Accepted Manuscript: 10.1016/j.math.2013.09.007

Accepted Manuscript
Articular dysfunction patterns in patients with mechanical neck pain: a clinical

algorithm to guide specific mobilization and manipulation techniques
Vincent Dewitte, PT Axel Beernaert, PT Bart Vanthillo, PT Tom Barbe, PT Lieven
Danneels, PT, PhD Barbara Cagnie, PT, PhD
PII:
S1356-689X(13)00160-4
DOI:
10.1016/j.math.2013.09.007
Reference:
YMATH 1498
To appear in:
Manual Therapy
Received Date: 19 July 2013

Revised Date:
11 September 2013
Accepted Date: 28 September 2013
Please cite this article as: Dewitte V, Beernaert A, Vanthillo B, Barbe T, Danneels L, Cagnie B, Articular
dysfunction patterns in patients with mechanical neck pain: a clinical algorithm to guide specific
mobilization and manipulation techniques, Manual Therapy (2013), doi: 10.1016/j.math.2013.09.007.
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Title: Articular dysfunction patterns in patients with mechanical neck pain: a clinical
algorithm to guide specific mobilization and manipulation techniques
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Authors:
Vincent Dewitte, PT (Corresponding author)
Ghent University, Department of Rehabilitation sciences and Physiotherapy, De Pintelaan 185
3B3, 9000 Ghent
Email : vincent.dewitte@ugent.be
Tel: 0032 9 332 12 17
Fax: 0032 9 332 38 11
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Axel Beernaert, PT
3B3, 9000 Ghent
Email: axel.beernaert@skynet.be
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Bart Vanthillo, PT
3B3, 9000 Ghent
Email: bart.vanthillo@ugent.be
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Tom Barbe, PT
3B3, 9000 Ghent
Email: tom.barbe@ugent.be
Lieven Danneels, PT, PhD
3B3, 9000 Ghent
Email: lieven.danneels@ugent.be
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Barbara Cagnie, PT, PhD

3B3, 9000 Ghent
Email: barbara.cagnie@ugent.be
Tel: 0032 9 332 52 65
Fax: 0032 9 332 38 11
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Abstract
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In view of a didactical approach for teaching cervical mobilization and manipulation techniques
to students as well as their use in daily practice, it is mandatory to acquire sound clinical
reasoning to optimally apply advanced technical skills. The aim of this Masterclass is to present a
clinical algorithm to guide (novice) therapists in their clinical reasoning to identify patients who
are likely to respond to mobilization and/or manipulation. The presented clinical reasoning
process is situated within the context of pain mechanisms and is narrowed to and applicable in
patients with a dominant input pain mechanism. Based on key features in subjective and clinical
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examination, patients with mechanical nociceptive pain probably arising from articular
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structures can be categorized into specific articular dysfunction patterns. Pending on these
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patterns, specific mobilization and manipulation techniques are warranted. The proposed
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patterns are illustrated in 3 case studies. This clinical algorithm is the corollary of empirical
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expertise and is complemented by in-depth discussions and knowledge exchange with
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international colleagues. Consequently, it is intended that a carefully targeted approach
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contributes to an increase in specificity and safety in the use of cervical mobilizations and
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manipulation techniques as valuable adjuncts to other manual therapy modalities.
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Keywords: articular dysfunction patterns; clinical reasoning; cervical spine; spinal manipulation
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Introduction
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For centuries, spinal mobilization and manipulation techniques have been passed down from
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one generation of manipulators to the next. Although these techniques have undoubtedly
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evolved over time, their progression has largely been a culmination of imitation and iterative
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adaptation, leading to a great variety of spinal manipulation techniques (Evans, 2010).
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Nowadays, an eclectic approach is used in most manual therapy courses, including aspects of
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Maitland, Kaltenborn-Evjenth, Hartman and other philosophies and principles.
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Although recent systematic reviews (Gross et al. , 2010, Bronfort et al. , 2012, Chaibi and Russell,
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2012) have demonstrated evidence (low to moderate quality) that cervical manipulation and
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mobilization are beneficial, these reviews highlight the lack of knowledge on optimal techniques
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and doses.
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In view of a didactical approach for teaching students as well as for daily practice, it is
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mandatory not only to learn advanced technical skills, but also to acquire sound clinical
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reasoning skills (Gifford and Butler, 1997, Kelly, 2003, Puentedura et al. , 2012). Only if both
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aspects are integrated, spinal manipulation and mobilization may be considered proficient. In
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2003, Hing et al. (Hing et al. , 2003) published a comprehensive paper in Manual Therapy to
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discuss manipulation of the cervical spine, detailing the teaching strategies developed for
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cervical spine manipulation in New Zealand, outlining the clinical assessment and providing
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examples of the procedures in practice. What is missing in this article, and in a lot of handbooks
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on manual therapy, is the sound clinical reasoning behind manipulation. It is mandatory to 1)
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recognize key features in the subjective examination and clinical examination to identify
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patients likely to benefit from cervical mobilization and manipulation, and 2) to define optimal
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techniques pending on the individual presentation of the patient.
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Therefore, the aim of this Masterclass is to present a clinical algorithm for guiding therapists in
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their clinical reasoning to identify patients with predominantly mechanical nociceptive pain
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arising from the articular structures, who are likely to respond to mobilization and/or
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manipulation. This clinical algorithm is mainly based on many years of clinical experience using
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a standardized way in assessing and treating neck pain patients. According to Jones, a form of
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pattern recognition develops, when a well-structured approach is followed, building on many
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years of clinical practice (Jones, 1992, 1995, Doody and McAteer, 2002). Considering the
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empirical foundation of this process, the desire to communicate these prototypes to
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(international) colleagues arose so that definition and interpretation of similar patterns could be
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modeled into a more comprehensive and refined form. To our knowledge these symptoms have
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not been clustered before in distinct dysfunction patterns along with specific treatment
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recommendations. Therefore the authors have attempted to describe specific findings per
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dysfunction pattern and, where possible, complemented them with the limited evidence
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available.
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In this masterclass the reasoning framework of interest to (articular) mechanical neck pain is
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outlined. In light of this reasoning process, an attempt is made to categorize subjects into a
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specific articular dysfunction pattern based on the characteristics identified during subjective
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examination and clinical examination. This is then linked to specific mobilization and
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manipulation techniques, which are summarized in a clinical algorithm to guide specific
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treatment. In the last part of this Masterclass, this clinical algorithm is illustrated by different
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case studies.
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Articular dysfunctions in a broader perspective
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Figure 1 represents a model, that enables the therapist to systematically analyze and appraise
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the impact of the different components as a basis for clinical decisions and aims to contribute to
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a more efficient way of managing patients (Danneels et al. , 2011). This planetary model is not a
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new model, but is a didactic representation mainly inspired by an adapted model of the
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International Classification of Functioning, Disability and Health (ICF). The structure of the ICF is
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reflected in a vertical plan, whereas the pain mechanisms and psychosocial factors surround this
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vertical structure reflecting their continuous interaction with the different components of the
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vertical axis. As musculoskeletal pain is multidimensional in nature (Smart and Doody, 2006,
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2007) this planetary representation endeavors to capture the dynamic character of the
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reasoning process.
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The process of clinical decision-making is preferably well structured and stepwise instead of
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vague and global. If a structured path is followed the therapist can avoid gaps and enhance
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efficiency in the approach to the patient (Petty and Moore, 2001). After the subjective
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examination different features should be interpreted. First of all, the importance of excluding red
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flags prior to further investigation to prevent misdirection and enhance safety is warranted
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(Barker et al. , 2000, Childs et al. , 2005, Alexander, 2011, Puentedura et al. , 2012).
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Subsequently, the dominant pain mechanism should be defined (Gifford and Butler, 1997,
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Gifford, 1998, Jones et al. , 2002). Pain mechanisms have been broadly categorized into: 1) input
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mechanisms, including nociceptive pain and peripheral neurogenic pain; 2) processing
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mechanisms, including central pain and central sensitization, and the cognitiveaffective
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mechanisms of pain; and 3) output mechanisms, including autonomic, motor, neuroendocrine
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and immune system (Gifford and Butler, 1997, Gifford, 1998). In case of a dominant input
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component, hypotheses about the possible nociceptive sources of symptoms can be formulated
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(Alexander, 2011, Bogduk, 2011). Identifying impairments in activity and participation as well
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as contributing psychosocial factors are also an essential part to give the clinician a fairly
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comprehensive understanding of the patients signs and symptoms. Clinical examination is
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mainly important to further confirm or reject the former formulated hypotheses regarding
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impairment in structure and function. From a compilation of the subjective examination analysis
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and the relevant clinical findings emerging from the examination, therapeutic goals and tools can
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be determined (Jones, 1995). Reassessment at subsequent treatment sessions is necessary to
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evaluate treatment progression and to readjust the treatment plan if needed. Moreover, the
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evaluation of perceived treatment effects is an integral part of the reflective reasoning process
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(Jones, 1992, Doody and McAteer, 2002, Smart and Doody, 2006).
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Care is needed to avoid a preoccupation with one structure or diagnosis at the expense of others,
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as this will be reflected in the management (Jones, 1995). Nonetheless, given the context of this
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paper the presented clinical reasoning process is narrowed to and applicable in patients with a
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dominant input pain mechanism with mechanical nociceptive pain probably arising from
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articular structures. Even though minor symptoms coming from muscular or neurological
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structures might be present in patients suffering from mechanical neck pain, the dominant pain
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source should be articular to justify the use of specific mobilizations and/or manipulations. It is
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essential to rule out dominant processing mechanisms since manipulative therapy would not be
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the first choice of treatment in these patients. Furthermore, when there seems to be a dominant
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output component with maladaptive movement patterns as a generator of the patients
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condition, manipulative therapy can be used only secondary to relieve patients nociceptive
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symptoms. In the latter case, the focus should be on the motor control aspect since this might be
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the source of the vicious circle that could lead to a more chronic condition.
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Based on clinical experience and available evidence in the literature, the type of clinical
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presentation that would suggest an amenity to manipulative therapy may include (McCarthy,
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2001, Hing et al. , 2003, Childs et al. , 2008, Gellhorn, 2011, Dunning et al. , 2012, Puentedura et
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al. , 2012):
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primary complaint of neck pain (defined as pain in the region between the superior nuchal
line and first thoracic spinous process);
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a problem that is mechanical in nature and fits with a biomechanical pattern that is regular
and recognizable;
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a non-traumatic history of onset suggestive of mechanical dysfunction;
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a limited symptom duration (according to Puentedura et al. (2012) less than 38 days);
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limited range of motion (ROM) (direction specific), with a side-to-side difference in cervical
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rotation ROM of at least 10;
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pain that has clear mechanical aggravating and easing positions or movements;
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local provocation tests produce recognizable symptoms;
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spinal movement patterns that, when examined actively and passively, suggest a movement
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restriction that is local to one or two functional spinal units;
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no neurological findings in clinical history or manual assessment;
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no signs of central hyperexcitability;
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no indication that referral to other health care providers is necessary (to exclude red flags);
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a positive expectation that manipulation will help.
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The presumption of a predominant articular dysfunction as an inherent cause of neck
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complaints is supported by the prevalence of several of the above listed findings. As there is no
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particular recipe or protocol for the articular patient, the key part in the clinical reasoning
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process is to make decisions based on information collected in both subjective and clinical
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examination. The hypothesis of an articular dysfunction is only valid if a cluster of articular
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symptoms is endorsed. A key reasoning issue is the relevance of an unique finding within the
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individual presentation of the patient (Gifford and Butler, 1997). For example, a stiff neck may
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be of little relevance in a patient with dominant processing mechanisms, since any attempt to
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loosen the joints up may simply be an additional input to the system that the body is unable to
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handle (Gifford and Butler, 1997). An overemphasis on findings which support the articular
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hypothesis, might lead to ignoring findings which do not support it, possibly leading to incorrect
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interpretations (Jones, 1992, 1995, Jones et al. , 2002).
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Given the number of articular techniques available (Hartman, 1997, Kaltenborn et al. , 1993,
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Hing et al. , 2003, Evans, 2010, Gross et al. , 2010, Williams and Cuesta-Vargas, 2013), it is
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crucial, to define optimal techniques pending on the individual presentation of the patient. In the
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next section we will propose a model of articular dysfunction patterns mainly based on years of
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clinical experience in treating neck pain patients. These patterns will guide the manual therapist
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to choose the appropriate mobilizations and manipulative techniques for the individual patient.
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This section specifically focuses on the mid and lower cervical spine. As the anatomy and clinical
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biomechanics of the upper cervical spine is far more complex (Pal et al. , 2001) and requires a
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different approach, this will not be discussed.
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Clinical subgroups
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Articular dysfunction patterns are clinically divided into two main categories: a convergence
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pattern and a divergence pattern. Table 1 gives an overview of the key clinical findings during
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the subjective and physical examination.
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Convergence pattern
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A monosegmental convergence pattern is characterized by pain provocation and motion
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restriction mainly during extension and ipsilateral side bending and rotation. This pattern is
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associated with unilateral compression pain that can appear at the start, mid- or end range of
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motion. This clinical pattern is further clarified by combined passive movement testing, which
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reproduces the patients symptoms. This will generally be a combination of extension, ipsilateral
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side bending and rotation. The intervertebral movement tests may give additional information
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about the quality and quantity of the segmental joint play. Dorsocaudal (downslope) gliding is
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usually restricted at the same side of the compression pain.
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A convergence pattern is often found in acute cases and is frequently characterized by a
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pronounced movement restriction and associated antalgic posture. The head is deviated in
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flexion and rotation away from the painful side to avoid closing of the zygapophysial (facet)
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joint. Extension and rotation are highly restricted and painful, associated with hypertonic
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muscles.
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Divergence pattern
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A monosegmental divergence pattern is rarely associated with an antalgic posture and high
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intensity or severity of symptoms is uncommon. This pattern is considered when pain is
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provoked and movement is restricted during flexion and contralateral side bending and rotation.
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The divergence pattern is associated with unilateral stretch pain originating from
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capsuloligamentous structures, usually appearing at the end range of motion. A passive
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combined movement, including flexion, (contralateral) side bending and rotation will increase
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the stretch on the capsuloligamentous structures and may produce pain or comparable
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symptoms.
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The intervertebral movement test, performing ventrocranial (upslope) gliding is usually
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restricted at the same side of the stretch pain.
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In case of a divergence pattern special note is made to differentiate the stretch symptoms
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between articular and muscular/neural tissue.
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Mixed pattern
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Clinically a third pattern in the cervical spine can be described and added to the two regular
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patterns, which is called a mixed pattern. This pattern is characterized by multisegmental and
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multidirectional dysfunctions that can be diagnosed in a degenerative cervical spine. A
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degenerative cervical spine is characterized by general stiffness, multisegmental movement
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restrictions, a mixed pattern of compression/stretch pain and a combination of
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convergence/divergence patterns.
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Mobilization and manipulative techniques
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Various segmental mobilizations and manipulative techniques co-exist and have been described
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in different ways regarding aim, nature and execution (Kaltenborn et al. , 1993, Hartman, 1997,
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Williams and Cuesta-Vargas, 2013). Most manual therapists use the manipulative approach as a
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progression of localized mobilization techniques. This enables the therapist to work towards an
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articular barrier adding different components to the mobilization while sensing the tissue
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responses and the nature of the barrier. This will also enhance safety due to the careful
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interpretation of pre-manipulative local and general symptoms. In addition, it allows the patient
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to agree or disagree with the performed procedure through body symptoms (embodied
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consent), sending signals (implied consent) or verbally (express consent) (Fenety et al. , 2009).
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Different manipulative approaches can be distinguished, ranging from translatoric and
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distraction to gapping techniques. It is essential to use techniques that both limit ROM and the
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applied force in order to enhance safety. Roughly, two fundamentally different approaches can
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be distinguished: focus and locking approach.
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In the focus approach the applied force and amplitude will be limited by adding concomitant
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components at the involved segment. The different components may consist of flexion or
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extension, contralateral rotation, ipsilateral side bending, with additional non-voluntary
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movements such as traction, side glide and compression. The affected segment is placed in a
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non-physiological position (side bending coupled with rotation to the opposite side) to more
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easily obtain the articular barrier (Hartman, 1997).
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In the locking techniques the adjacent spinal segments caudal or cranial to the affected segment
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should be placed in a non-physiological position to constrain their movement, whereas the
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affected segment is placed in a physiological position (side bending coupled with rotation to the
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same side) so it is more effectively targeted (Kaltenborn et al. , 1993).
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The most frequently used manipulative procedures in the mid and lower cervical spine will be
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described briefly.
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Translatoric techniques
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Translatoric techniques are defined as an applied glide or thrust parallel to the zygapophysial
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joint plane and are referred to as upslope or downslope techniques depending on the direction
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of the thrust. These techniques are termed as such as the aim is to move the zygapophysial joint
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either up its slope simulating opening of the joint as would occur during flexion and
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contralateral rotation or down the slope simulating closing of the joint as would occur during
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extension and ipsilateral side bending (Hing et al. , 2003, Williams and Cuesta-Vargas, 2013).
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The upslope focus technique (figure 2) comprises of a cradle or chin hold to the head with the
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ipsilateral hand contacting the articular pillar of the superior segment. The head is positioned in
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contralateral rotation and ipsilateral side bending. Slight flexion can be added as a third
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component. The thrust is directed to the opposite eye (ventrocranial). While performing a
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manipulation in upslope direction an indirect downslope movement occurs on the opposite side
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of the same segmental level (= indirect downslope technique).
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This upslope technique can also be performed while using a locking approach. An often-used
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upslope technique with caudal locking (figure 3) consists of stabilizing the caudal segments by
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placing them in a non-physiological position (rotation and contralateral side bending). The
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affected segment is placed in a physiological position and a translation is given in an upslope
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direction.
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The downslope focus technique (figure 4) comprises of the therapist adopting a cradle or chin
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hold of the head with the ipsilateral hand contacting the articular pillar at the superior segment.
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The head is positioned in contralateral rotation and ipsilateral side bending. Slight extension can
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be added as a third component. A translatoric thrust is given in the direction of the opposite
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inferior scapular angle (dorsocaudal).
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Distraction techniques
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For the distraction techniques (figure 5) the premanipulative positioning is similar to the upslope
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technique, but the applied thrust direction is perpendicular to the joint plane with the contact
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hand placed onto the articular pillar of the superior segment.
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Gapping technique
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Gapping techniques (figure 6) are indirect techniques as the aim is to create a separation of the
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affected zygapophysial joint at the opposite side. The applied force is directed perpendicular to
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the contact point.
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Therapeutic guidelines for mobilization and manipulative techniques
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In the succeeding paragraph this selection of mobilizations and manipulative techniques will be
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linked to the aforementioned articular dysfunction patterns. This is summarized in a clinical
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algorithm that is presented in figure 7.
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Convergence pattern
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In a first phase of treating a convergence pattern any compression at the affected side should be
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avoided since this would aggravate the condition. Therefore, a direct distraction technique and
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an indirect gapping approach are both indicated. The primary goal in gapping techniques is to
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obtain pain relief (neurophysiological effect) as the effect on mobility is non-specific (Bialosky et
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al. , 2009, Evans, 2010, Bialosky et al. , 2012).
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In the second stage the remaining function deficits should be addressed. First of all, the use of an
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indirect downslope technique to restore downslope mobility at the affected side is appropriate.
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An added benefit in this approach is restoring mobility without creating excessive
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compressional force on the affected zygapophysial joint. Both the locking and focus upslope
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technique are applicable but the latter creates more cavitation at the opposite side.
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In the final phase, when a painless end range downslope restriction is still present, a direct
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downslope technique might be warranted. The use of segmental traction as an additional
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component is often needed to cope with the compressional forces related to this technique.
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Divergence pattern
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In case of a cervical divergence pattern, the main goal is to restore the upslope translation.
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Creating a separation by an indirect gapping technique is contraindicated in this case, since this
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would create unnecessary tension onto the capsuloligamentous structures. Translatoric
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techniques in the upslope direction are the first choice of treatment in order to restore upslope
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translation. Both focus and locking techniques can be carried out.
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If necessary, one could start off with a distraction manipulation since this does not create an end
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range distension of the zygapophysial capsule due to the positioning in ipsilateral side bending
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and contralateral rotation.
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Case studies
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Tables 2, 3 and 4 represent three case studies of individuals with mechanical nociceptive neck
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pain, each illustrating the importance of subjective examination and clinical examination to
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guide treatment.
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Within the scope of this Masterclass, the analysis of examination findings and therapeutic
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interventions is limited to those of interest to the discussed patterns. The reader is referred to
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several more thorough and technical accounts for additional information (Beernaert et al. , 2006,
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Alexander, 2011, Danneels et al. , 2011, Gellhorn, 2011, Puentedura et al. , 2012). The
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management plan is also directed to the scope of this article, so other interventions will not be
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discussed.
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Conclusion
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The intention of this Masterclass was to propose a clinical algorithm to guide (novice) therapists
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in their clinical reasoning to identify patients with predominantly mechanical nociceptive pain
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arising from the articular structures, who are likely to respond to mobilization and/or
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manipulation. This clinical algorithm is the corollary of empirical expertise (collected during
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years of clinical fieldwork) and complemented by gathered wisdom ranging from in-depth
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discussions and knowledge exchange with international colleagues.
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One could argue that the established framework is a simplified and therefore incorrect image of
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reality. However, the authors do emphasize that the added value of the proposed articular
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dysfunction patterns can only be fully appreciated when this is considered within a broader
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perspective (as stated in section 2). Nevertheless, treating patients requires a sense of
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awareness for subtle distinctions, where adaptation entails the key to success.
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Tables
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Table 1: Features of mono-segmental cervical spine convergence and divergence patterns
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Cervical spine divergence pattern

Subjective examination
Feeling of painful strain at end ROM
Movement restriction at end ROM
Unilateral stretch pain
High intensity or severity of symptoms is rare
Antalgic posture is uncommon
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Cervical spine convergence pattern

Feeling of locking
Movement restriction
Unilateral compression pain
Often in acute cases
Antalgic posture
Physical examination
Active and passive combined flexion,
contralateral side bending, and rotation is
limited and evokes comparable signs
Passive shoulder elevation in this position
does not result in increased ROM/decreased
pain
Articular examination
Provocation tests (spring testing) are positive
at the impaired segment(s)
Intervertebral Movement Tests: ipsilateral
downslope restriction
Segmental distraction alleviates the pain
Articular examination
Provocation tests are positive at the impaired
segment(s)
Intervertebral Movement Tests: ipsilateral
upslope restriction
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Active and passive combined extension,
ipsilateral side bending, and rotation is limited
and evokes comparable signs
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Observation
Subtle antalgic posture: the head slightly bent
forward, rotated and side bent to the left. The
patient is not aware of this position, and is not
able to actively correct her posture when
instructed, because of the pain. Neck-shoulder
muscles are hypertonic on both sides, although
right more than left.
Active and passive movement examination
Extension, right side bending and right rotation
are limited and provocative.
End range side bending to the left feels
restricted and causes muscle tension.
Passive elevation of the right shoulder improves
ROM during left side bending.
Combined passive movement examination
The combination of extension, right side bending
and right rotation is limited and painful
(comparable sign).
Provocation tests
Central PA on the spinous process at C5/6
segment and the UPA at C5/6 reproduce the
symptoms on the right side with localized
hyperalgesia only.
Passive physiological intervertebral joint tests
Restricted downslope gliding at the right C5/6
zygapophysial joint.
Neurological examination
Negative.
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Case study 1: convergence pattern

A 37-year-old female office worker presented
with a 2-week history of neck pain and
movement restriction, upon referral from a GP.
The pain developed gradually over time without
a traumatic antecedent. There was no history of
similar complaints.
Her chief complaint was neck pain, localized at
the right neck-shoulder border, mainly when
performing specific neck movements to the
right. The patient experienced a feeling of
locking while looking over her right shoulder
and moving her head towards extension and
right rotation.
There was no referred pain to the upper limbs.
The pain at rest was scored 5/10 (VAS), rising
to 7-8/10 during certain neck movements such
as tilting the head backwards and rotation
towards the right. Complaints were localized at
the lower third of the Cx spine.
There was no pain at night while sleeping.
No technical investigations were performed.
Medication was not recommended.
None of the reported symptoms were
considered to be of significant importance
regarding YF or RF detection.
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Table 2: Case study 1: convergence pattern
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Hypothesis
The key findings resulting from the subjective
and clinical examination endorse the hypothesis
for a dominant mechanical nociceptive cause
assuming an articular convergence condition of
the right zygapophysial joint.
Management plan
The nature of the patients articular dysfunction
indicates that a passive approach, using localized
segmental mobilizations and manipulations, is
appropriate to reduce symptoms and to increase
mobility. Given the severity and intensity of the
symptoms, our first technique of choice would be
a gapping technique creating a cavity at the right
C5/6 zygapophysial joint. This is to avoid
compression in the affected zygapophysial joint
and to alleviate the pain. In a second phase a
translatoric (downslope) technique would be
warranted to optimally normalize the downslope
gliding.
Abbreviations are as follows; GP, general practitioner; VAS, visual analogue scale (0-10; 0 = no pain, 10 = worst pain ever); Cx, cervical; YF, yellow flag; RF, red flag;
PA, posterior-anterior provocation; UPA, unilateral posterior-anterior provocation.
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Observation
Forward head posture when seated. The patient
can actively correct posture to good position
when facilitated.
Hypothesis
and clinical examination suggest a dominant
mechanical nociceptive cause assuming an
articular divergence condition of the left
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Flexion, right side bending and right rotation are
limited at end range of movement and
provocative. Passive left shoulder elevation does
not alter the restriction nor the symptoms.
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The combination of flexion, right side bending
and right rotation is limited at end range of
motion and painful (comparable sign).
Provocation tests
The central PA on the spinous process of C2 and
the left UPA at C2/3 reproduce the symptoms on
the left side.
Management plan
The nature of this articular dysfunction allows us
to choose a passive approach, using localized
specific mobilizations and manipulations to
reduce the patients symptoms and increase
segmental mobility. In this case a translatoric
technique (upslope) is preferred to avoid
excessive stretch on the capsuloligamentous
structures of the left zygapophysial joint capsule
and to normalize the upslope gliding.

Restricted upslope gliding at the left C2/3
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Case study 2: divergence pattern

A 45-year-old male plumber, presented upon
doctor referral with symptoms in the Cx spine,
which had been present for about 2 months.
This pain was localized to the left side of his
neck and became painful when performing
specific neck movements. The pain developed
gradually, with no history of trauma.
There was no history of similar complaints.
The patient described his complaint as a
bothersome sensation of strain and movement
restriction at end range Cx flexion and while
bending the head to the right side.
The last 3 days preceding the consultation, the
complaint emerged on the left side during
functional activities.
The pain at rest was scored 4/10 (VAS), rising
to 6/10 during neck flexion and right side
bending. The symptoms were localized at the
upper third of the neck on the left side.
No other complaints such as headache,
temporo-orofacial pain, dizziness, or symptoms
in the upper limbs were present.
There was no pain at night while sleeping.
No technical investigations were performed.
Medication was not recommended.
regarding YF or RF detection.
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Table 3: Case study 2: divergence pattern
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Negative.
Abbreviations are as follows; GP, general practitioner; VAS, visual analogue scale (0-10; 0 = no pain, 10 = worst pain ever); Cx, cervical; YF, yellow flag; RF, red flag;
PA, posterior-anterior provocation; UPA, unilateral posterior-anterior provocation.
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Table 4: Case study 3: mixed pattern
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Case study 3: mixed pattern

Hypothesis
A 62-year-old male engineer presented with a
Observation
5-month history of neck pain. He mainly
and clinical examination put up evidence for a
Forward head posture and protracted shoulders
complained of rigidity associated with bilateral
dominant
mechanical
nociceptive
cause,
when seated. The patient has difficulties actively
neck-shoulder pain, which was more
assuming a mixed pattern of articular
correcting his posture, even when facilitated.
pronounced on the right side compared to the
convergence and divergence conditions of the
left. The pain was predominantly located at the
zygapophysial joints.
All neck movements elicit pain and are
lower Cx spine without irradiating symptoms to
restricted.
the upper limbs. Two years before the current
consultation he received PT intervention for
Management plan
similar complaints with beneficial results on
The nature of the articular dysfunction demands
No clear pattern of restriction and/or pain.
symptom reduction.
a more gentle approach and indicates the use of
There was no history of trauma in the past.
(segmental)
traction
and/or
(midrange)
Provocation
tests
All end range movements were limited and
translatoric
mobilizations.
Given
the
The
central
PA
on
the
spinous
process
of
C5
and
provocative, scored 4/10 (VAS). The most
degenerative
condition
of
the
spine,
even
though
C6 and both left and right UPAs at C5 and C6
limited movement was neck extension followed
medical imagery is present, this does not
reproduce the symptoms. Segmental traction on
by flexion and rotation without differences
preclude the possibility of side effects or adverse
C5/6
and
C6/7
along
the
longitudinal
axis
between sides. The patient did report having
responses to spinal manipulations. Therefore
alleviates
the
symptoms.
trouble having a good nights rest, albeit related
specific midrange mobilizations should take
to frequent urge to urinate (established
precedence on more cumbersome end range
prostate problem).
mobilizations or (in)direct targeted techniques.
Up and downslope gliding are restricted at the
Plain radiographs revealed degenerative
Distraction manipulations could be indicated if
hypomobile
C5/6
and
C6/7
segments.
changes at the lower Cx spine, mainly present at
used with caution.
the C5/6/7 level.
Apart from the known prostate problem, the
patient reported good physical health. No
Negative.
systemic diseases were documented and based
on the patients subjective examination no
other signs of specific pathology could be
detected. No pain medication was taken.
regarding YF detection.
Abbreviations are as follows; GP, general practitioner; VAS, visual analogue scale (0-10; 0 = no pain, 10 = worst pain ever); Cx, cervical ; YF, yellow flag; RF, red flag;
PT, physical therapy; PA, posterior-anterior provocation; UPA, unilateral posterior-anterior provocation.
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Figures
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Figure 1: Planetary model
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Figure 2: Upslope focus technique for the right C3/4 segment
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The therapist positions the head and cervical spine (cradle hold) with the right hand contacting
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the articular pillar of the superior segment (C3). The head is positioned in left rotation and right
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side bending. Slight flexion can be added as a third component. The thrust is directed to the left
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eye (ventrocranial white arrow).
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Figure 3: Upslope technique with caudal locking for the right C3/4 segment
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The therapist stabilizes the caudal segments by placing them in a non-physiological position
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(slight extension, left rotation and right side bending). The affected C3/4 segment is placed in a
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physiological position (slight extension, left rotation and left side bending) and a translation is
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given in an upslope direction (white arrow).
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Figure 4: Downslope technique for the right C3/4 segment
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The therapist positions the head and cervical spine (cradle hold) with the right hand contacting
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side bending. Slight extension can be added as a third component. A translatoric thrust is given
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in the direction of the opposite inferior scapular angle (dorsocaudal white arrow).
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Figure 5: Distraction technique for the right C3/4 segment
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The therapist positions the head and cervical spine (chin hold) with the right hand contacting
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side bending. Slight flexion or extension can be added as a third component. The thrust direction
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is perpendicular to the joint plane with the right hand placed onto the articular pillar of the C3
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segment (white arrow).
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Figure 6: Gapping technique for the right C3/4 segment
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The therapist positions the head and cervical spine (cradle hold) with the left hand contacting
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the articular pillar of the superior segment (C3). The head is positioned in right rotation and left
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side bending. Slight extension can be added as a third component. The thrust direction is
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perpendicular to the contact point with the left hand placed onto the articular pillar of the C3
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segment (white arrow).
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EXAMINATION
SUBJECTIVE EXAMINATION
RULE OUT RED FLAGS
PHYSICAL EXAMINATION
MECHANICAL NOCICEPTIVE NECK PAIN

probably arising from articular structures
stretch pain during flexion and

contralateral side bending /rotation
compression pain during extension and

ipsilateral side bending /rotation
intervertebral movement
tests
upslope restriction contralateral
downslope restriction ipsilateral
SC
combined movement
tests
DIVERGENCE PATTERN
CONVERGENCE PATTERN
treatment
goal
treatment
technique
pain relief and

functional improvement
distraction technique
translatoric upslope technique
focus approach
locking approach
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Figure 7: Clinical algorithm
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OBSERVATION
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pain
relief
functional
improvement
distraction technique
gapping technique
translatoric technique
indirect upslope technique
direct downslope technique

Accepted Manuscript: 10.1016/j.math.2013.09.007

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Accepted Manuscript

Articular dysfunction patterns in patients with mechanical neck pain: a clinical

Received Date: 19 July 2013

Accepted Date: 28 September 2013

Barbara Cagnie, PT, PhD

expertise and is complemented by in-depth discussions and knowledge exchange with

international colleagues. Consequently, it is intended that a carefully targeted approach

manipulation techniques as valuable adjuncts to other manual therapy modalities.

adaptation, leading to a great variety of spinal manipulation techniques (Evans, 2010).

Maitland, Kaltenborn-Evjenth, Hartman and other philosophies and principles.

on manual therapy, is the sound clinical reasoning behind manipulation. It is mandatory to 1)

techniques pending on the individual presentation of the patient.

pattern recognition develops, when a well-structured approach is followed, building on many

empirical foundation of this process, the desire to communicate these prototypes to

manipulation techniques, which are summarized in a clinical algorithm to guide specific

Articular dysfunctions in a broader perspective

mechanisms, including nociceptive pain and peripheral neurogenic pain; 2) processing

mechanisms of pain; and 3) output mechanisms, including autonomic, motor, neuroendocrine

comprehensive understanding of the patients signs and symptoms. Clinical examination is

be determined (Jones, 1995). Reassessment at subsequent treatment sessions is necessary to

output component with maladaptive movement patterns as a generator of the patients

a non-traumatic history of onset suggestive of mechanical dysfunction;

rotation ROM of at least 10;

local provocation tests produce recognizable symptoms;

restriction that is local to one or two functional spinal units;

no neurological findings in clinical history or manual assessment;

no signs of central hyperexcitability;

a positive expectation that manipulation will help.

The presumption of a predominant articular dysfunction as an inherent cause of neck

examination. The hypothesis of an articular dysfunction is only valid if a cluster of articular

interpretations (Jones, 1992, 1995, Jones et al. , 2002).

different approach, this will not be discussed.

the subjective and physical examination.

A monosegmental convergence pattern is characterized by pain provocation and motion

usually restricted at the same side of the compression pain.

A convergence pattern is often found in acute cases and is frequently characterized by a

intensity or severity of symptoms is uncommon. This pattern is considered when pain is

capsuloligamentous structures, usually appearing at the end range of motion. A passive

The intervertebral movement test, performing ventrocranial (upslope) gliding is usually

restricted at the same side of the stretch pain.

between articular and muscular/neural tissue.

multidirectional dysfunctions that can be diagnosed in a degenerative cervical spine. A

degenerative cervical spine is characterized by general stiffness, multisegmental movement

restrictions, a mixed pattern of compression/stretch pain and a combination of

Mobilization and manipulative techniques

Different manipulative approaches can be distinguished, ranging from translatoric and

be distinguished: focus and locking approach.

extension, contralateral rotation, ipsilateral side bending, with additional non-voluntary

easily obtain the articular barrier (Hartman, 1997).

should be placed in a non-physiological position to constrain their movement, whereas the

same side) so it is more effectively targeted (Kaltenborn et al. , 1993).

of the same segmental level (= indirect downslope technique).

affected segment is placed in a physiological position and a translation is given in an upslope

inferior scapular angle (dorsocaudal).

hand placed onto the articular pillar of the superior segment.

the contact point.

Therapeutic guidelines for mobilization and manipulative techniques

linked to the aforementioned articular dysfunction patterns. This is summarized in a clinical

algorithm that is presented in figure 7.

al. , 2009, Evans, 2010, Bialosky et al. , 2012).

An added benefit in this approach is restoring mobility without creating excessive

downslope technique might be warranted. The use of segmental traction as an additional

would create unnecessary tension onto the capsuloligamentous structures. Translatoric