vertebra requires
immediate orthopedic referral. Nevertheless. keep in mind that
overdiagnosing instability of C2 on C3 is a common error.
Compression or flexion damage is sometimes seen, but extension injuries

(eg, whiplash) are more common. Spinous process fractures usually
occur at the C6 or C7 level after acute flexion or a blow to the flexed neck
producing ligamentous avulsion. There is an immediate "hot" pain in the
area of the spinous process that is increased by mild neck flexion. Again,
any injury to C6 or C7 can be difficult to view on film because of
overlapping structures.
Spinal Cord Injury
There are direct and indirect classes of cephalad spinal cord injuries.
Direct injury to the cord, the nerve roots, or both, may be from impact
forces or shattered bone fragments. The cord may be crushed, pierced, or
cut. These types of injury are generally associated with an open wound.
Indirect injury to the cord can be caused by the disturbance of tissues
near the spine by violent forces such as falls, crushes, or blows.
When the cervical cord is injured, there is loss of sensation and flaccid
paralysis cephally. The lower limbs exhibit spastic paralysis. If the space
in which the spinal fluid flows between the spinal cord and the
surrounding vertebral column is either compressed or enlarged, severe
headache occurs. Posttrauma penile erection strongly suggests either
cervical or thoracic cord injury.
Many cervical cord injuries are caused by extreme flexion where

subluxation or fracture/dislocation occurs. Hemorrhage arises at the site
with the same reaction as brain injury (liquefaction, softening,
disintegration). Congenital fusions and stenosis may predispose a child
to spinal cord trauma during a sporting activity.
VERTEBRAL ARTERY ABNORMALITIES
Vertebral artery abnormalities such as deflection and arteriosclerosis

must be determined before any form of cervical manipulation or
adjustment is performed. Also, arteriosclerosis is no longer thought of as
an "old person's disease." Autopsy studies of young soldiers killed in the
Viet Nam War showed well established systemic arteriosclerosis in the
majority of the 18--21-year age group.
The vertebral artery is a captive vessel from C6 upward. Extremes of

rotation and flexion occur at the upper cervical region, but the four
normal curves in the vertebral artery help to compensate for neck
movements. Deflection may be caused by any tensile stretching of the
artery during neck trauma. In later years, deflection is commonly
associated with bony spurs from covertebral joints or grossly
hyperplastic posterior vertebral articulations from arthrosis.
Smith explains that extension of the cervical spine allows the tip of the
superior articular process of the posterior joint to glide forward and
upward. If sufficiently hyperplastic, forced motion may cause
encroachment on the vertebral arteries and/or the IVFs. Deflection of the
artery and any resulting symptoms are exaggerated by rotation and/or
extension of the neck. As a result of pressure against the artery, there
may be temporary lessening in the volume of blood flow. Atheromatous
changes may also occur within the vascular wall. Symptoms include
headache, vertigo, nausea, vomiting, nystagmus, and suboccipital
tenderness, which may be provoked by cervical extension. Sometimes
symptoms are aggravated by dorsal extension and relieved by forward
flexion with cervical traction.
CERVICOTHORACIC TUNNEL COMPRESSION SYNDROMES
The cervicothoracic junction is a unique area that receives far less

attention than it deserves in all the healing arts. It is a common site of
developmental anomalies; it is a major site of arterial, lymphatic, and
neurologic traffic; and it presents the juncture of the highly mobile
cervical spine with the very limited thoracic spine. This latter point is
biomechanically significant.
Several cervicotrhoracic syndromes fall in the class of neurovascular

compression syndromes (also termed thoracic outlet or inlet syndromes),
each of which may produce the symptom complex of radiating pain over
the shoulders and down the arms, atrophic disturbances, paresthesias,
and vasomotor disturbances. These features, however, do not necessarily
indicate the specific cause of the problem.
Origin
Trauma to the head, neck, or shoulder girdle is a common factor. In some

cases, poor posture, anomalies, or muscle spasm or contractures may be
involved. Reduced tone in the muscles of the shoulder girdle, by itself,
has been shown to allow depression of the clavicle that narrows the
thoracic outlet and compresses the neurovascular bundle. Subluxation
syndromes (eg, retrolisthesis) may also initiate these and other
disturbances of the shoulder girdle.
Cervical pathology such as spinal canal or IVF encroachment by a

buckling ligamentum flavum, spinal stenosis, or spurs should be a
consideration. Degenerating dura and dentates become thickened, dura
and arachnoid adhesions become prevalent, and osteochondrophytes
may develop from the borders of the canal or foramen --all of which tend
to restrict the cord and/or nerve roots during cervical motion.
Osteochondrophytes near the foramen can readily compress the

vertebral artery against the nerve root. Differential diagnosis must
exclude a cervical rib etiology (rare), infectious neuritis, banding
adhesions, arthritis of the shoulder joint, clavicle fracture callus, bifid
clavicle, cervical arthritis, subacromial bursitis, 1st rib subluxation and
posttraumatic deformities, spinal or shoulder girdle malignancies,
Pancoast's tumor of the lung apex, and heart disease. Aneurysm of the
subclavian artery is rare.
Anatomical Considerations. Working above and behind to produce

shoulder abduction and retraction (eg, painting a ceiling, repairing a
ceiling fixture) produces temporary clavicle encroachment on the
brachial plexus and presses the subclavian artery against the scalenus
medius. For many years, symptoms were attributed to costoclavicular
compression from shoulder depression. However, postmortem stress
tests have shown the following:
1. When the arm is depressed, the clavicle moves inferior and anterior,
and this widens the space between the clavicle and 1st rib.
2. When the shoulder is depressed, the upper and middle trunks of the
brachial plexus are stretched tightly over the tendinous edge of the
scalenus medius and the lower trunks are pulled into the angle formed by
the 1st rib and the scalenus medius tendon. Most symptoms found on
shoulder depression will be the result of this traction. There is no
compression of the subclavian artery against either scaleni.
3. When the shoulder is retracted, the clavicle does not impinge the
subclavian vein but the tendon of the subclavius muscle compresses the
vein against the 1st rib. The middle third of the clavicle pushes the
neurovascular bundle against the anterior scalenus medius, and this
causes compression if a space-occupying lesion is also present (eg,
cervical rib, extrafascial band).
Clinical Features
Symptoms usually do not occur until after the ribs have ossified. Two
groups of manifestation are seen: those of scalenus anticus syndrome
and those due to cervical rib pressure. The symptoms of cervical rib and
scalenus syndrome are similar, but the scalenus anticus muscle is the
primary factor in the production of neurocirculatory compression
whether a cervical rib exists or not.
Symptoms usually arise from compression of the lower cords of the
brachial plexus and subclavian vessels such as numbness and pain in
ulnar nerve distribution. Pain is worse at night because of pressure from
the recumbent position, and its intensity varies throughout the day. Arm
fatigue and weakness, finger cramps, numbness, tingling, coldness of the
hand, areas of hyperesthesia, muscle degeneration in the hand, a lump at
the base of the neck, tremor, and/or discoloration of the fingers are
characteristic. Work and exercise accentuate symptoms, while rest and
elevation of the extremity relieve symptoms. Adson's and other similar
compression signs will usually be positive.
Neural vs Circulatory Symptoms. Compression of nerve tissue results in

numbness, pain, paralysis, and loss of function. Compression of vascular
structures results in moderate pain and swelling. Obstructed circulation
results in clotting within the vessels with possible consequent infarction
in the tissues supplied. These unilateral phenomena are somewhat
limited to the cervicobrachial distribution.
Clinical Maneuvers and Tests
Posttrauma radiographs should be taken before performing a neurologic

or orthopedic test. It is important to rule out possible conditions that
would be aggravated by any testing procedure.
Passive Cervical Compression Tests. Two tests are involved. First, with
the patient sitting, the examiner stands behind the patient. The patient's
head is laterally flexed and rotated slightly toward the side being
examined. The examiner places interlocked fingers on the patient's scalp
and gently presses caudally. If an IVF is narrowed, the maneuver will
insult the foramen by compressing the disc and further narrowing the
foramen, causing pain and reduplication of other related symptoms. In
the second test, the patient's neck is extended by the examiner who then
places interlocked hands on the patient's scalp and gently presses
caudally. If an IVF is narrowed, this maneuver mechanically
compromises foraminal diameters bilaterally and causes pain and
reduplication of other related symptoms described earlier.
Active Cervical Rotary Compression Test. The sitting patient should be

observed while voluntarily laterally flexing his head toward the side being
examined. With the neck so flexed, the patient is instructed to rotate his
chin toward the same side, which narrows the IVF diameter on the side
of concavity. Pain or reduplication of other symptoms suggests a
narrowing of one or more IVFs.
Shoulder Depression Test. With the patient sitting, the examiner stands
behind the subject. The patient's head is laterally flexed away from the
side being examined. The doctor stabilizes the patient's shoulder with
one hand and applies pressure alongside the patient's head with the palm
of the other hand; stretching the dural root sleeves and nerve roots or
aggravating radicular pain if the nerve roots adhere to the foramina.
Extravasations, edema, encroachments, and conversion of fibrinogen
into fibrin can result in interfascicular, foraminal, and articular
adhesions and inflammation restricting fascicular glide and the ingress
and egress of the foraminal content. Thus, pain and reduplication of
other symptoms during the test suggest adhesions between the nerve's
dura sleeve and other structures in and about the involved IVFs.
Cervical Distraction Test. With the patient sitting, the examiner stands
to the side of the patient and places one hand under the patient's chin
and the other hand under the base of the occiput. Slowly and gradually
the patient's head is lifted to remove weight from the cervical spine. This
maneuver elongates the IVFs, decreases the pressure on the joint
capsules around the facet joints, and stretches the paravertebral
musculature. If the maneuver decreases pain and relieves other
symptoms, it is a probable indication of narrowing of one or more IVFs,
cervical facet syndrome, or spastic paravertebral muscles.
Spurling's Test. This is a variation of the passive cervical compression

test. The patient's head is turned to the maximum toward one side and
then laterally flexed to the maximum. A fist is placed on the patient's
scalp, and a moderate blow is delivered to it by the other fist. The
patient's position produces reduced IVF spaces, and the blow causes a
herniated disc to sharply bulge further into the IVF space or to aggravate
an irritated nerve root, thus increasing the symptoms.
Adson's Test. With the patient sitting, the examiner palpates the radial
pulse and advises the patient to bend his head obliquely backward to the
opposite side being examined, to take a deep breath, and to tighten the
neck and chest muscles on the side tested. This maneuver decreases the
interscalene space and increases any existing compression of the
subclavian artery and lower components (C8 and T1) of the brachial
plexus against the 1st rib. Marked weakening of the pulse or increased
paresthesiae are signs of pressure on the neurovascular bundle,
particularly of the subclavian artery as it passes between or through the
scaleni musculature, thus indicating a probable cervical rib. 1st rib, or
scalenus anticus syndrome.
Wright's Test. With the patient sitting, the radial pulse is palpated from
the posterior in the downward position and as the arm is passively
moved through an 180 arc. If the pulse diminishes or disappears in this
arc or if neurologic symptoms develop, it suggests pressure on the
axillary artery and vein under the pectoralis minor tendon and coracoid
process or compression in the retroclavicular space between the clavicle
and 1st rib, and thus be a hyperabduction syndrome.
Eden's Test. With the patient sitting, the examiner palpates the patient's
radial pulse and instructs the patient to pull the shoulders backward
firmly, throw the chest out in a "military posture," and hold a deep
inspiration as the pulse is examined. The test is positive if weakening or
loss of the pulse occurs, suggesting pressure on the neurovascular bundle
as it passes between the clavicle and the 1st rib, and thus a
costoclavicular syndrome.
VERTEBROBASILAR SYSTEM PATENCY TESTS
Although cerebrovascular accidents are extremely rare following cervical

manipulation, a few cases have been reported that justify special
evaluation before cervical manipulation. Four clinical tests are described
below to evaluate the patency of the vertebrobasilar system. These tests
are helpful but not definitive in themselves.
Maigne's Test
The examiner places a sitting patient's head in extension and rotation.

This position is held for about 15--40 seconds on each side. A positive
sign is indicated by nystagmus or other symptoms of vertebrobasilar
ischemia.
DeKleyn's Test
The patient is placed supine on an adjusting table, and the head rest is
lowered. The examiner extends and rotates the patient's head, and this
position is held for about 15--40 seconds on each side. A positive sign
suggests the same as that in Maigne's test.
Hautant's Test
The examiner places a sitting patient's upper limbs so that they are
abducted forward with the palms turned upward (supinated). The patient
is instructed to close his eyes, and the examiner extends and rotates the
patient's head. This position is held loosely for about 15--40 seconds on
each side. A positive sign is for one or both arms to drop into a pronated
position.
ARTHROKINEMATICS
Many injuries of the cervical spine can be attributed to the small curved
vertebral bodies, the wide range of movement in many planes, and the
more laterally placed intervertebral articulations that require nerve roots
to leave the spinal canal in an anterolateral direction. There is greater
space within the cervical canal than below, but this space is occupied by
cord enlargement to accommodate the brachial and cervical plexuses.
The segmental function of these plexuses is shown in Table 1.
Table 1. Segmental Function of Cervical Nerves
Function
Segment
CERVICAL PLEXUS (C1--C4)
Motor to head and neck extensors,

C1 infrahyoid, rectus capitis anterior and lateral,
and longus capitis.
Sensory to lateral occiput and submandibular

C2 area; motor, same as C1 plus longus colli.
Sensory to lateral occiput and lateral neck,

C3 overlapping C2 area; motor to head and neck
extensors, infrahyoid, longus capitis, longus
colli; levator scapulae, scaleni, and trapezius.
Sensory to lower lateral neck and medial

C4 shoulder area; motor to head and neck
extensors, longus coli, levator scapulae,
scaleni, trapezius, and diaphragm.
BRACHIAL PLEXUS (C5--T1)
Sensory to clavicle level and lateral arm

C5 (axillary nerve); motor to deltoid, biceps,
biceps tendon reflex. Primary root in
shoulder abduction, exits between C4-C5
discs.
Sensory to lateral forearm, thumb, index and

C6 half of 2nd finger (sensory branches of
musculocutaneous nerve); motor to biceps,
wrist extensors, brachioradialis tendon
reflex. Primary root in wrist extension, exits
between C5-C6 discs.
Sensory to second finger; motor to wrist

C7 flexors, finger extensors, triceps, triceps
tendon reflex. Primary root in finger
extension, exits between C6-C7 discs.
Sensory to medial forearm (medial

C8 antebrachial nerve), ring and little fingers
(ulnar nerve); motor to finger flexors,
interossei; no reflex applicable. Primary root
in finger flexion, exits between C7-T1 discs.
Sensory to medial arm (medial brachial

T1 cutaneous nerve); motor to interossei; no
reflex applicable. Primary root in finger
abduction, exits between T1-T2 discs.
STRUCTURAL CHARACTERISTICS OF THE CERVICAL

REGION
In the healthy cervical (or lumbar) spine displaying a moderate degree of

lordosis, a good share of weight bearing is on the zygapophyses because
the line of cumulative loading of compressive forces is posterior to the
center of the vertebral bodies. This produces considerable articular
jamming that tends to restrict a wide range of rotation. That is, the rotary
motion occurring at the zygapophyses does so on firmly compressed
facets. Fortunately, there is some structural adaptation for this. For the
normal adult spine, the cervical discs average 3 mm in thickness, there is
a 2:5 disc/body ratio, a 4:7 nucleus/anulus ratio, and the nucleus sits in a
position that is slightly posterior to the center of the disc. In addition, the
surface area of the cervical facets is larger in proportion to the surface
area of the vertebral body than at any other region of the spine. This
design contributes greatly to the overall segmental base of support in the
neck. In fact, the weight-bearing surfaces of the facets are more than half
(67%) that of the centrum. In addition, the superior facets below the axis
face posterosuperior and medial to compensate for the normal
anteroinferior tilt of the vertebral bodies.
The more the cervical curve flattens, the more superimposed weight is
shifted to the discs. With the shift of normal compressive force normally
at the posterior toward the anterior of the vertebral motion unit, the
discs are forced to carry more weight and assume a greater responsibility
in cervical stability. In time, this unusual compressive force on the
nucleus can produce degenerative anular thinning, spurs, eburnation,
and Schmorl's nodes. The posterior joints become relatively lax and
predispose retropositioning and posterior subluxations. Add the
disruptive forces of trauma, and this noxious situation is greatly
increased.
The Upper Cervical Spine
The spinal canal of the upper cervical region is relatively large to

accommodate the cervical enlargement of the cord. The pedicles,
apophyseal joints, uncinate processes, and transverse processes have
characteristics peculiar and specific to the cervical spine.
The Atlas. The atlas can be considered a sesamoid between the occiput
and axis that serves as a biomechanical washer or bearing between the
occipital condyles and the axis. The absent body of the atlas is
represented by its anterior arch and the dens of the axis, and the inner
aspect of the anterior arch contains a facet for the dens. An IVD does not
exist between the occiput and the atlas, nor does the atlas exhibit IVFs or
a distinct spinous process.
The Axis. The inferior facets of the atlas fit the superior facets of the axis
like epaulets on sloping shoulders. The plane is about 110 to the vertical.
To allow maximum rotation of the upper cervical complex without stress
to the contents of the vertebral canal, the instantaneous axis of rotation is
placed close to the spinal cord (ie, near the atlanto-odontoid
articulation).
The C2--C3 Interface. Rotation of C2 on C3 is limited by a mechanical

blocking mechanism that protects the vertebral artery from excessive
torsion. The anterior tip of the superior articular process of C3 impinges
on the lateral margin of the foramen transversarium of C2. This blocking
mechanism is also found in the subjacent cervical vertebrae.
The Occipitocervical ligaments
It is well to be able to mentally picture the upper cervical ligament

complex for serious sprains in this area can occur. The cross-shaped
cruciate ligament completely secures the odontoid process. Its main
portion is the triangular bilateral transverse ligament, which passes
posteriorly on the dens and connects to the lateral masses of the atlas,
transversing in front of the spinal cord. Its main function is to restrict
anterior translation of the atlas. There are also two vertical bands. One
rides from the dens upward to the basiocciput, and the other extends
from the dens posteriorly down to the body of the axis. Because these
ligaments are usually tough, the odontoid usually fractures prior to
ligament failure. In addition, accessory atlantoaxial ligaments extend
superiorly and laterally from the base of the inferior vertical cruciate and
join the base of the dens with the inferomedial aspect of the lateral mass
of C1. Anterior to the upper arm of the cruciate are the apical and alar
ligaments.
The Lower Cervical Area
Nature has made many structural adaptations in the mid- and lower-
cervical region. The laminae are slender and overlap, and this shingling
increases with age. The osseous elevations on the posterolateral aspect
forming the uncovertebral pseudojoints tend to protect the spinal canal
from lateral IVD herniation, but hypertrophy of these joints added to IVD
degeneration can readily lead to IVF encroachment. The IVDs are
broader anteriorly than posteriorly to accommodate the cervical lordosis.
The Articular Facets. The middle and lower cervical articular processes
incline medially in the coronal plane and obliquely in the sagittal plane
so that they are near a 45 angle to the vertical. Their bilateral articular
surface area, which shares a good part of head weight with the vertebral
body, is about 67% of that of the vertebral body.
The Capsular Ligaments. The short, thick, dense capsular ligaments bind
the articulating processes of each vertebral motion unit, enclosing the
articular cartilage and synovial tissue. Their fibers are firmly bound to
the periosteum of the superior and inferior processes and arranged at a
90 angle to the plane of the facet. This allows maximum laxity when the
facets are in a position of rest. They normally allow no more than 2--3
mm of movement from the neutral position per segment, and possibly
provide more cervical stability than any other ligament. Capsulitis from
overstretch in acute subluxation is common. The posterior joint capsules
enjoy an abundance of nociceptors and mechanoreceptors, far more than
any other area of the spine. Within the capsule, small tongues of
meniscus-like tissue flaps project from the articular surfaces into the
synovial space. They are infrequently nipped in severe jarring at an
unguarded moment during the end of extension, rotation, or lateral
bending, establishing a site of apophyseal bursitis.
The Lower Cervical Perivertebral Ligaments. The five lower, relatively

similar, cervical vertebrae have eight intervertebral ligaments: four
posterior and four anterior in terms of the motion unit. The anterior
ligaments are the anterior longitudinal ligament, the anulus fibrosus, the
posterior longitudinal ligament, and the intertransverse ligament. The
posterior ligaments are the ligamentum flavum, the capsular ligaments,
and the interspinous and supraspinous ligaments.
The Intervertebral Foramen. The boundaries of the cervical IVFs are

designed for motion rather than stability as compared with the thoracic
and lumbar regions. The greatest degree of functional IVF diameter
narrowing occurs ipsilaterally in lateral bending with simultaneous
extension.
KINEMATICS
The head may be flexed forward so the chin strikes the sternum or
thrown sideward so that the ear strikes the shoulder and the neck can
still be within the normal range of motion. It is most rare, however, that
the occiput strikes the back and does not exceed normal cervical
extension.
The Upper Cervical Area
Movements in the cervical spine are relatively free because of the saddle-
like joints. The cervical spine is most flexible in flexion and rotation. The
latter occurs quite freely in the upper cervical area and is progressively
restricted caudally. The specific ranges of cervical motion differ among so
many authorities that any range offered here should be considered
hypothetical depending on individual planes of articulation, other
variances in structural design (eg, congenital, aging degeneration,
posttraumatic), and soft-tissue integrity. This variance in opinion is also
true for the centers of motion.
Upper-Cervical Instability. Moderately strong soft-tissue connections

exist in the occiput-atlas-axis complex. Bone, muscle, tendon, ligament,
fascia, and lymph node abnormalities tend to restrict motion, while
tissue tears and lax ligaments without associated muscle spasm may
allow too much motion. Stability is provided the C1--C2 joint by
paravertebral ligaments and muscle attachments. When weakening of
these supports occurs (eg, trauma, postural stress, rheumatoid arthritis),
a dangerous state of instability arises. Each infant presents a
considerable degree of cervical instability because of the relatively large
head weight superimposed on the small underdeveloped spine.
Extension and Flexion. Considerable cervical motion is concentrated in

specific spinal areas. About half of flexion and extension occurs at the
atlanto-occipital joints, with the other half distributed among the
remaining cervical joints. Inasmuch as the nucleus of the disc is nearer
the anterior of a complete cervical vertebra, A-P motion is more
discernible at the spinous process than at the anterior aspect of the
vertebral body.
Active motion. Regional active cervical flexion and extension motions are
tested by having the patient raise and lower the chin as far as possible
without moving the shoulders. Note smoothness of motion and degree of
limitation bilaterally.
Passive motion. Passive cervical flexion and extension are examined by

placing the hands on the sides of the patient's skull and rolling the skull
anteroinferior so that the chin approximates the sternum and
posterosuperior so that the nose is perpendicular to the ceiling.
Rotation. Approximately half of cervical rotation takes place at the

atlantoaxial joints about the odontoid process, with the remaining half
distributed almost evenly among the other cervical joints. During
rotation, the odontoid represents a peg encased within a fairly enclosed
ring or a stake surrounded by a horseshoe.
Active Rotation. Regional active rotary motion is tested by having the

patient move his nose as far as possible to the left and right without
moving his shoulders. Note the smoothness of motion and degree of
limitation bilaterally.
Passive Rotation. Passive rotation is examined by placing the hands on

the patient's skull and turning the head first to one side and then to the
other so that the chin is in line with the shoulder.
Note: If a complete fixation occurs between C1 and C2, the remaining

cervical segments commonly become hypermobile in compensation.
Thus, gross inspection of neck rotation (or other motions) should never
be used to evaluate the function of individual segments.
Lateral Flexion. Cervical lateral bending is essentially performed by the
unilateral contraction of the neck flexors and extensors with motion
occurring in the coronal plane. Such side-bending is accompanied by
rotational torsion below C2 and distributed fairly equally in the normal
cervical joints. That is, when the cervical spine as a whole bends laterally,
it also tends to rotate anteriorly on the side of the concavity so that the
vertebral bodies arc further laterally than the spinous processes.
The Lower Cervical Area
The lower cervical IVDs contain an exceptional amount of elastin, which

allows the IVDs to conform to the many possible planes of movement.
Excessive flexion is limited by ligament and muscle restraints on the
separating posterior arches. Overextension is limited by bony apposition.
Other factors include the resistance of the anular fibers to translation, the
stiffness property of the anulus relative to its vertical height, and the
physical barrier produced by the uncinate processes that are fully
developed in late adolescence. Major joint movements and their
innervation are shown in Table 2.
Table 2. Major Joint Movements and Their Innervation
Segments Joints Movement/Roots
C2-T1 Scapulae Elevation and retraction (C2-5)
Depression and protraction (C5-

T1)
C5-T1 Shoulder Abduction (C5-6)
Abduction and flexion (C5-T1)
Extension (C5-8)
C5-T1 Elbows Extension (C6-T1)
Flexion (C5-6)
C6-T1 Wrists Flexion (C7-T1)
Supination, pronation, extension

(C6-7)
C6-T1 Fingers Extension (C6-8)
Flexion (C7-T1)
Lower-Cervical Instability. Subtle instability is rarely obvious in the

ambulatory patient. The most important stabilizing agents in the mid-
and lower-cervical spine are the anulus fibrosus, the anterior and
posterior ligaments, and the area muscles, especially, which serve as
important contributing stabilizers. On dynamic palpation, any segmental
motion exceeding 3 mm should arouse suspicions of lack of ligament
restraint.
Neurologic Insults. There is a rough correlation between the degree of

structural damage present and the extent of neurologic deficit. This is
more true in the lower cervical area than in the upper region where
severe damage may appear without overt neurologic signs. In either case,
it's doubtful that a deficit would exhibit without an unstable situation
existing. It is not unusual for a patient to display a neurologic deficit
without static displacement; ie, the vertebral segment has rebounded
back into a normal position of rest.
Segmental Angulation. Angulation of one vertebral segment on a lateral

roentgenograph more than 11 greater than an adjacent vertebra that is
not chronically compressed indicates instability and pathologic
displacement. While conservative traction may reduce the associated
displacement, it is doubtful in severe cases that a normal resting position
can be guaranteed without surgical fusion. But this should be considered
as a final alternative.
Facet Action. In the middle and lower cervical areas, A-P motion is a
distinctly gliding translation. During flexion and extension, the superior
vertebra's inferior facets slide anterosuperior and posteroinferior on the
inferior vertebra's superior facets. During full flexion, the facets may be
almost if not completely separated. Consequently, an adjustment force is
usually contraindicated in the fully flexed position. The center of motion
is often described as being in the superior aspect of the body of the
subjacent vertebra. Some pivotal tilting of the superior facets, backward
in extension and forward in flexion, is also normal near the end of the
range of motion. The facets also tend to separate (open) on the
contralateral side of rotation and lateral bending. They approximate
(jam) during extension and on the ipsilateral side of rotation and lateral
bending. Likewise, the foramina normally open on flexion, narrow on
extension, and close on the concave side of lateral flexion. Because of the
anterosuperior slant of the lower cervical facets, an inferior facet that
moves downward must also slide posterior, and vice versa.
Adjustment Precautions. Any corrective adjustment must consider the

state of the cervical curve, planes of articulation, facet tilting, and
degree of facet opening, as well as any underlying pathologic process
involved, and applying just enough force to overcome the resistance of
the fixation. Here, again, knowledge of the mechanism of trauma and the
ability to mentally picture the state of hidden tissues are underscored.
Coupling Patterns. During lateral bending, the vertebral bodies tend to

rotate toward the concavity while the spinous processes swing in a
greater arc toward the convexity. Note that this is exactly opposite to the
coupling action in the lumbar spine. During cervical bending to the
right, for example, the right facet of the superior vertebra slides down the
45 plane toward the right and posterior and the left facet slides up the 45
incline toward the left and anterior. This coupling phenomenon is seen in
circumstances in which an unusual ratio of axial rotation and lateral
bending produces a subluxation or unilateral facet dislocation.
The amount of cervical rotation coupled with lateral flexion varies with
the segmental level. At C2, there is 1 of rotation with every 1.5 of lateral
flexion. This 2:3 ratio changes caudally so that the degree of coupled
rotation decreases. For example, at C7, there is 1 of rotation for every 7.5
of lateral flexion, a 2:15 ratio.
Ranges of Motion. All cervical vertebrae from C2 to C7 partake in flexion,

extension, rotation, and lateral flexion, but some segments (eg, C5) are
more active than others. In the C3--C7 area, flexion and extension occur
as slight gliding translation of the upper on the lower facets,
accompanied by disc distortion. The site of greatest flexion is near the
C4--C5 level, while extension movement is fairly well diffused. This fact
likely accounts for the high incidence of arthritis at the midcervical area.
Rotation in this region is greatest near the C5--C6 level, slightly less
above and considerably less below. Lateral bending in greatest near the
C2--C3 level and is diminished caudally. The arc of lateral motion is
determined by the planes of the covertebral joints.
The Transitional Cervicothoracic Area
The lateral gravity line of the body falls anterior to the mid thoracic
region. With fatigue, there is a tendency for thoracic kyphosis to increase.
Thus, when cervical alignment is poor, equal concern must be given to
reduce an exaggerated thoracic kyphosis because the positions of the
cervical and thoracic regions are interrelated; ie, a thoracic kyphosis is
usually accompanied by a compensatory cervical lordosis, and vice versa.
In the cervicothoracic area, normal movement is somewhat similar to

that in the lumbosacral area insofar as the type of stress (not magnitude
of load) to which both areas are subjected is similar. L5 is relatively
immobile on the sacrum and C7 is relatively immobile on T1. Most
movement in the cervicothoracic junction is at C6--C7 and primarily that
of rotation.
Note: The use of examining A-P and lateral patient posture with a
plumbline was common in pioneer chiropractic. Because this practice has
been generally discontinued, some basic structural correlations can be
easily overlooked.
APPLIED ANATOMY OF THE CERVICAL PLEXUS
The dura of the spinal cord is firmly fixed to the margin of the foramen
magnum and to the 2nd and 3rd cervical vertebrae. In other spinal areas,
it is separated from the vertebral canal by the epidural space. Since both
the C1 nerve and the vertebral artery pass through this membrane and
both are beneath the superior articulation of the atlas and under the
overhanging occiput, atlanto-occipital distortion can produce traction of
the dura mater producing irritation of the artery and nerve unilaterally
and compressional occlusion contralaterally. De Rusha feels that this
helps us understand those cases of suboccipital neuralgia where a patient
upon turning his head to one side increases the headache and vertigo
that are relieved when the head is turned to the opposite side.
There is also a synapse between the upper cervical nerves and the
trigeminal nerve, which also supplies the dura mater. This may explain
why irritation of C1 results in a neuralgia not only confined to the base of
the skull but is also referred to the forehead or eye via the supraorbital
branch of the trigeminal. The greater occipital (C2) nerve does not tend
to do this. It exits between the posterior arch of the atlas and above the
lamina of the axis, referring pain to the atlanto-occipital area and
sometimes to the vertex of the scalp.
The superficial sensory cutaneous set of the cervical plexus (C1--C4) is

frequently involved in subluxations of the upper four segments (see Table
3), particularly when there are predisposing spondylitic degenerative
changes. Janse describes four resultant neuralgias: (1) lesser occipital
neuralgia, involving the posterior area of the occipitofrontalis muscle,
mastoid process, and upper posterior aspect of the auricle; (2) greater
auricular neuralgia, extending in front and behind the auricle, skin over
the parotid gland, paralleling the distribution of the auriculotemporal
branch of the trigeminus and easily misdiagnosed as chronic trifacial
neuralgia; (3) cervical cutaneous neuralgia, involving the area of the
middle third of the platysma to the midline, possibly extending from the
chin to the sternum; (4) supraclavicular neuralgia. Depending on which
rami are affected, the neuralgia may involve the suprasternal area,
pectoral area, or deltoid area. Thus, sternoclavicular and
acromioclavicular neuralgias may originate in the spinal levels of the
supraclavicular nerve.
Table 3. Nerve Function of the Cervical Plexus (C1--C4)
Nerve Function
Lesser occipital Sensory to skin behind ear and

mastoid process.
Greater auricular Sensory to skin over parotid, jaw

angle, ear lobe, and front of
mastoid process.
Cervical Sensory to skin over anterolateral

cutaneous portion of neck.
Supraclaviculars Sensory to skin over medial

infraclavicular area, pectoralis
major and deltoid.
Muscular Motor to capitus anterior and

branches lateralis, longus capitus, longus
colli, hyoid muscles,
sternocleidomastoideus, trapezius,
levator scapulae, scalenus medius.
Phrenic Sensory to costal and mediastinal

pleura and pericardium. Motor to
diaphragm.
De Rusha suggests that dysphagia and dysarthria may at times be due to
upper cervical involvement rather than a CNS situation. The C1 joins the
hypoglossal nerve supplying the intrinsic muscles of the tongue. It then
descends to join the descending cervical that is derived from C2 and C3.
A loop of nerves, the ansi hypoglossi, which supplies muscles necessary
for deglutition and speaking, is arises from C1--C3.
Irritative lesions involving the cervical articulations may in turn irritate

the sympathetic nerve plexuses ascending into the cranium via the
vertebral and carotid arteries. Some cases of visual and aural symptoms
are related to upper-cervical distortion where the arch of the atlas snugly
hugs the occiput, thus possibly irritating the sympathetic plexus near the
vertebral artery as well as partially compressing the vessel. To appreciate
this, note that the visual cortical area of the occipital lobe requires an
ideal blood supply dependent on the sympathetics ascending the great
vessels of the neck, and this holds true for the inner ear as well.
To test this syndrome, De Rusha suggests having the supine patient read
some printed matter while the examiner places gentle traction on the
skull, separating the atlanto-occipital articulations. A positive sign occurs
when the patient, often to his surprise, experiences momentarily
enhanced visual acuity or reduced tinnitus.
THE BRACHIAL PLEXUS
See Table 4 for review. Many features of brachial plexus involvement

manifest in the upper extremities and have been described in previous
papers in this series.
Table 4. Nerve Function of the Brachial Plexus (C5--T1)
Nerve Function
Radial Motor for wrist and thumb extension;

sensory to dorsal webspace between
thumb and index finger.
Ulnar Motor for little finger abduction;

sensory to distal ulnar aspect of little
finger.
Median Motor for thumb opposition and
abduction; sensory to distal radial
aspect of index finger.
Axillary Motor to deltoid muscle; sensory to

lateral arm and deltoid patch on upper
arm.
Musculo- Motor to biceps muscle; sensory to

cutaneous lateral forearm.
THE CERVICOTHORACIC JUNCTION AREA
The area of cervicothoracic transition is a complex of prevertebral and

postvertebral fascia and ligaments subject to shortening. It offers a
multitude of attaching and crossing muscles such as the longus colli,
trapezius, scaleni, sternocleidomastoid, erector spinae, interspinous and
intertransverse, multifidi and rotatores, splenius capitis, splenius
cervicis, semispinalis capitis, semispinalis cervicis, longissimus capitis,
longissimus cervicis, and the levator costarum and scapula --all subject
to spastic shortening and fibrotic changes that tether normal dynamics.
CLINICAL MANAGEMENT ELECTIVES IN CERVICAL

STRAIN/SPRAIN/IVD LESION
1. Stage of Acute Inflammation and Active Congestion
The major goals are to control pain and reduce swelling by

vasoconstriction, compression, and elevation; to prevent further
irritation, inflammation, and secondary infection by disinfection,
protection, and rest; and to enhance healing mechanisms. Common
electives include:
Disinfection of open skin (eg, scratches, abrasions, etc)

Cryotherapy
Cold packs
Ice massage
Vapocoolant spray
Pressure bandage
Protection (padding)
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Spondylotherapy (upper dorsal)
Mild pulsed ultrasound
Pulsed alternating current
Rest
Bedrest
Foam/padded appliance
Immobilization
Brace
Plaster cast
Rigid appliance
Indicated diet modification and nutritional supplementation.
2. Stage of Passive Congestion
The major goals are to control residual pain and swelling, provide rest
and protection, prevent stasis, disperse coagulates and gels, enhance
circulation and drainage, maintain muscle tone, and discourage adhesion
formation. Common electives include:
Indirect articular therapy (reflex therapy)

Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Light nonpercussion vibrotherapy
Mild passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Meridian therapy
Phonophoresis
Rest
Bedrest
Immobilization
Brace
Rigid appliance
Plaster cast
Orthopedic pillow
3. Stage of Consolidation and/or Formation of Fibrinous Coagulant
The major goals are the same as in Stage 2 plus enhancing muscle tone
and involved tissue integrity and stimulating healing processes. Common
electives include:
Mild articular adjustment technics

Moist superficial heat
Thermowraps
Spray-and-stretch
Moderate active range-of-motion exercises
Meridian therapy
Alternating traction
Sinusoidal current
Ultrasound
Phonophoresis
Microwave
Vibromassage
High-volt therapy
Interferential current
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest and Immobilization
Semirigid appliance
Orthopedic pillow
4. Stage of Fibroblastic Activity and Potential Fibrosis
At this stage, causes for pain should be corrected but some local
tenderness likely remains. The major goals are to defeat any tendency for
the formation of adhesions, taut scar tissue, and area fibrosis and to
prevent atrophy. Common electives are:
Prudent deep heat

Articular adjustment technics
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Active range-of-motion exercises without weight bearing
Motorized alternating traction
Negative galvanism
Ultrasound
Sinusoidal and pulsed muscle stimulation
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Flexible foam/padded appliance
Orthopedic pillow
5. Stage of Reconditioning
Direct articular therapy for chronic fixations

Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Orthopedic pillow
COMMENTARY
Extension Strain/Sprain (Whiplash Syndrome)
Traumatic overextension of the neck is not the most common cervical

injury, but it's certainly the most publicized. Forceful extension produces
tearing of the anterior longitudinal ligament that may coexist with an
avulsion fracture at the anterior vertebral bodies. Pedicle fracture or
severe posterior subluxation may also occur. Tenderness will usually be
shown along the lateral musculature. Upper extremity pain or numbness
and restricted cervical motion at an interspace during flexion-extension
may exhibit. Symptoms may be prolonged without demonstrable
evidence.
Mechanisms
Other than those occurring in automobile accidents, the forces in

whiplash are usually administered from below upward; eg, an uppercut
to the chin or a blow to the forehead while running forward. This is in
contrast to the compressive type of hyperextension or hyperflexion injury
where the force is usually from above downward. Thus, knowing the
direction of force, even if the magnitude is unknown, is important in
analyzing the effects. A facial injury usually suggests an accompanying
extension injury of the cervical spine as the head is forced backward
either by an external force or as a defensive maneuver.
Kinematics
In whiplash resulting from a mild automobile collision, the cervical

injury is due to indirect trauma from acceleration-deceleration forces. If
the head does not strike something, the damage is produced solely by
inertia forces. The body moves at the same speed as the automobile. If
the automobile is struck from the rear, the unrestrained head is whipped
backward, because the head is not restrained by the seat, and then
rebound forward. If the automobile is struck from the front or hits a
relatively immovable object, the head is thrown forward and then
rebound backward. Thus, the inertia force displaces the head in the
direction opposite to the automobile's acceleration. The first movement
is that of translation producing a shearing force at the base of the neck
because the bending moment is greatest at that point.
The rebound can be caused by several factors. In a front-end collision, for

example, there is an initial flexion elongation of the cervical spine after
impact that is followed by rebound extension. The rebound is produced
by the rapid deceleration of the automobile, the impact from the seat,
and the stretch reflex produced in the elongated neck and upper dorsal
muscles. This reflex can be quite severe. Because it occurs when the neck
is at its full range of movement, the pull generates considerable
compression as well as extension.
Effects
When the head is violently thrown backwards (eg, whiplash), the damage
may vary from minor to severe tearing of the anterior and posterior
longitudinal ligaments. This flattens the cervical curve in about 80% of
cases, and a degree of facet injury must exist even if not evident on film.
Stretching to the point of hematoma can occur in the scalene muscles,
sternocleidomastoideus, longus capitis, and longus cervicis.
Severe cord damage may occur that is usually attributed to momentary

pressure by the dura, ligamentum flavum, and laminae posteriorly, even
without roentgenologic evidence. Even without any cord deficit, severe
damage to the nerve roots may occur as the facets jam and close on the
IVFs, especially if fracture occurs. Incidence is highest at the C4--C6
area. Severe stretching of the vertebral arteries, sympathetic trunk, nerve
root, and spinal cord attachments to some degree is inevitable.
Cailliet points out that it is difficult to visualize a sprain causing rupture
of the ligaments of a joint without causing some derangement of the
opposing joint surfaces, which by definition is an orthopedic subluxation.
If a whiplash injury is considered a severe sprain, an orthopedic
subluxation injury must be assumed to have occurred even if it has been
spontaneously reduced. Such subluxations may occur during the initial
movement and/or the rebound movement, and it is not unusual to have
manifestations of a flexion sprain superimposed on manifestations of an
extension sprain. In the typical whiplash injury, whether it be from
hyperextension or hyperflexion or both, the effects of traumatic
elongation and compression are compounded by underlying fixations,
arteriosclerosis, spondylosis, ankylosing spondylitis, etc.
Case Management
Treatment of mild or moderate injuries not exhibiting severe neurologic

trauma requires reduction of subluxation, mobilization of fixations,
physiotherapeutic remedial aid of soft-tissue injury, a custom-fit
nonflexible supporting collar for several weeks depending on the clinical
symptoms and signs, and graduated therapeutic exercises. Continuous
traction, which reduces the cervical lordosis, may be helpful in extension
injuries after the acute stage, but it would usually be contraindicated
where the cervical curve has reversed (eg, flexion strain). The previously
described template offers several beneficial electives.
Flexion Strain/Sprain
Slight anterior subluxation is usually not serious, but neurologic

symptoms may appear locally or extend down the arm.
Mechanisms
An occipital blow usually suggests an accompanying flexion injury of the

anterior cervical spine and posterior soft tissues as the skull is forced
forward. Excessive flexion may also be a part of whiplash; ie,
superimposed on an excessive extension injury.
Effects
The posterior paraspinal tissues are overstretched, the facets are sprung
open, and the process of bleeding, edema, fibrosis, and adhesions is
initiated. Fractures of end-plates may be difficult to assess early. Disc
degeneration and posttraumatic osteoarthritis may follow, which lead to
spondylosis.
Case Management
Management is similar to that of extension injuries except that the period

of necessary immobilization is often shorter (6--8 weeks).
Lateral Flexion Strain/Sprain
Traumatic brachial plexus traction syndromes have been described in an

earlier paper of this series. These injuries usually occur when the head is
not only severely flexed sideward but also flexed forward and downward
below the shoulder.
OCCIPITAL AND CERVICAL SUBLUXATION SYNDROMES
Vertebral subluxations are difficult to classify under normal categories of

injury because they can involve bone, joint, muscle, fascia, ligament,
capsule, disc, nerve, cord, spinal fluid, and vascular tissues. Inasmuch as
all freely movable articulations are subject to subluxation, the atlanto-
occipital diarthrosis is no exception. The stress at this point is unusual
when one considers that the total weight of the cranium is supported by
the ring of the atlas about 1/20th the circumference of the skull and a
variety of spinal muscles, subject to spasm, have their attachments on the
occiput.
Aside from direct trauma, disturbances in the upper-cervical area usually

arise from muscular spasm of one or more of the six muscle bundles
having attachments on the occiput, atlas, or axis. Unequal tension and
ultimate fibrotic changes within the perivertebral structures can readily
influence the delicate nerve fibers and vascular and axoplasmic flow. The
vertebral artery is frequently involved by compression of the overlying
muscles in the suboccipital triangle. West points out that the vertebral
artery can be completely occluded during postmortem studies just by
turning the head backward and to the opposite side
Functional Anatomy Relative to Cervical Subluxations
The artery and vein supplying a spinal nerve course within the foramen
between the nerve and the fibrous tissue in the anterior portion of the
opening. It is unlikely that circulation to the nerve would be disrupted
without first irritating or compressing the nerve because the arteries and
veins are much smaller, blood pressure within the lumen makes them not
easily compressed, and nerve tissue is much more responsive to
encroachment irritation. Nevertheless, loss of mobility of any one or
more segments of the spine correspondingly influences its circulation.
Without the massing effects of motion, collateral microcirculation and

CSF flow along the nerve root is hampered. The resulting partial anoxia,
venous congestion, and stagnant lymph and CSF have a harmful
influence on nerve function. This is one reason why attaining the highest
degree of normal mobility possible after trauma is so important in
chiropractic rehabilitation. Mobility reflects a joint that is free of stasis,
binding adhesions, taut scar tissue, compression impingement, etc.
Once a vertebra loses its ideal relationship with contiguous structures

(subluxation) and becomes fixed or restricted at some point (fixation) in
its normal range of motion, it's no longer competent to fully participate
in ideal coordinated spinal dynamics. The affected area becomes the
target for unusual stress, weight-bearing and traumatic. In addition to
the attending circulatory, neuromechanical, and static changes in the
involved area, there is disturbed reflex activity that can manifest as
changes in superficial and deep reflexes, hyperkinesia, pupillary changes,
excessive lacrimation, tremors and spasms.
Add to factors explained above anomalies in the cervical area that can
predispose subluxations from minor overstress. The weight of the head
along with activity demands may contribute to chronic degenerative
spondylosis often superimposed on asymptomatic anomalies. A vicious
cycle is seen where subluxation contributes to degenerative processes
and these processes contribute to subluxation. This poses the question
when pain fades, "When can the patient be discharged?" But a better
question would be, "How long should periodic check-ups be continued to
monitor an asymptomatic patient?" There is no life that is void of stress.
Further Clinical Implications
Neurologic disturbances may result from muscular and fibrotic changes

along the cranial nerve pathways that emit from the skull and pass
intimately between and under suboccipital fasciculi. Five of the cranial
nerves are thus vulnerable: the facial, glossopharyngeal, vagus, spinal
accessory, and hypoglossal. In addition, circulatory impairment of major
and minor nerves of the neck may alter the function of those cranial
nerves that do not exit from the skull proper (eg, the olfactory, optic,
oculomotor, trochlear, trigeminal, abducens, and auditory) but which are
contained within the cranium and remote from direct vertebral
subluxation encroachment effects. We should not overlook the fact that it
is essentially muscle that produces and maintains the subluxation.
Concern must be given to why the subluxation is produced. Perpetuation
may be only by a self-generating reflex.
Due to the interlocking arrangement of the articular processes, a straight

posterior subluxation is an anatomical impossibility unless there is a
fracture of the articular processes. The body of any vertebra follows the
plane of the articular surfaces in movement. If a spinous process moves
left, it does so by inscribing an arc toward the superior and anterior while
simultaneously the right transverse process moves inferiorly and
somewhat posteriorly. It is thus improbable for an individual vertebra to
be rotated straight right or left on its longitudinal axis. A typical vertebra
cannot be subluxated without an articular process moving either
superiorly or inferiorly; thus it can be said that superiority or inferiority
attends every posterior/anterior subluxation.
If subluxation of a vertebra occurs in a superior direction, the contents of

the intervertebral foramen become compressed. Anatomic
disrelationship by elongating the short diameter of the intervertebral
foramen will cause indirect pressure upon the nerve trunk from
compression between the fibrous tissue in the anterior portion of the
foramen. If there is movement in an inferior direction, enlargement of
the foramen occurs. Because the nerve sheath is firmly anchored by
tissues connecting it to the borders of the foramen, a stretching effect is
exerted on the nerve sheath, altering its shape. It can thus be appreciated
that enlarging the intervertebral foramen can cause as much trouble as a
reduction in the size of the intervertebral foramen. In addition, it's
impossible to subluxate a vertebra between C2 and L5 inclusive without
changing the shape of the IVD in compensation.
CERVICAL SPONDYLOSIS
Three not infrequent diseases of the cervical spine with biomechanical

implications are spondylosis, rheumatic spondylitis, and ankylosing
spondylitis. In each of these conditions, severe subluxation is a cardinal
manifestation. Cervical spondylosis invariably has a traumatic origin.
This may be from a blow to the neck, a whiplash injury, a fall, or years of
poor neck posture (eg, typing, overhead work). It's prevalence in the late
degenerative stage is likely due to inadequate posttraumatic
rehabilitation
Cervical spondylosis is a chronic condition in which there is progressive

degeneration of the IVDs leading to secondary changes in adjacent
vertebrae, including the posterior apophyseal joints. It is the result of
direct trauma (ie, disc injury), occupational stress, aging degeneration, or
found in association with and adjacent to congenitally defective
vertebrae.
Clinical Implications
Spondylosis may produce compression of either the nerve root or spinal

cord. During the degenerative process, intradisc pressure decreases, the
anulus protrudes, and the end plates approximate due to reduction of
disc thickness. As the disc protrudes, it loosens the attachment of the
posterior longitudinal ligament and this allows the anulus to extrude into
the cavity formed between the posterior vertebral body and the ligament.
This portion of the anulus, in time, becomes fibrous and then calcifies. It
is for this process that posterior osteophytes prevail in the cervical and
lumbar regions, while anterior spurs are more common to the dorsal
spine.
Etiology
Jeffreys sees a correlation of cervical spondylosis to carpal tunnel

syndrome, lateral humeral epicondylitis, cervical stenosis, and low-back
and/or lower extremity osteoarthritis. Pre-existing spinal stenosis, a
thickened ligamentum flavum, a protruding disc, and spur formation not
uncommonly complicate the picture of cervical spondylosis. There is
almost no correlation between the degree of perceived pain in the neck
and the degree of arthritic changes noted in early x-ray films. The weight
of the head in faulty posture (eg, exaggerated dorsal kyphosis and
cervical lordosis) along with activity stress may contribute to chronic
degenerative spondylosis often superimposed on asymptomatic
anomalies. Again we may see a vicious cycle in which subluxation
contributes to degenerative processes, and these processes contribute to
subluxation fixation.
Clinical Findings
The onset is usually rapid and insidious but may be subjectively and
objectively asymptomatic. The classic picture is one of a middle-aged
person with greatly restricted cervical motion with marked muscle
spasm, positive cervical compression test, insidious neck and arm pain
and paresthesia aggravated by sneezing or coughing, acute radiculopathy
from disc herniation, and usually some muscle weakness and
fasciculations. A general rule states that central herniation produces local
neck pain while lateral herniation produces upper extremity pain.
Whiting lists the manifestations that develop in spondylosis to also

include neck crepitus, subjective or objective; local neck tenderness;
headaches; neck pain radiating to the scapulae, trapezius, upper
extremities, occiput, or anterior thorax; extremity muscle weakness;
paresthesia of the upper and/or lower extremities; dizziness and fainting;
impaired vibration sense at the ankle; hyperactive patellar and Achilles
reflexes; and positive Babinski responses. From this one can see why the
diagnosis is made from roentgenologic findings. The Davis series may
suffice, but special views, tomography, myelography, or discography may
be necessary for firm diagnosis.
Because of the constant weight of the head, postural strains, occupational

insults, degrees of congenital anomalies, and posttraumatic or
postinfection effects with or without associated disc involvement, the
development of chronic degenerative spondylosis offers some distinct
progressive characteristics: (1) flattening of the cervical spine from
muscle spasm and adhesion development, (2) A-P fixation and restricted
mobility, (3) thinning of the atlanto-occipital and atlantoaxial articular
plates resulting in motion restriction, (4) middle and lower cervical disc
wearing and thinning which narrows the IVFs, (5) disc weakness
encouraging nuclear shifting and herniation contributing to nerve
encroachment, (6) osseous lipping and spurs with extensions into the
IVFs, and (7) infiltration and ossification of paravertebral ligaments
adding to inflexibility and pain upon movement.
Case Management and Prognosis
Whiting brings out that it is fortunate that most people with cervical
spondylosis are asymptomatic because there is no correction per se.
Initial treatment is aimed at reducing symptoms of neurologic and
vasomotor involvement or treating the soft-tissue injury superimposed
on the pre-existing spondylosis. A trial of conservative treatment with
emphasis on postural alignment may be preferred in cases
demonstrating signs of either cervical radiculopathy and/or myelopathy.
Patients suffering with symptoms of radiculopathy related to cervical

spondylosis tend to improve regardless of the treatment regimen.
Unfortunately, the degenerative changes of the IVDs, vertebral bodies,
and associated diarthrodial joints are permanent and, in most cases,
progressive. Treatment is therefore aimed at reducing symptoms and
future attacks by proper case management and prophylaxis. Traction and
stretching exercises are highly beneficial in the postacute stage.
Exacerbation of symptoms is quite common, and months or years may

elapse between attacks. With age and the gradual increase in
degenerative changes, attacks are more closely spaced, and recovery from
each attack is prolonged. Any trauma superimposed on silent cervical
spondylosis can result in permanent partial disability of the cervical
spine with symptoms far out of proportion to the severity of the injury.
REVERSAL OF THE NORMAL CERVICAL CURVE
In contrast to the primary thoracic kyphosis that is a structural curve, the

cervical and lumbar anterior curves are functional arcs produced by their
wedge-shaped IVDs and they normally flatten in the nonweightbearing
supine position. Likewise, they quickly adapt to changes involving the
direction of force. A pathologic straightening of the normal anterior
curve of the cervical spine, as viewed in a lateral weight-bearing x-ray
film, results in mechanical alteration of normal physiologic and
structural integrity. The normal vertical A-P line of gravity, as viewed
laterally with a plumbline, falls approximately through the odontoid and
touches the anterior border of T2. As the cervical spine tends to flatten in
the erect position, the gravity line passes closer to the center of the
cervical discs.
Clinical Findings
Cervical flattening is usually the result of paraspinal spasm secondary to

an underlying injury, irritation, or inflammatory process. The acute
clinical picture is often torticollis. Other manifestations include
headaches (occipital, occipital-frontal, supraorbital), vertigo, tenderness
elicited on lateral C4--C6 nerve roots, neuritis involving branches of the
brachial plexus due to nerve-root pressure, hyperesthesia of one or more
fingers, and loss or lessening of the biceps reflex on the same or
contralateral side. In rare instances, the triceps reflex may be involved.
One or more symptoms are frequently aggravated by an abnormal
position of the head such as during reading in bed, an awkward sleeping
position, or long-distance driving.
The typical radiographic findings include loss of the normal lordotic

curve by the straightened cervical spine (78% cases), anterior and
posterior subluxation on flexion and extension views, narrowing of IVD
spaces at C4--C6 in 46% of cases, discopathy at the affected vertebral
level as the injury progresses, and osteoarthritic changes that are often
accompanied by foraminal spurring.
A flattened cervical spine in the erect posture somewhat resembles a

normal spine during flexion. To appreciate the mechanisms involved, it is
well here to review the biomechanics involved. The nucleus of the disc
serves as a fulcrum during flexion and return extension. When the spine
is subjected to bending loads during flexion, half the disc on the convex
side suffers tension, widens, and contracts, while the other half of the
disc on the concave side suffers compression, thins, and bulges.
Concurrently, the nucleus bulges on the side of tension and contracts on
the side of compression, which increases tension on the adjacent anulus.
This creates a self-stabilizing counteracting flexion force to the vertebral
motion unit that aids a return to the resting position.
Case Management and Prognosis
Specific correction of offending vertebral subluxations should be

accomplished. Adjunctive care includes massage and methods to reduce
muscle spasm such as ultrasound, diathermy, hydrocollator packs, reflex
spinal techniques, and a rolled towel placed under the neck in the supine
position to increase the cervical curve. The individual should be
instructed to sleep without a pillow. Cervical muscle re-education is quite
helpful.
Prognosis is excellent if the condition is treated early and the case is not
complicated by fracture or dislocation, but guarded if injury is severe. In
cases of minimal cervical discopathy, at least symptomatic relief can be
expected. Prognosis is poor in advanced degenerative osteoarthritis.
TRAUMATIC BRACHIAL PLEXUS TRACTION
The branches of the brachial plexus in the shoulder lie just anterior to the
glenohumeral joint. The axillary nerve runs just below the joint. In
brachial plexus trauma, the entire plexus or any of its fibers may be
injured. These injuries may be divided into three general types: total-arm
palsies, upper-arm palsies (most common), and lower-arm palsies.
Motor disturbances are the main feature as sensory loss is obscured by
overlapping innervation.
The term Erb's palsy refers to the effects of a stretch injury or avulsion of
the upper roots of the brachial plexus. In contrast, Klumpke's palsy
means the effects of a stretch injury or avulsion of the lower roots of the
brachial plexus.
Bikele's Test
The sitting patient is asked to raise the involved arm laterally to a

horizontal and slightly backward position. Flex the elbow, and laterally
flex the neck to the opposite side. If active extension of the elbow, which
stretches the brachial plexus, produces resistance and increased
cervicothoracic radicular pain, the test is said to be positive for a nerve
root or spinal cord inflammatory process (eg, brachial neuritis,
meningitis).
Supine Tension Test
The patient is placed supine so that the scapula is fixed. Have the patient
laterally flex the neck to the opposite side of involvement. Abduct the
humerus to about 45 , externally rotate the arm, extend the elbow, and
extend the wrist. This maneuver places tension on the brachial plexus
and its peripheral branches and thus helps to elicit signs of a lesion. The
neurologic signs in brachial radiculopathy are shown in Table 5.
Table 5. Neurologic Signs in the Brachial Radiculopathies
Major Major Motor Reflex

Sensory Disorder Changes
Disorder
Nerve
Root (Hypalgesia) (Weakness) (+/- Reflexes)
Affected
C5 Lateral arm Biceps, Biceps

supraspinatus,
infraspinatus,
deltoid
C6 Lateral Brachioradialis Brachioradialis

forearm and
thumb
C7 Middle Triceps Triceps

finger
C8 Little finger Wrist and None

finger flexors
T1 Medial Intrinsic hand Finger flexors

forearm muscles
Case Management
Provide support in the functional position, apply cold initially and correct
any subluxations/fixations found. Once the acute symptoms are
controlled, massage, interferential therapy, lower cervical and upper
thoracic galvanic stimulation, ultrasound, moist heat, acupuncture, and
progressive exercises to reduce cervicothoracic postural distortions are
common recommendations.
Referral for suture is recommended in complete tears, and some

improvement can be hoped for. The prognosis is usually hopeless for full
recovery following avulsion from the cord. Fortunately, most injuries are
a neurapraxia, and full recovery can be anticipated in time. If the lesion is
due to simple stretching, contusion, or partial tearing, the prognosis is
good for conservative therapy and complete recovery can be expected in
most cases.
THE STINGER SYNDROME
Albright describes the "stinger" syndrome as an apparently mild brachial

plexus injury reflecting a transient radiculopathy at the time of impact.
Football "spearing" and head butting are common causes. The injury
usually occurs when the neck is forcibly hyperextended and laterally
flexed, and symptoms can usually be precipitated in this position during
examination.
Clinical Findings
The condition is initially felt as a painfully severe electrical shock-like

dysesthesia extending from the shoulder to the fingertips. This feeling
passes within a few moments and is replaced by sensations of numbness
and upper extremity weakness that may last from a few seconds to
several minutes.
A common site of injury is at the C5 or C6 root level, and because of this,

the most persistent sign will be weakness of the proximal shoulder
muscles. An initial attack rarely leaves residual neurologic symptoms.
Repetitive injuries of this nature, however, tend to have a cumulative
effect that may lead to axonotmesis and chronic muscle weakness that
may require up to 3 years for full recovery.
Complications
The most common lesion associated with the stinger syndrome is cervical
sprain with traumatic compression neuritis. Infrequently, an acute
cervical disc rupture or a spontaneously reduced hyperextension
dislocation may be associated. These later disorders are far more serious
and usually require hospitalization until the severity of the injury can be
properly assessed.
SUBLUXATION INDUCED TORTICOLLIS
Initial examination must be conducted with special care. Traumatic

dislocations of upper cervical vertebrae cause a distortion of the neck
much like that of torticollis. A rotary fracture-dislocation of a cervical
vertebra, especially of the atlas on the axis or the axis on C3, will produce
neck rigidity and a fast pulse. Fever is absent. Local and remote trigger
points are frequently involved. Even in mildly suspicious cases, the neck
should always be x-rayed in two or more planes before it is physically
examined.
The most common direct cause is that from irritating cervical

subluxation (eg, trauma, rotational overstress, unilateral chilling,
unbalanced lifting, instability). Subluxation may also be an
asymptomatic complicating factor to those etiologic factors mentioned
above. Barge states that the structural cause of torticollis is a rotatory
vertebral malposition and abnormal disc wedging, where the nucleus of
an involved disc has been forced to shift away from compressive forces.
The patient's symptoms are often self-limiting with time and rest that
allow the disc to expand in its nonweightbearing (decompressed) state
and the vertebral facets to be relieved of their jammed position.
It can be theorized, however, that if the neck does not achieve this
subluxation correction through disc imbibition a rotatory scoliosis is
produced in adaptation so that the victim may at least have a straight eye
level. But, as the now chronic subluxation has not been fully corrected, it
can serve as a focus for morbid neurologic and degenerative processes,
especially at the zygapophyses, covertebral joints, and IVFs.
Clinical Findings
Regardless of the cause of torticollis, the neck is rigid and tender, the
head tilts laterally toward the side of spasticity, and the chin is usually
rotated to the contralateral side. Special care must be taken to determine
the etiology and differentiate its many possible causes. Besides traumatic
causes, torticollis may have an inflammatory, a congenital, or a
neuropathic origin, or be the effect of various superimposed factors.
The pain associated with acute torticollis is attributed essentially to
zygapophyseal capsulitis and covertebral joint inflammation. This can
generally be confirmed by palpation and should not be confused with the
pain of stretching rigid muscles on the side of the concavity.
EFFECTS OF CERVICAL AREA HYPERTONICITY
Overuse is a common cause for taut muscles that fail to relax on rest.
Excessive hypertonicity of a muscle, confirmed by palpatory tone and
soreness, will tend to subluxate/fix its site of osseous attachment. Below
is a listing of common problem areas in the neck.
1. Splenius capitis. Increased tone tends to pull the C5--T3 spinous

processes lateral, superior, and anterior and to subluxate the occiput
inferior, medial, and posterior.
2. Scalenus anterior. Hypertonicity tends to pull the C3--C6 transverse

processes inferior, lateral, and anterior and the 1st rib superior and
medial.
3. Scalenus medius. Excessive tone tends to pull the C1--C7 transverse

processes inferior, lateral, and anterior and the 1st rib superior and
medial.
4. Scalenus posterior. Hypertonicity tends to pull the C4--C6 transverse

processes inferior, lateral, and anterior and the 2nd rib superior and
medial.
5. Obliquus capitis superior. Abnormal tone tends to roll the occiput

anterior and inferior and pull the atlas posterior and superior to produce
a lateral occiput tilt and condyle jamming.
6. Obliquus capitis inferior. Excessive tone tends to produce a rotary

torque of the atlas-axis motion unit.
7. Rectus capitis posterior major. Hypertonicity tends to pull the occiput

posterior, inferior, and medial and the spinous of the axis superior,
lateral, and anterior. Strong hypertonicity will lock the occiput and axis
so that they appear to act as one unit even though they are not
contiguous.
8. Interspinales. Excessive tone found between the spinous processes

tends to hyperextend the involved vertebral motion units.
9. Sternocleidomastoideus. Abnormal tone tends to pull the sternum and
clavicle posterior and superior and the occiput inferior and anterior.
10. Upper trapezius. Hypertonicity tends to pull the occiput

posteroinferiorly, the C7--T5 spinous processes laterally, and the
shoulder girdle medially and superiorly.
TRIGGER-POINT SYNDROMES
The muscle fascia of the posterior neck is a common site for trigger point
development. The cervical and suprascapular areas of the trapezius,
usually a few inches lateral to C7, frequently refer pain and deep
tenderness to the lateral neck (especially the submastoid area), temple
area, and angle of the jaw. The sternal division of the
sternocleidomastoideus refers pain chiefly to the eyebrow, cheek, tongue,
chin, pharynx, throat, and sternum. The clavicular division refers pain
mainly to the forehead (bilaterally), back of and/or deep within the ear,
and infrequently to the teeth.
Other common trigger points involved in "stiff neck" are in the levator
scapulae, the splenius cervicis lateral to the C4--C6 spinous processes,
and the splenius capitis over the C1--C2 laminae. These points are often
not found unless the cervical muscles are relaxed during palpation.
Management
Peripheral inhibitory afferent impulses can be generated to partially close

the pre-synaptic gate by deep massage, acupuncture, or transcutaneous
nerve stimulation. Ultrasound is not as beneficial. Most authorities feel
deep sustained manual pressure on trigger points is the best method, but
a few others prefer very strong short-duration pressure (1--2 seconds),
but keep in mind that deep pressure is contraindicated in any patient
receiving anti-inflammatory drugs (eg, cortisone). Subcutaneous
hemorrhage may result.
BARRE-LIEOU SYNDROME
The vertebral nerve has its origin in the middle cervical sympathetic
ganglion, and it offers vasomotor control over the vertebral artery. The
Barre-Lieou syndrome is thought to be the result of vertebral nerve
irritation causing circulatory impairment in the area of the cranial nuclei,
especially those of the trigeminal and auditory nerves.
Clinical Findings
The Barre-Lieou syndrome frequently occurs from trauma to the cervical
spine. An underlying cervical arthritis and/or an IVD lesion (possibly
related to spondylosis) are often present. Although the symptomatology
is generally considered nonspecific, Kimmel describes the common
features to be earache, eye pain, facial vasomotor disturbances,
headache, temporary blurred vision, tinnitus, and vertigo. Dysphagia,
phonation defects, and laryngeal and pharyngeal paresthesias are often
associated. If chronic cervical arthritis is the cause of sympathetic
irritation, especially in the midcervical area, corneal hyperesthesia and
small persistent ulcers usually appear that are confined to the exposed
conjunctiva.
Barre-Lieou Test
The sitting patient is asked to slowly but firmly rotate the head first to
one side and then to the other. Crawford reports that transient
mechanical occlusion of the vertebral artery may be precipitated by
simply turning the head, and this phenomenon is attributed to the
compressive action of the longus colli and scalene muscles on the
vertebral artery just before coursing through the IVF of C6. A positive
sign exhibits if dizziness, faintness, nausea, nystagmus, vertigo, and/or
visual blurring result, suggesting blockage (eg, buckling) of the vertebral
artery.
CERVICAL DISC DISORDERS
Grieve describes the clinical picture of cervical disc disorders as typically

"a hard osseocartilaginous spur produced by the disc together with the
adjacent margins of the vertebral bodies." Furthermore, contends
Cailliet, "the mechanism by which pain and disability originate in the
neck region can be considered broadly to result from encroachment of
space or faulty movement in the region of the neck through which the
nerves or blood vessels pass." This encroachment and/or faulty
movement commonly comprise apophyseal subluxation with osteophyte
formation, contributing to or superimposed on disc degeneration and/or
protrusion. This occurs most frequently in the C4--C6 area (ie, at the
apex of the cervical curve).
Disc Encroachment
Aggression of a disc on the spinal canal or an IVF as seen in the lumbar

region is not often seen in the cervical area. This is due to several factors.
First, the posterior longitudinal ligament completely covers the posterior
aspect of the disc and not just its central aspect as in the lumbar region.
This ligament is also stronger and thicker (double-layered) in the cervical
area. Next, the thickness of the cervical disc is so designed that it is wider
anteriorly and narrower posteriorly, and horizontally wider and stronger
in its posterior aspect. This tends to somewhat minimize posteriorly
directed movement of the nucleus. Also, the dorsolateral disc herniation
necessary for nerve root compression is minimized by the lips of the
covertebral joints, which form a hard wall between the anulus and the
exiting nerve.
Disc Degeneration
The cervical spine is readily subject to degenerative disc disease owing to

its great mobility and because it serves as a common site for various
congenital defects. Bone changes are more common posteriorly in the
upper cervicals and anteriorly in the lower cervicals. Cervical
degenerative changes can be demonstrated in about half the population
at 40 years of age and 70% of those at 65 years, many of which may be
asymptomatic. Various determinants, individually or in combination,
may be involved in initiating the process. These factors include trauma,
postural and occupational stress, biochemical abnormalities (eg,
hydration, mucopolysaccharide, collagen, lipid changes), biologic
changes (eg, aging), autoimmune responses, psychophysiologic effects
(eg, the sodium retention of depression), and genetic predisposition (eg,
identical development in twins).
Clinical Findings
IVDs below C3 exhibit a higher incidence and the greatest severity of

herniation. The C5 disc is the most frequently involved, followed by the
C6 disc. The C2 disc is the least frequently involved. In acute disorders,
interspace narrowing, straightening of the cervical curve, and instability
may be the only roentgenographic signs present. Instability will be
evident as aberrant segmental movement by comparing lateral films
made during full flexion and extension.
If the overt protrusion is central, cord signs and symptoms display such
as lower extremity spasticity and hyperactive reflexes. Sensory changes
are rarely evident. The gait may be ataxic. If the protrusion is
posterolateral, the nerve root will be involved rather than the cord.
Lhermitte's Sign. With the patient seated, flexing of the patient's neck
and hips simultaneously with the patient's knees extended may produce
sharp pain radiating down the spine and into the upper or lower
extremities. When pain is brought out, it suggests irritation of the spinal
dura mater by a protruding cervical disc, a tumor, a fracture, or multiple
sclerosis.
Chronic Disorders. Several structural changes arise in chronic disorders.

The vertebral bodies involved become elongated, the normal cervical
lordosis flattens, the anterosuperior angle of the vertebral bodies
becomes rounded, the involved body interspace narrows, the total height
of the neck is reduced, and the inferior apophyseal facet above tends to
subluxate posteriorly on the superior facet below and erode the lamina.
Posterior osteophytes form at the disc attachment peripherally, often
compromising the IVFs and vertebral canal. This may be noted by
narrowing of the A-P dimension of the spinal canal in lateral films and
foraminal encroachment on oblique films. These signs frequently occur
at the C6--C7 level.
Anterior osteophytes are considered the result of abnormal ligament

stress rather than part of the disc degeneration process. They frequently
occur below the C4 level, as do alterations of the covertebral joints.
Neurovascular Signs. The specific neurovascular manifestations of acute

cervical disc herniation are:
C2 disc protrusion (C3 nerve root level): posterior neck numbness and
pain radiating to the mastoid and ear. The reflexes test normal.
C3 disc protrusion (C4 nerve root level): posterior neck numbness and
pain radiating along the levator scapulae muscle and sometimes to the
pectorals. The reflexes are normal.
C4 disc protrusion (C5 nerve root level): lateral neck, shoulder, and arm
pain and paresthesia, deltoid weakness and possible atrophy, and
hypesthesia of C5 root distribution over the middle deltoid area (axillary
nerve distribution). The reflexes test normal.
C5 disc protrusion (C6 nerve root level): pain radiating down the lateral
arm and forearm into the thumb and index finger, hypesthesia of the
lateral forearm and thumb, and decreased biceps reflex, biceps and
supinator weakness.
C6 disc protrusion (C7 nerve root level): pain radiating down the
midforearm to the middle fingers, hypesthesia of the middle fingers,
decreased triceps and radial reflexes, and triceps and grip weakness.
C7 disc protrusion (C8 nerve root level): possible pain radiating down
the medial forearm and hand, ulnar hypesthesia, intrinsic muscle
weakness of the hand. However, these symptoms are uncommon. The
reflexes are normal.
These characteristics vary depending on the direction of the disc bulge;

eg, on the nerve root, IVF vessels, spinal cord, or combinations of
involvement. In some acute and many chronic cases, numbness may
manifest without pain. In acute disorders, these cervical signs may be
confused with those of shoulder or elbow bursitis, epicondylitis, or
subluxation, especially when no local cervical symptoms exist.
Autonomic Involvement. Vague autonomic symptoms may be exhibited

such as dizziness, blurred vision, and hearing difficulties. These can
usually be attributed to involvement of the plexus around the vertebral
artery or intermittent disruption of the blood flow.
Vertebral Artery Compression. Associated subluxation and osteophyte

development can produce vertebral artery compression, especially if a
degree of arteriosclerosis exists. Symptoms of unsteadiness, dizziness,
and fainting occur especially when the head is rotated contralaterally.
Case Management
Mobilization of a restricted facet, repositioning of a malpositioned

nucleus, and/or reduction of a protruded anulus are the goals of the
primary therapy. Adjustive treatment consists of specific positioning
performed with manual or mechanical traction at the involved vertebral
motion units to free impinged synovial fringes, reduce articular and disc
displacements, and mobilize areas of fixation. This should not be
performed with the neck in extension, and extreme care must be taken to
avoid joint, nerve, cord, or vascular insult.
Adjunctive therapy includes immobilization of the neck with a cervical

brace, heat (diathermy, ultrasound, infrared, moist hot packs) to reduce
pain from muscle ischemia, trigger point therapy, and periodic bed rest
with cervical traction by an orthopedic pillow. Gross vibrations (eg, long-
distance automobile riding) and neck hyperextension (eg, overhead
work) must be avoided. Goodheart feels that nutritional supplementation
with 140 mg of manganese glycerophosphate six times daily is helpful.
Isometric exercises during rehabilitation to lengthen the cervical spine
and strengthen the cervical muscles are extremely beneficial.
Referral for radical treatment is generally made if one of the following

occurs: (1) conservative treatment fails to produce remission of
symptoms; (2) attacks reappear after a short period; or (3) severe nerve
root compression with paralysis develops, indicated by muscle wasting
and/or a significant persistent sensory deficit.
TRAUMATIC CERVICAL SCOLIOSIS
Whether symptomatic or not, traumatic cervical scoliosis is something

quickly recognized by a chiropractor using a plumbline but rarely noticed
by an allopath. When viewed from the back, the vertical lateral line of
gravity passes through the occipital protuberance and the vertebrae's
spinous processes. In cervical scoliosis, the midcervical spinous
processes, especially, tend to deviate laterally from this line. That is, in
the common rotary cervical scoliosis, the spinous processes tend to rotate
toward the convex side of the lateral curve, the vertebral bodies rotate
toward the concave side, and the discs and articular facets are subjected
to abnormal stretching forces as they open on the side of convexity.
Compressive forces occur on the side of concavity. This type of cervical
scoliosis is usually the compensatory effect of a lower scoliosis to the
other side and a common cause of recurring episodes of idiopathic
torticollis.
Effect of a Flattening Curve
Cervical scoliosis is often mechanically predisposed by flattening rather

than exaggeration of the cervical lordosis. This is common during youth.
As described previously, the posterior joints become relatively lax during
flattening of the cervical spine. This encourages retropositioning and
posterior subluxations that are frequently the first step toward cervical
scoliosis.
The Self-Stabilization Factor
When a cervical disc is loaded unilaterally, the disc initially becomes

wedge-shaped and the normally parallel vertebral plateaus form an
angle. This vertically stretches the anular fibers opposite the weight-
bearing side, but this action is quickly counteracted by forces transmitted
laterally from the resilient nucleus to help the disc return to its normal
shape. This self-stabilization factor is the product of a healthy nucleus
and anulus working as a mechanical couple.
Disc Reactions in Cervical Scoliosis
Rotary forces must be considered. Because the apposing layers of anular

fibers run alternately oblique in opposite directions, the oblique disc
fibers angled toward the direction of twist become stretched when a
vertebra rotates. The oblique fibers running against the direction of
rotation tend to relax.
The greatest tension from stretch occurs centrally where the fibers are
nearly horizontal. This increases nuclear pressure by compression
proportional to the degree of rotation. If severe, the nucleus can be
dislodged from its central position.
Effect of Lateral Tilt in Cervical Scoliosis
Cervical scoliotic rotation is also associated with a lateral tilt that

increases the distance between the lateral margins of the vertebral bodies
on the convex side of the curve. This stretches the anulus laterally, which
produces a contraction of that part of the disc and a compensatory
bulging of its contralateral (thinned) aspect. If the anular filaments
become stretched or weakened and the disc loses some of its stiffness
property, the nucleus may shift from its central position so that the
vertebral segment is unable to return to its normal position. A firmly
locked rotational subluxation can result. Thus, vertebral tilting as seen in
subluxations with disc wedging alters the relationship of apposing
articular surfaces to produce a change in the direction of compressive
forces on these joints and the nucleus of the disc. Besides tilting, severe
rotation produces abnormal jamming compression forces on ipsilateral
facets and stretching tension forces on contralateral opened facets.
If continuous compression is applied to any active and mobile joint,

cartilaginous erosion followed by arthritis can be expected. When
continuous stretching is applied to any active and mobile synovial joint,
capsulitis can be expected. When scoliotic rotation takes place evenly
among the cervical segments and the cervical nuclei hold their relatively
central position in the discs, the situation is usually asymptomatic even if
erosion and arthritis are evident on roentgenographs. However, when a
nucleus fails to hold its central position and shifts laterally away from the
point of maximum compression, the superimposed vertebra will be
encouraged to present a fixed subluxation.
CERVICAL RIB SYNDROMES
Anomalous development of extra ribs in the cervical region may be a

single unilateral rib, be bilateral, or be multiple bilaterally. The condition
is usually seen at C7, and the cause is a variation in the position of the
limb buds. The bone(s) may vary from a small nubbin to a fully
developed rib. A small rudimentary rib may give rise to more symptoms
than a well-developed rib because of a fibrous band attached between the
cervical rib and sternum or 1st thoracic rib.
A cervical rib arising from C7 and ending free or attached to the T1 rib
appears as an angular fullness that may pulsate owing to the subclavian
artery above it. It is often encountered when percussing the apex of the
lung. The bone can be felt behind the artery by careful palpation in the
supraclavicular fossa and demonstrated by roentgenography. It rarely
produces symptoms, but pain or wasting in the arm and occasionally
thrombosis may occur. Additional features are described below.
Differentiation
The etiologic theories of the cervicobrachial syndrome are compression

of nerve trunks, trauma to nerve trunks, injuries to the sympathetic and
vasomotor nerves, trauma to the scalenus anterior muscle, embryologic
defects, postural or functional deficits, narrowing of the upper thoracic
cap as a result of adjacent infections or anatomic defects, acute infection
producing myositis, intermittent trauma to the subclavian artery, or a
cervical rib.
Symptoms arise at age 12 or later, after the ribs have ossified. The 4th
and 5th decades mark the highest incidence, probably because of
regressive muscular changes. Two groups of symptoms are seen, those of
the scalenus anticus syndrome and those due to cervical-rib
encroachment pressure. The symptoms of cervical rib and scalenus
syndrome are similar, and the scalenus anticus muscle is the primary
factor in the production of neurocirculatory compression whether a
cervical rib is present or not.
Symptoms are usually from compression of the lower cord of the brachial
plexus and subclavian vessels such as numbness and pain in ulnar nerve
distribution. Pain is worse at night because of pressure from the
recumbent position. Pain of varying intensity, tiredness and weakness of
the extremity, finger cramps, numbness, tingling, coldness of the hand,
areas of hyperesthesia, muscle degeneration in the hand, a lump at the
base of the neck, tremor, and discoloration of the fingers are
characteristic. Work and exercise accentuate symptoms, while rest and
elevation of the extremity relieve symptoms. Adson's and similar signs
are positive.
Trauma is a common precipitating factor in sports. Aneurysms of the

subclavian artery are rare. Differential diagnosis must exclude infectious
neuritis, shoulder or cervical arthritis, subacromial bursitis, deformities,
and cardiac disease. Compression of nerve tissue results in numbness,
pain, paralysis, and loss of function. Compression of vascular structures
produces moderate pain, edema, swelling, and obstruction of circulation
resulting in clotting within the vessels with possible infarction in the
tissues supplied. These unilateral phenomena are limited to the
cervicobrachial distribution.
Case Management
It has been Claypool's experience that palliative relief can be obtained in

some cases by correction of posture, gentle manipulation of the upper
thoracic and lower cervical spine, cervical traction, and other relaxing
physiotherapy. Those cases not responding to conservative treatment
require surgery, and those cases treated conservatively usually show a
recurrence of symptoms periodically.
POSTTRAUMATIC HEADACHES OF CERVICAL ORIGIN
Investigation of headaches of cervical origin begins after possible brain

or cord injury has been ruled out. It must also be kept in mind that
posttrauma examination may reveal a subclinical entity (eg, brain tumor,
aneurysm).
Markovich, the renowned neurologist, found that the most common

headache is the type caused by neuromuscular skeletal imbalance. He
points out that "the head in the human species has changed its position
from the quadruped to the erect, thereby changing the basic relationship
between the cervical spine and the head, with its important functional
structures, and the rest of the body." He calls attention to the delicate
interaction and highly sensitive biofeedback or servo-mechanisms that
continually make adjustments in body balance, vision, pressure, and
hearing with head and neck posture. "These regulatory, homeostatic
mechanisms can be disturbed by a variety of conditions, originating at
any level, including the inflammation and/or irritation of the cephalic
projection of the upper cervical nerves (cervico-occipital neuralgias)."
Sustained contraction of muscles at the occipitocervical area appears to

generate a type of "ischemic irritation" that includes the entrapment of
the C2 nerves (greater and lesser occipital) as they pierce thick muscle
and ascend to the back of the head to supply the posterior scalp, temples,
and ear lobes, sending branches to the top of the head, the back of the
eye, and the angle of the jaw.
The attending doctor should keep in mind that a patient may not exhibit
a specific picture. For example, vascular migraine may be superimposed
on occipitocervical neuralgia or episodes may be interposed, depending
on the causes involved.
POSTTRAUMATIC REHABILITATION GOALS
Although segmental spasm or instability may not be detectable by

observation, it usually becomes evident by alert dynamic palpation.
Careful localization of motion and muscle strength is necessary before
prescribing any exercise program to assist postural realignment.
Postural Strength and Balance
Besides strengthening damaged soft tissues, one goal of posttraumatic

exercise is to correct habitual postural problems that may be part of the
problem. Because the center of gravity of the head lies anterior to the
occipital condyles, definite force must be applied by the posterior
muscles of the neck to hold the head erect. In addition, several groups of
muscles are attached directly or indirectly to the anterior part of the
head, and their function adds to the force of gravity to increase the load
on the posterior cervical muscles. Gelb feels that the most important
anterior neck muscles are the masticatory and supra- and infra-hyoid
groups, which form a chain to the hyoid and mandible to which they
attach, joining the head to the shoulder girdle anteriorly.
Deformed cervical posture can be associated with or without neck pain.

As described previously, the deformity may be an exaggerated curve,
flattening, occipital tilt, rotation, and areas of complete or partial
segmental fixation. If pain arises, deviation may be toward or away from
the site of pain, depending on the primary site of irritation. Remember
that spinal stability is essentially under the control of neuromuscular
mechanisms rather than ligaments.
Dynamic and Static Proprioception
The abundant proprioceptors of the vertebral column enable the brain to

know where each segment is and what it is doing at any given time
without visual confirmation. Impulse data are specifically relayed about
the degree of muscle tension and/or the length of muscles via the muscle
spindles and Golgi tendon organs. Tension messages are moved through
fast-conducting nerves from annulospiral endings and through higher
threshold nerves from flower spray receptors in the muscle spindle. The
less complex Golgi tendon organs near the musculotendinous junctions
discharge impulses initiated by either muscle contraction or stretch.
Other receptors near the articular surfaces relate messages about facet
motion speed and direction of motion.
In postural realignment, Gelb points out that restoring muscles to their

physiologic resting length is a three-dimensional concept requiring
placing the origin and insertion of muscles in a correct three-dimensional
relationship. Lieb shows several full spine x-ray films of severe spinal
distortions greatly improved solely through improvement of dental
occlusion. If the temporomandibular joint has such a proprioceptive
influence on posture, it is no wonder that chiropractors who specialize in
solely upper-cervical or sacral correction exhibit a similar abundance of
such before-and-after exhibits because each spinal segment is richly
endowed with equal or greater receptors than that of the jaw.
Cervical Receptor Input
The apophyseal joints of the cervical spine are richly innervated with
mechanoreceptors and afferent fibers, endowed more than any other
spinal region. Activity of the cervical articular receptors exerts significant
facilitatory and inhibitory reflex effects on the muscles of the neck and
both the upper and lower extremities.
Wyke shows that the patterns of "normal cervical articular

mechanoreceptor reflexes are profoundly distorted when cervical
articular nociceptive afferent activity is added to that derived from the
normally functioning cervical mechanoreceptors." To underscore this
point, he reports that:
Manipulation of the head on the neck can produce coordinated flexion

and extension movements on the paralyzed arm and leg of a hemiplegic
patient.
Arm movement control in the absence of visual aid is considerably

affected by rotation of the head.
Induced unilateral local anesthesia of the cervical joints in healthy

subjects produces severe postural instability, dizziness, nystagmus, and
muscle incoordination.
These signs and symptoms are similar to those experienced by some

patients suffering from cervical spondylosis, ankylosing spondylitis, and
gross fixations, and some while wearing an orthopedic cervical collar.
Normal Cervical Righting Mechanisms
Several head extensors arise from the lower cervical and upper thoracic
vertebrae that exert an oblique posteroinferior pull on the occiput. If the
line of pull falls behind the atlanto-occipital joint, a rotary movement
results that tilts the occiput posteriorly and lifts the face so that the neck
is hyperextended. However, if this posterior rotation of the head is
inhibited by the cervical flexors (which is normal), the oblique pull has a
posterior translatory component when the head is anterior to the
midline. This serves to bring the head back toward the vertical gravity
line and into normal alignment. In addition, the longus group exerts a
bowstring action on the anterior cervicals that assists in axial extension
of the neck.
Thus, the extensors essentially serve to return the head to the midline
following flexion, but axial extension is really completed by a
straightening of the cervical lordosis produced by segmental flexion. If
this segmental flexion did not occur during extension, the face would rest
in the neutral position pointing superiorly. Simultaneously, the thoracic
extensors tend to straighten the dorsal curve so that the alignment of the
entire cervicothoracic region is improved.
Flexion fixation of the lower cervicals elongates the posterior upper-

thoracic soft tissues with adaptive shortening of the anterior elements
(eg, anterior longitudinal ligament, anterior disc anulus, pectorals,
intercostals). This is often seen in aging where it is contributed to by
degeneration of the normally fibroelastic ligamentum nuchae, which
helps to resist anterior deviation of the head. If this chronic flexion state
occurs, cervical extension to the midline following flexion is fairly limited
to increasing the cervical lordosis with little axial extension of the neck
by segmental flexion. The neck angles forward, and the jaw juts out as
the occiput rolls backward.
Cervical Strength Development
With two exceptions, specific isotonic exercises will not be described here
as the literature abounds with many good regimens. However, the
rationale behind isotonic cervical exercises following trauma deserves
attention.
Weak Extensor Strength. Clinical development of the trapezius,

semispinalis capitis, splenius group, and erector spinae should be made if
weak extension strength is evident. Only in the thoracic region do the
erector spinae act solely as erectors. Their contraction in the cervical
region produces hyperextension with posterior rotation of the occiput so
that the chin points upward. Hyperextension, viewed as hyperlordosis,
may be a manifestation of extensor hypertonicity or weak prevertebral
muscles.
Weak Flexor Strength. If weak neck flexion is evident, emphasis should

be on developing the sternocleidomastoideus, longus group, and rectus
capitis anterior and lateralis. The longus group and rectus capitis group
are direct antagonists to the posterior cervical muscles. They principally
serve to right the neck after extension but have some activity in flexion
from the neutral position. Hyperflexion, viewed as a flattened or kyphotic
cervical curve, may be a manifestation of prevertebral hypertonicity,
weak extensors, or a posteriorly displaced disc nucleus.
Rehabilitation Therapy Following Cervical Trauma
Fisk describes the reflex response to pain as an increase in isometric

muscle activity by the small gamma fibers and a decrease in isotonic
activity for continuous resting (splinting) an irritated area. This
functional inactivity tends to reduce impulses from the large fibers of
muscle and joint proprioceptors so that the spinal cord's theoretical
"gate" is kept open. Because prolonged inactivity leads to muscle
weakness and atrophy, shortening of related connective tissues, and
deterioration of articular cartilage, restoring motion and strength of a
stressed region is an important clinical and biomechanical objective.
Grieve states that posttraumatic soft-tissue changes secondary to joint

derangement or irritability become progressively prominent with age --
mild during youth, severe in the elderly. The periarticular connective
tissues adapt by shortening on one side of the joint and lengthening on
the other, resulting in a relatively permanent lateral flexion accompanied
by a degree of rotation. This makes chronic subluxations difficult to hold
in a corrected position. However, prior to this chronic state is the state of
prolonged isometric contraction described above, which is readily
amenable if comprehensive therapy is applied. Gillet and others have
confirmed this.
During the posttraumatic acute stage where there is neural excitation

from the inflamed area, temporary impulse activity over the large-fibered
proprioception circuits can be encouraged by movement, pressure,
stretching, heat, and cold stimuli. However, heat at this stage increases
swelling and movement provokes spasm, and thus are contraindicated.
The logical alternative is to apply isometric exercises soon after the
danger of recurrent hemorrhage has passed. This offers stretching
without motion that increases circulation without engorgement and
activates the large-fiber circuits, allowing a more rapid recovery. Even in
chronic disorders, vigorous active motion increases intradisc pressure
and can aggravate inelastic degenerated soft tissues. This would not be
true for isometric exercises.
Following are several isometric exercises recommended by Fisk for the

cervical spine that can readily be modified to meet varying clinical
situations. They are designed to increase strength, but they also teach the
patient the different perceptions of contraction and relaxation (eg,
helpful in controlling chronic tension). As the head is held in the neutral
position, these exercises are not contraindicated even in cases of
uncomplicated hypermobility or arthritis if the patient is carefully
instructed. Two or three exercise bouts daily are recommended.
Resisted Flexion Sitting. The patient sits erect with the head straight and
is instructed to place clasped hands against the forehead, breathe
normally, and attempt to push the head forward against the resisting
hand contact. This position should be held for about 7 seconds; then the
patient relaxes for several seconds and repeats the exercise until fatigued.
Resisted Extension Sitting. The patient sits erect with the head straight
and is instructed to clasp the hands behind the head above the cervical
spine. The patient is then asked to breathe normally, keep the head
straight, and attempt to push the head back against the resisting hands.
This position should be held for about 7 seconds. Then the patient
relaxes for several seconds and repeats the exercise several times until
fatigued.
Resisted Extension Supine. The above exercise can also be conducted in

the supine position by having the patient lie face up on a firm surface. A
small firm pillow or cushion should be placed under the neck to support
the head. The patient is instructed to firm the head against the pillow and
firmly tuck the chin in while breathing normally. This position should be
held for about 7 seconds; then the patient relaxes for several seconds and
repeats the exercise until fatigued.
Resisted Flexion Prone. In the alternative prone position, the patient lies
face down with his forehead on a large folded towel to allow breathing in
this position. The patient is instructed to tuck the chin in and firm the
forehead against the towel while breathing normally. Pressure should be
held for about 7 seconds; then the patient relaxes for several seconds and
repeats the exercise until fatigued.
Resisted Lateral Flexion Sitting. The patient sits erect with the head
straight and places the right hand over the right ear with the fingers
extending over the scalp. The patient is then asked to breathe normally
and attempt to bend the neck toward the side of contact while resisting
the effort with the contact hand. Again, this position should be held for
about 7 seconds. Then the patient relaxes for several seconds and repeats
the exercise about five times. The hand positions are then interchanged,
and the exercise is conducted for the other side.
Resisted Sidebending Laterally Recumbent. This exercise can also be

conducted in the lateral recumbent position. The patient lies on the side
with the underside of the face against a firm pillow so that the spine is
straight. The patient firms the head against the pillow while breathing
normally. This position is held for about 7 seconds; then the patient
relaxes for several seconds and repeats the exercise a few times. The
patient is then instructed to lie on the other side and to repeat the
exercise.
Resisted Rotation Sitting. The patient sits erect with the head straight
and is instructed to place the right hand on the right temple, and then
asked to breathe normally and attempt to look over the right shoulder
while resisting the movement with the hand contact. This position is also
held for about 7 seconds. Then the patient relaxes for several seconds and
repeats the exercise until fatigued. After a short rest, the left hand is
applied to the left temple and the exercise is conducted for the left side.
This exercise can also be done in the supine position.
Two mild active isotonic exercises can be incorporated into the regimen
when pain begins to diminish. These involve related shoulder and
scapular muscles that are often chronically tensed following cervical
trauma.
Shoulder-Shrugging. The patient stands or sits erect with the head

straight, the neck aligned vertically, and the arms hanging loosely at the
sides. The patient is asked to breathe normally, elevate the shoulders as
far as possible for several seconds, hold this position while the shoulders
are retracted as far as possible for several seconds, and then to drop the
shoulders in the retracted position and hold them there for several
seconds. The patient then relaxes for several seconds and repeats the
exercise for a few minutes until fatigued.
Arm Circling. Have the patient stand erect with the head straight, the
arms hanging loosely at the sides, and the feet slightly apart to widen the
base of support. The patient is instructed to breathe normally, flex
forward at the waist (when low-back pain is absent), and then bring the
arms back and up in an arc from the anterior to the posterior as far as
can be comfortably managed. This arm circling should be repeated
without resting intervals for as many times as fatigue will allow.
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***
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Original Article:http://www.mayoclinic.

Spinal cord injury

Signs and symptoms

 Pain or an intense stinging sensation caused by damage to the nerve fibers

Emergency signs and symptoms

 Fading in and out of consciousness

Injury may be traumatic or nontraumatic

Common causes of spinal cord injury

 Men. Spinal cord injury affects a disproportionate amount of men. In fact,

When to seek medical advice

 Dial 911 or call for emergency medical assistance.

These tests may include:

Other complications of a spinal cord injury may include:

 Medications. Methylprednisolone (Medrol) is a treatment option for acute

 Modern wheelchairs. Improved, lighter weight wheelchairs are making

Talking about your disability

Dealing with intimacy

Taking care of yourself

Aug 22, 2005

A Typical Day for Spinal Cord Rehabilitation

Managed by a team of experienced professionals, Good Shepherd's Spinal Cord Injury

Spinal Cord Injury Rehabilitation Program

 Home and work evaluations

Program Specialties Include:

Rehabilitation Nursing Program

Program Specialties Include:

 Complex wound management

Wound Care Program

Program Specialties Include:

 Physical medicine and rehabilitation

Complex Wound Rehabilitation

What is a complex wound?

Complex Wound Rehabilitation Program

Program Specialties Include:

 Physical medicine and rehabilitation

Burn Care Program

Program Specialties Include:

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Program Specialties Include:

Additional Pain Rehabilitation Services Include:

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Areas of Occupational Therapy Treatment Include:

 Spinal cord injury

Dysphagia Program Components

Program Specialties Include:

 Physical medicine and rehabilitation

Program Specialties Include:

 One-on-one treatment sessions

Cervical Spine Trauma

Manuscript Prepublication Copyright 1999

Copied by Chiro.Org with permission from ACAPress.com

Whether induced by trauma or not, cervical subluxation syndromes may

Common Injuries and Disorders of the Cervical Spine

Cervical spine injuries can be classified as (1) mild (eg, contusions,

Spasm of the sternocleidomastoideus and trapezius can be due to strain

Because of its great mobility, relatively small structures, and weight-

In general, trauma anteriorly to the neck implies soft-tissue damage and

Are there bleeding, spasm, pain, motion restrictions, sensory changes,

Vascular injuries feature vigorous bleeding, absent superficial artery

POSTTRAUMATIC ROENTGENOGRAPHIC CLUES

INJURY OF THE CERVICAL NERVE ROOTS

Neural dysfunction associated with either acute or chronic subluxation