THE SPINE:CERVICAL

MADE BY-
SHIVAM SHARMA
IV YEAR
 INTRODUCTION
•The vertebral column is divided into 5 regions:
Cervical, Thoracic, Lumbar, Sacral, Coccygeal.
•The column is composed of 33 short bones called
vertebrae and has 23 inter-vertebral disc.
• 7-Cervical,
12-Thoracic,
5-Lumbar,
5 of the remaining 9 vertebrae are fused to form the
Sacrum,
Remaining 4 forms the Coccygeal vertebrae.
•The vertebra increases in size from cervical to
lumbar and decreases in size from sacral to
coccygeus.
Primary and Secondary Curves.
•The 2 curves (Thoracic and Sacral) that retains the
original posterior convexity throughout life are called
Primary Curves a.k.a Kyphotic Curves.
•The 2 curves (Cervical and Lumbar) that shows a
reversal of original posterior convexity are called
Secondary Curves a.k.a Lordotic Curves.
 Structure Of The Cervical
Region.
•The first 2 cervical vertebrae, C1 and C2 or Atlas and
Axis are called Atypical Vertebrae.

•The C7 is a transitional vertebrae and therefore has

characteristics of both Cervical and Thoracic.
•Rest, C3 and C6 are Typical Vertebrae.
 CHARACTERISTICS OF TYPICAL CERVICAL
VERTEBRA

•The transverse processes possess a foramen transversarium for the

passage of the vertebral artery and veins.
•The spines are small and bifid.
•The body is small and broad from side to side.
•The vertebral foramen is large and triangular.

CHARACTERISTICS OF ATYPICAL CERVICAL

VERTEBRA

•1st,2nd
and 7th cervical vertebrae are atypical
•The 1st cervical vertebra does not possess a body or spinous process.
•The 2nd cervical vertebra has a peglike odontoid process
•The 7th cervical vertebra or vertebra prominens has the longest
spinous process and it is not bifid.
 Typical Cervical Vertebrae.
•The body of Cervical vertebrae is small.
•The transverse and antero-posterior diameter
increases from C2 to C7.
•The lateral margins of the upper surface of the
vertebral bodies from C3 to C7 support uncinate
process that gives the upper surface of the vertebrae a
saddle shaped form.
 Arches.
•Pedicles-The pedicles projects posteromediallly and
are located halfway b/w superior and inferior surface of
vertebrae.
•Lamina- >Projects postero-medially.
>Thin and slightly curved.
•Zygapophyseal Articular Surface-The process
supports paired superior facets that are flat, oval shaped
and faces supero-posteriorly.
•Transverse Process- A foreamen is located in the
transverse process bilaterally for the vertebral artery,
vein, venous plexus. It also has a groove for spinal
nerves.
•Spinous Process-
>They are short, slender, extend horizontally.
>The tip of spinous process is bifid (splits in 2
portions).
>Length decreases slightly from C2 to C3, remains
constant from C3 to C5 and increases at C7.
•Vertebral Foreamen- Large and triangular shaped.
 Atlanto-Axial Complex.
•The atlas (C1) has no body or spinous process and is
shaped like a ring.
•It has 4 articulating facets, 2 superior and 2 inferior.
•The superior zygapophyseal articulates with occipital
bone.
•The atlas also possess a facet on the internal surface
of the anterior arch for articulation with the dens
(odontoid process).
•The axis is atypical, as the anterior portion of the
body extends inferiorly and a vertical projection
called the dens arises from the superior surface of
body.
 Atlanto-Occipital Joint.
•Itis a plane synovial joint.
•Composed of 2 concave superior zygapophyseal
facets of the atlas that articulates with the 2 convex
occipital condyles of the skull.

•The atlanto-axial joint is composed of 3 separate

joints:
1. Atlanto-odontoid joint (b/w dens and atlas).
2. 2 lateral joints b/w sup. and inf. zygapophyseal
facets of the atlas.
Muscles
•Flexion of the head at atlanto-occipital joint is
produced by the longus capitis and rectus capitis
anterior muscles.

•The sternocleidomastoid muscle when acting

bilaterally will also flex head and neck.

•Extension at the atlanto-occipital joint is produced

by the recti capitis posteriores major and minor,
oblique capitis suprior, semispinalis capitis,
splenius capitis and cervical portion of the
trapezius.
•Latearl flexion at atlanto-occipital joint is done by rectus
capitis lateralis, semispinalis capitis, splenius capitis,
SCM and the cervical part of trapezius.

•Rotation at the atlanto-occipital joint is produced by the

oblique capitis superior, rectus capitis posterior minor,
splenius capitis and SCM.

•The scalene muscles acting bilaterally may either flex the

neck on the thorax or elevate the upper ribs when the
cervical spine is elevated.

•Extensors that produce rotation to opposite side are

multifidus rotators and semispinalis.

•Rotation to same side are oblique capitis and erector

spinae.
Mobility.
•The motions of flexion and extension, lateral flexion
and rotation are permitted in the cervical region.
•The atlanto-occipital joint permits primarily a
nodding motions of the head, however some axial
rotation and lateral flexion are possible.
• The combined ROM for flexion-extension
reportedly ranges from 10° to 30°(atlanto-occipital
joint)
•Motion at atlanto-axial joint includes rotation, lateral
flexion, flexion and extension. Approximately 55% to
58% of the total rotation of the cervical region occurs
at the atlanto-axial joint.
Range Of Motion
•Rotation at the atlanto-axial joint is limited by the
alar ligament.
•Flexion at the atlanto-occipital joint is limited by
osseous contact of the anterior ring of the foreamen
magnum of the skull on the dens.
•Extension is checked by the tectorial membrane.
Nerves
Major Motor Branches Of The Ulnar
Nerve
Major Motor Branches Of The
Median Nerve
Major Motor Branches Of The
Radial Nerve
Myotomes Of The Upper Limb
Dermatomes Of The Upper Limb
 Reflexes
•Ankle Jerk: S1 and S2
•Knee Jerk:L3 and L4
•Biceps Jerk: C5 and C6
•Triceps Jerk: C7 and C8
Manual Muscle Testing
A habitual poking chin can result in adaptive
shortening of the occipital muscles. It also causes the
cervical spine to change alignment resulting in
increased stress on the facet joints and posterior disc
and other posterior elements. The position may lead
to weakness of the deep neck flexors. This was
termed as Upper Cross Syndrome.
With this syndrome, the deep neck flexors are weak,
as are the rhomboids, serratus anterior and ofter the
lower trapezius.
Opposite these weak muscles are tight pectoralis
major, pectoralis minor, along with uppertrapezius
and levator scapulae.
 Following Conditions Involves
Cervical Region:
Cervical Radiculopathy
Cervical Myelopathy
Cervical Spondylolisthesis
Cervical Disc Herniation
Cervical Spine Stenosis
Torticolis
Cervical Rib
Cervial Spondylosis
Postural Neck Pain
 Cervical Radiculopathy
•Name-
•Age-generally seen above 40 years.
•Sex- males>females
•Occupation-teachers, clerks, tailors due to prolonged
flexion at the cervical spine.
•Address-
•Date of admission-
•Ward-
•Chief complaint-
a. pain radiating to the shoulder, arm or upper back.
b. Tingling sensation in hand and finger.
c. Muscle weakness.
•History of present illness-
a. pain being mild and intermittent at first but later
on it persists.
b. tingling sensation and weakness in hand and
fingers.
• Past medical history-
a. Posture
b. Trauma
c. Any surgery of cervical spine
d. Tumor in spine
• Family/Social/Personal history-smoker, alcoholic,
hereditary disease, dependent/independent.
•On observation-
a. Evaluation of head and neck posture and movement
during normal conversation.
b. Typically, patient tilts their head away from the side
of injury.
• On palpation-
a. Tenderness is usually noted along the cervical
paraspinal muscles.
b. Spasm on palpation these painful muscles can occur.
• On examination-
a. Active ROM is decreased.
b. Increase in pain on lateral bending, extension,
rotation.
c. Decreased reflexes
•Dermatomes-affected
•Myotomes-weak
 Torticolis
It is also known as Wry Neck.
It is a rotational deformity of the upper cervical spine that
causes turning and tilting of head.
•Name-
•Age-
a. Congenital.
b. At any age - Causes-
 Infective-TB of cervical spine.
 Traumatic-sprain, dislocation # of cervical spine.
 Myositis of SCM
 Spasmodic-painful, persistent or intermittent SCM
muscle contraction.
 Unilateral muscle paralysis- polio.
 Neuritis of spinal accessory nerve.
 Ocular disturbances- child turns head to one side
to see.
• Sex- congenital, and also in adults due to faulty
sleeping position
• Chief complaint-
a. Neck pain.
b. Head is tilted to one side and chin to opposite
side.
c. Inability to keep head upright.
d. Restriction of neck movements.
• History of present illness-lump is seen in the
SCM muscle which disappears spontaneously
within few months, leaving a fibrosed muscle.
•Past medical history-
a. Congenital- present at birth- mother notices the
impairment in neck functions.
b. Infective(TB of cervical spine)
c. Trauma
d. Polio
e. Ocular disturbances
• Family/Personal/Social history-smoker, alcoholic,
hereditary disease, dependent/independent.
• On observation-
a. Neck tilted to one side
b. Taut SCM muscle
c. Face rotated to opposite side
d. Restricted neck movements
•Facialasymmetry- flattening of face on the side of
contracted SCM muscle(due to the positioning of
head while child sleeps).
•On palpation-
a. Congenital muscular torticolis is usually
discovered in the 1st month of life.
b. There maybe a palpable mass ‘tumor’ that is
generally non tender, firm to soft and mobile
beneath the skin.
c. The mass is attached to or located within the body
of SCM muscle.
d. Spasm of the SCM muscle.
• On examination-
 MMT-Opposite side flexors are weak due to
continuous stretched position
Same side rotators are weak due to pain
ROM- decreased opposite side flexion and same side
rotation
 Cervical Rib
It is a rib arising from the 7th cervical vertebra, rarely
6th and 5th cervical vertebra.
 Developmental Anatomy- In the embryo, the nerves
are much larger in proportion to the ribs. When the
nerves are unusually large, as they are in cervical
region, they interfere with the development of the
costal processes. Formation of costal process
encounters little resistance from the small 1st thoracic
nerve root. As a result, there develops a rib extending
from the transverse process of the 7th cervical
vertebra.
•Name-
•Age- congenital
•Sex- female>male
•Side-more frequent on the right side
•Occupation- gymers due to heavy muscle mass
•Address-
•Date of admission-
•Ward-
•Chief complaint-
Neck stiffness
Pain in U/L
Sensory alterations
•History of present illness-
patient will have complaints of neurological
and vascular symptoms
Patient presents with tender supraclavicular
lung which is bony hard and fixed on
palpation
Loss of gripping
Wasting of thenar, hypothenar, interosseous
muscles
Tingling sensation in hand and fingers
Radiating pain to hand and fingers
Finger may be cold and blue in color
•Past medical history- congenital, postural
deformity(pronounced drooping of shoulder),
trauma, unusual lifting operation
•Family/Personal/Social history- smoker,
alcoholic, hereditary disease,
dependent/independent.
•On observation-
a. Trophic changes i.e. a thin glossy skin,
ulceration, ridging, brittleness of nails.
b. Localized area of gangrene indicating
thrombosis of the main artery.
•On palpation-
a. The irritated plexus is tender in deep pressure
lateral to and behind the SCM muscle.
b. Sensation is diminished over the ulnar border of
the forearm, volar aspect of the little finger, ulnar
half of ring finger.
c. The subclavian artery above the clavicle are felt to
be pulsating indicating vasospasm.
• On examination-
a. It maybe possible to feel the bony prominence of
the cervical rib at the base of the neck.
b. Flexion at MCP, extension at IP,
adduction/abduction of fingers, adduction of
thumb are weak.
 Cervical Spondylosis
When posterior arch defects are present but the
forward slipping has not occurred, the condition is
called Spondylosis or Prespondylolisthesis.
•Name-
•Age-
 60%>45 years
 85%>65 years
• Sex-
• Occupation-teachers, office clerks due to
continuous reading and writing.
• Address-
• Date of admission-
•Ward-
•Chief complaint-
a. Neck stiffness in morning
b. Pain radiates to shoulder, forearm and hand
c. Pain may get worse during coughing, sneezing
d. Ache on the back of the head
• History of present illness- unilateral pain and stiffness
initially intermittent but later persistent.
a. Pain aggravating factor-extension
b. Pain relieving factor-flexion
c. Onset- slow
• Past medical history-
a. Posture
b. Any surgery of cervical spine
c. Trauma
d. Fracture
•Family/Personal/Social history-smoker, alcoholic,
hereditary disease, dependent/independent.
•On observation-
a. Minimal or no cervical movement.
b. Torticolis maybe present.
• On palpation-
a. Tenderness over the paracervical muscles, generally
over trapezius.
b. Crepitation on movement maybe present.
• On examination-
a. Active ROM- limited ROM with pain
b. Passive ROM- limited ROM(symptoms maybe
exacerbated)
c. Decreased extension due to pain
d. Dermatomes- affected
 Cervical Disk Syndrome
If the disk material herniates because of trauma or old
age, it give rise to the cervical disk syndrome.
•Name-
•Age- 70%>=70 years
•Sex-male>female
•Occupation-tailor, gardeners, cobbler, porter
•Chief complaint-
a. Pain in neck which radiates into neck, shoulder,
arm and hand.
b. Limited neck movements.
c. Tingling and numbness.
•Address-
•Date of admission-
•Ward-
•History of present illness-
Young patients can give h/o trauma(soft disk lesions).
Old age patients can give h/o cervical spondylosis(hard
disk lesions).
Increase in pain on coughing, sneezing or straining
No relief in pain on rest
Pain aggravating factor-extension
Pain relieving factor-flexion
•Past medical history-
a. Prolonged posture
b. Earlier case of cervical spondylosis
c. Trauma
• Family/Personal/Social history-smoker, alcoholic,
• On observation-
• Movements of the neck are decreased due to pain
• On palpation-
a. Pain in neck, gradual or acute on onset
b. Localized tenderness over the spinous process
c. Trigger point tenderness at the scapular region is
present
• On examination-
a. h/o morning stiffness
b. Pain increases on hyperextension
c. Tingling and numbness develop if the nerve root is
compressed
d. Pressure against the top of head increases the pain
e. Radiating pain along the neck, shoulder, upper
arm,
 Cervical Spondylolisthesis
It occurs when one vertebra slips forward on the adjacent
vertebra.
• Name-
• Age-
a. Congenital-present at birth
b. Degenerative-after 40 years
c. Traumatic
• Sex-
• Occupation-instability from previous injury as in
drivers, sportsman
• Address-
• Date of admission-
• Ward-
•Chief complaint-
a. Neck pain
b. Neck stiffness
c. Pain extend towards the shoulder or even back of
head
d. Numbness or weakness extending into arms or
legs
• History of present illness-
a. Traumatic # dislocation
b. Subluxation
• Past medical history-
a. Traumatic
b. Congenital
c. Degenerative
•Family/Personal/Social history-smoker, alcoholic,
hereditary disease, dependent/independent
•On observation-
Limitation in cervical movements due to pain

•On palpation-

•Onexamination-
Weakness of arm
ROM- decreased
Numbness or weakness extending into arms or
legs(dermatomal involvement)
Myotomes affected
 Cervical Myelopathy
Cervical myelopathy refers to compression on cervical
spinal cord from either a disc herniation of cervical spinal
stenosis.
•Name-
•Age-50-70 years
•Sex-
•Occupation-
•Address-
•Date of admission-
•Ward-
•Chief complaint-
Neck stiffness
Parasthesia
Possible incordination in one or both L/L
Proprioceptive and/or sphincter disturbances
Loss of balance
Haorseness, vertigo, tinnitus, deafness
•History of present illness-
a. Pain aggravating factor-extension, side flexion,
rotation
b. Pain relieving factor-none
c. Arm position has no effect on pain
d. Possible loss of bowel bladder control
• Past medical history- a slipped disk, degenerated cervical
disk, tumor inside spinal cord, # of neck, traumatic injury
to cervical spine, autoimmune disease like MS, TM.
•Family/Personal/Social history-smoker, alcoholic,
hereditary disease, dependent/independent.
•On observation-
 Wide based gait
 Ataxia
 Proprioception affected
 Loss of hand functions
 Atrophy
 On palpation-
• On examination-
 Weak muscles- L/L muscles paraparesis
 Extension, rotation and side flexion may decrease
due to pain
 Sensation affected, abnormal pattern(dermatome
affected)
•Reflexes-
L/L DTR hyperactive
U/L DTR hyperactive
Decreased superficial reflex
 Cervical Spinal Stenosis
Cervical spine stenosis is the narrowing of the spinal canal
in the neck.
P.S- The spinal cord is the collection of nerves that runs
through the spinal canal from the base of the brain to the
lower back.
•Name-
•Age- 11-70 years
Most common: 30-60 years
•Sex-male>female
•Occupation-
•Address-
•Date of admission-
•Ward-
•Chiefcomplaint-
a. Pain
b. Sensory alterations
• History of present illness-
a. May be unilateral or bilateral pain(occurs in back,
buttocks, thighs, calves and feet)
b. Burning and numbness present in
L/L(dermatomal involvement)
c. Pain aggravating factor-extension
d. Pain relieving factor-flexion and prolonged bed
rest or walking uphill
e. Onset-slow
•Past
medical history-
a. Congenital
b. Disc bulge compressing spinal canal
c. Spondylosis(osteophyte formation)
• Family/Personal/Social history-smoker, alcoholic,
hereditary disease, dependent/independent.
• On observation-
a. Movements of the neck are decreased due to pain
• On palpation-
a. Normal pulses
b. Tenderness
c. Spasm
• On examination-
a. Dermatomes- usually several dermatomes
involved(sensory alteration)
b. MMT- decreased (myotomes affected)
c. ROM- decreased
 Postural Neck Pain
•Name-
•Age- Under 40 years
•Sex-
•Occupation- students, teachers, clerks due to
prolonged flexion at the cervical spine
•Address-
•Date of admission-
•Ward-
•Chief complaint-
Pain in neck
Neck stiffness
•History of present illness-
Pain may be intermittent initially but persists later
Pain referring to shoulder, arm, hand
•Past medical history-
Prolonged attainment of a particular posture
• Family/Personal/Social history-smoker, alcoholic,
hereditary disease, dependent/independent.
• On observation-
Mal-alignment of head and neck
Limitation of neck movements
•On palpation-
Tenderness
Spasm

•On examination-
Rom- active ROM limitation due to the pain
Dermatomes-
Myotomes-
Reflexes-
MMT-
Special Tests For Neurological
Symptoms
•Foraminal compression (Spurling’s) test
•Maximal cervical compression test
•Jackson’s compression test
•Distraction test
•Upper limb tension test
Foraminal Compression (Spurling’s)
Test
•This test is performed if, in the history, the patient
complained of nerve root symptoms, which at the
time of examination are diminished or absent.
•The patient bends or side flexes the head to the
unaffected side first followed by the affected side.
The examiner carefully straight down on head.
•A test result is classified as positive if pain radiates
into the arm towards which head is side flexed during
compression; this indicates pressure on a nerve root
(cervical radiculitis).
•If the pain is felt in opposite side to which the head is
taken, it is called a reverse spurling’s test which is
indicative of muscle spasm
The test positions narrow the intervertebral foreamen
so that the following conditions may lead to
symptoms: stenosis; cervical spondylosis; osteophyte;
trophic, arthritic or inflamed facet joint; or herniated
disc which also narrow the foreamen; or even
vertebral fractures.
Jackson’s Compression Test-
Modification of the foraminal compression test. The
patient rotates head to one side, the examiner then
carefully presses straight down on the head; then
repeated the same to other side. The test is positive if
pain radiates into the arm, indicating pressure on
nerve root.
Maximum Cervical Compression
Test
•With this test, the patient side flexes the head and
then rotates it to the same side. The test is repeated to
the other side.
•A positive test is indicated if pain radiates into the
arm.
•If the head is taken into extension (as well as side
flexion and rotation) and compression is applied, the
IV foramina close maximally to the side of movement
and symptoms are accentuated.
•Pain on the concave side indicates nerve root or facet
joint pathology, whereas pain on the convex side
indicates muscle strain
 Distraction Test
•Itis used for patients who have complains of
radicular symptoms in the history and during
examination.
•To perform the distraction test, examiner places one
hand under the patient’s chin and other hand around
the occiput, then slowly lifts the patient’s head.
•The test is positive if the pain is relieved or decreased
when head is lifted or distracted, indicating pressure
on nerve root that has been relieved.
 Upper Limb Tension Test
•The ULTT are equivalent to the SLR test in the
lumbar spine.
•They are tension test designed to put stress on the
neurological structures of the upper limb.
•This test, first described by Elvey, has since been
divided into four tests.
•Modifications of the position of the shoulder, elbow,
forearm, wrist and fingers places great stress on
specific nerves.
ULTT(MEDIAN NERVE BIAS)
MEDIAN NERVE ACTIVE
STRETCH
ULTT(ULNAR NERVE BIAS)
ULNAR NERVE ACTIVE
STRETCH
ULTT(RADIAL NERVE BIAS)
RADIAL NERVE ACTIVE
STRETCH
Lhermitte’s Sign-
•This is a test for spinal cord itself and a possible
UMN lesion.
•The patient is in long sitting position on the table.
The examiner passively flexes the patient’s head and
one hip simultaneously, with the leg kept straight.
•A positive test occurs if there is a sharp, electric
shock like pain down the spine and into the upper or
lower limbs; it indicates dural or meningeal irritation
in the spine or cervical myelopathy. Coughing or
sneezing may produce similar effects.
•This test is similar to a combination of Brudzinski
test and SLR test.
 Rehabilitation
Neurological-

TYPE OF LESION SYMPTOMS

Cord Compression Parasthesia

Cervical Dural Pain in dermatomes

Cervical Disc Limited ROM and pain in arm

Cervical Nerve Root Spasticity and In co-ordination

Pain management-
1. Short wave diathermy
2. Ultrasound(at trigger points)
3. Wax therapy
4. Hot packs
5. Infrared therapy
6. Cryotherapy(in acute cases)
7. Massage techniques such as kneeding, efflurage,
ischaemic compression
Exercises-
1. Strengthening of the weakened muscles
2. Stretching of the taut muscles
3. Neck muscles isometrics
4. Active assisted movements(if active is not
possible)
5. ROM maintenance
6. Joint mobility exercise(flexion, extension,
rotation, side flexion)
7. PNF techniques such as hold relax
8. Manipulation of the cervical spine is also done,
but only by an experienced therapist as it is a very
crucial region
Traction-
At cervical spine-
It is given as 1/7th of the body weight
It can be given intermittently or continuously
depending upon the need.
Recent studies found that traction at cervical spine
when given at 45º angle gives better result than the
traction given horizontally. Towel is kept below the
neck in it.
Contraindications to cervical traction-
Malignancy, spinal cord involvement, RA.
Cervical collars-
Indications-
1. Muscle support
2. Soft tissue support
3. Correction of any deformity
4. To relax the tensed muscle
5. Normally align the cervical spine
6. To immobilize the affected region
7. To prevent post surgical complications like re-
displacement
8. During driving, riding etc.
 Rehabilitation
•Prolapsed Cervical Disc
Treatment depends upon the severity of the condition.
Mild symptoms can usually be controlled with rest in a
conventional cervical collar, postural guidance and drug
therapy.
In sever cases there is stiff and painful neck with +ve
neurological signs. Immobilization of the neck in the
moulded or POP collar may ne necessary for 6 weeks or
continuous cervical traction may be given till signs reduce
or disappear.
disc lesion with rupture of annulus may be treated by
manipulation.
Traction is suited for irreducible nucleus pulposus
protrusion
•Physiotherapy management-
During immobilization-
i. Check the traction(positioning, line of pull and
magnitude)
ii. Postural guidance with immobilization
iii. Full ROM exercises for the shoulder joints
iv. Maximum use of upper extrimities
v. Scapular and shoulder girdle movements with
sustained holds
vi. Deep breathing and cycling motions without
straining the neck
vii. Isometrics to cervical muscles with mild tension
•Mobilization-
i. Relaxing thermotherapy modality
ii. Stronger but pain free cervical isometric exercise
iii. Intermittent cervical traction
iv. Relaxed passive mobilization of neck
v. Gradually increasing ROM and strengthening
exercises
vi. Postural guidance to avoid excessive flexion
attitudes
 Cervical Rib
•Treatment-
Surgery is indicated in patients with established
progressive vascular and neurological signs.
It consists of removal of the pressure causing
elements i.e. cervical rib and the associated fibrous
band and occasionally dividing the scaleni group of
muscles.
•Physiotherapy management-
Postural guidance
Thermotherapy modality for pain relief
Exercises to improve distal circulation of hand and
fingers
Exercises to improve tone, power and endurance of
the whole arm in general and small muscles of the
hand in particular.
•Movement which relieve symptoms-movements of
shoulder girdle like elevation, retraction and raising
the arm over head with elbow extended and wrist in
neutral with interlocked fingers.
Axial traction is applied to both the arms and held for
10-30 seconds may bring spontaneous relief.
1. Self resisted scapular elevation.
2. Self resisted scapular adduction
3. Endurance training exercise of shoulder girdle
4. PRE for shoulder girdle muscles with weight belt
5. Maximum cervical holds
 Torticolis
•Medical management- analgesics, anti inflammatory drugs.
•Surgical management- incision of the SCM if the ROM is
fixed.
•PT management-
Relaxed passive movement of head in the opposite direction
of the spasmodic muscles gradually altered to active
movement is the best form of exercise.
Controlled manipulation is beneficial.
The movement of rotation and side flexion are repeated in
the painless direction under traction
Other relaxed slow full range movements are helpful.
Temporary soft collar is useful during work and sleep to
maintain proper posture till acute pain subsides.
 Cervical Spondylolisthesis
The displacement is reduced by constant head traction.
The neck is then immobilized in a plaster jacket in
extension. If no relief, atlantoaxial fusion may be
necessary.
Congenital or post traumatic instability- if the
neurological signs are absent treatment by moulded plastic
collar is enough.
When the neurological symptom and severe dispacement
are present:
1. Reduction of the displacement by skull traction is
attempted.
2. If no relief, fusion of affected segment may be
necessary.
PT management-
Following conservative management-patient treated
with moulded collar or by constant bed traction:
i. Mobility of the legs and arms is maintained along
with the strengthening techniques.
ii. Emphasis is placed on the shoulder girdle and
scapular muscles.
iii. Gradual mobilization of the cervical spine and
progressive resistive techniques in the available
range are given with emphasis on isometrics for
the cervical extensor group of the muscles.
Cervical headache or cervicogenic headaches are
headaches caused by abnormalities in the cervical
region, the cause can be joint or muscular dysfunction
in the neck, poor posture, emotional tension, trigger
points in the neck muscles and head muscles etc.
The headaches may present as:
Pain and tension in the neck
Pain, ache and pressure in the forehead and back of
the head
Tension in the temple and jaw area
Pain that is made worse with prolonged posture
A headache with a feeling of light headedness and
dizziness
Cervical headaches are usually described as a
constant, steady, dull ache. It can be on one side or
both. The headache is usually felt at the base of the
skull and can be referred to the front of the skull and
to the temple area or over and behind the eyes.
PT MANAGEMENT-
Postural assessment and advice- without postural
correction cervical headaches can linger for extended
periods.
Mobilization- stiff joints in the neck should be
mobilised to restore the ROM
Stretching- strerching of the neck and shoulder
muscles can help alleviate headaches
Strengthening- cervical muscles retraining is vital.
Stress and tension management.
Soft tissue work and massage.
Acupuncture.
Workplace and ergonomic assessment.
Neural stretching.
Complications.