INTRO CERVICAL SPINE II

Copyright The Manual Therapy Institute 1998-2016

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CONTENT

Joint mobilizations 3

Peripheral entrapment neuropathies of the UE 8

Soft tissue mobilizations 11

Clinic exercises, home exercises 15

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Joint mobilizations

Upper cervical manual traction, seatedCup hands under occiput. Slightly extend the head to put O - A in the resting position. Distract.

Upper cervical manual distraction, supineOne hand cups the chin, the other molds around the occiput. Put little finger and hypothenar on occipital edge. Primary traction force is at the occiput.

Flexion mobilization O - AWeb space and index finger on occiput. Index finger other hand on C 1. Delto-pectoral groove on fore head. Flex head. Roll is provided by hand under occiput, glide provided by delto-pectoral groove pushing in A - P direction.Alternative: One hand on patient forehead, thumb and indexfinger of other hand stabilize C1. Hand on forehead produces upper cervical flexion.

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Extension mobilization O - ASame hand placement as in flexion. In this case, the delto- pectoral groove extends the head, the hand under occiput translates it in anterior direction. Gravity and soft tissue tension provide the stabilizing force for C 1. Very few indications for this technique, except when used as an indirect technique, or with people with flat necks.Alternative: One hand on patient forehead, the thumb and indexfinger of the other hand stabilize C1. The hand on forehead produces upper cervical extension.

Unilateral distraction technique O - APatient supine. Occiput in slight left rotation, right sidebending and extension. Contact under mastoid process. Mobilize occiput cranially

Side bending O - AOne hand under occiput. Delto pectoral groove on forehead. Thumb of left hand stabilizes the left TP of C1. Sidebend head to the right

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Mobilization C 1 - 2For right rotation. Index finger left hand wraps around posterior aspect of C 1.Other hand around occiput. Side bend head maximally to the left. Then rotate right, mobilizing C1 on C2.

Mid cervical manual traction seatedBoth hands under occiput. Patient leans back against therapist. Flex neck to segment targeted. Distract.

Mid cervical manual traction supine, 2 hand techniqueOne hand molds under patients chin, the other around SP above targeted segment. Flex down to the level. Distract.

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Mid cervical manual traction, towel technique Towel placed so that the inferior edge lies over the spinous process of the upper vertebra of level affected. Have patient tuck the chin.

Mid cervical flexionPatient supine. Stabilize lower vertebra of affected segment by molding index finger and thumb around spinous process. Other hand molds around neck and vertebra above. Place delto- pectoral groove on fore head. Flex up to level. Mobilizing hand draws vertebra up and forward.

C2 - 3 distraction, supinePatient supine. Occiput/atlas/axis: slight left sidebending and right rotation. Contract: left inferior facet of C 2. Mobilize C 2 cranially, in the direction of the opposite eye. This technique can be done in similar fashion for all the facet joints in the mid cervical spine.

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Down and back unilaterally, supineSide glide segment up to barrier. Then approach posterolateral part of articular process of upper vertebra with antero- lateral part of MCP 1. Mobilize down and back, in the direction of the opposite shoulder.

Up and forward unilaterally, supineRotate head up to barrier. Antero-lateral part of MCP 1 molds around the posterolateral part of the articular process of the superior vertebra. Mobilize in an up and forward direction, much like moving your hand around a cylinder.

Side glide METFor side glide right. Can be done in neutral, semi- flexion/ extension. Side glide head to right up to restriction barrier. Creates left side bending. Instruct patient to push head to right. Hold 6 sec. Then pick up slack in right side gliding.

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Peripheral entrapment neuropathies of the UE

Ulnar NerveThe ulnar nerve can get entrapped at the elbow at the cubital tunnel and at the wrist at Guyon’s canal.

Cubital tunnel syndrome is the second most common entrapment neuropathy in the UE. The cubital tunnel is formed by the medial edge of the trochlea and olecranon laterally and the medial epicondyle medially. The ulnar collateral ligament forms the floor of the tunnel. The cubital tunnel retinaculum (or arcuate ligament) forms the roof. Flexion tightens the retinaculum, narrowing the tunnel. Overhead sports activities are a common source of ulnar nerve irritation. Repetitive activities may produce adaptive changes such as bony hypertrophy, extension restrictions, or valgus deformities. Instability of the ulnar nerve at the elbow can also cause neuropathy. It usually presents as aching pain over the medial side of the elbow, sometimes radiating to the hand. It also produces sensory disturbances (numbness, tingling, coldness) over the ulnar side of the hand and ulnar one and one-half digits. Popping or painful snapping of the nerve with flexion or extension can occur. Motor involvement affects the hand intrinsic musculature, but spares the flexor carpi ulnaris and flexor digitorum profundus.Testing: sustained elbow flexion (1-3 minutes) will reproduce symptoms. Positive ANTT ulnar nerve.

Ulnar neuropathy in Guyon’s canal can be caused by carpal ganglions, hamate fractures, extrinsic trauma or compression. It may present as isolated or combined sensory and motor symptoms, depending on where the compression occurs. It can cause pain, paresthesia in the ulnar nerve distribution of the hand. Weakness may develop in the intrinsic muscles, producing decreased lateral pinch and grip strength. Patient may have problems with fine motor skills. Claw hand deformity may develop due to loss of intrinsic muscle strength.

Overt anesthesia along the arm cannot result from ulnar nerve compression. Medial arm symptoms arise from a site near, or proximal to, the axilla. Sensory innervation in the medial part of the arm comes from the medial brachial and medial antebrachial nerves from the medial cord.

To differentiate between C8-T1 radiculopathy and ulnar nerve entrapment, check strength of the extensor pollicis longus (EPL). The EPL is innervated by the radial nerve, level C8. Check sensation as well, as ulnar nerve sensory loss covers the medial hand and one and half fingers, whereas sensation loss in C8 dermatome is different.

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Median nerveThe median nerve can get entrapped at the ligament of Struthers, the pronator teres, the site of branching of the anterior interosseous nerve and at the wrist.

Entrapment at the ligament of Struthers is rare, as this vestigial ligament is present in just 1% of the population. This ligament, if present, stretches between a humeral spur, 3-5 cm proximal to the elbow, and the medial epicondyle. It covers the median nerve.

The pronator syndrome mainly stems from 2 sites of compression: A thickened lacertus fibrosis where it connects to the pronator teres muscle Pronator teres hypertrophy or fibrous bands within the muscle

It presents as an insidious onset of proximal anterior forearm pain, with occasional hand pain. Repeated pronation and wrist flexion increases the pain. Night pain is uncommon. Resisted pronation and wrist flexion reproduces symptoms. Sensory symptoms may involve the radial hand and 3.5 digits. Motor involvement is less common. There may be soft tissue changes at the pronator teres. Positive adverse neural tissue tension for median nerve.

The anterior interosseous branch is susceptible to compression by fibrous bands from the deep head of the pronator teres or flexor digitorum superficialis muscles. The median nerve divides to form the anterior interosseous nerve at the distal edge of the pronator teres. Compression results from repetitive trauma, casts or contusions. The anterior interosseous syndrome presents as proximal forearm pain that is increased with activity. There are no sensory changes. There may be decreased dexterity or weakness in pinch grip.

Median nerve compression at the wrist (carpal tunnel syndrome) is the most common of all peripheral nerve entrapment syndromes. It may stem from any condition that decreases the size of the carpal tunnel: fluid retention, external compression, excessive callus formation or malalignment after a Colles fracture, lunate dislocation, ganglions and synovitis. It presents as an acute or insidious onset of pain, paresthesia or anesthesia over the radial side of the pal and radial three and one half digits. Pain may radiate proximal to the wrist and is often nocturnal. Weakness can occur in thenar musculature and 1st and 2nd lumbricals, which hinders opposition and precision maneuvers. There will be a positive Phalen’s test, positive ANTT for median nerve, volar swelling and thenar atrophy.

To differentiate between C6-7 radiculopathy and median peripheral nerve entrapment of the median nerve, check reflex and strength of brachioradialis. The brachioradialis is innervated by radial nerve, level C6. Check sensation as well, as median nerve sensory loss covers the first 3 fingers, whereas sensation loss in C6, 7 dermatomes is different.

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Radial nerveThe radial nerve and its branches are vulnerable to compression from the mid humeral region to the wrist. External compression is common over the posterior humerus and at the wrist. Internal structures are more often at fault in the elbow and forearm, although direct trauma can injure the superficial radial nerve in the forearm.

High radial nerve palsy usually results from trauma such as fractures, tourniquet use and “Saturday night palsy”. Activities like wrestling, throwing, gymnastics and weightlifting can compress the radial nerve between triceps and humerus. It produces mixed motor and sensory symptoms. Depending on the level of the lesion it may or may not involve the triceps. Pain may radiate proximal or distal to the elbow. Sensory changes occur in the posterior forearm, dorsal hand and dorsal aspect of the radial 3 and one-half digits. Weakness may affect the supinator, wrist extensor, thumb extensor/abductor and finger MP extensor muscles.

Radial tunnel (or posterior interosseous) syndrome is the most common compression neuropathy of the radial nerve. The radial nerve splits near the radial head into the posterior interosseous and superficial radial nerves. The posterior interosseous nerve (PIN) enters the 5 cm long radial tunnel, passing from the anterior to the dorsal compartment of the forearm. There are 4 common sites of compression in the radial tunnel:

Fibrous bands anterior to the radial head A vascular arcade The tendinous margin of the extensor carpi radialis brevis The proximal edge of the supinator (arcade of Frohse)

The radial tunnel syndrome manifests as local tenderness and extensor weakness. Night pain is common. No sensory changes.

To differentiate between C6-7 radiculopathy and posterior interosseous nerve, check sensation as the PIN is a motor nerve only and provides no cutaneous sensation. The pain associated with PIN entrapment may simulate lateral epicondylitis, but careful palpation will give you the clue needed. The radial nerve will be tender on palpation.ANTT is + for the radial nerve.

References Wadsworth, C. (1997) Peripheral Nerve Compression Neuropathy. Home

Study Course 97-2. APTA-Orthopedic Section. Boucher, B. Peripheral nerve entrapment of the upper extremity. Lecture.

Texas State University. July 2003

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Soft tissue mobilizations

STM to scalenes, SCM and suboccipitals in supine, with or without 4 inch ethafoam roll and belt

Suboccipital release. Can use contract relax, using eye movement.

Clear bony prominences scapula

clavicle

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sternum

gutter

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Functional movement patterns

Seated cervical STM with FMP: flexion and diagonal flexion

FMP to increase cervical rotation. Patient supine. Therapist uses fist to stabilize.

FMP to improve thoracic extension. Patient is seated with hands clasped behind the head.

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Arm circles

Clinical exercises

supine rotation with pulley

sidelying on slant board, side bending with bolster

prone chin tuck with thoracic extension over 2 pillows

supine chin tuck with neck flexion

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Home exercises

Pivot prone

Supine sustained pressure to sub occipitals with double tennis balls

Single tennis ball for self STM

Self distraction mid cervical spine

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SelfmobilizationsTowel technique for O-A flexion mobilization. Very helpful with headaches caused by upper cervical joint dysfunction.

Towel technique for mid cervical joint dysfunction

Towel technique for mid cervical extension

Hand collar to mobilize down and back

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C T junction

Cervical rotation with neck flexion

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