Chapter 24

The Cervical Spine

Copyright 2005 Lippincott Williams & Wilkins

 Anatomy

Cervical spine is composed of two functional units.

1. Craniovertebral (CV)
 Atlanto-occipital (AO)
 Atlantoaxial (AA) joints

2. Mid-lower cervical spine

Copyright 2005 Lippincott Williams & Wilkins

Atlanto-Occipital Joint

Copyright 2005 Lippincott Williams & Wilkins

Atlanto-Occipital Joint Movement
Flexion/Extension/Left Side Flex with
Right Rotation

Copyright 2005 Lippincott Williams & Wilkins

Atlantoaxial Joint

Copyright 2005 Lippincott Williams & Wilkins

Atlantoaxial Joint Movement
Flexion/Extension/Left Rotation with
Right Side Flexion

Copyright 2005 Lippincott Williams & Wilkins

Ligaments of CV Complex

Copyright 2005 Lippincott Williams & Wilkins

 Midcervical Spine
C2-T1
Composed of several joints

Zygapophyseal (paired)
Uncovertebral (paired)
Interbody (disk)

Copyright 2005 Lippincott Williams & Wilkins

Uncovertebral/Interbody Joint

Copyright 2005 Lippincott Williams & Wilkins

Motion at Midcervical Spine

Copyright 2005 Lippincott Williams & Wilkins

ROM of Intervertebral Segments
Normal/Hypermobile – Elastic/Neutral Zone

Copyright 2005 Lippincott Williams & Wilkins

 Motion at Midcervical Spine
Consists of

 Flexion
 Extension
 Rotation/side flexion coupling
ipsilaterally

Copyright 2005 Lippincott Williams & Wilkins

 Vascular and Nervous System

 Vertebral artery tests should be performed for

each patient before performing end range
rotation of the neck, and particularly with the
addition of extension and traction.
 The C1 nerve root exits through the
osseoligamentous tunnel formed by the posterior
AO membrane, which puts it at risk for
impingement.

Copyright 2005 Lippincott Williams & Wilkins

 Craniovertebral Musculature

Muscle Action
 Rectus capitis posterior  AO extension
minor  CV extension and
 Rectus capitis posterior ipsilateral rotation
major  AO ipsilateral
 Superior oblique SF/extenstion
 Inferior oblique  AO ipsilateral rotation
 Rectus capitis lateralis  AO ipsilateral SF
 Rectus capitis anterior  AO flexion

Copyright 2005 Lippincott Williams & Wilkins

 Muscles
Midcervical – Flexion

 Longus colli
 Longus capitis
 Anterior scalenes
 Sternocleidomastiod

Copyright 2005 Lippincott Williams & Wilkins

 Midcervical Extension
 SCM  Semispinalis, capitis, and
 Trapezius (upper fibers) cervicis
 Levator scapula  Longissimus, capitis, and
 Splenius capitis and cervicis
cervicis  Iliocostalis cervicis
 Spinalis, capitis and  Interspinalis (most distinct
cervicis (blends with in CSP)
semispinalis)  Multifidus
 Rotatores (inconsistent)

Copyright 2005 Lippincott Williams & Wilkins

 Examination and Evaluation
Examination should include entire spine,
particularly the thoracic spine, the TMJ, and the
shoulder girdle complex.

History and Clearing Tests

 Functional questionnaires (neck disability

index, etc.)
 Shoulder girdle tests (if indicated)

Copyright 2005 Lippincott Williams & Wilkins

 Posture Examination

Static Alignment
 Standing vs. sitting alignment –
All 3 planes
 Supine alignment
 Assess resting position of each
vertebral segment through
palpation

Copyright 2005 Lippincott Williams & Wilkins

 Movement Examination
Movement/Motion tests
 AROM  Myofascial extensibility
 Combined movements  Muscle lengths
 Cervical spine passive  Neuromeningeal
mobility extensibility
 Passive intervertebral  Upper limb tension tests
movements (median, radial, ulnar
 Passive accessory nerve bias)
vertebral movements

Copyright 2005 Lippincott Williams & Wilkins

Muscle Performance, Neurologic, and
Special Tests

 Manual muscle tests (recruitment,

strength, endurance)
 Neurologic exam of sensation,
motor activity, and reflex integrity
 Stability tests
 Vertebral artery tests
 Foraminal compression test

Copyright 2005 Lippincott Williams & Wilkins

Therapeutic Exercise Interventions for
Common Physiologic Impairments
Impaired Muscle Performance

Deep anterior cervical flexors tend to weaken.

Patient is taught to perform a preset nod to

activate deep stabilizing muscles (cervical
core) prior to any motion of the head.

Copyright 2005 Lippincott Williams & Wilkins

 Therapeutic Exercise Intervention
Deep Cervical Flexors
 Primary exercise is
head nod exercise.
 Discourage use of
SCMs.
 Consider gravity-
lessened position
initially.

Copyright 2005 Lippincott Williams & Wilkins

Graduate from Deep Cervical Flexors
to SCM/Scalene-Assisted

Copyright 2005 Lippincott Williams & Wilkins

 Cervical Extensors

 NME can be effective in initial stages of training.

 Teach patient to apply resistance to the
contraction of specific muscle determined to be
weak.

Copyright 2005 Lippincott Williams & Wilkins

Cervical Extensors – Exercise Example

Copyright 2005 Lippincott Williams & Wilkins

Specific Manual Resistance to
Cervical Extensors

Copyright 2005 Lippincott Williams & Wilkins

Rotation and Side Flexion Components
 Foam wedge can be used for autoresistance.
 Sidelying with towel/roll used as a fulcrum.

Strengthening Functional Movement Patterns

 Once patient is able to perform movements without
hypertranslation, graduate to multiplanar movements.

Copyright 2005 Lippincott Williams & Wilkins

Side Flexor and Rotator Activation

Copyright 2005 Lippincott Williams & Wilkins

 Mobility Impairment

Hypomobility
 Segmental articular mobility restriction
 Capsular thickening and contracture
 Degenerative bony changes
 Segmental muscle spasm
 Myofascial extensibility
 Adverse neuromeningeal tension

Copyright 2005 Lippincott Williams & Wilkins

Therapeutic Exercise Considerations

 Postural education – correct FHP

 ROM exercises in restricted planes
(consider gravity!)
 Exercise localized segment according to
mobility test
 Stretch short muscles
 Strengthen long muscles in shortened
range

Copyright 2005 Lippincott Williams & Wilkins

Stretching Suboccipitals/Scalenes

Copyright 2005 Lippincott Williams & Wilkins

 Hypermobility
Excessive motion of the intervertebral segment.

Treatment
 Postural correction exercises.
 Consider taping of scapula to reduce pull on segment.
 Manually stabilize hypermobile segment or perform
cocontractions at involved levels.
 Gradually challenge cervical musculature while
preventing excessive motion at involved segment.

Copyright 2005 Lippincott Williams & Wilkins

Levator Scapula Stretch While
Stabilizing C4

Copyright 2005 Lippincott Williams & Wilkins

 Posture Impairment
FHP
Treatment
 Muscle imbalance  Lengthen short muscles
and strengthen weak
muscles
 Neuromeningeal  Side flexion and elevation
extensibility of scapula

 Articular hypomobility  Manual therapy and

mobility exercises
 Proprioception  Postural correction

Copyright 2005 Lippincott Williams & Wilkins

FHP – Axial Extension/Minimal
Lordosis/Excessive Lordosis

Copyright 2005 Lippincott Williams & Wilkins

Therapeutic Exercise Interventions for
Common Diagnoses
Disk Dysfunction
Changes in disk alter its biomechanical properties and
prevent normal function.

Treatment
 Initially aimed at rest positions
 Postural education (including pelvic girdle)
 Manual therapy to mobilize hypomobile segments
 Manual traction to decrease compression
 Stretching exercises during acute phase
 Progression of stabilization exercises for hypermobile segments

Copyright 2005 Lippincott Williams & Wilkins

 Cervical Sprain and Strain
Most common incident is WAD after MVA

Treatment
 Proper resting position/postural education
 Ice/heat and therapeutic modalities to control
inflammation and pain
 Rhythmic neck rotations (supine)
 Subacute – Manual mobilization techniques
 Mobility exercises can slowly progress into larger
arc movements while maintaining postural integrity
 Specific strengthening exercises are introduced in
remodeling phase

Copyright 2005 Lippincott Williams & Wilkins

 Neural Entrapment
Cervical nerve roots become entrapped at their
exit at the intervertebral foramen.

Treatment
 Postural exercises/re-education
 Address neuromeningeal hypomobility
 Treatment of cervical/thoracic spine, shoulder
girdle, and wrist are common

Copyright 2005 Lippincott Williams & Wilkins

 Cervicogenic Headache
Referred pain to head and/or face from first
three or four cervical nerves.

Treatment
 Generalized ROM exercises for mobility
 Specific muscle stretches (especially upper
cervical)
 Exercises to increase muscle performance
of deep upper cervical flexors

Copyright 2005 Lippincott Williams & Wilkins

 Summary

 CV complex includes AO and AA joints.

 Ligaments – Alar, transverse, tectorial membrane,
anterior/posterior AO membranes, posterior AA ligament.
 AO joint – Bicondylar, modified ovoid joint; two degrees
of motion (flexion/extension and combined side
flexion/rotation).
 AA joint – Multi-joint, complex, degrees of motion
(flexion/extension and combined side flexion/rotation).

Copyright 2005 Lippincott Williams & Wilkins

 Summary (cont.)
 Midcervical joints – Zygapophyseal joints, UV joints,
interbody joints.
 Important midcervical ligaments – Anterior/posterior
longitudinal, ligamentum flavum, interspinous, and
ligamentum nuchae.
 Coordinated motion occurs among joints of midcervical
spine. Each segment – two degrees of motion
(flexion/extension and combined side flexion/rotation).
 Cervical spine exam and evaluation includes subjective
history, physical exam, vocational environment.

Copyright 2005 Lippincott Williams & Wilkins

 Summary (cont.)
 Physical exam includes visual observation,
active/passive movement tests, myofascial and
neurological meningeal extensibility, MMT, neurologic
and clearing tests of thorax, shoulder girdle, and TMJ.
 Common physiologic impairments include muscle
performance, posture, mobility.
 A therapeutic exercise program is developed to address
each impairment and improve overall function.

Copyright 2005 Lippincott Williams & Wilkins

 Summary (cont.)

 Common diagnoses of cervical spine are disk

dysfunction, sprain or strain, neural entrapment,
cervicogenic headache.
 For any patient presenting with a particular
diagnosis, impairments are identified and prioritized
according to those requiring immediate attention
and those most likely to be tolerated by the patient.

Copyright 2005 Lippincott Williams & Wilkins