Download Supine-Direct-HVLA

Cervical Techniques
Know the following things about the
Cervical spine and upper extremities
• DTR’s
• Sensory
• Motor
Deep Tendon Reflexes
• There are three basic deep tendon reflexes, which evaluate the
integrity of the C5, C6 and C7 nerve supply. These are known as the
biceps reflex, the Brachioradialis reflex, and the triceps reflex.
BICEPS REFLEX – C5
Although there are multiple innervations to the biceps via C5 and
C6, primary innervation is associated with C5.
BRACHIORADIALIS REFLEX – C6
Although there are multiple innervations to the Brachioradialis via
C5 and C6, primary innervation is associated with C6.
TRICEPS REFLEX – C7
The triceps muscle is innervated by the radial nerve primarily C7.
Sensory
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•
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•
•
Know your dermatome
C5: lateral arm
C6: radial forearm, thumb
C7: long finger
C8: small finger
T1: ulnar forearm, medial aspect of elbow
Motor
• Compare strength testing from each upper
extremities
– Have them push against your resistance
– You let them win
Manual Muscle Testing- Biceps
• The patient’s elbow is flexed
to 90 degrees and forearm
is placed in supination with
the palm facing up.
• The examiner places one
hand under elbow for
stabilization and the other
hand at the distal forearm
to resist movement. Instruct
the patient to flex the
forearm.
Manual Muscle Testing- Triceps
• The patient’s arm is
abducted to 90 degrees and
the elbow is flexed to 90
degrees.
• The examiner places one
hand under the elbow joint
for stabilization and the
other hand at the distal
forearm to resist the
movement. Instruct the
patient to extend the
forearm.
Manual Muscle Testing- Flexor
Compartment
• The patient’s elbow is
flexed to 90 degrees and
forearm is placed in
supination with the wrist
neutral and palm up.
• The examiner places one
hand under the proximal
forearm for stabilization
and the other hand over
the patient’s hand to resist
movement. Instruct the
patient to flex the wrist.
Manual Muscle Testing- Extensor
Compartment
• The patient’s elbow is
flexed to 90 degrees and
forearm is placed in
supination with the wrist
neutral and palm up.
• The examiner places one
hand under the proximal
forearm for stabilization
and the other hand over
the patient’s hand to resist
movement. Instruct the
patient to extend the wrist.
Know the following Special Tests
•
•
•
•
Spurling’s
Lhermitte’s
Tinel’s
Phalen’s
• Vascular Testing:
– Carotid Bruits
– Thoracic Outlet Syndrome
(TOS)
• Adson’s
• Costoclavicular (“military”)
• Hyperabduction
(“Wright’s”)
• Elevated Arms (“Roo’s”)
– Vertebrobasilar
insufficiency (“underburg”)
– Allen’s
Spurling’s Test
• Region of Body you are testing
– Cervical/neck
• What you are testing for
– Cervical radiculopathy
• How to do it
– 3 Stages: The examiner passively hyperextends and laterally flexes the
patient’s neck toward the involved side
• What a + sign means
– pain/parasthesias radiating from shoulder to the elbow ipsilateral to side
of rotation (reproduction of pt’s symptoms). It could also originate pain
from the trapezius and levator scapulae
• Special Notes
– Use Axial Compression (Modified Spurling’s – no compression).
– Has low sensitivity but high specificity (can rule cervical radiculopathy out
but not confirm it)
– If the patient feels better, think anterior/middle scalene issue
Lhermitte’s Test
• Region of Body you are testing
– Cervical/Neck
• What you are testing for
– multiple sclerosis or large disc herniation
• How to do it
– Need hips and head flexed, so Pt is in the long sitting
position with Flexion of cervical spine
• What a + sign means
– Electric shock or lightening-like paresthesias or dysthesias
in the hands or legs upon cervical flexions
• Special Notes
– a.k.a. Barber’s chair phenomenon
Tinel’s Test
• Region of Body you are testing
– Thumb/hand
• What you are testing for
– Median Nerve
• How to do it
– Tap over the median nerve
• What a + sign means
– Numbness
• Special Notes
– numbness in distribution of median n. (test for carpal
tunnel)
Phalen’s Test
• Region of Body you are testing
– Thumb/hand
• What you are testing for
– Median Nerve
• How to do it
– hold wrist in flexion for 60 sec, median n compression
• What a + sign means
– Numbness
• Special Notes
– numbness in distribution of median n. (test for carpal
tunnel)
Adson’s Test - TOC
• Region of Body you are testing
– cervical vascular
• What you are testing for
– TOS – Thoracic outlet syndrome
• How to do it
– With the patient in a sitting position, hands resting on thighs, the
examiner palpates (feels) both radial pulses as the patient rapidly fills
the lungs by deep inspiration and, with breath held, hyperextends the
neck and turns the head toward the 'affected' side.
• What a + sign means
– If the radial pulse on that side is decidedly or completely obliterated,
the result is considered positive. (need to hold for 10 – 15 sec)
• Special Notes
– Be sure you feel the pulse on the “affected” side, and that you turn the
head towards the ipsilateral side you are testing
Costoclavicular (“military”) test - TOC
• Region of Body you are testing
– Vascular
• What you are testing for
– Thoracic Outlet Syndrome
• How to do it
– Pt should be seated. The shoulders are drawn downward
and backward. This maneuver narrows the costoclavicular
space by approximating the clavicle to the first rib and thus
tends to compress the neurovascular bundle.
• What a + sign means
– Changes in the radial pulse with production of symptoms
indicate compression.
Hyperabduction (Wright’s) test – TOC
• Region of Body you are testing
– Vascular
• What you are testing for
– Thoracic Outlet Syndrome
• How to do it
– Pt should be supine. When the arm is hyperabducted to
180 degrees, the components of the neurovascular bundle
are pulled around the pectoralis minor tendon, the
coracoid process, and the head of the humerus.
• What a + sign means
– If the radial pulse is decreased, compression should be
suspected.
Elevated arms (Roo’s) test – TOC
• Region of Body you are testing
– Vascular
• What you are testing for
– Thoracic Outlet Syndrome (HIGHLY sensitive)
• How to do it
– Pt standing, and Both arms are placed at right angles
to the shoulder and the forearms are at right angles to
the upper arms. Both hands are opened and closed as
fast as possible to see if symptoms occur. Do for 3 min
• What a + sign means
– Tingling, numbness will occur, but wait full 3 min
Vertebrobasilar Insufficiency
(Underburg/ Wallenburg) Test
• Region of Body you are testing
– Vascular
• What you are testing for
– Vertebral artery insufficiency
• How to do it
– Have the pt lay supine, and you extend and SB the neck, and wait 30
sec
• What a + sign means
– Dizziness, fainting, vertigo, N/V, lightheadedness, blurred vision, and
nystagmus (fast eye twitching) are all considered positive indicators of
reduced/blocked blood flow.
• Special Notes
– + test indicates vertebral a. insufficiency on the ipsilateral side you are
testing
Allen’s Test
• Region of Body you are testing
– vascular in hand
• What you are testing for
– radial/ulnar artery insufficiency
• How to do it
– Pt rapidly open and close fist then hold it closed. Examiner will
occlude ulnar and radial artery. Instruct the pt to open fist and
examiner should release one artery--look for pink repeat for
opposite artery
• What a + sign means
– Poor return of color
• Special Notes
– test for Carpal Tunnel Syndrome as well
Examination of the Cervical Spine
• Range of Motion (passive and active)
– Flexion/Extension
– OA Motion: Flexion/Extension
– Rotation
– Side bending
• Segmental Diagnosis
– OA
– AA
– C2 – C7 = Typical Cervicals
Range of motion Testing
• Range of Motion (passive and active)
– Flexion/Extension
– OA Motion: Flexion/Extension
– Rotation
– Side bending
Segmental Diagnosis
– OA  Flexion and Extension SxRy
– AA  Rotation
– C2 – C7 =
Typical Cervicals  SxRx
Summary
Level
Major Motion
Minor Motion
Diagnosis
OA
FB/BB
(Flexion/Extension)
Side-bending/
Rotation is
opposite
FB (F) or
BB (E) SxRy
AA
Rotation only
“Wobble”
RL or RR
Sidebending/Rotation
and
FB/BB
(Flexion/Extension)
Slight
Translation
(SB & R is on
same side)
FB (F) or
BB (E)
RxSx
C2-C7
Cervical Soft Tissue
•
•
•
•
Forward bending stretching
Longitudinal stretching
Kneading
Trapezius stretching
Forward bending stretching
• Objective: Stretch
posterior cervical
tissues
• 1) doctor at head of
table; patient supine.
• Cross forearms and
place them behind pt’s
head with fingertips on
pt’s shoulders.
• Exert slow forward
bending stretch until a
restrictive barrier is
engaged, slowly
increase to next barrier
Longitudinal Stretching
• Objective: Relax the
paravertebral muscles
(PVM).
• 1) doctor at head of table;
patient supine.
• 2) palmar surfaces of fingers of
both hands under the neck
near spinous processes
• 3) lift PVM with fingers and
draw it toward you (cephalad =
toward head)
• 4) release and carry tissue
away from you (caudally =
toward tail)
Kneading
• Objective: Relax the
cervical paravertebral
muscles (PVM).
• 1) doctor standing on
patient’s side; patient
supine.
• 2) With caudad hand, reach
across patient and cup
PVM; Place cephalad hand
on pt’s forehead
• 4) Push head away from
you, then pull up and
laterally on PVM tissue
letting head roll back
toward you.
Trapezius Stretch
• Objective: Relax the
trapezius muscle
• 1) Patient supine,
doctor at head of
table
• 2) Stabilize one
shoulder with
opposite hand
• 3) With free hand
contact same side of
head as stabilized
shoulder and
introduce GENTLE
stretch
ME for Cervical Spine
• C2 – C3 supine direct ME (isometric)
Kimberly manual 4221.11A-3, pg 79
Supine-Direct-ME
C3 RLSL
• Reach under spine to
contact the convex
side.
• Pull with fingers to
induce Right
Sidebending (reverse
the curve)
Supine-Direct-ME
C3 RLSL
• Place counterforce on
LEFT side of patients head
• Direct patient through 3-4
cycles of Muscle energy.
• Note:
– Readjust in SMALL
INCREMENTS with finger on
C-spine
HVLA for Cervical Spine
• C2 – C3
– Supine – Direct Method – HVLA Rotation
emphasis, Kimberly manual, 4221.11A-1, pg 78
– Supine – Direct Method – HVLA sidebending
emphasis, Kimberly manual, 4421.11A-2, pg 79
• C4 – C7
• Supine – Direct Method – HVLA, Kimberly manual,
4221.11B-1, pg 81
For C2 – C3:
Supine – Direct Method – HVLA
Rotation emphasis, Kimberly manual,
pg 78
1. Backward Bend
2. Rotate into the barrier
3. Sidebend away from barrier (slightly)
4. HVLA Rotation Thrust
Supine-Direct-HVLA Rot Emphasis
C3 RLSL
• Bilateral contact at
articular pillars at
inferior portion of C3
Supine-Direct-HVLA Rot Emphasis
C3 RLSL
• Backward Bend at C3/C4
joint by lifting anterior
• Do not hyperextend entire
cervical spine, only the
ONE segment.
Supine-Direct-HVLA Rot Emphasis
C3 RLSL
• Maintain tight contact
at Left articular pillar!!
• Rotate to the Right to
the restrictive barrier
Supine-Direct-HVLA Rot Emphasis
C3 RLSL
• Sidebend slightly to the
LEFT over your THRUST
POINT (SB left)
• Note:
– This SB motion to the left is
only meant to tighten the
restrictive barrier. It does not
reverse the coronal plane
Supine-Direct-HVLA Rot Emphasis
C3 RLSL
• HVLA thrust in
rotation
• Both hands must
rotate!
For C2 – C3:
Supine – Direct Method – HVLA
sidebending emphasis, Kimberly manual,
4421.11A-2, pg 79
• Key Points
– Contact pillar @ lower vertebra of the segment
– Forward bend
– Sidebend over fulcrum
– Rotate away
– Thrust to opposite orbit
Supine-Direct-HVLA
The Segment (C3-C4)
L
• C3 RLSL
•C3 is the upper vertebra of
the segment
•C4 is the lower vertebra of
the segment
R
Supine-Direct-HVLA
C3 RLSL
• Support head in LEFT hand
Will need to change
C3 RLSL
• Contact
RIGHT
articular pillar
at inferior
border of C3
with thrust
contact of
RIGHT hand
– use lateral margin
of index finger
– intent is to close
facet joint C3 on
C4
3
4
Supine-Direct-HVLA
C3 RLSL
• Contact RIGHT articullar
pillar of C4 with thrust
contact of RIGHT hand
– use lateral margin of index
finger
– intent is to close facet joint
C3 on C4
Supine-Direct-HVLA
C3 RLSL
• Forward bend with a tight
contact at the RIGHT
articular pillar of C3/C4
Supine-Direct-HVLA
C3 RLSL
• Maintain tight contact in
FB
• Sidebend RIGHT over your
thrusting fulcrum at C3/C4
Supine-Direct-HVLA
C3 RLSL
• Rotate to the LEFT to tighten
the barrier
• Do not lose previous
localization!!
Supine-Direct-HVLA
C3 RLSL
• HVLA thrust toward
opposite orbit of eye
– glide C3 into C4 to close facet
– counterforce must be
maintained with Right hand
C4 – C7
Supine – Direct Method – HVLA, Kimberly manual,
4221.11B-1, pg 81
• Key Points
– Contact pillar @ upper vertebra of the segment
– Forward bend
– Sidebend over fulcrum
– Rotate away
– Thrust to opposite scapula
Supine-Direct-HVLA
The Segment (C4-C5)
L
• C4 RLSL
•C4 is the upper vertebra of
the segment
•C5 is the lower vertebra of
the segment
R
Supine-Direct-HVLA
C4 RLSL
• Support head in LEFT hand
Supine-Direct-HVLA
C4 RLSL
• Contact RIGHT articular pillar
of C4 with thrust contact of
RIGHT hand
– use lateral margin of index
finger or MP joint
– intent is to force C4 down onto
C5
4
5
Supine-Direct-HVLA
C4 RLSL
• Contact RIGHT articullar pillar
of C4 with thrust contact of
RIGHT hand
– use lateral margin of index
finger
– intent is to force C4 down onto
C5
Supine-Direct-HVLA
C4 RLSL
• Forward bend with a tight
contact at the RIGHT
articular pillar of C4
Supine-Direct-HVLA
C4 RLSL
• Maintain tight contact in
FB
• Sidebend RIGHT over your
thrusting fulcrum @C4
Supine-Direct-HVLA
C4 RLSL
• Rotate to the LEFT to
tighten the barrier
• Do not lose previous
localization!!
• Final adjustment of
flexion/extension in
sagittal plane
Supine-Direct-HVLA
C4 RLSL
• HVLA thrust toward
opposite inferior angle of
the scapula
– force C4 down onto C5