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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 • • • • • • 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