Chapter 24
The Cervical Spine
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Anatomy
Cervical spine is composed of two functional units.
1. Craniovertebral (CV)


Atlanto-occipital (AO)
Atlantoaxial (AA) joints
2. Mid-lower cervical spine
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Atlanto-Occipital Joint
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Atlanto-Occipital Joint Movement
Flexion/Extension/Left Side Flex with
Right Rotation
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Atlantoaxial Joint
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Atlantoaxial Joint Movement
Flexion/Extension/Left Rotation with
Right Side Flexion
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Ligaments of CV Complex
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Midcervical Spine
C2-T1
Composed of several joints
Zygapophyseal (paired)
Uncovertebral (paired)
Interbody (disk)
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Uncovertebral/Interbody Joint
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Motion at Midcervical Spine
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ROM of Intervertebral Segments
Normal/Hypermobile – Elastic/Neutral Zone
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Motion at Midcervical Spine
Consists of
Flexion
Extension
Rotation/side flexion coupling
ipsilaterally
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Vascular and Nervous System
Vertebral artery tests should be performed for
each patient before performing end range
rotation of the neck, and particularly with the
addition of extension and traction.
The C1 nerve root exits through the
osseoligamentous tunnel formed by the
posterior AO membrane, which puts it at risk for
impingement.
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Craniovertebral Musculature
Muscle
Action
 Rectus capitis posterior
minor
 Rectus capitis posterior
major
 Superior oblique
 Inferior oblique
 Rectus capitis lateralis
 Rectus capitis anterior
 AO extension
 CV extension and
ipsilateral rotation
 AO ipsilateral
SF/extenstion
 AO ipsilateral rotation
 AO ipsilateral SF
 AO flexion
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Muscles
Midcervical – Flexion
Longus colli
Longus capitis
Anterior scalenes
Sternocleidomastiod
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Midcervical Extension
 SCM
 Trapezius (upper fibers)
 Levator scapula
 Splenius capitis and
cervicis
 Spinalis, capitis and
cervicis (blends with
semispinalis)
 Semispinalis, capitis, and
cervicis
 Longissimus, capitis, and
cervicis
 Iliocostalis cervicis
 Interspinalis (most distinct
in CSP)
 Multifidus
 Rotatores (inconsistent)
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Examination and Evaluation
Examination should include entire spine,
particularly the thoracic spine, the TMJ, and
the shoulder girdle complex.
History and Clearing Tests
Functional questionnaires (neck disability
index, etc.)
Shoulder girdle tests (if indicated)
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Posture Examination
Static Alignment
Standing vs. sitting alignment – All
3 planes
Supine alignment
Assess resting position of each
vertebral segment through
palpation
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Movement Examination
Movement/Motion tests
 AROM
 Combined movements
 Cervical spine passive
mobility
 Passive intervertebral
movements
 Passive accessory
vertebral movements
 Myofascial extensibility
 Muscle lengths
 Neuromeningeal
extensibility
 Upper limb tension tests
(median, radial, ulnar
nerve bias)
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Muscle Performance, Neurologic, and
Special Tests
Manual muscle tests
(recruitment, strength,
endurance)
Neurologic exam of sensation,
motor activity, and reflex integrity
Stability tests
Vertebral artery tests
Foraminal compression test
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Therapeutic Exercise Interventions for
Common Physiologic Impairments
Impaired Muscle Performance
Deep anterior cervical flexors tend to weaken.
Patient is taught to perform a preset nod to
activate deep stabilizing muscles (cervical
core) prior to any motion of the head.
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Therapeutic Exercise Intervention
Deep Cervical Flexors
Primary exercise is
head nod exercise.
Discourage use of
SCMs.
Consider gravitylessened position
initially.
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Graduate from Deep Cervical Flexors
to SCM/Scalene-Assisted
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Cervical Extensors
NME can be effective in initial stages of training.
Teach patient to apply resistance to the
contraction of specific muscle determined to be
weak.
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Cervical Extensors – Exercise Example
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Specific Manual Resistance to
Cervical Extensors
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Rotation and Side Flexion Components
 Foam wedge can be used for autoresistance.
 Sidelying with towel/roll used as a fulcrum.
Strengthening Functional Movement Patterns
 Once patient is able to perform movements without
hypertranslation, graduate to multiplanar movements.
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Side Flexor and Rotator Activation
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Mobility Impairment
Hypomobility
Segmental articular mobility restriction
Capsular thickening and contracture
Degenerative bony changes
Segmental muscle spasm
Myofascial extensibility
Adverse neuromeningeal tension
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Therapeutic Exercise Considerations
Postural education – correct FHP
ROM exercises in restricted planes
(consider gravity!)
Exercise localized segment according to
mobility test
Stretch short muscles
Strengthen long muscles in shortened
range
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Stretching Suboccipitals/Scalenes
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Hypermobility
Excessive motion of the intervertebral segment.
Treatment
 Postural correction exercises.
 Consider taping of scapula to reduce pull on segment.
 Manually stabilize hypermobile segment or perform
cocontractions at involved levels.
 Gradually challenge cervical musculature while
preventing excessive motion at involved segment.
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Levator Scapula Stretch While
Stabilizing C4
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Posture Impairment
FHP
Treatment
 Muscle imbalance
 Neuromeningeal
extensibility
 Articular hypomobility
 Proprioception
 Lengthen short muscles
and strengthen weak
muscles
 Side flexion and elevation
of scapula
 Manual therapy and
mobility exercises
 Postural correction
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FHP – Axial Extension/Minimal
Lordosis/Excessive Lordosis
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Therapeutic Exercise Interventions for
Common Diagnoses
Disk Dysfunction
Changes in disk alter its biomechanical properties and
prevent normal function.
Treatment




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Initially aimed at rest positions
Postural education (including pelvic girdle)
Manual therapy to mobilize hypomobile segments
Manual traction to decrease compression
Stretching exercises during acute phase
Progression of stabilization exercises for hypermobile segments
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Cervical Sprain and Strain
Most common incident is WAD after MVA
Treatment
 Proper resting position/postural education
 Ice/heat and therapeutic modalities to control
inflammation and pain
 Rhythmic neck rotations (supine)
 Subacute – Manual mobilization techniques
 Mobility exercises can slowly progress into larger
arc movements while maintaining postural integrity
 Specific strengthening exercises are introduced in
remodeling phase
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Neural Entrapment
Cervical nerve roots become entrapped at their
exit at the intervertebral foramen.
Treatment
Postural exercises/re-education
Address neuromeningeal hypomobility
Treatment of cervical/thoracic spine, shoulder
girdle, and wrist are common
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Cervicogenic Headache
Referred pain to head and/or face from first
three or four cervical nerves.
Treatment
Generalized ROM exercises for mobility
Specific muscle stretches (especially upper
cervical)
Exercises to increase muscle performance
of deep upper cervical flexors
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Summary
 CV complex includes AO and AA joints.
 Ligaments – Alar, transverse, tectorial membrane,
anterior/posterior AO membranes, posterior AA ligament.
 AO joint – Bicondylar, modified ovoid joint; two degrees
of motion (flexion/extension and combined side
flexion/rotation).
 AA joint – Multi-joint, complex, degrees of motion
(flexion/extension and combined side flexion/rotation).
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Summary (cont.)
 Midcervical joints – Zygapophyseal joints, UV joints,
interbody joints.
 Important midcervical ligaments – Anterior/posterior
longitudinal, ligamentum flavum, interspinous, and
ligamentum nuchae.
 Coordinated motion occurs among joints of midcervical
spine. Each segment – two degrees of motion
(flexion/extension and combined side flexion/rotation).
 Cervical spine exam and evaluation includes subjective
history, physical exam, vocational environment.
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Summary (cont.)
 Physical exam includes visual observation,
active/passive movement tests, myofascial and
neurological meningeal extensibility, MMT, neurologic
and clearing tests of thorax, shoulder girdle, and TMJ.
 Common physiologic impairments include muscle
performance, posture, mobility.
 A therapeutic exercise program is developed to address
each impairment and improve overall function.
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Summary (cont.)
 Common diagnoses of cervical spine are disk
dysfunction, sprain or strain, neural entrapment,
cervicogenic headache.
 For any patient presenting with a particular
diagnosis, impairments are identified and prioritized
according to those requiring immediate attention
and those most likely to be tolerated by the patient.
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