Overview of Manual Therapy Assessment and Treatment of the Cervicothoracic Spine

Megan Casey Douglas, PT, DPT, MTC, OCS

Megan Casey Douglas, PT, DPT, MTC, OCS

Bellingham, WA Director of Physical Therapy at Northwest Physical Therapy- Skagit Valley, Private Practice Recently moved from Cincinnati, OH DPT, MTC thru University of St. Augustine OCS thru APTA MPT Andrews University BS- Miami University Teaching Experience
Adjunct University of Dayton College of Mt. St. Joseph Continuing Education

WHAT IS MANUAL THERAPY?

A clinical approach utilizing skilled, specific handson techniques, including but not limited to manipulation/mobilization, used by the physical therapist to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.1,2 (Definition from American Academy of Orthopedic Manual Physical Therapy (AAOMPT) and American Physical Therapy Association (APTA).

Anatomy of the Cervical Spine

Anatomy of the Cervical Spine

Spinous Process Articular pillar formed by articular process and interarticular parts Zygapophyseal joints- 45 At T1 1st costal facet for 1st rib

Mid-Cervical Vertebra
Body Transverse Process Anterior tubercle Posterior tubercle Groove for spinal N. Transverse foramen Pedicle Superior articular facet Inferior articular process Vertebral foramen Spino s process
C4Vertebra vs C7

Anatomy of C1 and C2
Atlas(c1)Anatomy Axis(C2)Anatomy

Ligaments of the Cervical Spine

Tectorial membrane becomes PLL Capsule of OA joint Capsule of AA joint Capsule of zygapophyseal joint
Posteriorview(s.p.removed)

Ligaments of the Cervical Spine

Anteriorview

Anterior Longitudinal Ligament

Ligaments of the OA joint

Posteriorview

Alar ligaments Cruciate ligament Apical ligament of dens

Cervical Spine Ligaments

RightLateralView

Ligamentum nuchae Ligamenta flava Spinous process of C7 vertebra Vertebral a.

Cervical Spine Musculature

Cervical Spine Musculature

Cervical Spine Musculature

Biomechanics of the Cervical Spine

Biomechanics of the Cervical Spine

Biomechanics of Cervical Spine

Mid cervical forward bending
Facets slide up, approx. 40% displacement Lateral interbody joints slide forward Vertebrae step minimally Spinal canal narrows but lengthens, volume remains the same.

Biomechanics of Cervical Spine

Mid Cervical Backward Bending
Facets slide down, then fulcrum on pedicle. Lateral interbodies slide back
Vertebrae step considerably!!

Ligamentum flavum bulges inward Spinal canal shortens and narrows significantly Cord may be compressed in the presence of degenerative changes

Biomechanics of Cervical Spine

Mid Cervical Sidebending /Rotation Right
Facets slide down and back on the right Facets slide up and forward on the left, causing right rotation

Biomechanics of Cervical Spine

If patient is instructed to face forward with sidebending Right, AA Rotation Left has occurred. If patient is instructed to rotate right, keeping eyes level with the horizon, SB Left occurs subcranially (OA, AA). Approx. half of cervical rotation originates from the AA joint (C1/C2).

Anatomy/Biomechanics of the upper thoracic spine

T1 has a unifacet for articulation of the first rib T1 through T3 generally follow lower cervical biomechanics Lower thoracic segments similar to lumbar spine

Cervical Evaluation

Cervical Evaluation
Observation/ Posture
Symmetry, resting position of head on neck Forward Head Posture (FHP) Increase/Decrease in thoracic kyphosis

AROM testing
Flexion, Extension, SB R/L, ROT R/L
Veers R/L with flexion/extension SB R/L, seated, arms supported/ unsupported

Rotation- should recruit down to approx. T3 OA nodding/SB, AA rotation

Cervical Evaluation
Neurovascular assessment Special Tests
Alar Odontoid Integrity Transverse Ligament Vertebral A.??

Precautions, trauma, diagnostic tests

Cervical Evaluation
PROM/joint mobility testing
Supine, neutral to slight flexion
OA/ AA mobility Check SB R/L, Rot R/L Cervical upglides Cervical downglides Upper thoracic joint mobility (from supine, PA) 1st rib mobility

Muscle length, Soft tissue restrictions Palpation

Cervical Evaluation
Video Demonstration
Cervical upglides Cervical downglides Upper thoracic PA mobility 1st rib mobility- depression

Cervical and Upper Thoracic Manipulation

Indications for Manipulation

Restricted accessory joint motion Neurophysiological benefit and pain control.

Contraindications/Precautions for Manipulation

Disease states Hemarthrosis Hypermobility Muscle holding Fracture Acute inflammation Fusion/Joint replacement Anticoagulant therapy Osteoporosis

Grades of Manipulation

Grades of Manipulation
Non-Thrust
Maitland- Grade I Grade II Grade III Grade IV Traditional- stretch Paris- progressive oscillation Mulligan- mobilizes with active movement

Thrust
Traditional- High Velocity Low Amplitude (HVLAT)

Distraction
Traditional- Manual Mechanical Paris- Positional

Cervical Manipulation TechniquesVideo Demonstration

Cervical upglides Cervical downglides Upper thoracic PA mobility 1st rib mobility- depression Cervical Traction Suboccipital Release/Inhibitive Distraction

Cervical DDD Cervical OA, facet arthropathy Cervical Radiculopathy

Disc protrustion/herniation Foramenal stenosis due to OA

Common Diagnoses that may benefit from Manual Therapy

Cervical Sprain/Strain Cervicogenic Headache

Forward Head Posture can contribute to...

Muscle Imbalance/ Adaptive shortening Joint restrictions
Areas of relative hypo/hypermobility Facet arthropathy DDD Compromise of neural foramen

Cervicogenic Headaches Thoracic Outlet Syndrome TMJ disorders

Key Tips to Remember

Treatment to improve posture/ reduce FHP and optimize intended cervical spine biomechanics Treat joint restrictions with manipulation Stabilize areas of hypermobility Avoid manipulative forces thru hypermobile segments

Key Tips to Remember

Joint restrictions may not be where the patient complains of pain/tenderness Pain is deceiving/ referral patterns

Key Tips to Remember

After acute phase/palliative treatments, go to the source of the problem
Disc protrusion- symptom Muscle sprain/strain may be guarding due to underlying problem Cervicogenic Headache
FHP? Joint restriction of OA, AA

Case Study 1
Manual Therapy Cervical Radiculopathy Treatment Acute phase Patient is a 39 y/o CPA Manual traction (in April!) and has a straight pull pronounced FHP add slight SB L/ Rot L, flex Suboccipital release Pain increases Rotation Subacute R, SB R, and Ext.
Intermittent R UE burning down to elbow, n/t in R hand Weakness in C6 myotome Tenderness over R
Cervical upglides on R? Upper thoracic manipulation 1st rib depression Address other joint restrictions, soft tissue restrictions

Chronic

Case Study 2
Manual Therapy Left Upper Trapezius Treatment Strain Patient is a 24 y/o Cervical downglides student, woke with on Left side pain on L side of neck If c/o pain with Pain and decreased L downglide, try cervical SB and L Rotation upglides on Right and Ext. ROM side. Pain and decreased Recheck joint mobility downglide C3/C4 facet Reassess L UT, may try Trigger point in L UT and pain with L UT massage/stretching if

Case Study 3
Cervical DDD, HAs
Patient is a 58 y/o female, complaining of bilateral neck pain and headaches X-rays show DDD at C5/C6 and C6/C7 Patient has sedentary desk job and a significant FHP/increased thoracic kyphosis Denies radicular Sx Complains of increasing HAs as work day

Manual Therapy Treatment

Posture! Education/Ergonomics Manipulate joint restrictions- upper/mid thoracic, upper/mid cervical? Caution: hypermobility at C5/6, C6/7?? Suboccipital Release/ Inhibitive distraction OA, AA manipulations if restrictions present- also may decrease Has Address soft tissue t i ti l

Evidence Supporting Manual Therapy of the Cervical Spine

Bronfort G, Haas M, Evans R, Bouter L. 2004 Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain: a Systematic Review and Best Evidence Synthesis. The Spine Journal, 4(3):335-56. Eldridge L, Russell J. 2005. Effectiveness of Cervical Spine manipulation and Prescribed Exercise in Reduction of Cervicogenic Headache Pain and Frequency. International J of Osteopathic Med. 8:106-113. Fernandez-de-las-Penas C, Alsonso-Blanco C, San-Roman J, MiangolarraPage JC. Methodological Quality of Randomized Controlled Trials of Spinal Manipulaiton and Mobilzation in Tension-Type Headache, Migraine, and Cervicogenic Headache. JOSPT 2006 Mar;36(3):160-9. Gross A, Hoving J, Haines T, et.al. 2004 A Cochrane Review of Manpulation and Mobilization for Mechanical Neck Disorders. Spine 29(14):1541-1548.

Evidence Supporting Manual Therapy of the Cervical Spine

Jull G, Trott P, Potter H. et. al. 2002. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine 27(17)1835-1843. Lessinck M, Damen L, Verhagen A. et. al. 2004 The Effectiveness of Physiotherapy and Manipulation in Patinets with Tension-Type Headache: A Systematic Review. Pain 112:381-388. McNair PJ, Portero P, Chiquet C, Mawston G, Lavaste F. Acute Neck Pain: Cervical Spine Range of Motion and Position Sense prior to and after Joint Mobilization. Man. Ther. 2007 Nov;12(4)390-4. Zito G, Jull G, Story I. 2006. Clinical Tests of Musculoskeletal Dysfunction in the Diagnosis of Cervicogenic Headache. Man. Ther. 11(2):118-129.

References
Anatomy pictures
Netter, F.H. Atlas of Human Anatomy. 2nd ed. 1997

Paris SV. Manipulation and Management of the Spine. S1 thru S4. University of St. Augustine, St. Augsutine, FL 32086 Greenman PE. Principles of Manual Medicine. Lippincott, Williams, & Wilkins. Philadelphia, PA. 2003

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Overview of Manual Therapy Assessment and Treatment of the Cervicothoracic Spine Megan Douglas, PT, DPT, MTC, OCS

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